€¦ · XLS file · Web view2008-12-02 · supply of additional high dose contrast material(s) during magnetic resonance high dose contrast mri i2d imaging, e.g., gadoteridol injection

Query_110708

Page 1

HCPCS CODES FOR 2009IMPORTANT NOTE: CURRENT AND OLD CODES LISTED. SEE DATES IN COLUMNS AT, AU, AND AV.PUBLISHER: CENTERS FOR MEDICARE & MEDICARE SERVICES.DATA NON-ESSENTIAL TO MOST HOME IV PROVIDERS IS HIDDEN BY NATIONAL HOME INFUSION ASSOCIATION.

HCPC A1 A2 A3 A4 A5 A6 A7 A8 A9 AA AD AD AE AF AG AH AJ AK AM AP AP AQ AQ AR AS AS AT AT AU AV AW AX BA BL BO BP BP BR BR BU BU CA CA CB CB CB CC CC CD CD CE CE CE CF CF

Query_110708

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CG CR E1 E2 E3 E4 EA EA EB EB EC EC ED ED ED EE EE EE EJ EJ EM EP EP ET EY EY F1 F2 F3 F4 F5 F6 F7 F8 F9 FA FB FB FB FC FP G1 G2 G3 G4 G5 G6 G6 G7 G7 G8 G8 G9 G9 GA GB GB GC GC GD GD

Query_110708

Page 3

GE GE GF GF GF GG GG GH GJ GK GL GL GM GN GO GP GQ GR GR GR GS GS GT GV GV GW GY GY GZ H9 HA HB HC HD HE HF HG HH HI HI HJ HK HL HM HN HO HP HQ HR HS HT HU HV HW HX HY HZ J1 J2 J2 J3

Query_110708

Page 4

J3 JA JB JC JD JW K0 K0 K0 K1 K1 K1 K2 K2 K2 K2 K3 K3 K3 K3 K3 K4 K4 K4 K4 KA KB KC KD KE KE KF KG KH KI KJ KJ KK KL KM KN KO KP KQ KR KS KT KT KU KV KV KW KX KY KZ LC LD LL LL LR LS

Query_110708

Page 5

LT M2 MS MS NR NR NU P1 P2 P3 P4 P5 P6 PL Q0 Q0 Q1 Q1 Q2 Q3 Q4 Q5 Q5 Q6 Q7 Q8 Q9 QA QB QC QD QE QF QF QG QH QJ QJ QJ QK QK QL QM QN QP QP QP QQ QR QS QT QU QV QW QX QY QY QZ RA RB RC

Query_110708

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RD RE RE RP RP RP RP RR RT SA SB SC SD SD SE SF SF SG SH SJ SK SL SM SN SQ SS ST SU SU SV SW SY SY T1 T2 T3 T4 T5 T6 T7 T8 T9 TA TC TC TC TC TC TC TC TD TE TF TG TH TJ TK TL TM TN TP

Query_110708

Page 7

TQ TR TR TS TT TU TV TW U1 U2 U3 U4 U5 U6 U7 U8 U9 UA UB UC UD UE UF UG UH UJ UK UK UN UP UQ UR US VPA0021A0080A0080A0090A0090A0100A0110A0120A0120A0130A0140A0140A0160A0170A0180A0190A0200A0210A0225A0380A0382A0384A0384A0384A0390A0392A0392

Query_110708

Page 8

A0394A0396A0398A0420A0422A0424A0424A0425A0426A0426A0427A0427A0428A0429A0430A0431A0432A0432A0432A0433A0434A0435A0436A0800A0888A0888A0998A0999A4206A4207A4208A4209A4210A4211A4212A4213A4215A4216A4217A4218A4220A4221A4221A4222A4222A4223A4223A4230A4231A4232A4233A4233A4234A4234A4235A4235A4236A4236A4244A4245A4246

Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

Page 22

A9560A9560A9561A9562A9563A9564A9565A9566A9567A9567A9568A9569A9569A9570A9571A9572A9576A9577A9578A9579A9579A9580A9600A9605A9698A9699A9700A9900A9900A9901A9999B4034B4035B4036B4081B4082B4083B4086B4086B4087B4088B4100B4102B4102B4103B4103B4104B4149B4149B4149B4150B4150B4150B4152B4152B4152B4152B4153B4153B4153B4153

Query_110708

Page 23

B4154B4154B4154B4154B4155B4155B4155B4155B4157B4157B4157B4157B4158B4158B4158B4158B4159B4159B4159B4159B4160B4160B4160B4160B4161B4161B4161B4162B4162B4162B4162B4164B4164B4168B4172B4172B4176B4176B4178B4178B4180B4180B4184B4184B4185B4186B4186B4189B4189B4189B4193B4193B4193B4197B4197B4197B4199B4199B4199B4216B4216

Query_110708

Page 24

B4220B4222B4224B5000B5000B5000B5100B5100B5100B5200B5200B5200B9000B9002B9004B9006B9998B9999C1079C1079C1080C1080C1081C1081C1082C1082C1083C1083C1091C1091C1092C1092C1093C1093C1122C1122C1178C1200C1200C1201C1201C1300C1305C1713C1714C1715C1716C1717C1718C1719C1720C1721C1722C1724C1725C1725C1726C1727C1728C1729C1730

Query_110708

Page 25

C1730C1731C1731C1732C1733C1733C1750C1751C1751C1752C1753C1754C1755C1756C1757C1758C1759C1760C1762C1763C1764C1765C1766C1766C1767C1768C1769C1770C1771C1772C1773C1775C1775C1776C1777C1778C1779C1780C1781C1782C1783C1784C1785C1786C1787C1788C1789C1813C1814C1815C1816C1817C1818C1819C1820C1820C1821C1874C1875C1876C1877

Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

Page 30

C9437C9438C9439C9440C9704C9704C9713C9713C9716C9718C9719C9719C9719C9720C9720C9721C9721C9722C9722C9722C9723C9724C9724C9725C9725C9726C9726C9727C9728C9728C9728C9898C9899C9899D0120D0140D0145D0145D0150D0160D0170D0170D0180D0210D0220D0230D0240D0250D0260D0270D0272D0273D0274D0277D0290D0310D0320D0321D0322D0330D0340

Query_110708

Page 31

D0350D0360D0362D0362D0363D0363D0415D0416D0417D0418D0421D0425D0431D0431D0431D0460D0470D0472D0472D0473D0473D0474D0474D0474D0475D0476D0477D0478D0479D0480D0480D0481D0482D0483D0484D0485D0485D0486D0486D0502D0999D1110D1120D1201D1203D1204D1205D1206D1206D1310D1320D1330D1351D1510D1515D1520D1525D1550D1555D2140D2150

Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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D9630D9910D9911D9920D9930D9940D9941D9942D9950D9951D9952D9970D9971D9972D9973D9974D9999E0100E0105E0105E0110E0110E0111E0111E0112E0112E0113E0114E0114E0116E0116E0117E0118E0130E0135E0140E0141E0143E0144E0144E0147E0148E0149E0153E0154E0155E0156E0157E0158E0159E0160E0161E0161E0162E0163E0164E0165E0166E0167E0168E0168

Query_110708

Page 42

E0169E0170E0171E0172E0175E0180E0181E0181E0182E0184E0185E0186E0187E0188E0189E0190E0190E0191E0193E0194E0196E0197E0198E0199E0200E0202E0203E0205E0210E0215E0217E0218E0220E0221E0225E0230E0231E0231E0232E0232E0235E0236E0238E0239E0240E0241E0242E0243E0244E0245E0246E0247E0248E0249E0250E0251E0255E0256E0260E0260E0261

Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

Page 56

E8001E8001E8002E8002G0008G0009G0010G0027G0030G0030G0031G0031G0032G0032G0033G0033G0034G0034G0035G0035G0036G0036G0037G0037G0038G0038G0039G0039G0039G0040G0040G0041G0041G0042G0042G0043G0043G0043G0044G0044G0045G0045G0046G0046G0047G0047G0101G0102G0103G0104G0105G0106G0106G0107G0107G0108G0108G0109G0109G0110G0111

Query_110708

Page 57

G0112G0113G0114G0115G0116G0117G0117G0118G0118G0120G0120G0121G0121G0122G0123G0123G0123G0124G0124G0124G0125G0127G0128G0128G0128G0129G0129G0129G0130G0130G0141G0141G0143G0143G0143G0144G0144G0144G0145G0145G0145G0147G0147G0148G0148G0151G0152G0153G0153G0154G0155G0156G0166G0168G0173G0173G0175G0175G0176G0176G0176

Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

Page 87

G9138G9139G9139G9139G9140G9140G9140G9140G9140G9140G9140G9140H0001H0002H0002H0003H0003H0004H0005H0006H0007H0008H0009H0010H0010H0011H0011H0012H0012H0013H0013H0014H0015H0015H0015H0015H0016H0016H0017H0017H0018H0018H0019H0019H0019H0020H0020H0021H0021H0022H0023H0023H0024H0024H0025H0025H0026H0026H0027H0027H0027

Query_110708

Page 88

H0028H0028H0028H0029H0029H0030H0031H0032H0033H0034H0035H0036H0037H0038H0039H0040H0041H0042H0043H0044H0045H0046H0047H0048H0048H0049H0050H1000H1001H1002H1003H1004H1005H1010H1011H1011H2000H2001H2010H2011H2012H2013H2014H2015H2016H2017H2018H2019H2020H2021H2022H2023H2024H2025H2026H2027H2028H2029H2030H2031H2032

Query_110708

Page 89

H2033H2034H2035H2036H2037H2037J0120J0128J0129J0130J0132J0133J0135J0150J0150J0152J0152J0170J0180J0190J0200J0205J0207J0210J0215J0220J0256J0270J0270J0270J0275J0275J0275J0278J0280J0282J0285J0287J0288J0289J0290J0295J0300J0330J0348J0350J0360J0364J0365J0380J0390J0395J0400J0456J0460J0470J0475J0476J0480J0500J0515

Query_110708

Page 90

J0520J0530J0530J0540J0540J0550J0550J0560J0570J0580J0583J0585J0587J0592J0594J0595J0600J0610J0620J0630J0636J0637J0640J0641J0670J0690J0692J0694J0696J0697J0698J0702J0704J0706J0710J0713J0715J0720J0725J0735J0740J0743J0744J0745J0760J0770J0780J0795J0800J0835J0850J0878J0880J0881J0882J0885J0886J0894J0895J0900J0945

Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

Page 101

J9265J9266J9268J9270J9280J9290J9291J9293J9300J9303J9305J9310J9320J9330J9340J9350J9355J9357J9360J9370J9375J9380J9390J9395J9600J9999K0001K0002K0003K0004K0005K0006K0007K0009K0010K0011K0011K0011K0012K0014K0015K0017K0018K0019K0020K0037K0038K0039K0040K0041K0042K0043K0044K0045K0046K0047K0050K0051K0052K0053K0056

Query_110708

Page 102

K0056K0064K0065K0066K0067K0068K0069K0070K0071K0072K0073K0074K0075K0076K0077K0078K0090K0091K0091K0092K0093K0093K0094K0095K0096K0097K0098K0099K0102K0104K0105K0106K0108K0195K0415K0415K0416K0416K0452K0455K0455K0462K0552K0553K0553K0554K0555K0600K0600K0600K0601K0601K0602K0602K0603K0603K0604K0604K0605K0605K0606

Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

Page 107

K0859K0860K0860K0861K0861K0862K0862K0863K0863K0864K0864K0868K0868K0869K0869K0870K0870K0871K0871K0877K0877K0878K0878K0879K0879K0880K0880K0884K0884K0885K0885K0886K0886K0890K0890K0891K0891K0898K0899L0100L0100L0110L0112L0112L0113L0113L0120L0130L0140L0150L0150L0160L0170L0172L0174L0174L0180L0190L0190L0200L0200

Query_110708

Page 108

L0210L0220L0430L0430L0450L0450L0450L0450L0452L0452L0452L0454L0454L0454L0454L0454L0456L0456L0456L0456L0456L0456L0458L0458L0458L0458L0458L0458L0458L0460L0460L0460L0460L0460L0460L0460L0462L0462L0462L0462L0462L0462L0462L0464L0464L0464L0464L0464L0464L0464L0466L0466L0466L0466L0466L0468L0468L0468L0468L0468L0468

Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

Page 135


Query_110708

Page 136

L8695L8699L9900L9900M0064M0064M0064M0075M0076M0100M0300M0301P2028P2029P2031P2033P2038P3000P3000P3001P3001P7001P9010P9011P9012P9016P9017P9017P9019P9020P9021P9022P9023P9031P9032P9033P9034P9035P9036P9037P9038P9039P9040P9041P9043P9044P9045P9046P9047P9048P9050P9051P9052P9053P9054P9054P9055P9056P9057P9057P9058

Query_110708

Page 137

P9059P9060P9603P9603P9603P9604P9604P9604P9612P9612P9615Q0035Q0081Q0083Q0083Q0084Q0085Q0085Q0091Q0091Q0092Q0111Q0112Q0113Q0114Q0115Q0136Q0137Q0144Q0163Q0163Q0163Q0164Q0164Q0164Q0165Q0165Q0165Q0166Q0166Q0166Q0167Q0167Q0167Q0168Q0168Q0168Q0169Q0169Q0169Q0170Q0170Q0170Q0171Q0171Q0171Q0172Q0172Q0172Q0173Q0173

Query_110708

Page 138

Q0173Q0174Q0174Q0174Q0175Q0175Q0175Q0176Q0176Q0176Q0177Q0177Q0177Q0178Q0178Q0178Q0179Q0179Q0179Q0180Q0180Q0180Q0181Q0181Q0181Q0187Q0480Q0481Q0481Q0482Q0482Q0483Q0483Q0484Q0484Q0485Q0485Q0486Q0486Q0487Q0487Q0488Q0488Q0489Q0489Q0490Q0490Q0491Q0491Q0492Q0492Q0493Q0493Q0494Q0494Q0495Q0495Q0496Q0496Q0497Q0497

Query_110708

Page 139


Query_110708

Page 140


Query_110708

Page 141


Query_110708

Page 142

Q4107Q4108Q4109Q4110Q4111Q4112Q4113Q4114Q5001Q5002Q5003Q5003Q5004Q5005Q5006Q5007Q5008Q5009Q9941Q9942Q9943Q9944Q9945Q9946Q9947Q9948Q9949Q9950Q9951Q9952Q9953Q9954Q9955Q9956Q9957Q9958Q9959Q9960Q9961Q9962Q9963Q9964Q9964Q9965Q9966Q9967R0070R0070R0075R0075R0076S0012S0014S0016S0017S0020S0021S0023S0028S0030S0032

Query_110708

Page 143

S0034S0039S0040S0071S0072S0073S0074S0077S0078S0080S0081S0088S0090S0091S0091S0092S0093S0104S0106S0107S0108S0109S0114S0116S0117S0118S0122S0126S0128S0132S0133S0136S0137S0138S0139S0140S0141S0142S0142S0143S0143S0145S0146S0147S0155S0156S0157S0158S0159S0160S0161S0162S0164S0166S0167S0168S0170S0171S0172S0173S0174

Query_110708

Page 144


Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

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Query_110708

Page 158

S9559S9559S9559S9560S9560S9560S9560S9562S9562S9562S9590S9590S9590S9590S9810S9810S9810S9900S9900S9900S9970S9975S9976S9977S9981S9982S9986S9986S9988S9989S9989S9990S9991S9992S9992S9992S9994S9994S9996S9999T1000T1001T1002T1003T1004T1005T1006T1007T1007T1009T1009T1010T1010T1012T1013T1014T1015T1016T1017T1018T1019

Query_110708

Page 159

T1019T1019T1019T1020T1020T1020T1020T1021T1022T1022T1023T1023T1023T1024T1024T1025T1025T1025T1026T1026T1026T1027T1028T1028T1029T1029T1030T1031T1502T1502T1503T1503T1999T1999T2001T2002T2003T2004T2005T2006T2007T2007T2010T2010T2011T2011T2012T2013T2014T2015T2016T2017T2018T2019T2020T2021T2022T2023T2024T2025T2026

Query_110708

Page 160

T2027T2028T2029T2030T2031T2032T2033T2034T2035T2035T2036T2037T2038T2039T2040T2041T2042T2043T2044T2045T2046T2048T2048T2048T2049T2101T4521T4522T4523T4524T4525T4525T4526T4526T4527T4527T4528T4528T4529T4529T4530T4531T4531T4532T4532T4533T4534T4535T4536T4537T4538T4539T4540T4541T4542T4543T5001T5999V2020V2025V2100

Query_110708

Page 161

V2101V2102V2103V2103V2104V2104V2105V2105V2106V2106V2107V2107V2108V2108V2109V2109V2110V2110V2111V2111V2112V2112V2113V2113V2114V2115V2118V2121V2199V2200V2201V2202V2203V2203V2204V2204V2205V2205V2206V2206V2207V2207V2208V2208V2209V2209V2210V2210V2211V2211V2212V2212V2213V2213V2214V2215V2218V2219V2220V2221V2299

Query_110708

Page 162


Query_110708

Page 163


Query_110708

Page 164

V5230V5240V5241V5242V5243V5244V5245V5246V5247V5248V5249V5250V5251V5252V5253V5254V5255V5256V5257V5258V5259V5260V5261V5262V5263V5264V5265V5266V5267V5268V5269V5270V5271V5272V5273V5274V5275V5298V5299V5336V5336V5362V5363V5364

Query_110708

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HCPCS CODES FOR 2009IMPORTANT NOTE: CURRENT AND OLD CODES LISTED. SEE DATES IN COLUMNS AT, AU, AND AV.PUBLISHER: CENTERS FOR MEDICARE & MEDICARE SERVICES.DATA NON-ESSENTIAL TO MOST HOME IV PROVIDERS IS HIDDEN BY NATIONAL HOME INFUSION ASSOCIATION.

Long DescriptionDRESSING FOR ONE WOUNDDRESSING FOR TWO WOUNDSDRESSING FOR THREE WOUNDSDRESSING FOR FOUR WOUNDSDRESSING FOR FIVE WOUNDSDRESSING FOR SIX WOUNDSDRESSING FOR SEVEN WOUNDSDRESSING FOR EIGHT WOUNDSDRESSING FOR NINE OR MORE WOUNDSANESTHESIA SERVICES PERFORMED PERSONALLY BY ANESTHESIOLOGISTMEDICAL SUPERVISION BY A PHYSICIAN: MORE THAN FOUR CONCURRENT ANESTHESIAPROCEDURESREGISTERED DIETICIANSPECIALTY PHYSICIANPRIMARY PHYSICIANCLINICAL PSYCHOLOGISTCLINICAL SOCIAL WORKERNON PARTICIPATING PHYSICIANPHYSICIAN, TEAM MEMBER SERVICEDETERMINATION OF REFRACTIVE STATE WAS NOT PERFORMED IN THE COURSE OF DIAGNOSTICOPHTHALMOLOGICAL EXAMINATIONPHYSICIAN PROVIDING A SERVICE IN AN UNLISTED HEALTH PROFESSIONAL SHORTAGE AREA(HPSA)PHYSICIAN PROVIDER SERVICES IN A PHYSICIAN SCARCITY AREAPHYSICIAN ASSISTANT, NURSE PRACTITIONER, OR CLINICAL NURSE SPECIALIST SERVICESFOR ASSISTANT AT SURGERYACUTE TREATMENT (THIS MODIFIER SHOULD BE USED WHEN REPORTING SERVICE 98940,98941, 98942)ITEM FURNISHED IN CONJUNCTION WITH A UROLOGICAL, OSTOMY, OR TRACHEOSTOMY SUPPLYITEM FURNISHED IN CONJUNCTION WITH A PROSTHETIC DEVICE, PROSTHETIC OR ORTHOTICITEM FURNISHED IN CONJUNCTION WITH A SURGICAL DRESSINGITEM FURNISHED IN CONJUNCTION WITH DIALYSIS SERVICESITEM FURNISHED IN CONJUNCTION WITH PARENTERAL ENTERAL NUTRITION (PEN) SERVICESSPECIAL ACQUISITION OF BLOOD AND BLOOD PRODUCTSORALLY ADMINISTERED NUTRITION, NOT BY FEEDING TUBETHE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND HASELECTED TO PURCHASE THE ITEMTHE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND HASELECTED TO RENT THE ITEMTHE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND AFTER30 DAYS HAS NOT INFORMED THE SUPPLIER OF HIS/HER DECISIONPROCEDURE PAYABLE ONLY IN THE INPATIENT SETTING WHEN PERFORMED EMERGENTLY ON ANOUTPATIENT WHO EXPIRES PRIOR TO ADMISSIONSERVICE ORDERED BY A RENAL DIALYSIS FACILITY (RDF) PHYSICIAN AS PART OF THEESRD BENEFICIARY'S DIALYSIS BENEFIT, IS NOT PART OF THE COMPOSITE RATE, AND ISSEPARATELY REIMBURSABLEPROCEDURE CODE CHANGE (USE 'CC' WHEN THE PROCEDURE CODE SUBMITTED WAS CHANGEDEITHER FOR ADMINISTRATIVE REASONS OR BECAUSE AN INCORRECT CODE WAS FILED)AMCC TEST HAS BEEN ORDERED BY AN ESRD FACILITY OR MCP PHYSICIAN THAT IS PART OFTHE COMPOSITE RATE AND IS NOT SEPARATELY BILLABLEAMCC TEST HAS BEEN ORDERED BY AN ESRD FACILITY OR MCP PHYSICIAN THAT IS ACOMPOSITE RATE TEST BUT IS BEYOND THE NORMAL FREQUENCY COVERED UNDER THE RATEAND IS SEPARATELY REIMBURSABLE BASED ON MEDICAL NECESSITYAMCC TEST HAS BEEN ORDERED BY AN ESRD FACILITY OR MCP PHYSICIAN THAT IS NOTPART OF THE COMPOSITE RATE AND IS SEPARATELY BILLABLE

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POLICY CRITERIA APPLIEDCATASTROPHE/DISASTER RELATEDUPPER LEFT, EYELIDLOWER LEFT, EYELIDUPPER RIGHT, EYELIDLOWER RIGHT, EYELIDERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TOANTI-CANCER CHEMOTHERAPYERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TOANTI-CANCER RADIOTHERAPYERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA NOT DUE TOANTI-CANCER RADIOTHERAPY OR ANTI-CANCER CHEMOTHERAPYHEMATOCRIT LEVEL HAS EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS EXCEEDED 13.0 G/DL)FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELY PRIOR TO AND INCLUDING THECURRENT CYCLEHEMATOCRIT LEVEL HAS NOT EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS NOT EXCEEDED13.0 G/DL) FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELY PRIOR TO ANDINCLUDING THE CURRENT CYCLESUBSEQUENT CLAIMS FOR A DEFINED COURSE OF THERAPY, E.G., EPO, SODIUMHYALURONATE, INFLIXIMABEMERGENCY RESERVE SUPPLY (FOR ESRD BENEFIT ONLY)SERVICE PROVIDED AS PART OF MEDICAID EARLY PERIODIC SCREENING DIAGNOSIS ANDTREATMENT (EPSDT) PROGRAMEMERGENCY SERVICESNO PHYSICIAN OR OTHER LICENSED HEALTH CARE PROVIDER ORDER FOR THIS ITEM ORSERVICELEFT HAND, SECOND DIGITLEFT HAND, THIRD DIGITLEFT HAND, FOURTH DIGITLEFT HAND, FIFTH DIGITRIGHT HAND, THUMBRIGHT HAND, SECOND DIGITRIGHT HAND, THIRD DIGITRIGHT HAND, FOURTH DIGITRIGHT HAND, FIFTH DIGITLEFT HAND, THUMBITEM PROVIDED WITHOUT COST TO PROVIDER, SUPPLIER OR PRACTITIONER, OR FULLCREDIT RECEIVED FOR REPLACED DEVICE (EXAMPLES, BUT NOT LIMITED TO, COVEREDUNDER WARRANTY, REPLACED DUE TO DEFECT, FREE SAMPLES)PARTIAL CREDIT RECEIVED FOR REPLACED DEVICESERVICE PROVIDED AS PART OF FAMILY PLANNING PROGRAMMOST RECENT URR READING OF LESS THAN 60MOST RECENT URR READING OF 60 TO 64.9MOST RECENT URR READING OF 65 TO 69.9MOST RECENT URR READING OF 70 TO 74.9MOST RECENT URR READING OF 75 OR GREATERESRD PATIENT FOR WHOM LESS THAN SIX DIALYSIS SESSIONS HAVE BEEN PROVIDED IN AMONTHPREGNANCY RESULTED FROM RAPE OR INCEST OR PREGNANCY CERTIFIED BY PHYSICIAN ASLIFE THREATENINGMONITORED ANESTHESIA CARE (MAC) FOR DEEP COMPLEX, COMPLICATED, OR MARKEDLYINVASIVE SURGICAL PROCEDUREMONITORED ANESTHESIA CARE FOR PATIENT WHO HAS HISTORY OF SEVERECARDIO-PULMONARY CONDITIONWAIVER OF LIABILITY STATEMENT ON FILECLAIM BEING RE-SUBMITTED FOR PAYMENT BECAUSE IT IS NO LONGER COVERED UNDER AGLOBAL PAYMENT DEMONSTRATIONTHIS SERVICE HAS BEEN PERFORMED IN PART BY A RESIDENT UNDER THE DIRECTION OF ATEACHING PHYSICIANUNITS OF SERVICE EXCEEDS MEDICALLY UNLIKELY EDIT VALUE AND REPRESENTSREASONABLE AND NECESSARY SERVICES

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Page 167

THIS SERVICE HAS BEEN PERFORMED BY A RESIDENT WITHOUT THE PRESENCE OF ATEACHING PHYSICIAN UNDER THE PRIMARY CARE EXCEPTIONNON-PHYSICIAN (E.G. NURSE PRACTITIONER (NP), CERTIFIED REGISTERED NURSEANESTHETIST (CRNA), CERTIFIED REGISTERED NURSE (CRN), CLINICAL NURSE SPECIALIST(CNS), PHYSICIAN ASSISTANT (PA)) SERVICES IN A CRITICAL ACCESS HOSPITALPERFORMANCE AND PAYMENT OF A SCREENING MAMMOGRAM AND DIAGNOSTIC MAMMOGRAM ONTHE SAME PATIENT, SAME DAYDIAGNOSTIC MAMMOGRAM CONVERTED FROM SCREENING MAMMOGRAM ON SAME DAY"OPT OUT" PHYSICIAN OR PRACTITIONER EMERGENCY OR URGENT SERVICEREASONABLE AND NECESSARY ITEM/SERVICE ASSOCIATED WITH A GA OR GZ MODIFIERMEDICALLY UNNECESSARY UPGRADE PROVIDED INSTEAD OF NON-UPGRADED ITEM, NO CHARGE,NO ADVANCE BENEFICIARY NOTICE (ABN)MULTIPLE PATIENTS ON ONE AMBULANCE TRIPSERVICES DELIVERED UNDER AN OUTPATIENT SPEECH LANGUAGE PATHOLOGY PLAN OF CARESERVICES DELIVERED UNDER AN OUTPATIENT OCCUPATIONAL THERAPY PLAN OF CARESERVICES DELIVERED UNDER AN OUTPATIENT PHYSICAL THERAPY PLAN OF CAREVIA ASYNCHRONOUS TELECOMMUNICATIONS SYSTEMTHIS SERVICE WAS PERFORMED IN WHOLE OR IN PART BY A RESIDENT IN A DEPARTMENT OFVETERANS AFFAIRS MEDICAL CENTER OR CLINIC, SUPERVISED IN ACCORDANCE WITH VAPOLICYDOSAGE OF EPO OR DARBEPOIETIN ALFA HAS BEEN REDUCED AND MAINTAINED IN RESPONSETO HEMATOCRIT OR HEMOGLOBIN LEVELVIA INTERACTIVE AUDIO AND VIDEO TELECOMMUNICATION SYSTEMSATTENDING PHYSICIAN NOT EMPLOYED OR PAID UNDER ARRANGEMENT BY THE PATIENT'SHOSPICE PROVIDERSERVICE NOT RELATED TO THE HOSPICE PATIENT'S TERMINAL CONDITIONITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANYMEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFITITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE AND NECESSARYCOURT-ORDEREDCHILD/ADOLESCENT PROGRAMADULT PROGRAM, NON GERIATRICADULT PROGRAM, GERIATRICPREGNANT/PARENTING WOMEN'S PROGRAMMENTAL HEALTH PROGRAMSUBSTANCE ABUSE PROGRAMOPIOID ADDICTION TREATMENT PROGRAMINTEGRATED MENTAL HEALTH/SUBSTANCE ABUSE PROGRAMINTEGRATED MENTAL HEALTH AND MENTAL RETARDATION/DEVELOPMENTAL DISABILITIESPROGRAMEMPLOYEE ASSISTANCE PROGRAMSPECIALIZED MENTAL HEALTH PROGRAMS FOR HIGH-RISK POPULATIONSINTERNLESS THAN BACHELOR DEGREE LEVELBACHELORS DEGREE LEVELMASTERS DEGREE LEVELDOCTORAL LEVELGROUP SETTINGFAMILY/COUPLE WITH CLIENT PRESENTFAMILY/COUPLE WITHOUT CLIENT PRESENTMULTI-DISCIPLINARY TEAMFUNDED BY CHILD WELFARE AGENCYFUNDED STATE ADDICTIONS AGENCYFUNDED BY STATE MENTAL HEALTH AGENCYFUNDED BY COUNTY/LOCAL AGENCYFUNDED BY JUVENILE JUSTICE AGENCYFUNDED BY CRIMINAL JUSTICE AGENCYCOMPETITIVE ACQUISITION PROGRAM NO-PAY SUBMISSION FOR A PRESCRIPTION NUMBERCOMPETITIVE ACQUISITION PROGRAM, RESTOCKING OF EMERGENCY DRUGS AFTER EMERGENCYADMINISTRATIONCOMPETITIVE ACQUISITION PROGRAM (CAP), DRUG NOT AVAILABLE THROUGH CAP AS

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Page 168

WRITTEN, REIMBURSED UNDER AVERAGE SALES PRICE METHODOLOGYADMINISTERED INTRAVENOUSLYADMINISTERED SUBCUTANEOUSLYSKIN SUBSTITUTE USED AS A GRAFTSKIN SUBSTITUTE NOT USED AS A GRAFTDRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENTLOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 0 - DOES NOT HAVE THE ABILITY ORPOTENTIAL TO AMBULATE OR TRANSFER SAFELY WITH OR WITHOUT ASSISTANCE AND APROSTHESIS DOES NOT ENHANCE THEIR QUALITY OF LIFE OR MOBILITY.LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 1 - HAS THE ABILITY OR POTENTIAL TOUSE A PROSTHESIS FOR TRANSFERS OR AMBULATION ON LEVEL SURFACES AT FIXEDCADENCE. TYPICAL OF THE LIMITED AND UNLIMITED HOUSEHOLD AMBULATOR.LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 2 - HAS THE ABILITY OR POTENTIALFOR AMBULATION WITH THE ABILITY TO TRAVERSE LOW LEVEL ENVIRONMENTAL BARRIERSSUCH AS CURBS, STAIRS OR UNEVEN SURFACES. TYPICAL OF THE LIMITED COMMUNITYAMBULATOR.LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 3 - HAS THE ABILITY OR POTENTIALFOR AMBULATION WITH VARIABLE CADENCE. TYPICAL OF THE COMMUNITY AMBULATOR WHOHAS THE ABILITY TO TRANSVERSE MOST ENVIRONMENTAL BARRIERS AND MAY HAVEVOCATIONAL, THERAPEUTIC, OR EXERCISE ACTIVITY THAT DEMANDS PROSTHETICUTILIZATION BEYOND SIMPLE LOCOMOTION.LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 4 - HAS THE ABILITY OR POTENTIALFOR PROSTHETIC AMBULATION THAT EXCEEDS THE BASIC AMBULATION SKILLS, EXHIBITINGHIGH IMPACT, STRESS, OR ENERGY LEVELS, TYPICAL OF THE PROSTHETIC DEMANDS OF THECHILD, ACTIVE ADULT, OR ATHLETE.ADD ON OPTION/ACCESSORY FOR WHEELCHAIRBENEFICIARY REQUESTED UPGRADE FOR ABN, MORE THAN 4 MODIFIERS IDENTIFIED ON CLAIMREPLACEMENT OF SPECIAL POWER WHEELCHAIR INTERFACEDRUG OR BIOLOGICAL INFUSED THROUGH DMEBID UNDER ROUND ONE OF THE DMEPOS COMPETITIVE BIDDING PROGRAM FOR USE WITHNON-COMPETITIVE BID BASE EQUIPMENTITEM DESIGNATED BY FDA AS CLASS III DEVICEDMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 1DMEPOS ITEM, INITIAL CLAIM, PURCHASE OR FIRST MONTH RENTALDMEPOS ITEM, SECOND OR THIRD MONTH RENTALDMEPOS ITEM, PARENTERAL ENTERAL NUTRITION (PEN) PUMP OR CAPPED RENTAL, MONTHSFOUR TO FIFTEENDMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 2DMEPOS ITEM DELIVERED VIA MAILREPLACEMENT OF FACIAL PROSTHESIS INCLUDING NEW IMPRESSION/MOULAGEREPLACEMENT OF FACIAL PROSTHESIS USING PREVIOUS MASTER MODELSINGLE DRUG UNIT DOSE FORMULATIONFIRST DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATIONSECOND OR SUBSEQUENT DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATIONRENTAL ITEM, BILLING FOR PARTIAL MONTHGLUCOSE MONITOR SUPPLY FOR DIABETIC BENEFICIARY NOT TREATED WITH INSULINBENEFICIARY RESIDES IN A COMPETITIVE BIDDING AREA AND TRAVELS OUTSIDE THATCOMPETITIVE BIDDING AREA AND RECEIVES A COMPETITIVE BID ITEMDMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 3DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM THAT IS FURNISHED ASPART OF A PROFESSIONAL SERVICEDMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 4REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN METDMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 5NEW COVERAGE NOT IMPLEMENTED BY MANAGED CARELEFT CIRCUMFLEX CORONARY ARTERYLEFT ANTERIOR DESCENDING CORONARY ARTERYLEASE/RENTAL (USE THE 'LL' MODIFIER WHEN DME EQUIPMENT RENTAL IS TO BE APPLIEDAGAINST THE PURCHASE PRICE)LABORATORY ROUND TRIPFDA-MONITORED INTRAOCULAR LENS IMPLANT

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Page 169

LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY)MEDICARE SECONDARY PAYER (MSP)SIX MONTH MAINTENANCE AND SERVICING FEE FOR REASONABLE AND NECESSARY PARTS ANDLABOR WHICH ARE NOT COVERED UNDER ANY MANUFACTURER OR SUPPLIER WARRANTYNEW WHEN RENTED (USE THE 'NR' MODIFIER WHEN DME WHICH WAS NEW AT THE TIME OFRENTAL IS SUBSEQUENTLY PURCHASED)NEW EQUIPMENTA NORMAL HEALTHY PATIENTA PATIENT WITH MILD SYSTEMIC DISEASEA PATIENT WITH SEVERE SYSTEMIC DISEASEA PATIENT WITH SEVERE SYSTEMIC DISEASE THAT IS A CONSTANT THREAT TO LIFEA MORIBUND PATIENT WHO IS NOT EXPECTED TO SURVIVE WITHOUT THE OPERATIONA DECLARED BRAIN-DEAD PATIENT WHOSE ORGANS ARE BEING REMOVED FOR DONOR PURPOSESPROGRESSIVE ADDITION LENSESINVESTIGATIONAL CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT ISIN AN APPROVED CLINICAL RESEARCH STUDYROUTINE CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN ANAPPROVED CLINICAL RESEARCH STUDYHCFA/ORD DEMONSTRATION PROJECT PROCEDURE/SERVICELIVE KIDNEY DONOR SURGERY AND RELATED SERVICESSERVICE FOR ORDERING/REFERRING PHYSICIAN QUALIFIES AS A SERVICE EXEMPTIONSERVICE FURNISHED BY A SUBSTITUTE PHYSICIAN UNDER A RECIPROCAL BILLINGARRANGEMENTSERVICE FURNISHED BY A LOCUM TENENS PHYSICIANONE CLASS A FINDINGTWO CLASS B FINDINGSONE CLASS B AND TWO CLASS C FINDINGSFDA INVESTIGATIONAL DEVICE EXEMPTIONPHYSICIAN PROVIDING SERVICE IN A RURAL HPSASINGLE CHANNEL MONITORINGRECORDING AND STORAGE IN SOLID STATE MEMORY BY A DIGITAL RECORDERPRESCRIBED AMOUNT OF OXYGEN IS LESS THAN 1 LITER PER MINUTE (LPM)PRESCRIBED AMOUNT OF OXYGEN EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLEOXYGEN IS PRESCRIBEDPRESCRIBED AMOUNT OF OXYGEN IS GREATER THAN 4 LITERS PER MINUTE(LPM)OXYGEN CONSERVING DEVICE IS BEING USED WITH AN OXYGEN DELIVERY SYSTEMSERVICES/ITEMS PROVIDED TO A PRISONER OR PATIENT IN STATE OR LOCAL CUSTODY,HOWEVER THE STATE OR LOCAL GOVERNMENT, AS APPLICABLE, MEETS THE REQUIREMENTS IN42 CFR 411.4 (B)MEDICAL DIRECTION OF TWO, THREE, OR FOUR CONCURRENT ANESTHESIA PROCEDURESINVOLVING QUALIFIED INDIVIDUALSPATIENT PRONOUNCED DEAD AFTER AMBULANCE CALLEDAMBULANCE SERVICE PROVIDED UNDER ARRANGEMENT BY A PROVIDER OF SERVICESAMBULANCE SERVICE FURNISHED DIRECTLY BY A PROVIDER OF SERVICESDOCUMENTATION IS ON FILE SHOWING THAT THE LABORATORY TEST(S) WAS ORDEREDINDIVIDUALLY OR ORDERED AS A CPT-RECOGNIZED PANEL OTHER THAN AUTOMATED PROFILECODES 80002-80019, G0058, G0059, AND G0060.CLAIM SUBMITTED WITH A WRITTEN STATEMENT OF INTENTITEM OR SERVICE PROVIDED IN A MEDICARE SPECIFIED STUDYMONITORED ANESTHESIA CARE SERVICERECORDING AND STORAGE ON TAPE BY AN ANALOG TAPE RECORDERPHYSICIAN PROVIDING SERVICE IN AN URBAN HPSAITEM OR SERVICE PROVIDED AS ROUTINE CARE IN A MEDICARE QUALIFYING CLINICAL TRIALCLIA WAIVED TESTCRNA SERVICE: WITH MEDICAL DIRECTION BY A PHYSICIANMEDICAL DIRECTION OF ONE CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) BY ANANESTHESIOLOGISTCRNA SERVICE: WITHOUT MEDICAL DIRECTION BY A PHYSICIANREPLACEMENT OF A DME ITEMREPLACEMENT OF A PART OF DME FURNISHED AS PART OF A REPAIRRIGHT CORONARY ARTERY

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DRUG PROVIDED TO BENEFICIARY, BUT NOT ADMINISTERED "INCIDENT-TO"FURNISHED IN FULL COMPLIANCE WITH FDA-MANDATED RISK EVALUATION AND MITIGATIONSTRATEGY (REMS)REPLACEMENT AND REPAIR -RP MAY BE USED TO INDICATE REPLACEMENT OF DME, ORTHOTICAND PROSTHETIC DEVICES WHICH HAVE BEEN IN USE FOR SOMETIME. THE CLAIM SHOWSTHE CODE FOR THE PART, FOLLOWED BY THE 'RP' MODIFIER AND THE CHARGE FOR THEPART.RENTAL (USE THE 'RR' MODIFIER WHEN DME IS TO BE RENTED)RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY)NURSE PRACTITIONER RENDERING SERVICE IN COLLABORATION WITH A PHYSICIANNURSE MIDWIFEMEDICALLY NECESSARY SERVICE OR SUPPLYSERVICES PROVIDED BY REGISTERED NURSE WITH SPECIALIZED, HIGHLY TECHNICAL HOMEINFUSION TRAININGSTATE AND/OR FEDERALLY-FUNDED PROGRAMS/SERVICESSECOND OPINION ORDERED BY A PROFESSIONAL REVIEW ORGANIZATION (PRO) PER SECTION9401, P.L. 99-272 (100% REIMBURSEMENT - NO MEDICARE DEDUCTIBLE OR COINSURANCE)AMBULATORY SURGICAL CENTER (ASC) FACILITY SERVICESECOND CONCURRENTLY ADMINISTERED INFUSION THERAPYTHIRD OR MORE CONCURRENTLY ADMINISTERED INFUSION THERAPYMEMBER OF HIGH RISK POPULATION (USE ONLY WITH CODES FOR IMMUNIZATION)STATE SUPPLIED VACCINESECOND SURGICAL OPINIONTHIRD SURGICAL OPINIONITEM ORDERED BY HOME HEALTHHOME INFUSION SERVICES PROVIDED IN THE INFUSION SUITE OF THE IV THERAPY PROVIDERRELATED TO TRAUMA OR INJURYPROCEDURE PERFORMED IN PHYSICIAN'S OFFICE (TO DENOTE USE OF FACILITY ANDEQUIPMENT)PHARMACEUTICALS DELIVERED TO PATIENT'S HOME BUT NOT UTILIZEDSERVICES PROVIDED BY A CERTIFIED DIABETIC EDUCATORPERSONS WHO ARE IN CLOSE CONTACT WITH MEMBER OF HIGH-RISK POPULATION (USE ONLYWITH CODES FOR IMMUNIZATION)LEFT FOOT, SECOND DIGITLEFT FOOT, THIRD DIGITLEFT FOOT, FOURTH DIGITLEFT FOOT, FIFTH DIGITRIGHT FOOT, GREAT TOERIGHT FOOT, SECOND DIGITRIGHT FOOT, THIRD DIGITRIGHT FOOT, FOURTH DIGITRIGHT FOOT, FIFTH DIGITLEFT FOOT, GREAT TOETECHNICAL COMPONENT. UNDER CERTAIN CIRCUMSTANCES, A CHARGE MAY BE MADE FOR THETECHNICAL COMPONENT ALONE. UNDER THOSE CIRCUMSTANCES THE TECHNICAL COMPONENTCHARGE IS IDENTIFIED BY ADDING MODIFIER 'TC' TO THE USUAL PROCEDURE NUMBER.TECHNICAL COMPONENT CHARGES ARE INSTITUTIONAL CHARGES AND NOT BILLED SEPARATELYBY PHYSICIANS. HOWEVER, PORTABLE X-RAY SUPPLIERS ONLY BILL FOR TECHNICALCOMPONENT AND SHOULD UTILIZE MODIFIER TC. THE CHARGE DATA FROM PORTABLE X-RAYSUPPLIERS WILL THEN BE USED TO BUILD CUSTOMARY AND PREVAILING PROFILES.RNLPN/LVNINTERMEDIATE LEVEL OF CARECOMPLEX/HIGH TECH LEVEL OF CAREOBSTETRICAL TREATMENT/SERVICES, PRENATAL OR POSTPARTUMPROGRAM GROUP, CHILD AND/OR ADOLESCENTEXTRA PATIENT OR PASSENGER, NON-AMBULANCEEARLY INTERVENTION/INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP)INDIVIDUALIZED EDUCATION PROGRAM (IEP)RURAL/OUTSIDE PROVIDERS' CUSTOMARY SERVICE AREAMEDICAL TRANSPORT, UNLOADED VEHICLE

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BASIC LIFE SUPPORT TRANSPORT BY A VOLUNTEER AMBULANCE PROVIDERSCHOOL-BASED INDIVIDUALIZED EDUCATION PROGRAM (IEP) SERVICES PROVIDED OUTSIDETHE PUBLIC SCHOOL DISTRICT RESPONSIBLE FOR THE STUDENTFOLLOW-UP SERVICEINDIVIDUALIZED SERVICE PROVIDED TO MORE THAN ONE PATIENT IN SAME SETTINGSPECIAL PAYMENT RATE, OVERTIMESPECIAL PAYMENT RATES, HOLIDAYS/WEEKENDSBACK-UP EQUIPMENTMEDICAID LEVEL OF CARE 1, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 2, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 3, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 4, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 5, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 6, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 7, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 8, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 9, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 10, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 11, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 12, AS DEFINED BY EACH STATEMEDICAID LEVEL OF CARE 13, AS DEFINED BY EACH STATEUSED DURABLE MEDICAL EQUIPMENTSERVICES PROVIDED IN THE MORNINGSERVICES PROVIDED IN THE AFTERNOONSERVICES PROVIDED IN THE EVENINGSERVICES PROVIDED AT NIGHTSERVICES PROVIDED ON BEHALF OF THE CLIENT TO SOMEONE OTHER THAN THE CLIENT(COLLATERAL RELATIONSHIP)TWO PATIENTS SERVEDTHREE PATIENTS SERVEDFOUR PATIENTS SERVEDFIVE PATIENTS SERVEDSIX OR MORE PATIENTS SERVEDAPHAKIC PATIENTAMBULANCE SERVICE, OUTSIDE STATE PER MILE, TRANSPORT (MEDICAID ONLY)NON-EMERGENCY TRANSPORTATION, PER MILE - VEHICLE PROVIDED BY VOLUNTEER(INDIVIDUAL OR ORGANIZATION), WITH NO VESTED INTERESTNON-EMERGENCY TRANSPORTATION, PER MILE - VEHICLE PROVIDED BY INDIVIDUAL (FAMILYMEMBER, SELF, NEIGHBOR) WITH VESTED INTERESTNON-EMERGENCY TRANSPORTATION; TAXINON-EMERGENCY TRANSPORTATION AND BUS, INTRA OR INTER STATE CARRIERNON-EMERGENCY TRANSPORTATION: MINI-BUS, MOUNTAIN AREA TRANSPORTS, OR OTHERTRANSPORTATION SYSTEMSNON-EMERGENCY TRANSPORTATION: WHEEL-CHAIR VANNON-EMERGENCY TRANSPORTATION AND AIR TRAVEL (PRIVATE OR COMMERCIAL) INTRA ORINTER STATENON-EMERGENCY TRANSPORTATION: PER MILE - CASE WORKER OR SOCIAL WORKERTRANSPORTATION ANCILLARY: PARKING FEES, TOLLS, OTHERNON-EMERGENCY TRANSPORTATION: ANCILLARY: LODGING-RECIPIENTNON-EMERGENCY TRANSPORTATION: ANCILLARY: MEALS-RECIPIENTNON-EMERGENCY TRANSPORTATION: ANCILLARY: LODGING ESCORTNON-EMERGENCY TRANSPORTATION: ANCILLARY: MEALS-ESCORTAMBULANCE SERVICE, NEONATAL TRANSPORT, BASE RATE, EMERGENCY TRANSPORT, ONE WAYBLS MILEAGE (PER MILE)BLS ROUTINE DISPOSABLE SUPPLIESBLS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; DEFIBRILLATION (USED BY ALSAMBULANCES AND BLS AMBULANCES IN JURISDICTIONS WHERE DEFIBRILLATION ISPERMITTED IN BLS AMBULANCES)ALS MILEAGE (PER MILE)ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; DEFIBRILLATION (TO BE USED ONLY INJURISDICTIONS WHERE DEFIBRILLATION CANNOT BE PERFORMED IN BLS AMBULANCES)

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Page 172

ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; IV DRUG THERAPYALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; ESOPHAGEAL INTUBATIONALS ROUTINE DISPOSABLE SUPPLIESAMBULANCE WAITING TIME (ALS OR BLS), ONE HALF (1/2) HOUR INCREMENTSAMBULANCE (ALS OR BLS) OXYGEN AND OXYGEN SUPPLIES, LIFE SUSTAINING SITUATIONEXTRA AMBULANCE ATTENDANT, GROUND (ALS OR BLS) OR AIR (FIXED OR ROTARY WINGED);(REQUIRES MEDICAL REVIEW)GROUND MILEAGE, PER STATUTE MILEAMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 (ALS1)AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1(ALS1-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 VOLUNTEERAMBULANCE COMPANY WHICH IS PROHIBITED BY STATE LAW FROM BILLING THIRD PARTYPAYERSADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)SPECIALTY CARE TRANSPORT (SCT)FIXED WING AIR MILEAGE, PER STATUTE MILEROTARY WING AIR MILEAGE, PER STATUTE MILEAMBULANCE TRANSPORT PROVIDED BETWEEN THE HOURS OF 7PM AND 7AMNONCOVERED AMBULANCE MILEAGE, PER MILE (E.G., FOR MILES TRAVELED BEYOND CLOSESTAPPROPRIATE FACILITY)AMBULANCE RESPONSE AND TREATMENT, NO TRANSPORTUNLISTED AMBULANCE SERVICESYRINGE WITH NEEDLE, STERILE, 1 CC OR LESS, EACHSYRINGE WITH NEEDLE, STERILE 2CC, EACHSYRINGE WITH NEEDLE, STERILE 3CC, EACHSYRINGE WITH NEEDLE, STERILE 5CC OR GREATER, EACHNEEDLE-FREE INJECTION DEVICE, EACHSUPPLIES FOR SELF-ADMINISTERED INJECTIONSNON-CORING NEEDLE OR STYLET WITH OR WITHOUT CATHETERSYRINGE, STERILE, 20 CC OR GREATER, EACHNEEDLE, STERILE, ANY SIZE, EACHSTERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 MLSTERILE WATER/SALINE, 500 MLSTERILE SALINE OR WATER, METERED DOSE DISPENSER, 10 MLREFILL KIT FOR IMPLANTABLE INFUSION PUMPSUPPLIES FOR MAINTENANCE OF DRUG INFUSION CATHETER, PER WEEK (LIST DRUGSEPARATELY)INFUSION SUPPLIES FOR EXTERNAL DRUG INFUSION PUMP, PER CASSETTE OR BAG (LISTDRUGS SEPARATELY)INFUSION SUPPLIES NOT USED WITH EXTERNAL INFUSION PUMP, PER CASSETTE OR BAG(LIST DRUGS SEPARATELY)INFUSION SET FOR EXTERNAL INSULIN PUMP, NON NEEDLE CANNULA TYPEINFUSION SET FOR EXTERNAL INSULIN PUMP, NEEDLE TYPESYRINGE WITH NEEDLE FOR EXTERNAL INSULIN PUMP, STERILE, 3CCREPLACEMENT BATTERY, ALKALINE (OTHER THAN J CELL), FOR USE WITH MEDICALLYNECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACHREPLACEMENT BATTERY, ALKALINE, J CELL, FOR USE WITH MEDICALLY NECESSARY HOMEBLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACHREPLACEMENT BATTERY, LITHIUM, FOR USE WITH MEDICALLY NECESSARY HOME BLOODGLUCOSE MONITOR OWNED BY PATIENT, EACHREPLACEMENT BATTERY, SILVER OXIDE, FOR USE WITH MEDICALLY NECESSARY HOME BLOODGLUCOSE MONITOR OWNED BY PATIENT, EACHALCOHOL OR PEROXIDE, PER PINTALCOHOL WIPES, PER BOXBETADINE OR PHISOHEX SOLUTION, PER PINT

Query_110708

Page 173

BETADINE OR IODINE SWABS/WIPES, PER BOXCHLORHEXIDINE CONTAINING ANTISEPTIC, 1 MLURINE TEST OR REAGENT STRIPS OR TABLETS (100 TABLETS OR STRIPS)BLOOD KETONE TEST OR REAGENT STRIP, EACHBLOOD GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50STRIPSREPLACEMENT BATTERY, ANY TYPE, FOR USE WITH MEDICALLY NECESSARY HOME BLOODGLUCOSE MONITOR OWNED BY PATIENT, EACHPLATFORMS FOR HOME BLOOD GLUCOSE MONITOR, 50 PER BOXNORMAL, LOW AND HIGH CALIBRATOR SOLUTION / CHIPSREPLACEMENT LENS SHIELD CARTRIDGE FOR USE WITH LASER SKIN PIERCING DEVICE, EACHSPRING-POWERED DEVICE FOR LANCET, EACHLANCETS, PER BOX OF 100LEVONORGESTREL (CONTRACEPTIVE) IMPLANTS SYSTEM, INCLUDING IMPLANTS AND SUPPLIESCERVICAL CAP FOR CONTRACEPTIVE USETEMPORARY, ABSORBABLE LACRIMAL DUCT IMPLANT, EACHPERMANENT, LONG TERM, NON-DISSOLVABLE LACRIMAL DUCT IMPLANT, EACHPARAFFIN, PER POUNDDIAPHRAGM FOR CONTRACEPTIVE USECONTRACEPTIVE SUPPLY, CONDOM, MALE, EACHCONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EACHCONTRACEPTIVE SUPPLY, SPERMICIDE (E.G., FOAM, GEL), EACHDISPOSABLE ENDOSCOPE SHEATH, EACHADHESIVE SKIN SUPPORT ATTACHMENT FOR USE WITH EXTERNAL BREAST PROSTHESIS, EACHTUBING FOR BREAST PUMP, REPLACEMENTADAPTER FOR BREAST PUMP, REPLACEMENTCAP FOR BREAST PUMP BOTTLE, REPLACEMENTBREAST SHIELD AND SPLASH PROTECTOR FOR USE WITH BREAST PUMP, REPLACEMENTPOLYCARBONATE BOTTLE FOR USE WITH BREAST PUMP, REPLACEMENTLOCKING RING FOR BREAST PUMP, REPLACEMENTSACRAL NERVE STIMULATION TEST LEAD, EACHIMPLANTABLE ACCESS CATHETER, (E,G., VENOUS, ARTERIAL, EPIDURAL SUBARACHNOID, ORPERITONEAL, ETC.) EXTERNAL ACCESSIMPLANTABLE 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 HOURDISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOURINSERTION 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 ORHYDROPHILIC, ETC.)INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE,TWO-WAY, ALL SILICONEINSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE,THREE-WAY, FOR CONTINUOUS IRRIGATIONINSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAYLATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.)INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY,ALL SILICONEINSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE,THREE-WAY, FOR CONTINUOUS IRRIGATIONIRRIGATION TRAY WITH BULB OR PISTON SYRINGE, ANY PURPOSETHERAPEUTIC AGENT FOR URINARY CATHETER IRRIGATIONIRRIGATION SYRINGE, BULB OR PISTON, EACHMALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION CHAMBER, ANY TYPE, EACHFEMALE EXTERNAL URINARY COLLECTION DEVICE; MEATAL CUP, EACHFEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, EACHPERIANAL FECAL COLLECTION POUCH WITH ADHESIVE, EACHEXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FORUSE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACHLUBRICANT, INDIVIDUAL STERILE PACKET, EACH

Query_110708

Page 174

URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, EACHURINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACHINCONTINENCE SUPPLY; MISCELLANEOUSINDWELLING CATHETER; FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE,SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACHINDWELLING CATHETER; SPECIALTY TYPE, EG; COUDE, MUSHROOM, WING, ETC.), EACHINDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE, EACHINDWELLING CATHETER; FOLEY TYPE, THREE WAY FOR CONTINUOUS IRRIGATION, EACHMALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION COMPARTMENT, EXTENDED WEAR,EACH (E.G., 2 PER MONTH)MALE EXTERNAL CATHETER, WITH OR WITHOUT ADHESIVE, DISPOSABLE, EACHINTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON,SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACHINTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP, WITH OR WITHOUT COATING(TEFLON, SILICONE, SILICONE ELASTOMERIC, OR HYDROPHILIC, ETC.), EACHINTERMITTENT URINARY CATHETER, WITH INSERTION SUPPLIESINSERTION TRAY WITH DRAINAGE BAG BUT WITHOUT CATHETERIRRIGATION TUBING SET FOR CONTINUOUS BLADDER IRRIGATION THROUGH A THREE-WAYINDWELLING FOLEY CATHETER, EACHEXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE (NOT TO BE USED FOR CATHETERCLAMP), EACHBEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH ORWITHOUT TUBE, EACHURINARY DRAINAGE BAG, LEG OR ABDOMEN, VINYL, WITH OR WITHOUT TUBE, WITH STRAPS,EACHURINARY SUSPENSORY WITHOUT LEG BAG, EACHOSTOMY FACEPLATE, EACHSKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT; EACHOSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY, EACHADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OZADHESIVE REMOVER WIPES, ANY TYPE, PER 50OSTOMY VENT, ANY TYPE, EACHOSTOMY BELT, EACHOSTOMY FILTER, ANY TYPE, EACHOSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH, ETC), PER OZOSTOMY SKIN BARRIER, POWDER, PER OZOSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, STANDARD WEAR, WITH BUILT-INCONVEXITY, EACHOSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDIAN), WITH BUILT-INCONVEXITY, ANY SIZE, EACHOSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, PLASTIC, EACHOSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, RUBBER, EACHOSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, PLASTIC, EACHOSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, EACHOSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, EACHOSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, RUBBER, EACHOSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC, EACHOSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY PLASTIC, EACHOSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, EACHOSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EACHOSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITHOUT BUILT-INCONVEXITY, EACHOSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE),EACHOSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, (1 PIECE), EACHOSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1PIECE), EACHOSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-INCONVEXITY (1 PIECE), EACHOSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE), EACHOSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH BUILT-IN

Query_110708

Page 175

CONVEXITY (1 PIECE), EACHOSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-INCONVEXITY (1 PIECE), EACHOSTOMY DEODORANT, WITH OR WITHOUT LUBRICANT, FOR USE IN OSTOMY POUCH, PERFLUID OUNCEOSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, PER TABLETOSTOMY BELT WITH PERISTOMAL HERNIA SUPPORTIRRIGATION SUPPLY; SLEEVE, EACHOSTOMY IRRIGATION SUPPLY; BAG, EACHOSTOMY IRRIGATION SUPPLY; CONE/CATHETER, INCLUDING BRUSHOSTOMY IRRIGATION SETLUBRICANT, PER OUNCEOSTOMY RING, EACHOSTOMY SKIN BARRIER, NON-PECTIN BASED, PASTE, PER OUNCEOSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, PER OUNCEOSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDEDWEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACHOSTOMY SKIN BARRIER, WTIH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR,WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACHOSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR,WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACHOSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR,WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACHOSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITH BUILT-INCONVEXITY, EACHOSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECESYSTEM), WITHOUT FILTER, EACHOSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECESYSTEM), WITH FILTER, EACHOSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUTBUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACHOSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUTBUILT-IN CONVEXITY, LARGER THAN 4X4 INCHES, EACHOSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACHOSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITHFILTER (1 PIECE), EACHOSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH FILTER (1 PIECE), EACHOSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER(2 PIECE), EACHOSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACHOSTOMY SUPPLY; MISCELLANEOUSOSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTAL PACKET) FOR USE IN OSTOMY POUCH TOTHICKEN LIQUID STOMAL OUTPUT, EACHOSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2PIECE), EACHOSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACHOSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITHFILTER (2 PIECE SYSTEM), EACHOSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECESYSTEM), EACHOSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2PIECE SYSTEM), EACHOSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FAUCET-TYPETAP WITH VALVE (1 PIECE), EACHOSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITHFAUCET-TYPE TAP WITH VALVE (1 PIECE), EACHOSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-INCONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACHOSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE(1 PIECE), EACHOSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH

Query_110708

Page 176

FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACHOSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACHOSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPETAP WITH VALVE (2 PIECE), EACHTAPE, NON-WATERPROOF, PER 18 SQUARE INCHESTAPE, WATERPROOF, PER 18 SQUARE INCHESADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCEENEMA BAG WITH TUBING, REUSABLESURGICAL DRESSING HOLDER, NON-REUSABLE, EACHABDOMINAL DRESSING HOLDER, EACHSURGICAL DRESSING HOLDER, REUSABLE, EACHNON-ELASTIC BINDER FOR EXTREMITYGRAVLEE JET WASHERVABRA ASPIRATORTRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE, EACHMOISTURE EXCHANGER, DISPOSABLE, FOR USE WITH INVASIVE MECHANICAL VENTILATIONSURGICAL STOCKINGS ABOVE KNEE LENGTH, EACHSURGICAL STOCKINGS THIGH LENGTH, EACHSURGICAL STOCKINGS BELOW KNEE LENGTH, EACHSURGICAL STOCKINGS FULL LENGTH, EACHINCONTINENCE GARMENT, ANY TYPE, (E.G. BRIEF, DIAPER), EACHSURGICAL TRAYSDISPOSABLE UNDERPADS, ALL SIZESELECTRODES, (E.G., APNEA MONITOR), PER PAIRLEAD WIRES, (E.G., APNEA MONITOR), PER PAIRCONDUCTIVE GEL OR PASTE, FOR USE WITH ELECTRICAL DEVICE (E.G., TENS, NMES), PEROZCOUPLING GEL OR PASTE, FOR USE WITH ULTRASOUND DEVICE, PER OZPESSARY, RUBBER, ANY TYPEPESSARY, NON RUBBER, ANY TYPESLINGSSPLINTTOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOSABLECAST SUPPLIES (E.G. PLASTER)SPECIAL CASTING MATERIAL (E.G. FIBERGLASS)ELECTRICAL STIMULATOR SUPPLIES, 2 LEAD, PER MONTH, (E.G. TENS, NMES)SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE, REPLACEMENT ONLY, EACHLITHIUM ION BATTERY FOR NON-PROSTHETIC USE, REPLACEMENTTUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH POSITIVE AIRWAY PRESSUREDEVICETRACHEAL SUCTION CATHETER, CLOSED SYSTEM, EACHOXYGEN PROBE FOR USE WITH OXIMETER DEVICE, REPLACEMENTTRANSTRACHEAL OXYGEN CATHETER, EACHBATTERY, HEAVY DUTY; REPLACEMENT FOR PATIENT OWNED VENTILATORBATTERY CABLES; REPLACEMENT FOR PATIENT-OWNED VENTILATORBATTERY CHARGER; REPLACEMENT FOR PATIENT-OWNED VENTILATORPEAK EXPIRATORY FLOW RATE METER, HAND HELDCANNULA, NASALTUBING (OXYGEN), PER FOOTMOUTH PIECEBREATHING CIRCUITSFACE TENTVARIABLE CONCENTRATION MASKTRACHEOSTOMY, INNER CANNULATRACHEAL SUCTION CATHETER, ANY TYPE OTHER THAN CLOSED SYSTEM, EACHTRACHEOSTOMY CARE KIT FOR NEW TRACHEOSTOMYTRACHEOSTOMY CLEANING BRUSH, EACHSPACER, BAG OR RESERVOIR, WITH OR WITHOUT MASK, FOR USE WITH METERED DOSEINHALEROROPHARYNGEAL SUCTION CATHETER, EACHTRACHEOSTOMY CARE KIT FOR ESTABLISHED TRACHEOSTOMY

Query_110708

Page 177

REPLACEMENT BATTERIES, MEDICALLY NECESSARY, TRANSCUTANEOUS ELECTRICALSTIMULATOR, OWNED BY PATIENTREPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP, ANY TYPE, EACHREPLACEMENT BULB/LAMP FOR ULTRAVIOLET LIGHT THERAPY SYSTEM, EACHREPLACEMENT BULB FOR THERAPEUTIC LIGHT BOX, TABLETOP MODELUNDERARM PAD, CRUTCH, REPLACEMENT, EACHREPLACEMENT, HANDGRIP, CANE, CRUTCH, OR WALKER, EACHREPLACEMENT, TIP, CANE, CRUTCH, WALKER, EACH.REPLACEMENT BATTERY FOR PATIENT-OWNED EAR PULSE GENERATOR, EACHREPLACEMENT PAD FOR INFRARED HEATING PAD SYSTEM, EACHREPLACEMENT PAD FOR USE WITH MEDICALLY NECESSARY ALTERNATING PRESSURE PADOWNED BY PATIENTRADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIEDINDIUM IN-111 SATUMOMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 6MILLICURIESSUPPLY OF ADDITIONAL HIGH DOSE CONTRAST MATERIAL(S) DURING MAGNETIC RESONANCEIMAGING, E.G., GADOTERIDOL INJECTIONSUPPLY OF LOW OSMOLAR CONTRAST MATERIAL (100-199 MGS OF IODINE)SUPPLY OF LOW OSMOLAR CONTRAST MATERIAL (200-299 MGS OF IODINE)SUPPLY OF LOW OSMOLAR CONTRAST MATERIAL (300-399 MGS OF IODINE)SUPPLY OF PARAMAGNETIC CONTRAST MATERIAL, EG., GADOLINIUMTISSUE MARKER, IMPLANTABLE, ANY TYPE, EACHSURGICAL SUPPLY; MISCELLANEOUSIMPLANTABLE RADIATION DOSIMETER, EACHCALIBRATED MICROCAPILLARY TUBE, EACHMICROCAPILLARY TUBE SEALANTPERITONEAL DIALYSIS CATHETER ANCHORING DEVICE, BELT, EACHNEEDLE, ANY SIZE, EACHSYRINGE, WITH OR WITHOUT NEEDLE, EACHSPHYGMOMANOMETER/BLOOD PRESSURE APPARATUS WITH CUFF AND STETHOSCOPEBLOOD PRESSURE CUFF ONLYAUTOMATIC BLOOD PRESSURE MONITORDISPOSABLE CYCLER SET USED WITH CYCLER DIALYSIS MACHINE, EACHDRAINAGE EXTENSION LINE, STERILE, FOR DIALYSIS, EACHEXTENSION LINE WITH EASY LOCK CONNECTORS, USED WITH DIALYSISCHEMICALS/ANTISEPTICS SOLUTION USED TO CLEAN/STERILIZE DIALYSIS EQUIPMENT, PER8 OZACTIVATED CARBON FILTER FOR HEMODIALYSIS, EACHDIALYZER (ARTIFICIAL KIDNEYS), ALL TYPES, ALL SIZES, FOR HEMODIALYSIS, EACHBICARBONATE CONCENTRATE, SOLUTION, FOR HEMODIALYSIS, PER GALLONBICARBONATE CONCENTRATE, POWDER, FOR HEMODIALYSIS, PER PACKETACETATE CONCENTRATE SOLUTION, FOR HEMODIALYSIS, PER GALLONACID CONCENTRATE, SOLUTION, FOR HEMODIALYSIS, PER GALLONTREATED WATER (DEIONIZED, DISTILLED, OR REVERSE OSMOSIS) FOR PERITONEALDIALYSIS, PER GALLON"Y SET" TUBING FOR PERITONEAL DIALYSISDIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN249CC, BUT LESS THAN OR EQUAL TO 999CC, FOR PERITONEAL DIALYSISDIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN999CC BUT LESS THAN OR EQUAL TO 1999CC, FOR PERITONEAL DIALYSISDIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN1999CC BUT LESS THAN OR EQUAL TO 2999CC, FOR PERITONEAL DIALYSISDIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN2999CC BUT LESS THAN OR EQUAL TO 3999CC, FOR PERITONEAL DIALYSISDIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN3999CC BUT LESS THAN OR EQUAL TO 4999CC, FOR PERITONEAL DIALYSISDIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN4999CC BUT LESS THAN OR EQUAL TO 5999CC, FOR PERITONEAL DIALYSISDIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN5999CC, FOR PERITONEAL DIALYSISDIALYSATE SOLUTION, NON-DEXTROSE CONTAINING, 500 ML

Query_110708

Page 178

FISTULA CANNULATION SET FOR HEMODIALYSIS, EACHTOPICAL ANESTHETIC, FOR DIALYSIS, PER GRAMINJECTABLE ANESTHETIC, FOR DIALYSIS, PER 10 MLSHUNT ACCESSORY, FOR HEMODIALYSIS, ANY TYPE, EACHBLOOD TUBING, ARTERIAL OR VENOUS, FOR HEMODIALYSIS, EACHBLOOD TUBING, ARTERIAL AND VENOUS COMBINED, FOR HEMODIALYSIS, EACHDIALYSATE SOLUTION TEST KIT, FOR PERITONEAL DIALYSIS, ANY TYPE, EACHDIALYSATE CONCENTRATE, POWDER, ADDITIVE FOR PERITONEAL DIALYSIS, PER PACKETDIALYSATE CONCENTRATE, SOLUTION, ADDITIVE FOR PERITONEAL DIALYSIS, PER 10 MLBLOOD COLLECTION TUBE, VACUUM, FOR DIALYSIS, PER 50SERUM CLOTTING TIME TUBE, FOR DIALYSIS, PER 50BLOOD GLUCOSE TEST STRIPS, FOR DIALYSIS, PER 50OCCULT BLOOD TEST STRIPS, FOR DIALYSIS, PER 50AMMONIA TEST STRIPS, FOR DIALYSIS, PER 50PROTAMINE SULFATE, FOR HEMODIALYSIS, PER 50 MGDISPOSABLE CATHETER TIPS FOR PERITONEAL DIALYSIS, PER 10PLUMBING AND/OR ELECTRICAL WORK FOR HOME HEMODIALYSIS EQUIPMENTCONTRACTS, REPAIR AND MAINTENANCE, FOR HEMODIALYSIS EQUIPMENTDRAIN BAG/BOTTLE, FOR DIALYSIS, EACHMISCELLANEOUS DIALYSIS SUPPLIES, NOT OTHERWISE SPECIFIEDVENOUS PRESSURE CLAMP, FOR HEMODIALYSIS, EACHGLOVES, NON-STERILE, PER 100SURGICAL MASK, PER 20TOURNIQUET FOR DIALYSIS, EACHGLOVES, STERILE, PER PAIRORAL THERMOMETER, REUSABLE, ANY TYPE, EACHRECTAL THERMOMETER, REUSABLE, ANY TYPE, EACHOSTOMY POUCH, CLOSED; WITH BARRIER ATTACHED (1 PIECE), EACHOSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED (1 PIECE), EACHOSTOMY POUCH, CLOSED; FOR USE ON FACEPLATE, EACHOSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACHSTOMA CAPOSTOMY POUCH, DRAINABLE; WITH BARRIER ATTACHED, (1 PIECE), EACHOSTOMY POUCH, DRAINABLE; WITHOUT BARRIER ATTACHED (1 PIECE), EACHOSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE (2 PIECE SYSTEM), EACHOSTOMY POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE), EACHOSTOMY POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE), EACHOSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACHCONTINENT DEVICE; PLUG FOR CONTINENT STOMACONTINENT DEVICE; CATHETER FOR CONTINENT STOMACONTINENT DEVICE, STOMA ABSORPTIVE COVER FOR CONTINENT STOMAOSTOMY ACCESSORY; CONVEX INSERTBEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, EACHURINARY SUSPENSORY WITH LEG BAG, WITH OR WITHOUT TUBE, EACHURINARY LEG BAG; LATEXLEG STRAP; LATEX, REPLACEMENT ONLY, PER SETLEG STRAP; FOAM OR FABRIC, REPLACEMENT ONLY, PER SETSKIN BARRIER, WIPES OR SWABS, PER BOX 50SKIN BARRIER, WIPES OR SWABS, EACHSKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, EACHSKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, EACHADHESIVE OR NON-ADHESIVE; DISK OR FOAM PADAPPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ.PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENTFOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION ANDSUPPLY OF OFF-THE-SHELF DEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE MULTI-DENSITY INSERT(S), PER SHOEFOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION ANDSUPPLY OF SHOE MOLDED FROM CAST(S) OF PATIENT'S FOOT (CUSTOM MOLDED SHOE), PERSHOEFOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF

Query_110708

Page 179

DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH ROLLER OR RIGID ROCKER BOTTOM, PERSHOEFOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELFDEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH WEDGE(S), PER SHOEFOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELFDEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH METATARSAL BAR, PER SHOEFOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELFDEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH OFF-SET HEEL(S), PER SHOEFOR DIABETICS ONLY, NOT OTHERWISE SPECIFIED MODIFICATION (INCLUDING FITTING) OFOFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE, PER SHOEFOR DIABETICS ONLY, DELUXE FEATURE OF OFF-THE-SHELF DEPTH-INLAY SHOE ORCUSTOM-MOLDED SHOE, PER SHOEFOR DIABETICS ONLY, DIRECT FORMED, MOLDED TO FOOT WITH EXTERNAL HEAT SOURCE(I.E. HEAT GUN) MULTIPLE DENSITY INSERT (S), PREFABRICATED, PER SHOEFOR DIABETICS ONLY, DIRECT FORMED, COMPRESSION MOLDED TO PATIENT'S FOOT WITHOUTEXTERNAL HEAT SOURCE, MULTIPLE-DENSITY INSERT(S) PREFABRICATED, PER SHOEFOR DIABETICS ONLY, CUSTOM-MOLDED FROM MODEL OF PATIENT'S FOOT, MULTIPLEDENSITY INSERT(S), CUSTOM-FABRICATED, PER SHOEFOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOTAFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACTWITH PATIENT'S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 1/4 INCH MATERIAL OFSHORE A 35 DUROMETER OR 3/16 INCH MATERIAL OF SHORE A 40 DUROMETER (OR HIGHER),PREFABRICATED, EACHFOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OFPATIENT'S FOOT, TOTAL CONTACT WITH PATIENT'S FOOT, INCLUDING ARCH, BASE LAYERMINIMUM OF 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER OR HIGHER), INCLUDES ARCHFILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EACHNON-CONTACT WOUND WARMING WOUND COVER FOR USE WITH THE NON-CONTACT WOUNDWARMING DEVICE AND WARMING CARDCOLLAGEN BASED WOUND FILLER, DRY FORM, STERILE, PER GRAM OF COLLAGENCOLLAGEN BASED WOUND FILLER, GEL/PASTE, STERILE, PER GRAM OF COLLAGENCOLLAGEN DRESSING, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACHCOLLAGEN DRESSING, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OREQUAL TO 48 SQ. IN., EACHCOLLAGEN DRESSING, STERILE, PAD SIZE MORE THAN 48 SQ. IN., EACHCOLLAGEN DRESSING WOUND FILLER, STERILE, PER 6 INCHESGEL SHEET FOR DERMAL OR EPIDERMAL APPLICATION, (E.G., SILICONE, HYDROGEL,OTHER), EACHWOUND POUCH, EACHALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ.IN. OR LESS, EACH DRESSINGALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORETHAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSINGALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORETHAN 48 SQ. IN., EACH DRESSINGALGINATE OR OTHER FIBER GELLING DRESSING, WOUND FILLER, STERILE, PER 6 INCHESCOMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACHDRESSINGCOMPOSITE DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSINGCOMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER,EACH DRESSINGCOMPOSITE DRESSING, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZEADHESIVE BORDER, EACH DRESSINGCOMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OREQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSINGCOMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZEADHESIVE BORDER, EACH DRESSINGCONTACT LAYER, STERILE, 16 SQ. IN. OR LESS, EACH DRESSINGCONTACT LAYER, STERILE, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ.IN., EACH DRESSING

Query_110708

Page 180

CONTACT LAYER, STERILE, MORE THAN 48 SQ. IN., EACH DRESSINGFOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUTADHESIVE BORDER, EACH DRESSINGFOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESSTHAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSINGFOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUTADHESIVE BORDER, EACH DRESSINGFOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZEADHESIVE BORDER, EACH DRESSINGFOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESSTHAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSINGFOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANYSIZE ADHESIVE BORDER, EACH DRESSINGFOAM DRESSING, WOUND FILLER, STERILE, PER GRAMGAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUTADHESIVE BORDER, EACH DRESSINGGAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESSTHAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSINGGAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUTADHESIVE BORDER, EACH DRESSINGGAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZEADHESIVE BORDER, EACH DRESSINGGAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OREQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSINGGAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZEADHESIVE BORDER, EACH DRESSINGGAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE,PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSINGGAUZE, 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., WITHOUTADHESIVE BORDER, EACH DRESSINGGAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE,PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSINGGAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE 16 SQ. IN. ORLESS, WITHOUT ADHESIVE BORDER, EACH DRESSINGGAUZE, 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 DRESSINGGAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE MORE THAN 48 SQ.IN., WITHOUT ADHESIVE BORDER, EACH DRESSINGGAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZE 16SQ. IN. OR LESS, EACH DRESSINGGAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZEGREATER THAN 16 SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSINGGAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZE MORETHAN 48 SQ. IN., EACH DRESSINGHYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS,WITHOUT ADHESIVE BORDER, EACH DRESSINGHYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUTLESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSINGHYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN.,WITHOUT ADHESIVE BORDER, EACH DRESSINGHYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHANY SIZE ADHESIVE BORDER, EACH DRESSINGHYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUTLESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSINGHYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN.,WITH ANY SIZE ADHESIVE BORDER, EACH DRESSINGHYDROCOLLOID DRESSING, WOUND FILLER, PASTE, STERILE, PER OUNCEHYDROCOLLOID DRESSING, WOUND FILLER, DRY FORM, STERILE, PER GRAMHYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUTADHESIVE BORDER, EACH DRESSING

Query_110708

Page 181

HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESSTHAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSINGHYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUTADHESIVE BORDER, EACH DRESSINGHYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANYSIZE ADHESIVE BORDER, EACH DRESSINGHYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESSTHAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSINGHYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHANY SIZE ADHESIVE BORDER, EACH DRESSINGHYDROGEL DRESSING, WOUND FILLER, GEL, STERILE, PER FLUID OUNCESKIN SEALANTS, PROTECTANTS, MOISTURIZERS, OINTMENTS, ANY TYPE, ANY SIZESPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. ORLESS, WITHOUT ADHESIVE BORDER, EACH DRESSINGSPECIALTY 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 DRESSINGSPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ.IN., WITHOUT ADHESIVE BORDER, EACH DRESSINGSPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. ORLESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSINGSPECIALTY 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, EACHDRESSINGSPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ.IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSINGTRANSPARENT FILM, STERILE, 16 SQ. IN. OR LESS, EACH DRESSINGTRANSPARENT FILM, STERILE, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48SQ. IN., EACH DRESSINGTRANSPARENT FILM, STERILE, MORE THAN 48 SQ. IN., EACH DRESSINGWOUND CLEANSERS, STERILE, ANY TYPE, ANY SIZEWOUND FILLER, GEL/PASTE, STERILE, PER FLUID OUNCE, NOT OTHERWISE SPECIFIEDWOUND FILLER, DRY FORM, STERILE, PER GRAM, NOT OTHERWISE SPECIFIEDGAUZE, IMPREGNATED, OTHER THAN WATER, NORMAL SALINE, OR ZINC PASTE, STERILE,ANY WIDTH, PER LINEAR YARDGAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVEBORDER, EACH DRESSINGGAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. LESS THAN OREQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSINGGAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUTADHESIVE BORDER, EACH DRESSINGPACKING STRIPS, NON-IMPREGNATED, STERILE, UP TO 2 INCHES IN WIDTH, PER LINEARYARDEYE PAD, STERILE, EACHEYE PAD, NON-STERILE, EACHEYE PATCH, OCCLUSIVE, EACHADHESIVE BANDAGE, FIRST-AID TYPE, ANY SIZE, EACHPADDING BANDAGE, NON-ELASTIC, NON-WOVEN/NON-KNITTED, WIDTH GREATER THAN OREQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARDCONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH LESS THANTHREE INCHES, PER YARDCONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH GREATER THANOR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARDCONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH GREATER THANOR EQUAL TO 5 INCHES, PER YARDCONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH LESS THAN THREEINCHES, PER YARDCONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OREQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARDCONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OREQUAL TO FIVE INCHES, PER YARDLIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH LESS THAN THREE

Query_110708

Page 182

INCHES, PER YARDLIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUALTO THREE INCHES AND LESS THAN FIVE INCHES, PER YARDLIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUALTO FIVE INCHES, PER YARDMODERATE COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE OF 1.25TO 1.34 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN OR EQUAL TOTHREE INCHES AND LESS THAN FIVE INCHES, PER YARDHIGH COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE GREATER THANOR EQUAL TO 1.35 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN OREQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARDSELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH LESS THAN THREEINCHES, PER YARDSELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH GREATER THAN OREQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARDSELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH GREATER THAN OREQUAL TO FIVE INCHES, PER YARDZINC PASTE IMPREGNATED BANDAGE, NON-ELASTIC, KNITTED/WOVEN, WIDTH GREATER THANOR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARDTUBULAR DRESSING WITH OR WITHOUT ELASTIC, ANY WIDTH, PER LINEAR YARDCOMPRESSION BURN GARMENT, BODYSUIT (HEAD TO FOOT), CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, CHIN STRAP, CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, FACIAL HOOD, CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, GLOVE TO WRIST, CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, GLOVE TO ELBOW, CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, GLOVE TO AXILLA, CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, FOOT TO KNEE LENGTH, CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, FOOT TO THIGH LENGTH, CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, UPPER TRUNK TO WAIST INCLUDING ARM OPENINGS (VEST),CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, TRUNK, INCLUDING ARMS DOWN TO LEG OPENINGS (LEOTARD),CUSTOM FABRICATEDCOMPRESSION BURN GARMENT, LOWER TRUNK INCLUDING LEG OPENINGS (PANTY), CUSTOMFABRICATEDCOMPRESSION BURN GARMENT, NOT OTHERWISE CLASSIFIEDCOMPRESSION BURN MASK, FACE AND/OR NECK, PLASTIC OR EQUAL, CUSTOM FABRICATEDGRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACHGRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACHGRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACHGRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACHGRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACHGRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACHGRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACHGRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACHGRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40-50 MMHG, EACHGRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, EACHGRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, EACHGRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40-50 MMHG, EACHGRADIENT COMPRESSION STOCKING, CUSTOM MADEGRADIENT COMPRESSION STOCKING, LYMPHEDEMAGRADIENT COMPRESSION STOCKING, GARTER BELTGRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG, EACHGRADIENT COMPRESSION STOCKING, NOT OTHERWISE SPECIFIEDWOUND CARE SET, FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, INCLUDESALL SUPPLIES AND ACCESSORIESCANISTER SET FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY ORPORTABLE, EACHCANISTER, DISPOSABLE, USED WITH SUCTION PUMP, EACHCANISTER, NON-DISPOSABLE, USED WITH SUCTION PUMP, EACHTUBING, USED WITH SUCTION PUMP, EACHADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER,

Query_110708

Page 183

DISPOSABLESMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, DISPOSABLEADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER,NON-DISPOSABLEADMINISTRATION SET, WITH SMALL VOLUME FILTERED PNEUMATIC NEBULIZERLARGE VOLUME NEBULIZER, DISPOSABLE, UNFILLED, USED WITH AEROSOL COMPRESSORLARGE VOLUME NEBULIZER, DISPOSABLE, PREFILLED, USED WITH AEROSOL COMPRESSORRESERVOIR BOTTLE, NON-DISPOSABLE, USED WITH LARGE VOLUME ULTRASONIC NEBULIZERCORRUGATED TUBING, DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER, 100 FEETCORRUGATED TUBING, NON-DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER, 10 FEETWATER COLLECTION DEVICE, USED WITH LARGE VOLUME NEBULIZERFILTER, DISPOSABLE, USED WITH AEROSOL COMPRESSORFILTER, NONDISPOSABLE, USED WITH AEROSOL COMPRESSOR OR ULTRASONIC GENERATORAEROSOL MASK, USED WITH DME NEBULIZERDOME AND MOUTHPIECE, USED WITH SMALL VOLUME ULTRASONIC NEBULIZERNEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, NOT USED WITHOXYGENWATER, DISTILLED, USED WITH LARGE VOLUME NEBULIZER, 1000 MLHIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, REPLACEMENT FOR USE WITHPATIENT OWNED EQUIPMENT, EACHHIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM HOSE, REPLACEMENT FOR USE WITHPATIENT OWNED EQUIPMENT, EACHCOMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSUREDEVICE, EACHORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACHNASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIRFULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACHFACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACHCUSHION FOR USE ON NASAL MASK INTERFACE, REPLACEMENT ONLY, EACHPILLOW FOR USE ON NASAL CANNULA TYPE INTERFACE, REPLACEMENT ONLY, PAIRNASAL INTERFACE (MASK OR CANNULA TYPE) USED WITH POSITIVE AIRWAY PRESSUREDEVICE, WITH OR WITHOUT HEAD STRAPHEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICECHINSTRAP USED WITH POSITIVE AIRWAY PRESSURE DEVICETUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICEFILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICEFILTER, NON DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICEONE WAY CHEST DRAIN VALVEWATER SEAL DRAINAGE CONTAINER AND TUBING FOR USE WITH IMPLANTED CHEST TUBEIMPLANTED PLEURAL CATHETER, EACHVACUUM DRAINAGE BOTTLE AND TUBING FOR USE WITH IMPLANTED CATHETERORAL INTERFACE USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACHEXHALATION PORT WITH OR WITHOUT SWIVEL USED WITH ACCESSORIES FOR POSITIVEAIRWAY DEVICES, REPLACEMENT ONLYWATER CHAMBER FOR HUMIDIFIER, USED WITH POSITIVE AIRWAY PRESSURE DEVICE,REPLACEMENT, EACHTRACHEOSTOMA VALVE, INCLUDING DIAPHRAGM, EACHREPLACEMENT DIAPHRAGM/FACEPLATE FOR TRACHEOSTOMA VALVE, EACHFILTER HOLDER OR FILTER CAP, REUSABLE, FOR USE IN A TRACHEOSTOMA HEAT ANDMOISTURE EXCHANGE SYSTEM, EACHFILTER FOR USE IN A TRACHEOSTOMA HEAT AND MOISTURE EXCHANGE SYSTEM, EACHHOUSING, REUSABLE WITHOUT ADHESIVE, FOR USE IN A HEAT AND MOISTURE EXCHANGESYSTEM AND/OR WITH A TRACHEOSTOMA VALVE, EACHADHESIVE DISC FOR USE IN A HEAT AND MOISTURE EXCHANGE SYSTEM AND/OR WITHTRACHEOSTOMA VALVE, ANY TYPE EACHFILTER HOLDER AND INTEGRATED FILTER WITHOUT ADHESIVE, FOR USE IN A TRACHEOSTOMAHEAT AND MOISTURE EXCHANGE SYSTEM, EACHHOUSING AND INTEGRATED ADHESIVE, FOR USE IN A TRACHEOSTOMA HEAT AND MOISTUREEXCHANGE SYSTEM AND/OR WITH A TRACHEOSTOMA VALVE, EACHFILTER HOLDER AND INTEGRATED FILTER HOUSING, AND ADHESIVE, FOR USE AS ATRACHEOSTOMA HEAT AND MOISTURE EXCHANGE SYSTEM, EACH

Query_110708

Page 184

TRACHEOSTOMY/LARYNGECTOMY TUBE, NON-CUFFED, POLYVINYLCHLORIDE (PVC), SILICONEOR EQUAL, EACHTRACHEOSTOMY/LARYNGECTOMY TUBE, CUFFED, POLYVINYLCHLORIDE (PVC), SILICONE OREQUAL, EACHTRACHEOSTOMY/LARYNGECTOMY TUBE, STAINLESS STEEL OR EQUAL (STERILIZABLE ANDREUSABLE), EACHTRACHEOSTOMY SHOWER PROTECTOR, EACHTRACHEOSTOMA STENT/STUD/BUTTON, EACHTRACHEOSTOMY MASK, EACHTRACHEOSTOMY TUBE COLLAR/HOLDER, EACHTRACHEOSTOMY/LARYNGECTOMY TUBE PLUG/STOP, EACHHELMET, PROTECTIVE, SOFT, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIESHELMET, PROTECTIVE, HARD, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIESHELMET, PROTECTIVE, SOFT, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS ANDACCESSORIESHELMET, PROTECTIVE, HARD, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS ANDACCESSORIESSOFT INTERFACE FOR HELMET, REPLACEMENT ONLYNON-PRESCRIPTION DRUGSSINGLE VITAMIN/MINERAL/TRACE ELEMENT, ORAL, PER DOSE, NOT OTHERWISE SPECIFIEDMULTIPLE VITAMINS, WITH OR WITHOUT MINERALS AND TRACE ELEMENTS, ORAL, PER DOSE,NOT OTHERWISE SPECIFIEDARTIFICIAL SALIVA, 30 MLPEDICULOSIS (LICE INFESTATION) TREATMENT, TOPICAL, FOR ADMINISTRATION BYPATIENT/CARETAKERNON-COVERED ITEM OR SERVICEEXTERNAL AMBULATORY INSULIN DELIVERY SYSTEM, DISPOSABLE, EACH, INCLUDES ALLSUPPLIES AND ACCESSORIESHOME GLUCOSE DISPOSABLE MONITOR, INCLUDES TEST STRIPSSENSOR; INVASIVE (E.G. SUBCUTANEOUS), DISPOSABLE, FOR USE WITH INTERSTITIALCONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY SUPPLYTRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORINGSYSTEMRECEIVER (MONITOR); EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSEMONITORING SYSTEMMONITORING FEATURE/DEVICE, STAND-ALONE OR INTEGRATED, ANY TYPE, INCLUDES ALLACCESSORIES, COMPONENTS AND ELECTRONICS, NOT OTHERWISE CLASSIFIEDALERT OR ALARM DEVICE, NOT OTHERWISE CLASSIFIEDREACHING/GRABBING DEVICE, ANY TYPE, ANY LENGTH, EACHWIG, ANY TYPE, EACHFOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACHSPIROMETER, NON-ELECTRONIC, INCLUDES ALL ACCESSORIESEXERCISE EQUIPMENTTECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIESTECHNETIUM TC-99M TEBOROXIME, DIAGNOSTIC, PER STUDY DOSETECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSETECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIESTECHNETIUM TC-99M APCITIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIESTHALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIEINDIUM IN-111 CAPROMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 10MILLICURIESIODINE I-131 IOBENGUANE SULFATE, DIAGNOSTIC, PER 0.5 MILLICURIEIODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER MILLICURIETECHNETIUM TC-99M DISOFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIESSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC 99M,DEPREOTIDE, PER MCITECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIESUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99MMEBROFENIN, PER MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99MPYROPHOSPHATE, PER MCI

Query_110708

Page 185

SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99MPENTETATE, PER MCIIODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999MICROCURIESIODINE I-131 SODIUM IODIDE CAPSULE(S), THERAPEUTIC, PER MILLICURIESUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99MMACROAGGREGATED ALBUMIN, PER MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99MSULFUR COLLOID, PER MCITECHNETIUM TC-99M EXAMETAZIME, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIESSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, INDIUM-111 IBRITUMOMABTIUXETAN, PER MCISUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, YTTRIUM 90 IBRITUMOMABTIUXETAN, PER MCIIODINE I-131 IODINATED SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIESSUPPLY OF LOW OR ISO-OSMOLAR CONTRAST MATERIAL, 10 MG OF IODINENITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIESIODINE I-125, SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIEIODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIEIODINE I-131 SODIUM IODIDE SOLUTION, DIAGNOSTIC, PER MILLICURIEIODINE I-131 SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIEIODINE I-131 SODIUM IODIDE, DIAGNOSTIC, PER MICROCURIE (UP TO 100 MICROCURIES)IODINE I-125 SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIESSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, I-131 TOSITUMOMAB, PERMILLICURIESUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, I-131 TOSITUMOMAB, PERMILLICURIEINJECTION, METHYLENE BLUE, 1 MLTECHNETIUM TC-99M DEPREOTIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 35 MILLICURIESTECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIESTECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25MILLICURIESTECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIESTECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10MILLICURIESTECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20MILLICURIESINDIUM IN-111 IBRITUMOMAB TIUXETAN, DIAGNOSTIC, PER STUDY DOSE, UP TO 5MILLICURIESYTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAPEUTIC, PER TREATMENT DOSE, UP TO 40MILLICURIESIODINE I-131 TOSITUMOMAB, DIAGNOSTIC, PER STUDY DOSEIODINE I-131 TOSITUMOMAB, THERAPEUTIC, PER TREATMENT DOSECOBALT CO-57/58, CYANOCOBALAMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIEINDIUM IN-111 OXYQUINOLINE, DIAGNOSTIC, PER 0.5 MILLICURIEINDIUM IN-111 PENTETATE, DIAGNOSTIC, PER 0.5 MILLICURIETECHNETIUM TC-99M ARCITUMOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIESTECHNETIUM TC-99M SODIUM GLUCEPTATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25MILLICURIETECHNETIUM TC-99M SUCCIMER, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIESFLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIESCHROMIUM CR-51 SODIUM CHROMATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 250MICROCURIESIODINE I-125 SODIUM IOTHALAMATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 10MICROCURIESRUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 MILLICURIESGALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIETECHNETIUM TC-99M BICISATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIESXENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIESCOBALT CO-57 CYANOCOBALAMIN, ORAL, DIAGNOSTIC, PER STUDY DOSE, UP TO 1MICROCURIE

Query_110708

Page 186

TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE, UP TO 30MILLICURIESTECHNETIUM TC-99M OXIDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIESTECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIESSODIUM PHOSPHATE P-32, THERAPEUTIC, PER MILLICURIECHROMIC PHOSPHATE P-32 SUSPENSION, THERAPEUTIC, PER MILLICURIEINDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER MILLICURIETECHNETIUM TC-99M FANOLESOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIESTECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, AEROSOL, PER STUDY DOSE, UP TO 75MILLICURIESTECHNETIUM TC-99M ARCITUMOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIESTECHNETIUM TC-99M EXAMETAZIME LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC,PER STUDY DOSEINDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSEINDIUM IN-111 LABELED AUTOLOGOUS PLATELETS, DIAGNOSTIC, PER STUDY DOSEINDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 6 MILLICURIESINJECTION, GADOTERIDOL, (PROHANCE MULTIPACK), PER MLINJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE), PER MLINJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE MULTIPACK), PER MLINJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISESPECIFIED (NOS), PER MLSODIUM FLUORIDE F-18, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIESSTRONTIUM SR-89 CHLORIDE, THERAPEUTIC, PER MILLICURIESAMARIUM SM-153 LEXIDRONAMM, THERAPEUTIC, PER 50 MILLICURIESNON-RADIOACTIVE CONTRAST IMAGING MATERIAL, NOT OTHERWISE CLASSIFIED, PER STUDYRADIOPHARMACEUTICAL, THERAPEUTIC, NOT OTHERWISE CLASSIFIEDSUPPLY OF INJECTABLE CONTRAST MATERIAL FOR USE IN ECHOCARDIOGRAPHY, PER STUDYMISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCSCODEDME DELIVERY, SET UP, AND/OR DISPENSING SERVICE COMPONENT OF ANOTHER HCPCS CODEMISCELLANEOUS DME SUPPLY OR ACCESSORY, NOT OTHERWISE SPECIFIEDENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAYENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAYENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAYNASOGASTRIC TUBING WITH STYLETNASOGASTRIC TUBING WITHOUT STYLETSTOMACH TUBE - LEVINE TYPEGASTROSTOMY / JEJUNOSTOMY TUBE, ANY MATERIAL, ANY TYPE, (STANDARD OR LOWPROFILE), EACHGASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, ANY MATERIAL, ANY TYPE, EACHGASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE, ANY MATERIAL, ANY TYPE, EACHFOOD THICKENER, ADMINISTERED ORALLY, PER OUNCEENTERAL FORMULA, FOR ADULTS, USED TO REPLACE FLUIDS AND ELECTROLYTES (E.G.CLEAR LIQUIDS), 500 ML = 1 UNITENTERAL FORMULA, FOR PEDIATRICS, USED TO REPLACE FLUIDS AND ELECTROLYTES (E.G.CLEAR LIQUIDS), 500 ML = 1 UNITADDITIVE FOR ENTERAL FORMULA (E.G. FIBER)ENTERAL FORMULA, MANUFACTURED BLENDERIZED NATURAL FOODS WITH INTACT NUTRIENTS,INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDEFIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNITENTERAL FORMULA, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDESPROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER,ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNITENTERAL FORMULA, NUTRITIONALLY COMPLETE, CALORICALLY DENSE (EQUAL TO OR GREATERTHAN 1.5 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS,CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGHAN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNITENTERAL FORMULA, NUTRITIONALLY COMPLETE, HYDROLYZED PROTEINS (AMINO ACIDS ANDPEPTIDE CHAIN), INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAYINCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1UNIT

Query_110708

Page 187

ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS, EXCLUDESINHERITED DISEASE OF METABOLISM, INCLUDES ALTERED COMPOSITION OF PROTEINS,FATS, CARBOHYDRATES, VITAMINS AND/OR MINERALS, MAY INCLUDE FIBER, ADMINISTEREDTHROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNITENTERAL FORMULA, NUTRITIONALLY INCOMPLETE/MODULAR NUTRIENTS, INCLUDES SPECIFICNUTRIENTS, CARBOHYDRATES (E.G. GLUCOSE POLYMERS), PROTEINS/AMINO ACIDS (E.G.GLUTAMINE, ARGININE), FAT (E.G. MEDIUM CHAIN TRIGLYCERIDES) OR COMBINATION,ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNITENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS FORINHERITED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES,VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERALFEEDING TUBE, 100 CALORIES = 1 UNITENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS,INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDEFIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES =1 UNITENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE SOY BASED WITH INTACTNUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAYINCLUDE FIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100CALORIES = 1 UNITENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE CALORICALLY DENSE(EQUAL TO OR GREATER THAN 0.7 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDESPROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER,ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNITENTERAL FORMULA, FOR PEDIATRICS, HYDROLYZED/AMINO ACIDS AND PEPTIDE CHAINPROTEINS, INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDEFIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNITENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS FOR INHERITED DISEASEOF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS,MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES =1 UNITPARENTERAL NUTRITION SOLUTION: CARBOHYDRATES (DEXTROSE), 50% OR LESS (500 ML =1 UNIT) - HOMEMIXPARENTERAL NUTRITION SOLUTION; AMINO ACID, 3.5%, (500 ML = 1 UNIT) - HOMEMIXPARENTERAL NUTRITION SOLUTION; AMINO ACID, 5.5% THROUGH 7%, (500 ML = 1 UNIT) -HOMEMIXPARENTERAL NUTRITION SOLUTION; AMINO ACID, 7% THROUGH 8.5%, (500 ML = 1 UNIT) -HOMEMIXPARENTERAL NUTRITION SOLUTION: AMINO ACID, GREATER THAN 8.5% (500 ML = 1 UNIT)- HOMEMIXPARENTERAL NUTRITION SOLUTION; CARBOHYDRATES (DEXTROSE), GREATER THAN 50% (500ML=1 UNIT) - HOMEMIXPARENTERAL NUTRITION SOLUTION; LIPIDS, 10% WITH ADMINISTRATION SET (500 ML = 1UNIT)PARENTERAL NUTRITION SOLUTION, PER 10 GRAMS LIPIDSPARENTERAL NUTRITION SOLUTION, LIPIDS, 20% WITH ADMINISTRATION SET (500 ML = 1UNIT)PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITHELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANYSTRENGTH, 10 TO 51 GRAMS OF PROTEIN - PREMIXPARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITHELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANYSTRENGTH, 52 TO 73 GRAMS OF PROTEIN - PREMIXPARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITHELECTROLYTES, TRACE ELEMENTS AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH,74 TO 100 GRAMS OF PROTEIN - PREMIXPARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITHELECTROLYTES, TRACE ELEMENTS AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH,OVER 100 GRAMS OF PROTEIN - PREMIXPARENTERAL NUTRITION; ADDITIVES (VITAMINS, TRACE ELEMENTS, HEPARIN,ELECTROLYTES) HOMEMIX PER DAY

Query_110708

Page 188

PARENTERAL NUTRITION SUPPLY KIT; PREMIX, PER DAYPARENTERAL NUTRITION SUPPLY KIT; HOME MIX, PER DAYPARENTERAL NUTRITION ADMINISTRATION KIT, PER DAYPARENTERAL NUTRITION SOLUTION: COMPOUNDED AMINO ACID AND CARBOHYDRATES WITHELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANYSTRENGTH, RENAL - AMIROSYN RF, NEPHRAMINE, RENAMINE - PREMIXPARENTERAL NUTRITION SOLUTION: COMPOUNDED AMINO ACID AND CARBOHYDRATES WITHELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANYSTRENGTH, HEPATIC - FREAMINE HBC, HEPATAMINE - PREMIXPARENTERAL NUTRITION SOLUTION: COMPOUNDED AMINO ACID AND CARBOHYDRATES WITHELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANYSTRENGTH, STRESS - BRANCH CHAIN AMINO ACIDS - PREMIXENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARMENTERAL NUTRITION INFUSION PUMP - WITH ALARMPARENTERAL NUTRITION INFUSION PUMP, PORTABLEPARENTERAL NUTRITION INFUSION PUMP, STATIONARYNOC FOR ENTERAL SUPPLIESNOC FOR PARENTERAL SUPPLIESSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, CYANOCOBALAMIN CO57/58, PER 0.5 MICROCURIESUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, I-131 TOSITUMOMAB, PERDOSESUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, I-131 TOSITUMOMAB, PERDOSESUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, INDIUM-111 IBRITUMOMABTIUXETAN, PER DOSESUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, YTTRIUM 90 IBRITUMOMABTIUXETAN, PER DOSESUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, INDIUM 111OXYQUINOLINE, PER 0.5 MILLICURIESUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, INDIUM 111 PENTETATE,PER 0.5 MILLICURIESUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC 99MFANOLESOMAB, PER DOSE (10 - 20 MCI)SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC 99MARCITUMOMAB, PER VIALINJECTION, BUSULFAN, PER 6 MGSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC 99MSODIUM GLUCOHEPTONATE, PER VIALSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC 99MSUCCIMER, PER VIALHYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVALGRAFTSKIN, PER 44 SQUARE CENTIMETERSANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE)CATHETER, TRANSLUMINAL ATHERECTOMY, DIRECTIONALBRACHYTHERAPY NEEDLEBRACHYTHERAPY SOURCE, NON-STRANDED, GOLD-198, PER SOURCEBRACHYTHERAPY SOURCE, NON-STRANDED, HIGH DOSE RATE IRIDIUM-192, PER SOURCEBRACHYTHERAPY SOURCE, IODINE 125, PER SOURCEBRACHYTHERAPY SOURCE, NON-STRANDED, NON-HIGH DOSE RATE IRIDIUM-192, PER SOURCEBRACHYTHERAPY SOURCE, PALLADIUM 103, PER SOURCECARDIOVERTER-DEFIBRILLATOR, DUAL CHAMBER (IMPLANTABLE)CARDIOVERTER-DEFIBRILLATOR, SINGLE CHAMBER (IMPLANTABLE)CATHETER, TRANSLUMINAL ATHERECTOMY, ROTATIONALCATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE,INFUSION/PERFUSION CAPABILITY)CATHETER, BALLOON DILATATION, NON-VASCULARCATHETER, BALLOON TISSUE DISSECTOR, NON-VASCULAR (INSERTABLE)CATHETER, BRACHYTHERAPY SEED ADMINISTRATIONCATHETER, DRAINAGECATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC, OTHER THAN 3D MAPPING (19 OR FEWER

Query_110708

Page 189

ELECTRODES)CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC, OTHER THAN 3D MAPPING (20 OR MOREELECTRODES)CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, 3D OR VECTOR MAPPINGCATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, OTHER THAN 3D OR VECTORMAPPING, OTHER THAN COOL-TIPCATHETER, HEMODIALYSIS/PERITONEAL, LONG-TERMCATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THANHEMODIALYSIS)CATHETER, HEMODIALYSIS/PERITONEAL, SHORT-TERMCATHETER, INTRAVASCULAR ULTRASOUNDCATHETER, INTRADISCALCATHETER, INTRASPINALCATHETER, PACING, TRANSESOPHAGEALCATHETER, THROMBECTOMY/EMBOLECTOMYCATHETER, URETERALCATHETER, INTRACARDIAC ECHOCARDIOGRAPHYCLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)CONNECTIVE TISSUE, HUMAN (INCLUDES FASCIA LATA)CONNECTIVE TISSUE, NON-HUMAN (INCLUDES SYNTHETIC)EVENT RECORDER, CARDIAC (IMPLANTABLE)ADHESION BARRIERINTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHERTHAN PEEL-AWAYGENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLEGRAFT, VASCULARGUIDE WIREIMAGING COIL, MAGNETIC RESONANCE (INSERTABLE)REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFTINFUSION PUMP, PROGRAMMABLE (IMPLANTABLE)RETRIEVAL DEVICE, INSERTABLE (USED TO RETRIEVE FRACTURED MEDICAL DEVICES)SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, FLUORODEOXYGLUCOSE F18(2-DEOXY-2-[18F]FLUORO-D-GLUCOSE), PER DOSE (4-40 MCI/ML)JOINT DEVICE (IMPLANTABLE)LEAD, CARDIOVERTER-DEFIBRILLATOR, ENDOCARDIAL SINGLE COIL (IMPLANTABLE)LEAD, NEUROSTIMULATOR (IMPLANTABLE)LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASSLENS, INTRAOCULAR (NEW TECHNOLOGY)MESH (IMPLANTABLE)MORCELLATOROCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICEOCULAR DEVICE, INTRAOPERATIVE, DETACHED RETINAPACEMAKER, DUAL CHAMBER, RATE-RESPONSIVE (IMPLANTABLE)PACEMAKER, SINGLE CHAMBER, RATE-RESPONSIVE (IMPLANTABLE)PATIENT PROGRAMMER, NEUROSTIMULATORPORT, INDWELLING (IMPLANTABLE)PROSTHESIS, BREAST (IMPLANTABLE)PROSTHESIS, PENILE, INFLATABLERETINAL TAMPONADE DEVICE, SILICONE OILPROSTHESIS, URINARY SPHINCTER (IMPLANTABLE)RECEIVER AND/OR TRANSMITTER, NEUROSTIMULATOR (IMPLANTABLE)SEPTAL DEFECT IMPLANT SYSTEM, INTRACARDIACINTEGRATED KERATOPROSTHESISSURGICAL TISSUE LOCALIZATION AND EXCISION DEVICE (IMPLANTABLE)GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), WITH RECHARGEABLE BATTERY ANDCHARGING SYSTEMINTERSPINOUS PROCESS DISTRACTION DEVICE (IMPLANTABLE)STENT, COATED/COVERED, WITH DELIVERY SYSTEMSTENT, COATED/COVERED, WITHOUT DELIVERY SYSTEMSTENT, NON-COATED/NON-COVERED, WITH DELIVERY SYSTEMSTENT, NON-COATED/NON-COVERED, WITHOUT DELIVERY SYSTEM

Query_110708

Page 190

MATERIAL FOR VOCAL CORD MEDIALIZATION, SYNTHETIC (IMPLANTABLE)TISSUE MARKER (IMPLANTABLE)VENA CAVA FILTERDIALYSIS ACCESS SYSTEM (IMPLANTABLE)CARDIOVERTER-DEFIBRILLATOR, OTHER THAN SINGLE OR DUAL CHAMBER (IMPLANTABLE)ADAPTOR/EXTENSION, PACING LEAD OR NEUROSTIMULATOR LEAD (IMPLANTABLE)EMBOLIZATION PROTECTIVE SYSTEMCATHETER, TRANSLUMINAL ANGIOPLASTY, LASERCATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)CATHETER, ABLATION, NON-CARDIAC, ENDOVASCULAR (IMPLANTABLE)INFUSION PUMP, NON-PROGRAMMABLE, PERMANENT (IMPLANTABLE)INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, FIXED-CURVE,PEEL-AWAYINTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, FIXED-CURVE,OTHER THAN PEEL-AWAYINTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIACELECTROPHYSIOLOGICAL, NON-LASERLEAD, CARDIOVERTER-DEFIBRILLATOR, ENDOCARDIAL DUAL COIL (IMPLANTABLE)LEAD, CARDIOVERTER-DEFIBRILLATOR, OTHER THAN ENDOCARDIAL SINGLE OR DUAL COIL(IMPLANTABLE)LEAD, NEUROSTIMULATOR TEST KIT (IMPLANTABLE)LEAD, PACEMAKER, OTHER THAN TRANSVENOUS VDD SINGLE PASSLEAD, PACEMAKER/CARDIOVERTER-DEFIBRILLATOR COMBINATION (IMPLANTABLE)LEAD, LEFT VENTRICULAR CORONARY VENOUS SYSTEMPROBE, PERCUTANEOUS LUMBAR DISCECTOMYSEALANT, PULMONARY, LIQUIDBRACHYTHERAPY SOURCE, NON-STRANDED, YTTRIUM-90, PER SOURCESTENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEMPROBE, CRYOABLATIONPACEMAKER, DUAL CHAMBER, NON RATE-RESPONSIVE (IMPLANTABLE)PACEMAKER, SINGLE CHAMBER, NON RATE-RESPONSIVE (IMPLANTABLE)PACEMAKER, OTHER THAN SINGLE OR DUAL CHAMBER (IMPLANTABLE)PROSTHESIS, PENILE, NON-INFLATABLESTENT, NON-CORONARY, TEMPORARY, WITH DELIVERY SYSTEMINFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)CATHETER, SUPRAPUBIC/CYSTOSCOPICCATHETER, OCCLUSIONINTRODUCER/SHEATH, OTHER THAN GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, LASERCATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, OTHER THAN 3D OR VECTORMAPPING, COOL-TIPREPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFTBRACHYTHERAPY SOLUTION, IODINE-125, PER MCIBRACHYTHERAPY SOURCE, CESIUM-131, PER SOURCEBRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, IODINE-125, GREATER THAN1.01 MCI (NIST), PER SOURCEBRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, PALADIUM-103, GREATER THAN2.2 MCI (NIST), PER SOURCEBRACHYTHERAPY LINEAR SOURCE, NON-STRANDED, PALADIUM-103, PER 1 MMBRACHYTHERAPY SOURCE, NON-STRANDED, YTTERBIUM-169, PER SOURCEBRACHYTHERAPY SOURCE, STRANDED, IODINE-125, PER SOURCEBRACHYTHERAPY SOURCE, NON-STRANDED, IODINE-125, PER SOURCEBRACHYTHERAPY SOURCE, STRANDED, PALLADIUM-103, PER SOURCEBRACHYTHERAPY SOURCE, NON-STRANDED, PALLADIUM-103, PER SOURCEBRACHYTHERAPY SOURCE, STRANDED, CESIUM-131, PER SOURCEBRACHYTHERAPY SOURCE, NON-STRANDED, CESIUM-131, PER SOURCEBRACHYTHERAPY SOURCE, STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCEBRACHYTHERAPY SOURCE, NON-STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCEMAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMENMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMENMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,ABDOMEN

Query_110708

Page 191

MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; UNILATERALMAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; UNILATERALMAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST;UNILATERALMAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; BILATERALMAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; BILATERALMAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST;BILATERALMAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM)MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,CHEST (EXCLUDING MYOCARDIUM)MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITYMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITYMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,LOWER EXTREMITYMAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVISMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVISMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,PELVISTRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BYWITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; COMPLETETRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BYWITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; FOLLOW-UP OR LIMITED STUDYTRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BYWITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODERECORDING; COMPLETETRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BYWITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODERECORDING; FOLLOW-UP OR LIMITED STUDYTRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRASTFOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH ORWITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION,INTERPRETATION AND REPORTTRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRASTFOLLOWED BY WITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBEPLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORTTRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRASTFOLLOWED BY WITH CONTRAST, FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT,REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING(CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION ANDTO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASISTRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BYWITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODERECORDING, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLEEXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORTTRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BYWITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODERECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY,AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHYTRANSTHORACIC ECHOCARDIOGRAPHY, WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BYWITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODERECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USINGTREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITHINTERPRETATION AND REPORT; INCLUDING PERFORMANCE OF CONTINUOUSELECTROCARDIOGRAPHIC MONITORING, WITH PHYSICIAN SUPERVISIONINTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; UP TO 1 HOURINTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; EACH ADDITIONAL HOUR (LISTSEPARATELY IN ADDITION TO C8950)THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION; INTRAVENOUS PUSH OF EACH NEWSUBSTANCE/DRUG

Query_110708

Page 192

CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS; PUSH TECHNIQUECHEMOTHERAPY ADMINISTRATION, INTRAVENOUS; INFUSION TECHNIQUE, UP TO ONE HOURCHEMOTHERAPY ADMINISTRATION, INTRAVENOUS; INFUSION TECHNIQUE, EACH ADDITIONALHOUR (LIST SEPARATELY IN ADDITION TO C8954)INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION(MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMPINJECTION, SODIUM CHROMATE CR51, PER 0.25 MCIPALIVIZUMAB-RSV-IGM, PER 50 MGBACLOFEN INTRATHECAL SCREENING KIT (1 AMP)BACLOFEN INTRATHECAL REFILL KIT, PER 500 MCGBACLOFEN INTRATHECAL REFILL KIT, PER 2000 MCGSUPPLY OF CO 57 COBALTOUS CHLORIDE, RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENTSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, 51 SODIUM CHROMATE, PER50 MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, SODIUM IOTHALAMATEI-125 INJECTION, PER 10 UCIINJECTION, HEPATITIS B IMMUNE GLOBULIN, PER 1 MLINJECTION, PERFLUTREN LIPID MICROSPHERE, PER 2 ML VIALINJECTION, PANTOPRAZOLE SODIUM, PER VIALINJECTION, ARGATROBAN, PER 5 MGHUMAN FIBROBLAST DERIVED TEMPORARY SKIN SUBSTITUTE, PER 247 SQUARE CENTIMETERSINJECTION, NATALIZUMAB, PER 5 MGINJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, PER 1 MGINJECTION, PEGAPTANIB SODIUM, PER 0.3 MGINJECTION, CLOFARABINE, PER 1 MGBILAYERED CELLULAR MATRIX, PER 36 SQUARE CENTIMETERSHUMAN FIBROBLAST-DERIVED DERMAL SUBSTITUTE, PER 37.5 SQUARE CENTIMETERSINJECTION, SUSPENSION OF MICROSPHERES OF HUMAN SERUM ALBUMIN WITHOCTAFLUOROPROPANE, PER 3 MLINJECTION, PERFLEXANE LIPID MICROSPHERES, PER 10 ML VIALINJECTION, OXALIPLATIN, PER 5 MGCOLLAGEN-GLYCOSAMINOGLYCAN BILAYER MATRIX, PER CM2INJECTION, ALEFACEPT, FOR INTRAVENOUS USE, PER 7.5 MGINJECTION, ALEFACEPT, FOR INTRAMUSCULAR USE, PER 7.5 MGINJECTION, AZACITIDINE, PER 1 MGSODIUM HYALURONATE PER 30 MG DOSE, FOR INTRA-ARTICULAR INJECTIONACELLULAR DERMAL TISSUE MATRIX, PER 16CM2DECELLULARIZED SOFT TISSUE SCAFFOLD, PER 1 CCINJECTION, ADENOSINE FOR THERAPEUTIC OR DIAGNOSTIC USE, 6 MG (NOT TO BE USED TOREPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, INSTEAD USE A9270)INJECTION, GALSULFASE, PER 5 MGINJECTION, FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT, PER 0.59 MGINJECTION, ZICONOTIDE FOR INTRATHECAL INFUSION, PER 5 MCGINJECTION, MICAFUNGIN SODIUM, PER 1 MGINJECTION, TIGECYCLINE, PER 1 MGINJECTION, IBANDRONATE SODIUM, PER 1 MGINJECTION, ABATACEPT, PER 10 MGINJECTION, DECITABINE, PER 1 MGINJECTION, IDURSULFASE, 1 MGINJECTION, RANIBIZUMAB, 0.5 MGINJECTION, ALGLUCOSIDASE ALFA, 10 MGINJECTION, PANITUMUMAB, 10 MGINJECTION, ECULIZUMAB, 10 MGINJECTION, LANREOTIDE ACETATE, 1 MGINJECTION, LEVETIRACETAM, 10 MGINJECTION, TEMSIROLIMUS, 1 MGINJECTION, IXABEPILONE, 1 MGINJECTION, DORIPENEM, 10 MGINJECTION, FOSAPREPITANT, 1 MGINJECTION, BENDAMUSTINE HCL, 1 MGINJECTION, REGADENOSON, 0.4 MG

Query_110708

Page 193

INJECTION, ROMIPLOSTIM, 10 MCGINJECTION, GADOXETATE DISODIUM, PER MLIOBENGUANE, I-123, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIESINJECTION, CLEVIDIPIEN BUTYRATE, 1 MGMICROPOROUS COLLAGEN TUBE OF NON-HUMAN ORIGIN, PER CENTIMETER LENGTHACELLULAR DERMAL TISSUE MATRIX OF NON-HUMAN ORIGIN, PER SQUARE CENTIMETER (DONOT REPORT C9351 IN CONJUNCTION WITH J7345)MICROPOROUS COLLAGEN IMPLANTABLE TUBE (NEURAGEN NERVE GUIDE), PER CENTIMETERLENGTHMICROPOROUS COLLAGEN IMPLANTABLE SLIT TUBE (NEURAWRAP NERVE PROTECTOR), PERCENTIMETER LENGTHACELLULAR PERICARDIAL TISSUE MATRIX OF NON-HUMAN ORIGIN (VERITAS), PER SQUARECENTIMETERCOLLAGEN NERVE CUFF (NEUROMATRIX), PER 0.5 CENTIMETER LENGTHTENDON, POROUS MATRIX OF CROSS-LINKED COLLAGEN AND GLYCOSAMINOGLYCAN MATRIX(TENOGLIDE TENDON PROTECTOR SHEET), PER SQUARE CENTIMETERDERMAL SUBSTITUTE, GRANULATED CROSS-LINKED COLLAGEN AND GLYCOSAMINOGLYCANMATRIX (FLOWABLE WOUND MATRIX), 1 CCDERMAL SUBSTITUTE, NATIVE, NON-DENATURED COLLAGEN (SURGIMEND COLLAGEN MATRIX),PER 0.5 SQUARE CENTIMETERSPOROUS PURIFIED COLLAGEN MATRIX BONE VOID FILLER (INTEGRA MOZAIKOSTEOCONDUCTIVE SCAFFOLD PUTTY, INTEGRA OS OSTEOCONDUCTIVE SCAFFOLD PUTTY), PER0.5 CCUNCLASSIFIED DRUGS OR BIOLOGICALSSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, THALLOUS CHLORIDE TL201, BRAND NAME, PER MCISUPPLY OF THERAPEUTIC RADIOPHARMACEUTICAL, STRONTIUM-89 CHLORIDE, BRAND NAME,PER MCISUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, I-131 SODIUM IODIDECAPSULE, BRAND NAME, PER MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC AGENT, I-131 SODIUM IODIDE CAPSULE,BRAND NAME, PER MILLICURIESUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC AGENT, I-131 SODIUM IODIDE SOLUTION,BRAND NAME, PER MILLICURIESUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC AGENT, I-131 SODIUM IODIDE SOLUTION,BRAND NAME, PER MILLICURIEINJECTION, DEXRAZOXANE HYDROCHLORIDE, BRAND NAME, PER 250 MGINJECTION, PAMIDRONATE DISODIUM, BRAND NAME, PER 30 MGSODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR INJECTION, BRANDNAMEETOPOSIDE, ORAL, BRAND NAME, 50 MGDOXORUBICIN HCL, BRAND NAME, 10 MGBLEOMYCIN SULFATE, BRAND NAME, 15 UNITSCISPLATIN, POWDER OR S0LUTION, BRAND NAME, PER 10 MGINJECTION, CLADRIBINE, BRAND NAME, PER 1 MGCYCLOPHOSPHAMIDE, BRAND NAME, 100 MGCYCLOPHOSPHAMIDE, LYOPHILIZED, BRAND NAME, 100 MGCYTARABINE, BRAND NAME, 100 MGDACARBAZINE, BRAND NAME, 100 MGDAUNORUBICIN, BRAND NAME, 10 MGETOPOSIDE, BRAND NAME, 10 MGFLOXURIDINE, BRAND NAME, 500 MGIFOSFAMIDE, BRAND NAME, 1 GMMESNA, BRAND NAME, 200 MGIDARUBICIN HYDROCHLORIDE, BRAND NAME, 5 MGLEUPROLIDE ACETATE, BRAND NAME, PER 1 MGPACLITAXEL, BRAND NAME, 30 MGMITOMYCIN, BRAND NAME, 5 MGTHIOTEPA, BRAND NAME, 15 MGINJECTION, GONADORELIN HYDROCHLORIDE, BRAND NAME, PER 100 MCGAZATHIOPRINE, PARENTERAL, BRAND NAME, PER 100 MG

Query_110708

Page 194

CARMUSTINE, BRAND NAME, 100 MGCYCLOSPORINE, ORAL, BRAND NAME, 100 MGDIETHYLSTILBESTROL DIPHOSPHATE, BRAND NAME, 250 MGVINORELBINE TARTRATE, BRAND NAME, PER 10 MGINJECTION OR INSERTION OF INERT SUBSTANCE FOR SUBMUCOSAL/INTRAMUSCULARINJECTION(S) INTO THE UPPER GASTROINTESTINAL TRACT, UNDER FLUOROSCOPIC GUIDANCENON-CONTACT LASER VAPORIZATION OF PROSTATE, INCLUDING COAGULATION CONTROL OFINTRAOPERATIVE AND POST-OPERATIVE BLEEDINGCREATIONS OF THERMAL ANAL LESIONS BY RADIOFREQUENCY ENERGYKYPHOPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTIONKYPHOPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; EACHADDITIONAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARYPROCEDURE)HIGH-ENERGY (GREATER THAN 0.22MJ/MM2) EXTRACORPOREAL SHOCK WAVE (ESW) TREATMENTFOR CHRONIC LATERAL EPICONDYLITIS (TENNIS ELBOW)HIGH-ENERGY (GREATER THAN 0.22MJ/MM2) EXTRACORPOREAL SHOCK WAVE (ESW) TREATMENTFOR CHRONIC PLANTAR FASCIITISSTEREOSCOPIC KV X-RAY IMAGING WITH INFRARED TRACKING FOR LOCALIZATION OF TARGETVOLUME (DO NOT REPORT C9722 IN CONJUNCTION WITH G0173, G0243, G0251, G0339 ORG0340)DYNAMIC INFRARED BLOOD PERFUSION IMAGING (DIRI)ENDOSCOPIC FULL-THICKNESS PLICATION IN THE GASTRIC CARDIA USING ENDOSCOPICPLICATION SYSTEM (EPS); INCLUDES ENDOSCOPYPLACEMENT OF ENDORECTAL INTRACAVITARY APPLICATOR FOR HIGH INTENSITYBRACHYTHERAPYPLACEMENT AND REMOVAL (IF PERFORMED) OF APPLICATOR INTO BREAST FOR RADIATIONTHERAPYINSERTION OF IMPLANTS INTO THE SOFT PALATE; MINIMUM OF THREE IMPLANTSPLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY/SURGERY GUIDANCE (EG,FIDUCIAL MARKERS, DOSIMETER), OTHER THAN PROSTATE (ANY APPROACH), SINGLE ORMULTIPLERADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAYIMPLANTED PROSTHETIC DEVICE, PAYABLE ONLY FOR INPATIENTS WHO DO NOT HAVEINPATIENT COVERAGEPERIODIC ORAL EVALUATION - ESTABLISHED PATIENTLIMITED ORAL EVALUATION - PROBLEM FOCUSEDORAL EVALUATION FOR A PATIENT UNDER THREE YEARS OF AGE AND COUNSELING WITHPRIMARY CAREGIVERCOMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENTDETAILED AND EXTENSIVE ORAL EVALUATION - PROBLEM FOCUSED, BY REPORTRE-EVALUATION-LIMITED, PROBLEM FOCUSED (ESTABLISHED PATIENT; NOT POST-OPERATIVEVISIT)COMPREHENSIVE PERIODONTAL EVALUATION - NEW OR ESTABLISHED PATIENTINTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS)INTRAORAL-PERIAPICAL-FIRST FILMINTRAORAL-PERIAPICAL-EACH ADDITIONAL FILMINTRAORAL-0CCLUSAL FILMEXTRAORAL-FIRST FILMEXTRAORAL-EACH ADDITIONAL FILMBITEWING-SINGLE FILMBITEWINGS-TWO FILMSBITEWINGS - THREE FILMSBITEWINGS-FOUR FILMSVERTICAL BITEWINGS - 7 TO 8 FILMSPOSTERIOR-ANTERIOR OR LATERAL SKULL AND FACIAL BONE SURVEY FILMSIALOGRAPHYTEMPOROMANDIBULAR JOINT ARTHROGRAM, INCLUDING INJECTIONOTHER TEMPOROMANDIBULAR JOINT FILMS, BY REPORTTOMOGRAPHIC SURVEYPANORAMIC FILMCEPHALOMETRIC FILM

Query_110708

Page 195

ORAL/FACIAL PHOTOGRAPHIC IMAGESCONE BEAM CT - CRANIOFACIAL DATA CAPTURECONE BEAM - TWO-DIMENSIONAL IMAGE RECONSTRUCTION USING EXISTING DATA, INCLUDESMULTIPLE IMAGESCONE BEAM - THREE-DIMENSIONAL IMAGE RECONSTRUCTION USING EXISTING DATA,INCLUDES MULTIPLE IMAGESCOLLECTION OF MICROORGANISMS FOR CULTURE AND SENSITIVITYVIRAL CULTURECOLLECTION AND PREPARATION OF SALIVA SAMPLE FOR LABORATORY DIAGNOSTIC TESTINGANALYSIS OF SALIVA SAMPLEGENETIC TEST FOR SUSCEPTIBILITY TO ORAL DISEASESCARIES SUSCEPTIBILITY TESTSADJUNCTIVE PRE-DIAGNOSTIC TEST THAT AIDS IN DETECTION OF MUCOSAL ABNORMALITIESINCLUDING PREMALIGNANT AND MALIGNANT LESIONS, NOT TO INCLUDE CYTOLOGY OR BIOPSYPROCEDURESPULP VITALITY TESTSDIAGNOSTIC CASTSACCESSION OF TISSUE, GROSS EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTENREPORTACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINATION, PREPARATION ANDTRANSMISSION OF WRITTEN REPORTACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINATION, INCLUDING ASSESSMENT OFSURGICAL MARGINS FOR PRESENCE OF DISEASE, PREPARATION AND TRANSMISSION OFWRITTEN REPORTDECALCIFICATION PROCEDURESPECIAL STAINS FOR MICROORGANISMSSPECIAL STAINS, NOT FOR MICROORGANISMSIMMUNOHISTOCHEMICAL STAINSTISSUE IN-SITU HYBRIDIZATION, INCLUDING INTERPRETATIONACCESSION OF EXFOLIATIVE CYTOLOGIC SMEARS, MICROSCOPIC EXAMINATION, PREPARATIONAND TRANSMISSION OF WRITTEN REPORTELECTRON MICROSCOPY - DIAGNOSTICDIRECT IMMUNOFLUORESCENCEINDIRECT IMMUNOFLUORESCENCECONSULTATION ON SLIDES PREPARED ELSEWHERECONSULTATION, INCLUDING PREPARATION OF SLIDES FROM BIOPSY MATERIAL SUPPLIED BYREFERRING SOURCELABORATORY ACCESSION OF BRUSH BIOPSY SAMPLE, MICROSCOPIC EXAMINATION,PREPARATION AND TRANSMISSION OF WRITTEN REPORTOTHER ORAL PATHOLOGY PROCEDURES, BY REPORTUNSPECIFIED DIAGNOSTIC PROCEDURE, BY REPORTPROPHYLAXIS-ADULTPROPHYLAXIS-CHILDTOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)-CHILDTOPICAL APPLICATION OF FLUORIDE - CHILDTOPICAL APPLICATION OF FLUORIDE - ADULTTOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)-ADULTTOPICAL FLUORIDE VARNISH; THERAPEUTIC APPLICATION FOR MODERATE TO HIGH CARIESRISK PATIENTSNUTRITIONAL COUNSELING FOR THE CONTROL OF DENTAL DISEASETOBACCO COUNSELING FOR THE CONTROL AND PREVENTION OF ORAL DISEASEORAL HYGIENE INSTRUCTIONSEALANT-PER TOOTHSPACE MAINTAINER-FIXED UNILATERALSPACE MAINTAINER-FIXED BILATERALSPACE MAINTAINER-REMOVABLE UNILATERALSPACE MAINTAINER-REMOVABLE BILATERALRECEMENTATION OF SPACE MAINTAINERREMOVAL OF FIXED SPACE MAINTAINERAMALGAM-ONE SURFACE, PRIMARY OR PERMANENTAMALGAM-TWO SURFACES, PRIMARY OR PERMANENT

Query_110708

Page 196

AMALGAM-THREE SURFACES, PRIMARY OR PERMANENTAMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENTRESIN-ONE SURFACE, ANTERIORRESIN-TWO SURFACES, ANTERIORRESIN-THREE SURFACES, ANTERIORRESIN-FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR)RESIN-BASED COMPOSITE CROWN, ANTERIORRESIN-BASED COMPOSITE - ONE SURFACE, POSTERIORRESIN-BASED COMPOSITE - TWO SURFACES, POSTERIORRESIN-BASED COMPOSITE - THREE SURFACES, POSTERIORRESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIORGOLD FOIL-ONE SURFACEGOLD FOIL-TWO SURFACESGOLD FOIL-THREE SURFACESINLAY-METALLIC-ONE SURFACEINLAY-METALLIC-TWO SURFACESINLAY-METALLIC-THREE OR MORE SURFACESONLAY-METALLIC-TWO SURFACESONLAY - METALLIC - THREE SURFACESONLAY - METALLIC - FOUR OR MORE SURFACESINLAY-PORCELAIN/CERAMIC-ONE SURFACEINLAY-PORCELAIN/CERAMIC-TWO SURFACESINLAY-PORCELAIN/CERAMIC-THREE OR MORE SURFACESONLAY - PORCELAIN/CERAMIC - TWO SURFACESONLAY - PORCELAIN/CERAMIC - THREE SURFACESONLAY - PORCELAIN/CERAMIC - FOUR OR MORE SURFACESINLAY - RESIN-BASED COMPOSITE - ONE SURFACEINLAY - RESIN-BASED COMPOSITE - TWO SURFACESINLAY - RESIN-BASED COMPOSITE - THREE OR MORE SURFACESONLAY - RESIN-BASED COMPOSITE - TWO SURFACESONLAY - RESIN-BASED COMPOSITE - THREE SURFACESONLAY - - RESIN-BASED COMPOSITE - FOUR OR MORE SURFACESCROWN - RESIN-BASED COMPOSITE (INDIRECT)CROWN - 3/4 RESIN-BASED COMPOSITE (INDIRECT)CROWN-RESIN WITH HIGH NOBLE METALCROWN-RESIN WITH PREDOMINANTLY BASE METALCROWN-RESIN WITH NOBLE METALCROWN-PORCELAIN/CERAMIC SUBSTRATECROWN-PORCELAIN FUSED TO HIGH NOBLE METALCROWN-PROCELAIN FUSED TO PREDOMINANTLY BASE METALCROWN-PORCELAIN FUSED TO NOBLE METALCROWN - 3/4 CAST HIGH NOBLE METALCROWN - 3/4 CAST PREDOMINANTLY BASE METALCROWN - 3/4 CAST NOBLE METALCROWN - 3/4 PORCELAIN/CERAMICCROWN-FULL CAST HIGH NOBLE METALCROWN-FULL CAST PREDOMINANTLY BASE METALCROWN-FULL CAST NOBLE METALCROWN-TITANIUMPROVISIONAL CROWNRECEMENT INLAY, ONLAY OR PARTIAL COVERAGE RESTORATIONRECEMENT CAST OR PREFABRICATED POST AND CORERECEMENT CROWNPREFABRICATED STAINLESS STEEL CROWN-PRIMARY TOOTHPREFABRICATED STAINLESS STEEL CROWN-PERMANENT TOOTHPREFABRICATED RESIN CROWNPREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOWPREFABRICATED ESTHETIC COATED STAINLESS STEEL CROWN - PRIMARY TOOTHSEDATIVE FILLINGCORE BUILD-UP, INCLUDING ANY PINSPIN RETENTION-PER TOOTH, IN ADDITION TO RESTORATION

Query_110708

Page 197

POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATEDEACH ADDITIONAL INDIRECTLY FABRICATED POST - SAME TOOTHPREFABRICATED POST AND CORE IN ADDITION TO CROWNPOST REMOVAL (NOT IN CONJUCTION WITH ENDODONTIC THERAPY)EACH ADDITIONAL PREFABRICATED POST - SAME TOOTHLABIAL VENEER (LAMINATE)-CHAIRSIDELABIAL VENEER (RESIN LAMINATE)-LABORATORYLABIAL VENEER (PORCELAIN LAMINATE)-LABORATORYTEMPORARY CROWN (FRACTURED TOOTH)ADDITIONAL PROCEDURES TO CONSTRUCT NEW CROWN UNDER EXISTING PARTIAL DENTUREFRAMEWORKCOPINGCROWN REPAIR, BY REPORTUNSPECIFIED RESTORATIVE PROCEDURE, BY REPORTPULP CAP-DIRECT (EXCLUDING FINAL RESTORATION)PULP CAP-INDIRECT (EXCLUDING FINAL RESTORATION)THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) REMOVAL OF PULP CORONAL TOTHE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENTPULPAL DEBRIDEMENT, PRIMARY AND PERMANENT TEETHPARTIAL PULPOTOMY FOR APEXOGENESIS - PERMANENT TOOTH WITH INCOMPLETE ROOTDEVELOPMENTPULPAL THERAPY (RESORBABLE FILLING)-ANTERIOR, PRIMARY TOOTH (EXCLUDING FINALRESTORATION)PULPAL THERAPY (RESORBABLE FILLING)-POSTERIOR, PRIMARY TOOTH (EXCLUDING FINALRESTORATION)ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATION)ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL RESTORATION)ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL RESTORATION)TREATMENT OF ROOT CANAL OBSTRUCTION; NON-SURGICAL ACCESSINCOMPLETE ENDODONTIC THERAPY; INOPERABLE, UNRESTORABLE OR FRACTURED TOOTHINTERNAL ROOT REPAIR OF PERFORATION DEFECTSRETREATMENT OF PREVIOUS ROOT CANAL THERAPY-ANTERIORRETREATMENT OF PREVIOUS ROOT CANAL THERAPY-BICUSPIDRETREATMENT OF PREVIOUS ROOT CANAL THERAPY-MOLARAPEXIFICATION/RECALCIFICATION-INITIAL VISIT (APICAL CLOSURE/CALCIFIC REPAIR OFPERFORATIONS, ROOT RESORPTION, ETC.)APEXIFICATION/RECALCIFICATION-INTERIM MEDICATION REPLACEMENT (APICALCLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT RESORPTION, ETC.)APEXIFICATION/RECALCIFICATION-FINAL VISIT (INCLUDES COMPLETED ROOT CANALTHERAPY-APICAL CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT RESORPTION, ETC.)APICOECTOMY/PERIRADICULAR SURGERY-ANTERIORAPICOECTOMY/PERIRADICULAR SURGERY-BICUSPID (FIRST ROOT)APICOECTOMY/PERIRADICULAR SURGERY-MOLAR (FIRST ROOT).APICOECTOMY/PERIRADICULAR SURGERY (EACH ADDITIONAL ROOT)RETROGRADE FILLING-PER ROOTROOT AMPUTATION-PER ROOTENDODONTIC ENDOSSEOUS IMPLANTINTENTIONAL REPLANTATION (INCLUDING NECESSARY SPLINTING)SURGICAL PROCEDURE FOR ISOLATION OF TOOTH WITH RUBBER DAMHEMISECTION (INCLUDING ANY ROOT REMOVAL), NOT INCLUDING ROOT CANAL THERAPYCANAL PREPARATION AND FITTING OF PREFORMED DOWEL OR POSTUNSPECIFIED ENDODONTIC PROCEDURE, BY REPORTGINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDEDSPACES PER QUADRANTGINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDEDSPACES PER QUADRANTANATOMICAL CROWN EXPOSURE - FOUR OR MORE CONTIGUOUS TEETH PER QUADRANTANATOMICAL CROWN EXPOSURE - ONE TO THREE TEETH PER QUADRANTGINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE CONTIGUOUS TEETHOR TOOTH BOUNDED SPACES PER QUADRANTGINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - ONE TO THREE CONTIGUOUS TEETH

Query_110708

Page 198

OR TOOTH BOUNDED SPACES PER QUADRANTAPICALLY POSITIONED FLAPCLINICAL CROWN LENGTHENING-HARD TISSUEOSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) - FOUR OR MORE CONTIGUOUSTEETH OR TOOTH BOUNDED SPACES PER QUADRANTOSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) - ONE TO THREE CONTIGUOUSTEETH OR TOOTH BOUNDED SPACES PER QUADRANTBONE REPLACEMENT GRAFT - FIRST SITE IN QUADRANTBONE REPLACEMENT GRAFT - EACH ADDITIONAL SITE IN QUADRANTBIOLOGIC MATERIALS TO AID IN SOFT AND OSSEOUS TISSUE REGENERATIONGUIDED TISSUE REGENERATION - RESORBABLE BARRIER, PER SITEGUIDED TISSUE REGENERATION - NONRESORBABLE BARRIER, PER SITE, (INCLUDESMEMBRANE REMOVAL)SURGICAL REVISION PROCEDURE, PER TOOTHPEDICLE SOFT TISSUE GRAFT PROCEDUREFREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR SITE SURGERY)SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES, PER TOOTHDISTAL OR PROXIMAL WEDGE PROCEDURE (WHEN NOT PERFORMED IN CONJUCTION WITHSURGICAL PROCEDURES IN THE SAME ANATOMICAL AREA)SOFT TISSUE ALLOGRAFTCOMBINED CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFT, PER TOOTHPROVISIONAL SPLINTING-INTRACORONALPROVISIONAL SPLINTING-EXTRACORONALPERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANTPERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH, PER QUADRANTFULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND DIAGNOSISLOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA A CONTROLLED RELEASE VEHICLEINTO DISEASED CREVICULAR TISSUE, PER TOOTH, BY REPORTPERIODONTAL MAINTENANCEUNSCHEDULED DRESSING CHANGE (BY SOMEONE OTHER THAN TREATING DENTIST)UNSPECIFIED PERIODONTAL PROCEDURE, BY REPORTCOMPLETE DENTURE - MAXILLARYCOMPLETE DENTURE - MANDIBULARIMMEDIATE DENTURE - MAXILLARYIMMEDIATE DENTURE - MANDIBULARUPPER PARTIAL-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)LOWER PARTIAL-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES(INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES(INCLUDING ANY CONVENTIONAL CLASPS,RESTS AND TEETH)MAXILLARY PARTIAL DENTURE - FLEXIBLE BASE (INCLUDING ANY CLASPS, RESTS ANDTEETH)MANDIBULAR PARTIAL DENTURE - FLEXIBLE BASE (INCLUDING ANY CLASPS, RESTS ANDTEETH)REMOVABLE UNILATERAL PARTIAL DENTURE-ONE PIECE CAST METAL (INCLUDING CLASPS ANDTEETH)ADJUST COMPLETE DENTURE - MAXILLARYADJUST COMPLETE DENTURE - MANDIBULARADJUST PARTIAL DENTURE - MAXILLARYADJUST PARTIAL DENTURE - MANDIBULARREPAIR BROKEN COMPLETE DENTURE BASEREPLACE MISSING OR BROKEN TEETH-COMPLETE DENTURE (EACH TOOTH)REPAIR RESIN DENTURE BASEREPAIR CAST FRAMEWORKREPAIR OR REPLACE BROKEN CLASPREPLACE BROKEN TEETH-PER TOOTHADD TOOTH TO EXISTING PARTIAL DENTUREADD CLASP TO EXISTING PARTIAL DENTUREREPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MAXILLARY)REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MANDIBULAR)

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Page 199

REBASE COMPLETE MAXILLARY DENTUREREBASE COMPLETE MANDIBULAR DENTUREREBASE MAXILLARY PARTIAL DENTUREREBASE MANDIBULAR PARTIAL DENTURERELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)RELINE LOWER COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE)RELINE COMPLETE MAXILLARY DENTURE (LABORATORY)RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY)RELINE MAXILLARY PARTIAL DENTURE (LABORATORY)RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY)INTERIM COMPLETE DENTURE (MAXILLARY)INTERIM COMPLETE DENTURE (MANDIBULAR)INTERIM PARTIAL DENTURE (MAXILLARY)INTERIM PARTIAL DENTURE (MANDIBULAR)TISSUE CONDITIONING, MAXILLARYTISSUE CONDITIONING, MANDIBULAROVERDENTURE-COMPLETE, BY REPORTOVERDENTURE-PARTIAL, BY REPORTPRECISION ATTACHMENT, BY REPORTREPLACEMENT OF REPLACEABLE PART OF SEMI-PRECISION OR PRECISION ATTACHMENT (MALEOR FEMALE COMPONENT)MODIFICATION OF REMOVABLE PROSTHESIS FOLLOWING IMPLANT SURGERYUNSPECIFIED REMOVABLE PROSTHODONTIC PROCEDURE, BY REPORTFACIAL MOULAGE (SECTIONAL)FACIAL MOULAGE (COMPLETE)NASAL PROSTHESISAURICULAR PROSTHESISORBITAL PROSTHESISOCULAR PROSTHESISFACIAL PROSTHESISNASAL SEPTAL PROSTHESISOCULAR PROSTHESIS, INTERIMCRANIAL PROSTHESISFACIAL AUGMENTATION IMPLANT PROSTHESISNASAL PROSTHESIS, REPLACEMENTAURICULAR PROSTHESIS, REPLACEMENTORBITAL PROSTHESIS, REPLACEMENTFACIAL PROSTHESIS, REPLACEMENTOBTURATOR PROSTHESIS, SURGICALOBTURATOR PROSTHESIS, DEFINITIVEOBTURATOR PROSTHESIS, MODIFICATIONMANDIBULAR RESECTION PROSTHESIS WITH GUIDE FLANGEMANDIBULAR RESECTION PROSTHESIS WITHOUT GUIDE FLANGEOBTURATOR/PROSTHESIS, INTERIMTRISMUS APPLIANCE (NOT FOR TM TREATMENT)FEEDING AIDSPEECH AID PROSTHESIS, PEDIATRICSPEECH AID PROSTHESIS, ADULTPALATAL AUGMENTATION PROSTHESISPALATAL LIFT PROSTHESIS, DEFINITIVEPALATAL LIFT PROSTHESIS, INTERIMPALATAL LIFT PROSTHESIS, MODIFICATIONSPEECH AID PROSTHESIS, MODIFICATIONSURGICAL STENTRADIATION CARRIERRADIATION SHIELDRADIATION CONE LOCATORFLUORIDE GEL CARRIERCOMMISSURE SPLINT

Query_110708

Page 200

SURGICAL SPLINTTOPICAL MEDICAMENT CARRIERUNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORTSURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL IMPLANTSURGICAL PLACEMENT OF INTERIM IMPLANT BODY FOR TRANSITIONAL PROSTHESIS:ENDOSTEAL IMPLANTSURGICAL PLACEMENT: EPOSTEAL IMPLANTSURGICAL PLACEMENT: TRANSOSTEAL IMPLANTIMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR COMPLETELY EDENTULOUS ARCHIMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY EDENTULOUS ARCHDENTAL IMPLANT SUPPORTED CONNECTING BARPREFABRICATED ABUTMENT - INCLUDES PLACEMENTCUSTOM ABUTMENT - INCLUDES PLACEMENTABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWNABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (HIGH NOBLE METAL)ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (PREDOMINANTLY BASE METAL)ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (NOBLE METAL)ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE METAL)ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINANTLY BASE METAL)ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE METAL)IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWNIMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN (TITANIUM, TITANIUM ALLOY,HIGH NOBLE METAL)IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL)ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC FPDABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (HIGH NOBLE METAL)ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (PREDOMINANTLYBASE METAL)ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (NOBLE METAL)ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (HIGH NOBLE METAL)ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (PREDOMINANTLY BASE METAL)ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (NOBLE METAL)IMPLANT SUPPORTED RETAINER FOR CERAMIC FPDIMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (TITANIUM, TITANIUMALLOY, OR HIGH NOBLE METAL)IMPLANT SUPPORTED RETAINER FOR CAST METAL FPD (TITANIUM, TITANIUM ALLOY, ORHIGH NOBLE METAL)IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR COMPLETELY EDENTULOUS ARCHIMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR PARTIALLY EDENTULOUS ARCHIMPLANT MAINTENANCE PROCEDURES, INCLUDING: REMOVAL OF PROSTHESIS, CLEANSING OFPROSTHESIS AND ABUTMEN REINSERTION OF PROSTHESISREPAIR IMPLANTSUPPORTED PROSTHESIS BY REPORTREPLACEMENT OF SEMI-PRECISION OR PRECISION ATTACHMENT (MALE OR FEMALECOMPONENT) OF IMPLANT/ABUTMENT SUPPORTED PROSTHESIS, PER ATTACHMENTRECEMENT IMPLANT/ABUTMENT SUPPORTED CROWNRECEMENT IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL DENTUREABUTMENT SUPPORTED CROWN - (TITANIUM)REPAIR IMPLANT ABUTMENT, BY REPORTIMPLANT REMOVAL, BY REPORTRADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORTABUTMENT SUPPORTED RETAINER CROWN FOR FPD - (TITANIUM)UNSPECIFIED IMPLANT PROCEDURE, BY REPORTPONTIC - INDIRECT RESIN BASED COMPOSITEPONTIC-CAST HIGH NOBLE METALPONTIC-CAST PREDOMINANTLY BASE METALPONTIC-CAST NOBLE METALPONTIC - TITANIUMPONTIC-PORCELAIN FUSED TO HIGH NOBLE METALPONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE METALPONTIC-PORCELAIN FUSED TO NOBLE METALPONTIC - PORCELAIN/CERAMIC

Query_110708

Page 201

PONTIC-RESIN WITH HIGH NOBLE METALPONTIC-RESIN WITH PREDOMINANTLY BASE METALPONTIC-RESIN WITH NOBLE METALPROVISIONAL PONTICRETAINER-CAST METAL FOR RESIN BONDED FIXED PROSTHESISRETAINER - PORCELAIN/CERAMIC FOR RESIN BONDED FIXED PROSTHESISINLAY-PORCELAIN/CERAMIC, TWO SURFACESINLAY - PORCELAIN/CERAMIC, THREE OR MORE SURFACESINLAY - CAST HIGH NOBLE METAL, TWO SURFACESINLAY - CAST HIGH NOBLE METAL, THREE OR MORE SURFACESINLAY - CAST PREDOMINANTLY BASE METAL, TWO SURFACESINLAY - CAST PREDOMINANTLY BASE METAL, THREE OR MORE SURFACESINLAY - CAST NOBLE METAL, TWO SURFACESINLAY - CAST NOBLE METAL, THREE OR MORE SURFACESONLAY - PORCELAIN/CERAMIC, TWO SURFACESONLAY - PORCELAIN/CERAMIC, THREE OR MORE SURFACESONLAY - CAST HIGH NOBLE METAL, TWO SURFACESONLAY - CAST HIGH NOBLE METAL, THREE OR MORE SURFACESONLAY - CAST PREDOMINANTLY BASE METAL, TWO SURFACESONLAY - CAST PREDOMINANTLY BASE METAL, THREE OR MORE SURFACESONLAY - CAST NOBLE METAL, TWO SURFACESONLAY - CAST NOBLE METAL, THREE OR MORE SURFACESINLAY - TITANIUMONLAY - TITANIUMCROWN - INDIRECT RESIN BASED COMPOSITECROWN-RESIN WITH HIGH NOBLE METALCROWN-RESIN WITH PREDOMINANTLY BASE METALCROWN-RESIN WITH NOBLE METALCROWN - PORCELAIN/CERAMICCROWN-PORCELAIN FUSED TO HIGH NOBLE METALCROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METALCROWN-PORCELAIN FUSED TO NOBLE METALCROWN-3/4 CAST HIGH NOBLE METALCROWN - 3/4 CAST PREDOMINANTLY BASED METALCROWN - 3/4 CAST NOBLE METALCROWN - 3/4 PORCELAIN/CERAMICCROWN-FULL CAST HIGH NOBLE METALCROWN-FULL CAST PREDOMINANTLY BASE METALCROWN-FULL CAST NOBLE METALPROVISIONAL RETAINER CROWNCROWN - TITANIUMCONNECTOR BARRECEMENT BRIDGESTRESS BREAKERPRECISION ATTACHMENTPOST AND CORE IN ADDITION TO FIXED PARTIAL DENTURE RETAINER, INDIRECTLYFABRICATEDCAST POST AS PART OF BRIDGE RETAINERPREFABRICATED POST AND CORE IN ADDITION TO BRIDGE RETAINERCORE BUILD UP FOR RETAINER, INCLUDING ANY PINSCOPING-METALEACH ADDITIONAL INDIRECTLY FABRICATED POST - SAME TOOTHEACH ADDITIONAL PREFABRICATED POST - SAME TOOTHBRIDGE REPAIR, BY REPORTPEDIATRIC PARTIAL DENTURE, FIXEDUNSPECIFIED FIXED PROSTHODONTIC PROCEDURE, BY REPORTEXTRACTION, CORONAL REMNANTS - DECIDUOUS TOOTHEXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL)SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL FLAPAND REMOVAL OF BONE AND/OR SECTION OF TOOTHREMOVAL OF IMPACTED TOOTH-SOFT TISSUE

Query_110708

Page 202

REMOVAL OF IMPACTED TOOTH-PARTIALLY BONYREMOVAL OF IMPACTED TOOTH-COMPLETELY BONYREMOVAL OF IMPACTED TOOTH-COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONSSURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE)ORAL ANTRAL FISTULA CLOSUREPRIMARY CLOSURE OF A SINUS PERFORATIONTOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED OR DISPLACEDTOOTHTOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION FROM ONE SITE TO ANOTHER ANDSPLINTING AND/OR STABILIZATION)SURGICAL ACCESS OF AN UNERUPTED TOOTHMOBILIZATION OF ERUPTED OR MALPOSITIONED TOOTH TO AID ERUPTIONPLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPACTED TOOTHBIOPSY OF ORAL TISSUE - HARD (BONE, TOOTH)BIOPSY OF ORAL TISSUE - SOFTEXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTIONBRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTIONSURGICAL REPOSITIONING OF TEETHTRANSSEPTAL FIBEROTOMY/SUPRA CRESTAL FIBEROTOMY, BY REPORTSURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE [SCREW RETAINED PLATE] REQUIRINGSURGICAL FLAPSURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE REQUIRING SURGICAL FLAPSURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE WITHOUT SURGICAL FLAPALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTHSPACES, PER QUADRANTALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTHSPACES, PER QUADRANTALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTHSPACES, PER QUADRANTALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTHSPACES, PER QUADRANTVESTIBULOPLASTY-RIDGE EXTENSION (SECOND EPITHELIALIZATION)VESTIBULOPLASTY-RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS, MUSCLERE-ATTACHMENTS, REVISION OF SOFT TISSUE ATTACHMENT, AND MANAGEMENT OFHYPERTROPHIED AND HYPERPLASTIC TISSUE)EXCISION OF BENIGN LESION UP TO 1.25 CMEXCISION OF BENIGN LESION GREATER THAN 1.25 CMEXCISION OF BENIGN LESION, COMPLICATEDEXCISION OF MALIGNANT LESION UP TO 1.25 CMEXCISION OF MALIGNANT LESION GREATER THAN 1.25 CMEXCISION OF MALIGNANT LESION, COMPLICATEDEXCISION OF MALIGNANT TUMOR-LESION DIAMETER UP TO 1.25 CMEXCISION OF MALIGNANT TUMOR-LESION DIAMETER GREATER THAN 1.25 CMREMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER UP T0 1.25 CMREMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER GREATER THAN 1.25 CMREMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER UP TO 1.25 CMREMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER GREATER THAN1.25 CMDESTRUCTION OF LESION(S) BY PHYSICAL OR CHEMICAL METHODS, BY REPORTREMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR MANDIBLE)REMOVAL OF TORUS PALATINUSREMOVAL OF TORUS MANDIBULARISSURGICAL REDUCTION OF OSSEOUS TUBEROSITYRADICAL RESECTION OF MAXILLA OR MANDIBLEINCISION AND DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUEINCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE - COMPLICATED(INCLUDES DRAINAGE OF MULTIPLE FASCIAL SPACES)INCISION AND DRAINAGE OF ABSCESS-EXTRAORAL SOFT TISSUEINCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE - COMPLICATED(INCLUDES DRAINAGE OF MULTIPLE FASCIAL SPACES)REMOVAL OF FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUE

Query_110708

Page 203

REMOVAL OF REACTION-PRODUCING FOREIGN BODIES-MUSCULOSKELETAL SYSTEMPARTIAL OSTECTOMY/SEQUESTRECTOMY FOR REMOVAL OF NON-VITAL BONEMAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIGN BODYMAXILLA-OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT)MAXILLA-CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT)MANDIBLE-OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT)MANDIBLE-CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT)MALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTIONMALAR AND/OR ZYGOMATIC ARCH-CLOSED REDUCTIONALVEOLUS - CLOSED REDUCTION, MAY INCLUDE STABILIZATION OF TEETHALVEOLUS - OPEN REDUCTION, MAY INCLUDE STABILIZATION OF TEETHFACIAL BONES-COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICALAPPROACHESMAXILLA-OPEN REDUCTIONMAXILLA-CLOSED REDUCTIONMANDIBLE-OPEN REDUCTIONMANDIBLE-CLOSED REDUCTIONMALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTIONMALAR AND/OR ZYGOMATIC ARCH-CLOSED REDUCTIONALVEOLUS - OPEN REDUCTION STABILIZATION OF TEETHALVEOLUS, CLOSED REDUCTION STABILIZATION OF TEETHFACIAL BONES-COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICALAPPROACHESOPEN REDUCTION OF DISLOCATIONCLOSED REDUCTION OF DISLOCATIONMANIPULATION UNDER ANESTHESIACONDYLECTOMYSURGICAL DISCECTOMY; WITH/WITHOUT IMPLANTDISC REPAIRSYNOVECTOMYMYOTOMYJOINT RECONSTRUCTIONARTHROTOMYARTHROPLASTYARTHROCENTESISNON-ARTHROSCOPIC LYSIS AND LAVAGEARTHROSCOPY-DIAGNOSIS, WITH OR WITHOUT BIOPSYARTHROSCOPY-SURGICAL: LAVAGE AND LYSIS OF ADHESIONSARTHROSCOPY-SURGICAL: DISC REPOSITIONING AND STABILIZATIONARTHROSCOPY-SURGICAL: SYNOVECTOMYARTHROSCOPY-SURGICAL: DISCECTOMYARTHROSCOPY-SURGICAL: DEBRIDEMENTOCCLUSAL ORTHOTIC APPLIANCEUNSPECIFIED TMD THERAPY, BY REPORTSUTURE OF RECENT SMALL WOUNDS UP TO 5 CMCOMPLICATED SUTURE-UP TO 5 CMCOMPLICATED SUTURE-GREATER THAN 5 CMSKIN GRAFT (IDENTIFY DEFECT COVERED, LOCATION, AND TYPE OF GRAFT)OSTEOPLASTY-FOR ORTHOGNATHIC DEFORMITIESOSTEOTOMY - MANDIBULAR RAMIOSTEOTOMY - MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING THE GRAFTOSTEOTOMY-SEGMENTED OR SUBAPICALOSTEOTOMY-BODY OF MANDIBLELEFORT I (MAXILLA-TOTAL)LEFORT I (MAXILLA-SEGMENTED)LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE HYPOPLASIA ORRETRUSION)-WITHOUT BONE GRAFTLEFORT II OR LEFORT III-WITH BONE GRAFTOSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR MAXILLA -AUTOGENOUS OR NONAUTOGENOUS, BY REPORTSINUS AUGMENTATION WITH BONE OR BONE SUBSTITUTES

Query_110708

Page 204

BONE REPLACEMENT GRAFT FOR RIDGE PRESERVATION - PER SITEREPAIR OF MAXILLOFACIAL SOFT AND/OR HARD TISSUE DEFECTFRENULECTOMY (FRENECTOMY OR FRENOTOMY)-SEPARATE PROCEDUREFRENULOPLASTYEXCISION OF HYPERPLASTIC TISSUE-PER ARCHEXCISION OF PERICORONAL GINGIVASURGICAL REDUCTION OF FIBROUS TUBEROSITYSIALOLITHOTOMYEXCISION OF SALIVARY GLAND, BY REPORTSIALODOCHOPLASTYCLOSURE OF SALIVARY FISTULAEMERGENCY TRACHEOTOMYCORONOIDECTOMYSYNTHETIC GRAFT-MANDIBLE OR FACIAL BONES, BY REPORTIMPLANT-MANDIBLE FOR AUGMENTATION PURPOSES (EXCLUDING ALVEOLAR RIDGE), BY REPORTAPPLIANCE REMOVAL (NOT BY DENTIST WHO PLACED APPLIANCE), INCLUDES REMOVAL OFARCHBARINTRAORAL PLACEMENT OF A FIXATION DEVICE NOT IN CONJUNCTION WITH A FRACTUREUNSPECIFIED ORAL SURGERY PROCEDURE, BY REPORTLIMITED ORTHODONTIC TREATMENT OF THE PRIMARY DENTITIONLIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITIONLIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITIONLIMITED ORTHODONTIC TREATMENT OF THE ADULT DENTITIONINTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY DENTITIONINTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITIONCOMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITIONCOMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITIONCOMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DENTITIONREMOVABLE APPLIANCE THERAPYFIXED APPLIANCE THERAPYPRE-ORTHODONTIC VISITPERIODIC ORTHODONTIC TREATMENT VISIT (AS PART OF CONTRACT)ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OFRETAINER(S))ORTHODONTIC TREATMENT (ALTERNATIVE BILLING TO A CONTRACT FEE)REPAIR OF ORTHODONTIC APPLIANCEREPLACEMENT OF LOST OR BROKEN RETAINERREBONDING OR RECEMENTING; AND/OR REPAIR, AS REQUIRED, OF FIXED RETAINERSUNSPECIFIED ORTHODONTIC PROCEDURE, BY REPORTPALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN-MINOR PROCEDURESFIXED PARTIAL DENTURE SECTIONINGLOCAL ANESTHESIA N0T IN CONJUNCTION WITH OPERATIVE OR SURGICAL PROCEDURESREGIONAL BLOCK ANESTHESIATRIGEMINAL DIVISION BLOCK ANESTHESIALOCAL ANESTHESIADEEP SEDATION/GENERAL ANESTHESIA-FIRST 30 MINUTESDEEP SEDATION/GENERAL ANESTHESIA-EACH ADDITIONAL 15 MINUTESANALGESIA, ANXIOLYSIS, INHALATION OF NITROUS OXIDEINTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - FIRST 30 MINUTESINTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - EACH ADDITIONAL 15 MINUTESNON-INTRAVENOUS CONSCIOUS SEDATIONCONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THANREQUESTING DENTIST OR PHYSICIANHOUSE/EXTENDED CARE FACILITY CALLHOSPITAL CALLOFFICE VISIT FOR OBSERVATION (DURING REGULARLY SCHEDULED HOURS) NO OTHERSERVICES PERFORMEDOFFICE VISIT-AFTER REGULARLY SCHEDULED HOURSCASE PRESENTATION, DETAILED AND EXTENSIVE TREATMENT PLANNINGTHERAPEUTIC PARENTERAL DRUG, SINGLE ADMINISTRATIONTHERAPEUTIC PARENTERAL DRUGS, TWO OR MORE ADMINISTRATIONS, DIFFERENT MEDICATIONS

Query_110708

Page 205

OTHER DRUGS AND/OR MEDICAMENTS, BY REPORTAPPLICATION OF DESENSITIZING MEDICAMENTAPPLICATION OF DESENSITIZING RESIN FOR CERVICAL AND/OR ROOT SURFACE, PER TOOTHBEHAVIOR MANAGEMENT, BY REPORTTREATMENT OF COMPLICATIONS (POSTSURGICAL) - UNUSUAL CIRCUMSTANCES, BY REPORTOCCLUSAL GUARDS, BY REPORTFABRICATION OF ATHLETIC MOUTHGUARDREPAIR AND/OR RELINE OF OCCLUSAL GUARDOCCLUSION ANALYSIS-MOUNTED CASEOCCLUSAL ADJUSTMENT-LIMITEDOCCLUSAL ADJUSTMENT-COMPLETEENAMEL MICROABRASIONODONTOPLASTY 1 - 2 TEETH; INCLUDES REMOVAL OF ENAMEL PROJECTIONSEXTERNAL BLEACHING - PER ARCHEXTERNAL BLEACHING - PER TOOTHINTERNAL BLEACHING - PER TOOTHUNSPECIFIED ADJUNCTIVE PROCEDURE, BY REPORTCANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIPCANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE ORFIXED, WITH TIPSCRUTCHES, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED,PAIR, COMPLETE WITH TIPS AND HANDGRIPSCRUTCH FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED,EACH, WITH TIP AND HANDGRIPSCRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS ANDHANDGRIPSCRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIPCRUTCHES UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPSAND HANDGRIPSCRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, WITH PAD, TIP,HANDGRIP, WITH OR WITHOUT SHOCK ABSORBER, EACHCRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACHCRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WITHOUT WHEELS, EACHWALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHTWALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHTWALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HEIGHT, ANY TYPEWALKER, RIGID, WHEELED, ADJUSTABLE OR FIXED HEIGHTWALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHTWALKER, ENCLOSED, FOUR SIDED FRAMED, RIGID OR FOLDING, WHEELED WITH POSTERIORSEATWALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCEWALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACHWALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPEPLATFORM ATTACHMENT, FOREARM CRUTCH, EACHPLATFORM ATTACHMENT, WALKER, EACHWHEEL ATTACHMENT, RIGID PICK-UP WALKER, PER PAIRSEAT ATTACHMENT, WALKERCRUTCH ATTACHMENT, WALKER, EACHLEG EXTENSIONS FOR WALKER, PER SET OF FOUR (4)BRAKE ATTACHMENT FOR WHEELED WALKER, REPLACEMENT, EACHSITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODESITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE, WITHFAUCET ATTACHMENT/SSITZ BATH CHAIRCOMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMSCOMMODE CHAIR, MOBILE, WITH FIXED ARMSCOMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMSCOMMODE CHAIR, MOBILE, WITH DETACHABLE ARMSPAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLYCOMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH ORWITHOUT ARMS, ANY TYPE, EACH

Query_110708

Page 206

COMMODE CHAIR WITH SEAT LIFT MECHANISMCOMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPECOMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, NON-ELECTRIC, ANY TYPESEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPEFOOT REST, FOR USE WITH COMMODE CHAIR, EACHPRESSURE PAD, ALTERNATING WITH PUMPPOWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,INCLUDES HEAVY DUTYPUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLYDRY PRESSURE MATTRESSGEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTHAIR PRESSURE MATTRESSWATER PRESSURE MATTRESSSYNTHETIC SHEEPSKIN PADLAMBSWOOL SHEEPSKIN PAD, ANY SIZEPOSITIONING CUSHION/PILLOW/WEDGE, ANY SHAPE OR SIZE, INCLUDES ALL COMPONENTSAND ACCESSORIESHEEL OR ELBOW PROTECTOR, EACHPOWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY)AIR FLUIDIZED BEDGEL PRESSURE MATTRESSAIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTHWATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTHDRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTHHEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, OR INFRARED ELEMENTPHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTOMETERTHERAPEUTIC LIGHTBOX, MINIMUM 10,000 LUX, TABLE TOP MODELHEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEMENTELECTRIC HEAT PAD, STANDARDELECTRIC HEAT PAD, MOISTWATER CIRCULATING HEAT PAD WITH PUMPWATER CIRCULATING COLD PAD WITH PUMPHOT WATER BOTTLEINFRARED HEATING PAD SYSTEMHYDROCOLLATOR UNIT, INCLUDES PADSICE CAP OR COLLARNON-CONTACT WOUND WARMING DEVICE (TEMPERATURE CONTROL UNIT, AC ADAPTER ANDPOWER CORD) FOR USE WITH WARMING CARD AND WOUND COVERWARMING CARD FOR USE WITH THE NON CONTACT WOUND WARMING DEVICE AND NON CONTACTWOUND WARMING WOUND COVERPARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)PUMP FOR WATER CIRCULATING PADNON-ELECTRIC HEAT PAD, MOISTHYDROCOLLATOR UNIT, PORTABLEBATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZEBATH TUB WALL RAIL, EACHBATH TUB RAIL, FLOOR BASETOILET RAIL, EACHRAISED TOILET SEATTUB STOOL OR BENCHTRANSFER TUB RAIL ATTACHMENTTRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENINGTRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENINGPAD FOR WATER CIRCULATING HEAT UNITHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESSHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESSHOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESSHOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESSHOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDERAILS, WITH MATTRESSHOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE

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Page 207

RAILS, WITHOUT MATTRESSHOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPESIDE RAILS, WITH MATTRESSHOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPESIDE RAILS, WITHOUT MATTRESSHOSPITAL BED, INSTITUTIONAL TYPE INCLUDES: OSCILLATING, CIRCULATING AND STRYKERFRAME, WITH MATTRESSMATTRESS, INNERSPRINGMATTRESS, FOAM RUBBERBED BOARDOVER-BED TABLEBED PAN, STANDARD, METAL OR PLASTICBED PAN, FRACTURE, METAL OR PLASTICPOWERED PRESSURE-REDUCING AIR MATTRESSBED CRADLE, ANY TYPEHOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESSHOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESSHOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESSHOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESSHOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS,WITH MATTRESSHOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS,WITHOUT MATTRESSHOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS). WITHOUT SIDERAILS, WITH MATTRESSHOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDERAILS, WITHOUT MATTRESSPEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSEDHOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUTMATTRESSHOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESSHOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHMATTRESSHOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESSBED SIDE RAILS, HALF LENGTHBED SIDE RAILS, FULL LENGTHBED ACCESSORY: BOARD, TABLE, OR SUPPORT DEVICE, ANY TYPESAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPEURINAL; MALE, JUG-TYPE, ANY MATERIALURINAL; FEMALE, JUG-TYPE, ANY MATERIALHOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD,FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESSHOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES,TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING,INCLUDES MATTRESSCONTROL UNIT FOR ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEMDISPOSABLE PACK (WATER RESERVOIR BAG, SPECULUM, VALVING MECHANISM ANDCOLLECTION BAG/BOX) FOR USE WITH THE ELECTRONIC BOWEL IRRIGATION/EVACUATIONSYSTEMAIR PRESSURE ELEVATOR FOR HEELNONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESSLENGTH AND WIDTHPOWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTHNONPOWERED ADVANCED PRESSURE REDUCING MATTRESSSTATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER,CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, ANDTUBING

Query_110708

Page 208

STATIONARY COMPRESSED GAS SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER,HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBINGPORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER,HUMIDIFIER, CANNULA OR MASK, AND TUBINGPORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR,FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBINGPORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLYRESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA ORMASK, AND TUBINGPORTABLE LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES PORTABLE CONTAINER, SUPPLYRESERVOIR, FLOWMETER, HUMIDIFIER, CONTENTS GAUGE, CANNULA OR MASK, TUBING ANDREFILL ADAPTORSTATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS,REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBINGSTATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR, CONTENTSINDICATOR, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, ANDTUBINGOXYGEN CONTENTS, GASEOUS (FOR USE WITH OWNED GASEOUS STATIONARY SYSTEMS OR WHENBOTH A STATIONARY AND PORTABLE GASEOUS SYSTEM ARE OWNED), 1 MONTH'S SUPPLY = 1UNITOXYGEN CONTENTS, LIQUID (FOR USE WITH OWNED LIQUID STATIONARY SYSTEMS OR WHENBOTH A STATIONARY AND PORTABLE LIQUID SYSTEM ARE OWNED), 1 MONTH'S SUPPLY = 1UNITPORTABLE OXYGEN CONTENTS, GASEOUS (FOR USE ONLY WITH PORTABLE GASEOUS SYSTEMSWHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED), 1 MONTH'S SUPPLY = 1 UNITPORTABLE OXYGEN CONTENTS, LIQUID (FOR USE ONLY WITH PORTABLE LIQUID SYSTEMSWHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED), 1 MONTH'S SUPPLY = 1 UNITOXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELYVOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURECONTROL MODE, USED WITH INVASIVE INTERFACE (E.G., TRACHEOSTOMY TUBE)OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTSCHEST SHELL (CUIRASS)CHEST WRAPNEGATIVE PRESSURE VENTILATOR; PORTABLE OR STATIONARYVOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURECONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK)ROCKING BED WITH OR WITHOUT SIDE RAILSPRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURECONTROL MODE, USED WITH INVASIVE INTERFACE (E.G. TRACHEOSTOMY TUBE)PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURECONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK)RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATEFEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK(INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATEFEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK(INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATEFEATURE, USED WITH INVASIVE INTERFACE, E.G., TRACHEOSTOMY TUBE (INTERMITTENTASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME MODELINTRAPULMONARY PERCUSSIVE VENTILATION SYSTEM AND RELATED ACCESSORIESCOUGH STIMULATING DEVICE, ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESSUREHIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE GENERATOR SYSTEM, (INCLUDESHOSES AND VEST), EACHOSCILLATORY POSITIVE EXPIRATORY PRESSURE DEVICE, NON-ELECTRIC, ANY TYPE, EACHORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE ORNON-ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE ORNON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTSPIROMETER, ELECTRONIC, INCLUDES ALL ACCESSORIES

Query_110708

Page 209

IPPB MACHINE, ALL TYPES, WITH BUILT-IN NEBULIZATION; MANUAL OR AUTOMATICVALVES; INTERNAL OR EXTERNAL POWER SOURCEHUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLEMENTAL HUMIDIFICATION DURING IPPBTREATMENTS OR OXYGEN DELIVERYHUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE WITHREGULATOR OR FLOWMETERHUMIDIFIER, DURABLE FOR SUPPLEMENTAL HUMIDIFICATION DURING IPPB TREATMENT OROXYGEN DELIVERYHUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICEHUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICECOMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELF- CONTAINED ORCYLINDER DRIVENNEBULIZER, WITH COMPRESSORAEROSOL COMPRESSOR, BATTERY POWERED, FOR USE WITH SMALL VOLUME NEBULIZERAEROSOL COMPRESSOR, ADJUSTABLE PRESSURE, LIGHT DUTY FOR INTERMITTENT USEULTRASONIC/ELECTRONIC AEROSOL GENERATOR WITH SMALL VOLUME NEBULIZERNEBULIZER, ULTRASONIC, LARGE VOLUMENEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITHREGULATOR OR FLOWMETERNEBULIZER, WITH COMPRESSOR AND HEATERDISPENSING FEE COVERED DRUG ADMINISTERED THROUGH DME NEBULIZERRESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRICCONTINUOUS AIRWAY PRESSURE (CPAP) DEVICEBREAST PUMP, MANUAL, ANY TYPEBREAST PUMP, ELECTRIC (AC AND/OR DC), ANY TYPEBREAST PUMP, HOSPITAL GRADE, ELECTRIC (AC AND / OR DC), ANY TYPEVAPORIZER, ROOM TYPEPOSTURAL DRAINAGE BOARDHOME BLOOD GLUCOSE MONITORPACEMAKER MONITOR, SELF-CONTAINED, (CHECKS BATTERY DEPLETION, INCLUDES AUDIBLEAND VISIBLE CHECK SYSTEMS)PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKERCOMPONENTS, INCLUDES DIGITAL/VISIBLE CHECK SYSTEMSIMPLANTABLE CARDIAC EVENT RECORDER WITH MEMORY, ACTIVATOR AND PROGRAMMEREXTERNAL DEFIBRILLATOR WITH INTEGRATED ELECTROCARDIOGRAM ANALYSISAPNEA MONITOR, WITHOUT RECORDING FEATUREAPNEA MONITOR, WITH RECORDING FEATURESKIN PIERCING DEVICE FOR COLLECTION OF CAPILLARY BLOOD, LASER, EACHSLING OR SEAT, PATIENT LIFT, CANVAS OR NYLONPATIENT LIFT, BATHROOM OR TOILET, NOT OTHERWISE CLASSIFIEDSEAT LIFT MECHANISM INCORPORATED INTO A COMBINATION LIFT-CHAIR MECHANISMSEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-ELECTRICSEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-NON-ELECTRICPATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) ORPAD(S)PATIENT LIFT, ELECTRIC WITH SEAT OR SLINGMULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED LIFT, PATIENTACCESSIBLE CONTROLSCOMBINATION SIT TO STAND SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEATLIFTFEATURE, WITH OR WITHOUT WHEELSSTANDING FRAME SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER),ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELSPATIENT LIFT, MOVEABLE FROM ROOM TO ROOM WITH DISASSEMBLY AND REASSEMBLY,INCLUDES ALL COMPONENTS/ACCESSORIESPATIENT LIFT, FIXED SYSTEM, INCLUDES ALL COMPONENTS/ACCESSORIESSTANDING FRAME SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZEINCLUDING PEDIATRIC, WITH OR WITHOUT WHEELSSTANDING FRAME SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRICPNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODELPNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT CALIBRATED GRADIENT PRESSUREPNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE

Query_110708

Page 210

NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARMSEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, TRUNKSEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, CHESTNON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEGNON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARMNON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEGSEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEGSEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARMSEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEGSEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEGSEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARMSEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF LEGPNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID INFLATION/DEFLATION CYCLE,FOR ARTERIAL INSUFFICIENCY (UNILATERAL OR BILATERAL SYSTEM)INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL ACCESSORIES), NOT OTHERWISESPECIFIEDULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYEPROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESSULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYEPROTECTION, 4 FOOT PANELULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYEPROTECTION, 6 FOOT PANELULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDESBULBS/LAMPS, TIMER AND EYE PROTECTIONSAFETY EQUIPMENT (E.G., BELT, HARNESS OR VEST)HELMET WITH FACE GUARD AND SOFT INTERFACE MATERIAL, PREFABRICATEDTRANSFER DEVICE, ANY TYPE, EACHRESTRAINTS, ANY TYPE (BODY, CHEST, WRIST OR ANKLE)TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZEDSTIMULATIONTRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS,FOR MULTIPLE NERVE STIMULATIONFORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVEFIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC)INCONTINENCE TREATMENT SYSTEM, PELVIC FLOOR STIMULATOR, MONITOR, SENSOR AND/ORTRAINERNEUROMUSCULAR STIMULATOR FOR SCOLIOSISNEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNITELECTROMYOGRAPHY (EMG), BIOFEEDBACK DEVICEOSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINALAPPLICATIONSOSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, SPINAL APPLICATIONSOSTEOGENESIS STIMULATOR, ELECTRICAL, SURGICALLY IMPLANTEDIMPLANTABLE NEUROSTIMULATOR ELECTRODE, EACHPATIENT PROGRAMMER (EXTERNAL) FOR USE WITH IMPLANTABLE PROGRAMMABLENEUROSTIMULATOR PULSE GENERATORELECTRONIC SALIVARY REFLEX STIMULATOR (INTRA-ORAL/NON-INVASIVE)IMPLANTABLE NEUROSTIMULATOR PULSE GENERATORIMPLANTABLE NEUROSTIMULATOR RADIOFREQUENCY RECEIVERRADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATORRADIOFREQUENCY RECEIVERRADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE SACRAL ROOTNEUROSTIMULATOR RECEIVER FOR BOWEL AND BLADDER MANAGEMENT, REPLACEMENTOSTEOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON-INVASIVENON-THERMAL PULSED HIGH FREQUENCY RADIOWAVES, HIGH PEAK POWER ELECTROMAGNETICENERGY TREATMENT DEVICETRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALLACCESSORIESFUNCTIONAL NEUROMUSCULAR STIMULATION, TRANSCUTANEOUS STIMULATION OF SEQUENTIALMUSCLE GROUPS OF AMBULATION WITH COMPUTER CONTROL, USED FOR WALKING BY SPINALCORD INJURED, ENTIRE SYSTEM, AFTER COMPLETION OF TRAINING PROGRAM

Query_110708

Page 211

FDA APPROVED NERVE STIMULATOR, WITH REPLACEABLE BATTERIES, FOR TREATMENT OFNAUSEA AND VOMITINGELECTRICAL STIMULATION OR ELECTROMAGNETIC WOUND TREATMENT DEVICE, NOT OTHERWISECLASSIFIEDFUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/ORMUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOT OTHERWISE SPECIFIEDIV POLEAMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION 8 HOURS OR GREATERAMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION LESS THAN 8 HOURSAMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERYOPERATED, WITH ADMINISTRATIVE EQUIPMENT, WORN BY PATIENTINFUSION PUMP, IMPLANTABLE, NON-PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G.,PUMP, CATHETER, CONNECTORS, ETC.)INFUSION PUMP SYSTEM, IMPLANTABLE, PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G.,PUMP, CATHETER, CONNECTORS, ETC.)EXTERNAL AMBULATORY INFUSION PUMP, INSULINIMPLANTABLE INTRASPINAL (EPIDURAL/INTRATHECAL) CATHETER USED WITH IMPLANTABLEINFUSION PUMP, REPLACEMENTIMPLANTABLE PROGRAMMABLE INFUSION PUMP, REPLACEMENT (EXCLUDES IMPLANTABLEINTRASPINAL CATHETER)PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTI-CHANNELAMBULATORY TRACTION DEVICE, ALL TYPES, EACHTRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTIONTRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYINGTRACTION FORCE TO OTHER THAN MANDIBLETRACTION STAND, FREE STANDING, CERVICAL TRACTIONCERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAMECERVICAL TRACTION DEVICE, CERVICAL COLLAR WITH INFLATABLE AIR BLADDERTRACTION EQUIPMENT, OVERDOOR, CERVICALTRACTION FRAME, ATTACHED TO FOOTBOARD, EXTREMITY TRACTION, (E.G. BUCK'S)TRACTION STAND, FREE STANDING, EXTREMITY TRACTION, (E.G., BUCK'S)TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTIONTRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH GRAB BARTRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS,ATTACHED TO BED, WITH GRAB BARTRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS,FREE STANDING, COMPLETE WITH GRAB BARFRACTURE FRAME, ATTACHED TO BED, INCLUDES WEIGHTSFRACTURE FRAME, FREE STANDING, INCLUDES WEIGHTSCONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE ON KNEE ONLYCONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE OTHER THAN KNEETRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BARGRAVITY ASSISTED TRACTION DEVICE, ANY TYPECERVICAL HEAD HARNESS/HALTERPELVIC BELT/HARNESS/BOOTEXTREMITY BELT/HARNESSFRACTURE, FRAME, DUAL WITH CROSS BARS, ATTACHED TO BED, (E.G. BALKEN, 4 POSTER)FRACTURE FRAME, ATTACHMENTS FOR COMPLEX PELVIC TRACTIONFRACTURE FRAME, ATTACHMENTS FOR COMPLEX CERVICAL TRACTIONWHEELCHAIR ACCESSORY, TRAY, EACHHEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACHTOE LOOP/HOLDER, ANY TYPE, EACHPNEUMATIC TIRE, EACHSEMI-PNEUMATIC CASTER, EACHWHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTINGHARDWARE, EACHWHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXEDMOUNTING HARDWARE, EACHWHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTINGHARDWARE, EACH

Query_110708

Page 212

MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACHMANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACHWHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANYTYPE MOUNTING HARDWAREMANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACHMANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACHMANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, EACHCOMMODE SEAT, WHEELCHAIRNARROWING DEVICE, WHEELCHAIRNO.2 FOOTPLATES, EXCEPT FOR ELEVATING LEG RESTMANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACHWHEELCHAIR ACCESSORY, TRANSFER BOARD OR DEVICE, EACHWHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY,EACHMANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACHWEDGE CUSHION, WHEELCHAIRWHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACHSAFETY VEST, WHEELCHAIRWHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACHWHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACHMANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TOMOTORIZED WHEELCHAIR, JOYSTICK CONTROLMANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TOMOTORIZED WHEELCHAIR, TILLER CONTROLWHEELCHAIR ACCESSORY, SEAT LIFT MECHANISMMANUAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST, EACHWHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACHMANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERTARM REST, EACHWHEELCHAIR ACCESSORY, CALF REST/PAD, EACHTIRE, SOLID, EACHCASTER WITH A FORKCASTER WITHOUT FORKPNEUMATIC TIRE WITH WHEELTIRE, PNEUMATIC CASTERWHEEL, SINGLEWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLYWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEARREDUCTIONWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEARREDUCTIONWHEELCHAIR ACCESSORY, POWER SEATNG SYSTEM, RECLINE ONLY, WITH POWER SHEARREDUCTIONWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE,WITHOUT SHEAR REDUCTIONWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHMECHANICAL SHEAR REDUCTIONWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHPOWER SHEAR REDUCTIONWHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEGELEVATION SYSTEM, INCLUDING PUSHROD AND LEG REST, EACHWHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATIONSYSTEM, INCLUDING LEG REST, PAIRMODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BEDISPENSED WITH INITIAL CHAIR)RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIRSHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACHSHOCK ABSORBER FOR POWER WHEELCHAIR, EACHHEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR,EACHHEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR,

Query_110708

Page 213

EACHWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, HEAVY DUTY FEATURE, PATIENT WEIGHTCAPACITY GREATER THAN 250 POUNDS AND LESS THAN OR EQUAL TO 400 POUNDSRESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIRWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, EXTRA HEAVY DUTY FEATURE, WEIGHTCAPACITY GREATER THAN 400 POUNDSLATERAL THORACIC SUPPORT, NON-CONTOURED, FOR PEDIATRIC WHEELCHAIR, EACH(INCLUDES HARDWARE)LATERAL THORACIC SUPPORT, CONTOURED, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDESHARDWARE)LATERAL/ANTERIOR SUPPORT, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE)WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTINGHARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORYWHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXEDWHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALEDROLLABOUT CHAIR, ANY AND ALL TYPES WITH CASTORS 5" OR GREATERMULTI-POSITIONAL PATIENT TRANSFER SYSTEM, WITH INTEGRATED SEAT, OPERATED BYCARE GIVERTRANSPORT CHAIR, PEDIATRIC SIZETRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300POUNDSTRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN300 POUNDSFULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLEELEVATING LEG RESTSFULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAYDETACHABLE ELEVATING LEGRESTSFULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAYDETACHABLE FOOTRESTHEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTHEMI-WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAYDETACHABLE ELEVATING LEG RESTSHEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOT RESTSHEMI-WHEELCHAIR DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLEFOOTRESTSHIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAYDETACHABLE ELEVATING LEG RESTSHIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH,SWING AWAY DETACHABLE ELEVATING LEG RESTSHIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, FIXED LENGTH ARMS, SWING AWAY DETACHABLEFOOTRESTHIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH,SWING AWAY DETACHABLE FOOT RESTSWIDE HEAVY DUTY WHEEL CHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH), SWING AWAYDETACHABLE ELEVATING LEG RESTSWIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWINGAWAY DETACHABLE FOOTRESTSSEMI-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLEELEVATING LEG RESTSSEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTSTANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLEFOOTRESTSWHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLEFOOTRESTSWHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLEELEVATING LEGRESTSWHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTSMANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACEAMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING

Query_110708

Page 214

LEGRESTSAMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, WITHOUT FOOTRESTS OR LEGRESTAMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) WITHOUT FOOTRESTS ORLEGRESTAMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLEFOOTRESTSAMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLEELEVATING LEGRESTSHEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATINGLEGRESTSAMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTMOTORIZED WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATINGLEG RESTSMOTORIZED WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH SWING AWAY,DETACHABLE ELEVATING LEG RESTMOTORIZED WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOT RESTSMOTORIZED WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAYDETACHABLE FOOT RESTSWHEELCHAIR; SPECIALLY SIZED OR CONSTRUCTED, (INDICATE BRAND NAME, MODEL NUMBER,IF ANY) AND JUSTIFICATIONWHEELCHAIR WITH FIXED ARM, FOOTRESTSWHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTSWHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTSWHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTSWHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15DEGREES, BUT LESS THAN 80 DEGREES), EACHWHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80DEGREES), EACHSPECIAL HEIGHT ARMS FOR WHEELCHAIRSPECIAL BACK HEIGHT FOR WHEELCHAIRWHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIEDPOWER OPERATED VEHICLE (THREE OR FOUR WHEEL NONHIGHWAY) SPECIFY BRAND NAME ANDMODEL NUMBERWHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITH SEATINGSYSTEMWHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEATINGSYSTEMWHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SEATINGSYSTEMWHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATINGSYSTEMWHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEMWHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEMWHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEMWHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEMPOWER WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIEDLIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, (DESK OR FULL LENGTH) SWING AWAYDETACHABLE, ELEVATING LEGRESTLIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTLIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAYDETACHABLE FOOTRESTLIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATINGLEGRESTSHEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTSHEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTHEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAYDETACHABLE FOOTRESTHEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEGRESTSPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOORSPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERYSPECIAL WHEELCHAIR SEAT DEPTH AND/OR WIDTH, BY CONSTRUCTION

Query_110708

Page 215

WHIRLPOOL, PORTABLE (OVERTUB TYPE)WHIRLPOOL, NON-PORTABLE (BUILT-IN TYPE)REPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL EQUIPMENT REQUIRING THE SKILLOF A TECHNICIAN, LABOR COMPONENT, PER 15 MINUTESREGULATOROXYGEN ACCESSORY, WHEELED CART FOR PORTABLE CYLINDER OR PORTABLE CONCENTRATOR,ANY TYPE, REPLACEMENT ONLY, EACHSTAND/RACKOXYGEN ACCESSORY, BATTERY PACK/CARTRIDGE FOR PORTABLE CONCENTRATOR, ANY TYPE,REPLACEMENT ONLY, EACHOXYGEN ACCESSORY, BATTERY CHARGER FOR PORTABLE CONCENTRATOR, ANY TYPE,REPLACEMENT ONLY, EACHOXYGEN ACCESSORY, DC POWER ADAPTER FOR PORTABLE CONCENTRATOR, ANY TYPE,REPLACEMENT ONLY, EACHIMMERSION EXTERNAL HEATER FOR NEBULIZEROXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT ORGREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATEOXYGEN CONCENTRATOR, DUAL DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT ORGREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE, EACHPORTABLE OXYGEN CONCENTRATOR, RENTALDURABLE MEDICAL EQUIPMENT, MISCELLANEOUSOXYGEN AND WATER VAPOR ENRICHING SYSTEM WITH HEATED DELIVERYOXYGEN AND WATER VAPOR ENRICHING SYSTEM WITHOUT HEATED DELIVERYCENTRIFUGE, FOR DIALYSISKIDNEY, DIALYSATE DELIVERY SYST. KIDNEY MACHINE, PUMP RECIRCULAT- ING, AIRREMOVAL SYST, FLOWRATE METER, POWER OFF, HEATER AND TEMPERATURE CONTROL WITHALARM, I.V.POLES, PRESSURE GAUGE, CONCENTRATE CONTAINERHEPARIN INFUSION PUMP FOR HEMODIALYSISAIR BUBBLE DETECTOR FOR HEMODIALYSIS, EACH, REPLACEMENTPRESSURE ALARM FOR HEMODIALYSIS, EACH, REPLACEMENTBATH CONDUCTIVITY METER FOR HEMODIALYSIS, EACHBLOOD LEAK DETECTOR FOR HEMODIALYSIS, EACH, REPLACEMENTADJUSTABLE CHAIR, FOR ESRD PATIENTSTRANSDUCER PROTECTORS/FLUID BARRIERS, FOR HEMODIALYSIS, ANY SIZE, PER 10UNIPUNCTURE CONTROL SYSTEM FOR HEMODIALYSISHEMODIALYSIS MACHINEAUTOMATIC INTERMITTENT PERITIONEAL DIALYSIS SYSTEMCYCLER DIALYSIS MACHINE FOR PERITONEAL DIALYSISDELIVERY AND/OR INSTALLATION CHARGES FOR HEMODIALYSIS EQUIPMENTREVERSE OSMOSIS WATER PURIFICATION SYSTEM, FOR HEMODIALYSISDEIONIZER WATER PURIFICATION SYSTEM, FOR HEMODIALYSISBLOOD PUMP FOR HEMODIALYSIS, REPLACEMENTWATER SOFTENING SYSTEM, FOR HEMODIALYSISRECIPROCATING PERITONEAL DIALYSIS SYSTEMWEARABLE ARTIFICIAL KIDNEY, EACHPERITONEAL DIALYSIS CLAMPS, EACHCOMPACT (PORTABLE) TRAVEL HEMODIALYZER SYSTEMSORBENT CARTRIDGES, FOR HEMODIALYSIS, PER 10HEMOSTATS, EACHSCALE, EACHDIALYSIS EQUIPMENT, NOT OTHERWISE SPECIFIEDJAW MOTION REHABILITATION SYSTEMREPLACEMENT CUSHIONS FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 6REPLACEMENT MEASURING SCALES FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 200DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACEMATERIALSTATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXTENSION AND/OR FLEXION, WITH ORWITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIESDYNAMIC ADJUSTABLE FOREARM PRONATION/SUPINATION DEVICE, INCLUDES SOFT INTERFACEMATERIALDYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE

Query_110708

Page 216

MATERIALSTATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEXION AND/OR EXTENSION, WITH ORWITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIESDYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACEMATERIALSTATIC PROGRESSIVE STRETCH KNEE DEVICE, EXTENSION AND/OR FLEXION, WITH ORWITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIESDYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROLDYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACEMATERIALSTATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEXION AND/OR EXTENSION, WITH ORWITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIESSTATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, WITH ORWITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIESREPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICEREPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVESTRETCH DEVICEDYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACEMATERIALDYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACEMATERIALDYNAMIC ADJUSTABLE SHOULDER FLEXION / ABDUCTION / ROTATION DEVICE, INCLUDESSOFT INTERFACE MATERIALSTATIC PROGRESSIVE STRETCH SHOULDER DEVICE, WITH OR WITHOUT RANGE OF MOTIONADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIESCOMMUNICATION BOARD, NON-ELECTRONIC AUGMENTATIVE OR ALTERNATIVE COMMUNICATIONDEVICEGASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRICBLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZERBLOOD GLUCOSE MONITOR WITH INTEGRATED LANCING/BLOOD SAMPLEPULSE GENERATOR SYSTEM FOR TYMPANIC TREATMENT OF INNER EAR ENDOLYMPHATIC FLUIDMANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OREQUAL TO 20 INCHES AND LESS THAN 24 INCHESMANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHESMANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22INCHESMANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHESMANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS (INCLUDES ERGONOMIC ORCONTOURED), ANY TYPE, REPLACEMENT ONLY, EACHMANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACHWHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACHWHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACHACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACHWHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACHMANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC PROPULSION TIRE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE (REMOVABLE),ANY TYPE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, FOAM FILLED PROPULSION TIRE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, FOAM PROPULSION TIRE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) PROPULSION TIRE, ANY SIZE,EACHMANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE),ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATEDWHEEL, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, VALVE, ANY TYPE, REPLACEMENT ONLY, EACH

Query_110708

Page 217

MANUAL WHEELCHAIR ACCESSORY, PROPULSION WHEEL EXCLUDES TIRE, ANY SIZE, EACHMANUAL WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENTONLY, EACHMANUAL WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACHMANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE WHEEL, EACHMANUAL WHEELCHAIR ACCESSORY, WHEEL BRAKING SYSTEM AND LOCK, COMPLETE, EACHMANUAL WHEELCHAIR ACCESSORY, MANUAL STANDING SYSTEMMANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT),INCLUDES ANY TYPE MOUNTING HARDWAREBACK, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARESEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWAREBACK, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHINGHARDWARESEAT, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHINGHARDWAREMANUAL WHEELCHAIR ACCESSORY, FOR PEDIATRIC SIZE WHEELCHAIR, DYNAMIC SEATINGFRAME, ALLOWS COORDINATED MOVEMENT OF MULTIPLE POSITIONING FEATURESPOWER WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEMPOWER WHEELCHAIR ACCESSORY, POWER STANDING SYSTEMPOWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLERAND ONE POWER SEATING SYSTEM MOTOR, INCLUDING ALL RELATED ELECTRONICS,INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTINGHARDWAREPOWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLERAND TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS,INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTINGHARDWAREPOWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONALREMOTE JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWAREPOWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER,INCLUDING ALL FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACHPOWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, REMOTE JOYSTICK ORTOUCHPAD, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, AND FIXED MOUNTINGHARDWAREPOWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK,NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, ANDFIXED MOUNTING HARDWAREPOWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICALSWITCHES, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOPSWITCH, AND FIXED MOUNTING HARDWAREPOWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE FOR HAND CONTROLINTERFACE, PREFABRICATEDPOWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL INTERFACEPOWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL, INCLUDINGALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND MANUAL SWINGAWAY MOUNTINGHARDWAREPOWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACEPOWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL,INCLUDING ALL RELATED ELECTRONICS, MECHANICAL DIRECTION CHANGE SWITCH, ANDFIXED MOUNTING HARDWAREPOWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE,ELECTRONIC, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTINGHARDWAREPOWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM,NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH,MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWAREPOWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM,NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH,MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWAREPOWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, PROPORTIONAL, INCLUDING ALLRELATED ELECTRONICS AND FIXED MOUNTING HARDWARE

Query_110708

Page 218

POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 20-23 INCHESPOWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHESPOWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 OR 21 INCHESPOWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22-25 INCHESPOWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH GENERATINGDEVICE USING POWER WHEELCHAIR CONTROL INTERFACEPOWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACHPOWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G. GELCELL, ABSORBED GLASSMAT)POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACHPOWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G. GELCELL, ABSORBED GLASSMAT)POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACHPOWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL,ABSORBED GLASSMAT)POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONEBATTERY TYPE, SEALED OR NON-SEALED, EACHPOWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHERBATTERY TYPE, SEALED OR NON-SEALED, EACHPOWER WHEELCHAIR COMPONENT, MOTOR, REPLACEMENT ONLYPOWER WHEELCHAIR COMPONENT, GEAR BOX, REPLACEMENT ONLYPOWER WHEELCHAIR COMPONENT, MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLYPOWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G. GEL CELL,ABSORBED GLASSMAT), EACHPOWER WHEELCHAIR ACCESSORY, GROUP 27 NON-SEALED LEAD ACID BATTERY, EACHPOWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, COMPACT REMOTEJOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWAREPOWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, STANDARD REMOTEJOYSTICK (NOT INCLUDING CONTROLLER), PROPORTIONAL, INCLUDING ALL RELATEDELECTRONICS AND FIXED MOUNTING HARDWARE, REPLACEMENT ONLYPOWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, INCLUDING ALL RELATEDELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLYPOWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATEDELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLYPOWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATEDELECTRONICS AND MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUEPOWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENTONLY, EACHPOWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE,REPLACEMENT ONLY, EACHPOWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE (REMOVABLE),ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACHPOWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY,EACHPOWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE,REPLACEMENT ONLY, EACHPOWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENTONLY, EACHPOWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENTONLY, EACHPOWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY,EACHPOWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACHPOWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE,REPLACEMENT ONLY, EACHPOWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANYSIZE, REPLACEMENT ONLY, EACHPOWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATEDWHEEL, ANY SIZE, REPLACEMENT ONLY, EACHPOWER WHEELCHAIR ACCESSORY, VALVE FOR PNEUMATIC TIRE TUBE, ANY TYPE,REPLACEMENT ONLY, EACH

Query_110708

Page 219

POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENTONLY, EACHPOWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENTONLY, EACHPOWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACHPOWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACHPOWER WHEELCHAIR ACCESSORY, NOT OTHERWISE CLASSIFIED INTERFACE, INCLUDING ALLRELATED ELECTRONICS AND ANY TYPE MOUNTING HARDWARENEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLESPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, LESSTHAN OR EQUAL TO 8 MINUTES RECORDING TIMESPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES,GREATER THAN 8 MINUTES BUT LESS THAN OR EQUAL TO 20 MINUTES RECORDING TIMESPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES,GREATER THAN 20 MINUTES BUT LESS THAN OR EQUAL TO 40 MINUTES RECORDING TIMESPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES,GREATER THAN 40 MINUTES RECORDING TIMESPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING MESSAGE FORMULATION BYSPELLING AND ACCESS BY PHYSICAL CONTACT WITH THE DEVICESPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING MULTIPLE METHODS OFMESSAGE FORMULATION AND MULTIPLE METHODS OF DEVICE ACCESSSPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL COMPUTER OR PERSONAL DIGITALASSISTANTACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEMACCESSORY FOR SPEECH GENERATING DEVICE, NOT OTHERWISE CLASSIFIEDGENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTHGENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTHSKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTHSKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTHPOSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTHPOSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTHSKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22INCHES, ANY DEPTHSKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES ORGREATER, ANY DEPTHCUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZEWHEELCHAIR SEAT CUSHION, POWEREDGENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT,INCLUDING ANY TYPE MOUNTING HARDWAREGENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT,INCLUDING ANY TYPE MOUNTING HARDWAREPOSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANYHEIGHT, INCLUDING ANY TYPE MOUNTING HARDWAREPOSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANYHEIGHT, INCLUDING ANY TYPE MOUNTING HARDWAREPOSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWAREPOSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES ORGREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARECUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPEMOUNTING HARDWAREWHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), FOR USEWITH MANUAL WHEELCHAIR OR LIGHTWEIGHT POWER WHEELCHAIR, INCLUDES ANY TYPEMOUNTING HARDWAREREPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACHPOSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTHLESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWAREPOSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWAREGAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES ANDCOMPONENTS

Query_110708

Page 220

GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES ANDCOMPONENTSGAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES ANDCOMPONENTSADMINISTRATION OF INFLUENZA VIRUS VACCINEADMINISTRATION OF PNEUMOCOCCAL VACCINEADMINISTRATION OF HEPATITIS B VACCINESEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM EXCLUDING HUHNERPET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING PREVIOUS PET, G0030-G0047); SINGLESTUDY, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING PREVIOUS PET, G0030-G0047);MULTIPLE STUDIES, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING REST SPECT, 78464); SINGLE STUDY,REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING REST SPECT, 78464); MULTIPLESTUDIES, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS SPECT, 78465); SINGLESTUDY, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS SPECT, 78465); MULTIPLESTUDIES, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING CORONARY ANGIOGRAPHY,93510-93529); SINGLE STUDY, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING CORONARY ANGIOGRAPHY,93510-93529); MULTIPLE STUDIES, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS PLANAR MYOCARDIALPERFUSION, 78460); SINGLE STUDY, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS PLANAR MYOCARDIALPERFUSION, 78460); MULTIPLE STUDIES, REST OR STRESS (EXERCISE AND/ORPHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS ECHOCARDIOGRAM, 93350);SINGLE STUDY, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS ECHOCARDIOGRAM, 93350);MULTIPLE STUDIES, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS NUCLEAR VENTRICULOGRAM,78481 OR 78483); SINGLE STUDY, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS NUCLEAR VENTRICULOGRAM,78481 OR 78483); MULTIPLE STUDIES, REST OR STRESS (EXERCISE AND/ORPHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING REST ECG, 93000); SINGLE STUDY,REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING REST ECG, 93000); MULTIPLESTUDIES, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS ECG, 93015); SINGLE STUDY,REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS ECG, 93015); MULTIPLESTUDIES, REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC)CERVICAL OR VAGINAL CANCER SCREENING; PELVIC AND CLINICAL BREAST EXAMINATIONPROSTATE CANCER SCREENING; DIGITAL RECTAL EXAMINATIONPROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA)COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPYCOLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISKCOLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY,BARIUM ENEMACOLORECTAL CANCER SCREENING; FECAL-OCCULT BLOOD TEST, 1-3 SIMULTANEOUSDETERMINATIONSDIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, INDIVIDUAL, PER 30MINUTESDIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, GROUP SESSION (2 ORMORE), PER 30 MINUTESNETT PULM-REHAB; EDUCATION/SKILLS TRAINING, INDIVIDUALNETT PULM-REHAB; EDUCATION/SKILLS TRAINING, GROUP

Query_110708

Page 221

NETT PULM-REHAB; NUTRITIONAL GUIDANCE, INITIALNETT PULM-REHAB; NUTRITIONAL GUIDANCE, SUBSEQUENTNETT PULM-REHAB; PSYCHOSOCIAL CONSULTATIONNETT PULM-REHAB; PSYCHOLOGICAL TESTINGNETT PULM-REHAB; PSYCHOSOCIAL COUNSELLINGGLAUCOMA SCREENING FOR HIGH RISK PATIENTS FURNISHED BY AN OPTOMETRIST OROPHTHALMOLOGISTGLAUCOMA SCREENING FOR HIGH RISK PATIENT FURNISHED UNDER THE DIRECT SUPERVISIONOF AN OPTOMETRIST OR OPHTHALOMOLOGISTCOLORECTAL CANCER SCREENING; ALTERNATIVE TO G0105, SCREENING COLONOSCOPY,BARIUM ENEMA.COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FORHIGH RISKCOLORECTAL CANCER SCREENING; BARIUM ENEMASCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTEDIN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, SCREENING BYCYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISIONSCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTEDIN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, REQUIRINGINTERPRETATION BY PHYSICIANPET IMAGING REGIONAL OR WHOLE BODY; SINGLE PULMONARY NODULETRIMMING OF DYSTROPHIC NAILS, ANY NUMBERDIRECT (FACE-TO-FACE WITH PATIENT) SKILLED NURSING SERVICES OF A REGISTEREDNURSE PROVIDED IN A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY, EACH 10MINUTES BEYOND THE FIRST 5 MINUTESOCCUPATIONAL THERAPY SERVICES REQUIRING THE SKILLS OF A QUALIFIED OCCUPATIONALTHERAPIST, FURNISHED AS A COMPONENT OF A PARTIAL HOSPITALIZATION TREATMENTPROGRAM, PER SESSION (45 MINUTES OR MORE)SINGLE ENERGY X-RAY ABSORPTIOMETRY (SEXA) BONE DENSITY STUDY, ONE OR MORESITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL)SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATEDSYSTEM, WITH MANUAL RESCREENING, REQUIRING INTERPRETATION BY PHYSICIANSCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTEDIN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, WITH MANUAL SCREENINGAND RESCREENING BY CYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISIONSCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTEDIN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, WITH SCREENING BYAUTOMATED SYSTEM, UNDER PHYSICIAN SUPERVISIONSCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTEDIN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, WITH SCREENING BYAUTOMATED SYSTEM AND MANUAL RESCREENING UNDER PHYSICIAN SUPERVISIONSCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATEDSYSTEM UNDER PHYSICIAN SUPERVISIONSCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATEDSYSTEM WITH MANUAL RESCREENINGSERVICES OF PHYSICAL THERAPIST IN HOME HEALTH SETTING, EACH 15 MINUTESSERVICES OF OCCUPATIONAL THERAPIST IN HOME HEALTH SETTING, EACH 15 MINUTESSERVICES OF SPEECH AND LANGUAGE PATHOLOGIST IN HOME HEALTH SETTING, EACH 15MINUTESSERVICES OF SKILLED NURSE IN HOME HEALTH SETTING, EACH 15 MINUTESSERVICES OF CLINICAL SOCIAL WORKER IN HOME HEALTH SETTING, EACH 15 MINUTESSERVICES OF HOME HEALTH AIDE IN HOME HEALTH SETTING, EACH 15 MINUTESEXTERNAL COUNTERPULSATION, PER TREATMENT SESSIONWOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLYLINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPYIN ONE SESSIONSCHEDULED INTERDISCIPLINARY TEAM CONFERENCE (MINIMUM OF THREE EXCLUSIVE OFPATIENT CARE NURSING STAFF) WITH PATIENT PRESENTACTIVITY THERAPY, SUCH AS MUSIC, DANCE, ART OR PLAY THERAPIES NOT FORRECREATION, RELATED TO THE CARE AND TREATMENT OF PATIENT'S DISABLING MENTALHEALTH PROBLEMS, PER SESSION (45 MINUTES OR MORE)

Query_110708

Page 222

TRAINING AND EDUCATIONAL SERVICES RELATED TO THE CARE AND TREATMENT OFPATIENT'S DISABLING MENTAL HEALTH PROBLEMS PER SESSION (45 MINUTES OR MORE)PHYSICIAN RE-CERTIFICATION FOR MEDICARE-COVERED HOME HEALTH SERVICES UNDER AHOME HEALTH PLAN OF CARE (PATIENT NOT PRESENT), INCLUDING CONTACTS WITH HOMEHEALTH AGENCY AND REVIEW OF REPORTS OF PATIENT STATUS REQUIRED BY PHYSICIANS TOAFFIRM THE INITIAL IMPLEMENTATION OF THE PLAN OF CARE THAT MEETS PATIENT'SNEEDS, PER RE-CERTIFICATION PERIODPHYSICIAN CERTIFICATION FOR MEDICARE-COVERED HOME HEALTH SERVICES UNDER A HOMEHEALTH PLAN OF CARE (PATIENT NOT PRESENT), INCLUDING CONTACTS WITH HOME HEALTHAGENCY AND REVIEW OF REPORTS OF PATIENT STATUS REQUIRED BY PHYSICIANS TO AFFIRMTHE INITIAL IMPLEMENTATION OF THE PLAN OF CARE THAT MEETS PATIENT'S NEEDS, PERCERTIFICATION PERIODPHYSICIAN SUPERVISION OF A PATIENT RECEIVING MEDICARE-COVERED SERVICES PROVIDEDBY A PARTICIPATING HOME HEALTH AGENCY (PATIENT NOT PRESENT) REQUIRING COMPLEXAND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENTAND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS,REVIEW OF LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONECALLS) WITH OTHER HEALTH CARE PROFESSIONALS INVOLVED IN THE PATIENT'S CARE,INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/ORADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH, 30 MINUTES OR MOREPHYSICIAN SUPERVISION OF A PATIENT UNDER A MEDICARE-APPROVED HOSPICE (PATIENTNOT PRESENT) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVINGREGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OFSUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF LABORATORY AND OTHER STUDIES,COMMUNICATION (INCLUDING TELEPHONE CALLS) WITH OTHER HEALTH CARE PROFESSIONALSINVOLVED IN THE PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICALTREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH,30 MINUTES OR MOREDESTRUCTION OF LOCALIZED LESION OF CHOROID (FOR EXAMPLE, CHOROIDALNEOVASCULARIZATION); PHOTOCOAGULATION, FEEDER VESSEL TECHNIQUE (ONE OR MORESESSIONS)SCREENING MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL VIEWSDIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL VIEWSDIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, UNILATERAL, ALL VIEWSPET IMAGING WHOLE BODY; DIAGNOSIS; LUNG CANCER, NON-SMALL CELLPET IMAGING WHOLE BODY; INITIAL STAGING; LUNG CANCER; NON-SMALL CELL (REPLACESG0126)PET IMAGING WHOLE BODY; RESTAGING; LUNG CANCER; NON-SMALLPET IMAGING WHOLE BODY; DIAGNOSIS; COLORECTALPET IMAGING WHOLE BODY; INITIAL STAGING; COLORECTALPET IMAGING WHOLE BODY; RESTAGING; COLORECTAL CANCER (REPLACES G0163)PET IMAGING WHOLE BODY; DIAGNOSIS; MELANOMAPET IMAGING WHOLE BODY; INITIAL STAGING; MELANOMAPET IMAGING WHOLE BODY; RESTAGING; MELANOMA (REPLACES G0165)PET IMAGING WHOLE BODY; MELANOMA FOR NON-COVERED INDICATIONSPET IMAGING WHOLE BODY; DIAGNOSIS; LYMPHOMAPET IMAGING WHOLE BODY; INITIAL STAGING; LYMPHOMA (REPLACES G0164)PET IMAGING WHOLE BODY; RESTAGING; LYMPHOMA (REPLACES G0164)PET IMAGING WHOLE BODY OR REGIONAL; DIAGNOSIS; HEAD AND NECK CANCER; EXCLUDINGTHYROID AND CNS CANCERSPET IMAGING WHOLE BODY OR REGIONAL; INITIAL STAGING; HEAD AND NECK CANCER;EXCLUDING THYROID AND CNS CANCERSPET IMAGING WHOLE BODY OR REGIONAL; RESTAGING; HEAD AND NECK CANCER, EXCLUDINGTHYROID AND CNS CANCERSPET IMAGING WHOLE BODY; DIAGNOSIS; ESOPHAGEAL CANCERPET IMAGING WHOLE BODY; INITIAL STAGING; ESOPHAGEAL CANCERPET IMAGING WHOLE BODY; RESTAGING; ESOPHAGEAL CANCERPET IMAGING; METABOLIC BRAIN IMAGING FOR PRE-SURGICAL EVALUATION OF REFRACTORYSEIZURESPET IMAGING; METABOLIC ASSESSMENT FOR MYOCARDIAL VIABILITY FOLLOWINGINCONCLUSIVE SPECT STUDY

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PET, WHOLE BODY, FOR RECURRENCE OF COLORECTAL OR COLORECTAL METASTATIC CANCER;GAMMA CAMERAS ONLYPET, WHOLE BODY, FOR STAGING AND CHARACTERIZATION OF LYMPHOMA; GAMMA CAMERASONLYPET, WHOLE BODY, FOR RECURRENCE OF MELANOMA OR MELANOMA METASTATIC CANCER;GAMMA CAMERAS ONLYPET, REGIONAL OR WHOLE BODY, FOR SOLITARY PULMONARY NODULE FOLLOWING CT OR FORINITIAL STAGING OF PATHOLOGICALLY DIAGNOSED NONSMALL CELL LUNG CANCER; GAMMACAMERAS ONLYPET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIEDTHERAPEUTIC PROCEDURES TO INCREASE STRENGTH OR ENDURANCE OF RESPIRATORYMUSCLES, FACE TO FACE, ONE ON ONE, EACH 15 MINUTES (INCLUDES MONITORING)THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, OTHER THAN DESCRIBED BYG0237, ONE ON ONE, FACE TO FACE, PER 15 MINUTES (INCLUDES MONITORING)THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION OR INCREASE STRENGTH ORENDURANCE OF RESPIRATORY MUSCLES, TWO OR MORE INDIVIDUALS (INCLUDES MONITORING)MULTI-SOURCE PHOTON STEREOTACTIC RADIOSURGERY (COBALT 60 MULTI-SOURCECONVERGING BEAMS) PLAN, INCLUDING DOSE VOLUME HISTOGRAMS FOR TARGET ANDCRITICAL STRUCTURE TOLERANCES, PLAN OPTIMIZATION PERFORMED FOR HIGHLY CONFORMALDISTRIBUTIONS, PLAN POSITIONAL ACCURACY AND DOSE VERIFICATION, ALL LESIONSTREATED, PER COURSE OF TREATMENTMULTI-SOURCE PHOTON STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATORCHANGES AND CUSTOM PLUGGING, COMPLETE COURSE OF TREATMENT, ALL LESIONSOBSERVATION CARE PROVIDED BY A FACILITY TO A PATIENT WITH CHF, CHEST PAIN, ORASTHMA, MINIMUM EIGHT HOURSINITIAL PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC PATIENT WITH DIABETICSENSORY NEUROPATHY RESULTING IN A LOSS OF PROTECTIVE SENSATION (LOPS) WHICHMUST INCLUDE: (1) THE DIAGNOSIS OF LOPS, (2) A PATIENT HISTORY, (3) A PHYSICALEXAMINATION THAT CONSISTS OF AT LEAST THE FOLLOWING ELEMENTS: (A) VISUALINSPECTION OF THE FOREFOOT, HINDFOOT AND TOE WEB SPACES, (B)EVALUATION OF APROTECTIVE SENSATION, (C) EVALUATION OF FOOT STRUCTURE AND BIOMECHANICS, (D)EVALUATION OF VASCULAR STATUS AND SKIN INTEGRITY, AND (E) EVALUATION ANDRECOMMENDATION OF FOOTWEAR AND (4) PATIENT EDUCATIONFOLLOW-UP PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC PATIENT WITHDIABETIC SENSORY NEUROPATHY RESULTING IN A LOSS OF PROTECTIVE SENSATION (LOPS)TO INCLUDE AT LEAST THE FOLLOWING: (1) A PATIENT HISTORY, (2) A PHYSICALEXAMINATION THAT INCLUDES: (A) VISUAL INSPECTION OF THE FOREFOOT, HINDFOOT ANDTOE WEB SPACES, (B) EVALUATION OF PROTECTIVE SENSATION, (C) EVALUATION OF FOOTSTRUCTURE AND BIOMECHANICS, (D) EVALUATION OF VASCULAR STATUS AND SKININTEGRITY, AND (E) EVALUATION AND RECOMMENDATION OF FOOTWEAR, AND (3) PATIENTEDUCATIONROUTINE FOOT CARE BY A PHYSICIAN OF A DIABETIC PATIENT WITH DIABETIC SENSORYNEUROPATHY RESULTING IN A LOSS OF PROTECTIVE SENSATION (LOPS) TO INCLUDE, THELOCAL CARE OF SUPERFICIAL WOUNDS (I.E. SUPERFICIAL TO MUSCLE AND FASCIA) AND ATLEAST THE FOLLOWING IF PRESENT: (1) LOCAL CARE OF SUPERFICIAL WOUNDS, (2)DEBRIDEMENT OF CORNS AND CALLUSES, AND (3) TRIMMING AND DEBRIDEMENT OF NAILSDEMONSTRATION, PRIOR TO INITIAL USE, OF HOME INR MONITORING FOR PATIENT WITHEITHER MECHANICAL HEART VALVE(S), CHRONIC ATRIAL FIBRILLATION, OR VENOUSTHROMBOEMBOLISM WHO MEETS MEDICARE COVERAGE CRITERIA, UNDER THE DIRECTION OF APHYSICIAN; INCLUDES: FACE-TO-FACE DEMONSTRATION OF USE AND CARE OF THE INRMONITOR, OBTAINING AT LEAST ONE BLOOD SAMPLE, PROVISION OF INSTRUCTIONS FORREPORTING HOME INR TEST RESULTS, AND DOCUMENTATION OF PATIENT ABILITY TOPERFORM TESTING PRIOR TO ITS USEPROVISION OF TEST MATERIALS AND EQUIPMENT FOR HOME INR MONITORING OF PATIENTWITH EITHER MECHANICAL HEART VALVE(S), CHRONIC ATRIAL FIBRILLATION, OR VENOUSTHROMBOEMBOLISM WHO MEETS MEDICARE COVERAGE CRITERIA; INCLUDES PROVISION OFMATERIALS FOR USE IN THE HOME AND REPORTING OF TEST RESULTS TO PHYSICIAN; NOTOCCURRING MORE FREQUENTLY THAN ONCE A WEEKPHYSICIAN REVIEW, INTERPRETATION, AND PATIENT MANAGEMENT OF HOME INR TESTINGFOR A PATIENT WITH EITHER MECHANICAL HEART VALVE(S), CHROIC ATRIALFIBRILLATION, OR VENOUS THROMBOEMBOLISM WHO MEETS MEDICARE COVERAGE CRITERIA;

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INCLUDES FACE-TO-FACE VERIFICATION BY THE PHYSICIAN AT LEAST ONCE A YEAR (E.G.DURING AN EVALUATION AND MANAGEMENT SERVICE) THAT THE PATIENT USES THE DEVICEIN THE CONTEXT OF THE MANAGEMENT OF THE ANTICOAGULATION THERAPY FOLLOWINGINITIATION OF THE HOME INR MONITORING; NOT OCCURRING MORE FREQUENTLY THAN ONCEA WEEKLINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDINGCOLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS,PER SESSION, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENTPET IMAGING, FULL AND PARTIAL-RING PET SCANNERS ONLY, FOR INITIAL DIAGNOSIS OFBREAST CANCER AND/OR SURGICAL PLANNING FOR BREAST CANCER (E.G. INITIAL STAGINGOF AXILLARY LYMPH NODES)PET IMAGING FOR BREAST CANCER, FULL AND PARTIAL-RING PET SCANNERS ONLY,STAGING/RESTAGING OF LOCAL REGIONAL RECURRENCE OR DISTANT METASTASES (I.E.,STAGING/RESTAGING AFTER OR PRIOR TO COURSE OF TREATMENT)PET IMAGING FOR BREAST CANCER, FULL AND PARTIAL- RING PET SCANNERS ONLY,EVALUATION OF RESPONSE TO TREATMENT, PERFORMED DURING COURSE OF TREATMENTCURRENT PERCEPTION THRESHOLD/SENSORY NERVE CONDUCTION TEST, (SNCT) PER LIMB,ANY NERVEUNSCHEDULED OR EMERGENCY DIALYSIS TREATMENT FOR AN ESRD PATIENT IN A HOSPITALOUTPATIENT DEPARTMENT THAT IS NOT CERTIFIED AS AN ESRD FACILITYINTRAVENOUS INFUSION DURING SEPARATELY PAYABLE OBSERVATION STAY, PEROBSERVATION STAY (MUST BE REPORTED WITH G0244)INJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPYINJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROIDAND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHYDIRECT ADMISSION OF PATIENT WITH DIAGNOSIS OF CONGESTIVE HEART FAILURE, CHESTPAIN OR ASTHMA FOR OBSERVATION SERVICES THAT MEET ALL CRITERIA FOR G0244INITIAL NURSING ASSESSMENT OF PATIENT DIRECTLY ADMITTED TO OBSERVATION WITHDIAGNOSIS OTHER THAN CHF, CHEST PAIN OR ASTHMA OR PATIENT DIRECTLY ADMITTED TOOBSERVATION WITH DIAGNOSIS OF CHF, CHEST PAIN OR ASTHMA WHEN THE OBSERVATIONSTAY DOES NOT QUALIFY FOR G0244CRYOPRESERVATION, FREEZING AND STORAGE OF CELLS FOR THERAPEUTIC USE, EACH CELLLINETHAWING AND EXPANSION OF FROZEN CELLS FOR THERAPEUTIC USE, EACH ALIQUOTBONE MARROW OR PERIPHERAL STEM CELL HARVEST, MODIFICATION OR TREATMENT TOELIMINATE CELL TYPE(S) (E.G. T-CELLS, METASTATIC CARCINOMA)REMOVAL OF IMPACTED CERUMEN (ONE OR BOTH EARS) BY PHYSICIAN ON SAME DATE OFSERVICE AS AUDIOLOGIC FUNCTION TESTINGPLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE,POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G. ANGIOSEAL PLUG, VASCULAR PLUG)MEDICAL NUTRITION THERAPY; REASSESSMENT AND SUBSEQUENT INTERVENTION(S)FOLLOWING SECOND REFERRAL IN SAME YEAR FOR CHANGE IN DIAGNOSIS, MEDICALCONDITION OR TREATMENT REGIMEN (INCLUDING ADDITIONAL HOURS NEEDED FOR RENALDISEASE), INDIVIDUAL, FACE TO FACE WITH THE PATIENT, EACH 15 MINUTESMEDICAL NUTRITION THERAPY, REASSESSMENT AND SUBSEQUENT INTERVENTION(S)FOLLOWING SECOND REFERRAL IN SAME YEAR FOR CHANGE IN DIAGNOSIS, MEDICALCONDITION, OR TREATMENT REGIMEN (INCLUDING ADDITIONAL HOURS NEEDED FOR RENALDISEASE), GROUP (2 OR MORE INDIVIDUALS), EACH 30 MINUTESRENAL ANGIOGRAPHY, NON-SELECTIVE, ONE OR BOTH KIDNEYS, PERFORMED AT THE SAMETIME AS CARDIAC CATHETERIZATION AND/OR CORONARY ANGIOGRAPHY, INCLUDESPOSITIONING OR PLACEMENT OF ANY CATHETER IN THE ABDOMINAL AORTA AT OR NEAR THEORIGINS (OSTIA) OF THE RENAL ARTERIES, INJECTION OF DYE, FLUSH AORTOGRAM,PRODUCTION OF PERMANENT IMAGES, AND RADIOLOGIC SUPERVISION AND INTERPRETATION(LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE)ILIAC AND/OR FEMORAL ARTERY ANGIOGRAPHY, NON-SELECTIVE, BILATERAL ORIPSILATERAL TO CATHETER INSERTION, PERFORMED AT THE SAME TIME AS CARDIACCATHETERIZATION AND/OR CORONARY ANGIOGRAPHY, INCLUDES POSITIONING OR PLACEMENTOF THE CATHETER IN THE DISTAL AORTA OR IPSILATERAL FEMORAL OR ILIAC ARTERY,INJECTION OF DYE, PRODUCTION OF PERMANENT IMAGES, AND RADIOLOGIC SUPERVISIONAND INTERPRETATION (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE)EXTRACORPOREAL SHOCK WAVE THERAPY; INVOLVING ELBOW EPICONDYLITIS

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EXTRACORPOREAL SHOCK WAVE THERAPY; INVOLVING OTHER THAN ELBOW EPICONDYLITIS ORPLANTAR FASCITISELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR CHRONIC STAGEIII AND STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS, AND VENOUSSTATSIS ULCERS NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OFCONVENTIONAL CARE, AS PART OF A THERAPY PLAN OF CAREELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR WOUND CAREOTHER THAN DESCRIBED IN G0281ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S)OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARERECONSTRUCTION, COMPUTED TOMOGRAPHIC ANGIOGRAPHY OF AORTA FOR SURGICAL PLANNINGFOR VASCULAR SURGERYARTHROSCOPY, KNEE, SURGICAL, FOR REMOVAL OF LOOSE BODY, FOREIGN BODY,DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHRONDROPLASTY) AT THE TIME OFOTHER SURGICAL KNEE ARTHROSCOPY IN A DIFFERENT COMPARTMENT OF THE SAME KNEETRANSCATHETER PLACEMENT OF A DRUG ELUTING INTRACORONARY STENT(S), PERCUTANEOUS,WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; SINGLE VESSELTRANSCATHETER PLACEMENT OF A DRUG ELUTING INTRACORONARY STENT(S), PERCUTANEOUS,WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; EACH ADDITIONALVESSELNONCOVERED SURGICAL PROCEDURE(S) USING CONSCIOUS SEDATION, REGIONAL, GENERAL ORSPINAL ANESTHESIA IN A MEDICARE QUALIFYING CLINICAL TRIAL, PER DAYNONCOVERED PROCEDURE(S) USING EITHER NO ANESTHESIA OR LOCAL ANESTHESIA ONLY, INA MEDICARE QUALIFYING CLINICAL TRIAL, PER DAYELECTROMAGNETIC THERAPY, TO ONE OR MORE AREAS, FOR WOUND CARE OTHER THANDESCRIBED IN G0329 OR FOR OTHER USESPET IMAGING, FULL AND PARTIAL RING PET SCANNER ONLY, FOR RESTAGING OFPREVIOUSLY TREATED THYROID CANCER OF FOLLICULAR CELL ORIGIN FOLLOWING NEGATIVEI-131 WHOLE BODY SCANINSERTION OF SINGLE CHAMBER PACING CARDIOVERTER DEFIBRILLATOR PULSE GENERATORINSERTION OF DUAL CHAMBER PACING CARDIOVERTER DEFIBRILLATOR PULSE GENERATORINSERTION OR REPOSITIONING OF ELECTRODE LEAD FOR SINGLE CHAMBER PACINGCARDIOVERTER DEFIBRILLATOR AND INSERTION OF PULSE GENERATORINSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR DUAL CHAMBER PACINGCARDIOVERTER DEFIBRILLATOR AND INSERTION OF PULSE GENERATORPRE-OPERATIVE PULMONARY SURGERY SERVICES FOR PREPARATION FOR LVRS, COMPLETECOURSE OF SERVICES, TO INCLUDE A MINIMUM OF 16 DAYS OF SERVICESPRE-OPERATIVE PULMONARY SURGERY SERVICES FOR PREPARATION FOR LVRS, 10 TO 15DAYS OF SERVICESPRE-OPERATIVE PULMONARY SURGERY SERVICES FOR PREPARATION FOR LVRS, 1 TO 9 DAYSOF SERVICESPOST-DISCHARGE PULMONARY SURGERY SERVICES AFTER LVRS, MINIMUM OF 6 DAYS OFSERVICESCOMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, WITHOUT PLATELET COUNT) ANDAUTOMATED WBC DIFFERENTIAL COUNTCOMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC; WITHOUT PLATELET COUNT)END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS UNDER 2 YEARS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OFNUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF PARENTS;WITH 4 OR MORE FACE-TO-FACE PHYSICIAN VISITS PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENTFOR PATIENTS UNDER 2 YEARS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OFNUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF PARENTS;WITH 2 OR 3 FACE-TO-FACE PHYSICIAN VISITS PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS UNDER 2 YEARS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OFNUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF PARENTS;WITH 1 FACE-TO-FACE PHYSICIAN VISIT PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS BETWEEN 2 AND 11 YEARS OF AGE TO INCLUDE MONITORING FOR THEADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF

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PARENTS; WITH 4 OR MORE FACE-TO-FACE PHYSICIAN VISITS PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS BETWEEN 2 AND 11 YEARS OF AGE TO INCLUDE MONITORING FOR THEADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OFPARENTS; WITH 2 OR 3 FACE-TO-FACE PHYSICIAN VISITS PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS BETWEEN 2 AND 11 YEARS OF AGE TO INCLUDE MONITORING FOR THEADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OFPARENTS; WITH 1 FACE-TO-FACE PHYSICIAN VISIT PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES, DURING THE COURSE OFTREATMENT, FOR PATIENTS BETWEEN 12 AND 19 YEARS OF AGE TO INCLUDE MONITORINGFOR THE ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, ANDCOUNSELING OF PARENTS; WITH 4 OR MORE FACE-TO-FACE PHYSICIAN VISITS PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS BETWEEN 12 AND 19 YEARS OF AGE TO INCLUDE MONITORING FOR THEADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OFPARENTS; WITH 2 OR 3 FACE-TO-FACE PHYSICIAN VISITS PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS BETWEEN 12 AND 19 YEARS OF AGE TO INCLUDE MONITORING FOR THEADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OFPARENTS; WITH 1 FACE-TO-FACE PHYSICIAN VISIT PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS 20 YEARS OF AGE AND OVER; WITH 4 OR MORE FACE-TO-FACE PHYSICIANVISITS PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS 20 YEARS OF AGE AND OVER; WITH 2 OR 3 FACE-TO-FACE PHYSICIANVISITS PER MONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,FOR PATIENTS 20 YEARS OF AGE AND OVER; WITH 1 FACE-TO-FACE PHYSICIAN VISIT PERMONTHEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PERFULL MONTH; FOR PATIENTS UNDER TWO YEARS OF AGE TO INCLUDE MONITORING FORADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OFPARENTSEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PERFULL MONTH; FOR PATIENTS TWO TO ELEVEN YEARS OF AGE TO INCLUDE MONITORING FORADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OFPARENTSEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PERFULL MONTH; FOR PATIENTS TWELVE TO NINETEEN YEARS OF AGE TO INCLUDE MONITORINGFOR ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELINGOF PARENTSEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PERFULL MONTH; FOR PATIENTS TWENTY YEARS OF AGE AND OLDEREND STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY;FOR PATIENTS UNDER TWO YEARS OF AGEEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY;FOR PATIENTS BETWEEN TWO AND ELEVEN YEARS OF AGEEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY;FOR PATIENTS BETWEEN TWELVE AND NINETEEN YEARS OF AGEEND STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY;FOR PATIENTS TWENTY YEARS OF AGE AND OVERCOLORECTAL CANCER SCREENING; FECAL OCCULT BLOOD TEST, IMMUNOASSAY, 1-3SIMULTANEOUSELECTROMAGNETIC THERAPY, TO ONE OR MORE AREAS FOR CHRONIC STAGE III AND STAGEIV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS AND VENOUS STASIS ULCERSNOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONALCARE AS PART OF A THERAPY PLAN OF CARESERVICES FOR INTRAVENOUS INFUSION OF IMMUNOGLOBULIN PRIOR TO ADMINISTRATION(THIS SERVICE IS TO BE BILLED IN CONJUNCTION WITH ADMINISTRATION OFIMMUNOGLOBULIN)

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PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS ABENEFICIARYPET IMAGING, BRAIN IMAGING FOR THE DIFFERENTIAL DIAGNOSIS OF ALZHEIMER'SDISEASE WITH ABERRANT FEATURES VS FRONTO-TEMPORAL DEMENTIAHOSPICE EVALUATION AND COUNSELING SERVICES, PRE-ELECTIONLINEAR-ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY PLAN, INCLUDING DOSE VOLUMEHISTOGRAMS FOR TARGET AND CRITICAL STRUCTURE TOLERANCES, PLAN OPTIMIZATIONPERFORMED FOR HIGHLY CONFORMAL DISTRIBUTIONS, PLAN POSITIONAL ACCURACY AND DOSEVERIFICATION, ALL LESIONS TREATED, PER COURSE OF TREATMENTIMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY,COMPLETE COURSE OF THERAPY IN ONE SESSION OR FIRST SESSION OF FRACTIONATEDTREATMENTIMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY,DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATEDTREATMENT, ALL LESIONS, PER SESSION, SECOND THROUGH FIFTH SESSIONS, MAXIMUMFIVE SESSIONS PER COURSE OF TREATMENTPERCUTANEOUS ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHETERIZATION ANDINFUSIONLAPAROSCOPY FOR ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHETERIZATION ANDINFUSIONLAPAROTOMY FOR ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHETERIZATION ANDINFUSIONINITIAL PREVENTIVE PHYSICAL EXAMINATION; FACE-TO-FACE VISIT, SERVICES LIMITEDTO A NEW BENEFICIARY DURING THE FIRST 12 MONTHS OF MEDICARE ENROLLMENTINTRAVENOUS INFUSION, HYDRATION; INITIAL, UP TO ONE HOUREACH ADDITIONAL HOUR, UP TO EIGHT (8) HOURS (LIST SEPARATELY IN ADDITION TOCODE FOR PRIMARY PROCEDURE)INTRAVENOUS INFUSION, FOR THERAPEUTIC/DIAGNOSTIC (SPECIFY SUBSTANCE OR DRUG);INITIAL, UP TO ONE HOUREACH ADDITIONAL HOUR, UP TO EIGHT (8) HOURS (LIST SEPARATELY IN ADDITION TOCODE FOR PRIMARY PROCEDURE AND REPORT IN CONJUNCTION WITH G0347)ADDITIONAL SEQUENTIAL INFUSION, UP TO ONE HOUR (LIST SEPARATELY IN ADDITION TOCODE FOR PRIMARY PROCEDURE)CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)REPORT ONLY ONCE PER SUBSTANCE/DRUG REGARDLESS OF DURATION, REPORT G0350 INCONJUNCTION WITH G0345THERAPEUTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUSOR INTRAMUSCULARINTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUGEACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH (LIST SEPARATELY IN ADDITION TOCODE FOR PRIMARY PROCEDURE)CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR NON-HORMONALANTINEOPLASTICHORMONAL ANTI-NEOPLASTICINTRAVENOUS, PUSH TECHNIQUE, SINGLE OR INITIAL SUBSTANCE/DRUGINTRAVENOUS, PUSH TECHNIQUE, EACH ADDITIONAL SUBSTANCE/DRUG (LIST SEPARATELY INADDITION TO CODE FOR PRIMARY PROCEDURE)CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; UP TO ONE HOUR,SINGLE OR INITIAL SUBSTANCE/DRUGEACH ADDITIONAL HOUR, ONE TO EIGHT (8) HOURS (LIST SEPARATELY IN ADDITION TOCODE FOR PRIMARY PROCEDURE) USE G0360 IN CONJUNCTION WITH G0359INITIATION OF PROLONGED CHEMOTHERAPY INFUSION (MORE THAN EIGHT HOURS),REQUIRING USE OF A PORTABLE OR IMPLANTABLE PUMPEACH ADDITIONAL SEQUENTIAL INFUSION (DIFFERENT SUBSTANCE/DRUG), UP TO ONE HOUR(USE WITH G0359)IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS (DO NOTREPORT G0363 IF AN INJECTION OR INFUSION IS PROVIDED ON THE SAME DAY)BONE MARROW ASPIRATION PERFORMED WITH BONE MARROW BIOPSY THROUGH THE SAMEINCISION ON THE SAME DATE OF SERVICEVESSEL MAPPING OF VESSELS FOR HEMODIALYSIS ACCESS (SERVICES FOR PREOPERATIVEVESSEL MAPPING PRIOR TO CREATION OF HEMODIALYSIS ACCESS USING AN AUTOGENOUS

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HEMODIALYSIS CONDUIT, INCLUDING ARTERIAL INFLOW AND VENOUS OUTFLOW)ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; PERFORMED AS A COMPONENT OF THEINITIAL PREVENTIVE EXAMINATION WITH INTERPRETATION AND REPORTTRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A COMPONENT OFTHE INITIAL PREVENTIVE EXAMINATIONINTERPRETATION AND REPORT ONLY, PERFORMED AS A COMPONENT OF THE INITIALPREVENTIVE EXAMINATIONPHARMACY SUPPLY FEE FOR INITIAL IMMUNOSUPPRESSIVE DRUG(S) FIRST MONTH FOLLOWINGTRANSPLANTPHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVEDRUG(S)PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 30 DAYSPHYSICIAN SERVICE REQUIRED TO ESTABLISH AND DOCUMENT THE NEED FOR A POWERMOBILITY DEVICEPHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 90 DAYSSMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; INTERMEDIATE, GREATER THAN3 MINUTES UP TO 10 MINUTESSMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; INTENSIVE, GREATER THAN 10MINUTESADMINISTRATION OF VACCINE FOR PART D DRUGHOSPITAL OBSERVATION SERVICE, PER HOURDIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARELEVEL 1 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCYDEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAWAS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDESCARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELYPRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 ISBEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURREDDURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITSOUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON ANURGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)LEVEL 2 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCYDEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAWAS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDESCARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELYPRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 ISBEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURREDDURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITSOUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON ANURGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)LEVEL 3 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCYDEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAWAS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDESCARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELYPRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 ISBEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURREDDURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITSOUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON ANURGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)LEVEL 4 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCYDEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW

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AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDESCARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELYPRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 ISBEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURREDDURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITSOUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON ANURGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)LEVEL 5 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCYDEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAWAS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDESCARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING APREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELYPRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 ISBEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURREDDURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITSOUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON ANURGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)ULTRASOUND B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; FOR ABDOMINALAORTIC ANEURYSM (AAA) SCREENINGTRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICETRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FOR MAINTENANCE OF HEMODIALYSISACCESS, ARTERIOVENOUS FISTULA OR GRAFT; ARTERIALTRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FOR MAINTENANCE OF HEMODIALYSISACCESS, ARTERIOVENOUS FISTULA OR GRAFT; VENOUSBLOOD OCCULT TEST (E.G., GUAIAC), FECES, FOR SINGLE DETERMINATION FORCOLORECTAL NEOPLASM (I.E., PATIENT WAS PROVIDED THREE CARDS OR SINGLE TRIPLECARD FOR CONSECUTIVE COLLECTION)ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED ASSESSMENT(E.G., AUDIT, DAST), AND BRIEF INTERVENTION 15 TO 30 MINUTESALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED ASSESSMENT(E.G., AUDIT, DAST), AND INTERVENTION, GREATER THAN 30 MINUTESHOME SLEEP STUDY TEST (HST) WITH TYPE II PORTABLE MONITOR, UNATTENDED; MINIMUMOF 7 CHANNELS: EEG, EOG, EMG, ECG/HEART RATE, AIRFLOW, RESPIRATORY EFFORT ANDOXYGEN SATURATIONHOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGENSATURATIONHOME SLEEP TEST (HST) WITH TYPE IV PORTABLE MONITOR, UNATTENDED; MINIMUM OF 3CHANNELSINITIAL PREVENTIVE PHYSICAL EXAMINATION; FACE-TO-FACE VISIT, SERVICES LIMITEDTO NEW BENEFICIARY DURING THE FIRST 12 MONTHS OF MEDICARE ENROLLMENTELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; PERFORMED AS A SCREENING FOR THEINITIAL PREVENTIVE PHYSICAL EXAMINATION WITH INTERPRETATION AND REPORTELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUTINTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVEPHYSICAL EXAMINATIONELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; INTERPRETATION AND REPORT ONLY,PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATIONFOLLOW-UP INPATIENT TELEHEALTH CONSULTATION, LIMITED, PHYSICIANS TYPICALLYSPEND 15 MINUTES COMMUNICATING WITH THE PATIENT VIA TELEHEALTHFOLLOW-UP INPATIENT TELEHEALTH CONSULTATION, INTERMEDIATE, PHYSICIANS TYPICALLYSPEND 25 MINUTES COMMUNICATING WITH THE PATIENT VIA TELEHEALTHFOLLOW-UP INPATIENT TELEHEALTH CONSULTATION, COMPLEX, PHYSICIANS TYPICALLYSPEND 35 MINUTES OR MORE COMMUNICATING WITH THE PATIENT VIA TELEHEALTHSOCIAL WORK AND PSYCHOLOGICAL SERVICES, DIRECTLY RELATING TO AND/OR FURTHERINGTHE PATIENT'S REHABILITATION GOALS, EACH 15 MINUTES, FACE-TO-FACE; INDIVIDUAL(SERVICES PROVIDED BY A CORF-QUALIFIED SOCIAL WORKER OR PSYCHOLOGIST IN A CORF)

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GROUP PSYCHOTHERAPY OTHER THAN OF A MULTIPLE-FAMILY GROUP, IN A PARTIALHOSPITALIZATION SETTING, APPROXIMATELY 45 TO 50 MINUTESINTERACTIVE GROUP PSYCHOTHERAPY, IN A PARTIAL HOSPITALIZATION SETTING,APPROXIMATELY 45 TO 50 MINUTESOPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR ILIAC WINGFRACTURE(S), UNILATERAL OR BILATERAL FOR PELVIC BONE FRACTURE PATTERNS WHICH DONOT DISRUPT THE PELVIC RING INCLUDES INTERNAL FIXATION, WHEN PERFORMEDPERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC BONE FRACTURE AND/ORDISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL ORBILATERAL, (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM)OPEN TREATMENT OF ANTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION FOR FRACTUREPATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, INCLUDESINTERNAL FIXATION WHEN PERFORMED (INCLUDES PUBIC SYMPHYSIS AND/ORSUPERIOR/INFERIOR RAMI)OPEN TREATMENT OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FORFRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL,INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ILIUM, SACROILIAC JOINTAND/OR SACRUM)SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION FOR PROSTATE NEEDLESATURATION BIOPSY SAMPLING, 1-20 SPECIMENSSURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION FOR PROSTATE NEEDLESATURATION BIOPSY SAMPLING, 21-40 SPECIMENSSURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION FOR PROSTATE NEEDLESATURATION BIOPSY SAMPLING, 41-60 SPECIMENSSURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION FOR PROSTATE NEEDLESATURATION BIOPSY SAMPLING, GREATER THAN 60 SPECIMENSADMINISTRATION AND SUPPLY OF TOSITUMOMAB, 450 MGACUTE MYOCARDIAL INFARCTION: PATIENT DOCUMENTED TO HAVE RECEIVED ASPIRIN ATARRIVALACUTE MYOCARDIAL INFARCTION: PATIENT NOT DOCUMENTED TO HAVE RECEIVED ASPIRIN ATARRIVALCLINICIAN DOCUMENTED THAT ACUTE MYOCARDIAL INFARCTION PATIENT WAS NOT ANELIGIBLE CANDIDATE TO RECEIVE ASPIRIN AT ARRIVAL MEASUREACUTE MYOCARDIAL INFARCTION: PATIENT DOCUMENTED TO HAVE RECEIVED BETA-BLOCKERAT ARRIVALACUTE MYOCARDIAL INFARCTION: PATIENT NOT DOCUMENTED TO HAVE RECEIVEDBETA-BLOCKER AT ARRIVALCLINICIAN DOCUMENTED THAT ACUTE MYOCARDIAL INFARCTION PATIENT WAS NOT ANELIGIBLE CANDIDATE FOR BETA-BLOCKER AT ARRIVAL MEASUREPNEUMONIA: PATIENT DOCUMENTED TO HAVE RECEIVED ANTIBIOTIC WITHIN 4 HOURS OFPRESENTATIONPNEUMONIA: PATIENT NOT DOCUMENTED TO HAVE RECEIVED ANTIBIOTIC WITHIN 4 HOURS OFPRESENTATIONCLINICIAN DOCUMENTED THAT PNEUMONIA PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORANTIBIOTIC WITHIN 4 HOURS OF PRESENTATION MEASUREDIABETIC PATIENT WITH MOST RECENT HEMOGLOBIN A1C LEVEL (WITHIN THE LAST 6MONTHS) DOCUMENTED AS GREATER THAN 9%DIABETIC PATIENT WITH MOST RECENT HEMOGLOBIN A1C LEVEL (WITHIN THE LAST 6MONTHS) DOCUMENTED AS LESS THAN OR EQUAL TO 9%CLINICIAN DOCUMENTED THAT DIABETIC PATIENT WAS NOT ELIGIBLE CANDIDATE FORHEMOGLOBIN A1C MEASURECLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC PATIENT FOR THE REQUIRED TIMEFOR HEMOGLOBIN A1C MEASURE (6 MONTHS)DIABETIC PATIENT WITH MOST RECENT LOW-DENSITY LIPOPROTEIN (WITHIN THE LAST 12MONTHS) DOCUMENTED AS GREATER THAN OR EQUAL TO 100 MG/DLDIABETIC PATIENT WITH MOST RECENT LOW-DENSITY LIPOPROTEIN (WITHIN THE LAST 12MONTHS) DOCUMENTED AS LESS THAN 100 MG/DLCLINICIAN DOCUMENTED THAT DIABETIC PATIENT WAS NOT ELIGIBLE CANDIDATE FORLOW-DENSITY LIPOPROTEIN MEASURECLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC PATIENT FOR THE REQUIRED TIMEFOR LOW-DENSITY LIPOPROTEIN MEASURE (12 MONTHS)

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DIABETIC PATIENT WITH MOST RECENT BLOOD PRESSURE (WITHIN THE LAST 6 MONTHS)DOCUMENTED AS EQUAL TO OR GREATER THAN 140 SYSTOLIC OR EQUAL TO OR GREATER THAN80 MMHG DIASTOLICDIABETIC PATIENT WITH MOST RECENT BLOOD PRESSURE (WITHIN THE LAST 6 MONTHS)DOCUMENTED AS LESS THAN 140 SYSTOLIC AND LESS THAN 80 DIASTOLICCLINICIAN DOCUMENTED THAT THE DIABETIC PATIENT WAS NOT ELIGIBLE CANDIDATE FORBLOOD PRESSURE MEASURECLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC PATIENT FOR THE REQUIRED TIMEFOR BLOOD PRESSURE MEASURE (WITHIN THE LAST 6 MONTHS)HEART FAILURE PATIENT WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD)DOCUMENTED TO BE ON EITHER ANGIOTENSIN-CONVERTING ENZYME INHIBITOR ORANGIOTENSIN-RECEPTOR BLOCKER (ACE-I OR ARB) THERAPYHEART FAILURE PATIENT WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD) NOTDOCUMENTED TO BE ON EITHER ANGIOTENSIN-CONVERTING ENZYME INHIBITOR ORANGIOTENSIN-RECEPTOR BLOCKER (ACE-I OR ARB) THERAPYCLINICIAN DOCUMENTED THAT HEART FAILURE PATIENT WAS NOT AN ELIGIBLE CANDIDATEFOR EITHER ANGIOTENSIN-CONVERTING ENZYME INHIBITOR OR ANGIOTENSIN-RECEPTORBLOCKER (ACE-I OR ARB) THERAPY MEASUREHEART FAILURE PATIENT WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD)DOCUMENTED TO BE ON BETA-BLOCKER THERAPYHEART FAILURE PATIENT WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD) NOTDOCUMENTED TO BE ON BETA-BLOCKER THERAPYCLINICIAN DOCUMENTED THAT HEART FAILURE PATIENT WAS NOT ELIGIBLE CANDIDATE FORBETA-BLOCKER THERAPY MEASUREPRIOR MYOCARDIAL INFARCTION - CORONARY ARTERY DISEASE PATIENT DOCUMENTED TO BEON BETA-BLOCKER THERAPYPRIOR MYOCARDIAL INFARCTION - CORONARY ARTERY DISEASE PATIENT NOT DOCUMENTED TOBE ON BETA-BLOCKER THERAPYCLINICIAN DOCUMENTED THAT PRIOR MYOCARDIAL INFARCTION - CORONARY ARTERY DISEASEPATIENT WAS NOT ELIGIBLE CANDIDATE FOR BETA-BLOCKER THERAPY MEASURECORONARY ARTERY DISEASE PATIENT DOCUMENTED TO BE ON ANTIPLATELET THERAPYCORONARY ARTERY DISEASE PATIENT NOT DOCUMENTED TO BE ON ANTIPLATELET THERAPYCLINICIAN DOCUMENTED THAT CORONARY ARTERY DISEASE PATIENT WAS NOT ELIGIBLECANDIDATE FOR ANTIPLATELET THERAPY MEASURECORONARY ARTERY DISEASE - PATIENT WITH LOW-DENSITY LIPOPROTEIN DOCUMENTED TO BEGREATER THAN 100MG/DLCORONARY ARTERY DISEASE - PATIENT WITH LOW-DENSITY LIPOPROTEIN DOCUMENTED TO BELESS THAN OR EQUAL TO 100MG/DLCLINICIAN DOCUMENTED THAT CORONARY ARTERY DISEASE PATIENT WAS NOT ELIGIBLECANDIDATE FOR LOW-DENSITY LIPOPROTEIN MEASUREPATIENT (FEMALE) DOCUMENTED TO HAVE BEEN ASSESSED FOR OSTEOPOROSISPATIENT (FEMALE) NOT DOCUMENTED TO HAVE BEEN ASSESSED FOR OSTEOPOROSISCLINICIAN DOCUMENTED THAT (FEMALE) PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOROSTEOPOROSIS ASSESSMENT MEASUREPATIENT NOT DOCUMENTED FOR THE ASSESSMENT FOR FALLS WITHIN LAST 12 MONTHSPATIENT DOCUMENTED FOR THE ASSESSMENT FOR FALLS WITHIN LAST 12 MONTHSCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR THE FALLSASSESSMENT MEASURE WITHIN THE LAST 12 MONTHSPATIENT DOCUMENTED TO HAVE RECEIVED HEARING ASSESSMENTPATIENT NOT DOCUMENTED TO HAVE RECEIVED HEARING ASSESSMENTCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR HEARINGASSESSMENT MEASUREPATIENT DOCUMENTED FOR THE ASSESSMENT OF URINARY INCONTINENCEPATIENT NOT DOCUMENTED FOR THE ASSESSMENT OF URINARY INCONTINENCECLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR URINARYINCONTINENCE ASSESSMENT MEASUREEND STAGE RENAL DISEASE PATIENT WITH DOCUMENTED DIALYSIS DOSE OF URR GREATERTHAN OR EQUAL TO 65% (OR KT/V GREATER THAN OR EQUAL TO 1.2)END STAGE RENAL DISEASE PATIENT WITH DOCUMENTED DIALYSIS DOSE OF URR LESS THAN65% (OR KT/V LESS THAN 1.2)CLINICIAN DOCUMENTED THAT END STAGE RENAL DISEASE PATIENT WAS NOT AN ELIGIBLE

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CANDIDATE FOR URR OR KT/V MEASUREEND STAGE RENAL DISEASE PATIENT WITH DOCUMENTED HEMATOCRIT GREATER THAN OREQUAL TO 33 (OR HEMOGLOBIN GREATER THAN OR EQUAL TO 11)END STAGE RENAL DISEASE PATIENT WITH DOCUMENTED HEMATOCRIT LESS THAN 33 (ORHEMOGLOBIN LESS THAN 11)CLINICIAN DOCUMENTED THAT END STAGE RENAL DISEASE PATIENT WAS NOT AN ELIGIBLECANDIDATE FOR HEMATOCRIT (HEMOGLOBIN) MEASUREEND STAGE RENAL DISEASE PATIENT REQUIRING HEMODIALYSIS VASCULAR ACCESSDOCUMENTED TO HAVE RECEIVED AUTOGENOUS AV FISTULAEND STAGE RENAL DISEASE PATIENT REQUIRING HEMODIALYSIS DOCUMENTED TO HAVERECEIVED VASCULAR ACCESS OTHER THAN AUTOGENOUS AV FISTULAEND-STAGE RENAL DISEASE PATIENT REQUIRING HEMODIALYSIS VASCULAR ACCESS WAS NOTAN ELIGIBLE CANDIDATE FOR AUTOGENOUS AV FISTULANEWLY DIAGNOSED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENT DOCUMENTEDTO HAVE RECEIVED SMOKING CESSATION INTERVENTION, WITHIN 3 MONTHS OF DIAGNOSISNEWLY DIAGNOSED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENT NOTDOCUMENTED TO HAVE RECEIVED SMOKING CESSATION INTERVENTION, WITHIN 3 MONTHS OFDIAGNOSISOSTEOPOROSIS PATIENT DOCUMENTED TO HAVE BEEN PRESCRIBED CALCIUM AND VITAMIN DSUPPLEMENTSCLINICIAN DOCUMENTED THAT OSTEOPOROSIS PATIENT WAS NOT AN ELIGIBLE CANDIDATEFOR CALCIUM AND VITAMIN D SUPPLEMENT MEASURENEWLY DIAGNOSED OSTEOPOROSIS PATIENTS DOCUMENTED TO HAVE BEEN TREATED WITHANTIRESORPTIVE THERAPY AND/OR PTH WITHIN 3 MONTHS OF DIAGNOSISCLINICIAN DOCUMENTED THAT NEWLY DIAGNOSED OSTEOPOROSIS PATIENT WAS NOT ANELIGIBLE CANDIDATE FOR ANTIRESORPTIVE THERAPY AND/OR PTH TREATMENT MEASUREWITHIN 3 MONTHS OF DIAGNOSISWITHIN 6 MONTHS OF SUFFERING A NONTRAUMATIC FRACTURE, FEMALE PATIENT 65 YEARSOF AGE OR OLDER DOCUMENTED TO HAVE UNDERGONE BONE MINERAL DENSITY TESTING OR TOHAVE BEEN PRESCRIBED A DRUG TO TREAT OR PREVENT OSTEOPOROSISCLINICIAN DOCUMENTED THAT FEMALE PATIENT 65 YEARS OF AGE OR OLDER WHO SUFFEREDA NONTRAUMATIC FRACTURE WITHIN THE LAST 6 MONTHS WAS NOT AN ELIGIBLE CANDIDATEFOR MEASURE TO TEST BONE MINERAL DENSITY OR DRUG TO TREAT OR PREVENTOSTEOPOROSISPATIENT DOCUMENTED TO HAVE RECEIVED INFLUENZA VACCINATION DURING INFLUENZASEASONPATIENT NOT DOCUMENTED TO HAVE RECEIVED INFLUENZA VACCINATION DURING INFLUENZASEASONCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR INFLUENZAVACCINATION MEASUREPATIENT (FEMALE) DOCUMENTED TO HAVE RECEIVED A MAMMOGRAM DURING THE MEASUREMENTYEAR OR PRIOR YEAR TO THE MEASUREMENT YEARPATIENT (FEMALE) NOT DOCUMENTED TO HAVE RECEIVED A MAMMOGRAM DURING THEMEASUREMENT YEAR OR PRIOR YEAR TO THE MEASUREMENT YEARCLINICIAN DOCUMENTED THAT FEMALE PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORMAMMOGRAPHY MEASURECLINICIAN DID NOT PROVIDE CARE TO PATIENT FOR THE REQUIRED TIME OF MAMMOGRAPHYMEASURE (I.E., MEASUREMENT YEAR OR PRIOR YEAR)PATIENT DOCUMENTED TO HAVE RECEIVED PNEUMOCOCCAL VACCINATIONPATIENT NOT DOCUMENTED TO HAVE RECEIVED PNEUMOCOCCAL VACCINATIONCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORPNEUMOCOCCAL VACCINATION MEASUREPATIENT DOCUMENTED AS BEING TREATED WITH ANTIDEPRESSANT MEDICATION DURING THEENTIRE 12 WEEK ACUTE TREATMENT PHASEPATIENT NOT DOCUMENTED AS BEING TREATED WITH ANTIDEPRESSANT MEDICATION DURINGTHE ENTIRE 12 WEEKS ACUTE TREATMENT PHASECLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORANTIDEPRESSANT MEDICATION DURING THE ENTIRE 12 WEEK ACUTE TREATMENT PHASEMEASUREPATIENT DOCUMENTED AS BEING TREATED WITH ANTIDEPRESSANT MEDICATION FOR AT LEAST6 MONTHS CONTINUOUS TREATMENT PHASE

Query_110708

Page 233

PATIENT NOT DOCUMENTED AS BEING TREATED WITH ANTIDEPRESSANT MEDICATION FOR ATLEAST 6 MONTHS CONTINUOUS TREATMENT PHASECLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORANTIDEPRESSANT MEDICATION FOR CONTINUOUS TREATMENT PHASEPATIENT DOCUMENTED TO HAVE RECEIVED ANTIBIOTIC PROPHYLAXIS ONE HOUR PRIOR TOINCISION TIME (TWO HOURS FOR VANCOMYCIN)PATIENT NOT DOCUMENTED TO HAVE RECEIVED ANTIBIOTIC PROPHYLAXIS ONE HOUR PRIORTO INCISION TIME (TWO HOURS FOR VANCOMYCIN)CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ANTIBIOTICPROPHYLAXIS ONE HOUR PRIOR TO INCISION TIME (TWO HOURS FOR VANCOMYCIN) MEASUREPATIENT WITH DOCUMENTED RECEIPT OF THROMBOEMBOLISM PROPHYLAXISPATIENT WITHOUT DOCUMENTED RECEIPT OF THROMBOEMBOLISM PROPHYLAXISCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORTHROMBOEMBOLISM PROPHYLAXIS MEASUREPATIENT DOCUMENTED TO HAVE RECEIVED CORONARY ARTERY BYPASS GRAFT WITH USE OFINTERNAL MAMMARY ARTERYPATIENT DOCUMENTED TO HAVE RECEIVED CORONARY ARTERY BYPASS GRAFT WITHOUT USE OFINTERNAL MAMMARY ARTERYCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CORONARYARTERY BYPASS GRAFT WITH USE OF INTERNAL MAMMARY ARTERY MEASUREPATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DOCUMENTED TO HAVE RECEIVEDPRE-OPERATIVE BETA-BLOCKADEPATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT NOT DOCUMENTED TO HAVERECEIVED PRE-OPERATIVE BETA-BLOCKADECLINICIAN DOCUMENTED THAT PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFTWAS NOT AN ELIGIBLE CANDIDATE FOR PRE-OPERATIVE BETA-BLOCKADE MEASUREPATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DOCUMENTED TO HAVE PROLONGEDINTUBATIONPATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT NOT DOCUMENTED TO HAVEPROLONGED INTUBATIONPATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DOCUMENTED TO HAVE REQUIREDSURGICAL RE-EXPLORATIONPATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DID NOT REQUIRE SURGICALRE-EXPLORATIONPATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DOCUMENTED TO HAVE BEENDISCHARGED ON ASPIRIN OR CLOPIDOGRELPATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT NOT DOCUMENTED TO HAVE BEENDISCHARGED ON ASPIRIN OR CLOPIDOGRELCLINICIAN DOCUMENTED THAT PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFTWAS NOT AN ELIGIBLE CANDIDATE FOR ANTIPLATELET THERAPY AT DISCHARGE MEASURECLINICIAN HAS NOT PROVIDED CARE FOR THE CARDIAC PATIENT FOR THE REQUIRED TIMEFOR LOW-DENSITY LIPOPROTEIN MEASURE (6 MONTHS)PATIENT WITH HEART FAILURE AND ATRIAL FIBRILLATION DOCUMENTED TO BE ON WARFARINTHERAPYCLINICIAN DOCUMENTED THAT PATIENT WITH HEART FAILURE AND ATRIAL FIBRILLATIONWAS NOT AN ELIGIBLE CANDIDATE FOR WARFARIN THERAPY MEASUREPATIENTS DIAGNOSED WITH SYMPTOMATIC OSTEOARTHRITIS WITH DOCUMENTED ANNUALASSESSMENT OF FUNCTION AND PAINCLINICIAN DOCUMENTED THAT SYMPTOMATIC OSTEOARTHRITIS PATIENT WAS NOT ANELIGIBLE CANDIDATE FOR ANNUAL ASSESSMENT OF FUNCTION AND PAIN MEASURECLINICIAN DOCUMENTED TO HAVE GIVEN ORDER FOR PROPHYLACTIC ANTIBIOTIC TO BEGIVEN WITHIN ONE HOUR (IF VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (ORSTART OF PROCEDURE WHEN NO INCISION IS REQUIRED)CLINICIAN DOCUMENTED TO HAVE GIVEN THE PROPHYLACTIC ANTIBIOTIC WITHIN ONE HOUR(IF VANCOMYCIN, TWO HOURS) PRIOR TO THE SURGICAL INCISION (OR START OFPROCEDURE WHEN NO INCISION IS REQUIRED)CLINICIAN DID NOT DOCUMENT THAT AN ORDER FOR PROPHYLACTIC ANTIBIOTIC TO BEGIVEN WITHIN ONE HOUR (IF VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (ORSTART OF PROCEDURE WHEN NO INCISION IS REQUIRED) WAS GIVENCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORPROPHYLACTIC ANTIBIOTIC

Query_110708

Page 234

CLINICIAN DOCUMENTED TO HAVE GIVEN THE PROPHYLACTIC ANTIBIOTIC WITHIN ONE HOUR(IF VANCOMYCIN, TWO HOURS) PRIOR TO THE SURGICAL INCISION (OR START OFPROCEDURE WHEN NO INCISION IS REQUIRED)CLINICIAN DID NOT DOCUMENT A PROPHYLACTIC ANTIBIOTIC WAS ADMINISTERED WITHINONE HOUR (IF VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR START OFPROCEDURE WHEN NO INCISION IS REQUIRED)PATIENT DOCUMENTED TO HAVE ORDER FOR PROPHYLACTIC ANTIBIOTIC TO BE GIVEN WITHINONE HOUR (IF VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR START OFPROCEDURE WHEN NO INCISION IS REQUIRED)PATIENT DOCUMENTED TO HAVE ORDER FOR CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIALPROPHYLAXISCLINICIAN DOCUMENTED TO HAVE GIVEN CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIALPROPHYLAXISORDER FOR CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIAL PROPHYLAXIS NOT DOCUMENTEDPATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CEFAZOLIN OR CEFUROXIME FORANTIMICROBIAL PROPHYLAXISCLINICIAN DOCUMENTED AN ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTIC ANTIBIOTICSWITHIN 24 HOURS OF SURGICAL END TIMECLINICIAN DOCUMENTED THAT PROPHYLACTIC ANTIBIOTICS WERE DISCONTINUED WITHIN 24HOURS OF SURGICAL END TIMECLINICIAN DID NOT DOCUMENT AN ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTICANTIBIOTICS WITHIN 24 HOURS OF SURGICAL END TIMECLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORPROPHYLACTIC ANTIBIOTIC DISCONTINUATION WITHIN 24 HOURS OF SURGICAL END TIMECLINICIAN DOCUMENTED THAT PROPHYLACTIC ANTIBIOTIC WAS GIVENCLINICIAN DOCUMENTED AN ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTIC ANTIBIOTICSWITHIN 48 HOURS OF SURGICAL END TIMECLINICIAN DOCUMENTED THAT PROPHYLACTIC ANTIBIOTICS WERE DISCONTINUED WITHIN 48HOURS OF SURGICAL END TIMECLINICIAN DID NOT DOCUMENT AN ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTICANTIBIOTICS WITHIN 48 HOURS OF SURGICAL END TIMECLINICIAN DOCUMENTED PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DISCONTINUATIONOF PROPHYLACTIC ANTIBIOTIC DISCONTINUATION WITHIN 48 HOURS OF SURGICAL END TIMECLINICIAN DOCUMENTED THAT PROPHYLACTIC ANTIBIOTIC WAS GIVENCLINICIAN DOCUMENTED AN ORDER WAS GIVEN FOR APPROPRIATE VENOUS THROMBOEMBOLISM(VTE) PROPHYLAXIS TO BE GIVEN WITHIN 24 HRS PRIOR TO INCISION TIME OR 24 HOURSAFTER SURGERY END TIMECLINICIAN DOCUMENTED TO HAVE GIVEN VTE PROPHYLAXIS WITHIN 24 HRS PRIOR TOINCISION TIME OR 24 HOURS AFTER SURGERY END TIMECLINICIAN DID NOT DOCUMENT AN ORDER WAS GIVEN FOR APPROPRIATE VENOUSTHROMBOEMBOLISM (VTE) PROPHYLAXIS TO BE GIVEN WITHIN 24 HRS PRIOR TO INCISIONTIME OR 24 HOURS AFTER SURGERY END TIMECLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR VENOUSTHROMBOEMBOLISM (VTE) PROPHYLAXIS TO BE GIVEN WITHIN 24 HOURS PRIOR TO INCISIONTIME OR 24 HOURS AFTER SURGERY END TIMEPATIENT DOCUMENTED TO HAVE RECEIVED DVT PROPHYLAXIS BY END OF HOSPITAL DAY TWOPATIENT NOT DOCUMENTED TO HAVE RECEIVED DVT PROPHYLAXIS BY END OF HOSPITAL DAY 2PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DVT PROPHYLAXIS BY END OF HOSPITALDAY 2, INCLUDING PHYSICIAN DOCUMENTATION THAT PATIENT IS AMBULATORYPATIENT DOCUMENTED TO HAVE RECEIVED DVT PROPHYLAXIS BY END OF HOSPITAL DAY 2PATIENT NOT DOCUMENTED TO HAVE RECEIVED DVT PROPHYLAXIS BY END OF HOSPITAL DAY 2CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DVTPROPHYLAXIS BY THE END OF HOSPITAL DAY 2, INCLUDING PHYSICIAN DOCUMENTATIONTHAT PATIENT IS AMBULATORYPATIENT DOCUMENTED TO HAVE BEEN PRESCRIBED ANTIPLATELET THERAPY AT DISCHARGEPATIENT NOT DOCUMENTED TO HAVE RECEIVED PRESCRIPTION FOR ANTIPLATELET THERAPYAT DISCHARGECLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORANTIPLATELET THERAPY AT DISCHARGE, INCLUDING IDENTIFICATION FROM MEDICAL RECORDTHAT PATIENT IS ON ANTICOAGULATION THERAPYPATIENT DOCUMENTED TO HAVE BEEN PRESCRIBED AN ANTICOAGULANT AT DISCHARGE

Query_110708

Page 235

PATIENT NOT DOCUMENTED TO HAVE RECEIVED PRESCRIPTION FOR ANTICOAGULANT THERAPYAT DISCHARGEPATIENT NOT DOCUMENTED TO HAVE PERMANENT, PERSISTENT, OR PAROXYSMAL ATRIALFIBRILLATIONCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORANTICOAGULANT THERAPY AT DISCHARGEPATIENT DOCUMENTED TO HAVE BEEN ADMINISTERED OR CONSIDERED FOR T-PAPATIENT NOT ELIGIBLE FOR T-PA ADMINISTRATION, ISCHEMIC STROKE SYMPTOM ONSET OFMORE THAN 3 HOURSPATIENT NOT DOCUMENTED TO HAVE RECEIVED T-PA OR NOT DOCUMENTED TO HAVE BEENCONSIDERED A CANDIDATE FOR T-PA ADMINISTRATIONPATIENT DOCUMENTED TO HAVE RECEIVED DYSPHAGIA SCREENING PRIOR TO TAKING ANYFOODS, FLUIDS OR MEDICATION BY MOUTHPATIENT NOT DOCUMENTED TO HAVE RECEIVED DYSPHAGIA SCREENINGPATIENT NOT RECEIVING OR INELIGIBLE TO RECEIVE FOOD, FLUIDS OR MEDICATION BYMOUTH, OR DOCUMENTATION OF NPO (NOTHING BY MOUTH) ORDERCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DYSPHAGIASCREENING PRIOR TO TAKING ANY FOODS, FLUIDS OR MEDICATION BY MOUTHPATIENT DOCUMENTED TO HAVE RECEIVED ORDER FOR REHABILITATION SERVICES ORDOCUMENTATION OF CONSIDERATION FOR REHABILITATION SERVICESPATIENT NOT DOCUMENTED TO HAVE RECEIVED ORDER FOR OR CONSIDERATION FORREHABILITATION SERVICESINTERNAL CAROTID STENOSIS PATIENT BELOW 30%, REFERENCE TO MEASUREMENTS OFDISTAL INTERNAL CAROTID DIAMETER AS THE DENOMINATOR FOR STENOSIS MEASUREMENTNOT NECESSARYINTERNAL CAROTID STENOSIS PATIENT IN THE 30-99% RANGE, AND NO DOCUMENTATION OFREFERENCE TO MEASUREMENTS OF DISTAL INTERNAL CAROTID DIAMETER AS THEDENOMINATOR FOR STENOSIS MEASUREMENTCLINICIAN DOCUMENTED THAT PATIENT WHOSE FINAL REPORT OF THE CAROTID IMAGINGSTUDY PERFORMED (NECK MRA, NECK CTA, NECK DUPLEX ULTRASOUND, CAROTIDANGIOGRAM), WITH CHARACTERIZATION OF AN INTERNAL CAROTID STENOSIS IN THE 30-99%RANGE, WAS NOT AN ELIGIBLE CANDIDATE FOR REFERENCE TO MEASUREMENTS OF DISTALINTERNAL CAROTID DIAMETER AS THE DENOMINATOR FOR STENOSIS MEASUREMENTPATIENT DOCUMENTED TO HAVE RECEIVED CT OR MRI WITH PRESENCE OR ABSENCE OFHEMORRHAGE, MASS LESION AND ACUTE INFARCTION DOCUMENTED IN THE FINAL REPORTPATIENT NOT DOCUMENTED TO HAVE RECEIVED CT OR MRI AND THE PRESENCE OR ABSENCEOF HEMORRHAGE, MASS LESION AND ACUTE INFARCTION NOT DOCUMENTED IN THE FINALREPORTCLINICIAN DOCUMENTED PRESENCE OR ABSENCE ALARM SYMPTOMSPATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR MEDICAL HISTORY REVIEW WITHASSESSMENT OF NEW OR CHANGING MOLESPATIENT WITH ALARM SYMPTOM(S) DOCUMENTED TO HAVE HAD UPPER ENDOSCOPY PERFORMEDOR REFERRAL FOR UPPER ENDOSCOPYPATIENT WITH AT LEAST ONE ALARM SYMPTOM NOT DOCUMENTED TO HAVE HAD UPPERENDOSCOPY OR REFERRAL FOR UPPER ENDOSCOPYCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR UPPERENDOSCOPYPATIENT WITH SUSPICION OF BARRETT'S ESOPHAGUS IN ENDOSCOPY REPORT ANDDOCUMENTED TO HAVE RECEIVED AN ESOPHAGEAL BIOPSYPATIENT NOT DOCUMENTED TO HAVE RECEIVED AN ESOPHAGEAL BIOPSY WHEN SUSPICION OFBARRETT'S ESOPHAGUS IS INDICATED IN THE ENDOSCOPY REPORTCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ESOPHAGEALBIOPSYPATIENT DOCUMENTED TO HAVE RECEIVED AN ORDER FOR A BARIUM SWALLOW TESTPATIENT WITH NO DOCUMENTATION ORDER FOR BARIUM SWALLOW TESTCLINICIAN DOCUMENTATION THAT PATIENT WAS AN ELIGIBLE CANDIDATE FOR BARIUMSWALLOW TESTCLINICIAN DOCUMENTED RECONCILIATION OF DISCHARGE MEDICATIONS WITH CURRENTMEDICATION LIST IN MEDICAL RECORDCLINICIAN HAS NOT DOCUMENTED RECONCILIATION OF DISCHARGE MEDICATIONS WITHCURRENT MEDICATION LIST IN MEDICAL RECORD

Query_110708

Page 236

PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DISCHARGE MEDICATIONS REVIEWPATIENT DOCUMENTED TO HAVE SURROGATE DECISION MAKER OR ADVANCE CARE PLAN INMEDICAL RECORDPATIENT NOT DOCUMENTED TO HAVE SURROGATE DECISION MAKER OR ADVANCE CARE PLAN INMEDICAL RECORDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR SURROGATEDECISION MAKER OR ADVANCE CARE PLANPATIENT DOCUMENTED TO HAVE BEEN ASSESSED FOR PRESENCE OR ABSENCE OF URINARYINCONTINENCEPATIENT NOT DOCUMENTED TO HAVE BEEN ASSESSED FOR PRESENCE OR ABSENCE OF URINARYINCONTINENCECLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ANASSESSMENT OF THE PRESENCE OR ABSENCE OF URINARY INCONTINENCEPATIENT DOCUMENTED TO HAVE RECEIVED CHARACTERIZATION OF URINARY INCONTINENCEPATIENT NOT DOCUMENTED TO HAVE RECEIVED CHARACTERIZATION OF URINARY INCONTINENCEPATIENT DOCUMENTED TO HAVE RECEIVED A PLAN OF CARE FOR URINARY INCONTINENCEPATIENT NOT DOCUMENTED TO HAVE RECEIVED PLAN OF CARE FOR URINARY INCONTINENCECLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME TODEVELOP PLAN OF CARE FOR URINARY INCONTINENCEPATIENT DOCUMENTED TO HAVE RECEIVED SCREENING FOR FALL RISK (2 OR MORE FALLS INTHE PAST YEAR OR ANY FALL WITH INJURY IN THE PAST YEAR)PATIENT WITH NO DOCUMENTATION OF SCREENING FOR FALL RISKS (2 OR MORE FALLS INTHE PAST YEAR OR ANY FALL WITH INJURY IN THE PAST YEAR)CLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR FALLRISK SCREENINGCLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME TO SCREENFOR FALL RISKCLINICIAN HAS NOT DOCUMENTED PRESENCE OR ABSENCE OF ALARM SYMPTOMSPATIENT DOCUMENTED TO HAVE MEDICAL HISTORY TAKEN WHICH INCLUDED ASSESSMENT OFNEW OR CHANGING MOLESPATIENT NOT DOCUMENTED TO HAVE RECEIVED MEDICAL HISTORY WITH ASSESSMENT OF NEWOR CHANGING MOLESPATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR MEDICAL HISTORY REVIEW WITHASSESSMENT OF NEW OR CHANGING MOLESPATIENT DOCUMENTED TO HAVE RECEIVED COMPLETE PHYSICAL SKIN EXAMPATIENT NOT DOCUMENTED TO HAVE RECEIVED A COMPLETE PHYSICAL SKIN EXAMPATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR COMPLETE PHYSICAL SKIN EXAM DURINGTHE REPORTING YEARPATIENT DOCUMENTED TO HAVE RECEIVED COUNSELING TO PERFORM A SELF-EXAMINATIONPATIENT NOT DOCUMENTED TO HAVE RECEIVED COUNSELING TO PERFORM A SELF-EXAMINATIONPATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR COUNSELING TO PERFORM SELF-EXAMINATIONPATIENT DOCUMENTED TO HAVE RECEIVED A PRESCRIPTION FOR PHARMACOLOGIC THERAPYFOR OSTEOPOROSISPATIENT NOT DOCUMENTED TO HAVE RECEIVED PHARMACOLOGIC THERAPYCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORPHARMACOLOGIC THERAPYCLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME FOR THEPHARMACOLOGIC THERAPY MEASUREPATIENT DOCUMENTED TO HAVE RECEIVED CALCIUM AND VITAMIN D OR COUNSELING ON BOTHCALCIUM AND VITAMIN D USE, AND EXERCISEPATIENT WITH NO DOCUMENTATION OF CALCIUM AND VITAMIN D USE OR COUNSELINGREGARDING BOTH CALCIUM AND VITAMIN D USE, OR EXERCISECLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CALCIUMAND VITAMIN D, AND EXERCISE DURING THE REPORTING YEARCLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME FOR THECALCIUM, VITAMIN D, AND EXERCISE MEASURECOPD PATIENT WITH SPIROMETRY RESULTS DOCUMENTEDCOPD PATIENT WITHOUT SPIROMETRY RESULTS DOCUMENTEDCOPD PATIENT WAS NOT ELIGIBLE FOR SPIROMETRY RESULTSCOPD PATIENT DOCUMENTED TO HAVE RECEIVED INHALED BRONCHODILATOR THERAPYCOPD PATIENT NOT DOCUMENTED TO HAVE INHALED BRONCHODILATOR THERAPY PRESCRIBED

Query_110708

Page 237

COPD PATIENT WAS NOT ELIGIBLE FOR INHALED BRONCHODILATOR THERAPYPATIENT DOCUMENTED TO HAVE RECEIVED OPTIC NERVE HEAD EVALUATIONPATIENT NOT DOCUMENTED TO HAVE RECEIVED OPTIC NERVE HEAD EVALUATIONCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR OPTIC NERVEHEAD EVALUATION DURING THE REPORTING YEARCLINICIAN HAS NOT PROVIDED CARE FOR THE PRIMARY OPEN-ANGLE GLAUCOMA PATIENT FORTHE REQUIRED TIME FOR OPTIC NERVE HEAD EVALUATION MEASUREPATIENT DOCUMENTED TO HAVE A SPECIFIC TARGET INTRAOCULAR PRESSURE RANGE GOALPATIENT NOT DOCUMENTED TO HAVE A SPECIFIC TARGET INTRAOCULAR PRESSURE RANGE GOALCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR A SPECIFICTARGET INTRAOCULAR PRESSURE RANGE GOALCLINICIAN HAS NOT PROVIDED CARE FOR THE PRIMARY OPEN-ANGLE GLAUCOMA PATIENT FORTHE REQUIRED TIME FOR TREATMENT RANGE GOAL DOCUMENTATION MEASUREMENTPRIMARY OPEN-ANGLE GLAUCOMA PATIENT WITH INTRAOCULAR PRESSURE ABOVE THE TARGETRANGE GOAL DOCUMENTED TO HAVE RECEIVED PLAN OF CAREPRIMARY OPEN-ANGLE GLAUCOMA PATIENT WITH INTRAOCULAR PRESSURE AT OR BELOW GOAL,NO PLAN OF CARE NECESSARYPRIMARY OPEN-ANGLE GLAUCOMA PATIENT WITH INTRAOCULAR PRESSURE ABOVE THE TARGETRANGE GOAL, AND NOT DOCUMENTED TO HAVE RECEIVED PLAN OF CARE DURING THEREPORTING YEARPATIENT DOCUMENTED TO HAVE BEEN PRESCRIBED/RECOMMENDED ANTIOXIDANT VITAMIN ORMINERAL SUPPLEMENTPATIENT NOT DOCUMENTED TO HAVE BEEN PRESCRIBED/RECOMMENDED AT LEAST ONEANTIOXIDANT VITAMIN OR MINERAL SUPPLEMENT DURING THE REPORTING YEARCLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORANTIOXIDANT VITAMIN OR MINERAL SUPPLEMENT DURING THE REPORTING YEARCLINICIAN HAS NOT PROVIDED CARE FOR THE AGE-RELATED MACULAR DEGENERATIONPATIENT FOR THE REQUIRED TIME FOR ANTIOXIDANT SUPPLEMENTPRESCRIPTION/RECOMMENDED MEASUREPATIENT DOCUMENTED TO HAVE RECEIVED MACULAR EXAM, INCLUDING DOCUMENTATION OFTHE PRESENCE OR ABSENCE OF MACULAR THICKENING OR HEMORRHAGE AND THE LEVEL OFMACULAR DEGENERATION SEVERITYPATIENT NOT DOCUMENTED TO HAVE RECEIVED MACULAR EXAM WITH DOCUMENTATION OFPRESENCE OR ABSENCE OF MACULAR THICKENING OR HEMORRHAGE AND NO DOCUMENTATION OFLEVEL OF MACULAR DEGENERATION SEVERITYCLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR MACULAREXAMINATION DURING THE REPORTING YEARCLINICIAN HAS NOT PROVIDED CARE FOR THE AGE-RELATED MACULAR DEGENERATIONPATIENT FOR THE REQUIRED TIME FOR MACULAR EXAMINATION MEASUREMENTPATIENT DOCUMENTED TO HAVE VISUAL FUNCTIONAL STATUS ASSESSEDPATIENT DOCUMENTED NOT TO HAVE VISUAL FUNCTIONAL STATUS ASSESSEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ASSESSMENTOF VISUAL FUNCTIONAL STATUSCLINICIAN HAS NOT PROVIDED CARE FOR THE CATARACT PATIENT FOR THE REQUIRED TIMEFOR ASSESSMENT OF VISUAL FUNCTIONAL STATUS MEASUREMENTPATIENT DOCUMENTED TO HAVE HAD PRE-SURGICAL AXIAL LENGTH, CORNEAL POWERMEASUREMENT AND METHOD OF INTRAOCULAR LENS POWER CALCULATIONPATIENT NOT DOCUMENTED TO HAVE HAD PRE-SURGICAL AXIAL LENGTH, CORNEAL POWERMEASUREMENT AND METHOD OF INTRAOCULAR LENS POWER CALCULATIONCLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORPRE-SURGICAL AXIAL LENGTH, CORNEAL POWER MEASUREMENT AND METHOD OF INTRAOCULARLENS POWER CALCULATIONCLINICIAN HAS NOT PROVIDED CARE FOR THE CATARACT PATIENT FOR THE REQUIRED TIMEFOR PRE-SURGICAL MEASUREMENT AND INTRAOCULAR LENS POWER CALCULATION MEASUREPATIENT DOCUMENTED TO HAVE RECEIVED FUNDUS EVALUATION WITHIN SIX MONTHS PRIORTO CATARACT SURGERYPATIENT NOT DOCUMENTED TO HAVE RECEIVED FUNDUS EVALUATION WITHIN SIX MONTHSPRIOR TO CATARACT SURGERYPATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR PRE-SURGICAL FUNDUS EVALUATIONCLINICIAN HAS NOT PROVIDED CARE FOR THE CATARACT PATIENT FOR THE REQUIRED TIMEFOR FUNDUS EVALUATION MEASUREMENT

Query_110708

Page 238

PATIENT DOCUMENTED TO HAVE RECEIVED DILATED MACULAR OR FUNDUS EXAM WITH LEVELOF SEVERITY OF RETINOPATHY AND THE PRESENCE OR ABSENCE OF MACULAR EDEMADOCUMENTEDPATIENT NOT DOCUMENTED TO HAVE RECEIVED DILATED MACULAR OR FUNDUS EXAM WITHLEVEL OF SEVERITY OF RETINOPATHY AND THE PRESENCE OR ABSENCE OF MACULAR EDEMANOT DOCUMENTEDCLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DILATEDMACULAR OR FUNDUS EXAM DURING THE REPORTING YEARCLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC RETINOPATHY PATIENT FOR THEREQUIRED TIME FOR MACULAR EDEMA AND RETINOPATHY MEASUREMENTPATIENT DOCUMENTED TO HAVE HAD FINDINGS OF MACULAR OR FUNDUS EXAM COMMUNICATEDTO THE PHYSICIAN MANAGING THE DIABETES CAREDOCUMENTATION OF FINDINGS OF MACULAR OR FUNDUS EXAM NOT COMMUNICATED TO THEPHYSICIAN MANAGING THE PATIENT'S ONGOING DIABETES CARECLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR THEFINDINGS OF THEIR MACULAR OR FUNDUS EXAM BEING COMMUNICATED TO THE PHYSICIANMANAGING THEIR DIABETES CARE DURING THE REPORTING YEARCLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC RETINOPATHY PATIENT FOR THEREQUIRED TIME FOR PHYSICIAN COMMUNICATION MEASUREMENTCLINICIAN DOCUMENTED THAT COMMUNICATION WAS SENT TO THE PHYSICIAN MANAGINGONGOING CARE OF PATIENT THAT A FRACTURE OCCURRED AND THAT THE PATIENT WAS ORSHOULD BE TESTED OR TREATED FOR OSTEOPOROSISCLINICIAN HAS NOT DOCUMENTED THAT COMMUNICATION WAS SENT TO THE PHYSICIANMANAGING ONGOING CARE OF PATIENT THAT A FRACTURE OCCURRED AND THAT THE PATIENTWAS OR SHOULD BE TESTED OR TREATED FOR OSTEOPOROSISPATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR COMMUNICATION WITH THE PHYSICIANMANAGING THE PATIENT'S ONGOING CARE THAT A FRACTURE OCCURRED AND THAT THEPATIENT WAS OR SHOULD BE TESTED OR TREATED FOR OSTEOPOROSISPATIENT DOCUMENTED TO HAVE HAD CENTRAL DEXA PERFORMED AND RESULTS DOCUMENTED ORCENTRAL DEXA ORDERED OR PHARMACOLOGIC THERAPY PRESCRIBEDPATIENT NOT DOCUMENTED TO HAVE HAD CENTRAL DEXA MEASUREMENT OR PHARMACOLOGICTHERAPYCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CENTRALDEXA MEASUREMENT OR PRESCRIBING PHARMACOLOGICCLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME FORCENTRAL DEXA MEASUREMENT OR PHARMACOLOGICAL THERAPY MEASUREPATIENT DOCUMENTED TO HAVE HAD CENTRAL DEXA ORDERED OR PERFORMED AND RESULTSDOCUMENTED OR PHARMACOLOGICAL THERAPY PRESCRIBEDPATIENT NOT DOCUMENTED TO HAVE HAD CENTRAL DEXA MEASUREMENT ORDERED ORPERFORMED OR PHARMACOLOGIC THERAPYCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CENTRALDEXA MEASUREMENT OR PHARMACOLOGIC THERAPYCLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME FORCENTRAL DEXA MEASUREMENT OR PHARMACOLOGICAL THERAPY MEASUREINTERNAL CAROTID STENOSIS PATIENT IN THE 30-99% RANGE DOCUMENTED TO HAVEREFERENCE TO MEASUREMENTS OF DISTAL INTERNAL CAROTID DIAMETER AS THEDENOMINATOR FOR STENOSIS MEASUREMENTPATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DOCUMENTATION OF PRESENCE OR ABSENCEOF ALARM SYMPTOMSPATIENT DOCUMENTED TO HAVE HAD 12-LEAD ECG PERFORMEDPATIENT NOT DOCUMENTED TO HAVE HAD ECGCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ECGPATIENT DOCUMENTED TO HAVE RECEIVED OR TAKEN ASPIRIN 24 HOURS BEFORE EMERGENCYDEPARTMENT ARRIVAL OR DURING EMERGENCY DEPARTMENT STAYPATIENT NOT DOCUMENTED TO HAVE RECEIVED OR TAKEN ASPIRIN 24 HOURS BEFOREEMERGENCY DEPARTMENT ARRIVAL OR DURING EMERGENCY DEPARTMENT STAYCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE TO RECEIVEASPIRINPATIENT DOCUMENTED TO HAVE HAD ECG PERFORMEDPATIENT NOT DOCUMENTED TO HAVE HAD ECGCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ECG

Query_110708

Page 239

PATIENT DOCUMENTED TO HAVE HAD VITAL SIGNS RECORDED AND REVIEWEDPATIENT NOT DOCUMENTED TO HAVE VITAL SIGNS RECORDED AND REVIEWEDPATIENT DOCUMENTED TO HAVE OXYGEN SATURATION ASSESSEDPATIENT NOT DOCUMENTED TO HAVE OXYGEN SATURATION ASSESSEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR OXYGENSATURATION ASSESSMENTPATIENT DOCUMENTED TO HAVE MENTAL STATUS ASSESSEDPATIENT NOT DOCUMENTED TO HAVE MENTAL STATUS ASSESSEDPATIENT DOCUMENTED TO HAVE APPROPRIATE EMPIRIC ANTIBIOTIC PRESCRIBEDPATIENT NOT DOCUMENTED TO HAVE APPROPRIATE EMPIRIC ANTIBIOTIC PRESCRIBEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR APPROPRIATEEMPIRIC ANTIBIOTICASTHMA PATIENTS WITH NUMERIC FREQUENCY OF SYMPTOMS OR PATIENT COMPLETION OF ANASTHMA ASSESSMENT TOOL/SURVEY/QUESTIONNAIRE NOT DOCUMENTEDCHEMOTHERAPY DOCUMENTED AS NOT RECEIVED OR PRESCRIBED FOR STAGE III COLONCANCER PATIENTSCHEMOTHERAPY DOCUMENTED AS RECEIVED OR PRESCRIBED FOR STAGE III COLON CANCERPATIENTSCHEMOTHERAPY PLAN DOCUMENTED PRIOR TO CHEMOTHERAPY ADMINISTRATIONCHEMOTHERAPY PLAN NOT DOCUMENTED PRIOR TO CHEMOTHERAPY ADMINISTRATIONCHRONIC LYMPHOCYTIC LEUKEMIA (CLL) PATIENT WITH NO DOCUMENTATION OF BASELINEFLOW CYTOMETRY PERFORMEDCLINICIAN DOCUMENTATION THAT BREAST CANCER PATIENT WAS NOT ELIGIBLE FORTAMOXIFEN OR AROMATASE INHIBITOR THERAPY MEASURECLINICIAN DOCUMENTATION THAT COLON CANCER PATIENT IS NOT ELIGIBLE FORCHEMOTHERAPY MEASURECLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORRADIATION THERAPY MEASUREDOCUMENTATION OF RADIATION THERAPY RECOMMENDED WITHIN 12 MONTHS OF FIRST OFFICEVISITFOR PATIENTS WITH ER OR PR POSITIVE, STAGE IC-III BREAST CANCER, CLINICIAN DIDNOT DOCUMENT THAT THE PATIENT RECEIVED OR WAS PRESCRIBED TAMOXIFEN OR AROMATASEINHIBITORFOR PATIENTS WITH ER OR PR POSITIVE, STAGE IC-III BREAST CANCER, CLINICIANDOCUMENTED OR PRESCRIBED THAT THE PATIENT IS RECEIVING TAMOXIFEN OR AROMATASEINHIBITORMULTIPLE MYELOMA PATIENTS WITH NO DOCUMENTATION OF PRESCRIBED OR RECEIVEDINTRAVENOUS BISPHOSPHONATE THERAPYNO DOCUMENTATION OF RADIATION THERAPY RECOMMENDED WITHIN 12 MONTHS OF FIRSTOFFICE VISITBASELINE CYTOGENETIC TESTING NOT PERFORMED IN PATIENTS WITH MYELODYSPLASTICSYNDROME (MDS) OR ACUTE LEUKEMIASDIABETIC PATIENTS WITH NO DOCUMENTATION OF HEMOGLOBIN A1C LEVEL (WITHIN THELAST 12 MONTHS)DIABETIC PATIENTS WITH NO DOCUMENTATION OF LOW-DENSITY LIPOPROTEIN (WITHIN THELAST 12 MONTHS)END-STAGE RENAL DISEASE PATIENT WITH A HEMATOCRIT OR HEMOGLOBIN NOT DOCUMENTEDEND-STAGE RENAL DISEASE PATIENT WITH URR OR KT/V VALUE NOT DOCUMENTED, BUTOTHERWISE ELIGIBLE FOR MEASUREMYELODYSPLASTIC SYNDROME (MDS) PATIENTS WITH NO DOCUMENTATION OF IRON STORESPRIOR TO RECEIVING ERYTHROPOIETIN THERAPYDIABETIC PATIENTS WITH NO DOCUMENTATION OF BLOOD PRESSURE MEASUREMENT (WITHINTHE LAST 12 MONTHS)PATIENTS WITH PERSISTENT ASTHMA, NO DOCUMENTATION OF PREFERRED LONG TERMCONTROL MEDICATION OR ACCEPTABLE ALTERNATIVE TREATMENT PRESCRIBEDLEFT VENTRICULAR EJECTION FRACTION (LVEF) >= 40% OR DOCUMENTATION AS NORMAL ORMILDLY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTIONLEFT VENTRICULAR EJECTION FRACTION (LVEF) NOT PERFORMED OR DOCUMENTEDDILATED MACULAR OR FUNDUS EXAM PERFORMED, INCLUDING DOCUMENTATION OF THEPRESENCE OR ABSENCE OF MACULAR EDEMA AND LEVEL OF SEVERITY OF RETINOPATHYDILATED MACULAR OR FUNDUS EXAM NOT PERFORMED

Query_110708

Page 240

PATIENT WITH CENTRAL DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) RESULTS DOCUMENTEDOR ORDERED OR PHARMACOLOGIC THERAPY (OTHER THAN MINERALS/VITAMINS) FOROSTEOPOROSIS PRESCRIBED)PATIENT WITH CENTRAL DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) RESULTS NOTDOCUMENTED OR NOT ORDERED OR PHARMACOLOGIC THERAPY (OTHER THANMINERALS/VITAMINS) FOR OSTEOPOROSIS NOT PRESCRIBEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR SCREENINGOR THERAPY FOR OSTEOPOROSIS FOR WOMEN MEASURETOBACCO (SMOKE) USE CESSATION INTERVENTION, COUNSELINGTOBACCO (SMOKE) USE CESSATION INTERVENTION NOT COUNSELEDLOWER EXTREMITY NEUROLOGICAL EXAM PERFORMED AND DOCUMENTEDLOWER EXTREMITY NEUROLOGICAL EXAM NOT PERFORMEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR LOWEREXTREMITY NEUROLOGICAL EXAM MEASUREABI MEASURED AND DOCUMENTEDABI MEASUREMENT WAS NOT OBTAINEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ABIMEASUREMENT MEASUREFOOTWEAR EVALUATION PERFORMED AND DOCUMENTEDFOOTWEAR EVALUATION WAS NOT PERFORMEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR FOOTWEAREVALUATION MEASURECALCULATED BMI ABOVE THE UPPER PARAMETER AND A FOLLOW-UP PLAN WAS DOCUMENTED INTHE MEDICAL RECORDCALCULATED BMI BELOW THE LOWER PARAMETER AND A FOLLOW-UP PLAN WAS DOCUMENTED INTHE MEDICAL RECORDCALCULATED BMI OUTSIDE NORMAL PARAMETERS, NO FOLLOW-UP PLAN WAS DOCUMENTED INTHE MEDICAL RECORDCALCULATED BMI WITHIN NORMAL PARAMETERS AND DOCUMENTEDBMI NOT CALCULATEDPATIENT NOT ELIGIBLE FOR BMI CALCULATIONDOCUMENTED THAT PATIENT WAS SCREENED AND EITHER INFLUENZA VACCINATION STATUS ISCURRENT OR PATIENT WAS COUNSELEDINFLUENZA VACCINE STATUS WAS NOT SCREENEDINFLUENZA VACCINE STATUS SCREENED, PATIENT NOT CURRENT AND COUNSELING WAS NOTPROVIDEDDOCUMENTED THAT PATIENT WAS NOT APPROPRIATE FOR SCREENING AND/OR COUNSELINGABOUT THE INFLUENZA VACCINE (E.G., ALLERGY TO EGGS)LIST OF CURRENT MEDICATIONS WITH DOSAGES (INCLUDES PRESCRIPTION,OVER-THE-COUNTER, HERBALS, VITAMIN/MINERAL/DIETARY [NUTRITIONAL] SUPPLEMENTS)AND VERIFICATION WITH THE PATIENT OR AUTHORIZED REPRESENTATIVE DOCUMENTED BYTHE PROVIDERPROVIDER DOCUMENTATION OF CURRENT MEDICATIONS WITH DOSAGES (INCLUDESPRESCRIPTION, OVER-THE-COUNTER, HERBALS, VITAMIN/MINERAL/DIETARY [NUTRITIONAL]SUPPLEMENTS) WITHOUT DOCUMENTED PATIENT VERIFICATIONINCOMPLETE OR NO PROVIDER DOCUMENTATION THAT PATIENT'S CURRENT MEDICATIONS WITHDOSAGES (INCLUDES PRESCRIPTION, OVER-THE-COUNTER, HERBALS,VITAMIN/MINERAL/DIETARY [NUTRITIONAL] SUPPLEMENTS) WERE ASSESSEDPROVIDER DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR MEDICATION ASSESSMENTPOSITIVE SCREEN FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL AND AFOLLOW-UP PLAN DOCUMENTEDNO DOCUMENTATION OF CLINICAL DEPRESSION SCREENING USING A STANDARDIZED TOOLSCREENING FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL NOT DOCUMENTED,PATIENT NOT ELIGIBLE/APPROPRIATEDOCUMENTATION OF COGNITIVE IMPAIRMENT SCREENING USING A STANDARDIZED TOOLNO DOCUMENTATION OF COGNITIVE IMPAIRMENT SCREENING USING A STANDARDIZED TOOLPATIENT NOT ELIGIBLE/NOT APPROPRIATE FOR COGNITIVE IMPAIRMENT SCREENINGDOCUMENTATION OF CLINICIAN AND PATIENT INVOLVEMENT WITH THE DEVELOPMENT OF APLAN OF CARE INCLUDING SIGNATURE BY THE PRACTITIONER/THERAPIST AND EITHER ACO-SIGNATURE BY THE PATIENT OR DOCUMENTED VERBAL AGREEMENT OBTAINED FROM THEPATIENT OR, WHEN NECESSARY, AN AUTHORIZED REPRESENTATIVE

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Page 241

NO DOCUMENTATION OF CLINICIAN AND PATIENT INVOLVEMENT WITH THE DEVELOPMENT OF APLAN OF CARE INCLUDING SIGNATURE BY THE PRACTITIONER/THERAPIST AND EITHER ACO-SIGNATURE BY THE PATIENT OR DOCUMENTED VERBAL AGREEMENT OBTAINED FROM THEPATIENT OR, WHEN NECESSARY, AN AUTHORIZED REPRESENTATIVEDOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR CO-DEVELOPING A PLAN OF CAREINCLUDING SIGNATURE BY THE PRACTITIONER/THERAPIST AND EITHER A CO-SIGNATURE BYTHE PATIENT OR DOCUMENTED VERBAL AGREEMENT OBTAINED FROM THE PATIENT OR, WHENNECESSARY, AN AUTHORIZED REPRESENTATIVEDOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY ANDDESCRIPTION) PRIOR TO INITIATION OF TREATMENT OR DOCUMENTATION OF THE ABSENCEOF PAIN AS A RESULT OF ASSESSMENT THROUGH DISCUSSION WITH THE PATIENT INCLUDINGTHE USE OF A STANDARDIZED TOOL AND A FOLLOW-UP PLAN IS DOCUMENTEDNO DOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY ANDDESCRIPTION) PRIOR TO INITIATION OF TREATMENTDOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR PAIN ASSESSMENTALL PRESCRIPTIONS CREATED DURING THE ENCOUNTER WERE GENERATED USING A QUALIFIEDE-PRESCRIBING SYSTEMNO PRESCRIPTIONS WERE GENERATED DURING THE ENCOUNTER, PROVIDER DOES HAVE ACCESSTO A QUALIFIED E-PRESCRIBING SYSTEMPROVIDER DOES HAVE ACCESS TO A QUALIFIED E-PRESCRIBING SYSTEM AND SOME OR ALLOF THE PRESCRIPTIONS GENERATED DURING THE ENCOUNTER WERE PRINTED OR PHONED INAS REQUIRED BY STATE OR FEDERAL LAW OR REGULATIONS, PATIENT REQUEST OR PHARMACYSYSTEM BEING UNABLE TO RECEIVE ELECTRONIC TRANSMISSION; OR BECAUSE THEY WEREFOR NARCOTICS OR OTHER CONTROLLED SUBSTANCESPATIENT ENCOUNTER WAS DOCUMENTED USING A CCHIT CERTIFIED EHRPATIENT ENCOUNTER WAS DOCUMENTED USING A QUALIFIED (NON-CCHIT CERTIFIED) EHRPATIENT ENCOUNTER WAS NOT DOCUMENTED USING AN EMR DUE TO SYSTEM REASONS SUCHAS, THE SYSTEM BEING INOPERABLE AT THE TIME OF THE VISIT; USE OF THIS CODEIMPLIES THAT AN EMR IS IN PLACE AND GENERALLY AVAILABLEBETA-BLOCKER THERAPY PRESCRIBED FOR PATIENTS WITH LEFT VENTRICULAR EJECTIONFRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFTVENTRICULAR SYSTOLIC FUNCTIONCLINICIAN DOCUMENTED PATIENT WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF)<40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULARSYSTOLIC FUNCTION WAS NOT ELIGIBLE CANDIDATE FOR BETA-BLOCKER THERAPYBETA-BLOCKER THERAPY NOT PRESCRIBED FOR PATIENTS WITH LEFT VENTRICULAR EJECTIONFRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFTVENTRICULAR SYSTOLIC FUNCTIONTOBACCO USE CESSATION INTERVENTION, COUNSELINGTOBACCO USE CESSATION INTERVENTION NOT COUNSELED, REASON NOT SPECIFIEDCURRENT TOBACCO SMOKERCURRENT SMOKELESS TOBACCO USERCURRENT TOBACCO NON-USERCLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR GENOTYPETESTING; PATIENT NOT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS CCLINICIAN DOCUMENTED THAT PATIENT IS RECEIVING ANTIVIRAL TREATMENT FORHEPATITIS CCLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR QUANTITATIVERNA TESTING AT WEEK 12; PATIENT NOT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITISCPATIENT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS CCLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR COUNSELINGREGARDING CONTRACEPTION PRIOR TO ANTIVIRAL TREATMENT; PATIENT NOT RECEIVINGANTIVIRAL TREATMENT FOR HEPATITIS CPATIENT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C DOCUMENTEDCLINICIAN DOCUMENTED THAT PROSTATE CANCER PATIENT IS NOT AN ELIGIBLE CANDIDATEFOR ADJUVANT HORMONAL THERAPY; LOW OR INTERMEDIATE RISK OF RECURRENCE OR RISKOF RECURRENCE NOT DETERMINEDHIGH RISK OF RECURRENCE OF PROSTATE CANCERCLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR SUICIDE RISKASSESSMENT; MAJOR DEPRESSIVE DISORDER, IN REMISSION

Query_110708

Page 242

DOCUMENTATION OF NEW DIAGNOSIS OF INITIAL OR RECURRENT EPISODE OF MAJORDEPRESSIVE DISORDERANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER(ARB) THERAPY PRESCRIBED FOR PATIENTS WITH A LEFT VENTRICULAR EJECTION FRACTION(LVEF) <40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFTVENTRICULAR SYSTOLIC FUNCTIONCLINICIAN DOCUMENTED THAT PATIENT WITH A LEFT VENTRICULAR EJECTION FRACTION(LVEF) <40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFTVENTRICULAR SYSTOLIC FUNCTION WAS NOT AN ELIGIBLE CANDIDATE FOR ANGIOTENSINCONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPYPATIENT WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF) >=40% OR DOCUMENTATIONAS NORMAL OR MILDLY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTIONLEFT VENTRICULAR EJECTION FRACTION (LVEF) WAS NOT PERFORMED OR DOCUMENTEDANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER(ARB) THERAPY NOT PRESCRIBED FOR PATIENTS WITH A LEFT VENTRICULAR EJECTIONFRACTION (LVEF) <40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFTVENTRICULAR SYSTOLIC FUNCTION, REASON NOT SPECIFIEDANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER(ARB) THERAPY PRESCRIBEDANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER(ARB) THERAPY NOT PRESCRIBED FOR REASONS DOCUMENTED BY THE CLINICIANANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER(ARB) THERAPY NOT PRESCRIBED, REASON NOT SPECIFIEDMOST RECENT BLOOD PRESSURE HAS A SYSTOLIC MEASUREMENT OF <130 MM/HG AND ADIASTOLIC MEASUREMENT OF <80 MM/HGMOST RECENT BLOOD PRESSURE HAS A SYSTOLIC MEASUREMENT OF >=130 MM/HG AND/OR ADIASTOLIC MEASUREMENT OF >=80 MM/HGBLOOD PRESSURE MEASUREMENT NOT PERFORMED OR DOCUMENTED, REASON NOT SPECIFIEDCLINICIAN PRESCRIBED ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR ORANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPYCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ANGIOTENSINCONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPYCLINICIAN DID NOT PRESCRIBE ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR ORANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY, REASON NOT SPECIFIEDINFLUENZA IMMUNIZATION WAS ORDERED OR ADMINISTEREDINFLUENZA IMMUNIZATION WAS NOT ORDERED OR ADMINISTERED FOR REASONS DOCUMENTEDBY CLINICIANINFLUENZA IMMUNIZATION WAS NOT ORDERED OR ADMINISTERED, REASON NOT SPECIFIEDI INTEND TO REPORT THE DIABETES MELLITUS MEASURES GROUPI INTEND TO REPORT THE PREVENTIVE CARE MEASURES GROUPI INTEND TO REPORT THE CHRONIC KIDNEY DISEASE (CKD) MEASURES GROUPCLINICIAN INTENDS TO REPORT THE END STAGE RENAL DISEASE (ESRD) MEASURE GROUPI INTEND TO REPORT THE CORONARY ARTERY DISEASE (CAD) MEASURES GROUPI INTEND TO REPORT THE RHEUMATOID ARTHRITIS MEASURES GROUPI INTEND TO REPORT THE HIV/AIDS MEASURES GROUPI INTEND TO REPORT THE PERIOPERATIVE CARE MEASURES GROUPI INTEND TO REPORT THE BACK PAIN MEASURES GROUPALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE DIABETES MELLITUSMEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE CKD MEASURES GROUP HAVEBEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE PREVENTIVE CARE MEASURESGROUP HAVE BEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE CORONARY ARTERY BYPASSGRAFT (CABG) MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE CORONARY ARTERY DISEASE(CAD) MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE RHEUMATOID ARTHRITISMEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE HIV/AIDS MEASURES GROUPHAVE BEEN PERFORMED FOR THIS PATIENT

Query_110708

Page 243

ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE PERIOPERATIVE CAREMEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE BACK PAIN MEASURES GROUPHAVE BEEN PERFORMED FOR THIS PATIENTDOCUMENTATION THAT PROPHYLACTIC ANTIBIOTIC WAS GIVEN WITHIN ONE HOUR (IFFLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR STARTOF PROCEDURE WHEN NO INCISION IS REQUIRED)DOCUMENTATION OF ORDER FOR PROPHYLACTIC ANTIBIOTICS TO BE GIVEN WITHIN ONE HOUR(IF FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (ORSTART OF PROCEDURE WHEN NO INCISION IS REQUIRED)DOCUMENTATION THAT PROPHYLACTIC ANTIBIOTIC WAS NOT GIVEN WITHIN ONE HOUR (IFFLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR STARTOF PROCEDURE WHEN NO INCISION IS REQUIRED), REASON NOT SPECIFIEDPATIENT RECEIVING ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSINRECEPTOR BLOCKER (ARB) THERAPYPROVIDER DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR PATIENT VERIFICATION OFCURRENT MEDICATIONSDOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY ANDDESCRIPTION) PRIOR TO INITIATION OF TREATMENT OR DOCUMENTATION OF THE ABSENCEOF PAIN AS A RESULT OF ASSESSMENT THROUGH DISCUSSION WITH THE PATIENT INCLUDINGTHE USE OF A STANDARDIZED TOOL; NO DOCUMENTATION OF A FOLLOW-UP PLAN, PATIENTNOT ELIGIBLEDOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY ANDDESCRIPTION) PRIOR TO INITIATION OF TREATMENT OR DOCUMENTATION OF THE ABSENCEOF PAIN AS A RESULT OF ASSESSMENT THROUGH DISCUSSION WITH THE PATIENT INCLUDINGTHE USE OF A STANDARDIZED TOOL; NO DOCUMENTATION OF A FOLLOW-UP PLAN, REASONNOT SPECIFIEDNEGATIVE SCREEN FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL, PATIENT NOTELIGIBLE/APPROPRIATE FOR FOLLOW-UP PLAN DOCUMENTEDSCREEN FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL DOCUMENTED, FOLLOW UPPLAN NOT DOCUMENTED, REASON NOT SPECIFIEDPAIN SEVERITY QUANTIFIED; PAIN PRESENTABI MEASURED AND DOCUMENTEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ABIMEASUREMENT MEASUREABI MEASUREMENT WAS NOT OBTAINEDPATIENT SCREENED FOR FUTURE FALLS RISK; DOCUMENTATION OF TWO OR MORE FALLS INTHE PAST YEAR OR ANY FALL WITH INJURY IN THE PAST YEARPATIENT SCREENED FOR FUTURE FALL RISK; DOCUMENTATION OF NO FALLS IN THE PASTYEAR OR ONLY ONE FALL WITHOUT INJURY IN THE PAST YEARCLINICAL STAGE PRIOR TO SURGERY FOR LUNG CANCER AND ESOPHAGEAL CANCER RESECTIONWAS RECORDEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT ELIGIBLE FOR CLINICAL STAGE PRIOR TOSURGERY FOR LUNG CANCER AND ESOPHAGEAL CANCER RESECTION MEASURECLINICIAN STAGE PRIOR TO SURGERY FOR LUNG CANCER AND ESOPHAGEAL CANCERRESECTION WAS NOT RECORDED, REASON NOT SPECIFIEDANTIPLATELET THERAPY RECEIVED (ASA [81-325 MG/DAY] AND/OR CLOPIDOGREL [75MG/DAY]) WITHIN 48 HOURS OF THE INITIATION OF SURGERY AND AT DISCHARGECLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FORANTIPLATELET THERAPYANTIPLATELET THERAPY NOT RECEIVED 48 HOURS PRIOR TO CEA AND AT DISCHARGE,REASON NOT SPECIFIEDPATCH CLOSURE USED FOR PATIENT UNDERGOING CONVENTIONAL CEACLINICIAN DOCUMENTED THAT PATIENT DID NOT RECEIVE CONVENTIONAL CEAPATCH CLOSURE NOT USED FOR PATIENT UNDERGOING CONVENTIONAL CEA, REASON NOTSPECIFIEDDOCUMENTATION OF ORDER FOR CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIAL PROPHYLAXISCLINICIAN DOCUMENTED THAT PATIENT WAS INELIGIBLE FOR PROPHYLACTIC ANTIBIOTICSELECTION MEASUREORDER FOR CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIAL PROPHYLAXIS NOT DOCUMENTED,REASON NOT SPECIFIED

Query_110708

Page 244

AUTOGENOUS AV FISTULA RECEIVEDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR AUTOGENOUSAV FISTULACLINICIAN DOCUMENTED THAT PATIENT RECEVIED VASCULAR ACCESS OTHER THANAUTOGENOUS AV FISTULA, REASON NOT SPECIFIEDPARTICIPATION BY A PHYSICIAN OR OTHER CLINICIAN IN SYSTEMATIC CLINICAL DATABASEREGISTRY THAT INCLUDES CONSENSUS-ENDORSED QUALITY MEASURESDOCUMENTATION OF AN ELDER MALTREATMENT SCREEN AND FOLLOW-UP PLANNO DOCUMENTATION OF AN ELDER MALTREATMENT SCREEN, PATIENT NOT ELIGIBLENO DOCUMENTATION OF AN ELDER MALTREATMENT SCREEN, REASON NOT SPECIFIEDELDER MALTREATMENT SCREEN DOCUMENTED, FOLLOW-UP PLAN NOT DOCUMENTED, PATIENTNOT ELIGIBLEELDER MALTREATMENT SCREEN DOCUMENTED, FOLLOW-UP PLAN NOT DOCUMENTED, REASON NOTSPECIFIEDDOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZEDTOOL AND CARE PLAN BASED ON IDENTIFIED DEFICIENCIESDOCUMENTATION THAT THE PATIENT IS NOT ELIGIBLE FOR A FUNCTIONAL OUTCOMEASSESSMENT USING A STANDARDIZED TOOLNO DOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING ASTANDARDIZED TOOL, REASON NOT SPECIFIEDDOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZEDTOOL; NO DOCUMENTATION OF A CARE PLAN, PATIENT NOT ELIGIBLEDOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZEDTOOL; NO DOCUMENTATION OF A CARE PLAN, REASON NOT SPECIFIEDI INTEND TO REPORT THE CORONARY ARTERY BYPASS GRAFT (CABG) MEASURES GROUPCOORDINATED CARE FEE, INITIAL RATECOORDINATED CARE FEE, MAINTENANCE RATECOORDINATED CARE FEE, RISK ADJUSTED HIGH, INITIALCOORDINATED CARE FEE, RISK ADJUSTED LOW, INITIALCOORDINATED CARE FEE, RISK ADJUSTED MAINTENANCECOORDINATED CARE FEE, HOME MONITORINGCOORDINATED CARE FEE, SCHEDULED TEAM CONFERENCECOORDINATED CARE FEE, PHYSICIAN COORDINATED CARE OVERSIGHT SERVICESCOORDINATED CARE FEE, RISK ADJUSTED MAINTENANCE, LEVEL 3COORDINATED CARE FEE, RISK ADJUSTED MAINTENANCE, LEVEL 4COORDINATED CARE FEE, RISK ADJUSTED MAINTENANCE, LEVEL 5OTHER SPECIFIED CASE MANAGEMENT SERVICE NOT ELSEWHERE CLASSIFIEDESRD DEMO BASIC BUNDLE LEVEL IESRD DEMO EXPANDED BUNDLE INCLUDING VENOUS ACCESS AND RELATED SERVICESSMOKING CESSATION COUNSELING, INDIVIDUAL, IN THE ABSENCE OF OR IN ADDITION TOANY OTHER EVALUATION AND MANAGEMENT SERVICE, PER SESSION (6-10 MINUTES) [DEMOPROJECT CODE ONLY]AMANTADINE HYDROCHLORIDE, ORAL, PER 100 MG (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ZANAMIVIR, INHALATION POWDER, ADMINISTERED THROUGH INHALER, PER 10 MG (FOR USEIN A MEDICARE-APPROVED DEMONSTRATION PROJECT)OSELTAMIVIR PHOSPHATE, ORAL, PER 75 MG (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)RIMANTADINE HYDROCHLORIDE, ORAL, PER 100 MG (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR NAUSEA AND/OR VOMITING, PATIENT REPORTED, PERFORMEDAT THE TIME OF CHEMOTHERAPY ADMINISTRATION; ASSESSMENT LEVEL ONE: NOT AT ALL(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR NAUSEA AND/OR VOMITING, PATIENT REPORTED, PERFORMEDAT THE TIME OF CHEMOTHERAPY ADMINISTRATION; ASSESSMENT LEVEL TWO: A LITTLE (FORUSE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR NAUSEA AND/OR VOMITING, PATIENT REPORTED, PERFORMEDAT THE TIME OF CHEMOTHERAPY ADMINISTRATION; ASSESSMENT LEVEL THREE: QUITE A BIT(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR NAUSEA AND/OR VOMITING, PATIENT REPORTED, PERFORMEDAT THE TIME OF CHEMOTHERAPY ADMINISTRATION; ASSESSMENT LEVEL FOUR: VERY MUCH

Query_110708

Page 245

(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR PAIN, PATIENT REPORTED, PERFORMED AT THE TIME OFCHEMOTHERAPY ADMINISTRATION, ASSESSMENT LEVEL ONE: NOT AT ALL (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR PAIN, PATIENT REPORTED, PERFORMED AT THE TIME OFCHEMOTHERAPY ADMINISTRATION, ASSESSMENT LEVEL TWO: A LITTLE (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR PAIN, PATIENT REPORTED, PERFORMED AT THE TIME OFCHEMOTHERAPY ADMINISTRATION, ASSESSMENT LEVEL THREE: QUITE A BIT (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR PAIN, PATIENT REPORTED, PERFORMED AT THE TIME OFCHEMOTHERAPY ADMINISTRATION, ASSESSMENT LEVEL FOUR: VERY MUCH (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR LACK OF ENERGY (FATIGUE), PATIENT REPORTED,PERFORMED AT THE TIME OF CHEMOTHERAPY ADMINISTRATION, ASSESSMENT LEVEL ONE: NOTAT ALL (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR LACK OF ENERGY (FATIGUE), PATIENT REPORTED,PERFORMED AT THE TIME OF CHEMOTHERAPY ADMINISTRATION, ASSESSMENT LEVEL TWO: ALITTLE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR LACK OF ENERGY (FATIGUE), PATIENT REPORTED,PERFORMED AT THE TIME OF CHEMOTHERAPY ADMINISTRATION, ASSESSMENT LEVEL THREE:QUITE A BIT (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)CHEMOTHERAPY ASSESSMENT FOR LACK OF ENERGY (FATIGUE), PATIENT REPORTED,PERFORMED AT THE TIME OF CHEMOTHERAPY ADMINISTRATION, ASSESSMENT LEVEL FOUR:VERY MUCH (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)AMANTADINE HYDROCHLORIDE, ORAL BRAND, PER 100 MG (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ZANAMIVIR, INHALATION POWDER, ADMINISTERED THROUGH INHALER, BRAND, PER 10 MG(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)OSELTAMIVIR PHOSPHATE, ORAL, BRAND, PER 75 MG (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)RIMANTADINE HYDROCHLORIDE, ORAL, BRAND, PER 100 MG (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)REHABILITATION SERVICES FOR LOW VISION BY QUALIFIED OCCUPATIONAL THERAPIST,DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTESREHABILITATION SERVICES FOR LOW VISION BY CERTIFIED ORIENTATION AND MOBILITYSPECIALISTS, DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTESREHABILITATION SERVICES FOR LOW VISION BY CERTIFIED LOW VISION REHABILITATIONTHERAPIST, DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTESREHABILITATION SERVICES FOR LOW VISION BY CERTIFIED LOW VISION REHABILITATIONTEACHER, DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTESONCOLOGY; PRIMARY FOCUS OF VISIT; WORK-UP, EVALUATION, OR STAGING AT THE TIMEOF CANCER DIAGNOSIS OR RECURRENCE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATIONPROJECT)ONCOLOGY; PRIMARY FOCUS OF VISIT; TREATMENT DECISION-MAKING AFTER DISEASE ISSTAGED OR RESTAGED, DISCUSSION OF TREATMENT OPTIONS, SUPERVISING/COORDINATINGACTIVE CANCER DIRECTED THERAPY OR MANAGING CONSEQUENCES OF CANCER DIRECTEDTHERAPY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRIMARY FOCUS OF VISIT; SURVEILLANCE FOR DISEASE RECURRENCE FORPATIENT WHO HAS COMPLETED DEFINITIVE CANCER-DIRECTED THERAPY AND CURRENTLYLACKS EVIDENCE OF RECURRENT DISEASE; CANCER DIRECTED THERAPY MIGHT BECONSIDERED IN THE FUTURE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRIMARY FOCUS OF VISIT; EXPECTANT MANAGEMENT OF PATIENT WITH EVIDENCEOF CANCER FOR WHOM NO CANCER DIRECTED THERAPY IS BEING ADMINISTERED OR ARRANGEDAT PRESENT; CANCER DIRECTED THERAPY MIGHT BE CONSIDERED IN THE FUTURE (FOR USEIN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRIMARY FOCUS OF VISIT; SUPERVISING, COORDINATING OR MANAGING CARE OFPATIENT WITH TERMINAL CANCER OR FOR WHOM OTHER MEDICAL ILLNESS PREVENTS FURTHERCANCER TREATMENT; INCLUDES SYMPTOM MANAGEMENT, END-OF-LIFE CARE PLANNING,MANAGEMENT OF PALLIATIVE THERAPIES (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)

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Page 246

ONCOLOGY; PRIMARY FOCUS OF VISIT; OTHER, UNSPECIFIED SERVICE NOT OTHERWISELISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT ADHERES TO GUIDELINES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES AS A RESULTOF PATIENT ENROLLMENT IN AN INSTITUTIONAL REVIEW BOARD APPROVED CLINICAL TRIAL(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES BECAUSE THETREATING PHYSICIAN DISAGREES WITH GUIDELINE RECOMMENDATIONS (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES BECAUSE THEPATIENT, AFTER BEING OFFERED TREATMENT CONSISTENT WITH GUIDELINES, HAS OPTEDFOR ALTERNATIVE TREATMENT OR MANAGEMENT, INCLUDING NO TREATMENT (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES FOR REASON(S)ASSOCIATED WITH PATIENT COMORBID ILLNESS OR PERFORMANCE STATUS NOT FACTOREDINTO GUIDELINES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRACTICE GUIDELINES; PATIENT'S CONDITION NOT ADDRESSED BY AVAILABLEGUIDELINES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES FOR OTHERREASON(S) NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; EXTENT OFDISEASE INITIALLY ESTABLISHED AS STAGE I (PRIOR TO NEO-ADJUVANT THERAPY, IFANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FORUSE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; EXTENT OFDISEASE INITIALLY ESTABLISHED AS STAGE II (PRIOR TO NEO-ADJUVANT THERAPY, IFANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FORUSE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; EXTENT OFDISEASE INITIALLY ESTABLISHED AS STAGE III A (PRIOR TO NEO-ADJUVANT THERAPY, IFANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FORUSE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; STAGE III B-IV AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; EXTENT OFDISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; LIMITED TO SMALL CELL AND COMBINED SMALLCELL/NON-SMALL CELL; EXTENT OF DISEASE INITIALLY ESTABLISHED AS LIMITED WITH NOEVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; SMALL CELL LUNG CANCER, LIMITED TO SMALL CELL ANDCOMBINED SMALL CELL/NON-SMALL CELL; EXTENSIVE STAGE AT DIAGNOSIS, METASTATIC,LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATIONPROJECT)ONCOLOGY; DISEASE STATUS; SMALL CELL LUNG CANCER, LIMITED TO SMALL CELL ANDCOMBINED SMALL CELL/NON-SMALL; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS,OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDEDUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; STAGE I ORSTAGE IIA-IIB; OR T3, N1, M0; AND ER AND/OR PR POSITIVE; WITH NO EVIDENCE OFDISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDEDUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; STAGE I, ORSTAGE IIA-IIB; OR T3, N1, M0; AND ER AND PR NEGATIVE; WITH NO EVIDENCE OFDISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDE

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Page 247

DUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; STAGEIIIA-IIIB; AND NOT T3, N1, M0; AND ER AND/OR PR POSITIVE; WITH NO EVIDENCE OFDISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDEDUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; STAGEIIIA-IIIB; AND NOT T3, N1, M0; AND ER AND PR NEGATIVE; WITH NO EVIDENCE OFDISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDEDUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 ATDIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDEDUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OFDISEASE UNKNOWN, UNDER EVALUATION, PRE-SURGICAL OR NOT LISTED (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA ASPREDOMINANT CELL TYPE; T1-T2C AND GLEASON 2-7 AND PSA < OR EQUAL TO 20 ATDIAGNOSIS WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA ASPREDOMINANT CELL TYPE; T2 OR T3A GLEASON 8-10 OR PSA > 20 AT DIAGNOSIS WITH NOEVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA ASPREDOMINANT CELL TYPE; T3B-T4, ANY N; ANY T, N1 AT DIAGNOSIS WITH NO EVIDENCEOF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA; AFTERINITIAL TREATMENT WITH RISING PSA OR FAILURE OF PSA DECLINE (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA;NON-CASTRATE, INCOMPLETELY CASTRATE; CLINICAL METASTASES OR M1 AT DIAGNOSIS(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA; CASTRATE;CLINICAL METASTASES OR M1 AT DIAGNOSIS (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA; EXTENT OFDISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLYESTABLISHED AS T1-3, N0, M0 WITH NO EVIDENCE OF DISEASE PROGRESSION,RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLYESTABLISHED AS T4, N0, M0 WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE,OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLYESTABLISHED AS T1-4, N1-2, M0 WITH NO EVIDENCE OF DISEASE PROGRESSION,RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLYRECURRENT, OR PROGRESSIVE WITH CURRENT CLINICAL, RADIOLOGIC, OR BIOCHEMICALEVIDENCE OF DISEASE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLYRECURRENT, OR PROGRESSIVE WITHOUT CURRENT CLINICAL, RADIOLOGIC, OR BIOCHEMICALEVIDENCE OF DISEASE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)

Query_110708

Page 248

ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING INPROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLYESTABLISHED AS T1-2, N0, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NOEVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLYESTABLISHED AS T3, N0, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NOEVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLYESTABLISHED AS T1-3, N1-2, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NOEVIDENCE OF DISEASE PROGRESSION, RECURRENCE OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLYESTABLISHED AS T4, ANY N, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NOEVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLYRECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING INPROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA ORSQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLYESTABLISHED AS T1-T3, N0-N1 OR NX (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITHNO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA ORSQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLYESTABLISHED AS T4, ANY N, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NOEVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA ORSQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC,LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATIONPROJECT)ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA ORSQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN,STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA ASPREDOMINANT CELL TYPE; POST R0 RESECTION (WITH OR WITHOUT NEOADJUVANT THERAPY)WITH NO EVIDENCE OF DISEASE RECURRENCE, PROGRESSION, OR METASTASES (FOR USE INA MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA ASPREDOMINANT CELL TYPE; POST R1 OR R2 RESECTION (WITH OR WITHOUT NEOADJUVANTTHERAPY) WITH NO EVIDENCE OF DISEASE PROGRESSION, OR METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA ASPREDOMINANT CELL TYPE; CLINICAL OR PATHOLOGIC M0, UNRESECTABLE WITH NO EVIDENCEOF DISEASE PROGRESSION, OR METASTASES (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA ASPREDOMINANT CELL TYPE; CLINICAL OR PATHOLOGIC M1 AT DIAGNOSIS, METASTATIC,

Query_110708

Page 249

LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATIONPROJECT)ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA ASPREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOTLISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA ASPREDOMINANT CELL TYPE; POST R0 RESECTION WITHOUT EVIDENCE OF DISEASEPROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA; POST R1OR R2 RESECTION WITH NO EVIDENCE OF DISEASE PROGRESSION, OR METASTASES (FOR USEIN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA;UNRESECTABLE AT DIAGNOSIS, M1 AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, ORPROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA; EXTENTOF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORALCAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; EXTENTOF DISEASE INITIALLY ESTABLISHED AS T1-T2 AND N0, M0 (PRIOR TO NEO-ADJUVANTTHERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, ORMETASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORALCAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; EXTENTOF DISEASE INITIALLY ESTABLISHED AS T3-4 AND/OR N1-3, M0 (PRIOR TO NEO-ADJUVANTTHERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, ORMETASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORALCAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; M1 ATDIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORALCAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; EXTENTOF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER;PATHOLOGIC STAGE IA-B (GRADE 1) WITHOUT EVIDENCE OF DISEASE PROGRESSION,RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER;PATHOLOGIC STAGE IA-B (GRADE 2-3); OR STAGE IC (ALL GRADES); OR STAGE II;WITHOUT EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE INA MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER;PATHOLOGIC STAGE III-IV; WITHOUT EVIDENCE OF PROGRESSION, RECURRENCE, ORMETASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER;EVIDENCE OF DISEASE PROGRESSION, OR RECURRENCE, AND/OR PLATINUM RESISTANCE (FORUSE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER; EXTENTOF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, LIMITED TO FOLLICULARLYMPHOMA, MANTLE CELL LYMPHOMA, DIFFUSE LARGE B-CELL LYMPHOMA, SMALLLYMPHOCYTIC LYMPHOMA; STAGE I, II AT DIAGNOSIS, NOT RELAPSED, NOT REFRACTORY(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, LIMITED TO FOLLICULARLYMPHOMA, MANTLE CELL LYMPHOMA, DIFFUSE LARGE B-CELL LYMPHOMA, SMALLLYMPHOCYTIC LYMPHOMA; STAGE III, IV NOT RELAPSED, NOT REFRACTORY (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA; TRANSFORMED FROM FOLLICULAR

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LYMPHOMA TO DIFFUSE LARGE B-CELL LYMPHOMA (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, LIMITED TO FOLLICULARLYMPHOMA, MANTLE CELL LYMPHOMA, DIFFUSE LARGE B-CELL LYMPHOMA, SMALLLYMPHOCYTIC LYMPHOMA; RELAPSED/REFRACTORY (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, LIMITED TO FOLLICULARLYMPHOMA, MANTLE CELL LYMPHOMA, DIFFUSE LARGE B-CELL LYMPHOMA, SMALLLYMPHOCYTIC LYMPHOMA; DIAGNOSTIC EVALUATION, STAGE NOT DETERMINED, EVALUATIONOF POSSIBLE RELAPSE OR NON-RESPONSE TO THERAPY, OR NOT LISTED (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIACHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; CHRONIC PHASE NOT IN HEMATOLOGIC,CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIACHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; ACCELERATED PHASE NOT INHEMATOLOGIC CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIACHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; BLAST PHASE NOT IN HEMATOLOGIC,CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIACHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; IN HEMATOLOGIC, CYTOGENETIC, ORMOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIACHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; EXTENT OF DISEASE UNKNOWN, UNDEREVALUATION, NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, SYSTEMIC DISEASE;SMOLDERING, STAGE I (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, SYSTEMIC DISEASE; STAGEII OR HIGHER (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, SYSTEMIC DISEASE; EXTENTOF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDEDUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OFDISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA;HORMONE-REFRACTORY/ANDROGEN-INDEPENDENT (E.G., RISING PSA ON ANTI-ANDROGENTHERAPY OR POST-ORCHIECTOMY); CLINICAL METASTASES (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA;HORMONE-RESPONSIVE; CLINICAL METASTASES OR M1 AT DIAGNOSIS (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION;STAGE I, II AT DIAGNOSIS, NOT RELAPSED, NOT REFRACTORY (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION;STAGE III, IV, NOT RELAPSED, NOT REFRACTORY (FOR USE IN A MEDICARE-APPROVEDDEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, TRANSFORMED FROM ORIGINALCELLULAR DIAGNOSIS TO A SECOND CELLULAR CLASSIFICATION (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION;RELAPSED/REFRACTORY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION;DIAGNOSTIC EVALUATION, STAGE NOT DETERMINED, EVALUATION OF POSSIBLE RELAPSE ORNON-RESPONSE TO THERAPY, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED

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DEMONSTRATION PROJECT)ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIACHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; EXTENT OF DISEASE UNKNOWN, STAGINGIN PROGRESS, NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)FRONTIER EXTENDED STAY CLINIC DEMONSTRATION; FOR A PATIENT STAY IN A CLINICAPPROVED FOR THE CMS DEMONSTRATION PROJECT; THE FOLLOWING MEASURES SHOULD BEPRESENT: THE STAY MUST BE EQUAL TO OR GREATER THAN 4 HOURS; WEATHER OR OTHERCONDITIONS MUST PREVENT TRANSFER OR THE CASE FALLS INTO A CATEGORY OFMONITORING AND OBSERVATION CASES THAT ARE PERMITTED BY THE RULES OF THEDEMONSTRATION; THERE IS A MAXIMUM FRONTIER EXTENDED STAY CLINIC (FESC) VISIT OF48 HOURS, EXCEPT IN THE CASE WHEN WEATHER OR OTHER CONDITIONS PREVENT TRANSFER;PAYMENT IS MADE ON EACH PERIOD UP TO 4 HOURS, AFTER THE FIRST 4 HOURSALCOHOL AND/OR DRUG ASSESSMENTBEHAVIORAL HEALTH SCREENING TO DETERMINE ELIGIBILITY FOR ADMISSION TO TREATMENTPROGRAMALCOHOL AND/OR DRUG SCREENING; LABORATORY ANALYSIS OF SPECIMENS FOR PRESENCE OFALCOHOL AND/OR DRUGSBEHAVIORAL HEALTH COUNSELING AND THERAPY, PER 15 MINUTESALCOHOL AND/OR DRUG SERVICES; GROUP COUNSELING BY A CLINICIANALCOHOL AND/OR DRUG SERVICES; CASE MANAGEMENTALCOHOL AND/OR DRUG SERVICES; CRISIS INTERVENTION (OUTPATIENT)ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (HOSPITAL INPATIENT)ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (HOSPITAL INPATIENT)ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (RESIDENTIAL ADDICTIONPROGRAM INPATIENT)ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (RESIDENTIAL ADDICTIONPROGRAM INPATIENT)ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (RESIDENTIAL ADDICTIONPROGRAM OUTPATIENT)ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (RESIDENTIAL ADDICTIONPROGRAM OUTPATIENT)ALCOHOL AND/OR DRUG SERVICES; AMBULATORY DETOXIFICATIONALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT (TREATMENT PROGRAM THATOPERATES AT LEAST 3 HOURS/DAY AND AT LEAST 3 DAYS/WEEK AND IS BASED ON ANINDIVIDUALIZED TREATMENT PLAN), INCLUDING ASSESSMENT, COUNSELING; CRISISINTERVENTION, AND ACTIVITY THERAPIES OR EDUCATIONALCOHOL AND/OR DRUG SERVICES; MEDICAL/SOMATIC (MEDICAL INTERVENTION INAMBULATORY SETTING)BEHAVIORAL HEALTH; RESIDENTIAL (HOSPITAL RESIDENTIAL TREATMENT PROGRAM),WITHOUT ROOM AND BOARD, PER DIEMBEHAVIORAL HEALTH; SHORT-TERM RESIDENTIAL (NON-HOSPITAL RESIDENTIAL TREATMENTPROGRAM), WITHOUT ROOM AND BOARD, PER DIEMBEHAVIORAL HEALTH; LONG-TERM RESIDENTIAL (NON-MEDICAL, NON-ACUTE CARE IN ARESIDENTIAL TREATMENT PROGRAM WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS),WITHOUT ROOM AND BOARD, PER DIEMALCOHOL AND/OR DRUG SERVICES; METHADONE ADMINISTRATION AND/OR SERVICE(PROVISION OF THE DRUG BY A LICENSED PROGRAM)ALCOHOL AND/OR DRUG TRAINING SERVICE (FOR STAFF AND PERSONNEL NOT EMPLOYED BYPROVIDERS)ALCOHOL AND/OR DRUG INTERVENTION SERVICE (PLANNED FACILITATION)BEHAVIORAL HEALTH OUTREACH SERVICE (PLANNED APPROACH TO REACH A TARGETEDPOPULATION)BEHAVIORAL HEALTH PREVENTION INFORMATION DISSEMINATION SERVICE (ONE-WAY DIRECTOR NON-DIRECT CONTACT WITH SERVICE AUDIENCES TO AFFECT KNOWLEDGE AND ATTITUDE)BEHAVIORAL HEALTH PREVENTION EDUCATION SERVICE (DELIVERY OF SERVICES WITHTARGET POPULATION TO AFFECT KNOWLEDGE, ATTITUDE AND/OR BEHAVIOR)ALCOHOL AND/OR DRUG PREVENTION PROCESS SERVICE, COMMUNITY-BASED (DELIVERY OFSERVICES TO DEVELOP SKILLS OF IMPACTORS)ALCOHOL AND/OR DRUG PREVENTION ENVIRONMENTAL SERVICE (BROAD RANGE OF EXTERNALACTIVITIES GEARED TOWARD MODIFYING SYSTEMS IN ORDER TO MAINSTREAM PREVENTIONTHROUGH POLICY AND LAW)

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ALCOHOL AND/OR DRUG PREVENTION PROBLEM IDENTIFICATION AND REFERRAL SERVICE(E.G. STUDENT ASSISTANCE AND EMPLOYEE ASSISTANCE PROGRAMS), DOES NOT INCLUDEASSESSMENTALCOHOL AND/OR DRUG PREVENTION ALTERNATIVES SERVICE (SERVICES FOR POPULATIONSTHAT EXCLUDE ALCOHOL AND OTHER DRUG USE E.G. ALCOHOL FREE SOCIAL EVENTS)BEHAVIORAL HEALTH HOTLINE SERVICEMENTAL HEALTH ASSESSMENT, BY NON-PHYSICIANMENTAL HEALTH SERVICE PLAN DEVELOPMENT BY NON-PHYSICIANORAL MEDICATION ADMINISTRATION, DIRECT OBSERVATIONMEDICATION TRAINING AND SUPPORT, PER 15 MINUTESMENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURSCOMMUNITY PSYCHIATRIC SUPPORTIVE TREATMENT, FACE-TO-FACE, PER 15 MINUTESCOMMUNITY PSYCHIATRIC SUPPORTIVE TREATMENT PROGRAM, PER DIEMSELF-HELP/PEER SERVICES, PER 15 MINUTESASSERTIVE COMMUNITY TREATMENT, FACE-TO-FACE, PER 15 MINUTESASSERTIVE COMMUNITY TREATMENT PROGRAM, PER DIEMFOSTER CARE, CHILD, NON-THERAPEUTIC, PER DIEMFOSTER CARE, CHILD, NON-THERAPEUTIC, PER MONTHSUPPORTED HOUSING, PER DIEMSUPPORTED HOUSING, PER MONTHRESPITE CARE SERVICES, NOT IN THE HOME, PER DIEMMENTAL HEALTH SERVICES, NOT OTHERWISE SPECIFIEDALCOHOL AND/OR OTHER DRUG ABUSE SERVICES, NOT OTHERWISE SPECIFIEDALCOHOL AND/OR OTHER DRUG TESTING: COLLECTION AND HANDLING ONLY, SPECIMENSOTHER THAN BLOODALCOHOL AND/OR DRUG SCREENINGALCOHOL AND/OR DRUG SERVICES, BRIEF INTERVENTION, PER 15 MINUTESPRENATAL CARE, AT-RISK ASSESSMENTPRENATAL CARE, AT-RISK ENHANCED SERVICE; ANTEPARTUM MANAGEMENTPRENATAL CARE, AT RISK ENHANCED SERVICE; CARE COORDINATIONPRENATAL CARE, AT-RISK ENHANCED SERVICE; EDUCATIONPRENATAL CARE, AT-RISK ENHANCED SERVICE; FOLLOW-UP HOME VISITPRENATAL CARE, AT-RISK ENHANCED SERVICE PACKAGE (INCLUDES H1001-H1004)NON-MEDICAL FAMILY PLANNING EDUCATION, PER SESSIONFAMILY ASSESSMENT BY LICENSED BEHAVIORAL HEALTH PROFESSIONAL FOR STATE DEFINEDPURPOSESCOMPREHENSIVE MULTIDISCIPLINARY EVALUATIONREHABILITATION PROGRAM, PER 1/2 DAYCOMPREHENSIVE MEDICATION SERVICES, PER 15 MINUTESCRISIS INTERVENTION SERVICE, PER 15 MINUTESBEHAVIORAL HEALTH DAY TREATMENT, PER HOURPSYCHIATRIC HEALTH FACILITY SERVICE, PER DIEMSKILLS TRAINING AND DEVELOPMENT, PER 15 MINUTESCOMPREHENSIVE COMMUNITY SUPPORT SERVICES, PER 15 MINUTESCOMPREHENSIVE COMMUNITY SUPPORT SERVICES, PER DIEMPSYCHOSOCIAL REHABILITATION SERVICES, PER 15 MINUTESPSYCHOSOCIAL REHABILITATION SERVICES, PER DIEMTHERAPEUTIC BEHAVIORAL SERVICES, PER 15 MINUTESTHERAPEUTIC BEHAVIORAL SERVICES, PER DIEMCOMMUNITY-BASED WRAP-AROUND SERVICES, PER 15 MINUTESCOMMUNITY-BASED WRAP-AROUND SERVICES, PER DIEMSUPPORTED EMPLOYMENT, PER 15 MINUTESSUPPORTED EMPLOYMENT, PER DIEMONGOING SUPPORT TO MAINTAIN EMPLOYMENT, PER 15 MINUTESONGOING SUPPORT TO MAINTAIN EMPLOYMENT, PER DIEMPSYCHOEDUCATIONAL SERVICE, PER 15 MINUTESSEXUAL OFFENDER TREATMENT SERVICE, PER 15 MINUTESSEXUAL OFFENDER TREATMENT SERVICE, PER DIEMMENTAL HEALTH CLUBHOUSE SERVICES, PER 15 MINUTESMENTAL HEALTH CLUBHOUSE SERVICES, PER DIEMACTIVITY THERAPY, PER 15 MINUTES

Query_110708

Page 253

MULTISYSTEMIC THERAPY FOR JUVENILES, PER 15 MINUTESALCOHOL AND/OR DRUG ABUSE HALFWAY HOUSE SERVICES, PER DIEMALCOHOL AND/OR OTHER DRUG TREATMENT PROGRAM, PER HOURALCOHOL AND/OR OTHER DRUG TREATMENT PROGRAM, PER DIEMDEVELOPMENTAL DELAY PREVENTION ACTIVITIES, DEPENDENT CHILD OF CLIENT, PER 15MINUTESINJECTION, TETRACYCLINE, UP TO 250 MGINJECTION, ABARELIX, 10 MGINJECTION, ABATACEPT, 10 MGINJECTION ABCIXIMAB, 10 MGINJECTION, ACETYLCYSTEINE, 100 MGINJECTION, ACYCLOVIR, 5 MGINJECTION, ADALIMUMAB, 20 MGINJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE USED TO REPORT ANYADENOSINE PHOSPHATE COMPOUNDS, INSTEAD USE A9270)INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE USED TO REPORT ANYADENOSINE PHOSPHATE COMPOUNDS; INSTEAD USE A9270)INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULEINJECTION, AGALSIDASE BETA, 1 MGINJECTION, BIPERIDEN LACTATE, PER 5 MGINJECTION, ALATROFLOXACIN MESYLATE, 100 MGINJECTION, ALGLUCERASE, PER 10 UNITSINJECTION, AMIFOSTINE, 500 MGINJECTION, METHYLDOPATE HCL, UP TO 250 MGINJECTION, ALEFACEPT, 0.5 MGINJECTION, ALGLUCOSIDASE ALFA, 10 MGINJECTION, ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MGINJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUGADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUGIS SELF ADMINISTERED)ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE WHEN DRUGADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUGIS SELF ADMINISTERED)INJECTION, AMIKACIN SULFATE, 100 MGINJECTION, AMINOPHYLLIN, UP TO 250 MGINJECTION, AMIODARONE HYDROCHLORIDE, 30 MGINJECTION, AMPHOTERICIN B, 50 MGINJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MGINJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MGINJECTION, AMPHOTERICIN B LIPOSOME, 10 MGINJECTION, AMPICILLIN SODIUM, 500 MGINJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GMINJECTION, AMOBARBITAL, UP TO 125 MGINJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MGINJECTION, ANIDULAFUNGIN, 1 MGINJECTION, ANISTREPLASE, PER 30 UNITSINJECTION, HYDRALAZINE HCL, UP TO 20 MGINJECTION, APOMORPHINE HYDROCHLORIDE, 1 MGINJECTION, APROTONIN, 10,000 KIUINJECTION, METARAMINOL BITARTRATE, PER 10 MGINJECTION, CHLOROQUINE HYDROCHLORIDE, UP TO 250 MGINJECTION, ARBUTAMINE HCL, 1 MGINJECTION, ARIPIPRAZOLE, INTRAMUSCULAR, 0.25 MGINJECTION, AZITHROMYCIN, 500 MGINJECTION, ATROPINE SULFATE, UP TO 0.3 MGINJECTION, DIMERCAPROL, PER 100 MGINJECTION, BACLOFEN, 10 MGINJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIALINJECTION, BASILIXIMAB, 20 MGINJECTION, DICYCLOMINE HCL, UP TO 20 MGINJECTION, BENZTROPINE MESYLATE, PER 1 MG

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Page 254

INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, UP TO 5 MGINJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 600,000UNITSINJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 1,200,000UNITSINJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 2,400,000UNITSINJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITSINJECTION, PENICILLIN G BENZATHINE, UP TO 1,200,000 UNITSINJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 UNITSINJECTION, BIVALIRUDIN, 1 MGBOTULINUM TOXIN TYPE A, PER UNITBOTULINUM TOXIN TYPE B, PER 100 UNITSINJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUSULFAN, 1 MGINJECTION, BUTORPHANOL TARTRATE, 1 MGINJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MGINJECTION, CALCIUM GLUCONATE, PER 10 MLINJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, PER 10 MLINJECTION, CALCITONIN SALMON, UP TO 400 UNITSINJECTION, CALCITRIOL, 0.1 MCGINJECTION, CASPOFUNGIN ACETATE, 5 MGINJECTION, LEUCOVORIN CALCIUM, PER 50 MGINJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MGINJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 MLINJECTION, CEFAZOLIN SODIUM, 500 MGINJECTION, CEFEPIME HYDROCHLORIDE, 500 MGINJECTION, CEFOXITIN SODIUM, 1 GMINJECTION, CEFTRIAXONE SODIUM, PER 250 MGINJECTION, STERILE CEFUROXIME SODIUM, PER 750 MGINJECTION, CEFOTAXIME SODIUM, PER GMINJECTION, BETAMETHASONE ACETATE 3MG AND BETAMETHASONE SODIUM PHOSPHATE 3MGINJECTION, BETAMETHASONE SODIUM PHOSPHATE, PER 4 MGINJECTION, CAFFEINE CITRATE, 5MGINJECTION, CEPHAPIRIN SODIUM, UP TO 1 GMINJECTION, CEFTAZIDIME, PER 500 MGINJECTION, CEFTIZOXIME SODIUM, PER 500 MGINJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GMINJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITSINJECTION, CLONIDINE HYDROCHLORIDE, 1 MGINJECTION, CIDOFOVIR, 375 MGINJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MGINJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, 200 MGINJECTION, CODEINE PHOSPHATE, PER 30 MGINJECTION, COLCHICINE, PER 1MGINJECTION, COLISTIMETHATE SODIUM, UP TO 150 MGINJECTION, PROCHLORPERAZINE, UP TO 10 MGINJECTION, CORTICORELIN OVINE TRIFLUTATE, 1 MICROGRAMINJECTION, CORTICOTROPIN, UP TO 40 UNITSINJECTION, COSYNTROPIN, PER 0.25 MGINJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIALINJECTION, DAPTOMYCIN, 1 MGINJECTION, DARBEPOETIN ALFA, 5 MCGINJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS)INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITSINJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS)INJECTION, DECITABINE, 1 MGINJECTION, DEFEROXAMINE MESYLATE, 500 MGINJECTION, TESTOSTERONE ENANTHATE AND ESTRADIOL VALERATE, UP TO 1 CCINJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG

Query_110708

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INJECTION, ESTRADIOL VALERATE, UP TO 40 MGINJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MGINJECTION, METHYLPREDNISOLONE ACETATE, 20 MGINJECTION, METHYLPREDNISOLONE ACETATE, 40 MGINJECTION, METHYLPREDNISOLONE ACETATE, 80 MGINJECTION, MEDROXYPROGESTERONE ACETATE, 50 MGINJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150 MGINJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG / 25MGINJECTION, TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE, UP TO 1 MLINJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MGINJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MGINJECTION, DEXAMETHASONE ACETATE, 1 MGINJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MGINJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MGINJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MGINJECTION, DIGOXIN, UP TO 0.5 MGINJECTION, DIGOXIN IMMUNE FAB (OVINE), PER VIALINJECTION, PHENYTOIN SODIUM, PER 50 MGINJECTION, HYDROMORPHONE, UP TO 4 MGINJECTION, DYPHYLLINE, UP TO 500 MGINJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MGINJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MGINJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MGINJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 MLINJECTION, METHADONE HCL, UP TO 10 MGINJECTION, DIMENHYDRINATE, UP TO 50 MGINJECTION, DIPYRIDAMOLE, PER 10 MGINJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MGINJECTION, DOLASETRON MESYLATE, 10 MGINJECTION, DOPAMINE HCL, 40 MGINJECTION, DORIPENEM, 10 MGINJECTION, DOXERCALCIFEROL, 1 MCGINJECTION, ECULIZUMAB, 10 MGINJECTION, AMITRIPTYLINE HCL, UP TO 20 MGINJECTION, ENFUVIRTIDE, 1 MGINJECTION, EPOPROSTENOL, 0.5 MGINJECTION, EPTIFIBATIDE, 5 MGINJECTION, ERGONOVINE MALEATE, UP TO 0.2 MGINJECTION, ERTAPENEM SODIUM, 500 MGINJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MGINJECTION, ESTRADIOL VALERATE, UP TO 10 MGINJECTION, ESTRADIOL VALERATE, UP TO 20 MGINJECTION, ESTROGEN CONJUGATED, PER 25 MGINJECTION, ETHANOLAMINE OLEATE, 100 MGINJECTION, ESTRONE, PER 1 MGINJECTION, ETIDRONATE DISODIUM, PER 300 MGINJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUGADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUGIS SELF ADMINISTERED)INJECTION, FILGRASTIM (G-CSF), 300 MCGINJECTION, FILGRASTIM (G-CSF), 480 MCGINJECTION FLUCONAZOLE, 200 MGINJECTION, FOMEPIZOLE, 15 MGINJECTION, FOMIVIRSEN SODIUM, INTRAOCULAR, 1.65 MGINJECTION, FOSAPREPITANT, 1 MGINJECTION, FOSCARNET SODIUM, PER 1000 MGINJECTION, GALLIUM NITRATE, 1 MGINJECTION, GALSULFASE, 1 MGINJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MGINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC

Query_110708

Page 256

INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CCINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CCINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CCINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CCINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CCINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 7 CCINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 8 CCINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 9 CCINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 10 CCINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CCINJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MGINJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MGINJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 1GINJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 10 MGINJECTION, RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN, INTRAVENOUS, 50 MGINJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOTOTHERWISE SPECIFIED, 500 MGINJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), 500 MGINJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MGINJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS, NON-LYOPHILIZED,(E.G. LIQUID), 500 MGINJECTION, GANCICLOVIR SODIUM, 500 MGINJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 MLINJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS,NON-LYOPHILIZED (E.G. LIQUID), 500 MGINJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVENOUS, 0.5 MLINJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MGINJECTION, GATIFLOXACIN, 10MGINJECTION, GLATIRAMER ACETATE, 20 MGINJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MGINJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MGINJECTION, GONADORELIN HYDROCHLORIDE, PER 100 MCGINJECTION, GRANISETRON HYDROCHLORIDE, 100 MCGINJECTION, HALOPERIDOL, UP TO 5 MGINJECTION, HALOPERIDOL DECANOATE, PER 50 MGINJECTION, HEMIN, 1 MGINJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITSINJECTION, HEPARIN SODIUM, PER 1000 UNITSINJECTION, DALTEPARIN SODIUM, PER 2500 IUINJECTION, ENOXAPARIN SODIUM, 10 MGINJECTION, FONDAPARINUX SODIUM, 0.5 MGINJECTION, TINZAPARIN SODIUM, 1000 IUINJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITSINJECTION, HISTRELIN ACETATE, 10 MICROGRAMSINJECTION, HYDROCORTISONE ACETATE, UP TO 25 MGINJECTION, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 MGINJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MGINJECTION, DIAZOXIDE, UP TO 300 MGINJECTION, IBANDRONATE SODIUM, 1 MGINJECTION, IBUTILIDE FUMARATE, 1 MGINJECTION, IDURSULFASE, 1 MGINJECTION INFLIXIMAB, 10 MGINJECTION, IRON DEXTRAN, 50 MGINJECTION, IRON DEXTRAN 165, 50 MGINJECTION, IRON DEXTRAN 267, 50 MGINJECTION, IRON SUCROSE, 1 MGINJECTION, IMIGLUCERASE, PER UNITINJECTION, DROPERIDOL, UP TO 5 MGINJECTION, PROPRANOLOL HCL, UP TO 1 MG

Query_110708

Page 257

INJECTION, DROPERIDOL AND FENTANYL CITRATE, UP TO 2 ML AMPULEINJECTION, INSULIN, PER 5 UNITSINSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITSINJECTION, INTERFERON BETA-1A, 33 MCGINJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUGADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHENDRUG IS SELF ADMINISTERED)INJECTION, ITRACONAZOLE, 50 MGINJECTION, KANAMYCIN SULFATE, UP TO 500 MGINJECTION, KANAMYCIN SULFATE, UP TO 75 MGINJECTION, KETOROLAC TROMETHAMINE, PER 15 MGINJECTION, CEPHALOTHIN SODIUM, UP TO 1 GRAMINJECTION, LANREOTIDE, 1 MGINJECTION, LARONIDASE, 0.1 MGINJECTION, FUROSEMIDE, UP TO 20 MGINJECTION, LEPIRUDIN, 50 MGINJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MGINJECTION, LEVETIRACETAM, 10 MGINJECTION, LEVOCARNITINE, PER 1 GMINJECTION, LEVOFLOXACIN, 250 MGINJECTION, LEVORPHANOL TARTRATE, UP TO 2 MGINJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MGINJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MGINJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MGINJECTION, LINCOMYCIN HCL, UP TO 300 MGINJECTION, LINEZOLID, 200MGINJECTION, LORAZEPAM, 2 MGINJECTION, MANNITOL, 25% IN 50 MLINJECTION, MECASERMIN, 1 MGINJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MGINJECTION, MEPERIDINE AND PROMETHAZINE HCL, UP TO 50 MGINJECTION, MEROPENEM, 100 MGINJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MGINJECTION, MICAFUNGIN SODIUM, 1 MGINJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MGINJECTION, MILRINONE LACTATE, 5 MGINJECTION, MORPHINE SULFATE, UP TO 10 MGINJECTION, MORPHINE SULFATE, 100MGINJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER 10 MGINJECTION, ZICONOTIDE, 1 MICROGRAMINJECTION, MOXIFLOXACIN, 100 MGINJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MGINJECTION, NALOXONE HYDROCHLORIDE, PER 1 MGINJECTION, NALTREXONE, DEPOT FORM, 1 MGINJECTION, NANDROLONE DECANOATE, UP TO 50 MGINJECTION, NANDROLONE DECANOATE, UP TO 100 MGINJECTION, NANDROLONE DECANOATE, UP TO 200 MGINJECTION, NATALIZUMAB, 1 MGINJECTION, NESIRITIDE, 0.25 MGINJECTION, NESIRITIDE, 0.1 MGINJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MGINJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUSINJECTION, 25 MCGINJECTION, OPRELVEKIN, 5 MGINJECTION, OMALIZUMAB, 5 MGINJECTION, ORPHENADRINE CITRATE, UP TO 60 MGINJECTION, PHENYLEPHRINE HCL, UP TO 1 MLINJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 MLINJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MGINJECTION, OXYMORPHONE HCL, UP TO 1 MGINJECTION, PALIFERMIN, 50 MICROGRAMS

Query_110708

Page 258

INJECTION, PAMIDRONATE DISODIUM, PER 30 MGINJECTION, PAPAVERINE HCL, UP TO 60 MGINJECTION, OXYTETRACYCLINE HCL, UP TO 50 MGINJECTION, PALONOSETRON HCL, 25 MCGINJECTION, PARICALCITOL, 1 MCGINJECTION, PEGAPTANIB SODIUM, 0.3 MGINJECTION, PEGADEMASE BOVINE, 25 IUINJECTION, PEGFILGRASTIM, 6 MGINJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITSINJECTION, PENTASTARCH, 10% SOLUTION, 100 MLINJECTION, PENTOBARBITAL SODIUM, PER 50 MGINJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITSINJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS (1.125GRAMS)PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MGINJECTION, PROMETHAZINE HCL, UP TO 50 MGINJECTION, PHENOBARBITAL SODIUM, UP TO 120 MGINJECTION, OXYTOCIN, UP TO 10 UNITSINJECTION, DESMOPRESSIN ACETATE, PER 1 MCGINJECTION, PREDNISOLONE ACETATE, UP TO 1 MLINJECTION, TOLAZOLINE HCL, UP TO 25 MGINJECTION, PROGESTERONE, PER 50 MGINJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MGINJECTION, PROCAINAMIDE HCL, UP TO 1 GMINJECTION, OXACILLIN SODIUM, UP TO 250 MGINJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MGINJECTION, PROTAMINE SULFATE, PER 10 MGINJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IUINJECTION, PROTIRELIN, PER 250 MCGINJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GMINJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MGINJECTION, METOCLOPRAMIDE HCL, UP TO 10 MGINJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350)INJECTION, RANIBIZUMAB, 0.1 MGINJECTION, RANITIDINE HYDROCHLORIDE, 25 MGINJECTION, RASBURICASE, 0.5 MGINJECTION, REGADENOSON, 0.1 MGINJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROGRAMS (250 I.U.)INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTRAMUSCULAR ORINTRAVENOUS, 100 IUINJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVENT DETERGENT, 100 IUINJECTION, RISPERIDONE, LONG ACTING, 0.5 MGINJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MGINJECTION, METHOCARBAMOL, UP TO 10 MLINJECTION, SINCALIDE, 5 MICROGRAMSINJECTION, THEOPHYLLINE, PER 40 MGINJECTION, SARGRAMOSTIM (GM-CSF), 50 MCGINJECTION, SECRETIN, SYNTHETIC, HUMAN, 1 MICROGRAMINJECTION, AUROTHIOGLUCOSE, UP TO 50 MGINJECTION, SODIUM CHLORIDE, 0.9%, PER 2 MLINJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MGINJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MGINJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MGINJECTION, SOMATREM, 1 MGINJECTION, SOMATROPIN, 1 MGINJECTION, PROMAZINE HCL, UP TO 25 MGINJECTION, RETEPLASE, 18.1 MGINJECTION, STREPTOKINASE, PER 250,000 IUINJECTION, ALTEPLASE RECOMBINANT, 1 MG

Query_110708

Page 259

INJECTION, STREPTOMYCIN, UP TO 1 GMINJECTION, FENTANYL CITRATE, 0.1 MGINJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUGADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUGIS SELF ADMINISTERED)INJECTION, PENTAZOCINE, 30 MGINJECTION, TENECTEPLASE, 50MGINJECTION, TENECTEPLASE, 1 MGINJECTION, TERBUTALINE SULFATE, UP TO 1 MGINJECTION, TERIPARATIDE, 10 MCGINJECTION, TESTOSTERONE ENANTHATE, UP TO 100 MGINJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MGINJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MGINJECTION, TESTOSTERONE PROPIONATE, UP TO 100 MGINJECTION, CHLORPROMAZINE HCL, UP TO 50 MGINJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG VIALINJECTION, TIGECYCLINE, 1 MGINJECTION, TIROFIBAN HCL, 0.25MGINJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MGINJECTION, TOBRAMYCIN SULFATE, UP TO 80 MGINJECTION, TORSEMIDE, 10 MG/MLINJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MGINJECTION, TREPROSTINIL, 1 MGINJECTION, TRIAMCINOLONE ACETONIDE, PRESERVATIVE FREE, 1 MGINJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MGINJECTION, TRIAMCINOLONE DIACETATE, PER 5MGINJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MGINJECTION, TRIMETREXATE GLUCURONATE, PER 25 MGINJECTION, PERPHENAZINE, UP TO 5 MGINJECTION, TRIPTORELIN PAMOATE, 3.75 MGINJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GMINJECTION, UREA, UP TO 40 GMINJECTION, UROFOLLITROPIN, 75 IUINJECTION, DIAZEPAM, UP TO 5 MGINJECTION, UROKINASE, 5000 IU VIALINJECTION, IV, UROKINASE, 250,000 I.U. VIALINJECTION, VANCOMYCIN HCL, 500 MGINJECTION, VERTEPORFIN, 0.1 MGINJECTION, TRIFLUPROMAZINE HCL, UP TO 20 MGINJECTION, HYDROXYZINE HCL, UP TO 25 MGINJECTION, THIAMINE HCL, 100 MGINJECTION, PYRIDOXINE HCL, 100 MGINJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCGINJECTION, PHYTONADIONE (VITAMIN K), PER 1 MGINJECTION, VORICONAZOLE, 10 MGINJECTION, HYALURONIDASE, UP TO 150 UNITSINJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1 USP UNIT (UP TO 999USP UNITS)INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1000 USP UNITSINJECTION, HYALURONIDASE, RECOMBINANT, 1 USP UNITINJECTION, MAGNESIUM SULFATE, PER 500 MGINJECTION, POTASSIUM CHLORIDE, PER 2 MEQINJECTION, ZIDOVUDINE, 10 MGINJECTION, ZIPRASIDONE MESYLATE, 10 MGINJECTION, ZOLEDRONIC ACID (ZOMETA), 1 MGINJECTION, ZOLEDRONIC ACID (RECLAST), 1 MGUNCLASSIFIED DRUGSEDETATE DISODIUM, PER 150 MGNASAL VACCINE INHALATIONDRUG ADMINISTERED THROUGH A METERED DOSE INHALERLAETRILE, AMYGDALIN, VITAMIN B17

Query_110708

Page 260

UNCLASSIFIED BIOLOGICSINFUSION, NORMAL SALINE SOLUTION , 1000 CCINFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT)5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT)INFUSION, NORMAL SALINE SOLUTION , 250 CCSTERILE SALINE OR WATER, UP TO 5 CC5% DEXTROSE/WATER (500 ML = 1 UNIT)INFUSION, D5W, 1000 CCINFUSION, DEXTRAN 40, 500 MLINFUSION, DEXTRAN 75, 500 MLRINGERS LACTATE INFUSION, UP TO 1000 CCHYPERTONIC SALINE SOLUTION, 50 OR 100 MEQ, 20 CC VIALINJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN),PER FACTOR VIII I.U.INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCOINJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, IUFACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAMFACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U.FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.FACTOR IX, COMPLEX, PER I.U.FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.ANTITHROMBIN III (HUMAN), PER I.U.ANTI-INHIBITOR, PER I.U.HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIEDINTRAUTERINE COPPER CONTRACEPTIVELEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MGCONTRACEPTIVE SUPPLY, HORMONE CONTAINING VAGINAL RING, EACHCONTRACEPTIVE SUPPLY, HORMONE CONTAINING PATCH, EACHLEVONORGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANTS AND SUPPLIESETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIESAMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SINGLE UNIT DOSAGEFORM (354 MG)GANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANTFLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANTSODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR INJECTIONHYALURONAN (SODIUM HYALURONATE) OR DERIVATIVE, INTRA-ARTICULAR INJECTION, PERINJECTIONHYLAN G-F 20, 16 MG, FOR INTRA-ARTICULAR INJECTIONHYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTICULAR INJECTION,PER DOSEHYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSEHYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSEHYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSEAUTOLOGOUS CULTURED CHONDROCYTES, IMPLANTDERMAL AND EPIDERMAL, (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, WITH OR WITHOUTBIOENGINEERED OR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE ELEMENTS, PERSQUARE CENTIMETERDERMAL (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITHOUT OTHERBIOENGINEERED OR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE ELEMENTS, PERSQUARE CENTIMETERDERMAL (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENGINEEREDOR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE ELEMENTS, PER SQUARE CENTIMETERDERMAL AND EPIDERMAL, (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITHOUTOTHER BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVEELEMENTS, PER SQUARE CENTIMETERDERMAL (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENGINEEREDOR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS, PER SQUARECENTIMETERDERMAL (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITHOUT OTHER

Query_110708

Page 261

BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS, PERSQUARE CENTIMETERDERMAL (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, INJECTABLE, WITH OR WITHOUT OTHERBIOENGINEERED OR PROCESSED ELEMENTS, BUT WITHOUT METABOLICALLY ACTIVE ELEMENTS,1 CCDERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHOUT OTHERBIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS(INTEGRA MATRIX), PER SQUARE CENTIMETERDERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHOUT OTHERBIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS(TISSUEMEND), PER SQUARE CENTIMETERDERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHOUT OTHERBIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS(PRIMATRIX), PER SQUARE CENTIMETERDERMAL (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, INJECTABLE, WITH OR WITHOUT OTHERBIOENGINEERED OR PROCESSED ELEMENTS, BUT WITHOUT METABOLIZED ACTIVE ELEMENTS,PER 10 MGAZATHIOPRINE, ORAL, 50 MGAZATHIOPRINE, PARENTERAL, 100 MGCYCLOSPORINE, ORAL, 100 MGLYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL, 250 MGMUROMONAB-CD3, PARENTERAL, 5 MGPREDNISONE, ORAL, PER 5MGTACROLIMUS, ORAL, PER 1 MGMETHYLPREDNISOLONE ORAL, PER 4 MGPREDNISOLONE ORAL, PER 5 MGLYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL, 25MGDACLIZUMAB, PARENTERAL, 25 MGCYCLOSPORINE, ORAL, 25 MGCYCLOSPORIN, PARENTERAL, 250 MGMYCOPHENOLATE MOFETIL, ORAL, 250 MGMYCOPHENOLIC ACID, ORAL, 180 MGSIROLIMUS, ORAL, 1 MGTACROLIMUS, PARENTERAL, 5 MGIMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIEDALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION,FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME,CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION,FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNITDOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, UNIT DOSE FORM, PER GRAMARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15 MICROGRAMSFORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMSLEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, CONCENTRATED FORM, 0.5 MGACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAMALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,UNIT DOSE, 1 MGALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,CONCENTRATED FORM, 1 MGALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MGLEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MGALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG

Query_110708

Page 262

LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MGLEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, UNIT DOSE, 0.5 MGALBUTEROL, UP TO 5 MG AND IPRATROPIUM BROMIDE, UP TO 1 MG, COMPOUNDEDINHALATION SOLUTION, ADMINISTERED THROUGH DMELEVALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 1 MG, COMPOUNDEDINHALATION SOLUTION, ADMINISTERED THROUGH DMEALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVEDFINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DMEBECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, UNIT DOSE FORM, PER MILLIGRAMBETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, UNIT DOSE FORM, PER MILLIGRAMBUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MGBUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,UNIT DOSE FORM, UP TO 0.5 MGBITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTEREDTHROUGH DME, CONCENTRATED FORM, PER MILLIGRAMBITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, PER MILLIGRAMCROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMSCROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, UNIT DOSE FORM, PER 10 MILLIGRAMSBUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAMBUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,CONCENTRATED FORM, PER 0.25 MILLIGRAMATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,CONCENTRATED FORM, PER MILLIGRAMATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,UNIT DOSE FORM, PER MILLIGRAMDEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, CONCENTRATED FORM, PER MILLIGRAMDEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, UNIT DOSE FORM, PER MILLIGRAMDORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMFORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,UNIT DOSE FORM, 12 MICROGRAMSFLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,UNIT DOSE, PER MILLIGRAMGLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, CONCENTRATED FORM, PER MILLIGRAMGLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, UNIT DOSE FORM, PER MILLIGRAMIPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMIPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, PER MILLIGRAMISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, CONCENTRATED FORM, PER MILLIGRAMISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAMISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, UNIT DOSE FORM, PER MILLIGRAMISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED

Query_110708

Page 263

THROUGH DME, CONCENTRATED FORM, PER MILLIGRAMISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAMISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, PER MILLIGRAMMETAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, CONCENTRATEDFORM, PER 10 MILLIGRAMSMETAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 10 MILLIGRAMSMETAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMSMETAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMSMETHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION THROUGH A NEBULIZER,PER 1 MGPENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, PER 300 MGTERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTEREDTHROUGH DME, CONCENTRATED FORM, PER MILLIGRAMTERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, PER MILLIGRAMTOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,UNIT DOSE FORM, ADMINISTERED THROUGH DME, PER 300 MILLIGRAMSTRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, CONCENTRATED FORM, PER MILLIGRAMTRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGHDME, UNIT DOSE FORM, PER MILLIGRAMTOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,UNIT DOSE FORM, PER 300 MILLIGRAMSNOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DMENOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DMEANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIEDPRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOSAPREPITANT, ORAL, 5 MGBUSULFAN; ORAL, 2 MGCABERGOLINE, ORAL, 0.25 MGCAPECITABINE, ORAL, 150 MGCAPECITABINE, ORAL, 500 MGCYCLOPHOSPHAMIDE; ORAL, 25 MGDEXAMETHASONE, ORAL, 0.25 MGETOPOSIDE; ORAL, 50 MGGEFITINIB, ORAL, 250 MGANTIEMETIC DRUG, ORAL, NOT OTHERWISE SPECIFIEDMELPHALAN; ORAL, 2 MGMETHOTREXATE; ORAL, 2.5 MGNABILONE, ORAL, 1 MGTEMOZOLOMIDE, ORAL, 5 MGTOPOTECAN, ORAL, 0.25 MGPRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOSINJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MGINJECTION, DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MGINJECTION, ALEMTUZUMAB, 10 MGINJECTION, ALDESLEUKIN, PER SINGLE USE VIALINJECTION, ARSENIC TRIOXIDE, 1 MGINJECTION, ASPARAGINASE, 10,000 UNITSINJECTION, AZACITIDINE, 1 MGINJECTION, CLOFARABINE, 1 MGBCG (INTRAVESICAL) PER INSTILLATIONINJECTION, BENDAMUSTINE HCL, 1 MG

Query_110708

Page 264

INJECTION, BEVACIZUMAB, 10 MGINJECTION, BLEOMYCIN SULFATE, 15 UNITSINJECTION, BORTEZOMIB, 0.1 MGINJECTION, CARBOPLATIN, 50 MGINJECTION, CARMUSTINE, 100 MGINJECTION, CETUXIMAB, 10 MGCISPLATIN, POWDER OR S0LUTION, PER 10 MGCISPLATIN, 50 MGINJECTION, CLADRIBINE, PER 1 MGCYCLOPHOSPHAMIDE, 100 MGCYCLOPHOSPHAMIDE, 200 MGCYCLOPHOSPHAMIDE, 500 MGCYCLOPHOSPHAMIDE, 1.0 GRAMCYCLOPHOSPHAMIDE, 2.0 GRAMCYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MGCYCLOPHOSPHAMIDE, LYOPHILIZED, 200 MGCYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MGCYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAMCYCLOPHOSPHAMIDE, LYOPHILIZED, 2.0 GRAMINJECTION, CYTARABINE LIPOSOME, 10 MGINJECTION, CYTARABINE, 100 MGINJECTION, CYTARABINE, 500 MGINJECTION, DACTINOMYCIN, 0.5 MGDACARBAZINE, 100 MGDACARBAZINE, 200 MGINJECTION, DAUNORUBICIN, 10 MGINJECTION, DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MGINJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMSINJECTION, DIETHYLSTILBESTROL DIPHOSPHATE, 250 MGINJECTION, DOCETAXEL, 20 MGINJECTION, ELLIOTTS' B SOLUTION, 1 MLINJECTION, EPIRUBICIN HCL, 2 MGINJECTION, ETOPOSIDE, 10 MGETOPOSIDE, 100 MGINJECTION, FLUDARABINE PHOSPHATE, 50 MGINJECTION, FLUOROURACIL, 500 MGINJECTION, FLOXURIDINE, 500 MGINJECTION, GEMCITABINE HYDROCHLORIDE, 200 MGGOSERELIN ACETATE IMPLANT, PER 3.6 MGINJECTION, IRINOTECAN, 20 MGINJECTION, IXABEPILONE, 1 MGINJECTION, IFOSFAMIDE, 1 GRAMINJECTION, MESNA, 200 MGINJECTION, IDARUBICIN HYDROCHLORIDE, 5 MGINJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAMINJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITSINJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITSINJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IUINJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITSLEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MGLEUPROLIDE ACETATE, PER 1 MGLEUPROLIDE ACETATE IMPLANT, 65 MGHISTRELIN IMPLANT (VANTAS), 50 MGHISTRELIN IMPLANT (SUPPRELIN LA), 50 MGINJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MGINJECTION, MELPHALAN HYDROCHLORIDE, 50 MGMETHOTREXATE SODIUM, 5 MGMETHOTREXATE SODIUM, 50 MGINJECTION, NELARABINE, 50 MGINJECTION, OXALIPLATIN, 0.5 MGINJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG

Query_110708

Page 265

INJECTION, PACLITAXEL, 30 MGINJECTION, PEGASPARGASE, PER SINGLE DOSE VIALINJECTION, PENTOSTATIN, 10 MGINJECTION, PLICAMYCIN, 2.5 MGMITOMYCIN, 5 MGMITOMYCIN, 20 MGMITOMYCIN, 40 MGINJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MGINJECTION, GEMTUZUMAB OZOGAMICIN, 5 MGINJECTION, PANITUMUMAB, 10 MGINJECTION, PEMETREXED, 10 MGINJECTION, RITUXIMAB, 100 MGINJECTION, STREPTOZOCIN, 1 GRAMINJECTION, TEMSIROLIMUS, 1 MGINJECTION, THIOTEPA, 15 MGINJECTION, TOPOTECAN, 4 MGINJECTION, TRASTUZUMAB, 10 MGINJECTION, VALRUBICIN, INTRAVESICAL, 200 MGINJECTION, VINBLASTINE SULFATE, 1 MGVINCRISTINE SULFATE, 1 MGVINCRISTINE SULFATE, 2 MGVINCRISTINE SULFATE, 5 MGINJECTION, VINORELBINE TARTRATE, 10 MGINJECTION, FULVESTRANT, 25 MGINJECTION, PORFIMER SODIUM, 75 MGNOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGSSTANDARD WHEELCHAIRSTANDARD HEMI (LOW SEAT) WHEELCHAIRLIGHTWEIGHT WHEELCHAIRHIGH STRENGTH, LIGHTWEIGHT WHEELCHAIRULTRALIGHTWEIGHT WHEELCHAIRHEAVY DUTY WHEELCHAIREXTRA HEAVY DUTY WHEELCHAIROTHER MANUAL WHEELCHAIR/BASESTANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIRSTANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR WITH PROGRAMMABLE CONTROLPARAMETERS FOR SPEED ADJUSTMENT, TREMOR DAMPENING, ACCELERATION CONTROL ANDBRAKINGLIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIROTHER MOTORIZED/POWER WHEELCHAIR BASEDETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACHDETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACHDETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, EACHARM PAD, EACHFIXED, ADJUSTABLE HEIGHT ARMREST, PAIRHIGH MOUNT FLIP-UP FOOTREST, EACHLEG STRAP, EACHLEG STRAP, H STYLE, EACHADJUSTABLE ANGLE FOOTPLATE, EACHLARGE SIZE FOOTPLATE, EACHSTANDARD SIZE FOOTPLATE, EACHFOOTREST, LOWER EXTENSION TUBE, EACHFOOTREST, UPPER HANGER BRACKET, EACHFOOTREST, COMPLETE ASSEMBLYELEVATING LEGREST, LOWER EXTENSION TUBE, EACHELEVATING LEGREST, UPPER HANGER BRACKET, EACHRATCHET ASSEMBLYCAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, EACHSWINGAWAY, DETACHABLE FOOTRESTS, EACHELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACHSEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH

Query_110708

Page 266

STRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIRZERO PRESSURE TUBE (FLAT FREE INSERTS), ANY SIZE, EACHSPOKE PROTECTORS, EACHSOLID TIRE, ANY SIZE, EACHPNEUMATIC TIRE, ANY SIZE, EACHPNEUMATIC TIRE TUBE, EACHREAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACHREAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACHFRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, EACHFRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, EACHCASTER PIN LOCK,EACHPNEUMATIC CASTER TIRE, ANY SIZE, EACHSEMI-PNEUMATIC CASTER TIRE, ANY SIZE, EACHSOLID CASTER TIRE, ANY SIZE, EACHFRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACHPNEUMATIC CASTER TIRE TUBE, EACHREAR WHEEL TIRE FOR POWER WHEELCHAIR, ANY SIZE, EACHREAR WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR POWER WHEELCHAIR, ANY SIZE,EACHREAR WHEEL ASSEMBLY FOR POWER WHEELCHAIR, COMPLETE, EACHREAR WHEEL, ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER WHEELCHAIR,ANY SIZE, EACHWHEEL TIRE FOR POWER BASE, ANY SIZE, EACHWHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR EACH BASE, ANY SIZE, EACHWHEEL ASSEMBLY FOR POWER BASE, COMPLETE, EACHWHEEL ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER BASE, ANY SIZE, EACHDRIVE BELT FOR POWER WHEELCHAIRFRONT CASTER FOR POWER WHEELCHAIR, EACHCRUTCH AND CANE HOLDER, EACHCYLINDER TANK CARRIER, EACHIV HANGER, EACHARM TROUGH, EACHWHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIEDELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE)PRESCRIPTION ANTIEMETIC DRUG, ORAL, PER 1 MG, FOR USE IN CONJUNCTION WITH ORALANTI-CANCER DRUG, NOT OTHERWISE SPECIFIEDPRESCRIPTION ANTIEMETIC DRUG, RECTAL, PER 1 MG, FOR USE IN CONJUNCTION WITHORAL ANTI-CANCER DRUG, NOT OTHERWISE SPECIFIEDWHEELCHAIR BEARINGS, ANY TYPEINFUSION PUMP USED FOR UNINTERRUPTED PARENTERAL ADMINISTRATION OF MEDICATION,(E.G., EPOPROSTENOL OR TREPROSTINOL)TEMPORARY REPLACEMENT FOR PATIENT OWNED EQUIPMENT BEING REPAIRED, ANY TYPESUPPLIES FOR EXTERNAL DRUG INFUSION PUMP, SYRINGE TYPE CARTRIDGE, STERILE, EACHCOMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSUREDEVICE, EACHORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACHNASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIRFUNCTIONAL NEUROMUSCULAR STIMULATOR, TRANSCUTANEOUS STIMULATION OF MUSCLES OFAMBULATION WITH COMPUTER CONTROL, USED FOR WALKING BY SPINAL CORD INJURED,ENTIRE SYSTEM, AFTER COMPLETION OF TRAINING PROGRAMREPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, SILVER OXIDE,1.5 VOLT, EACHREPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, SILVER OXIDE,3 VOLT, EACHREPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, ALKALINE, 1.5VOLT, EACHREPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 3.6VOLT, EACHREPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 4.5VOLT, EACHAUTOMATIC EXTERNAL DEFIBRILLATOR, WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS,

Query_110708

Page 267

GARMENT TYPEREPLACEMENT BATTERY FOR AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENT TYPE ONLY,EACHREPLACEMENT GARMENT FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR, EACHREPLACEMENT ELECTRODES FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENTTYPE ONLY, EACHTLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGIDPLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION ANDTERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THESYMPHYSIS PUBIS TO THE XIPHOID, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THESAGITTAL AND CORONAL PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPINGPLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTTLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGIDPLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION ANDTERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THESYMPHYSIS PUBIS TO THE XIPHOID, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THESAGITTAL AND CORONAL PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPINGPLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTTUBULAR ELASTIC DRESSING, ANY WIDTH, PER LINEAR YARDFOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOTAFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACTWITH PATIENT'S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 1/4 INCH MATERIAL OFSHORE A 35 DUROMETER OR 3/16 INCH MATERIAL OF SHORE A 40 DUROMETER (OR HIGHER),PREFABRICATED, EACHFOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OFPATIENT'S FOOT, TOTAL CONTACT WITH PATIENT'S FOOT, INCLUDING ARCH, BASE LAYERMINIMUM OF 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER OR HIGHER, INCLUDES ARCHFILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EACHSACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTIONABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUSABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTIONABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUSABDOMEN DESIGN, CUSTOM FABRICATEDSACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGIDPANELS OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIAC JOINT,INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTSACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGIDPANELS PLACED OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIACJOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, CUSTOMFABRICATEDLUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT, POSTERIOR EXTENDS FROM L1TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THEINTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMENDESIGN, SHOULDER STRAPS, STAYS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTLUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOREXTENDS FROM L1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TOREDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDEPADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTLUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS,POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES,MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOREXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES,

Query_110708

Page 268

MAY INCLUDE STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOREXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES,MAY INCLUDE STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S),POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDESSTRAPS, CLOSURES, MAY INCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUSABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIORPANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS,INCLUDES STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTLUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIORPANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS,INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUSABDOMEN DESIGN, CUSTOM FABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIORFRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAYINCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIORFRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAYINCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, CUSTOMFABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGIDPOSTERIOR FRAME/PANELS, LATERAL ARTICULATING DESIGN TO FLEX THE LUMBAR SPINE,POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERALSTRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAYINCLUDE PADDING, ANTERIOR PANEL, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTLUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGIDPOSTERIOR FRAME/PANELS, LATERAL ARTICULATING DESIGN TO FLEX THE LUMBAR SPINE,POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERALSTRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAYINCLUDE PADDING, ANTERIOR PANEL, PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR ANDPOSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS,CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR ANDPOSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS,CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN,CUSTOM FABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S)POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, ANTERIOREXTENDS FROM SYMPHYSIS PUBIS TO XYPHOID, PRODUCES INTRACAVITARY PRESSURE TO

Query_110708

Page 269

REDUCE LOAD ON THE INTERVERTEBRAL DISCS, OVERALL STRENGTH IS PROVIDED BYOVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES, INCLUDES STRAPS, CLOSURES,MAY INCLUDE SOFT INTERFACE, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S),POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, ANTERIOREXTENDS FROM SYMPHYSIS PUBIS TO XIPHOID, PRODUCES INTRACAVITARY PRESSURE TOREDUCE LOAD ON THE INTERVERTEBRAL DISCS, OVERALL STRENGTH IS PROVIDED BYOVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES, INCLUDES STRAPS, CLOSURES,MAY INCLUDE SOFT INTERFACE, PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATEDWHEELCHAIR ACCESSORY, WHEELCHAIR SEAT OR BACK CUSHION, DOES NOT MEET SPECIFICCODE CRITERIA OR NO WRITTEN CODING VERIFICATION FROM DME PDACADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM,MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONICSENSOR(S), ANY TYPEPORTABLE OXYGEN CONCENTRATOR, RENTALADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL COMPONENTS,REPLACEMENT ONLY, EACHCONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEMLITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR,OTHER THAN EAR LEVEL, REPLACEMENT, EACHLITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, EARLEVEL, REPLACEMENT, EACHPOWER WHEELCHAIR ACCESSORY, 12 TO 24 AMP HOUR SEALED LEAD ACID BATTERY, EACH(E.G., GEL CELL, ABSORBED GLASSMAT)SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES,ANY DEPTHSKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES ORGREATER, ANY DEPTHSKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESSTHAN 22 INCHES, ANY DEPTHSKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22INCHES OR GREATER, ANY DEPTHPORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLEOXYGEN CYLINDERS; INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER,HUMIDIFIER, CANNULA OR MASK, AND TUBINGPOWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO ANDINCLUDING 300 POUNDSPOWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450POUNDSPOWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO600 POUNDSPOWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO ANDINCLUDING 300 POUNDSPOWER OPERATED VEHICLE, GROUP 2 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450POUNDSPOWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO600 POUNDSPOWER OPERATED VEHICLE, NOT OTHERWISE CLASSIFIEDPOWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHTCAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHTCAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UPTO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENTWEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHTCAPACITY UP TO AND INCLUDING 300 POUNDS

Query_110708

Page 270

POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHTCAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UPTO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHTCAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENTWEIGHT CAPACITY 451 TO 600 POUNDSPOWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHTCAPACITY 451 TO 600 POUNDSPOWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENTWEIGHT CAPACITY 601 POUNDS OR MOREPOWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT 601POUNDS OR MOREPOWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, SLING/SOLID SEAT/BACK,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, CAPTAINS CHAIR, PATIENTWEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR,PATIENT WEIGHT CAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SINGLE POWER OPTION SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDSPOWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MOREPOWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHTCAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 3 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UPTO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHTCAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENTWEIGHT CAPACITY 451 TO 600 POUNDSPOWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHTCAPACITY 451 TO 600 POUNDSPOWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENTWEIGHT CAPACITY 601 POUNDS OR MOREPOWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHTCAPACITY 601 POUNDS OR MOREPOWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR,

Query_110708

Page 271

PATIENT WEIGHT CAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDSPOWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDSPOWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MOREPOWER WHEELCHAIR, GROUP 4 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHTCAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 4 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UPTO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHTCAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENTWEIGHT CAPACITY 451 TO 600 POUNDSPOWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT 451 TO 600 POUNDSPOWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR,PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDSPOWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDSPOWER WHEELCHAIR, GROUP 5 PEDIATRIC, SINGLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDSPOWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION, SLING/SOLIDSEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDSPOWER WHEELCHAIR, NOT OTHERWISE CLASSIFIEDPOWER MOBILITY DEVICE, NOT CODED BY DME PDAC OR DOES NOT MEET CRITERIACRANIAL ORTHOSIS (HELMET), WITH OR WITHOUT SOFT INTERFACE, MOLDED TO PATIENTMODELCRANIAL ORTHOSIS (HELMET), WITH OR WITHOUT SOFT-INTERFACE, NON-MOLDEDCRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, WITH OR WITHOUT SOFTINTERFACE MATERIAL, ADJUSTABLE RANGE OF MOTION JOINT, CUSTOM FABRICATEDCRANIAL CERVICAL ORTHOSIS, TORTICOLLIS TYPE, WITH OR WITHOUT JOINT, WITH ORWITHOUT SOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTCERVICAL, FLEXIBLE, NON-ADJUSTABLE (FOAM COLLAR)CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR, MOLDED TO PATIENTCERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR)CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED CHIN CUP (PLASTIC COLLAR WITHMANDIBULAR/OCCIPITAL PIECE)CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPITAL/MANDIBULAR SUPPORTCERVICAL, COLLAR, MOLDED TO PATIENT MODELCERVICAL, COLLAR, SEMI-RIGID THERMOPLASTIC FOAM, TWO PIECECERVICAL, COLLAR, SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE WITH THORACICEXTENSIONCERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLECERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLECERVICAL BARS (SOMI, GUILFORD, TAYLOR TYPES)CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLECERVICAL BARS, AND THORACIC EXTENSION

Query_110708

Page 272

THORACIC, RIB BELTTHORACIC, RIB BELT, CUSTOM FABRICATEDSPINAL ORTHOSIS, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH INTERFACE MATERIAL,CUSTOM FITTED (DEWALL POSTURE PROTECTOR ONLY)TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTEVERTEBRAL DISKS WITH RIGIDSTAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTTLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGIDSTAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, CUSTOM FABRICATEDTLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM SACROCOCCYGEAL JUNCTION TOABOVE T-9 VERTEBRA, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL PLANE,PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITHRIGID STAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTTLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR PANELAND SOFT ANTERIOR APRON, EXTENDS FROM THE SACROCOCCYGEAL JUNCTION ANDTERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, RESTRICTS GROSS TRUNK MOTION INTHE SAGITTAL PLANE, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THEINTERVERTEBRAL DISKS, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTTLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTICSHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUSTINFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TOTHE XIPHOID, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL,AND TRANVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC ANDSTABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTTLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTICSHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUSTINFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TOTHE STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL,CORONAL, AND TRANVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPINGPLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTTLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLASTICSHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUSTINFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TOTHE STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL,CORONAL, AND TRANSVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPINGPLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTTLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, FOUR RIGID PLASTICSHELLS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUSTINFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO THESTERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL,AND TRANVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC ANDSTABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTTLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRONWITH STRAPS, CLOSURES AND PADDING, RESTRICTS GROSS TRUNK MOTION IN SAGITTALPLANE, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISKS,INCLUDES FITTING AND SHAPING THE FRAME, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTTLSO, SAGITTAL-CORONAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFTANTERIOR APRON WITH STRAPS, CLOSURES AND PADDING, EXTENDS FROM SACROCOCCYGEALJUNCTION OVER SCAPULAE, LATERAL STRENGTH PROVIDED BY PELVIC, THORACIC, ANDLATERAL FRAME PIECES, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, AND CORONALPLANES, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISKS,INCLUDES FITTING AND SHAPING THE FRAME, PREFABRICATED, INCLUDES FITTING AND

Query_110708

Page 273

ADJUSTMENTTLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRONWITH STRAPS, CLOSURES AND PADDING, EXTENDS FROM SACROCOCCYGEAL JUNCTION TOSCAPULA, LATERAL STRENGTH PROVIDED BY PELVIC, THORACIC, AND LATERAL FRAMEPIECES, ROTATIONAL STRENGTH PROVIDED BY SUBCLAVICULAR EXTENSIONS, RESTRICTSGROSS TRUNK MOTION IN SAGITTAL, CORONAL, AND TRANVERSE PLANES, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS, INCLUDESFITTING AND SHAPING THE FRAME, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTTLSO, TRIPLANAR CONTROL, HYPEREXTENSION, RIGID ANTERIOR AND LATERAL FRAMEEXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTCH WITH TWO ANTERIOR COMPONENTS (ONEPUBIC AND ONE STERNAL), POSTERIOR AND LATERAL PADS WITH STRAPS AND CLOSURES,LIMITS SPINAL FLEXION, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL, ANDTRANSVERSE PLANES, INCLUDES FITTING AND SHAPING THE FRAME, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTTLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER,WITH MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEALJUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROMSYMPHYSIS PUBIS TO STERNAL NOTCH, ANTERIOR OR POSTERIOR OPENING, RESTRICTSGROSS TRUNK MOTION IN SAGITTAL, CORONAL, AND TRANSVERSE PLANES, INCLUDES ACARVED PLASTER OR CAD-CAM MODEL, CUSTOM FABRICATEDTLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER,MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTIONAND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSISPUBIS TO STERNAL NOTCH, ANTERIOR OR POSTERIOR OPENING, RESTRICTS GROSS TRUNKMOTION IN SAGITTAL, CORONAL, AND TRANSVERSE PLANES, INCLUDES A CARVED PLASTEROR CAD-CAM MODEL, CUSTOM FABRICATEDTLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER,WITH MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEALJUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROMSYMPHYSIS PUBIS TO STERNAL NOTCH, LATERAL STRENGTH IS ENHANCED BY OVERLAPPINGPLASTIC, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL, AND TRANSVERSEPLANES, INCLUDES A CARVED PLASTER OR CAD-CAM MODEL, CUSTOM FABRICATEDTLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER,MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTIONAND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSISPUBIS TO STERNAL NOTCH, LATERAL STRENGTH IS ENHANCED BY OVERLAPPING PLASTIC,RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL, AND TRANSVERSE PLANES,INCLUDES A CARVED PLASTER OR CAD-CAM MODEL, CUSTOM FABRICATEDTLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER,MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTIONAND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSISPUBIS TO STERNAL NOTCH, ANTERIOR OR POSTERIOR OPENING, RESTRICTS GROSS TRUNKMOTION IN SAGITTAL, CORONAL, AND TRANSVERSE PLANES, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTTLSO, SAGITTAL-CORONAL CONTROL, ONE PIECE RIGID PLASTIC SHELL, WITH OVERLAPPINGREINFORCED ANTERIOR, WITH MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROMSACROCOCCYGEAL JUNCTION AND TERMINATES AT OR BEFORE THE T-9 VERTEBRA, ANTERIOREXTENDS FROM SYMPHYSIS PUBIS TO XIPHOID, ANTERIOR OPENING, RESTRICTS GROSSTRUNK MOTION IN SAGITTAL AND CORONAL PLANES, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTTLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGIDPLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION ANDTERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THESYMPHYSIS PUBIS TO THE XIPHOID, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THESAGITTAL AND CORONAL PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPINGPLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTTLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGIDPLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION ANDTERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THESYMPHYSIS PUBIS TO THE XIPHOID, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE

Query_110708

Page 274

SAGITTAL AND CORONAL PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPINGPLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTSACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTIONABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUSABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTIONABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUSABDOMEN DESIGN, CUSTOM FABRICATEDSACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGIDPANELS OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIAC JOINT,INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTSACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGIDPANELS PLACED OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIACJOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, CUSTOMFABRICATEDLUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT, POSTERIOR EXTENDS FROM L-1TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THEINTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMENDESIGN, SHOULDER STRAPS, STAYS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTLUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOREXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TOREDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDEPADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTLUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS,POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES,MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOREXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES,MAY INCLUDE STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOREXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES,MAY INCLUDE STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S),POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDESSTRAPS, CLOSURES, MAY INCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUSABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIORPANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS,INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUSABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIORPANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS,INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUSABDOMEN DESIGN, CUSTOM FABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIORFRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAYINCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

Query_110708

Page 275

LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIORFRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANEL(S), PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS,CLOSURES, MAY INCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMENDESIGN, CUSTOM FABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGIDPOSTERIOR FRAME/PANEL(S), LATERAL ARTICULATING DESIGN TO FLEX THE LUMBAR SPINE,POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERALSTRENGTH PROVIDED BY RIGID LATERAL FRAME/PANEL(S), PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAYINCLUDE PADDING, ANTERIOR PANEL, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTLUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGIDPOSTERIOR FRAME/PANELS, LATERAL ARTICULATING DESIGN TO FLEX THE LUMBAR SPINE,POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERALSTRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARYPRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAYINCLUDE PADDING, ANTERIOR PANEL, PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR ANDPOSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS,CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR ANDPOSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS,CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN,CUSTOM FABRICATEDLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S),POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, ANTERIOREXTENDS FROM SYMPHYSIS PUBIS TO XYPHOID, PRODUCES INTRACAVITARY PRESSURE TOREDUCE LOAD ON THE INTERVERTEBRAL DISCS, OVERALL STRENGTH IS PROVIDED BYOVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES, INCLUDES STRAPS, CLOSURES,MAY INCLUDE SOFT INTERFACE, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTLUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S),POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, ANTERIOREXTENDS FROM SYMPHYSIS PUBIS TO XYPHOID, PRODUCES INTRACAVITARY PRESSURE TOREDUCE LOAD ON THE INTERVERTEBRAL DISCS, OVERALL STRENGTH IS PROVIDED BYOVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES, INCLUDES STRAPS, CLOSURES,MAY INCLUDE SOFT INTERFACE, PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATEDCERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES (CTLSO), ANTERIOR-POSTERIOR-LATERALCONTROL, MOLDED TO PATIENT MODEL, (MINERVA TYPE)CTLSO, ANTERIOR-POSTERIOR-LATERAL-CONTROL, MOLDED TO PATIENT MODEL, WITHINTERFACE MATERIAL, (MINERVA TYPE)HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO JACKET VESTHALO PROCEDURE, CERVICAL HALO INCORPORATED INTO PLASTER BODY JACKETHALO PROCEDURE, CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSISADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE COMPATIBLE SYSTEMS, RINGSAND PINS, ANY MATERIALADDITION TO HALO PROCEDURES, MAGNETIC REASONANCE IMAGE COMPATIBLE SYSTEMADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIALTORSO SUPPORT, POST SURGICAL SUPPORT, PADS FOR POST SURGICAL SUPPORTTLSO, CORSET FRONTLSO, CORSET FRONTTLSO, FULL CORSETLSO, FULL CORSETAXILLARY CRUTCH EXTENSION

Query_110708

Page 276

PERONEAL STRAPS, PAIRSTOCKING SUPPORTER GRIPS, SET OF FOUR (4)PROTECTIVE BODY SOCK, EACHADDITION TO SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIEDCERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OFFURNISHING INITIAL ORTHOSIS, INCLUDING MODELCERVICAL THORACIC LUMBAR SACRAL ORTHOSIS, IMMOBILIZER, INFANT SIZE,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTTENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, INCLUDES FITTING ANDADJUSTMENTADDITION TO CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) OR SCOLIOSISORTHOSIS, AXILLA SLINGADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PADADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD, FLOATINGADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR BOLSTER PADADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR OR LUMBAR RIB PADADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, STERNAL PADADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, THORACIC PADADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, TRAPEZIUS SLINGADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGERADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER, BILATERAL WITH VERTICALEXTENSIONSADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR SLINGADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHERADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER,MOLDED TO PATIENT MODELADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, COVER FOR UPRIGHT, EACHTHORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), INCLUSIVE OF FURNISHING INITIALORTHOSIS ONLYADDITION TO TLSO, (LOW PROFILE), LATERAL THORACIC EXTENSIONADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC EXTENSIONADDITION TO TLSO, (LOW PROFILE), MILWAUKEE TYPE SUPERSTRUCTUREADDITION TO TLSO, (LOW PROFILE), LUMBAR DEROTATION PADADDITION TO TLSO, (LOW PROFILE), ANTERIOR ASIS PADADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC DEROTATION PADADDITION TO TLSO, (LOW PROFILE), ABDOMINAL PADADDITION TO TLSO, (LOW PROFILE), RIB GUSSET (ELASTIC), EACHADDITION TO TLSO, (LOW PROFILE), LATERAL TROCHANTERIC PADOTHER SCOLIOSIS PROCEDURE, BODY JACKET MOLDED TO PATIENT MODELOTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKETSPINAL ORTHOSIS, NOT OTHERWISE SPECIFIEDTHORACIC-HIP-KNEE-ANKLE ORTHOSIS (THKAO), MOBILITY FRAME (NEWINGTON, PARAPODIUMTYPES)THKAO, STANDING FRAME, WITH OR WITHOUT TRAY AND ACCESSORIESTHKAO, SWIVEL WALKERHIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, FREJKA TYPE WITHCOVER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTHIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (FREJKA COVER ONLY),PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTHIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (PAVLIK HARNESS),PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTHIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, SEMI-FLEXIBLE (VON ROSEN TYPE),CUSTOM-FABRICATEDHIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PELVIC BAND OR SPREADERBAR, THIGH CUFFS, CUSTOM-FABRICATEDHIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, ADJUSTABLE, (ILFLEDTYPE), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTHIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BAR,ADULT SIZE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT, ANY TYPEHIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PLASTIC, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT

Query_110708

Page 277

HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, DYNAMIC, PELVIC CONTROL,ADJUSTABLE HIP MOTION CONTROL, THIGH CUFFS (RANCHO HIP ACTION TYPE), CUSTOMFABRICATEDHIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE,CUSTOM FABRICATEDHIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTCOMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDUCTIONAND INTERNAL ROTATION CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTLEGG PERTHES ORTHOSIS, (TORONTO TYPE), CUSTOM-FABRICATEDLEGG PERTHES ORTHOSIS, (NEWINGTON TYPE), CUSTOM FABRICATEDLEGG PERTHES ORTHOSIS, TRILATERAL, (TACHDIJAN TYPE), CUSTOM-FABRICATEDLEGG PERTHES ORTHOSIS, (SCOTTISH RITE TYPE), CUSTOM-FABRICATEDLEGG PERTHES ORTHOSIS, LEGG PERTHES SLING (SAM BROWN TYPE), PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTLEGG PERTHES ORTHOSIS, (PATTEN BOTTOM TYPE), CUSTOM-FABRICATEDKNEE ORTHOSIS, ELASTIC WITH STAYS, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTKNEE ORTHOSIS, ELASTIC WITH JOINTS, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTKNEE ORTHOSIS, ELASTIC OR OTHER ELASTIC TYPE MATERIAL WITH CONDYLAR PAD(S),PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLARCONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ORTHOSIS, ELASTIC KNEE CAP, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ORTHOSIS, IMMOBILIZER, CANVAS LONGITUDINAL, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTKNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTKNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONALORTHOSIS, RIGID SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID, CUSTOM-FABRICATEDKNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MATERIAL,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ORTHOSIS, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOMFABRICATEDKNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION ANDEXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATIONCONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTKNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION ANDEXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATIONCONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATEDKNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION ANDEXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATIONCONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTKNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION ANDEXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATIONCONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATEDKNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIRSUPPORT CHAMBER(S), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ORTHOSIS, SWEDISH TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ORTHOSIS, MOLDED PLASTIC, THIGH AND CALF SECTIONS, WITH DOUBLE UPRIGHTKNEE JOINTS, CUSTOM-FABRICATEDKNEE ORTHOSIS, MOLDED PLASTIC, POLYCENTRIC KNEE JOINTS, PNEUMATIC KNEE PADS(CTI), CUSTOM-FABRICATEDKNEE ORTHOSIS, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET,CUSTOM-FABRICATED (SK)KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF LACERS WITH KNEE JOINTS,CUSTOM-FABRICATED

Query_110708

Page 278

KNEE ORTHOSIS, DOUBLE UPRIGHT, NON-MOLDED THIGH AND CALF CUFFS/LACERS WITH KNEEJOINTS, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND,CUSTOM-FABRICATEDANKLE ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G.NEOPRENE, LYCRA)ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTANKLE FOOT ORTHOSIS, MOLDED ANKLE GAUNTLET, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTAFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOMFABRICATEDANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS ORPERLSTEIN TYPE), CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTAFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION),CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE),PLASTIC, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE),PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP,CALF BAND/CUFF (SINGLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP,CALF BAND/CUFF (DOUBLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATEDKNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIRRUP,THIGH AND CALF BANDS/CUFFS (SINGLE BAR 'AK' ORTHOSIS), CUSTOM-FABRICATEDKNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCECONTROL, AUTOMATIC LOCK AND SWING PHASE RELEASE, MECHANICAL ACTIVATION,INCLUDES ANKLE JOINT, ANY TYPE, CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH ANDCALF BANDS/CUFFS (SINGLE BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT,CUSTOM-FABRICATEDKNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH ANDCALF BANDS/CUFFS (DOUBLE BAR 'AK' ORTHOSIS), CUSTOM-FABRICATEDKNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH ANDCALF BANDS/CUFFS, (DOUBLE BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOMFABRICATEDKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREEMOTION KNEE, MEDIAL LATERAL ROTATION CONTROL, WITH OR WITHOUT FREE MOTIONANKLE, CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, STATIC (PEDIATRIC SIZE), WITHOUT FREEMOTION ANKLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREEMOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREEMOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE,MULTI-AXIS ANKLE, CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, POLY-AXIAL HINGE,

Query_110708

Page 279

MEDIAL LATERAL ROTATION CONTROL, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOMFABRICATEDHIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL ROTATION STRAPS,PELVIC BAND/BELT, CUSTOM FABRICATEDHIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, HIPJOINT, PELVIC BAND/BELT, CUSTOM-FABRICATEDHIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, BALLBEARING HIP JOINT, PELVIC BAND/ BELT, CUSTOM-FABRICATEDHIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL ROTATION STRAPS,PELVIC BAND/BELT, CUSTOM FABRICATEDHIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, HIPJOINT, PELVIC BAND/BELT, CUSTOM-FABRICATEDHIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, BALLBEARING HIP JOINT, PELVIC BAND/ BELT, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS,THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS,CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS,THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATEDKNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS,CUSTOM-FABRICATEDKAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTKAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH ANKLEJOINTSADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINTADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINTADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTABLE MOTION KNEE JOINT,LERMAN TYPEADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, QUADRILATERAL BRIMADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELTADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND, THIGHFLANGE, AND PELVIC BELTADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINTADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACHJOINTADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST,EACH JOINTADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENTADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLEFOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLYADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE ATTACHMENTADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT MODEL, STIRRUPATTACHMENTADDITION TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP (SCOTT-CRAIG TYPE)ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUPADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION ('T') STRAP, PADDED/LINEDOR MALLEOLUS PADADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION,PADDED/LINED

Query_110708

Page 280

ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOTADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP INVOLVEMENT),JOINTED, ADJUSTABLEADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHTADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSISONLYADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOMFABRICATED ORTHOSIS ONLYADDITION TO LOWER EXTREMITY, ANTERIOR SWING BANDADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODELADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENTMODEL, (USED FOR 'PTB' 'AFO' ORTHOSES)ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANKADDITION TO LOWER EXTREMITY, PATTEN BOTTOMADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLIDSTIRRUPADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINTADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINTADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEEANKLE FOOT ORTHOSIS, EACH JOINTADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINTADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINTADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVEADDITION TO KNEE JOINT, DROP LOCK, EACHADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE, OREQUAL), ANY MATERIAL, EACH JOINTADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION, EACHJOINTADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION,EACH JOINTADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RINGADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHTBEARING, RINGADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, MOLDEDTO PATIENT MODELADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM,CUSTOM FITTEDADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROWM-L BRIM MOLDED TO PATIENT MODELADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROWM-L BRIM, CUSTOM FITTEDADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LACER, NON-MOLDEDADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENTMODELADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH ROLL CUFFADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE TWOPOSITION JOINT, EACHADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PELVIC SLINGADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE, OR THRUSTBEARING, FREE, EACHADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS OR THRUSTBEARING, LOCK, EACHADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, HEAVY DUTY, EACHADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, ADJUSTABLE FLEXION, EACHADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, ADJUSTABLE FLEXION,EXTENSION, ABDUCTION CONTROL, EACHADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PLASTIC, MOLDED TO PATIENT MODEL,RECIPROCATING HIP JOINT AND CABLESADDITION TO LOWER EXTREMITY, PELVIC CONTROL, METAL FRAME, RECIPROCATING HIPJOINT AND CABLESADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT, UNILATERAL

Query_110708

Page 281

ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT, BILATERALADDITION TO LOWER EXTREMITY, PELVIC AND THORACIC CONTROL, GLUTEAL PAD, EACHADDITION TO LOWER EXTREMITY, THORACIC CONTROL, THORACIC BANDADDITION TO LOWER EXTREMITY, THORACIC CONTROL, PARASPINAL UPRIGHTSADDITION TO LOWER EXTREMITY, THORACIC CONTROL, LATERAL SUPPORT UPRIGHTSADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BARADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALLHYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATEDORTHOSIS ONLYADDITION TO LOWER EXTREMITY ORTHOSIS, EXTENSION, PER EXTENSION, PER BAR (FORLINEAL ADJUSTMENT FOR GROWTH)ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BARADDITION TO LOWER EXTREMITY ORTHOSIS, ANY MATERIAL - PER BAR OR JOINTADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PER BARADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACHADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAPADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERALPULL, FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLYADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PADADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOWKNEE SECTIONADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVEKNEE SECTIONADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTH SOCK, FRACTURE OR EQUAL,EACHADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORAL LENGTH SOCK, FRACTURE OR EQUAL,EACHADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSIONSTYLE MECHANISM, EACHLOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIEDFOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL,EACHFOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SPENCO, EACHFOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE OR EQUAL, EACHFOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SILICONE GEL, EACHFOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPPORT,EACHFOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/ METATARSALSUPPORT, EACHFOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACHFOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGHSTRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, EACHFOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, EACHFOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, METATARSAL, EACHFOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL/ METATARSAL, EACHFOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL, EACHFOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, METATARSAL, EACHFOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL/METATARSAL,EACHHALLUS-VALGUS NIGHT DYNAMIC SPLINTFOOT, ABDUCTION ROTATION BAR, INCLUDING SHOESFOOT, ABDUCTION ROTATATION BAR, WITHOUT SHOESFOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICEFOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, EACHORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, INFANTORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, CHILDORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIORORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANTORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, CHILDORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, JUNIORSURGICAL BOOT, EACH, INFANT

Query_110708

Page 282

SURGICAL BOOT, EACH, CHILDSURGICAL BOOT, EACH, JUNIORBENESCH BOOT, PAIR, INFANTBENESCH BOOT, PAIR, CHILDBENESCH BOOT, PAIR, JUNIORORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACHORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH INLAY, EACHORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACHORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACHORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACHORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACHORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE(ORTHOSIS)ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE(ORTHOSIS)ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH INLAY, EACHORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETIC SHOE,EACHFOOT, SHOE MOLDED TO PATIENT MODEL, SILICONE SHOE, EACHFOOT, SHOE MOLDED TO PATIENT MODEL, PLASTAZOTE (OR SIMILAR), CUSTOM FABRICATED,EACHFOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR) CUSTOM FITTED, EACHNON-STANDARD SIZE OR WIDTHNON-STANDARD SIZE OR LENGTHORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE FOR SPLIT SIZESURGICAL BOOT/SHOE, EACHPLASTAZOTE SANDAL, EACHLIFT, ELEVATION, HEEL, TAPERED TO METATARSALS, PER INCHLIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCHLIFT, ELEVATION, HEEL AND SOLE, CORK, PER INCHLIFT, ELEVATION, METAL EXTENSION (SKATE)LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCHLIFT, ELEVATION, HEEL, PER INCHHEEL WEDGE, SACHHEEL WEDGESOLE WEDGE, OUTSIDE SOLESOLE WEDGE, BETWEEN SOLECLUBFOOT WEDGEOUTFLARE WEDGEMETATARSAL BAR WEDGE, ROCKERMETATARSAL BAR WEDGE, BETWEEN SOLEFULL SOLE AND HEEL WEDGE, BETWEEN SOLEHEEL, COUNTER, PLASTIC REINFORCEDHEEL, COUNTER, LEATHER REINFORCEDHEEL, SACH CUSHION TYPEHEEL, NEW LEATHER, STANDARDHEEL, NEW RUBBER, STANDARDHEEL, THOMAS WITH WEDGEHEEL, THOMAS EXTENDED TO BALLHEEL, PAD AND DEPRESSION FOR SPURHEEL, PAD, REMOVABLE FOR SPURORTHOPEDIC SHOE ADDITION, INSOLE, LEATHERORTHOPEDIC SHOE ADDITION, INSOLE, RUBBERORTHOPEDIC SHOE ADDITION, INSOLE, FELT COVERED WITH LEATHERORTHOPEDIC SHOE ADDITION, SOLE, HALFORTHOPEDIC SHOE ADDITION, SOLE, FULLORTHOPEDIC SHOE ADDITION, TOE TAP STANDARDORTHOPEDIC SHOE ADDITION, TOE TAP, HORSESHOEORTHOPEDIC SHOE ADDITION, SPECIAL EXTENSION TO INSTEP (LEATHER WITH EYELETS)ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TO VELCRO CLOSUREORTHOPEDIC SHOE ADDITION, CONVERT FIRM SHOE COUNTER TO SOFT COUNTER

Query_110708

Page 283

ORTHOPEDIC SHOE ADDITION, MARCH BARTRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTINGTRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEWTRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, EXISTINGTRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, NEWTRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, DENNIS BROWNE SPLINT(RIVETON), BOTH SHOESORTHOPEDIC SHOE, MODIFICATION, ADDITION OR TRANSFER, NOT OTHERWISE SPECIFIEDSHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTSHOULDER ORTHOSIS, SINGLE SHOULDER, ELASTIC, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT (E.G. NEOPRENE, LYCRA)SHOULDER ORTHOSIS, DOUBLE SHOULDER, ELASTIC, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT (E.G. NEOPRENE, LYCRA)SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, CANVAS ANDWEBBING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ORTHOSIS, ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE), PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTSHOULDER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFTINTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENTAND SUPPORT BAR, WITHOUT JOINTS, MAY INLCUDE SOFT INTERFACE, STRAPS, CUSTOMFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENTAND SUPPORT BAR, INCLUDES NONTORSION JOINT/TURNBUCKLE, MAY INCLUDE SOFTINTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ORTHOSIS, VEST TYPE ABDUCTION RESTRAINER, CANVAS WEBBING TYPE OREQUAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ORTHOSIS, HARD PLASTIC, SHOULDER STABILIZER, PRE-FABRICATED, INCLUDESFITTING AND ADJUSTMENTELBOW ORTHOSIS, ELASTIC WITH STAYS, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTELBOW ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G.NEOPRENE, LYCRA)ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOMFABRICATED, INCLUDES FITTING AND ADJUSTMENTELBOW ORTHOSIS, ELASTIC WITH METAL JOINTS, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, FREE MOTION,CUSTOM-FABRICATEDELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ FLEXIONASSIST, CUSTOM-FABRICATEDELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE POSITION LOCKWITH ACTIVE CONTROL, CUSTOM-FABRICATEDELBOW ORTHOSIS, WITH ADJUSTABLE POSITION LOCKING JOINT(S), PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTS, ANY TYPEELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, INCLUDES SOFT INTERFACE MATERIAL,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTELBOW WRIST HAND ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE,STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTELBOW WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTICBANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED,INCLUDES FITTING AND ADJUSTMENTELBOW WRIST HAND FINGER ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFTINTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTELBOW WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS,ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOMFABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, SHORT OPPONENS, NO ATTACHMENTS, CUSTOM-FABRICATEDWRIST HAND FINGER ORTHOSIS, LONG OPPONENS, NO ATTACHMENT, CUSTOM-FABRICATEDWRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S),

Query_110708

Page 284

TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL,STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTS, ANY TYPEWRIST HAND FINGER ORTHOSIS, RIGID WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACEMATERIAL; STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTWHFO, ADDITION TO SHORT AND LONG OPPONENS, THUMB ABDUCTION ('C') BARWHFO, ADDITION TO SHORT AND LONG OPPONENS, SECOND M.P. ABDUCTION ASSISTWHFO, ADDITION TO SHORT AND LONG OPPONENS, I.P. EXTENSION ASSIST, WITH M.P.EXTENSION STOPWHFO, ADDITION TO SHORT AND LONG OPPONENS, M.P. EXTENSION STOPWHFO, ADDITION TO SHORT AND LONG OPPONENS, M.P. EXTENSION ASSISTWHFO, ADDITION TO SHORT AND LONG OPPONENS, M.P. SPRING EXTENSION ASSISTWHFO, ADDITION TO SHORT AND LONG OPPONENS, SPRING SWIVEL THUMBWHFO, ADDITION TO SHORT AND LONG OPPONENS, THUMB I.P. EXTENSION ASSIST, WITHM.P. STOPWHO, ADDITION TO SHORT AND LONG OPPONENS, ACTION WRIST, WITH DORSIFLEXION ASSISTWHFO, ADDITION TO SHORT AND LONG OPPONENS, ADJUSTABLE M.P. FLEXION CONTROLWHFO, ADDITION TO SHORT AND LONG OPPONENS, ADJUSTABLE M.P. FLEXION CONTROL ANDI.P.ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLETORSION STYLE MECHANISM, EACHWRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION, FINGER FLEXION/EXTENSION, WRIST OR FINGER DRIVEN, CUSTOM-FABRICATEDWRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION, FINGER FLEXION/EXTENSION, CABLE DRIVEN, CUSTOM-FABRICATEDWRIST HAND FINGER ORTHOSIS, EXTERNAL POWERED, COMPRESSED GAS, CUSTOM-FABRICATEDWRIST HAND FINGER ORTHOSIS, EXTERNAL POWERED, ELECTRIC, CUSTOM-FABRICATEDWRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS,TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDESFITTING AND ADJUSTMENTWRIST HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOMFABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, WRIST GAUNTLET WITH THUMB SPICA, CUSTOM-FABRICATEDWRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G.NEOPRENE, LYCRA)WRIST HAND FINGER ORTHOSIS, SWANSON DESIGN, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTWRIST HAND FINGER ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT (E.G. NEOPRENE, LYCRA)HAND FINGER ORTHOSIS, FLEXION GLOVE WITH ELASTIC FINGER CONTROL, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTHAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS,CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND ORTHOSIS, WRIST EXTENSION COCK-UP, PREFABRICATED, INCLUDESFITTING/ADJUSTMENTWRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS,TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, WRIST EXTENSION COCK-UP WITH OUTRIGGER,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTHAND ORTHOSIS, METACARPAL FRACTURE ORTHOSIS, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTHAND FINGER ORTHOSIS, KNUCKLE BENDER, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTHAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOMFABRICATED, INCLUDES FITTING AND ADJUSTMENTHAND FINGER ORTHOSIS, KNUCKLE BENDER WITH OUTRIGGER, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT

Query_110708

Page 285

HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS,TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDESFITTING AND ADJUSTMENTHAND FINGER ORTHOSIS, KNUCKLE BENDER, TWO SEGMENT TO FLEX JOINTS,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTHAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, OPPENHEIMER, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTFINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP),NON TORSION JOINT/SPRING, EXTENSION/FLEXION, MAY INCLUDE SOFT INTERFACEMATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, THOMAS SUSPENSION, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTFINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP),WITHOUT JOINT/SPRING, EXTENSION/FLEXION (E.G. STATIC OR RING TYPE), MAY INCLUDESOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTHAND FINGER ORTHOSIS, FINGER EXTENSION, WITH CLOCK SPRING, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTHAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES,ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, FINGER EXTENSION, WITH WRIST SUPPORT,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S),TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL,STRAPS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTFINGER ORTHOSIS, SAFETY PIN, SPRING WIRE, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTFINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED,INCLUDES FITTING AND ADJUSTMENTFINGER ORTHOSIS, SAFETY PIN, MODIFIED, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTFINGER ORTHOSIS, NONTORSION JOINT, MAY INCLUDE SOFT INTERFACE, CUSTOMFABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, PALMER, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTWRIST HAND FINGER ORTHOSIS, DORSAL WRIST, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTWRIST HAND FINGER ORTHOSIS, DORSAL WRIST, WITH OUTRIGGER ATTACHMENT,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTHAND FINGER ORTHOSIS, REVERSE KNUCKLE BENDER, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTHAND FINGER ORTHOSIS, REVERSE KNUCKLE BENDER, WITH OUTRIGGER, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENTHAND FINGER ORTHOSIS, COMPOSITE ELASTIC, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTFINGER ORTHOSIS, FINGER KNUCKLE BENDER, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTWRIST HAND FINGER ORTHOSIS, COMBINATION OPPENHEIMER, WITH KNUCKLE BENDER ANDTWO ATTACHMENTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTWRIST HAND FINGER ORTHOSIS, COMBINATION OPPENHEIMER, WITH REVERSE KNUCKLE ANDTWO ATTACHMENTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTHAND FINGER ORTHOSIS, SPREADING HAND, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTADDITION OF JOINT TO UPPER EXTREMITY ORTHOSIS, ANY MATERIAL; PER JOINTSHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, AIRPLANE DESIGN,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAYINCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING ANDADJUSTMENT

Query_110708

Page 286

SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, ERBS PALSEY DESIGN,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW WRIST HAND ORTHOSIS, MOLDED SHOULDER, ARM, FOREARM AND WRIST,WITH ARTICULATING ELBOW JOINT, CUSTOM-FABRICATEDSHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,ADJUSTABLE RANCHO TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,RECLINING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN),THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE,STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,FRICTION ARM SUPPORT (FRICTION DAMPENING TO PROXIMAL AND DISTAL JOINTS),PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT, MONOSUSPENSION ARM AND HANDSUPPORT, OVERHEAD ELBOW FOREARM HAND SLING SUPPORT, YOKE TYPE SUSPENSIONSUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSEO, ADDITION TO MOBILE ARM SUPPORT, ELEVATING PROXIMAL ARMSHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORENONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE,STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTSEO, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL ROCKER ARM WITH ELASTICBALANCE CONTROLSHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN),THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION JOINTS,ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOMFABRICATED, INCLUDES FITTING AND ADJUSTMENTSEO, ADDITION TO MOBILE ARM SUPPORT, SUPINATORSHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS,MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING ANDADJUSTMENTSHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANEDESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFTINTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE ORMORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE,STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANEDESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSIONJOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOMFABRICATED, INCLUDES FITTING AND ADJUSTMENTUPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTUPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS/ULNAR, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTUPPER EXTREMITY FRACTURE ORTHOSIS, WRIST, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTUPPER EXTREMITY FRACTURE ORTHOSIS, FOREARM, HAND WITH WRIST HINGE,CUSTOM-FABRICATEDUPPER EXTREMITY FRACTURE ORTHOSIS, COMBINATION OF HUMERAL, RADIUS/ULNAR, WRIST,(EXAMPLE--COLLES' FRACTURE), CUSTOM FABRICATEDADDITION TO UPPER EXTREMITY ORTHOSIS, SOCK, FRACTURE OR EQUAL, EACHUPPER LIMB ORTHOSIS, NOT OTHERWISE SPECIFIEDREPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLSO OR SO)REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPEREPLACE TRILATERAL SOCKET BRIMREPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MODELREPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTEDREPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

Query_110708

Page 287

REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLYREPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLYREPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLYREPLACE HIGH ROLL CUFFREPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFOREPLACE METAL BANDS KAFO, PROXIMAL THIGHREPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGHREPLACE LEATHER CUFF KAFO, PROXIMAL THIGHREPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGHREPLACE PRETIBIAL SHELLREPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTESREPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTSANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE(E.G., PNEUMATIC, GEL), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTWALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUTINTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTPNEUMATIC FULL LEG SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTPNEUMATIC KNEE SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTWALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACEMATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTREPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFOREPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINTSTATIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FORFIT, FOR POSITIONING, PRESSURE REDUCTION, MAY BE USED FOR MINIMAL AMBULATION,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTFOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTPARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLERPARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLERPARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT, WITH TOE FILLERANKLE, SYMES, MOLDED SOCKET, SACH FOOTANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET, ARTICULATED ANKLE/FOOTBELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOTBELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOTKNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS,SHIN, SACH FOOTKNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE CONFIGURATION,EXTERNAL KNEE JOINTS, SHIN, SACH FOOTABOVE KNEE, MOLDED SOCKET, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOTABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH FOOT BLOCKS, NOANKLE JOINTS, EACHABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH ARTICULATEDANKLE/FOOT, DYNAMICALLY ALIGNED, EACHABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT FRICTION KNEE,SHIN, SACH FOOTHIP DISARTICULATION, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXISCONSTANT FRICTION KNEE, SHIN, SACH FOOTHIP DISARTICULATION, TILT TABLE TYPE; MOLDED SOCKET, LOCKING HIP JOINT, SINGLEAXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOTHEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANTFRICTION KNEE, SHIN, SACH FOOTBELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEMKNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS,SHIN, SACH FOOT, ENDOSKELETAL SYSTEMABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLEAXIS KNEEHIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIPJOINT, SINGLE AXIS KNEE, SACH FOOTHEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT,SINGLE AXIS KNEE, SACH FOOTIMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID

Query_110708

Page 288

DRESSING, INCLUDING FITTING, ALIGNMENT, SUSPENSION, AND ONE CAST CHANGE, BELOWKNEEIMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGIDDRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION, BELOW KNEE, EACHADDITIONAL CAST CHANGE AND REALIGNMENTIMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGIDDRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION AND ONE CAST CHANGE 'AK'OR KNEE DISARTICULATIONIMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGIDDRESSING, INCL. FITTING, ALIGNMENT AND SUPENSION, 'AK' OR KNEE DISARTICULATION,EACH ADDITIONAL CAST CHANGE AND REALIGNMENTIMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARINGRIGID DRESSING, BELOW KNEEIMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARINGRIGID DRESSING, ABOVE KNEEINITIAL, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER,SACH FOOT, PLASTER SOCKET, DIRECT FORMEDINITIAL, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLESYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMEDPREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NOCOVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODELPREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NOCOVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMEDPREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NOCOVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODELPREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, NO COVER, SACHFOOT, PREFABRICATED, ADJUSTABLE OPEN END SOCKETPREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NOCOVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODELPREPARATORY, ABOVE KNEE- KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET,NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TOMODELPREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET,NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL,DIRECT FORMEDPREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET,NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL,MOLDED TO MODELPREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET,NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PREFABRICATED ADJUSTABLE OPENEND SOCKETPREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET,NON-ALIGNABLE SYSTEM, PYLON NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TOMODELPREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT,THERMOPLASTIC OR EQUAL, MOLDED TO PATIENT MODELPREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT,LAMINATED SOCKET, MOLDED TO PATIENT MODELADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, HYDRACADENCESYSTEMADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE - KNEEDISARTICULATION, 4 BAR LINKAGE, WITH FRICTION SWING PHASE CONTROLADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE-KNEEDISARTICULATION, 4 BAR LINKAGE, WITH HYDRAULIC SWING PHASE CONTROLADDITION TO LOWER EXTREMITY, EXOSKELETAL SYSTEM, ABOVE KNEE-KNEEDISARTICULATION, 4 BAR LINKAGE, WITH PNEUMATIC SWING PHASE CONTROLADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, UNIVERSALMULTIPLEX SYSTEM, FRICTION SWING PHASE CONTROLADDITION TO LOWER EXTREMITY, QUICK CHANGE SELF-ALIGNING UNIT, ABOVE KNEE ORBELOW KNEE, EACHADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES

Query_110708

Page 289

ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEEADDITION TO LOWER EXTREMITY, TEST SOCKET, KNEE DISARTICULATIONADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEEADDITION TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTICULATIONADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTOMYADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKETADDITION TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WALL SOCKETADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, ACRYLIC SOCKETADDITION TO LOWER EXTREMITY, SYMES TYPE, 'PTB' BRIM DESIGN SOCKETADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING (CANADIAN) SOCKETADDITION TO LOWER EXTREMITY, SYMES TYPE, MEDIAL OPENING SOCKETADDITION TO LOWER EXTREMITY, BELOW KNEE, TOTAL CONTACTADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKETADDITION TO LOWER EXTREMITY, BELOW KNEE, WOOD SOCKETADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, LEATHER SOCKETADDITION TO LOWER EXTREMITY, ABOVE KNEE, LEATHER SOCKETADDITION TO LOWER EXTREMITY, HIP DISARTICULATION, FLEXIBLE INNER SOCKET,EXTERNAL FRAMEADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKETADDITION TO LOWER EXTREMITY, BELOW KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAMEADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR, FLUID, GEL OR EQUAL, CUSHIONSOCKETADDITION TO LOWER EXTREMITY, BELOW KNEE SUCTION SOCKETADDITION TO LOWER EXTREMITY, ABOVE KNEE, AIR, FLUID, GEL OR EQUAL, CUSHIONSOCKETADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKETADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE OR KNEE DISARTICULATIONSOCKETADDITION TO LOWER EXTREMITY, ABOVE KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAMEADDITION TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE KNEE OR KNEEDISARTICULATION SOCKETADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, EXPANDABLE WALL SOCKETADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES, (KEMBLO, PELITE, ALIPLAST,PLASTAZOTE OR EQUAL)ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE (KEMBLO, PELITE,ALIPLAST, PLASTAZOTE OR EQUAL)ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION (KEMBLO,PELITE, ALIPLAST, PLASTAZOTE OR EQUAL)ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE (KEMBLO, PELITE,ALIPLAST, PLASTAZOTE OR EQUAL)ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER SYMESADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER, BELOW KNEEADDITION TO LOWER EXTREMITY, BELOW KNEE, CUFF SUSPENSIONADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL CUSHIONADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED SUPRACONDYLAR SUSPENSION('PTS' OR SIMILAR)ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE SUSPENSION LOCKINGMECHANISM (SHUTTLE, LANYARD OR EQUAL), EXCLUDES SOCKET INSERTADDITION TO LOWER EXTREMITY, BELOW KNEE, REMOVABLE MEDIAL BRIM SUSPENSIONADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROMEXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OREQUAL, FOR USE WITH LOCKING MECHANISMADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, SINGLE AXIS, PAIRADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, POLYCENTRIC, PAIRADDITIONS TO LOWER EXTREMITY, BELOW KNEE, JOINT COVERS, PAIRADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROMEXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OREQUAL, NOT FOR USE WITH LOCKING MECHANISMADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, NONMOLDEDADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKETINSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC

Query_110708

Page 290

OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHERTHAN INITIAL, USE CODE L5673 OR L5679)ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, GLUTEAL/ISCHIAL, MOLDEDADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKETINSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL,ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY(FOR OTHER THAN INITIAL, USE CODE L5673 OR L5679)ADDITION TO LOWER EXTREMITY, BELOW KNEE, FORK STRAPADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, SUSPENSION/SEALING SLEEVE,WITH OR WITHOUT VALVE, ANY MATERIAL, EACHADDITION TO LOWER EXTREMITY, BELOW KNEE, BACK CHECK (EXTENSION CONTROL)ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, WEBBINGADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, PADDED AND LINEDADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, LIGHTADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, PADDED AND LINEDADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL, SLEEVE SUSPENSION,NEOPRENE OR EQUAL, EACHADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC JOINTADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC BANDADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, SILESIANBANDAGEALL LOWER EXTREMITY PROSTHESES, SHOULDER HARNESSREPLACEMENT, SOCKET, BELOW KNEE, MOLDED TO PATIENT MODELREPLACEMENT, SOCKET, ABOVE KNEE/KNEE DISARTICULATION, INCLUDING ATTACHMENTPLATE, MOLDED TO PATIENT MODELREPLACEMENT, SOCKET, HIP DISARTICULATION, INCLUDING HIP JOINT, MOLDED TOPATIENT MODELANKLE, SYMES, MOLDED TO PATIENT MODEL, SOCKET WITHOUT SOLID ANKLE CUSHION HEEL(SACH) FOOT, REPLACEMENT ONLYCUSTOM SHAPED PROTECTIVE COVER, BELOW KNEECUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEECUSTOM SHAPED PROTECTIVE COVER, KNEE DISARTICULATIONCUSTOM SHAPED PROTECTIVE COVER, HIP DISARTICULATIONADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCKADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHTMATERIALADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCEPHASE CONTROL (SAFETY KNEE)ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRICTION SWINGPHASE CONTROLADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASELOCKADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING ANDSTANCE PHASE CONTROLADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTIONSTANCE PHASE CONTROLADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROLADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FLUIDSWING PHASE CONTROLADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCEPHASE CONTROLADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATICSWING PHASE CONTROLADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENTAND MOISTURE EVACUATION SYSTEMADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENTAND MOISTURE EVACUATION SYSTEM, HEAVY DUTYADDITION, EXOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM,CARBON FIBER OR EQUAL)ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM,CARBON FIBER OR EQUAL)

Query_110708

Page 291

ADDITION, EXOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL(TITANIUM, CARBON FIBER OR EQUAL)ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCKADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHTMATERIALADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCEPHASE CONTROL (SAFETY KNEE)ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, HYDRAULIC SWING PHASECONTROL, MECHANICAL STANCE PHASE LOCKADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASELOCKADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING, ANDSTANCE PHASE CONTROLADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTIONSTANCE PHASE CONTROLADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROLADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PHASECONTROL, WITH MINIATURE HIGH ACTIVITY FRAMEADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCEPHASE CONTROLADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/ SWING PHASECONTROLADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, 4-BAR LINKAGE OR MULTIAXIAL, PNEUMATICSWING PHASE CONTROLADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUSTABLEADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENINGFEATURE, WITH OR WITHOUT ADJUSTABILITYADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, KNEEEXTENSION ASSISTADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MECHANICAL HIP EXTENSIONASSISTADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM,MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONICSENSOR(S), ANY TYPEADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM,MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONICSENSOR(S), ANY TYPEADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM,MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONICSENSOR(S), ANY TYPEADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ALIGNABLE SYSTEMADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, ALIGNABLESYSTEMADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIPDISARTICULATION, MANUAL LOCKADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAMEADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM,CARBON FIBER OR EQUAL)ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM,CARBON FIBER OR EQUAL)ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL(TITANIUM, CARBON FIBER OR EQUAL)ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, FLEXIBLE PROTECTIVE OUTER SURFACECOVERING SYSTEMADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, FLEXIBLE PROTECTIVE OUTER SURFACECOVERING SYSTEMADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLEXIBLE PROTECTIVE OUTERSURFACE COVERING SYSTEMADDITION TO LOWER LIMB PROSTHESIS, MULTIAXIAL ANKLE WITH SWING PHASE ACTIVEDORSIFLEXION FEATUREALL LOWER EXTREMITY PROSTHESES, FOOT, EXTERNAL KEEL, SACH FOOT

Query_110708

Page 292

ALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL (SACH) FOOT,REPLACEMENT ONLYALL LOWER EXTREMITY PROSTHESES, FLEXIBLE KEEL FOOT (SAFE, STEN, BOCK DYNAMIC OREQUAL)ALL LOWER EXTREMITY PROSTHESES, FOOT, SINGLE AXIS ANKLE/FOOTALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS ANKLE AND FLEXIBLE KEELFOOTALL LOWER EXTREMITY PROSTHESES, ENERGY STORING FOOT (SEATTLE CARBON COPY II OREQUAL)ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL ANKLE/FOOTALL LOWER EXTREMITY PROSTHESIS, MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT, ONEPIECE SYSTEMALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEMALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQUALALL EXOSKELETAL LOWER EXTREMITY PROSTHESES, AXIAL ROTATION UNITALL ENDOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT, WITH ORWITHOUT ADJUSTABILITYALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES, DYNAMIC PROSTHETIC PYLONALL LOWER EXTREMITY PROSTHESES, MULTI-AXIAL ROTATION UNIT ('MCP' OR EQUAL)ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLONADDITION TO LOWER LIMB PROSTHESIS, VERTICAL SHOCK REDUCING PYLON FEATUREADDITION TO LOWER EXTREMITY PROSTHESIS, USER ADJUSTABLE HEEL HEIGHTADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, FOOT ONLY, (FORPATIENT WEIGHT GREATER THAN 300 LBS)ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, KNEE ONLY, (FORPATIENT WEIGHT GREATER THAN 300 LBS)ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, OTHER THAN FOOT ORKNEE, (FOR PATIENT WEIGHT GREATER THAN 300 LBS)LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIEDPARTIAL HAND, ROBIN-AIDS, THUMB REMAINING (OR EQUAL)PARTIAL HAND, ROBIN-AIDS, LITTLE AND/OR RING FINGER REMAINING (OR EQUAL)PARTIAL HAND, ROBIN-AIDS, NO FINGER REMAINING (OR EQUAL)TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION PROSTHESIS, EXTERNALPOWER, SELF-SUSPENDED, INNER SOCKET WITH REMOVABLE FOREARM SECTION, ELECTRODESAND CABLES, TWO BATTERIES, CHARGER, MYOELECTRIC CONTROL OF TERMINAL DEVICEWRIST DISARTICULATION, MOLDED SOCKET, FLEXIBLE ELBOW HINGES, TRICEPS PADWRIST DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, FLEXIBLE ELBOWHINGES, TRICEPS PADBELOW ELBOW, MOLDED SOCKET, FLEXIBLE ELBOW HINGE, TRICEPS PADBELOW ELBOW, MOLDED SOCKET, (MUENSTER OR NORTHWESTERN SUSPENSION TYPES)BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STEP-UP HINGES, HALF CUFFBELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STUMP ACTIVATED LOCKING HINGE,HALF CUFFELBOW DISARTICULATION, MOLDED SOCKET, OUTSIDE LOCKING HINGE, FOREARMELBOW DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, OUTSIDE LOCKINGHINGES, FOREARMABOVE ELBOW, MOLDED DOUBLE WALL SOCKET, INTERNAL LOCKING ELBOW, FOREARMSHOULDER DISARTICULATION, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION,INTERNAL LOCKING ELBOW, FOREARMSHOULDER DISARTICULATION, PASSIVE RESTORATION (COMPLETE PROSTHESIS)SHOULDER DISARTICULATION, PASSIVE RESTORATION (SHOULDER CAP ONLY)INTERSCAPULAR THORACIC, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION,INTERNAL LOCKING ELBOW, FOREARMINTERSCAPULAR THORACIC, PASSIVE RESTORATION (COMPLETE PROSTHESIS)INTERSCAPULAR THORACIC, PASSIVE RESTORATION (SHOULDER CAP ONLY)IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGIDDRESSING, INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONECAST CHANGE, WRIST DISARTICULATION OR BELOW ELBOWIMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSINGINCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE,ELBOW DISARTICULATION OR ABOVE ELBOW

Query_110708

Page 293

IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSINGINCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE,SHOULDER DISARTICULATION OR INTERSCAPULAR THORACICIMMEDIATE POST SURGICAL OR EARLY FITTING, EACH ADDITIONAL CAST CHANGE ANDREALIGNMENTIMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF RIGID DRESSING ONLYBELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETICTISSUE SHAPINGELBOW DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFTPROSTHETIC TISSUE SHAPINGABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETICTISSUE SHAPINGSHOULDER DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFTPROSTHETIC TISSUE SHAPINGINTERSCAPULAR THORACIC, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFTPROSTHETIC TISSUE SHAPINGPREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL PLASTIC SOCKET,FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF,BOWDEN CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODELPREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL SOCKET, FRICTIONWRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDENCABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMEDPREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL PLASTIC SOCKET,FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLECONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODELPREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL SOCKET, FRICTIONWRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OREQUAL PYLON, NO COVER, DIRECT FORMEDPREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALLPLASTIC SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP,FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODELPREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALLSOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEADCABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMEDUPPER EXTREMITY ADDITIONS, POLYCENTRIC HINGE, PAIRUPPER EXTREMITY ADDITIONS, SINGLE PIVOT HINGE, PAIRUPPER EXTREMITY ADDITIONS, FLEXIBLE METAL HINGE, PAIRADDITION TO UPPER EXTREMITY PROSTHESIS, EXTERNAL POWERED, ADDITIONAL SWITCH,ANY TYPEUPPER EXTREMITY ADDITION, DISCONNECT LOCKING WRIST UNITUPPER EXTREMITY ADDITION, ADDITIONAL DISCONNECT INSERT FOR LOCKING WRIST UNIT,EACHUPPER EXTREMITY ADDITION, FLEXION/EXTENSION WRIST UNIT, WITH OR WITHOUTFRICTIONUPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH OR WITHOUTFRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICEUPPER EXTREMITY ADDITION, SPRING ASSISTED ROTATIONAL WRIST UNIT WITH LATCHRELEASEUPPER EXTREMITY ADDITION, FLEXION/EXTENSION AND ROTATION WRIST UNITUPPER EXTREMITY ADDITION, ROTATION WRIST UNIT WITH CABLE LOCKUPPER EXTREMITY ADDITION, QUICK DISCONNECT HOOK ADAPTER, OTTO BOCK OR EQUALUPPER EXTREMITY ADDITION, QUICK DISCONNECT LAMINATION COLLAR WITH COUPLINGPIECE, OTTO BOCK OR EQUALUPPER EXTREMITY ADDITION, STAINLESS STEEL, ANY WRISTUPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE, EACHUPPER EXTREMITY ADDITION, LIFT ASSIST FOR ELBOWUPPER EXTREMITY ADDITION, NUDGE CONTROL ELBOW LOCKUPPER EXTREMITY ADDITION TO PROSTHESIS, ELECTRIC LOCKING FEATURE, ONLY FOR USEWITH MANUALLY POWERED ELBOWUPPER EXTREMITY ADDITION, HEAVY DUTY FEATURE, ANY ELBOWUPPER EXTREMITY ADDITIONS, SHOULDER ABDUCTION JOINT, PAIR

Query_110708

Page 294

UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, PULLEY TYPEUPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, LEVER TYPEUPPER EXTREMITY ADDITION, SHOULDER FLEXION-ABDUCTION JOINT, EACHUPPER EXTREMITY ADDITION, SHOULDER JOINT, MULTIPOSITIONAL LOCKING, FLEXION,ADJUSTABLE ABDUCTION FRICTION CONTROL, FOR USE WITH BODY POWERED OR EXTERNALPOWERED SYSTEMUPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, BODY POWERED ACTUATORUPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, EXTERNAL POWERED ACTUATORUPPER EXTREMITY ADDITION, SHOULDER UNIVERSAL JOINT, EACHUPPER EXTREMITY ADDITION, STANDARD CONTROL CABLE, EXTRAUPPER EXTREMITY ADDITION, HEAVY DUTY CONTROL CABLEUPPER EXTREMITY ADDITION, TEFLON, OR EQUAL, CABLE LININGUPPER EXTREMITY ADDITION, HOOK TO HAND, CABLE ADAPTERUPPER EXTREMITY ADDITION, HARNESS, CHEST OR SHOULDER, SADDLE TYPEUPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), SINGLE CABLEDESIGNUPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), DUAL CABLEDESIGNUPPER EXTREMITY ADDITION, HARNESS, TRIPLE CONTROL, SIMULTANEOUS OPERATION OFTERMINAL DEVICE AND ELBOWUPPER EXTREMITY ADDITION, TEST SOCKET, WRIST DISARTICULATION OR BELOW ELBOWUPPER EXTREMITY ADDITION, TEST SOCKET, ELBOW DISARTICULATION OR ABOVE ELBOWUPPER EXTREMITY ADDITION, TEST SOCKET, SHOULDER DISARTICULATION ORINTERSCAPULAR THORACICUPPER EXTREMITY ADDITION, SUCTION SOCKETUPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, BELOW ELBOW OR WRISTDISARTICULATIONUPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, ABOVE ELBOW OR ELBOWDISARTICULATIONUPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, SHOULDER DISARTICULATIONUPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, INTERSCAPULAR-THORACICUPPER EXTREMITY ADDITION, REMOVABLE INSERT, EACHUPPER EXTREMITY ADDITION, SILICONE GEL INSERT OR EQUAL, EACHUPPER EXTREMITY ADDITION, LOCKING ELBOW, FOREARM COUNTERBALANCEADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOMFABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL,ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISMADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOMFABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL,ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISMADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOMFABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONEGEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIALONLY (FOR OTHER THAN INITIAL, USE CODE L6694 OR L6695)ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOMFABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATICAMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKINGMECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L6694 OR L6695)ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, LOCKMECHANISM, EXCLUDES SOCKET INSERTTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #3TERMINAL DEVICE, PASSIVE HAND/MITT, ANY MATERIAL, ANY SIZETERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY MATERIAL, ANY SIZETERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #5TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,LINED OR UNLINEDTERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,LINED OR UNLINEDTERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZETERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZETERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #5X

Query_110708

Page 295

TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,LINED OR UNLINED, PEDIATRICTERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,LINED OR UNLINED, PEDIATRICTERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,PEDIATRICTERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,PEDIATRICTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #5XATERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #6TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANYMATERIAL, ANY SIZE, LINED OR UNLINEDTERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANYMATERIAL, ANY SIZE, LINED OR UNLINEDTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #7TERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #7LOTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #8TERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #8XTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #88XTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #10PTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #10XTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #12PTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #99XTERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #555TERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #SS555TERMINAL DEVICE, HOOK-ACCU HOOK, OR EQUALTERMINAL DEVICE, HOOK-2 LOAD, OR EQUALTERMINAL DEVICE, HOOK-APRL VC, OR EQUALADDITION TO TERMINAL DEVICE, MODIFIER WRIST UNITTERMINAL DEVICE, HOOK, TRS GRIP, GRIP III, VC, OR EQUALTERMINAL DEVICE, HOOK, GRIP I, GRIP II, VC, OR EQUALTERMINAL DEVICE, HOOK, TRS ADEPT, INFANT OR CHILD, VC, OR EQUALTERMINAL DEVICE, HOOK, TRS SUPER SPORT, PASSIVEADDITION TO TERMINAL DEVICE, PRECISION PINCH DEVICETERMINAL DEVICE, HAND, DORRANCE, VOTERMINAL DEVICE, HAND, APRL, VCTERMINAL DEVICE, HAND, SIERRA, VOTERMINAL DEVICE, HAND, BECKER IMPERIALTERMINAL DEVICE, HAND, BECKER LOCK GRIPTERMINAL DEVICE, HAND, BECKER PLYLITETERMINAL DEVICE, HAND, ROBIN-AIDS, VOTERMINAL DEVICE, HAND, ROBIN-AIDS, VO SOFTTERMINAL DEVICE, HAND, PASSIVE HANDTERMINAL DEVICE, HAND, DETROIT INFANT HAND (MECHANICAL)TERMINAL DEVICE, HAND, PASSIVE INFANT HAND, (STEEPER, HOSMER OR EQUAL)TERMINAL DEVICE, HAND, CHILD MITTTERMINAL DEVICE, HAND, NYU CHILD HANDTERMINAL DEVICE, HAND, MECHANICAL INFANT HAND, STEEPER OR EQUALTERMINAL DEVICE, HAND, BOCK, VCTERMINAL DEVICE, HAND, BOCK, VOAUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB ELECTRIC PROSTHETIC TERMINALDEVICEMICROPROCESSOR CONTROL FEATURE, ADDITION TO UPPER LIMB PROSTHETIC TERMINALDEVICEREPLACEMENT SOCKET, BELOW ELBOW/WRIST DISARTICULATION, MOLDED TO PATIENT MODEL,FOR USE WITH OR WITHOUT EXTERNAL POWERREPLACEMENT SOCKET, ABOVE ELBOW/ELBOW DISARTICULATION, MOLDED TO PATIENT MODEL,FOR USE WITH OR WITHOUT EXTERNAL POWERREPLACEMENT SOCKET, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, MOLDED TOPATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWERADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY

Query_110708

Page 296

MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANYMATERIAL, CUSTOM FABRICATEDHAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITHGLOVE, THUMB OR ONE FINGER REMAININGHAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITHGLOVE, MULTIPLE FINGERS REMAININGHAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITHGLOVE, NO FINGERS REMAININGHAND RESTORATION (SHADING, AND MEASUREMENTS INCLUDED), REPLACEMENT GLOVE FORABOVEWRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLEFOREARM SHELL, OTTO BOCK OR EQUAL, SWITCH, CABLES, TWO BATTERIES AND ONECHARGER, SWITCH CONTROL OF TERMINAL DEVICEWRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLEFOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONECHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICEBELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARMSHELL, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCHCONTROL OF TERMINAL DEVICEBELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARMSHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER,MYOELECTRONIC CONTROL OF TERMINAL DEVICEELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERALSHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWOBATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICEELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERALSHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES,TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICEABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL,INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWOBATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICEABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL,INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWOBATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICESHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLESHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM,OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCHCONTROL OF TERMINAL DEVICESHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLESHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM,OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER,MYOELECTRONIC CONTROL OF TERMINAL DEVICEINTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDERSHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCKOR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OFTERMINAL DEVICEINTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDERSHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCKOR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONICCONTROL OF TERMINAL DEVICEELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULTELECTRIC HAND, SWITCH OR MYOELECTRIC, CONTROLLED, PEDIATRICELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULTELECTRONIC HAND, OTTO BOCK, STEEPER OR EQUAL, SWITCH CONTROLLEDELECTRONIC HAND, SYSTEM TEKNIK, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLEDELECTRONIC GREIFER, OTTO BOCK OR EQUAL, SWITCH CONTROLLEDELECTRONIC HAND, OTTO BOCK OR EQUAL, MYOELECTRONICALLY CONTROLLEDELECTRONIC HAND, SYSTEM TEKNIK, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLYCONTROLLEDELECTRONIC GREIFER, OTTO BOCK OR EQUAL, MYOELECTRONICALLY CONTROLLED

Query_110708

Page 297

PREHENSILE ACTUATOR, SWITCH CONTROLLEDELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, PEDIATRICELECTRONIC ELBOW, HOSMER OR EQUAL, SWITCH CONTROLLEDELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICEELECTRONIC ELBOW, MICROPROCESSOR SIMULTANEOUS CONTROL OF ELBOW AND TERMINALDEVICEELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLEDELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLEDELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLYCONTROLLEDELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLEDELECTRONIC WRIST ROTATOR, OTTO BOCK OR EQUALELECTRONIC WRIST ROTATOR, FOR UTAH ARMSERVO CONTROL, STEEPER OR EQUALANALOGUE CONTROL, UNB OR EQUALPROPORTIONAL CONTROL, 6-12 VOLT, LIBERTY, UTAH OR EQUALSIX VOLT BATTERY, EACHBATTERY CHARGER, SIX VOLT, EACHTWELVE VOLT BATTERY, EACHBATTERY CHARGER, TWELVE VOLT, EACHLITHIUM ION BATTERY, REPLACEMENTLITHIUM ION BATTERY CHARGERADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION,ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ULTRALIGHTMATERIAL (TITANIUM, CARBON FIBER OR EQUAL)ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULARTHORACIC, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION,ACRYLIC MATERIALADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ACRYLICMATERIALADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULARTHORACIC, ACRYLIC MATERIALUPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIEDREPAIR OF PROSTHETIC DEVICE, HOURLY RATE (EXCLUDES V5335 REPAIR OF ORAL ORLARYNGEAL PROSTHESIS OR ARTIFICIAL LARYNX)REPAIR OF PROSTHETIC DEVICE, REPAIR OR REPLACE MINOR PARTSREPAIR PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTESPROSTHETIC DONNING SLEEVE, ANY MATERIAL, EACHTERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,LINED OR UNLINED, PEDIATRICTERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,LINED OR UNLINED, PEDIATRICTERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,PEDIATRICTERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,PEDIATRICTERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANYMATERIAL, ANY SIZE, LINED OR UNLINEDTERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANYMATERIAL, ANY SIZE, LINED OR UNLINEDMALE VACUUM ERECTION SYSTEMBREAST PROSTHESIS, MASTECTOMY BRABREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM,UNILATERALBREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM,BILATERALBREAST PROSTHESIS, MASTECTOMY SLEEVEEXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY FORM, POST MASTECTOMYBREAST PROSTHESIS, MASTECTOMY FORM

Query_110708

Page 298

BREAST PROSTHESIS, SILICONE OR EQUALCUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO PATIENT MODELBREAST PROSTHESIS, NOT OTHERWISE SPECIFIEDNASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIANMIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIANORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIANUPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIANHEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIANAURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIANPARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIANNASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIANUNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT, PROVIDED BY A NON-PHYSICIANREPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR COMPONENT, 15 MINUTEINCREMENTS, PROVIDED BY A NON-PHYSICIANGRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACHGRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACHGRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACHGRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACHGRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACHGRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACHGRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACHGRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACHGRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40-50 MMHG, EACHGRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, EACHGRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, EACHGRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40-50 MMHG, EACHGRADIENT COMPRESSION STOCKING, CUSTOM MADEGRADIENT COMPRESSION STOCKING, LYMPHEDEMAGRADIENT COMPRESSION STOCKING, GARTER BELTGRADIENT COMPRESSION STOCKING, NOT OTHERWISE SPECIFIEDTRUSS, SINGLE WITH STANDARD PADTRUSS, DOUBLE WITH STANDARD PADSTRUSS, ADDITION TO STANDARD PAD, WATER PADTRUSS, ADDITION TO STANDARD PAD, SCROTAL PADPROSTHETIC SHEATH, BELOW KNEE, EACHPROSTHETIC SHEATH, ABOVE KNEE, EACHPROSTHETIC SHEATH, UPPER LIMB, EACHPROSTHETIC SHEATH/SOCK, INCLUDING A GEL CUSHION LAYER, BELOW KNEE OR ABOVEKNEE, EACHPROSTHETIC SOCK, MULTIPLE PLY, BELOW KNEE, EACHPROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNEE, EACHPROSTHETIC SOCK, MULTIPLE PLY, UPPER LIMB, EACHPROSTHETIC SHRINKER, BELOW KNEE, EACHPROSTHETIC SHRINKER, ABOVE KNEE, EACHPROSTHETIC SHRINKER, UPPER LIMB, EACHPROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW KNEE, EACHPROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVE KNEE, EACHPROSTHETIC SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACHUNLISTED PROCEDURE FOR MISCELLANEOUS PROSTHETIC SERVICESARTIFICIAL LARYNX, ANY TYPETRACHEOSTOMY SPEAKING VALVEARTIFICIAL LARYNX REPLACEMENT BATTERY / ACCESSORY, ANY TYPETRACHEO-ESOPHAGEAL VOICE PROSTHESIS, PATIENT INSERTED, ANY TYPE, EACHTRACHEO-ESOPHAGEAL VOICE PROSTHESIS, INSERTED BY A LICENSED HEALTH CAREPROVIDER, ANY TYPEVOICE AMPLIFIERINSERT FOR INDWELLING TRACHEOESOPHAGEAL PROSTHESIS, WITH OR WITHOUT VALVE,REPLACEMENT ONLY, EACHGELATIN CAPSULES OR EQUIVALENT, FOR USE WITH TRACHEOESOPHAGEAL VOICEPROSTHESIS, REPLACEMENT ONLY, PER 10CLEANING DEVICE USED WITH TRACHEOESOPHAGEAL VOICE PROSTHESIS, PIPET, BRUSH, OR

Query_110708

Page 299

EQUAL, REPLACEMENT ONLY, EACHTRACHEOESOPHAGEAL PUNCTURE DILATOR, REPLACEMENT ONLY, EACHGELATIN CAPSULE, APPLICATION DEVICE FOR USE WITH TRACHEOESOPHAGEAL VOICEPROSTHESIS, EACHIMPLANTABLE BREAST PROSTHESIS, SILICONE OR EQUALINJECTABLE BULKING AGENT, COLLAGEN IMPLANT, URINARY TRACT, 2.5 ML SYRINGE,INCLUDES SHIPPING AND NECESSARY SUPPLIESINJECTABLE BULKING AGENT, DEXTRANOMER/HYALURONIC ACID COPOLYMER IMPLANT,URINARY TRACT, 1 ML, INCLUDES SHIPPING AND NECESSARY SUPPLIESINJECTABLE BULKING AGENT, SYNTHETIC IMPLANT, URINARY TRACT, 1 ML SYRINGE,INCLUDES SHIPPING AND NECESSARY SUPPLIESARTIFICIAL CORNEAOCULAR IMPLANTAQUEOUS SHUNTOSSICULA IMPLANTCOCHLEAR DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTSHEADSET/HEADPIECE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENTMICROPHONE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENTTRANSMITTING COIL FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENTTRANSMITTER CABLE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENTCOCHLEAR IMPLANT EXTERNAL SPEECH PROCESSOR, REPLACEMENTLITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT, EACHZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT, EACHALKALINE BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, ANY SIZE, REPLACEMENT,EACHLITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR,OTHER THAN EAR LEVEL, REPLACEMENT, EACHLITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, EARLEVEL, REPLACEMENT, EACHMETACARPOPHALANGEAL JOINT IMPLANTMETACARPAL PHALANGEAL JOINT REPLACEMENT, TWO OR MORE PIECES, METAL (E.G.,STAINLESS STEEL OR COBALT CHROME), CERAMIC-LIKE MATERIAL (E.G., PYROCARBON),FOR SURGICAL IMPLANTATION (ALL SIZES, INCLUDES ENTIRE SYSTEM)METATARSAL JOINT IMPLANTHALLUX IMPLANTINTERPHALANGEAL JOINT SPACER, SILICONE OR EQUAL, EACHINTERPHALANGEAL FINGER JOINT REPLACEMENT, 2 OR MORE PIECES, METAL (E.G.,STAINLESS STEEL OR COBALT CHROME), CERAMIC-LIKE MATERIAL (E.G., PYROCARBON) FORSURGICAL IMPLANTATION, ANY SIZEVASCULAR GRAFT MATERIAL, SYNTHETIC, IMPLANTIMPLANTABLE NEUROSTIMULATOR ELECTRODE, EACHPATIENT PROGRAMMER (EXTERNAL) FOR USE WITH IMPLANTABLE PROGRAMMABLENEUROSTIMULATOR PULSE GENERATOR, REPLACEMENT ONLYIMPLANTABLE NEUROSTIMULATOR RADIOFREQUENCY RECEIVERRADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATORRADIOFREQUENCY RECEIVERRADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE SACRAL ROOTNEUROSTIMULATOR RECEIVER FOR BOWEL AND BLADDER MANAGEMENT, REPLACEMENTIMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, RECHARGEABLE,INCLUDES EXTENSIONIMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, NON-RECHARGEABLE,INCLUDES EXTENSIONIMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, RECHARGEABLE, INCLUDESEXTENSIONIMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, NON-RECHARGEABLE,INCLUDES EXTENSIONEXTERNAL RECHARGING SYSTEM FOR BATTERY (INTERNAL) FOR USE WITH IMPLANTABLENEUROSTIMULATOR, REPLACEMENT ONLYAUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTSAUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, REPLACEMENTEXTERNAL RECHARGING SYSTEM FOR BATTERY (EXTERNAL) FOR USE WITH IMPLANTABLE

Query_110708

Page 300

NEUROSTIMULATOR, REPLACEMENT ONLYPROSTHETIC IMPLANT, NOT OTHERWISE SPECIFIEDORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHERHCPCS "L" CODEBRIEF OFFICE VISIT FOR THE SOLE PURPOSE OF MONITORING OR CHANGING DRUGPRESCRIPTIONS USED IN THE TREATMENT OF MENTAL PSYCHONEUROTIC AND PERSONALITYDISORDERSCELLULAR THERAPYPROLOTHERAPYINTRAGASTRIC HYPOTHERMIA USING GASTRIC FREEZINGIV CHELATION THERAPY (CHEMICAL ENDARTERECTOMY)FABRIC WRAPPING OF ABDOMINAL ANEURYSMCEPHALIN FLOCULATION, BLOODCONGO RED, BLOODHAIR ANALYSIS (EXCLUDING ARSENIC)THYMOL TURBIDITY, BLOODMUCOPROTEIN, BLOOD (SEROMUCOID) (MEDICAL NECESSITY PROCEDURE)SCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO THREE SMEARS, BYTECHNICIAN UNDER PHYSICIAN SUPERVISIONSCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO THREE SMEARS,REQUIRING INTERPRETATION BY PHYSICIANCULTURE, BACTERIAL, URINE; QUANTITATIVE, SENSITIVITY STUDYBLOOD (WHOLE), FOR TRANSFUSION, PER UNITBLOOD, SPLIT UNITCRYOPRECIPITATE, EACH UNITRED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNITFRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACHUNITPLATELETS, EACH UNITPLATELET RICH PLASMA, EACH UNITRED BLOOD CELLS, EACH UNITRED BLOOD CELLS, WASHED, EACH UNITPLASMA, POOLED MULTIPLE DONOR, SOLVENT/DETERGENT TREATED, FROZEN, EACH UNITPLATELETS, LEUKOCYTES REDUCED, EACH UNITPLATELETS, IRRADIATED, EACH UNITPLATELETS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNITPLATELETS, PHERESIS, EACH UNITPLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNITPLATELETS, PHERESIS, IRRADIATED, EACH UNITPLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNITRED BLOOD CELLS, IRRADIATED, EACH UNITRED BLOOD CELLS, DEGLYCEROLIZED, EACH UNITRED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNITINFUSION, ALBUMIN (HUMAN), 5%, 50 MLINFUSION, PLASMA PROTEIN FRACTION (HUMAN), 5%, 50 MLPLASMA, CRYOPRECIPITATE REDUCED, EACH UNITINFUSION, ALBUMIN (HUMAN), 5%, 250 MLINFUSION, ALBUMIN (HUMAN), 25%, 20 MLINFUSION, ALBUMIN (HUMAN), 25%, 50 MLINFUSION, PLASMA PROTEIN FRACTION (HUMAN), 5%, 250MLGRANULOCYTES, PHERESIS, EACH UNITWHOLE BLOOD OR RED BLOOD CELLS, LEUKOCYTES REDUCED, CMV-NEGATIVE, EACH UNITPLATELETS, HLA-MATCHED LEUKOCYTES REDUCED, APHERESIS/PHERESIS, EACH UNITPLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNITWHOLE BLOOD OR RED BLOOD CELLS, LEUKOCYTES REDUCED, FROZEN, DEGLYCEROL, WASHED,EACH UNITPLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNITWHOLE BLOOD, LEUKOCYTES REDUCED, IRRADIATED, EACH UNITRED BLOOD CELLS, FROZEN/DEGLYCEROLIZED/WASHED, LEUKOCYTES REDUCED, IRRADIATED,EACH UNITRED BLOOD CELLS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT

Query_110708

Page 301

FRESH FROZEN PLASMA BETWEEN 8-24 HOURS OF COLLECTION, EACH UNITFRESH FROZEN PLASMA, DONOR RETESTED, EACH UNITTRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORYSPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT;PRORATED MILES ACTUALLY TRAVELLED.TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORYSPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT;PRORATED TRIP CHARGE.CATHETERIZATION FOR COLLECTION OF SPECIMEN, SINGLE PATIENT, ALL PLACES OFSERVICECATHETERIZATION FOR COLLECTION OF SPECIMEN (S) (MULTIPLE PATIENTS)CARDIOKYMOGRAPHYINFUSION THERAPY, USING OTHER THAN CHEMOTHERAPEUTIC DRUGS, PER VISITCHEMOTHERAPY ADMINISTRATION BY OTHER THAN INFUSION TECHNIQUE ONLY (EGSUBCUTANEOUS, INTRAMUSCULAR, PUSH), PER VISITCHEMOTHERAPY ADMINISTRATION BY INFUSION TECHNIQUE ONLY, PER VISITCHEMOTHERAPY ADMINISTRATION BY BOTH INFUSION TECHNIQUE AND OTHER TECHIQUE(S)(EG SUBCUTANEOUS, INTRAMUSCULAR, PUSH), PER VISITSCREENING PAPANICOLAOU SMEAR; OBTAINING, PREPARING AND CONVEYANCE OF CERVICALOR VAGINAL SMEAR TO LABORATORYSET-UP PORTABLE X-RAY EQUIPMENTWET MOUNTS, INCLUDING PREPARATIONS OF VAGINAL, CERVICAL OR SKIN SPECIMENSALL POTASSIUM HYDROXIDE (KOH) PREPARATIONSPINWORM EXAMINATIONSFERN TESTPOST-COITAL DIRECT, QUALITATIVE EXAMINATIONS OF VAGINAL OR CERVICAL MUCOUSINJECTION, EPOETIN ALPHA, (FOR NON ESRD USE), PER 1000 UNITSINJECTION, DARBEPOETIN ALFA, 1 MCG (NON-ESRD USE)AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAMDIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRESCRIPTIONANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETICAT TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED A 48 HOUR DOSAGE REGIMENPROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIMEOF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENPROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIMEOF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENGRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIMEOF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 HOUR DOSAGE REGIMENDRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS ACOMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OFCHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENDRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS ACOMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OFCHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENPROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTIONANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETICAT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENPROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESCRIPTIONANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETICAT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENCHLORPROMAZINE HYDROCHLORIDE, 10 MG, ORAL, FDA APPROVED PRESCRIPTIONANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETICAT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENCHLORPROMAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESCRIPTIONANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETICAT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENTRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED PRESCRIPTIONANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC

Query_110708

Page 302

AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENTHIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIMEOF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENPERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS ACOMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OFCHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENPERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS ACOMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OFCHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENHYDROXYZINE PAMOATE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FORUSE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OFCHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENHYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FORUSE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OFCHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIMEOF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENDOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FORUSE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OFCHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 HOUR DOSAGE REGIMENUNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE ASA COMPLETE THERAPEUTIC SUBSTITUTE FOR A IV ANTI-EMETIC AT THE TIME OFCHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMENFACTOR VIIA (COAGULATION FACTOR, RECOMBINANT) PER 1.2 MGDRIVER FOR USE WITH PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLYMICROPROCESSOR CONTROL UNIT FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYMICROPROCESSOR CONTROL UNIT FOR USE WITH ELECTRIC/PNEUMATIC COMBINATIONVENTRICULAR ASSIST DEVICE, REPLACEMENT ONLYMONITOR/DISPLAY MODULE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYMONITOR/DISPLAY MODULE FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULARASSIST DEVICE, REPLACEMENT ONLYMONITOR CONTROL CABLE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYMONITOR CONTROL CABLE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR ASSISTDEVICE, REPLACEMENT ONLYLEADS (PNEUMATIC/ELECTRICAL) FOR USE WITH ANY TYPE ELECTRIC/PNEUMATICVENTRICULAR ASSIST DEVICE, REPLACEMENT ONLYPOWER PACK BASE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE, REPLACEMENTONLYPOWER PACK BASE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYEMERGENCY POWER SOURCE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYEMERGENCY POWER SOURCE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR ASSISTDEVICE, REPLACEMENT ONLYEMERGENCY POWER SUPPLY CABLE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYEMERGENCY POWER SUPPLY CABLE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR ASSISTDEVICE, REPLACEMENT ONLYEMERGENCY HAND PUMP FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULARASSIST DEVICE, REPLACEMENT ONLYBATTERY/POWER PACK CHARGER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATICVENTRICULAR ASSIST DEVICE, REPLACEMENT ONLYBATTERY FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYBATTERY CLIPS FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSISTDEVICE, REPLACEMENT ONLY

Query_110708

Page 303

HOLSTER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYBELT/VEST FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSISTDEVICE, REPLACEMENT ONLYFILTERS FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYSHOWER COVER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSISTDEVICE, REPLACEMENT ONLYMOBILITY CART FOR PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLYBATTERY FOR PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY, EACHPOWER ADAPTER FOR PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY,VEHICLE TYPEMISCELLANEOUS SUPPLY OR ACCESSORY FOR USE WITH VENTRICULAR ASSIST DEVICEPHARMACY SUPPLY FEE FOR INITIAL IMMUNOSUPPRESSIVE DRUG(S), FIRST MONTHFOLLOWING TRANSPLANTPHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVEDRUG(S); FOR THE FIRST PRESCRIPTION IN A 30-DAY PERIODPHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVEDRUG(S); FOR A SUBSEQUENT PRESCRIPTION IN A 30-DAY PERIODPHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 30 DAYSPHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 90 DAYSINJECTION, SERMORELIN ACETATE, 1 MICROGRAMNEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 1 AS DEFINED IN FEDERAL REGISTERNOTICE, VOL 65, DATED MAY 3, 2000NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 2 AS DEFINED IN FEDERAL REGISTERNOTICE, VOL 65, DATED MAY 3, 2000NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 3 (REDUCED SPHERICAL ABERRATION)NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 4 AS DEFINED IN FEDERAL REGISTER NOTICENEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 5 AS DEFINED IN FEDERAL REGISTER NOTICEORAL, CABERGOLINE, 0.5 MGINJECTION, ELLIOTTS B SOLUTION, PER MLINJECTION, APROTININ, 10,000 KIUIRRIGATION SOLUTION FOR TREATMENT OF BLADDER CALCULI, FOR EXAMPLE RENACIDIN,PER 500 MLINJECTION, CORTICORELIN OVINE TRIFLUTATE, PER DOSEINJECTION, DIGOXIN IMMUNE FAB (OVINE), PER VIALINJECTION, ETHANOLAMINE OLEATE, 100 MGINJECTION, FOMEPIZOLE, 15 MGINJECTION, FOSPHENYTOIN, 50 MGINJECTION, HEMIN, PER 1 MGINJECTION, PEGADEMASE BOVINE, 25 IUINJECTION, PENTASTARCH, 10% SOLUTION, PER 100 MLINJECTION, SERMORELIN ACETATE, 0.5 MGINJECTION, TENIPOSIDE, 50 MGINJECTION, UROFOLLITROPIN, 75 IUINJECTION, BASILIXIMAB, 20 MGINJECTION, HISTRELIN ACETATE, 10 MCGINJECTION, LEPIRUDIN, 50 MGVON WILLEBRAND FACTOR COMPLEX, HUMAN, PER IUSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, RUBIDIUM RB-82, PER DOSERADIOELEMENTS FOR BRACHYTHERAPY, ANY TYPE, EACHSUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, GALLIUM GA 67, PER MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC99MBICISATE, PER UNIT DOSESUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, XENON XE 133, PER 10 MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99MMERTIATIDE, PER MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC 99MGLUCEPATATE, PER 5 MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, SODIUM PHOSPHATE P32,PER MCI

Query_110708

Page 304

SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, INDIUM 111-INPENTETREOTIDE, PER 3 MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC99MOXIDRONATE, PER MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC99M -LABELED RED BLOOD CELLS, PER MCISUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, CHROMIC PHOSPHATE P32SUSPENSION, PER MCISUPPLY OF ORAL RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, CYANOCOBALAMINCOBALT CO57, PER 0.5 MCITELEHEALTH ORIGINATING SITE FACILITY FEEALS VEHICLE USED, EMERGENCY TRANSPORT, NO ALS LEVEL SERVICES FURNISHEDALS VEHICLE USED, NON-EMERGENCY TRANSPORT, NO ALS LEVEL SERVICE FURNISHEDINJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR USEINJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USECOLLAGEN SKIN TESTCASTING SUPPLIES, BODY CAST ADULT, WITH OR WITHOUT HEAD, PLASTERCAST SUPPLIES, BODY CAST ADULT, WITH OR WITHOUT HEAD, FIBERGLASSCAST SUPPLIES, SHOULDER CAST, ADULT (11 YEARS +), PLASTERCAST SUPPLIES, SHOULDER CAST, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), PLASTERCAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, LONG ARM CAST, PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, LONG ARM CAST, PEDIATRIC (0-10 YEARS), FIBERGLASSCAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), PLASTERCAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), FIBERGLASSCAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), ADULT (11 YEARS+), PLASTERCAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), ADULT (11 YEARS+), FIBERGLASSCAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), PEDIATRIC (0-10YEARS), PLASTERCAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), PEDIATRIC (0-10YEARS), FIBERGLASSCAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), PLASTERCAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASSCAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), PLASTERCAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASSCAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), ADULT (11 YEARS +), PLASTERCAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0-10 YEARS), FIBERGLASSCAST SUPPLIES, LONG LEG CAST, ADULT (11 YEARS +), PLASTERCAST SUPPLIES, LONG LEG CAST, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, LONG LEG CAST, PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, LONG LEG CAST, PEDIATRIC (0-10 YEARS), FIBERGLASSCAST SUPPLIES, LONG LEG CYLINDER CAST, ADULT (11 YEARS +), PLASTERCAST SUPPLIES, LONG LEG CYLINDER CAST, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, LONG LEG CYLINDER CAST, PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, LONG LEG CYLINDER CAST, PEDIATRIC (0-10 YEARS), FIBERGLASSCAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), PLASTERCAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), FIBERGLASSCAST SUPPLIES, LONG LEG SPLINT, ADULT (11 YEARS +), PLASTER

Query_110708

Page 305

CAST SUPPLIES, LONG LEG SPLINT, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, LONG LEG SPLINT, PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, LONG LEG SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASSCAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), PLASTERCAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), FIBERGLASSCAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), PLASTERCAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASSFINGER SPLINT, STATICCAST SUPPLIES, FOR UNLISTED TYPES AND MATERIALS OF CASTSSPLINT SUPPLIES, MISCELLANEOUS (INCLUDES THERMOPLASTICS, STRAPPING, FASTENERS,PADDING AND OTHER SUPPLIES)INJECTION, DARBEPOETIN ALFA, 1 MCG (FOR ESRD ON DIALYSIS)INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS)INJECTION, ACYCLOVIR, 5 MGINJECTION, DOPAMINE HCL, 40 MGINJECTION, TREPROSTINIL, 1 MGINJECTION, NATALIZUMAB, 1 MGILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMSINJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS)DRUG OR BIOLOGICAL, NOT OTHERWISE CLASSIFIED, PART B DRUG COMPETITIVEACQUISITION PROGRAM (CAP)HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTICULAR INJECTION,PER DOSEHYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSEHYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSEHYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSEINJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MGINJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS, NON-LYOPHILIZED,(E.G. LIQUID), 500 MGINJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTRAMUSCULAR ORINTRAVENOUS, 100 IUINJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 MLINJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED, (E.G.LIQUID), 500 MGINJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MGALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION,FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME,CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION,FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNITDOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MGINJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN COFACTOR (NOTOTHERWISE SPECIFIED), PER I.U. VWF: RCOINJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MGINJECTION, IRON DEXTRAN, 50 MGFORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT,NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMSSKIN SUBSTITUTE, NOT OTHERWISE SPECIFIEDSKIN SUBSTITUTE, APLIGRAF, PER SQUARE CENTIMETERSKIN SUBSTITUTE, OASIS WOUND MATRIX, PER SQUARE CENTIMETERSKIN SUBSTITUTE, OASIS BURN MATRIX, PER SQUARE CENTIMETERSKIN SUBSTITUTE, INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQUARECENTIMETERSKIN SUBSTITUTE, INTEGRA DERMAL REGENERATION TEMPLATE (DRT), PER SQUARECENTIMETERSKIN SUBSTITUTE, DERMAGRAFT, PER SQUARE CENTIMETER

Query_110708

Page 306

SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETERSKIN SUBSTITUTE, INTEGRA MATRIX, PER SQUARE CENTIMETERSKIN SUBSTITUTE, TISSUEMEND, PER SQUARE CENTIMETERSKIN SUBSTITUTE, PRIMATRIX, PER SQUARE CENTIMETERSKIN SUBSTITUTE, GAMMAGRAFT, PER SQUARE CENTIMETERALLOGRAFT, CYMETRA, INJECTABLE, 1CCALLOGRAFT, GRAFTJACKET EXPRESS, INJECTABLE, 1CCINTEGRA FLOWABLE WOUND MATRIX, INJECTABLE, 1CCHOSPICE CARE PROVIDED IN PATIENT'S HOME/RESIDENCEHOSPICE CARE PROVIDED IN ASSISTED LIVING FACILITYHOSPICE CARE PROVIDED IN NURSING LONG TERM CARE FACILITY (LTC) OR NON-SKILLEDNURSING FACILITY (NF)HOSPICE CARE PROVIDED IN SKILLED NURSING FACILITY (SNF)HOSPICE CARE PROVIDED IN INPATIENT HOSPITALHOSPICE CARE PROVIDED IN INPATIENT HOSPICE FACILITYHOSPICE CARE PROVIDED IN LONG TERM CARE FACILITYHOSPICE CARE PROVIDED IN INPATIENT PSYCHIATRIC FACILITYHOSPICE CARE PROVIDED IN PLACE NOT OTHERWISE SPECIFIED (NOS)INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED, 1GINJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED, 10 MGINJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED, 1GINJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED, 10 MGLOW OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER MLLOW OSMOLAR CONTRAST MATERIAL, 150-199 MG/ML IODINE CONCENTRATION, PER MLLOW OSMOLAR CONTRAST MATERIAL, 200-249 MG/ML IODINE CONCENTRATION, PER MLLOW OSMOLAR CONTRAST MATERIAL, 250-299 MG/ML IODINE CONCENTRATION, PER MLLOW OSMOLAR CONTRAST MATERIAL, 300-349 MG/ML IODINE CONCENTRATION, PER MLLOW OSMOLAR CONTRAST MATERIAL, 350-399 MG/ML IODINE CONCENTRATION, PER MLLOW OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML IODINE CONCENTRATION, PER MLINJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, PER MLINJECTION, IRON-BASED MAGNETIC RESONANCE CONTRAST AGENT, PER MLORAL MAGNETIC RESONANCE CONTRAST AGENT, PER 100 MLINJECTION, PERFLEXANE LIPID MICROSPHERES, PER MLINJECTION, OCTAFLUOROPROPANE MICROSPHERES, PER MLINJECTION, PERFLUTREN LIPID MICROSPHERES, PER MLHIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER MLHIGH OSMOLAR CONTRAST MATERIAL, 150-199 MG/ML IODINE CONCENTRATION, PER MLHIGH OSMOLAR CONTRAST MATERIAL, 200-249 MG/ML IODINE CONCENTRATION, PER MLHIGH OSMOLAR CONTRAST MATERIAL, 250-299 MG/ML IODINE CONCENTRATION, PER MLHIGH OSMOLAR CONTRAST MATERIAL, 300-349 MG/ML IODINE CONCENTRATION, PER MLHIGH OSMOLAR CONTRAST MATERIAL, 350-399 MG/ML IODINE CONCENTRATION, PER MLHIGH OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML IODINE CONCENTRATION, PERMLLOW OSMOLAR CONTRAST MATERIAL, 100-199 MG/ML IODINE CONCENTRATION, PER MLLOW OSMOLAR CONTRAST MATERIAL, 200-299 MG/ML IODINE CONCENTRATION, PER MLLOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER MLTRANSPORTATION OF PORTABLE X-RAY EQUIPMENT AND PERSONNEL TO HOME OR NURSINGHOME, PER TRIP TO FACILITY OR LOCATION, ONE PATIENT SEENTRANSPORTATION OF PORTABLE X-RAY EQUIPMENT AND PERSONNEL TO HOME OR NURSINGHOME, PER TRIP TO FACILITY OR LOCATION, MORE THAN ONE PATIENT SEENTRANSPORTATION OF PORTABLE EKG TO FACILITY OR LOCATION, PER PATIENTBUTORPHANOL TARTRATE, NASAL SPRAY, 25 MGTACRINE HYDROCHLORIDE, 10 MGINJECTION, AMIKACIN SULFATE, 500 MGINJECTION, AMINOCAPROIC ACID, 5 GRAMSINJECTION, BUPIVICAINE HYDROCHLORIDE, 30 MLINJECTION, CEFOPERAZONE SODIUM, 1 GRAMINJECTION, CIMETIDINE HYDROCHLORIDE, 300 MGINJECTION, FAMOTIDINE, 20 MGINJECTION, METRONIDAZOLE, 500 MGINJECTION, NAFCILLIN SODIUM, 2 GRAMS

Query_110708

Page 307

INJECTION, OFLOXACIN, 400 MGINJECTION, SULFAMETHOXAZOLE AND TRIMETHOPRIM, 10 MLINJECTION, TICARCILLIN DISODIUM AND CLAVULANATE POTASSIUM, 3.1 GRAMSINJECTION, ACYCLOVIR SODIUM, 50 MGINJECTION, AMIKACIN SULFATE, 100 MGINJECTION, AZTREONAM, 500 MGINJECTION, CEFOTETAN DISODIUM, 500 MGINJECTION, CLINDAMYCIN PHOSPHATE, 300 MGINJECTION, FOSPHENYTOIN SODIUM, 750 MGINJECTION, PENTAMIDINE ISETHIONATE, 300 MGINJECTION, PIPERACILLIN SODIUM, 500 MGIMATINIB, 100 MGSILDENAFIL CITRATE, 25 MGGRANISETRON HYDROCHLORIDE, 1MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARESTATUTE, USE Q0166)INJECTION, HYDROMORPHONE HYDROCHLORIDE, 250 MG (LOADING DOSE FOR INFUSION PUMP)INJECTION, MORPHINE SULFATE, 500 MG (LOADING DOSE FOR INFUSION PUMP)ZIDOVUDINE, ORAL, 100 MGBUPROPION HCL SUSTAINED RELEASE TABLET, 150 MG, PER BOTTLE OF 60 TABLETSINJECTION, OMALIZUMAB, 25 MGMERCAPTOPURINE, ORAL, 50 MGMETHADONE, ORAL, 5 MGINJECTION, TREPROSTINIL SODIUM, 0.5 MGBEVACIZUMAB, 100 MGTRETINOIN, TOPICAL, 5 GRAMSINJECTION, ZICONOTIDE, FOR INTRATHECAL INFUSION, 1 MCGINJECTION, MENOTROPINS, 75 IUINJECTION, FOLLITROPIN ALFA, 75 IUINJECTION, FOLLITROPIN BETA, 75 IUINJECTION, GANIRELIX ACETATE, 250 MCGHISTRELIN, IMPLANT, 50 MGCLOZAPINE, 25 MGDIDANOSINE (DDI), 25 MGFINASTERIDE, 5 MGMINOXIDIL, 10 MGSAQUINAVIR, 200 MGZALCITABINE (DDC), 0.375 MGCOLISTIMETHATE SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DME,CONCENTRATED FORM, PER MGAZTREONAM, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PERGRAMINJECTION, PEGYLATED INTERFERON ALFA-2A, 180 MCG PER MLINJECTION, PEGYLATED INTERFERON ALFA-2B, 10 MCG PER 0.5 MLINJECTION, ALGLUCOSIDASE ALFA, 20 MGSTERILE DILUTANT FOR EPOPROSTENOL, 50MLEXEMESTANE, 25 MGBECAPLERMIN GEL 0.01%, 0.5 GMINJECTION, LARONIDASE, 0.58 MGINJECTION, AGALSIDASE BETA, 35 MGDEXTROAMPHETAMINE SULFATE, 5 MGCALCITROL, 0.25 MGINJECTION, EFALIZUMAB, 125 MGINJECTION, PANTOPRAZOLE SODIUM, 40 MGINJECTION, OLANZAPINE, 2.5 MGINJECTION, APOMORPHINE HYDROCHLORIDE, 1 MGINJECTION, AZACITIDINE, 100 MGANASTROZOLE, ORAL, 1MGINJECTION, BUMETANIDE, 0.5MGCHLORAMBUCIL, ORAL, 2MGDEXAMETHASONE, ORAL, 4MGDOLASETRON MESYLATE, ORAL 50MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE

Query_110708

Page 308

STATUTE, USE Q0180)FLUTAMIDE, ORAL, 125MGHYDROXYUREA, ORAL, 500MGLEVAMISOLE HYDROCHLORIDE, ORAL, 50MGLOMUSTINE, ORAL, 10MGMEGESTROL ACETATE, ORAL, 20MGETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIESONDANSETRON HYDROCHLORIDE, ORAL, 4MG (FOR CIRCUMSTANCES FALLING UNDER THEMEDICARE STATUTE, USE Q0179)PROCARBAZINE HYDROCHLORIDE, ORAL, 50MGPROCHLORPERAZINE MALEATE, ORAL, 5MG (FOR CIRCUMSTANCES FALLING UNDER THEMEDICARE STATUTE, USE Q0164 - Q0165)TAMOXIFEN CITRATE, ORAL, 10MGTESTOSTERONE PELLET, 75MGMIFEPRISTONE, ORAL, 200 MGMISOPROSTOL, ORAL, 200 MCGDIALYSIS/STRESS VITAMIN SUPPLEMENT, ORAL, 100 CAPSULESPNEUMOCOCCAL CONJUGATE VACCINE, POLYVALENT, INTRAMUSCULAR, FOR CHILDREN FROMFIVE YEARS TO NINE YEARS OF AGE WHO HAVE NOT PREVIOUSLY RECEIVED THE VACCINEINJECTABLE POLY-L-LACTIC ACID, RESTORATIVE IMPLANT, 1 ML, FACE (DEEP DERMIS,SUBCUTANEOUS LAYERS)PRENATAL VITAMINS, 30-DAY SUPPLYINJECTION, PEGAPTANIB SODIUM, 0.3 MGMEDICALLY INDUCED ABORTION BY ORAL INGESTION OF MEDICATION INCLUDING ALLASSOCIATED SERVICES AND SUPPLIES (E.G., PATIENT COUNSELING, OFFICE VISITS,CONFIRMATION OF PREGNANCY BY HCG, ULTRASOUND TO CONFIRM DURATION OF PREGNANCY,ULTRASOUND TO CONFIRM COMPLETION OF ABORTION) EXCEPT DRUGSPARTIAL HOSPITALIZATION SERVICES, LESS THAN 24 HOURS, PER DIEMPARAMEDIC INTERCEPT, NON-HOSPITAL-BASED ALS SERVICE (NON-VOLUNTARY),NON-TRANSPORTPARAMEDIC INTERCEPT, HOSPITAL-BASED ALS SERVICE (NON-VOLUNTARY), NON-TRANSPORTWHEELCHAIR VAN, MILEAGE, PER MILENON-EMERGENCY TRANSPORTATION; MILEAGE, PER MILEMEDICAL CONFERENCE BY A PHYSICIAN WITH INTERDISCIPLINARY TEAM OF HEALTHPROFESSIONALS OR REPRESENTATIVES OF COMMUNITY AGENCIES TO COORDINATE ACTIVITIESOF PATIENT CARE (PATIENT IS PRESENT); APPROXIMATELY 30 MINUTESMEDICAL CONFERENCE BY A PHYSICIAN WITH INTERDISCIPLINARY TEAM OF HEALTHPROFESSIONALS OR REPRESENTATIVES OF COMMUNITY AGENCIES TO COORDINATE ACTIVITIESOF PATIENT CARE (PATIENT IS PRESENT); APPROXIMATELY 60 MINUTESCOMPREHENSIVE GERIATRIC ASSESSMENT AND TREATMENT PLANNING PERFORMED BYASSESSMENT TEAMHOSPICE REFERRAL VISIT (ADVISING PATIENT AND FAMILY OF CARE OPTIONS) PERFORMEDBY NURSE, SOCIAL WORKER, OR OTHER DESIGNATED STAFFCOUNSELING AND DISCUSSION REGARDING ADVANCE DIRECTIVES OR END OF LIFE CAREPLANNING AND DECISIONS, WITH PATIENT AND/OR SURROGATE (LIST SEPARATELY INADDITION TO CODE FOR APPROPRIATE EVALUATION AND MANAGEMENT SERVICE)HISTORY AND PHYSICAL (OUTPATIENT OR OFFICE) RELATED TO SURGICAL PROCEDURE (LISTSEPARATELY IN ADDITION TO CODE FOR APPROPRIATE EVALUATION AND MANAGEMENTSERVICE)GENETIC COUNSELING, UNDER PHYSICIAN SUPERVISION, EACH 15 MINUTESPHYSICIAN MANAGEMENT OF PATIENT HOME CARE, STANDARD MONTHLY CASE RATE (PER 30DAYS)PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, HOSPICE MONTHLY CASE RATE (PER 30DAYS)PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, EPISODIC CARE MONTHLY CASE RATE (PER30 DAYS)PHYSICIAN VISIT AT MEMBER'S HOME, OUTSIDE OF A CAPITATION ARRANGEMENTNURSE PRACTITIONER VISIT AT MEMBER'S HOME, OUTSIDE OF A CAPITATION ARRANGEMENTCOMPLETED EARLY PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT) SERVICE(LIST IN ADDITION TO CODE FOR APPROPRIATE EVALUATION AND MANAGEMENT SERVICE)HOSPITALIST SERVICES (LIST SEPARATELY IN ADDITION TO CODE FOR APPROPRIATE

Query_110708

Page 309

EVALUATION AND MANAGEMENT SERVICE)DISEASE MANAGEMENT PROGRAM; INITIAL ASSESSMENT AND INITIATION OF THE PROGRAMDISEASE MANAGEMENT PROGRAM, FOLLOW-UP/REASSESSMENTDISEASE MANAGEMENT PROGRAM; PER DIEMTELEPHONE CALLS BY A REGISTERED NURSE TO A DISEASE MANAGEMENT PROGRAM MEMBERFOR MONITORING PURPOSES; PER MONTHLIFESTYLE MODIFICATION PROGRAM FOR MANAGEMENT OF CORONARY ARTERY DISEASE,INCLUDING ALL SUPPORTIVE SERVICES; FIRST QUARTER / STAGELIFESTYLE MODIFICATION PROGRAM FOR MANAGEMENT OF CORONARY ARTERY DISEASE,INCLUDING ALL SUPPORTIVE SERVICES; SECOND OR THIRD QUARTER / STAGELIFESTYLE MODIFICATION PROGRAM FOR MANAGEMENT OF CORONARY ARTERY DISEASE,INCLUDING ALL SUPPORTIVE SERVICES; FOURTH QUARTER / STAGEELECTROCARDIOGRAPHIC MONITORING UTILIZING A HOME COMPUTERIZED TELEMETRY STATIONWITH AUTOMATIC ACTIVATION AND REAL-TIME NOTIFICATION OF MONITORING STATION,24-HOUR ATTENDED MONITORING, INCLUDING RECORDING, MONITORING, RECEIPT OFTRANSMISSIONS, ANALYSIS, AND PHYSICIAN REVIEW AND INTERPRETATION; PER 24-HOURPERIODELECTROCARDIOGRAPHIC MONITORING UTILIZING A HOME COMPUTERIZED TELEMETRY STATIONWITH AUTOMATIC ACTIVATION AND REAL-TIME NOTIFICATION OF MONITORING STATION,24-HOUR ATTENDED MONITORING, INCLUDING RECORDING, MONITORING, RECEIPT OFTRANSMISSIONS, AND ANALYSIS; PER 24-HOUR PERIODELECTROCARDIOGRAPHIC MONITORING UTILIZING A HOME COMPUTERIZED TELEMETRY STATIONWITH AUTOMATIC ACTIVATION AND REAL-TIME NOTIFICATION OF MONITORING STATION,24-HOUR ATTENDED MONITORING, INCLUDING PHYSICIAN REVIEW AND INTERPRETATION;24-HOUR PERIODROUTINE FOOT CARE; REMOVAL AND/OR TRIMMING OF CORNS, CALLUSES AND/OR NAILS ANDPREVENTIVE MAINTENANCE IN SPECIFIC MEDICAL CONDITIONS (E.G. DIABETES), PER VISITIMPRESSION CASTING OF A FOOT PERFORMED BY A PRACTITIONER OTHER THAN THEMANUFACTURER OF THE ORTHOTICGLOBAL FEE FOR EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY TREATMENT OF KIDNEYSTONE(S)DISPOSABLE CONTACT LENS, PER LENSSINGLE VISION PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), PER LENSBIFOCAL VISION PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), PER LENSTRIFOCAL VISION PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), PER LENSNON-PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), PER LENSDAILY WEAR SPECIALTY CONTACT LENS, PER LENSCOLOR CONTACT LENS, PER LENSSCLERAL LENS, LIQUID BANDAGE DEVICE, PER LENSSAFETY EYEGLASS FRAMESSUNGLASSES FRAMESPOLYCARBONATE LENS (LIST THIS CODE IN ADDITION TO THE BASIC CODE FOR THE LENS)NONSTANDARD LENS (LIST THIS CODE IN ADDITION TO THE BASIC CODE FOR THE LENS)INTEGRAL LENS SERVICE, MISCELLANEOUS SERVICES REPORTED SEPARATELYCOMPREHENSIVE CONTACT LENS EVALUATIONDISPENSING NEW SPECTACLE LENSES FOR PATIENT SUPPLIED FRAMESCREENING PROCTOSCOPYDIGITAL RECTAL EXAMINATION, ANNUALANNUAL GYNECOLOGICAL EXAMINATION, NEW PATIENTANNUAL GYNECOLOGICAL EXAMINATION, ESTABLISHED PATIENTANNUAL GYNECOLOGICAL EXAMINATION; CLINICAL BREAST EXAMINATION WITHOUT PELVICEVALUATIONAUDIOMETRY FOR HEARING AID EVALUATION TO DETERMINE THE LEVEL AND DEGREE OFHEARING LOSSROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; NEW PATIENTROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; ESTABLISHED PATIENTPHYSICAL EXAM FOR COLLEGE, NEW OR ESTABLISHED PATIENT (LIST SEPARATELY INADDITION TO APPROPRIATE EVALUATION AND MANAGEMENT CODE)RETINAL TELESCREENING BY DIGITAL IMAGING OF MULTIPLE DIFFERENT FUNDUS AREAS TOSCREEN FOR VISION-THREATENING CONDITIONS, INCLUDING IMAGING, INTERPRETATION ANDREPORT

Query_110708

Page 310

REMOVAL OF SUTURES; BY A PHYSICIAN OTHER THAN THE PHYSICIAN WHO ORIGINALLYCLOSED THE WOUNDLASER IN SITU KERATOMILEUSIS (LASIK)PHOTOREFRACTIVE KERATECTOMY (PRK)PHOTOTHERAPEUTIC KERATECTOMY (PTK)COMPUTERIZED CORNEAL TOPOGRAPHY, UNILATERALDELUXE ITEM, PATIENT AWARE (LIST IN ADDITION TO CODE FOR BASIC ITEM)CUSTOMIZED ITEM (LIST IN ADDITION TO CODE FOR BASIC ITEM)IV TUBING EXTENSION SETNON-PVC (POLYVINYL CHLORIDE) INTRAVENOUS ADMINISTRATION SET, FOR USE WITH DRUGSTHAT ARE NOT STABLE IN PVC E.G. PACLITAXELINHALED NITRIC OXIDE FOR THE TREATMENT OF HYPOXIC RESPIRATORY FAILURE IN THENEONATE; PER DIEMCONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, PURCHASE (FOR PHYSICIANINTERPRETATION OF DATA, USE CPT CODE)CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, RENTAL, INCLUDING SENSOR,SENSOR REPLACEMENT, AND DOWNLOAD TO MONITOR (FOR PHYSICIAN INTERPRETATION OFDATA, USE CPT CODE)CRANIAL REMOLDING ORTHOSIS, PEDIATRIC, RIGID, WITH SOFT INTERFACE MATERIAL,CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT(S)TRANSPLANTATION OF SMALL INTESTINE AND LIVER ALLOGRAFTSTRANSPLANTATION OF MULTIVISCERAL ORGANSHARVESTING OF DONOR MULTIVISCERAL ORGANS, WITH PREPARATION AND MAINTENANCE OFALLOGRAFTS; FROM CADAVER DONORLOBAR LUNG TRANSPLANTATIONDONOR LOBECTOMY (LUNG) FOR TRANSPLANTATION, LIVING DONORSIMULTANEOUS PANCREAS KIDNEY TRANSPLANTATIONBREAST RECONSTRUCTION WITH GLUTEAL ARTERY PERFORATOR (GAP) FLAP, INCLUDINGHARVESTING OF THE FLAP, MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE ANDSHAPING THE FLAP INTO A BREAST, UNILATERALBREAST RECONSTRUCTION OF A SINGLE BREAST WITH "STACKED" DEEP INFERIOREPIGASTRIC PERFORATOR (DIEP) FLAP(S) AND/OR GLUTEAL ARTERY PERFORATOR (GAP)FLAP(S), INCLUDING HARVESTING OF THE FLAP(S), MICROVASCULAR TRANSFER, CLOSUREOF DONOR SITE(S) AND SHAPING THE FLAP INTO A BREAST, UNILATERALBREAST RECONSTRUCTION WITH DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP ORSUPERFICIAL INFERIOR EPIGASTRIC ARTERY (SIEA) FLAP, INCLUDING HARVESTING OF THEFLAP, MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE AND SHAPING THE FLAP INTO ABREAST, UNILATERACYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH ENDOSCOPIC LASERTREATMENT OF URETERAL CALCULI (INCLUDES URETERAL CATHETERIZATION)LAPAROSCOPY, SURGICAL; REPAIR INCISIONAL OR VENTRAL HERNIALAPAROSCOPY, SURGICAL; REPAIR UMBILICAL HERNIALAPAROSCOPY, SURGICAL; IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR INCISIONALOR VENTRAL HERNIA REPAIR (LIST SEPARATELY IN ADDITION TO CODE FOR INCISIONAL ORVENTRAL HERNIA REPAIR)LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), WITH ORWITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S)LAPAROSCOPIC ESOPHAGOMYOTOMY (HELLER TYPE)LASER-ASSISTED UVULOPALATOPLASTY (LAUP)LAPAROSCOPY, SURGICAL; GASTRIC RESTRICTIVE PROCEDURE, ADJUSTABLE GASTRIC BAND(INCLUDES PLACEMENT OF SUBCUTANEOUS PORT)ADJUSTMENT OF GASTRIC BAND DIAMETER VIA SUBCUTANEOUS PORT BY INJECTION ORASPIRATION OF SALINEABLATION, OPEN, ONE OR MORE RENAL TUMOR(S); CRYOSURGICALABLATION, PERCUTANEOUS, ONE OR MORE RENAL TUMOR(S); CRYOSURGICALTRANSCATHETER OCCLUSION OR EMBOLIZATION FOR TUMOR DESTRUCTION, PERCUTANEOUS,ANY METHOD, USING YTTRIUM-90 MICROSPHERESISLET CELL TISSUE TRANSPLANT FROM PANCREAS; ALLOGENEICADRENAL TISSUE TRANSPLANT TO BRAINADOPTIVE IMMUNOTHERAPY I.E. DEVELOPMENT OF SPECIFIC ANTI-TUMOR REACTIVITY (E.G.TUMOR-INFILTRATING LYMPHOCYTE THERAPY) PER COURSE OF TREATMENT

Query_110708

Page 311

ARTHROSCOPY, KNEE, SURGICAL FOR HARVESTING OF CARTILAGE (CHONDROCYTE CELLS)ARTHROSCOPY, SHOULDER, SURGICAL; TENODESIS OF BICEPSOSTEOTOMY, PERIACETABULAR, WITH INTERNAL FIXATIONARTHROEREISIS, SUBTALARMETAL-ON-METAL TOTAL HIP RESURFACING, INCLUDING ACETABULAR AND FEMORALCOMPONENTSLOW DENSITY LIPOPROTEIN (LDL) APHERESIS USING HEPARIN-INDUCED EXTRACORPOREALLDL PRECIPITATIONNEUROLYSIS, BY INJECTION, OF METATARSAL NEUROMA/INTERDIGITAL NEURITIS, ANYINTERSPACE OF THE FOOTCORD BLOOD HARVESTING FOR TRANSPLANTATION, ALLOGENEICCORD BLOOD-DERIVED STEM-CELL TRANSPLANTATION, ALLOGENEICBONE MARROW OR BLOOD-DERIVED STEM CELLS (PERIPHERAL OR UMBILICAL), ALLOGENEICOR AUTOLOGOUS, HARVESTING, TRANSPLANTATION, AND RELATED COMPLICATIONS;INCLUDING: PHERESIS AND CELL PREPARATION/STORAGE; MARROW ABLATIVE THERAPY;DRUGS, SUPPLIES, HOSPITALIZATION WITH OUTPATIENT FOLLOW-UP; MEDICAL/SURGICAL,DIAGNOSTIC, EMERGENCY, AND REHABILITATIVE SERVICES; AND THE NUMBER OF DAYS OFPRE-AND POST-TRANSPLANT CARE IN THE GLOBAL DEFINITIONSOLID ORGAN(S), COMPLETE OR SEGMENTAL, SINGLE ORGAN OR COMBINATION OF ORGANS;DECEASED OR LIVING DONOR (S), PROCUREMENT, TRANSPLANTATION, AND RELATEDCOMPLICATIONS; INCLUDING: DRUGS; SUPPLIES; HOSPITALIZATION WITH OUTPATIENTFOLLOW-UP; MEDICAL/SURGICAL, DIAGNOSTIC, EMERGENCY, AND REHABILITATIVESERVICES, AND THE NUMBER OF DAYS OF PRE- AND POST-TRANSPLANT CARE IN THE GLOBALDEFINITIONECHOSCLEROTHERAPYMINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVINGMINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;USING ARTERIAL GRAFT(S), SINGLE CORONARY ARTERIAL GRAFTMINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVINGMINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;USING ARTERIAL GRAFT(S), TWO CORONARY ARTERIAL GRAFTSMINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVINGMINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;USING VENOUS GRAFT ONLY, SINGLE CORONARY VENOUS GRAFTMINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVINGMINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;USING SINGLE ARTERIAL AND VENOUS GRAFT(S), SINGLE VENOUS GRAFTMINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVINGMINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;USING TWO ARTERIAL GRAFTS AND SINGLE VENOUS GRAFTIMPLANTATION OF GASTRIC ELECTRICAL STIMULATION DEVICEUPPER GASTROINTESTINAL ENDOSCOPY, INCLUDING ESOPHAGUS, STOMACH, AND EITHER THEDUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH INJECTION OF IMPLANT MATERIAL INTOAND ALONG THE MUSCLE OF THE LOWER ESOPHAGEAL SPHINCTER FOR TREATMENT OFGASTROESOPHAGEAL REFLUX DISEASEMYRINGOTOMY, LASER-ASSISTEDIMPLANTATION OF MAGNETIC COMPONENT OF SEMI-IMPLANTABLE HEARING DEVICE ONOSSICLES IN MIDDLE EARIMPLANTATION OF AUDITORY BRAIN STEM IMPLANTUTERINE ARTERY EMBOLIZATION FOR UTERINE FIBROIDSINDUCED ABORTION, 17 TO 24 WEEKSABORTION FOR MATERNAL INDICATION, 25 WEEKS OR GREATERINDUCED ABORTION, 25 TO 28 WEEKSINDUCED ABORTION, 29 TO 31 WEEKSINDUCED ABORTION, 32 WEEKS OR GREATERINSERTION OF VAGINAL CYLINDER FOR APPLICATION OF RADIATION SOURCE OR CLINICALBRACHYTHERAPY (REPORT SEPARATELY IN ADDITION TO RADIATION SOURCE DELIVERY)ARTHROSCOPY, SHOULDER, SURGICAL; WITH THERMALLY-INDUCED CAPSULORRHAPHYHIP CORE DECOMPRESSIONCHEMODENERVATION OF ABDUCTOR MUSCLE(S) OF VOCAL CORDCHEMODENERVATION OF ADDUCTOR MUSCLE(S) OF VOCAL CORD

Query_110708

Page 312

NASAL ENDOSCOPY FOR POST-OPERATIVE DEBRIDEMENT FOLLOWING FUNCTIONAL ENDOSCOPICSINUS SURGERY, NASAL AND/OR SINUS CAVITY(S), UNILATERAL OR BILATERALNASAL/SINUS ENDOSCOPY, SURGICAL; WITH ENLARGEMENT OF SINUS OSTIUM OPENING USINGINFLATABLE DEVICE (I.E., BALLOON SINUPLASTY)DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRALDISC, USING RADIOFREQUENCY ENERGY, SINGLE OR MULTIPLE LEVELS, LUMBARDISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S),INCLUDING OSTEOPHYTECTOMY; LUMBAR, SINGLE INTERSPACEDISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S),INCLUDING OSTEOPHYTECTOMY; LUMBAR, EACH ADDITIONAL INTERSPACE (LIST SEPARATELYIN ADDITION TO CODE FOR PRIMARY PROCEDURE)PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERALINJECTION; CERVICALEACH ADDITIONAL CERVICAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODEFOR PRIMARY PROCEDURE)KYPHOPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTIONKYPHOPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; EACHADDITIONAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARYPROCEDURE)REPAIR, CONGENITAL DIAPHRAGMATIC HERNIA IN THE FETUS USING TEMPORARY TRACHEALOCCLUSION, PROCEDURE PERFORMED IN UTEROREPAIR, URINARY TRACT OBSTRUCTION IN THE FETUS, PROCEDURE PERFORMED IN UTEROREPAIR, CONGENITAL CYSTIC ADENOMATOID MALFORMATION IN THE FETUS, PROCEDUREPERFORMED IN UTEROREPAIR, EXTRALOBAR PULMONARY SEQUESTRATION IN THE FETUS, PROCEDURE PERFORMED INUTEROREPAIR, MYELOMENINGOCELE IN THE FETUS, PROCEDURE PERFORMED IN UTEROREPAIR OF SACROCOCCYGEAL TERATOMA IN THE FETUS, PROCEDURE PERFORMED IN UTEROREPAIR, CONGENITAL MALFORMATION OF FETUS, PROCEDURE PERFORMED IN UTERO, NOTOTHERWISE CLASSIFIEDFETOSCOPIC LASER THERAPY FOR TREATMENT OF TWIN-TO-TWIN TRANSFUSION SYNDROMESURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC SURGICAL SYSTEM (LIST SEPARATELYIN ADDITION TO CODE FOR PRIMARY PROCEDURE)DIABETIC INDICATOR; RETINAL EYE EXAM, DILATED, BILATERALPERFORMANCE MEASUREMENT, EVALUATION OF PATIENT SELF ASSESSMENT, DEPRESSIONSTAT LABORATORY REQUEST (SITUATIONS OTHER THAN S3601)EMERGENCY STAT LABORATORY CHARGE FOR PATIENT WHO IS HOMEBOUND OR RESIDING IN ANURSING FACILITYBLOOD CHEMISTRY FOR FREE BETA HUMAN CHORIONIC GONADOTROPIN (HCG)NEWBORN METABOLIC SCREENING PANEL, INCLUDES TEST KIT, POSTAGE AND THELABORATORY TESTS SPECIFIED BY THE STATE FOR INCLUSION IN THIS PANEL (E.G.GALACTOSE; HEMOGLOBIN, ELECTROPHORESIS; HYDROXYPROGESTERONE, 17-D; PHENYLANINE(PKU); AND THYROXINE, TOTAL)MATERNAL SERUM TRIPLE MARKER SCREEN INCLUDING ALPHA-FETOPROTEIN (AFP), ESTRIOL,AND HUMAN CHORIONIC GONADOTROPIN (HCG)MATERNAL SERUM QUADRUPLE MARKER SCREEN INCLUDING ALPHA-FETOPROTEIN (AFP),ESTRIOL, HUMAN CHORIONIC GONADOTROPIN (HCG) AND INHIBIN APLACENTAL ALPHA MICROGLOBULIN-1 RAPID IMMUNOASSAY FOR DETECTION OF RUPTURE OFFETAL MEMBRANESEOSINOPHIL COUNT, BLOOD, DIRECTHIV-1 ANTIBODY TESTING OF ORAL MUCOSAL TRANSUDATESALIVA TEST, HORMONE LEVEL; DURING MENOPAUSESALIVA TEST, HORMONE LEVEL; TO ASSESS PRETERM LABOR RISKANTISPERM ANTIBODIES TEST (IMMUNOBEAD)IMMUNOASSAY FOR NUCLEAR MATRIX PROTEIN 22 (NMP-22), QUANTITATIVEGASTROINTESTINAL FAT ABSORPTION STUDYCIRCULATING TUMOR CELL TESTGENETIC TESTING FOR AMYOTROPHIC LATERAL SCLEROSIS (ALS)COMPLETE GENE SEQUENCE ANALYSIS; BRCA1 GENECOMPLETE GENE SEQUENCE ANALYSIS; BRCA2 GENECOMPLETE BRCA1 AND BRCA2 GENE SEQUENCE ANALYSIS FOR SUSCEPTIBILITY TO BREAST

Query_110708

Page 313

AND OVARIAN CANCERSINGLE MUTATION ANALYSIS (IN INDIVIDUAL WITH A KNOWN BRCA1 OR BRCA2 MUTATION INTHE FAMILY) FOR SUSCEPTIBILITY TO BREAST AND OVARIAN CANCERTHREE-MUTATION BRCA1 AND BRCA2 ANALYSIS FOR SUSCEPTIBILITY TO BREAST ANDOVARIAN CANCER IN ASHKENAZI INDIVIDUALSCOMPLETE GENE SEQUENCE ANALYSIS; MLH1 GENECOMPLETE GENE SEQUENCE ANALYSIS; MLH2 GENECOMPLETE MLH1 AND MLH2 GENE SEQUENCE ANALYSIS FOR HEREDITARY NONPOLYPOSISCOLORECTAL CANCER (HNPCC) GENETIC TESTINGSINGLE-MUTATION ANALYSIS (IN INDIVIDUAL WITH A KNOWN MLH1 AND MLH2 MUTATION INTHE FAMILY) FOR HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (HNPCC) GENETICTESTINGCOMPLETE APC GENE SEQUENCE ANALYSIS FOR SUSCEPTIBILITY TO FAMILIAL ADENOMATOUSPOLYPOSIS (FAP) AND ATTENUATED FAPSINGLE-MUTATION ANALYSIS (IN INDIVIDUAL WITH A KNOWN APC MUTATION IN THEFAMILY) FOR SUSCEPTIBILITY TO FAMILIAL ADENOMATOUS POLYPOSIS (FAP) ANDATTENUATED FAPCOMPLETE GENE SEQUENCE ANALYSIS FOR CYSTIC FIBROSIS GENETIC TESTINGCOMPLETE GENE SEQUENCE ANALYSIS FOR HEMOCHROMATOSIS GENETIC TESTINGDNA ANALYSIS FOR GERMLINE MUTATIONS OF THE RET PROTO-ONCOGENE FORSUSCEPTIBILITY TO MULTIPLE ENDOCRINE NEOPLASIA TYPE 2GENETIC TESTING FOR RETINOBLASTOMAGENETIC TESTING FOR VON HIPPEL-LINDAU DISEASEDNA ANALYSIS OF THE F5 GENE FOR SUSCEPTIBILITY TO FACTOR V LEIDEN THROMBOPHILIADNA ANALYSIS OF THE CONNEXIN 26 GENE (GJB2) FOR SUSCEPTIBILITY TO CONGENITAL,PROFOUND DEAFNESSGENETIC TESTING FOR ALPHA-THALASSEMIAGENETIC TESTING FOR HEMOGLOBIN E BETA-THALASSEMIAGENETIC TESTING FOR TAY-SACHS DISEASEGENETIC TESTING FOR GAUCHER DISEASEGENETIC TESTING FOR NIEMANN-PICK DISEASEGENETIC TESTING FOR SICKLE CELL ANEMIAGENETIC TESTING FOR CANAVAN DISEASEDNA ANALYSIS FOR APOE EPSILON 4 ALLELE FOR SUSCEPTIBILITY TO ALZHEIMER'S DISEASEGENETIC TESTING FOR MYOTONIC MUSCULAR DYSTROPHYGENE EXPRESSION PROFILING PANEL FOR USE IN THE MANAGEMENT OF BREAST CANCERTREATMENTGENETIC TESTING FOR DETECTION OF MUTATIONS IN THE PRESENILIN - 1 GENEGENETIC TESTING, COMPREHENSIVE CARDIAC ION CHANNEL ANALYSIS, FOR VARIANTS IN 5MAJOR CARDIAC ION CHANNEL GENES FOR INDIVIDUALS WITH HIGH INDEX OF SUSPICIONFOR FAMILIAL LONG QT SYNDROME (LQTS) OR RELATED SYNDROMESGENETIC TESTING, SODIUM CHANNEL, VOLTAGE-GATED, TYPE V, ALPHA SUBUNIT (SCN5A)AND VARIANTS FOR SUSPECTED BRUGADA SYNDROMEGENETIC TESTING, FAMILY-SPECIFIC ION CHANNEL ANALYSIS, FOR BLOOD-RELATIVES OFINDIVIDUALS (INDEX CASE) WHO HAVE PREVIOUSLY TESTED POSITIVE FOR A GENETICVARIANT OF A CARDIAC ION CHANNEL SYNDROME USING EITHER ONE OF THE ABOVE TESTCONFIGURATIONS OR CONFIRMED RESULTS FROM ANOTHER LABORATORYDNA ANALYSIS, FECAL, FOR COLORECTAL CANCER SCREENINGSURFACE ELECTROMYOGRAPHY (EMG)BALLISTOCARDIOGRAMMASTERS TWO STEPNON-INVASIVE ELECTRODIAGNOSTIC TESTING WITH AUTOMATIC COMPUTERIZED HAND-HELDDEVICE TO STIMULATE AND MEASURE NEUROMUSCULAR SIGNALS IN DIAGNOSING ANDEVALUATING SYSTEMIC AND ENTRAPMENT NEUROPATHIESINTERIM LABOR FACILITY GLOBAL (LABOR OCCURRING BUT NOT RESULTING IN DELIVERY)IN VITRO FERTILIZATION; INCLUDING BUT NOT LIMITED TO IDENTIFICATION ANDINCUBATION OF MATURE OOCYTES, FERTILIZATION WITH SPERM, INCUBATION OFEMBRYO(S), AND SUBSEQUENT VISUALIZATION FOR DETERMINATION OF DEVELOPMENTCOMPLETE CYCLE, GAMETE INTRAFALLOPIAN TRANSFER (GIFT), CASE RATECOMPLETE CYCLE, ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT), CASE RATECOMPLETE IN VITRO FERTILIZATION CYCLE, NOT OTHERWISE SPECIFIED, CASE RATE

Query_110708

Page 314

FROZEN IN VITRO FERTILIZATION CYCLE, CASE RATEINCOMPLETE CYCLE, TREATMENT CANCELLED PRIOR TO STIMULATION, CASE RATEFROZEN EMBRYO TRANSFER PROCEDURE CANCELLED BEFORE TRANSFER, CASE RATEIN VITRO FERTILIZATION PROCEDURE CANCELLED BEFORE ASPIRATION, CASE RATEIN VITRO FERTILIZATION PROCEDURE CANCELLED AFTER ASPIRATION, CASE RATEASSISTED OOCYTE FERTILIZATION, CASE RATEDONOR EGG CYCLE, INCOMPLETE, CASE RATEDONOR SERVICES FOR IN VITRO FERTILIZATION (SPERM OR EMBRYO), CASE RATEPROCUREMENT OF DONOR SPERM FROM SPERM BANKSTORAGE OF PREVIOUSLY FROZEN EMBRYOSMICROSURGICAL EPIDIDYMAL SPERM ASPIRATION (MESA)SPERM PROCUREMENT AND CRYOPRESERVATION SERVICES; INITIAL VISITSPERM PROCUREMENT AND CRYOPRESERVATION SERVICES; SUBSEQUENT VISITSTIMULATED INTRAUTERINE INSEMINATION (IUI), CASE RATEINTRAVAGINAL CULTURE (IVC), CASE RATECRYOPRESERVED EMBRYO TRANSFER, CASE RATEMONITORING AND STORAGE OF CRYOPRESERVED EMBRYOS, PER 30 DAYSMANAGEMENT OF OVULATION INDUCTION (INTERPRETATION OF DIAGNOSTIC TESTS ANDSTUDIES, NON-FACE-TO-FACE MEDICAL MANAGEMENT OF THE PATIENT), PER CYCLEINSERTION OF LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEMCONTRACEPTIVE INTRAUTERINE DEVICE (E.G. PROGESTACERT IUD), INCLUDING IMPLANTSAND SUPPLIESNICOTINE PATCHES, LEGENDNICOTINE PATCHES, NON-LEGENDCONTRACEPTIVE PILLS FOR BIRTH CONTROLSMOKING CESSATION GUMPRESCRIPTION DRUG, GENERICPRESCRIPTION DRUG, BRAND NAME5% DEXTROSE AND 0.45% NORMAL SALINE, 1000 ML5% DEXTROSE IN LACTATED RINGER'S, 1000 ML5% DEXTROSE WITH POTASSIUM CHLORIDE, 1000 ML5% DEXTROSE/0.45% NORMAL SALINE WITH POTASSIUM CHLORIDE AND MAGNESIUM SULFATE,1000 ML5% DEXTROSE/0.45% NORMAL SALINE WITH POTASSIUM CHLORIDE AND MAGNESIUM SULFATE,1500 MLHOME INFUSION THERAPY, ROUTINE SERVICE OF INFUSION DEVICE (E.G. PUMPMAINTENANCE)HOME INFUSION THERAPY, REPAIR OF INFUSION DEVICE (E.G. PUMP REPAIR)DAY CARE SERVICES, ADULT; PER 15 MINUTESDAY CARE SERVICES, ADULT; PER HALF DAYDAY CARE SERVICES, ADULT; PER DIEMDAY CARE SERVICES, CENTER-BASED; SERVICES NOT INCLUDED IN PROGRAM FEE, PER DIEMHOME CARE TRAINING TO HOME CARE CLIENT, PER 15 MINUTESHOME CARE TRAINING TO HOME CARE CLIENT, PER SESSIONHOME CARE TRAINING, FAMILY; PER 15 MINUTESHOME CARE TRAINING, FAMILY; PER SESSIONHOME CARE TRAINING, NON-FAMILY; PER 15 MINUTESHOME CARE TRAINING, NON-FAMILY; PER SESSIONCHORE SERVICES; PER 15 MINUTESCHORE SERVICES; PER DIEMATTENDANT CARE SERVICES; PER 15 MINUTESATTENDANT CARE SERVICES; PER DIEMHOMEMAKER SERVICE, NOS; PER 15 MINUTESHOMEMAKER SERVICE, NOS; PER DIEMCOMPANION CARE, ADULT (E.G. IADL/ADL); PER 15 MINUTESCOMPANION CARE, ADULT (E.G. IADL/ADL); PER DIEMFOSTER CARE, ADULT; PER DIEMFOSTER CARE, ADULT; PER MONTHFOSTER CARE, THERAPEUTIC, CHILD; PER DIEMFOSTER CARE, THERAPEUTIC, CHILD; PER MONTHUNSKILLED RESPITE CARE, NOT HOSPICE; PER 15 MINUTES

Query_110708

Page 315

UNSKILLED RESPITE CARE, NOT HOSPICE; PER DIEMEMERGENCY RESPONSE SYSTEM; INSTALLATION AND TESTINGEMERGENCY RESPONSE SYSTEM; SERVICE FEE, PER MONTH (EXCLUDES INSTALLATION ANDTESTING)EMERGENCY RESPONSE SYSTEM; PURCHASE ONLYHOME MODIFICATIONS; PER SERVICEHOME DELIVERED MEALS, INCLUDING PREPARATION; PER MEALLAUNDRY SERVICE, EXTERNAL, PROFESSIONAL; PER ORDERHOME HEALTH RESPIRATORY THERAPY, INITIAL EVALUATIONHOME HEALTH RESPIRATORY THERAPY, NOS, PER DIEMMEDICATION REMINDER SERVICE, NON-FACE-TO-FACE; PER MONTHWELLNESS ASSESSMENT, PERFORMED BY NON-PHYSICIANPERSONAL CARE ITEM, NOS, EACHHOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, NOT OTHERWISE CLASSIFIED;INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, SIMPLE (SINGLE LUMEN),INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT, (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, COMPLEX (MORE THAN ONELUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, IMPLANTED ACCESS DEVICE,INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT, (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEM (USE THIS CODE FOR INTERIM MAINTENANCE OFVASCULAR ACCESS NOT CURRENTLY IN USE)HOME INFUSION THERAPY, ALL SUPPLIES NECESSARY FOR RESTORATION OF CATHETERPATENCY OR DECLOTTINGHOME INFUSION THERAPY, ALL SUPPLIES NECESSARY FOR CATHETER REPAIRHOME INFUSION THERAPY, ALL SUPPLIES (INCLUDING CATHETER) NECESSARY FOR APERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC) LINE INSERTIONHOME INFUSION THERAPY, ALL SUPPLIES (INCLUDING CATHETER) NECESSARY FOR AMIDLINE CATHETER INSERTIONHOME INFUSION THERAPY, INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUSCATHETER (PICC), NURSING SERVICES ONLY (NO SUPPLIES OR CATHETER INCLUDED)HOME INFUSION THERAPY, INSERTION OF MIDLINE VENOUS CATHETER, NURSING SERVICESONLY (NO SUPPLIES OR CATHETER INCLUDED)INSULIN, RAPID ONSET, 5 UNITSINSULIN, MOST RAPID ONSET (LISPRO OR ASPART); 5 UNITSINSULIN, INTERMEDIATE ACTING (NPH OR LENTE); 5 UNITSINSULIN, LONG ACTING; 5 UNITSINSULIN DELIVERY DEVICE, REUSABLE PEN; 1.5 ML SIZEINSULIN DELIVERY DEVICE, REUSABLE PEN; 3 ML SIZEINSULIN CARTRIDGE FOR USE IN INSULIN DELIVERY DEVICE OTHER THAN PUMP; 150 UNITSINSULIN CARTRIDGE FOR USE IN INSULIN DELIVERY DEVICE OTHER THAN PUMP; 300 UNITSINSULIN DELIVERY DEVICE, DISPOSABLE PEN (INCLUDING INSULIN); 1.5 ML SIZEINSULIN DELIVERY DEVICE, DISPOSABLE PEN (INCLUDING INSULIN); 3 ML SIZERADIOIMMUNOPHARMACEUTICAL LOCALIZATION OF TARGETED CELLS; WHOLE BODYSCLERAL APPLICATION OF TANTALUM RING(S) FOR LOCALIZATION OF LESIONS FOR PROTONBEAM THERAPYMAGNETIC SOURCE IMAGINGMAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)TOPOGRAPHIC BRAIN MAPPINGMAGNETIC RESONANCE IMAGING (MRI), LOW-FIELDINTRAOPERATIVE RADIATION THERAPY (SINGLE ADMINISTRATION)ULTRASOUND GUIDANCE FOR MULTIFETAL PREGNANCY REDUCTION(S), TECHNICAL COMPONENT(ONLY TO BE USED WHEN THE PHYSICIAN DOING THE REDUCTION PROCEDURE DOES NOT

Query_110708

Page 316

PERFORM THE ULTRASOUND, GUIDANCE IS INCLUDED IN THE CPT CODE FOR MULTIFETALPREGNANCY REDUCTION - 59866)COMPUTER ANALYSIS OF FULL-FIELD DIGITAL MAMMOGRAM AND FURTHER PHYSICIAN REVIEWFOR INTERPRETATION, MAMMOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FORPRIMARY PROCEDURE)SCINTIMAMMOGRAPHY (RADIOIMMUNOSCINTIGRAPHY OF THE BREAST), UNILATERAL,INCLUDING SUPPLY OF RADIOPHARMACEUTICALFLUORINE-18 FLUORODEOXYGLUCOSE (F-18 FDG) IMAGING USING DUAL-HEAD COINCIDENCEDETECTION SYSTEM (NON-DEDICATED PET SCAN)ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINE CT)COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CORONARY ARTERIES, WITH CONTRAST MATERIAL(S)WIG (FOR MEDICALLY-INDUCED OR CONGENITAL HAIR LOSS)PORTABLE PEAK FLOW METERASTHMA KIT (INCLUDING BUT NOT LIMITED TO PORTABLE PEAK EXPIRATORY FLOW METER,INSTRUCTIONAL VIDEO, BROCHURE, AND/OR SPACER)HOLDING CHAMBER OR SPACER FOR USE WITH AN INHALER OR NEBULIZER; WITHOUT MASKHOLDING CHAMBER OR SPACER FOR USE WITH AN INHALER OR NEBULIZER; WITH MASKPEAK EXPIRATORY FLOW RATE (PHYSICIAN SERVICES)OXYGEN CONTENTS, GASEOUS, 1 UNIT EQUALS 1 CUBIC FOOTOXYGEN CONTENTS, LIQUID, 1 UNIT EQUALS 1 POUNDFLUTTER DEVICESWIVEL ADAPTORTRACHEOSTOMY SUPPLY, NOT OTHERWISE CLASSIFIEDELECTRONIC SPIROMETER (OR MICROSPIROMETER)MUCUS TRAPORAL ORTHOTIC FOR TREATMENT OF SLEEP APNEA, INCLUDES FITTING, FABRICATION, ANDMATERIALSMANDIBULAR ORTHOPEDIC REPOSITIONING DEVICE, EACHHABERMAN FEEDER FOR CLEFT LIP/PALATEENURESIS ALARM, USING AUDITORY BUZZER AND/OR VIBRATION DEVICEINFECTION CONTROL SUPPLIES, NOT OTHERWISE SPECIFIEDSUPPLIES FOR HOME DELIVERY OF INFANTGRADIENT PRESSURE AID (SLEEVE AND GLOVE COMBINATION), CUSTOM MADEGRADIENT PRESSURE AID (SLEEVE AND GLOVE COMBINATION), READY MADEGRADIENT PRESSURE AID (SLEEVE), CUSTOM MADE, MEDIUM WEIGHTGRADIENT PRESSURE AID (SLEEVE), CUSTOM MADE, HEAVY WEIGHTGRADIENT PRESSURE AID (SLEEVE), READY MADEGRADIENT PRESSURE AID (GLOVE), CUSTOM MADE, MEDIUM WEIGHTGRADIENT PRESSURE AID (GLOVE), CUSTOM MADE, HEAVY WEIGHTGRADIENT PRESSURE AID (GLOVE), READY MADEGRADIENT PRESSURE AID (GAUNTLET), READY MADEGRADIENT PRESSURE EXTERIOR WRAPPADDING FOR COMPRESSION BANDAGE, ROLLCOMPRESSION BANDAGE, ROLLINTERIM POST-OPERATIVE ORTHOTIC DEVICE FOR UPPER EXTREMITY, CUSTOM MADESPLINT, PREFABRICATED, DIGIT (SPECIFY DIGIT BY USE OF MODIFIER)SPLINT, PREFABRICATED, WRIST OR ANKLESPLINT, PREFABRICATED, ELBOWCAMISOLE, POST-MASTECTOMYINSULIN SYRINGES (100 SYRINGES, ANY SIZE)EQUESTRIAN/HIPPOTHERAPY, PER SESSIONAPPLICATION OF A MODALITY (REQUIRING CONSTANT PROVIDER ATTENDANCE) TO ONE ORMORE AREAS; LOW-LEVEL LASER; EACH 15 MINUTESCOMPLEX LYMPHEDEMA THERAPY, EACH 15 MINUTESPHYSICAL OR MANIPULATIVE THERAPY PERFORMED FOR MAINTENANCE RATHER THANRESTORATIONRESUSCITATION BAG (FOR USE BY PATIENT ON ARTIFICIAL RESPIRATION DURING POWERFAILURE OR OTHER CATASTROPHIC EVENT)HOME UTERINE MONITOR WITH OR WITHOUT ASSOCIATED NURSING SERVICESULTRAFILTRATION MONITORAUTOMATED EEG MONITORING

Query_110708

Page 317

DIGITAL SUBTRACTION ANGIOGRAPHY (USE IN ADDITION TO CPT CODE FOR THE PROCEDUREFOR FURTHER IDENTIFICATION)PARANASAL SINUS ULTRASOUNDOMNICARDIOGRAM/CARDIOINTEGRAMEXTRACORPOREAL SHOCKWAVE LITHOTRIPSY FOR GALL STONES (IF PERFORMED WITH ERCP,USE 43265)PROCUREN OR OTHER GROWTH FACTOR PREPARATION TO PROMOTE WOUND HEALINGCOMA STIMULATION PER DIEMHOME ADMINISTRATION OF AEROSOLIZED DRUG THERAPY (E.G., PENTAMIDINE);ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ALLNECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY),PER DIEMSMOKING CESSATION TREATMENTGLOBAL FEE URGENT CARE CENTERSSERVICES PROVIDED IN AN URGENT CARE CENTER (LIST IN ADDITION TO CODE FORSERVICE)VERTEBRAL AXIAL DECOMPRESSION, PER SESSIONCANOLITH REPOSITIONING, PER VISITHOME VISIT FOR WOUND CAREHOME VISIT, PHOTOTHERAPY SERVICES (E.G. BILI-LITE), INCLUDING EQUIPMENT RENTAL,NURSING SERVICES, BLOOD DRAW, SUPPLIES, AND OTHER SERVICES, PER DIEMCONGESTIVE HEART FAILURE TELEMONITORING, EQUIPMENT RENTAL, INCLUDING TELESCALE,COMPUTER SYSTEM AND SOFTWARE, TELEPHONE CONNECTIONS, AND MAINTENANCE, PER MONTHBACK SCHOOL, PER VISITHOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PROVIDING CARE IN THE HOME; PERHOURNURSING CARE, IN THE HOME; BY REGISTERED NURSE, PER HOUR (USE FOR GENERALNURSING CARE ONLY, NOT TO BE USED WHEN CPT CODES 99500-99602 CAN BE USED)NURSING CARE, IN THE HOME; BY LICENSED PRACTICAL NURSE, PER HOURRESPITE CARE, IN THE HOME, PER DIEMHOSPICE CARE, IN THE HOME, PER DIEMSOCIAL WORK VISIT, IN THE HOME, PER DIEMSPEECH THERAPY, IN THE HOME, PER DIEMOCCUPATIONAL THERAPY, IN THE HOME, PER DIEMPHYSICAL THERAPY; IN THE HOME, PER DIEMDIABETIC MANAGEMENT PROGRAM, FOLLOW-UP VISIT TO NON-MD PROVIDERDIABETIC MANAGEMENT PROGRAM, FOLLOW-UP VISIT TO MD PROVIDERINSULIN PUMP INITIATION, INSTRUCTION IN INITIAL USE OF PUMP (PUMP NOT INCLUDED)EVALUATION BY OCULARISTSPEECH THERAPY, RE-EVALUATIONHOME MANAGEMENT OF PRETERM LABOR, INCLUDING ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESOR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USETHIS CODE WITH ANY HOME INFUSION PER DIEM CODE)HOME MANAGEMENT OF PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM), INCLUDINGADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ANDALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODEDSEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEMCODE)HOME MANAGEMENT OF GESTATIONAL HYPERTENSION, INCLUDES ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY); PER DIEM (DO NOT USETHIS CODE WITH ANY HOME INFUSION PER DIEM CODE)HOME MANAGEMENT OF POSTPARTUM HYPERTENSION, INCLUDES ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USETHIS CODE WITH ANY HOME INFUSION PER DIEM CODE)HOME MANAGEMENT OF PREECLAMPSIA, INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONALPHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT(DRUGS AND NURSING SERVICES CODED SEPARATELY); PER DIEM (DO NOT USE THIS CODEWITH ANY HOME INFUSION PER DIEM CODE)

Query_110708

Page 318

HOME MANAGEMENT OF GESTATIONAL DIABETES, INCLUDES ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY); PER DIEM (DO NOT USETHIS CODE WITH ANY HOME INFUSION PER DIEM CODE)HOME INFUSION THERAPY, PAIN MANAGEMENT INFUSION; ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT, (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOTUSE THIS CODE WITH S9326, S9327 OR S9328)HOME INFUSION THERAPY, CONTINUOUS (TWENTY-FOUR HOURS OR MORE) PAIN MANAGEMENTINFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITSCODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, INTERMITTENT (LESS THAN TWENTY-FOUR HOURS) PAINMANAGEMENT INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES,CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, IMPLANTED PUMP PAIN MANAGEMENT INFUSION; ADMINISTRATIVESERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARYSUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, CHEMOTHERAPY INFUSION; ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USETHIS CODE WITH S9330 OR S9331)HOME INFUSION THERAPY, CONTINUOUS (TWENTY-FOUR HOURS OR MORE) CHEMOTHERAPYINFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, INTERMITTENT (LESS THAN TWENTY-FOUR HOURS) CHEMOTHERAPYINFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME THERAPY, HEMODIALYSIS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACYSERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGSAND NURSING SERVICES CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, CONTINUOUS ANTICOAGULANT INFUSION THERAPY (E.G.HEPARIN), ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITSCODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, IMMUNOTHERAPY, ADMINISTRATIVE SERVICES, PROFESSIONALPHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT(DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME THERAPY; PERITONEAL DIALYSIS, ADMINISTRATIVE SERVICES, PROFESSIONALPHARMACY SERVICES, CARE COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT(DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME THERAPY; ENTERAL NUTRITION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACYSERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (ENTERALFORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME THERAPY; ENTERAL NUTRITION VIA GRAVITY; ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (ENTERAL FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME THERAPY; ENTERAL NUTRITION VIA PUMP; ADMINISTRATIVE SERVICES, PROFESSIONALPHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT(ENTERAL FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME THERAPY; ENTERAL NUTRITION VIA BOLUS; ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (ENTERAL FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ANTI-HEMOPHILIC AGENT INFUSION THERAPY (E.G. FACTORVIII); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ALPHA-1-PROTEINASE INHIBITOR (E.G., PROLASTIN);

Query_110708

Page 319

ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ANDALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODEDSEPARATELY), PER DIEMHOME INFUSION THERAPY, UNINTERRUPTED, LONG-TERM, CONTROLLED RATE INTRAVENOUS ORSUBCUTANEOUS INFUSION THERAPY (E.G. EPOPROSTENOL); ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, SYMPATHOMIMETIC/INOTROPIC AGENT INFUSION THERAPY (E.G.,DOBUTAMINE); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITSCODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, TOCOLYTIC INFUSION THERAPY; ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, CONTINUOUS OR INTERMITTENT ANTI-EMETIC INFUSION THERAPY;ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ANDALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND VISITS CODED SEPARATELY), PERDIEMHOME INFUSION THERAPY, CONTINUOUS INSULIN INFUSION THERAPY; ADMINISTRATIVESERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARYSUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, CHELATION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONALPHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT(DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ENZYME REPLACEMENT INTRAVENOUS THERAPY; (E.G.IMIGLUCERASE); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ANTI-TUMOR NECROSIS FACTOR INTRAVENOUS THERAPY; (E.G.INFLIXIMAB); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, DIURETIC INTRAVENOUS THERAPY; ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ANTI-SPASMOTIC THERAPY; ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); ADMINISTRATIVESERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARYSUPPLIES AND EQUIPMENT INCLUDING STANDARD TPN FORMULA (LIPIDS, SPECIALTY AMINOACID FORMULAS, DRUGS OTHER THAN IN STANDARD FORMULA AND NURSING VISITS CODEDSEPARATELY), PER DIEM (DO NOT USE WITH HOME INFUSION CODES S9365-S9368 USINGDAILY VOLUME SCALES)HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); ONE LITER PER DAY,ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ANDALL NECESSARY SUPPLIES AND EQUIPMENT INCLUDING STANDARD TPN FORMULA (LIPIDS,SPECIALTY AMINO ACID FORMULAS, DRUGS OTHER THAN IN STANDARD FORMULA AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); MORE THAN ONE LITERBUT NO MORE THAN TWO LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONALPHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENTINCLUDING STANDARD TPN FORMULA (LIPIDS, SPECIALTY AMINO ACID FORMULAS, DRUGSOTHER THAN IN STANDARD FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); MORE THAN TWO LITERSBUT NO MORE THAN THREE LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONALPHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENTINCLUDING STANDARD TPN FORMULA (LIPIDS, SPECIALTY AMINO ACID FORMULAS, DRUGSOTHER THAN IN STANDARD FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); MORE THAN THREE LITERSPER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE

Query_110708

Page 320

COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT INCLUDING STANDARD TPNFORMULA (LIPIDS, SPECIALTY AMINO ACID FORMULAS, DRUGS OTHER THAN IN STANDARDFORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME THERAPY, INTERMITTENT ANTI-EMETIC INJECTION THERAPY; ADMINISTRATIVESERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARYSUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME THERAPY; INTERMITTENT ANTICOAGULANT INJECTION THERAPY (E.G. HEPARIN);ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ANDALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODEDSEPARATELY), PER DIEM (DO NOT USE THIS CODE FOR FLUSHING OF INFUSION DEVICESWITH HEPARIN TO MAINTAIN PATENCY)HOME INFUSION THERAPY, HYDRATION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONALPHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT(DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE WITHHYDRATION THERAPY CODES S9374-S9377 USING DAILY VOLUME SCALES)HOME INFUSION THERAPY, HYDRATION THERAPY; ONE LITER PER DAY, ADMINISTRATIVESERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARYSUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, HYDRATION THERAPY; MORE THAN ONE LITER BUT NO MORE THANTWO LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES,CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, HYDRATION THERAPY; MORE THAN TWO LITERS BUT NO MORE THANTHREE LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES,CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, HYDRATION THERAPY; MORE THAN THREE LITERS PER DAY,ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ANDALL NECESSARY SUPPLIES (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, INFUSION THERAPY, NOT OTHERWISE CLASSIFIED;ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ANDALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODEDSEPARATELY), PER DIEMDELIVERY OR SERVICE TO HIGH RISK AREAS REQUIRING ESCORT OR EXTRA PROTECTION,PER VISITANTICOAGULATION CLINIC, INCLUSIVE OF ALL SERVICES EXCEPT LABORATORY TESTS, PERSESSIONPHARMACY COMPOUNDING AND DISPENSING SERVICESMEDICAL FOOD NUTRITIONALLY COMPLETE, ADMINISTERED ORALLY, PROVIDING 100% OFNUTRITIONAL INTAKEMODIFIED SOLID FOOD SUPPLEMENTS FOR INBORN ERRORS OF METABOLISMMEDICAL FOODS FOR INBORN ERRORS OF METABOLISMCHILDBIRTH PREPARATION/LAMAZE CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONCHILDBIRTH REFRESHER CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONCESAREAN BIRTH CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONVBAC (VAGINAL BIRTH AFTER CESAREAN) CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONASTHMA EDUCATION, NON-PHYSICIAN PROVIDER, PER SESSIONBIRTHING CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONLACTATION CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONPARENTING CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONPATIENT EDUCATION, NOT OTHERWISE CLASSIFIED, NON-PHYSICIAN PROVIDER,INDIVIDUAL, PER SESSIONPATIENT EDUCATION, NOT OTHERWISE CLASSIFIED, NON-PHYSICIAN PROVIDER, GROUP, PERSESSIONINFANT SAFETY (INCLUDING CPR) CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONWEIGHT MANAGEMENT CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONEXERCISE CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONNUTRITION CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONSMOKING CESSATION CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONSTRESS MANAGEMENT CLASSES, NON-PHYSICIAN PROVIDER, PER SESSIONDIABETIC MANAGEMENT PROGRAM, GROUP SESSION

Query_110708

Page 321

DIABETIC MANAGEMENT PROGRAM, NURSE VISITDIABETIC MANAGEMENT PROGRAM, DIETITIAN VISITNUTRITIONAL COUNSELING, DIETITIAN VISITCARDIAC REHABILITATION PROGRAM, NON-PHYSICIAN PROVIDER, PER DIEMPULMONARY REHABILITATION PROGRAM, NON-PHYSICIAN PROVIDER, PER DIEMENTEROSTOMAL THERAPY BY A REGISTERED NURSE CERTIFIED IN ENTEROSTOMAL THERAPY,PER DIEMAMBULATORY SETTING SUBSTANCE ABUSE TREATMENT OR DETOXIFICATION SERVICES, PERDIEMVESTIBULAR REHABILITATION PROGRAM, NON-PHYSICIAN PROVIDER, PER DIEMINTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, PER DIEMFAMILY STABILIZATION SERVICES, PER 15 MINUTESCRISIS INTERVENTION MENTAL HEALTH SERVICES, PER HOURCRISIS INTERVENTION MENTAL HEALTH SERVICES, PER DIEMHOME INFUSION THERAPY, CORTICOSTEROID INFUSION; ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY;ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ANDALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODEDSEPARATELY, PER DIEM) (DO NOT USE THIS CODE WITH HOME INFUSION CODES FOR HOURLYDOSING SCHEDULES S9497-S9504)HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY3 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY24 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY12 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY8 HOURS, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL; ONCE EVERY 6HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL; ONCE EVERY 4HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN(S), SINGLE HOME BOUND, NURSINGHOME, OR SKILLED NURSING FACILITY PATIENTHOME THERAPY; HEMATOPOIETIC HORMONE INJECTION THERAPY (E.G.ERYTHROPOIETIN,G-CSF, GM-CSF); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME TRANSFUSION OF BLOOD PRODUCT(S); ADMINISTRATIVE SERVICES, PROFESSIONALPHARMACY SERVICES, CARE COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT(BLOOD PRODUCTS, DRUGS, AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INJECTABLE THERAPY, NOT OTHERWISE CLASSIFIED, INCLUDING ADMINISTRATIVESERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARYSUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INJECTABLE THERAPY; GROWTH HORMONE, INCLUDING ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM

Query_110708

Page 322

HOME INJECTABLE THERAPY, INTERFERON, INCLUDING ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME INJECTABLE THERAPY; HORMONAL THERAPY (E.G.; LEUPROLIDE, GOSERELIN),INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARECOORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSINGVISITS CODED SEPARATELY), PER DIEMHOME INJECTABLE THERAPY, PALIVIZUMAB, INCLUDING ADMINISTRATIVE SERVICES,PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEMHOME THERAPY, IRRIGATION THERAPY (E.G. STERILE IRRIGATION OF AN ORGAN ORANATOMICAL CAVITY); INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACYSERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGSAND NURSING VISITS CODED SEPARATELY), PER DIEMHOME THERAPY; PROFESSIONAL PHARMACY SERVICES FOR PROVISION OF INFUSION,SPECIALTY DRUG ADMINISTRATION, AND/OR DISEASE STATE MANAGEMENT, NOT OTHERWISECLASSIFIED, PER HOUR (DO NOT USE THIS CODE WITH ANY PER DIEM CODE)SERVICES BY AUTHORIZED CHRISTIAN SCIENCE PRACTITIONER FOR THE PROCESS OFHEALING, PER DIEM; NOT TO BE USED FOR REST OR STUDY; EXCLUDES IN-PATIENTSERVICESHEALTH CLUB MEMBERSHIP, ANNUALTRANSPLANT RELATED LODGING, MEALS AND TRANSPORTATION, PER DIEMLODGING, PER DIEM, NOT OTHERWISE CLASSIFIEDMEALS, PER DIEM, NOT OTHERWISE SPECIFIEDMEDICAL RECORDS COPYING FEE, ADMINISTRATIVEMEDICAL RECORDS COPYING FEE, PER PAGENOT MEDICALLY NECESSARY SERVICE (PATIENT IS AWARE THAT SERVICE NOT MEDICALLYNECESSARY)SERVICES PROVIDED AS PART OF A PHASE I CLINICAL TRIALSERVICES PROVIDED OUTSIDE OF THE UNITED STATES OF AMERICA (LIST IN ADDITION TOCODE(S) FOR SERVICES(S))SERVICES PROVIDED AS PART OF A PHASE II CLINICAL TRIALSERVICES PROVIDED AS PART OF A PHASE III CLINICAL TRIALTRANSPORTATION COSTS TO AND FROM TRIAL LOCATION AND LOCAL TRANSPORTATION COSTS(E.G., FARES FOR TAXICAB OR BUS) FOR CLINICAL TRIAL PARTICIPANT AND ONECAREGIVER/COMPANIONLODGING COSTS (E.G., HOTEL CHARGES) FOR CLINICAL TRIAL PARTICIPANT AND ONECAREGIVER/COMPANIONMEALS FOR CLINICAL TRIAL PARTICIPANT AND ONE CAREGIVER/COMPANIONSALES TAXPRIVATE DUTY / INDEPENDENT NURSING SERVICE(S) - LICENSED, UP TO 15 MINUTESNURSING ASSESSMENT / EVALUATIONRN SERVICES, UP TO 15 MINUTESLPN/LVN SERVICES, UP TO 15 MINUTESSERVICES OF A QUALIFIED NURSING AIDE, UP TO 15 MINUTESRESPITE CARE SERVICES, UP TO 15 MINUTESALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, FAMILY/COUPLE COUNSELINGALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, TREATMENT PLAN DEVELOPMENT AND/ORMODIFICATIONCHILD SITTING SERVICES FOR CHILDREN OF THE INDIVIDUAL RECEIVING ALCOHOL AND/ORSUBSTANCE ABUSE SERVICESMEALS FOR INDIVIDUALS RECEIVING ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES (WHENMEALS NOT INCLUDED IN THE PROGRAM)ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, SKILLS DEVELOPMENTSIGN LANGUAGE OR ORAL INTERPRETIVE SERVICES, PER 15 MINUTESTELEHEALTH TRANSMISSION, PER MINUTE, PROFESSIONAL SERVICES BILL SEPARATELYCLINIC VISIT/ENCOUNTER, ALL-INCLUSIVECASE MANAGEMENT, EACH 15 MINUTESTARGETED CASE MANAGEMENT, EACH 15 MINUTESSCHOOL-BASED INDIVIDUALIZED EDUCATION PROGRAM (IEP) SERVICES, BUNDLEDPERSONAL CARE SERVICES, PER 15 MINUTES, NOT FOR AN INPATIENT OR RESIDENT OF A

Query_110708

Page 323

HOSPITAL, NURSING FACILITY, ICF/MR OR IMD, PART OF THE INDIVIDUALIZED PLAN OFTREATMENT (CODE MAY NOT BE USED TO IDENTIFY SERVICES PROVIDED BY HOME HEALTHAIDE OR CERTIFIED NURSE ASSISTANT)PERSONAL CARE SERVICES, PER DIEM, NOT FOR AN INPATIENT OR RESIDENT OF AHOSPITAL, NURSING FACILITY, ICF/MR OR IMD, PART OF THE INDIVIDUALIZED PLAN OFTREATMENT (CODE MAY NOT BE USED TO IDENTIFY SERVICES PROVIDED BY HOME HEALTHAIDE OR CERTIFIED NURSE ASSISTANT)HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PER VISITCONTRACTED HOME HEALTH AGENCY SERVICES, ALL SERVICES PROVIDED UNDER CONTRACT,PER DAYSCREENING TO DETERMINE THE APPROPRIATENESS OF CONSIDERATION OF AN INDIVIDUALFOR PARTICIPATION IN A SPECIFIED PROGRAM, PROJECT OR TREATMENT PROTOCOL, PERENCOUNTEREVALUATION AND TREATMENT BY AN INTEGRATED, SPECIALTY TEAM CONTRACTED TO PROVIDECOORDINATED CARE TO MULTIPLE OR SEVERELY HANDICAPPED CHILDREN, PER ENCOUNTERINTENSIVE, EXTENDED MULTIDISCIPLINARY SERVICES PROVIDED IN A CLINIC SETTING TOCHILDREN WITH COMPLEX MEDICAL, PHYSICAL, MENTAL AND PSYCHOSOCIAL IMPAIRMENTS,PER DIEMINTENSIVE, EXTENDED MULTIDISCIPLINARY SERVICES PROVIDED IN A CLINIC SETTING TOCHILDREN WITH COMPLEX MEDICAL, PHYSICAL, MEDICAL AND PSYCHOSOCIAL IMPAIRMENTS,PER HOURFAMILY TRAINING AND COUNSELING FOR CHILD DEVELOPMENT, PER 15 MINUTESASSESSMENT OF HOME, PHYSICAL AND FAMILY ENVIRONMENT, TO DETERMINE SUITABILITYTO MEET PATIENT'S MEDICAL NEEDSCOMPREHENSIVE ENVIRONMENTAL LEAD INVESTIGATION, NOT INCLUDING LABORATORYANALYSIS, PER DWELLINGNURSING CARE, IN THE HOME, BY REGISTERED NURSE, PER DIEMNURSING CARE, IN THE HOME, BY LICENSED PRACTICAL NURSE, PER DIEMADMINISTRATION OF ORAL, INTRAMUSCULAR AND/OR SUBCUTANEOUS MEDICATION BY HEALTHCARE AGENCY/PROFESSIONAL, PER VISITADMINISTRATION OF MEDICATION, OTHER THAN ORAL AND/OR INJECTABLE, BY A HEALTHCARE AGENCY/PROFESSIONAL, PER VISITMISCELLANEOUS THERAPEUTIC ITEMS AND SUPPLIES, RETAIL PURCHASES, NOT OTHERWISECLASSIFIED; IDENTIFY PRODUCT IN "REMARKS"NON-EMERGENCY TRANSPORTATION; PATIENT ATTENDANT/ESCORTNON-EMERGENCY TRANSPORTATION; PER DIEMNON-EMERGENCY TRANSPORTATION; ENCOUNTER/TRIPNON-EMERGENCY TRANSPORT; COMMERCIAL CARRIER, MULTI-PASSNON-EMERGENCY TRANSPORTATION; STRETCHER VANAMBULANCE RESPONSE AND TREATMENT, NO TRANSPORTTRANSPORTATION WAITING TIME, AIR AMBULANCE AND NON-EMERGENCY VEHICLE, ONE-HALF(1/2) HOUR INCREMENTSPREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I IDENTIFICATIONSCREENING, PER SCREENPREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL II EVALUATION, PEREVALUATIONHABILITATION, EDUCATIONAL; WAIVER, PER DIEMHABILITATION, EDUCATIONAL, WAIVER; PER HOURHABILITATION, PREVOCATIONAL, WAIVER; PER DIEMHABILITATION, PREVOCATIONAL, WAIVER; PER HOURHABILITATION, RESIDENTIAL, WAIVER; PER DIEMHABILITATION, RESIDENTIAL, WAIVER; 15 MINUTESHABILITATION, SUPPORTED EMPLOYMENT, WAIVER; PER DIEMHABILITATION, SUPPORTED EMPLOYMENT, WAIVER; PER 15 MINUTESDAY HABILITATION, WAIVER; PER DIEMDAY HABILITATION, WAIVER; PER 15 MINUTESCASE MANAGEMENT, PER MONTHTARGETED CASE MANAGEMENT; PER MONTHSERVICE ASSESSMENT/PLAN OF CARE DEVELOPMENT, WAIVERWAIVER SERVICES; NOT OTHERWISE SPECIFIED (NOS)SPECIALIZED CHILDCARE, WAIVER; PER DIEM

Query_110708

Page 324

SPECIALIZED CHILDCARE, WAIVER; PER 15 MINUTESSPECIALIZED SUPPLY, NOT OTHERWISE SPECIFIED, WAIVERSPECIALIZED MEDICAL EQUIPMENT, NOT OTHERWISE SPECIFIED, WAIVERASSISTED LIVING, WAIVER; PER MONTHASSISTED LIVING; WAIVER, PER DIEMRESIDENTIAL CARE, NOT OTHERWISE SPECIFIED (NOS), WAIVER; PER MONTHRESIDENTIAL CARE, NOT OTHERWISE SPECIFIED (NOS), WAIVER; PER DIEMCRISIS INTERVENTION, WAIVER; PER DIEMUTILITY SERVICES TO SUPPORT MEDICAL EQUIPMENT AND ASSISTIVE TECHNOLOGY/DEVICES,WAIVERTHERAPEUTIC CAMPING, OVERNIGHT, WAIVER; EACH SESSIONTHERAPEUTIC CAMPING, DAY, WAIVER; EACH SESSIONCOMMUNITY TRANSITION, WAIVER; PER SERVICEVEHICLE MODIFICATIONS, WAIVER; PER SERVICEFINANCIAL MANAGEMENT, SELF-DIRECTED, WAIVER; PER 15 MINUTESSUPPORTS BROKERAGE, SELF-DIRECTED, WAIVER; PER 15 MINUTESHOSPICE ROUTINE HOME CARE; PER DIEMHOSPICE CONTINUOUS HOME CARE; PER HOURHOSPICE INPATIENT RESPITE CARE; PER DIEMHOSPICE GENERAL INPATIENT CARE; PER DIEMHOSPICE LONG TERM CARE, ROOM AND BOARD ONLY; PER DIEMBEHAVIORAL HEALTH; LONG-TERM CARE RESIDENTIAL (NON-ACUTE CARE IN A RESIDENTIALTREATMENT PROGRAM WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), WITH ROOM ANDBOARD, PER DIEMNON-EMERGENCY TRANSPORTATION; STRETCHER VAN, MILEAGE; PER MILEHUMAN BREAST MILK PROCESSING, STORAGE AND DISTRIBUTION ONLYADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, SMALL, EACHADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, MEDIUM, EACHADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, LARGE, EACHADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, EXTRA LARGE, EACHADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,SMALL SIZE, EACHADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,MEDIUM SIZE, EACHADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,LARGE SIZE, EACHADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,EXTRA LARGE SIZE, EACHPEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, SMALL/MEDIUMSIZE, EACHPEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, LARGE SIZE, EACHPEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,SMALL/MEDIUM SIZE, EACHPEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,LARGE SIZE, EACHYOUTH SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, EACHYOUTH SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, EACHDISPOSABLE LINER/SHIELD/GUARD/PAD/UNDERGARMENT, FOR INCONTINENCE, EACHINCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, REUSABLE, ANY SIZE, EACHINCONTINENCE PRODUCT, PROTECTIVE UNDERPAD, REUSABLE, BED SIZE, EACHDIAPER SERVICE, REUSABLE DIAPER, EACH DIAPERINCONTINENCE PRODUCT, DIAPER/BRIEF, REUSABLE, ANY SIZE, EACHINCONTINENCE PRODUCT, PROTECTIVE UNDERPAD, REUSABLE, CHAIR SIZE, EACHINCONTINENCE PRODUCT, DISPOSABLE UNDERPAD, LARGE, EACHINCONTINENCE PRODUCT, DISPOSABLE UNDERPAD, SMALL SIZE, EACHDISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, BARIATRIC, EACHPOSITIONING SEAT FOR PERSONS WITH SPECIAL ORTHOPEDIC NEEDSSUPPLY, NOT OTHERWISE SPECIFIEDFRAMES, PURCHASESDELUXE FRAMESPHERE, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00, PER LENS

Query_110708

Page 325

SPHERE, SINGLE VISION, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER LENSSPHERE, SINGLE VISION, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D, PER LENSSPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12 TO2.00D CYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12 TO4.00D CYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO6.00D CYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00DCYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00 SPHERE,.12 TO 2.00D CYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00DSPHERE, 2.12 TO 4.00D CYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00DSPHERE, 4.25 TO 6.00D CYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO 7.00D SPHERE, OVER 6.00DCYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00DSPHERE, .25 TO 2.25D CYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00DSPHERE, 2.25D TO 4.00D CYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00DSPHERE, 4.25 TO 6.00D CYLINDER, PER LENSSPHEROCYLINDER, SINGLE VISION, SPHERE OVER PLUS OR MINUS 12.00D, PER LENSLENTICULAR, (MYODISC), PER LENS, SINGLE VISIONANISEIKONIC LENS, SINGLE VISIONLENTICULAR LENS, PER LENS, SINGLENOT OTHERWISE CLASSIFIED, SINGLE VISION LENSSPHERE, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D, PER LENSSPHERE, BIFOCAL, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER LENSSPHERE, BIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D, PER LENSSPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12 TO 2.00DCYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12 TO 4.00DCYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00DCYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00DCYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,.12TO 2.00D CYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 2.12TO 4.00D CYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 4.25TO 6.00D CYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, OVER6.00D CYLINDER,PER LENSSPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25TO 2.25D CYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,2.25 TO 4.00D CYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,4.25 TO 6.00D CYLINDER, PER LENSSPHEROCYLINDER, BIFOCAL, SPHERE OVER PLUS OR MINUS 12.00D, PER LENSLENTICULAR (MYODISC), PER LENS, BIFOCALANISEIKONIC, PER LENS, BIFOCALBIFOCAL SEG WIDTH OVER 28MMBIFOCAL ADD OVER 3.25DLENTICULAR LENS, PER LENS, BIFOCALSPECIALTY BIFOCAL (BY REPORT)

Query_110708

Page 326

SPHERE, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D, PER LENSSPHERE, TRIFOCAL, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER LENSSPHERE, TRIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00, PER LENSSPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12-2.00DCYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.25-4.00DCYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00CYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00DCYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, .12TO 2.00D CYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,2.12 TO 4.00D CYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,4.25 TO 6.00D CYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,OVER 6.00D CYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,.25 TO 2.25D CYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,2.25 TO 4.00D CYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,4.25 TO 6.00D CYLINDER, PER LENSSPHEROCYLINDER, TRIFOCAL, SPHERE OVER PLUS OR MINUS 12 .00D, PER LENSLENTICULAR, (MYODISC), PER LENS, TRIFOCALANISEIKONIC LENS, TRIFOCALTRIFOCAL SEG WIDTH OVER 28 MMTRIFOCAL ADD OVER 3.25DLENTICULAR LENS, PER LENS, TRIFOCALSPECIALTY TRIFOCAL (BY REPORT)VARIABLE ASPHERICITY LENS, SINGLE VISION, FULL FIELD, GLASS OR PLASTIC, PER LENSVARIABLE ASPHERICITY LENS, BIFOCAL, FULL FIELD, GLASS OR PLASTIC, PER LENSVARIABLE SPHERICITY LENS, OTHER TYPECONTACT LENS, PMMA, SPHERICAL, PER LENSCONTACT LENS, PMMA, TORIC OR PRISM BALLAST, PER LENSCONTACT LENS PMMA, BIFOCAL, PER LENSCONTACT LENS, PMMA, COLOR VISION DEFICIENCY, PER LENSCONTACT LENS, GAS PERMEABLE, SPHERICAL, PER LENSCONTACT LENS, GAS PERMEABLE, TORIC, PRISM BALLAST, PER LENSCONTACT LENS, GAS PERMEABLE, BIFOCAL, PER LENSCONTACT LENS, GAS PERMEABLE, EXTENDED WEAR, PER LENSCONTACT LENS, HYDROPHILIC, SPHERICAL, PER LENSCONTACT LENS, HYDROPHILIC, TORIC, OR PRISM BALLAST, PER LENSCONTACT LENS, HYDROPHILLIC, BIFOCAL, PER LENSCONTACT LENS, HYDROPHILIC, EXTENDED WEAR, PER LENSCONTACT LENS, SCLERAL, GAS IMPERMEABLE, PER LENS (FOR CONTACT LENSMODIFICATION, SEE 92325)CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION,SEE 92325)CONTACT LENS, OTHER TYPEHAND HELD LOW VISION AIDS AND OTHER NONSPECTACLE MOUNTED AIDSSINGLE LENS SPECTACLE MOUNTED LOW VISION AIDSTELESCOPIC AND OTHER COMPOUND LENS SYSTEM, INCLUDING DISTANCE VISIONTELESCOPIC, NEAR VISION TELESCOPES AND COMPOUND MICROSCOPIC LENS SYSTEMPROSTHETIC EYE, PLASTIC, CUSTOMPOLISHING/RESURFACING OF OCULAR PROSTHESISENLARGEMENT OF OCULAR PROSTHESISREDUCTION OF OCULAR PROSTHESISSCLERAL COVER SHELL

Query_110708

Page 327

FABRICATION AND FITTING OF OCULAR CONFORMERPROSTHETIC EYE, OTHER TYPEANTERIOR CHAMBER INTRAOCULAR LENSIRIS SUPPORTED INTRAOCULAR LENSPOSTERIOR CHAMBER INTRAOCULAR LENSBALANCE LENS, PER LENSDELUXE LENS FEATURESLAB OFF PRISM, GLASS OR PLASTIC, PER LENSPRISM, PER LENSPRESS-ON LENS, FRESNELL PRISM, PER LENSSPECIAL BASE CURVE, GLASS OR PLASTIC, PER LENSTINT, PHOTOCHROMATIC, PER LENSADDITION TO LENS; TINT, ANY COLOR, SOLID, GRADIENT OR EQUAL, EXCLUDESPHOTOCHROMATIC, ANY LENS MATERIAL, PER LENSANTI-REFLECTIVE COATING, PER LENSU-V LENS, PER LENSEYE GLASS CASESCRATCH RESISTANT COATING, PER LENSMIRROR COATING, ANY TYPE, SOLID, GRADIENT OR EQUAL, ANY LENS MATERIAL, PER LENSPOLARIZATION, ANY LENS MATERIAL, PER LENSOCCLUDER LENS, PER LENSOVERSIZE LENS, PER LENSPROGRESSIVE LENS, PER LENSLENS, INDEX 1.54 TO 1.65 PLASTIC OR 1.60 TO 1.79 GLASS, EXCLUDES POLYCARBONATE,PER LENSLENS, INDEX GREATER THAN OR EQUAL TO 1.66 PLASTIC OR GREATER THAN OR EQUAL TO1.80 GLASS, EXCLUDES POLYCARBONATE, PER LENSLENS, POLYCARBONATE OR EQUAL, ANY INDEX, PER LENSPROCESSING, PRESERVING AND TRANSPORTING CORNEAL TISSUESPECIALTY OCCUPATIONAL MULTIFOCAL LENS, PER LENSASTIGMATISM CORRECTING FUNCTION OF INTRAOCULAR LENSPRESBYOPIA CORRECTING FUNCTION OF INTRAOCULAR LENSAMNIOTIC MEMBRANE FOR SURGICAL RECONSTRUCTION, PER PROCEDUREVISION SUPPLY, ACCESSORY AND/OR SERVICE COMPONENT OF ANOTHER HCPCS VISION CODEVISION SERVICE, MISCELLANEOUSHEARING SCREENINGASSESSMENT FOR HEARING AIDFITTING/ORIENTATION/CHECKING OF HEARING AIDREPAIR/MODIFICATION OF A HEARING AIDCONFORMITY EVALUATIONHEARING AID, MONAURAL, BODY WORN, AIR CONDUCTIONHEARING AID, MONAURAL, BODY WORN, BONE CONDUCTIONHEARING AID, MONAURAL, IN THE EARHEARING AID, MONAURAL, BEHIND THE EARGLASSES, AIR CONDUCTIONGLASSES, BONE CONDUCTIONDISPENSING FEE, UNSPECIFIED HEARING AIDSEMI-IMPLANTABLE MIDDLE EAR HEARING PROSTHESISHEARING AID, BILATERAL, BODY WORNDISPENSING FEE, BILATERALBINAURAL, BODYBINAURAL, IN THE EARBINAURAL, BEHIND THE EARBINAURAL, GLASSESDISPENSING FEE, BINAURALHEARING AID, CROS, IN THE EARHEARING AID, CROS, BEHIND THE EARHEARING AID, CROS, GLASSESDISPENSING FEE, CROSHEARING AID, BICROS, IN THE EARHEARING AID, BICROS, BEHIND THE EAR

Query_110708

Page 328

HEARING AID, BICROS, GLASSESDISPENSING FEE, BICROSDISPENSING FEE, MONAURAL HEARING AID, ANY TYPEHEARING AID, ANALOG, MONAURAL, CIC (COMPLETELY IN THE EAR CANAL)HEARING AID, ANALOG, MONAURAL, ITC (IN THE CANAL)HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, CICHEARING AID, DIGITALLY PROGRAMMABLE, ANALOG, MONAURAL, ITCHEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, ITE (IN THE EAR)HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, BTE (BEHIND THE EAR)HEARING AID, ANALOG, BINAURAL, CICHEARING AID, ANALOG, BINAURAL, ITCHEARING AID, DIGITALLY PROGRAMMABLE ANALOG, BINAURAL, CICHEARING AID, DIGITALLY PROGRAMMABLE ANALOG, BINAURAL, ITCHEARING AID, DIGITALLY PROGRAMMABLE, BINAURAL, ITEHEARING AID, DIGITALLY PROGRAMMABLE, BINAURAL, BTEHEARING AID, DIGITAL, MONAURAL, CICHEARING AID, DIGITAL, MONAURAL, ITCHEARING AID, DIGITAL, MONAURAL, ITEHEARING AID, DIGITAL, MONAURAL, BTEHEARING AID, DIGITAL, BINAURAL, CICHEARING AID, DIGITAL, BINAURAL, ITCHEARING AID, DIGITAL, BINAURAL, ITEHEARING AID, DIGITAL, BINAURAL, BTEHEARING AID, DISPOSABLE, ANY TYPE, MONAURALHEARING AID, DISPOSABLE, ANY TYPE, BINAURALEAR MOLD/INSERT, NOT DISPOSABLE, ANY TYPEEAR MOLD/INSERT, DISPOSABLE, ANY TYPEBATTERY FOR USE IN HEARING DEVICEHEARING AID SUPPLIES / ACCESSORIESASSISTIVE LISTENING DEVICE, TELEPHONE AMPLIFIER, ANY TYPEASSISTIVE LISTENING DEVICE, ALERTING, ANY TYPEASSISTIVE LISTENING DEVICE, TELEVISION AMPLIFIER, ANY TYPEASSISTIVE LISTENING DEVICE, TELEVISION CAPTION DECODERASSISTIVE LISTENING DEVICE, TDDASSISTIVE LISTENING DEVICE, FOR USE WITH COCHLEAR IMPLANTASSISTIVE LISTENING DEVICE, NOT OTHERWISE SPECIFIEDEAR IMPRESSION, EACHHEARING AID, NOT OTHERWISE CLASSIFIEDHEARING SERVICE, MISCELLANEOUSREPAIR/MODIFICATION OF AUGMENTATIVE COMMUNICATIVE SYSTEM OR DEVICE (EXCLUDESADAPTIVE HEARING AID)SPEECH SCREENINGLANGUAGE SCREENINGDYSPHAGIA SCREENING

Query_110708

Page 329

Short Description Code Add Date Action Eff DateDressing for one wound 20020701 20020701Dressing for two wounds 20020701 20020701Dressing for three wounds 20020701 20020701Dressing for four wounds 20020701 20020701Dressing for five wounds 20020701 20020701Dressing for six wounds 20020701 20020701Dressing for seven wounds 20020701 20020701Dressing for eight wounds 20020701 20020701Dressing for 9 or more wound 20020701 20020701Anesthesia perf by anesgst 19840101 20010101MD supervision, >4 anes proc 19840101 20010101

Registered dietician 20050101 20050101Specialty physician 20050101 20050101Primary physician 20050101 20050101Clinical psychologist 19910101 19970101Clinical social worker 19910101 19970101Non participating physician 20050101 20050101Physician, team member svc 19910101 19970101No dtmn of refractive state 19840101 19970101

Physician service HPSA area 20060101 20060101

Physician scarcity area 20050101 20050101Assistant at surgery service 19880101 19990101

Acute treatment 19840101 19980101

Uro, ostomy or trach item 20030101 20030101Item w prosthetic/orthotic 20030101 20030101Item w a surgical dressing 20030101 20030101Item w dialysis services 20030101 20030101Item w pen services 20030101 20030101Spec acquisition blood prods 20050701 20050701Nutrition oral admin no tube 20030101 20030101Bene electd to purchase item 19920101 19970101

Bene elected to rent item 19920101 19970101

Bene undecided on purch/rent 19920101 19970101

Procedure payable inpatient 20030101 20030101

ESRD bene part a snf-sep pay 20030401 20040101

Procedure code change 19900101 19970101

AMCC test for ESRD or MCP MD 20040101 20040101

Med neces AMCC tst sep reimb 20040101 20040101

AMCC tst not composite rate 20040101 20040101

Query_110708

Page 330

Policy criteria applied 20080701 20080701Catastrophe/disaster related 20050821 20050821Upper left eyelid 19950101 19990101Lower left eyelid 19950101 19990101Upper right eyelid 19950101 19990101Lower right eyelid 19950101 19990101ESA, anemia, chemo-induced 20080101 20080101

ESA, anemia, radio-induced 20080101 20080101

ESA, anemia, non-chemo/radio 20080101 20080101

HCT>39% or Hgb>13g>=3 cycle 20080101 20080101

HCT>39% or Hgb>13g<3 cycle 20080101 20080101

Subsequent claim 19910101 20000101

Emer reserve supply (ESRD) 19910101 19970101Medicaid EPSDT program svc 19870101 19970101

Emergency Services 19840101 20020101No md order for item/service 20030101 20030101

Left hand, second digit 19950101 19990101Left hand, third digit 19950101 19990101Left hand, fourth digit 19950101 19990101Left hand, fifth digit 19950101 19990101Right hand, thumb 19950101 19990101Right hand, second digit 19950101 19990101Right hand, third digit 19950101 19990101Right hand, fourth digit 19950101 19990101Right hand, fifth digit 19950101 19990101Left hand, thumb 19950101 19990101Item provided without cost 20060101 20080101

Part credit, replaced device 20080101 20080101Svc part of family plan pgm 19870101 20050101URR reading of less than 60 19970101 19980101 URR reading of 60 to 64.9 19970101 19980101URR reading of 65 to 69.9 19970101 19980101URR reading of 70 to 74.9 19970101 19970101URR reading of 75 or greater 19970101 19980101ESRD patient <6 dialysis/mth 19980501 19980501

Payment limits do not apply 19990701 19990701

Monitored anesthesia care 19990701 19990701

MAC for at risk patient 19990701 19990701

Waiver of Liability on file 19950101 19970101Claim resubmitted 20020101 20020101

Resident/teaching phys serv 19970101 20010101

Unit of service > MUE value 20080101 20080101

Query_110708

Page 331

Resident prim care exception 19970101 19970101

Nonphysician serv c a hosp 20030401 20030401

Payment screen mam + diagmam 20020101 20020101

Diag mammo to screening mamo 19981001 19981001Opt out provider of er srvc 19981001 19981001Actual item/service ordered 20020101 20080101Upgraded item, no charge 20020101 20080101

Multiple transports 20020101 20020101OP speech language service 19990101 20030101OP occupational therapy serv 19990101 20030101OP PT services 19990101 20030101Telehealth store and forward 20011001 20011001Service by va resident 20060101 20060101

Epo/darbepoietin reduced 25% 20060101 20061001

InteractiveTelecommunication 19990101 19990101Attending phys not hospice 20020101 20020101

Service unrelated to term co 20020101 20020101Statutorily excluded 20020101 20070701

Not reasonable and necessary 20020101 20020101Court-ordered 20030101 20030101Child/adolescent program 20030101 20030101Adult program non-geriatric 20030101 20030101Adult program geriatric 20030101 20030101Pregnant/parenting program 20030101 20030101Mental health program 20030101 20030101Substance abuse program 20030101 20030101Opioid addiction tx program 20030101 20030101Mental hlth/substance abs pr 20030101 20030101M hlth/m retrdtn/dev dis pro 20030101 20030101

Employee assistance program 20030101 20030101Spec hgh rsk mntl hlth pop p 20030101 20030101intern 20030101 20030101Less than bachelor degree lv 20030101 20030101Bachelors degree level 20030101 20030101Masters degree level 20030101 20030101Doctoral level 20030101 20030101Group setting 20030101 20030101Family/couple w client prsnt 20030101 20030101Family/couple w/o client prs 20030101 20030101Multi-disciplinary team 20030101 20030101Child welfare agency funded 20030101 20030101Funded state addiction agncy 20030101 20030101State mntl hlth agncy funded 20030101 20030101County/local agency funded 20030101 20030101Funded by juvenile justice 20030101 20030101Criminal justice agncy fund 20030101 20030101CAP no-pay for prescript num 20060101 20060101CAP restock of emerg drugs 20060101 20060101

CAP drug unavail thru cap 20060101 20060101

Query_110708

Page 332

Administered intravenously 20070101 20070101Administered subcutaneously 20070101 20070101Skin substitute graft 20090101 20090101Skin sub not used as a graft 20090101 20090101Discarded drug not administe 20030101 20030101Lwr ext prost functnl lvl 0 19930101 20030101

Lwr ext prost functnl lvl 1 19930101 19970101




Wheelchair add-on option/acc 19940101 19970101>4 modifiers on claim 20030101 20030101Repl special pwr wc intrface 20050101 20050101Drug/biological DME infused 20040101 20040101Bid under round 1 DMEPOS CB 20090101 20090101

FDA class III device 20040401 20040401DMEPOS comp bid prgm no 1 20070701 20070701DMEPOS ini clm, pur/1 mo rnt 19940101 19970101DMEPOS 2nd or 3rd mo rental 19940101 19970101DMEPOS PEN pmp or 4-15mo rnt 19940101 19970101

DMEPOS comp bid prgm no 2 20070701 20070701DMEPOS mailorder comp bid 20070701 20090101Rplc facial prosth new imp 19960101 20010101Rplc facial prosth old mod 19960101 20010101Single drug unit dose form 19970401 19970401First drug of multi drug u d 19970401 199704012nd/subsqnt drg multi drg ud 19970401 19970401Rental item partial month 20020101 20020101Glucose monitor supply 19981001 19981001Item from noncontract supply 20070701 20080401

DMEPOS comp bid prgm no 3 20070701 20070701DMEPOS item, profession serv 20080101 20080101

DMEPOS comp bid prgm no 4 20080101 20080101Documentation on file 20020701 20020701DMEPOS comp bid prgm no 5 20080101 20080101New cov not implement by m+c 20031001 20031001Lft circum coronary artery 19970101 19970101Left ant des coronary artery 19970101 19970101Lease/rental (appld to pur) 19840101 19970101

Laboratory round trip 19870101 19970101FDA-monitored IOL implant 19910101 19970101

Query_110708

Page 333

Left side 19840101 19970101Medicare secondary payer 20070101 200701016-mo maint/svc fee parts/lbr 19890101 19970101

New when rented 19840101 19970101

New equipment 19840101 19970101Normal healthy patient 20060101 20060101Patient w/mild syst disease 20060101 20060101Patient w/severe sys disease 20060101 20060101Pt w/sev sys dis threat life 20060101 20060101Pt not expect surv w/o oper 20060101 20060101Brain-dead pt organs removed 20060101 20060101Progressive addition lenses 19890101 19970101Invest clinical research 20080101 20080101

Routine clinical research 20080101 20080101

HCFA/ORD demo procedure/svc 19920101 19970101Liver donor surgery/services 19950101 20030101Svc exempt - ordrg/rfrng MD 19940101 19970101Subst MD svc, recip bill arr 19930101 19970101

Locum tenens MD service 19930101 19970101One Class A finding 19950101 19970101Two Class B findings 19950101 199701011 Class B & 2 Class C fndngs 19950101 19970101FDA investigational device 19960101 20080101MD prvdg svc in rural HPSA 19920101 20060101Single channel monitoring 19890101 19970101Rcrdg/strg in sld st memory 19890101 19970101Prescribed oxygen < 1 LPM 19890101 19970101Prscrbd oxygen >4 LPM & port 19890101 19970101

Prescribed oxygen > 4 LPM 19890101 19970101Oxygen cnsrvg dvc w del sys 19890101 19970101Patient in state/locl custod 20030101 20030101

Med dir 2-4 cncrnt anes proc 19950101 20010101

Patient died after amb call 19990101 19990101Ambulance arr by provider 19960101 19990101Ambulance furn by provider 19960101 19990101Individually ordered lab tst 19960101 19960301

SOI submitted 20001001 20060101Item/serv in medicare study 20050101 20080101Monitored anesthesia care 19900101 19960701Rcrdg/strg tape analog recdr 19890101 19970101MD providing svc urban HPSA 19910101 20060101Item or service provided 20000919 20080101CLIA waived test 19960101 19961001CRNA svc w/ MD med direction 19930101 19970101Medically directed CRNA 19980101 20010101

CRNA svc w/o med dir by MD 19930101 19970101Replacement of DME item 20090101 20090101Replacement part, DME item 20090101 20090101Right coronary artery 19970101 19970101

Query_110708

Page 334

Drug admin not incident-to 20040101 20040101Furnish full compliance REMS 20090101 20090101

Replacement & repair(DMEPOS) 19840101 20090101

Rental (DME) 19840101 19970101Right side 19840101 19970101Nurse practitioner w physici 20010701 20010701Nurse midwife 20010701 20010701Medically necessary serv/sup 20010701 20010701Serv by home infusion RN 20010701 20010701

State/fed funded program/ser 20010701 200107012nd opinion ordered by PRO 19870101 19970101

ASC facility service 19920101 199701012nd concurrent infusion ther 20010701 200107013rd concurrent infusion ther 20010701 20010701High risk population 20020401 20020401State supplied vaccine 20020401 20020401Second opinion 20020701 20020701Third opinion 20020701 20020701Item ordered by home health 20021001 20021001HIT in infusion suite 20041001 20041001Related to trauma or injury 20030101 20030101Performed in phys office 20030101 20030101

Drugs delivered not used 20030101 20030101Serv by cert diab educator 20040401 20040401Contact w/high-risk pop 20050101 20050101

Left foot, second digit 19950101 19990101Left foot, third digit 19950101 19990101Left foot, fourth digit 19950101 19990101Left foot, fifth digit 19950101 19990101Right foot, great toe 19950101 19990101Right foot, second digit 19950101 19990101Right foot, third digit 19950101 19990101Right foot, fourth digit 19950101 19990101Right foot, fifth digit 19950101 19990101Left foot, great toe 19950101 19990101Technical component 19840101 19970101

RN 20010701 20010701LPN/LVN 20010701 20010701Intermediate level of care 20010701 20010701Complex/High Tech level care 20010701 20010701OB TX/Srvcs prenatl/postpart 20010701 20010701Child/adolescent program gp 20010701 20010701Extra patient or passenger 20020401 20020401Early intervention IFSP 20020401 20020401Individualized ed prgrm(IEP) 20020401 20020401Rural/out of service area 20020401 20020401Med transprt unloaded vehicl 20020401 20020401

Query_110708

Page 335

BLS by volunteer amb providr 20020401 20020401School-based IEP out of dist 20020701 20020701

Follow-up service 20021001 20060101Additional patient 20021001 20021001Overtime payment rate 20030101 20030101Holiday/weekend payment rate 20030101 20030101Back-up equipment 20030101 20030101M/caid care lev 1 state def 20020701 20020701M/caid care lev 2 state def 20020701 20020701M/caid care lev 3 state def 20020701 20020701M/caid care lev 4 state def 20020701 20020701M/caid care lev 5 state def 20020701 20020701M/caid care lev 6 state def 20020701 20020701M/caid care lev 7 state def 20020701 20020701M/caid care lev 8 state def 20020701 20020701M/caid care lev 9 state def 20020701 20020701M/caid care lev 10 state def 20020701 20020701M/caid care lev 11 state def 20020701 20020701M/caid care lev 12 state def 20020701 20020701M/caid care lev 13 state def 20020701 20020701Used durable med equipment 19840101 19970101Services provided, morning 20030401 20030401Services provided, afternoon 20030401 20030401Services provided, evening 20030401 20030401Services provided, night 20030401 20030401Svc on behalf client-collat 20030401 20030401

Two patients served 20040101 20040101Three patients served 20040101 20040101Four patients served 20040101 20040101Five patients served 20040101 20040101Six or more patients served 20040101 20040101Aphakic patient 19840101 19970101Outside state ambulance serv 19850101 19960910Noninterest escort in non er 19820101 20030101

Interest escort in non er 19820101 20030101

Nonemergency transport taxi 19820101 20030101Nonemergency transport bus 19840101 19950101Noner transport mini-bus 19820101 20030101

Noner transport wheelch van 19820101 19950101Nonemergency transport air 19850101 19960910

Noner transport case worker 19840101 19950101Transport parking fees/tolls 19820101 20030101Noner transport lodgng recip 19820101 19950101Noner transport meals recip 19840101 19950101Noner transport lodgng escrt 19820101 19950101Noner transport meals escort 19840101 19950101Neonatal emergency transport 19850101 20030401Basic life support mileage 19950101 20030101Basic support routine suppls 19950101 19950101Bls defibrillation supplies 19950101 19950101

Advanced life support mileag 19950101 20030101Als defibrillation supplies 19950101 19950101

Query_110708

Page 336

Als IV drug therapy supplies 19950101 19950101Als esophageal intub suppls 19950101 19950101Als routine disposble suppls 19950101 19950101Ambulance waiting 1/2 hr 19950101 19950101Ambulance 02 life sustaining 19950101 19950101Extra ambulance attendant 19950101 20030101

Ground mileage 20010101 20010101Als 1 20010101 20010101

ALS1-emergency 20010101 20010101

bls 20010101 20010101BLS-emergency 20010101 20010101Fixed wing air transport 20010101 20010101Rotary wing air transport 20010101 20010101PI volunteer ambulance co 20010101 20010101

als 2 20010101 20010101Specialty care transport 20010101 20010101Fixed wing air mileage 20010101 20010101Rotary wing air mileage 20010101 20010101Amb trans 7pm-7am 20040101 20070101Noncovered ambulance mileage 19950101 19950101

Ambulance response/treatment 20060101 20060101Unlisted ambulance service 19870101 199801011 CC sterile syringe&needle 19850101 200801012 CC sterile syringe&needle 19850101 200701013 CC sterile syringe&needle 19850101 200701015+ CC sterile syringe&needle 19850101 20070101Nonneedle injection device 19890101 19960101Supp for self-adm injections 19930101 19970101Non coring needle or stylet 19930101 2000010120+ CC syringe only 19850101 20070101Sterile needle 19850101 20070101Sterile water/saline, 10 ml 20040101 20070101Sterile water/saline, 500 ml 20040101 20040101Sterile saline or water 20060101 20060101Infusion pump refill kit 19940101 19980303Maint drug infus cath per wk 19970101 19970101

Infusion supplies with pump 19970101 20050101

Infusion supplies w/o pump 20050101 20070101

Infus insulin pump non needl 19960101 20000101Infusion insulin pump needle 19960101 20000101Syringe w/needle insulin 3cc 19960101 20030401Alkalin batt for glucose mon 20060101 20060101

J-cell batt for glucose mon 20060101 20060101

Lithium batt for glucose mon 20060101 20060101

Silvr oxide batt glucose mon 20060101 20060101

Alcohol or peroxide per pint 19850101 20070101Alcohol wipes per box 19850101 20070101Betadine/phisohex solution 19850101 20070101

Query_110708

Page 337

Betadine/iodine swabs/wipes 19850101 20070101Chlorhexidine antisept 20040101 20040101Urine reagent strips/tablets 19900101 19970101Blood ketone test or strip 20080101 20080101Blood glucose/reagent strips 19860101 19980701

Battery for glucose monitor 19960101 20060101

Glucose monitor platforms 19970101 20020101Calibrator solution/chips 19850101 20020101Replace Lensshield Cartridge 20020101 20020101Lancet device each 19960101 20020101Lancets per box 19850101 19960101Levonorgestrel implant 19930101 20060101Cervical cap contraceptive 19990101 19990101Temporary tear duct plug 19940101 19980101Permanent tear duct plug 19940101 19980101Paraffin 19860101 20020101Diaphragm 20030101 20030101Male condom 20030101 20030101Female condom 20030101 20030101Spermicide 20030101 20030101Disposable endoscope sheath 19940101 19950401Brst prsths adhsv attchmnt 20000101 20000101Replacement breastpump tube 20030101 20070101Replacement breastpump adpt 20030101 20070101Replacement breastpump cap 20030101 20070101Replcmnt breast pump shield 20030101 20070101Replcmnt breast pump bottle 20030101 20070101Replcmnt breastpump lok ring 20030101 20070101Sacral nerve stim test lead 20010101 20020101Cath impl vasc access portal 19860101 20020101

Implantable access syst perc 19960101 20030101

Drug delivery system >=50 ML 19930101 20060101Drug delivery system <=50 ml 19930101 20070101Insert tray w/o bag/cath 19900101 19900101Catheter w/o bag 2-way latex 19900101 19900101

Cath w/o bag 2-way silicone 19900101 19900101

Catheter w/bag 3-way 19900101 19900101

Cath w/drainage 2-way latex 19900101 19900101

Cath w/drainage 2-way silcne 19900101 19900101

Cath w/drainage 3-way 19900101 19900101

Irrigation tray 19900101 19920101Cath therapeutic irrig agent 19970101 20030101Irrigation syringe 19900101 19960101Male external catheter 19900101 20070101Fem urinary collect dev cup 19900101 19900101Fem urinary collect pouch 19900101 19900101Stool collection pouch 19900101 19960101Extension drainage tubing 20010101 20030101

Lube sterile packet 20010101 20050101

Query_110708

Page 338

Urinary cath anchor device 20010101 20030101Urinary cath leg strap 20010101 20030101Incontinence supply 19900101 19900101Indwelling catheter latex 19900101 19960101

Indwelling catheter special 19900101 19960101Cath indw foley 2 way silicn 19830101 19960101Cath indw foley 3 way 19830101 19960101Male ext cath extended wear 20010101 20070101

Disposable male external cat 20050101 20050101Straight tip urine catheter 19900101 20020101

Coude tip urinary catheter 19900101 20020101

Intermittent urinary cath 19970101 20030101Cath insertion tray w/bag 19860101 19900101Bladder irrigation tubing 19840101 19960101

Ext ureth clmp or compr dvc 19850101 19960101

Bedside drainage bag 19850101 19960101

Urinary leg or abdomen bag 19850101 20020101

Urinary suspensory w/o leg b 19850101 20070101Ostomy face plate 19850101 19960101Solid skin barrier 19850101 19900101Ostomy clamp, replacement 20060101 20060101Adhesive, liquid or equal 19850101 20030101Adhesive remover wipes 19970101 20030101Ostomy vent 20040101 20040101Ostomy belt 19850101 19960101Ostomy filter 19970101 19970101Skin barrier liquid per oz 20000101 20030101Skin barrier powder per oz 20000101 20030101Skin barrier solid 4x4 equiv 20000101 20060101

Skin barrier with flange 20000101 20030101

Drainable plastic pch w fcpl 20000101 20030101Drainable rubber pch w fcplt 20000101 20030101Drainable plstic pch w/o fp 20000101 20030101Drainable rubber pch w/o fp 20000101 20030101Urinary plastic pouch w fcpl 20000101 20030101Urinary rubber pouch w fcplt 20000101 20030101Urinary plastic pouch w/o fp 20000101 20030101Urinary hvy plstc pch w/o fp 20000101 20030101Urinary rubber pouch w/o fp 20000101 20030101Ostomy faceplt/silicone ring 20000101 20030101Ost skn barrier sld ext wear 20000101 20030101

Ost clsd pouch w att st barr 20000101 20030101

Drainable pch w ex wear barr 20000101 20030101Drainable pch w st wear barr 20000101 20030101

Drainable pch ex wear convex 20000101 20030101

Urinary pouch w ex wear barr 20000101 20030101Urinary pouch w st wear barr 20000101 20030101

Query_110708

Page 339

Urine pch w ex wear bar conv 20000101 20030101

Ostomy pouch liq deodorant 20000101 20070101

Ostomy pouch solid deodorant 20000101 20030101Peristomal hernia supprt blt 20010101 20030101Irrigation supply sleeve 19900101 19960101Ostomy irrigation bag 19890101 19970101Ostomy irrig cone/cath w brs 19890101 19970101Ostomy irrigation set 19820101 19900101Lubricant per ounce 19850101 19950101Ostomy ring each 19850101 19950101Nonpectin based ostomy paste 20030101 20030101Pectin based ostomy paste 20030101 20030101Ext wear ost skn barr <=4sq" 20030101 20030101

Ext wear ost skn barr >4sq" 20030101 20030101

Ost skn barr convex <=4 sq i 20030101 20060101

Ost skn barr extnd >4 sq 20030101 20060101

Ost skn barr extnd =4sq 20060101 20060101

Ost pouch drain high output 20060101 20060101

2 pc drainable ost pouch 20030101 20030101

Ost sknbar w/o conv<=4 sq in 20030101 20060101

Ost skn barr w/o conv >4 sqi 20030101 20060101

Ost pch clsd w barrier/filtr 20040101 20040101Ost pch w bar/bltinconv/fltr 20040101 20040101

Ost pch clsd w/o bar w filtr 20040101 20040101Ost pch for bar w flange/flt 20040101 20040101

Ost pch clsd for bar w lk fl 20040101 20040101Ostomy supply misc 19850101 20070101Ost pouch absorbent material 20030101 20030101

Ost pch for bar w lk fl/fltr 20040101 20040101

Ost pch drain w bar & filter 20040101 20040101Ost pch drain for barrier fl 20040101 20040101

Ost pch drain 2 piece system 20040101 20040101

Ost pch drain/barr lk flng/f 20040101 20040101

Urine ost pouch w faucet/tap 20040101 20040101

Urine ost pouch w bltinconv 20040101 20040101

Ost urine pch w b/bltin conv 20040101 20040101

Ost pch urine w barrier/tapv 20040101 20040101

Os pch urine w bar/fange/tap 20040101 20040101

Query_110708

Page 340

Urine ost pch bar w lock fln 20040101 20040101Ost pch urine w lock flng/ft 20040101 20040101

Non-waterproof tape 20030101 20030101Waterproof tape 20030101 20030101Adhesive remover per ounce 19890101 19950101Reusable enema bag 20030101 20070101Surgicl dress hold non-reuse 20070101 20070101Abdmnl drssng holder/binder 19980101 20070101Surgical dress holder reuse 20070101 20070101Non-elastic extremity binder 19940101 19950101Gravlee jet washer 19860101 20010101Vabra aspirator 19860101 20010101Tracheostoma filter 19970101 20030101Moisture exchanger 19990101 20030101Above knee surgical stocking 19860101 20030101Thigh length surg stocking 19860101 20030101Below knee surgical stocking 19860101 20030101Full length surg stocking 19860101 20030101Incontinence garment anytype 20050101 20050101Surgical trays 19820101 20000101Disposable underpads 19860101 20050101Electrodes, pair 19840101 20000101Lead wires, pair 19840101 20000101Conductive gel or paste 19850101 20070101

Coupling gel or paste 20070101 20070101Pessary rubber, any type 20010101 20010101Pessary, non rubber,any type 20010101 20010101Slings 19830101 19960101Splint 19820101 20010701Hyperbaric o2 chamber disps 19960101 19960101Cast supplies (plaster) 19820101 20030101Special casting material 19840101 20030101TENS suppl 2 lead per month 19960101 20030101Sleeve, inter limb comp dev 20070101 20070101Lith ion batt, non-pros use 20070101 20070101Tubing with heating element 20060101 20060101

Trach suction cath close sys 20050101 20050101Oxygen probe used w oximeter 20030101 20030101Transtracheal oxygen cath 20010101 20090101Heavy duty battery 19900101 19960101Battery cables 19900101 19960101Battery charger 19900101 19960101Hand-held PEFR meter 19990101 19990101Cannula nasal 19900101 20090101Tubing (oxygen) per foot 19900101 20090101Mouth piece 19900101 20090101Breathing circuits 19900101 19930101Face tent 19900101 19960101Variable concentration mask 19900101 20090101Tracheostomy inner cannula 19900101 20040101Tracheal suction tube 19900101 20030101Trach care kit for new trach 19900101 20030101Tracheostomy cleaning brush 19900101 20030101Spacer bag/reservoir 19910101 19970101

Oropharyngeal suction cath 19960101 19960101Tracheostomy care kit 19960101 20030101

Query_110708

Page 341

Repl bat t.e.n.s. own by pt 19910101 20060101

Infus pump rplcemnt battery 20030101 20070101Uvl replacement bulb 20030101 20030101Replacement bulb th lightbox 20030101 20030101Underarm crutch pad 19910101 19960101Handgrip for cane etc 19910101 19960101Repl tip cane/crutch/walker 19910101 19960101Repl batt pulse gen sys 20040101 20040101Infrared ht sys replcmnt pad 20030101 20030101Alternating pressure pad 19910101 19960101

Radiopharm dx agent noc 19940101 20060101In111 satumomab 19950101 20060101

High dose contrast MRI 19950101 20060101

Contrast 100-199 MGs iodine 19940101 20060101Contrast 200-299 MGs iodine 19940101 20060101Contrast 300-399 MGs iodine 19940101 20060101Supp- paramagnetic contr mat 19900101 20060101Implantable tissue marker 20080101 20080101Surgical supplies 19820101 19980101Implant radiation dosimeter 20080101 20080101Calibrated microcap tube 20020101 20020101Microcapillary tube sealant 20020101 20020101PD catheter anchor belt 20030101 20030101Needle any size 20020101 20060101Syringe w/wo needle 20020101 20030101Sphyg/bp app w cuff and stet 19860101 20030101Dialysis blood pressure cuff 19860101 20030101Automatic bp monitor, dial 19860101 20030101Disposable cycler set 20040101 20040101Drainage ext line, dialysis 20040101 20040101Ext line w easy lock connect 20040101 20040101Chem/antisept solution, 8oz 20040101 20040101

Activated carbon filter, ea 19860101 20020101Dialyzer, each 19860101 20020101Bicarbonate conc sol per gal 20020101 20020101Bicarbonate conc pow per pac 20020101 20020101Acetate conc sol per gallon 20020101 20020101Acid conc sol per gallon 20020101 20020101Treated water per gallon 19860101 20020101

"Y set" tubing 20020101 20020101Dialysat sol fld vol > 249cc 20020101 20020101

Dialysat sol fld vol > 999cc 20020101 20020101

Dialys sol fld vol > 1999cc 20020101 20020101





Dialysate solution, non-dex 20040101 20040101

Query_110708

Page 342

Fistula cannulation set, ea 19860101 20020101Topical anesthetic, per gram 20020101 20020101Inj anesthetic per 10 ml 20020101 20020101Shunt accessory 19860101 20020101Art or venous blood tubing 19860101 20020101Comb art/venous blood tubing 19860101 20020101Dialysate sol test kit, each 19860101 20020101Dialysate conc pow per pack 19860101 20020101Dialysate conc sol add 10 ml 20020101 20020101Blood collection tube/vacuum 19860101 20020101Serum clotting time tube 19860101 20020101Blood glucose test strips 19860101 20020101Occult blood test strips 19860101 20020101Ammonia test strips 19860101 20020101Protamine sulfate per 50 mg 20020101 20020101Disposable catheter tips 19860101 20020101Plumb/elec wk hm hemo equip 19860101 20020101Repair/maint cont hemo equip 19860101 20020101Drain bag/bottle 20020101 20020101Misc dialysis supplies noc 19860101 20020101Venous pressure clamp 19860101 20020101Non-sterile gloves 19860101 20030101Surgical mask 20020101 20030101Tourniquet for dialysis, ea 20020101 20020101Sterile, gloves per pair 20030101 20030101Reusable oral thermometer 20030101 20030101Reusable rectal thermometer 20030101 20070101Pouch clsd w barr attached 19900101 20030101Clsd ostomy pouch w/o barr 19900101 20030101Clsd ostomy pouch faceplate 19900101 20030101Clsd ostomy pouch w/flange 19900101 20030101Stoma cap 19900101 19900101Pouch drainable w barrier at 19900101 20030101Drnble ostomy pouch w/o barr 19900101 20030101Drain ostomy pouch w/flange 19900101 20030101Urinary pouch w/barrier 19900101 20030101Urinary pouch w/o barrier 19900101 20030101Urinary pouch on barr w/flng 19900101 20030101Continent stoma plug 19900101 19900101Continent stoma catheter 19900101 19900101Stoma absorptive cover 20080101 20080101Ostomy accessory convex inse 19900101 19900101Bedside drain btl w/wo tube 19900101 19970101Urinary suspensory 19900101 20080101Urinary leg bag 19900101 19900101Latex leg strap 19900101 19980101Foam/fabric leg strap 19900101 19980101Skin barrier wipes box pr 50 19900101 20060101Skin barrier, wipe or swab 20060101 20060101Solid skin barrier 6x6 19900101 19900101Solid skin barrier 8x8 19900101 19900101Disk/foam pad +or- adhesive 19900101 20000101Appliance cleaner 19900101 19900101Percutaneous catheter anchor 19990101 20030101Diab shoe for density insert 19950101 20050101

Diabetic custom molded shoe 19950101 20050101

Diabetic shoe w/roller/rockr 19950101 20050101

Query_110708

Page 343

Diabetic shoe with wedge 19950101 20050101

Diab shoe w/metatarsal bar 19950101 20050101

Diabetic shoe w/off set heel 19950101 20050101

Modification diabetic shoe 19950101 20050101

Diabetic deluxe shoe 20000101 20050101

Direct heat form shoe insert 20020101 20060101

Compression form shoe insert 20020101 20050101

Custom fab molded shoe inser 20020101 20060101

Multi den insert direct form 20060101 20060101

Multi den insert custom mold 20060101 20060101

Wound warming wound cover 20020101 20020701

Collagen based wound filler 20020101 20090101Collagen gel/paste wound fil 20030101 20090101Collagen dressing <=16 sq in 20010101 20090101Collagen drsg>6<=48 sq in 20010101 20090101

Collagen dressing >48 sq in 20010101 20090101Collagen dsg wound filler 20010101 20090101Silicone gel sheet, each 19970101 20070101

Wound pouch each 19970101 20030101Alginate dressing <=16 sq in 19970101 20090101

Alginate drsg >16 <=48 sq in 19970101 20090101

alginate dressing > 48 sq in 19970101 20090101

Alginate drsg wound filler 19970101 20090101Compos drsg <=16 no border 19990101 20090101

Compos drsg >16<=48 no bdr 19990101 20090101

Compos drsg >48 no border 19990101 20090101

Composite drsg <= 16 sq in 19970101 20090101

Composite drsg >16<=48 sq in 19970101 20090101

Composite drsg > 48 sq in 19970101 20090101

Contact layer <= 16 sq in 19970101 20090101Contact layer >16<= 48 sq in 19970101 20090101

Query_110708

Page 344

Contact layer > 48 sq in 19970101 20090101Foam drsg <=16 sq in w/o bdr 19970101 20090101

Foam drg >16<=48 sq in w/o b 19970101 20090101

Foam drg > 48 sq in w/o brdr 19970101 20090101

Foam drg <=16 sq in w/border 19970101 20090101

Foam drg >16<=48 sq in w/bdr 19970101 20090101

Foam drg > 48 sq in w/border 19970101 20090101

Foam dressing wound filler 19970101 20090101Non-sterile gauze<=16 sq in 19970101 20030101

Non-sterile gauze>16<=48 sq 19970101 20030101

Non-sterile gauze > 48 sq in 19970101 20030101

Gauze <= 16 sq in w/border 19970101 20090101

Gauze >16 <=48 sq in w/bordr 19970101 20090101

Gauze > 48 sq in w/border 19970101 20090101

Gauze <=16 in no w/sal w/o b 19970101 20090101

Gauze >16<=48 no w/sal w/o b 19970101 20090101

Gauze > 48 in no w/sal w/o b 19970101 20090101

Gauze <= 16 sq in water/sal 19970101 20090101

Gauze >16<=48 sq in watr/sal 19970101 20090101

Gauze > 48 sq in water/salne 19970101 20090101

Hydrogel dsg<=16 sq in 20010101 20090101

Hydrogel dsg>16<=48 sq in 20010101 20090101

Hydrogel dressing >48 sq in 20010101 20090101

Hydrocolld drg <=16 w/o bdr 19970101 20090101

Hydrocolld drg >16<=48 w/o b 19970101 20090101

Hydrocolld drg > 48 in w/o b 19970101 20090101

Hydrocolld drg <=16 in w/bdr 19970101 20090101

Hydrocolld drg >16<=48 w/bdr 19970101 20090101

Hydrocolld drg > 48 in w/bdr 19970101 20090101

Hydrocolld drg filler paste 19970101 20090101Hydrocolloid drg filler dry 19970101 20090101Hydrogel drg <=16 in w/o bdr 19970101 20090101

Query_110708

Page 345

Hydrogel drg >16<=48 w/o bdr 19970101 20090101

Hydrogel drg >48 in w/o bdr 19970101 20090101

Hydrogel drg <= 16 in w/bdr 19970101 20090101

Hydrogel drg >16<=48 in w/b 19970101 20090101

Hydrogel drg > 48 sq in w/b 19970101 20090101

Hydrogel drsg gel filler 19970101 20090101Skin seal protect moisturizr 19970101 20030101Absorpt drg <=16 sq in w/o b 19970101 20090101

Absorpt drg >16 <=48 w/o bdr 19970101 20090101

Absorpt drg > 48 sq in w/o b 19970101 20090101

Absorpt drg <=16 sq in w/bdr 19970101 20090101

Absorpt drg >16<=48 in w/bdr 19970101 20090101

Absorpt drg > 48 sq in w/bdr 19970101 20090101

Transparent film <= 16 sq in 19970101 20090101Transparent film >16<=48 in 19970101 20090101

Transparent film > 48 sq in 19970101 20090101Wound cleanser any type/size 19970101 20090101Wound filler gel/paste /oz 19970101 20090101Wound filler dry form / gram 19970101 20090101Impreg gauze no h20/sal/yard 19970101 20090101

Sterile gauze <= 16 sq in 19970101 20060101

Sterile gauze>16 <= 48 sq in 19970101 20030101

Sterile gauze > 48 sq in 19970101 20030101

Packing strips, non-impreg 20040101 20090101

Sterile eye pad 20030101 20030101Non-sterile eye pad 20030101 20030101Occlusive eye patch 20030101 20070101Adhesive bandage, first-aid 20080101 20080101Pad band w>=3" <5"/yd 20040101 20040101

Conform band n/s w<3"/yd 20040101 20040101

Conform band n/s w>=3"<5"/yd 20040101 20040101

Conform band n/s w>=5"/yd 20040101 20040101

Conform band s w <3"/yd 20040101 20040101

Conform band s w>=3" <5"/yd 20040101 20040101

Conform band s w >=5"/yd 20040101 20040101

Lt compres band <3"/yd 20040101 20040101

Query_110708

Page 346

Lt compres band >=3" <5"/yd 20040101 20040101

Lt compres band >=5"/yd 20040101 20040101

Mod compres band w>=3"<5"/yd 20040101 20040101

High compres band w>=3"<5"yd 20040101 20040101

Self-adher band w <3"/yd 20040101 20040101

Self-adher band w>=3" <5"/yd 20040101 20040101

Self-adher band >=5"/yd 20040101 20040101

Zinc paste band w >=3"<5"/yd 20040101 20040101

Tubular dressing 20060101 20060101Compres burngarment bodysuit 20030101 20030101Compres burngarment chinstrp 20030101 20030101Compres burngarment facehood 20030101 20030101Cmprsburngarment glove-wrist 20030101 20030101Cmprsburngarment glove-elbow 20030101 20030101Cmprsburngrmnt glove-axilla 20030101 20030101Cmprs burngarment foot-knee 20030101 20030101Cmprs burngarment foot-thigh 20030101 20030101Compres burn garment jacket 20030101 20030101

Compres burn garment leotard 20030101 20030101

Compres burn garment panty 20030101 20030101

Compres burn garment, noc 20030101 20030101Compress burn mask face/neck 20060101 20060101Compression stocking BK18-30 20060101 20060101Compression stocking BK30-40 20060101 20060101Compression stocking BK40-50 20060101 20060101Gc stocking thighlngth 18-30 20060101 20060101Gc stocking thighlngth 30-40 20060101 20060101Gc stocking thighlngth 40-50 20060101 20060101Gc stocking full lngth 18-30 20060101 20060101Gc stocking full lngth 30-40 20060101 20060101Gc stocking full lngth 40-50 20060101 20060101Gc stocking waistlngth 18-30 20060101 20060101Gc stocking waistlngth 30-40 20060101 20060101Gc stocking waistlngth 40-50 20060101 20060101Gc stocking custom made 20060101 20060101Gc stocking lymphedema 20060101 20060101Gc stocking garter belt 20060101 20060101Grad comp non-elastic BK 20090101 20090101G compression stocking 20060101 20060101Neg pres wound ther drsg set 20040101 20060101

Neg press wound ther canistr 20040101 20060101

Disposable canister for pump 20000101 20000101Nondisposable pump canister 20000101 20000101Tubing used w suction pump 20000101 20000101Nebulizer administration set 20000101 20000101

Query_110708

Page 347

Disposable nebulizer sml vol 20000101 20000101Nondisposable nebulizer set 20000101 20000101

Filtered nebulizer admin set 20000101 20000101Lg vol nebulizer disposable 20000101 20000101Disposable nebulizer prefill 20000101 20000101Nebulizer reservoir bottle 20000101 20000101Disposable corrugated tubing 20000101 20000101Nondispos corrugated tubing 20000101 20000101Nebulizer water collec devic 20000101 20000101Disposable compressor filter 20000101 20000101Compressor nondispos filter 20000101 20000101Aerosol mask used w nebulize 20000101 20000101Nebulizer dome & mouthpiece 20000101 20000101Nebulizer not used w oxygen 20000101 20000101

Water distilled w/nebulizer 20010101 20010101Replace chest compress vest 20030101 20030101

Replace chst cmprss sys hose 20030101 20030101

Combination oral/nasal mask 20080101 20080101

Repl oral cushion combo mask 20080101 20080101Repl nasal pillow comb mask 20080101 20080101CPAP full face mask 20030101 20030101Replacement facemask interfa 20030101 20030101Replacement nasal cushion 20030101 20060101Replacement nasal pillows 20030101 20060101Nasal application device 20030101 20030101

Pos airway press headgear 20030101 20030101Pos airway press chinstrap 20030101 20030101Pos airway pressure tubing 20030101 20030101Pos airway pressure filter 20030101 20030101Filter, non disposable w pap 20030101 20030101One way chest drain valve 20050101 20050101Water seal drain container 20050101 20050101Implanted pleural catheter 20030101 20030101Vacuum drainagebottle/tubing 20030101 20030101PAP oral interface 20030101 20030101Repl exhalation port for PAP 20050101 20050101

Repl water chamber, PAP dev 20040101 20040101

Tracheostoma valve w diaphra 20010101 20010101Replacement diaphragm/fplate 20010101 20010101HMES filter holder or cap 20010101 20010101

Tracheostoma HMES filter 20010101 20010101HMES or trach valve housing 20010101 20010101

HMES/trachvalve adhesivedisk 20010101 20010101

Integrated filter & holder 20010101 20010101

Housing & Integrated Adhesiv 20010101 20010101

Heat & moisture exchange sys 20010101 20010101

Query_110708

Page 348

Trach/laryn tube non-cuffed 20040101 20040101

Trach/laryn tube cuffed 20040101 20040101

Trach/laryn tube stainless 20040101 20040101

Tracheostomy shower protect 20040101 20040101Tracheostoma stent/stud/bttn 20040101 20040101Tracheostomy mask 20040101 20040101Tracheostomy tube collar 20040101 20040101Trach/laryn tube plug/stop 20050101 20050101Soft protect helmet prefab 20070101 20070101Hard protect helmet prefab 20070101 20070101Soft protect helmet custom 20070101 20070101

Hard protect helmet custom 20070101 20070101

Repl soft interface, helmet 20070101 20070101Misc/exper non-prescript dru 19860101 19950401Single vitamin nos 20050101 20050101Multi-vitamin nos 20050101 20050101

Artificial saliva 20080101 20080101Lice treatment, topical 20050101 20050101

Non-covered item or service 19860101 20020101Ext amb insulin delivery sys 20080101 20080101

Disp home glucose monitor 20060101 20060101Disposable sensor, CGM sys 20080101 20080101

External transmitter, CGM 20080101 20080101

External receiver, CGM sys 20080101 20080101

Monitoring feature/deviceNOC 20070101 20070101

Alert device, noc 20040101 20040101Reaching/grabbing device 20060101 20060101Wig any type 20060101 20060101Foot press off load supp dev 20080101 20080101Non-electronic spirometer 20090101 20090101Exercise equipment 19930101 19950401Tc99m sestamibi 19960101 20060101Technetium TC-99m teboroxime 20080101 20080101Tc99m tetrofosmin 19980101 20090101Tc99m medronate 19970101 20060101Tc99m apcitide 20000101 20060101TL201 thallium 19960101 20060101In111 capromab 19990101 20060101

I131 iodobenguate, dx 20010101 20060101Iodine I-123 sod iodide mil 20080101 20080101Tc99m disofenin 20010101 20060101Technetium TC 99m depreotide 20020101 20060101

Tc99m pertechnetate 20030101 20060101Technetium tc-99m mebrofenin 20030101 20060101

Technetiumtc99mpyrophosphate 20030101 20060101

Query_110708

Page 349

Technetium tc-99m pentetate 20030101 20060101

Iodine I-123 sod iodide mic 20030101 20080101

I131 iodide cap, rx 20030101 20060101Technetiumtc-99mmacroag albu 20030101 20060101

Technetiumtc-99m sulfur clld 20030101 20060101

Tc99m exametazime 20030101 20060101Indium111ibritumomabtiuxetan 20030101 20060101

Yttrium90ibritumomabtiuxetan 20030101 20060101

I131 serum albumin, dx 20030101 20060101Low/iso-osmolar contrast mat 20040101 20060101Nitrogen N-13 ammonia 20040101 20060101Iodine I-125 sodium iodide 20070101 20070101Iodine I-131 iodide cap, dx 20040101 20060101I131 iodide sol, dx 20040101 20060101I131 iodide sol, rx 20040101 20060101I131 max 100uCi 20040101 20060101I125 serum albumin, dx 20040101 20060101I-131 tositumomab diagnostic 20040101 20060101

I-131 tositumomab therapeut 20040101 20060101

Injection, methylene blue 20060101 20060101Tc99m depreotide 20060101 20060101Tc99m mebrofenin 20060101 20060101Tc99m pyrophosphate 20060101 20060101

Tc99m pentetate 20060101 20060101Tc99m MAA 20060101 20060101

Tc99m sulfur colloid 20060101 20060101

In111 ibritumomab, dx 20060101 20060101

Y90 ibritumomab, rx 20060101 20060101

I131 tositumomab, dx 20060101 20060101I131 tositumomab, rx 20060101 20060101Co57/58 20060101 20060101In111 oxyquinoline 20060101 20060101In111 pentetate 20060101 20060101Tc99m arcitumomab 20060101 20070101Tc99m gluceptate 20060101 20060101

Tc99m succimer 20060101 20060101F18 fdg 20060101 20060101Cr51 chromate 20060101 20060101

I125 iothalamate, dx 20060101 20060101

Rb82 rubidium 20060101 20060101Ga67 gallium 20060101 20060101Tc99m bicisate 20060101 20060101Xe133 xenon 10mci 20060101 20060101Co57 cyano 20060101 20060101

Query_110708

Page 350

Tc99m labeled rbc 20060101 20060101

Tc99m oxidronate 20060101 20060101Tc99m mertiatide 20060101 20060101P32 Na phosphate 20060101 20060101P32 chromic phosphate 20060101 20060101In111 pentetreotide 20060101 20080101Tc99m fanolesomab 20060101 20060101Technetium TC-99m aerosol 20060101 20060101

Technetium tc99m arcitumomab 20070101 20070101Technetium TC-99m auto WBC 20080101 20080101

Indium In-111 auto WBC 20080101 20080101Indium IN-111 auto platelet 20080101 20080101Indium In-111 pentetreotide 20080101 20080101Inj prohance multipack 20080101 20080101Inj multihance 20080101 20080101Inj multihance multipack 20080101 20080101Gad-base MR contrast NOS,1ml 20080101 20080101

Sodium fluoride F-18 20090101 20090101Sr89 strontium 19980101 20060101Sm 153 lexidronm 19990101 20060101Non-rad contrast materialNOC 20060101 20060101Radiopharm rx agent noc 20030101 20060101Echocardiography Contrast 20010101 20010101Supply/accessory/service 20000101 20010101

Delivery/set up/dispensing 20000101 20010101DME supply or accessory, nos 20040101 20040101Enter feed supkit syr by day 19860101 20080101Enteral feed supp pump per d 19860101 20020101Enteral feed sup kit grav by 19860101 20020101Enteral ng tubing w/ stylet 19860101 20020101Enteral ng tubing w/o stylet 19860101 20020101Enteral stomach tube levine 19860101 20020101Gastrostomy/jejunostomy tube 20020101 20080101

Gastro/jejuno tube, std 20080101 20080101Gastro/jejuno tube, low-pro 20080101 20080101Food thickener oral 20030101 20050101EF adult fluids and electro 20050101 20050101

EF ped fluid and electrolyte 20050101 20050101

Additive for enteral formula 20050101 20050101EF blenderized foods 20050101 20060101

EF complet w/intact nutrient 19860101 20050101

EF calorie dense>/=1.5Kcal 19840101 20050101

EF hydrolyzed/amino acids 19860101 20050101

Query_110708

Page 351

EF spec metabolic noninherit 19840101 20050101

EF incomplete/modular 19860101 20050101

EF special metabolic inherit 20050101 20050101

EF ped complete intact nut 20050101 20050101

EF ped complete soy based 20050101 20050101

EF ped caloric dense>/=0.7kc 20050101 20050101

EF ped hydrolyzed/amino acid 20050101 20050101

EF ped specmetabolic inherit 20050101 20050101

Parenteral 50% dextrose solu 19860101 20020101

Parenteral sol amino acid 3. 19840101 20020101Parenteral sol amino acid 5. 19840101 20020101

Parenteral sol amino acid 7- 19860101 20020101

Parenteral sol amino acid > 19880101 20020101

Parenteral sol carb > 50% 19860101 20020101

Parenteral sol lipids 10% 19840101 20060101

Parenteral sol 10 gm lipids 20060101 20060101Parenteral sol lipids 20% 19860101 20060101

Parenteral sol amino acid & 19880101 20020101

Parenteral sol 52-73 gm prot 19880101 20020101

Parenteral sol 74-100 gm pro 19880101 20020101

Parenteral sol > 100gm prote 19880101 20020101

Parenteral nutrition additiv 19840101 20020101

Query_110708

Page 352

Parenteral supply kit premix 19840101 20020101Parenteral supply kit homemi 19860101 20020101Parenteral administration ki 19860101 20020101Parenteral sol renal-amirosy 19880101 20020101

Parenteral sol hepatic-fream 19880101 20020101

Parenteral sol stres-brnch c 19880101 20020101

Enter infusion pump w/o alrm 19880101 20020101Enteral infusion pump w/ ala 19880101 20020101Parenteral infus pump portab 19880101 20020101Parenteral infus pump statio 19880101 20020101Enteral supp not otherwise c 19850101 19960101Parenteral supp not othrws c 19850101 19960101CO 57/58 per 0.5 uCi 20000801 20060101

I-131 tositumomab, dx 20040101 20060101

I-131 tositumomab, tx 20040101 20060101

In-111 ibritumomab tiuxetan 20040101 20060101

Yttrium 90 ibritumomab tiuxe 20040101 20060101

IN111 oxyquinoline,per0.5mCi 20000801 20060101

IN 111 pentetate per 0.5 mCi 20000801 20060101

TC99M fanolesomab 20050101 20060101

Tc 99M ARCITUMOMAB PER VIAL 20000801 20060101

BUSULFAN IV, 6 Mg 20000801 20070101TC 99M Sodium Glucoheptonat 20000801 20060101

TC 99M SUCCIMER, PER Vial 20000801 20060101

HYPERBARIC Oxygen 20000801 20030701Apligraf 20000801 20060101Anchor/screw bn/bn,tis/bn 20010401 20040101Cath, trans atherectomy, dir 20010401 20040101Brachytherapy needle 20010401 20040101Brachytx, non-str, Gold-198 20010401 20010401Brachytx, non-str,HDR Ir-192 20010401 20010401Brachytx source, Iodine 125 20010401 20070701Brachytx, NS, Non-HDRIr-192 20010401 20010401Brachytx sour, Palladium 103 20010401 20070701AICD, dual chamber 20010401 20040101AICD, single chamber 20010401 20040101Cath, trans atherec,rotation 20010401 20040101Cath, translumin non-laser 20010401 20040101

Cath, bal dil, non-vascular 20010401 20040101Cath, bal tis dis, non-vas 20010401 20040101Cath, brachytx seed adm 20010401 20040101Cath, drainage 20010401 20040101Cath, EP, 19 or few elect 20010401 20040101

Query_110708

Page 353

Cath, EP, 20 or more elec 20010401 20040101

Cath, EP, diag/abl, 3D/vect 20010401 20040101Cath, EP, othr than cool-tip 20010401 20040101

Cath, hemodialysis,long-term 20010401 20010401Cath, inf, per/cent/midline 20010401 20040101

Cath,hemodialysis,short-term 20010401 20010401Cath, intravas ultrasound 20010401 20040101Catheter, intradiscal 20010401 20040101Catheter, intraspinal 20010401 20040101Cath, pacing, transesoph 20010401 20040101Cath, thrombectomy/embolect 20010401 20040101Catheter, ureteral 20010401 20040101Cath, intra echocardiography 20010401 20040101Closure dev, vasc 20010401 20040101Conn tiss, human(inc fascia) 20010401 20040101Conn tiss, non-human 20010401 20040101Event recorder, cardiac 20010401 20040101Adhesion barrier 20010701 20010701Intro/sheath,strble,non-peel 20010401 20040101

Generator, neuro non-recharg 20010401 20060101Graft, vascular 20010401 20040101Guide wire 20010401 20040101Imaging coil, MR, insertable 20010401 20040101Rep dev, urinary, w/sling 20010401 20040101Infusion pump, programmable 20010401 20040101Ret dev, insertable 20010401 20040101FDG, per dose (4-40 mCi/ml) 20020401 20060101

Joint device (implantable) 20010401 20040101Lead, AICD, endo single coil 20010401 20040101Lead, neurostimulator 20010401 20040101Lead, pmkr, transvenous VDD 20010401 20040101Lens, intraocular (new tech) 20010401 20040101Mesh (implantable) 20010401 20040101Morcellator 20010401 20040101Ocular imp, aqueous drain de 20020701 20020701Ocular dev, intraop, det ret 20010401 20040101Pmkr, dual, rate-resp 20010401 20040101Pmkr, single, rate-resp 20010401 20040101Patient progr, neurostim 20010401 20040101Port, indwelling, imp 20010401 20040101Prosthesis, breast, imp 20010401 20040101Prosthesis, penile, inflatab 20010401 20040101Retinal tamp, silicone oil 20030401 20030401Pros, urinary sph, imp 20010401 20040101Receiver/transmitter, neuro 20010401 20040101Septal defect imp sys 20010401 20040101Integrated keratoprosthesis 20030701 20030701Tissue localization-excision 20040101 20040101Generator neuro rechg bat sy 20060101 20060101

Interspinous implant 20070101 20070101Stent, coated/cov w/del sys 20010401 20040101Stent, coated/cov w/o del sy 20010401 20040101Stent, non-coa/non-cov w/del 20010401 20040101Stent, non-coat/cov w/o del 20010401 20040101

Query_110708

Page 354

Matrl for vocal cord 20010401 20040101Tissue marker, implantable 20010401 20040101Vena cava filter 20010401 20040101Dialysis access system 20010401 20040101AICD, other than sing/dual 20010401 20040101Adapt/ext, pacing/neuro lead 20010401 20040101Embolization Protect syst 20030101 20030101Cath, translumin angio laser 20010401 20040101Catheter, guiding 20010401 20040101Endovas non-cardiac abl cath 20020701 20020701Infusion pump,non-prog, perm 20010401 20040101Intro/sheath,fixed,peel-away 20010401 20040101

Intro/sheath, fixed,non-peel 20010401 20040101

Intro/sheath, non-laser 20010401 20020701

Lead, AICD, endo dual coil 20010401 20040101Lead, AICD, non sing/dual 20010401 20040101

Lead, neurostim test kit 20010401 20040101Lead, pmkr, other than trans 20010401 20040101Lead, pmkr/AICD combination 20010401 20040101Lead, coronary venous 20020701 20020701Probe, perc lumb disc 20030101 20030101Sealant, pulmonary, liquid 20010401 20040101Brachytx, non-str,Yttrium-90 20010401 20010401Stent, non-cor, tem w/o del 20010401 20040101Probe, cryoablation 20010401 20010401Pmkr, dual, non rate-resp 20010401 20040101Pmkr, single, non rate-resp 20010401 20010401Pmkr, other than sing/dual 20010401 20040101Prosthesis, penile, non-inf 20010401 20040101Stent, non-cor, tem w/del sy 20010401 20040101Infusion pump, non-prog,temp 20010401 20040101Cath, suprapubic/cystoscopic 20010401 20040101Catheter, occlusion 20010401 20040101Intro/sheath, laser 20010401 20040101Cath, EP, cool-tip 20010401 20040101

Rep dev, urinary, w/o sling 20010401 20040101Brachytx sol, I-125, per mCi 20030101 20070101Brachytx source, Cesium-131 20040101 20070701Brachytx, non-str, HA, I-125 20050101 20070701

Brachytx, non-str, HA, P-103 20050101 20070701

Brachy linear, non-str,P-103 20050101 20070701Brachy,non-str,Ytterbium-169 20051001 20070701Brachytx, stranded, I-125 20070701 20070701Brachytx, non-stranded,I-125 20070701 20070701Brachytx, stranded, P-103 20070701 20070701Brachytx, non-stranded,P-103 20070701 20070701Brachytx, stranded, C-131 20070701 20070701Brachytx, non-stranded,C-131 20070701 20070701Brachytx, stranded, NOS 20070701 20070701Brachytx, non-stranded, NOS 20070701 20070701MRA w/cont, abd 20011001 20011001MRA w/o cont, abd 20011001 20011001MRA w/o fol w/cont, abd 20011001 20011001

Query_110708

Page 355

MRI w/cont, breast, uni 20011001 20011001MRI w/o cont, breast, uni 20011001 20011001MRI w/o fol w/cont, brst, un 20011001 20011001

MRI w/cont, breast, bi 20011001 20011001MRI w/o cont, breast, bi 20011001 20011001MRI w/o fol w/cont, breast, 20011001 20011001

MRA w/cont, chest 20011001 20011001MRA w/o cont, chest 20011001 20011001MRA w/o fol w/cont, chest 20011001 20011001

MRA w/cont, lwr ext 20011001 20011001MRA w/o cont, lwr ext 20011001 20011001MRA w/o fol w/cont, lwr ext 20011001 20011001

MRA w/cont, pelvis 20030701 20030701MRA w/o cont, pelvis 20030701 20030701MRA w/o fol w/cont, pelvis 20030701 20030701

TTE w or w/o fol w/cont, com 20080101 20080101

TTE w or w/o fol w/cont, f/u 20080101 20090101

2D TTE w or w/o fol w/con,co 20080101 20080101

2D TTE w or w/o fol w/con,fu 20080101 20080101

2D TEE w or w/o fol w/con,in 20080101 20080101

TEE w or w/o fol w/cont,cong 20080101 20080101

TEE w or w/o fol w/cont, mon 20080101 20080101

TTE w or w/o fol w/con,stres 20080101 20080101

TTE w or wo fol wcon,Doppler 20090101 20090101

TTE w or w/o contr, cont ECG 20090101 20090101

IV inf, tx/dx, up to 1 hr 20060101 20070101IV inf, tx/dx, each addl hr 20060101 20070101

Tx, prophy, dx IV push 20060101 20070101

Query_110708

Page 356

Chemotx adm, IV push 20060101 20070101Chemotx adm, IV inf up to 1h 20060101 20070101Chemotx adm, IV inf, addl hr 20060101 20070101

Prolonged IV inf, req pump 20060101 20060101

Na chromateCr51, per 0.25mCi 20001001 20060101Palivizumab, per 50 mg 20001001 20090101Baclofen Intrathecal kit-1am 20001001 20060101Baclofen Refill Kit-500mcg 20001001 20060101Baclofen Refill Kit-2000mcg 20001001 20060101Co 57 cobaltous chloride 20010401 2006010151 Na Chromate, 50mCi 20001001 20060101

Na Iothalamate I-125, 10 uCi 20001001 20060101

Hep B imm glob, per 1 ml 20001001 20060101Perflutren lipid micro, 2ml 20020101 20060101Inj pantoprazole sodium, via 20020101 20020101Injection, argatroban 20030101 20030101Transcyte, per 247 sq cm 20030701 20060101Injection, natalizumab 20041123 20050401Paclitaxel protein pr 20050107 20060101Inj pegaptanib sodium 20041217 20060101Inj clofarabine 20050701 20060101Orcel, per 36 cm2 20020101 20060101Dermagraft, per 37.5 sq cm 20020101 20060101Octafluoropropane 20030401 20060101

Perflexane lipid micro 20030401 20060101Oxaliplatin 20030701 20060101Integra, per cm2 20050101 20060101Inj, alefacept, IV 20040101 20060101Inj, alefacept, IM 20040101 20060101Injection, azacitidine 20040519 20060101Sodium hyaluronate 20050101 20070101Graftjacket Reg Matrix 20050101 20070101Graftjacket SftTis 20050101 20070101Inj adenosine, tx dx 20050401 20060101

Injection, galsulfase 20050531 20070101Fluocinolone acetonide 20051001 20070101Ziconotide intrathecal inf 20051001 20060101Injection, micafungin sodium 20060401 20070101Injection, tigecycline 20060401 20070101Injection ibandronate sodium 20060701 20070101Injection, abatacept 20060701 20070101Injection, decitabine 20061001 20070101Injection, idursulfase 20070101 20080101Injection, ranibizumab 20070101 20080101Inj, alglucosidase alfa 20070101 20080101Injection, panitumumab 20070101 20080101Injection, eculizumab 20071001 20080101Inj, lanreotide acetate 20080101 20090101Inj, levetiracetam 20080101 20090101Inj, temsirolimus 20080101 20090101Injection, ixabepilone 20080101 20090101Injection, doripenem 20080401 20090101Injection, fosaprepitant 20080701 20090101Injection, bendamustine hcl 20081001 20090101Injection, regadenoson 20081001 20090101

Query_110708

Page 357

Injection, romiplostim 20090101 20090101Inj, gadoxetate disodium 20090101 20090101Inj, iobenguane, I-123, dx 20090101 20090101Inj, clevidipine butyrate 20090101 20090101Porous collagen tube per cm 20070101 20080101Acellular derm tissue percm2 20070101 20080101

Neuragen nerve guide, per cm 20080101 20080101

Neurawrap nerve protector,cm 20080101 20080101

Veritas collagen matrix, cm2 20080101 20080101

Neuromatrix nerve cuff, cm 20080101 20080101TenoGlide tendon prot, cm2 20080701 20080701

Flowable wound matrix, 1 cc 20080701 20090101

SurgiMend, 0.5cm2 20080701 20080701

Implant, bone void filler 20081001 20081001

Unclassified drugs or biolog 20040101 20040101Thallous chloride, brand 20040101 20060101

Strontium-89 chloride,brand 20040101 20060101

Th I131 so iodide cap, brand 20040101 20060101

Dx I131 so iodide cap, brand 20040101 20060101

Dx I131 so iodide sol, brand 20040101 20060101

Th I131 so iodide sol, brand 20040101 20060101

Dexrazoxane HCl inj, brand 20040101 20060101Pamidronate disodium, brand 20040101 20060101Sodium hyaluronate inj, bran 20040101 20060101

Etoposide oral, brand 20040101 20060101Doxorubic hcl chemo, brand 20040101 20060101Bleomycin sulfate inj, brand 20040101 20060101Cisplatin inj, brand 20040101 20060101Inj cladribine, brand 20040101 20060101Cyclophosphamide inj, brand 20040101 20060101Cyclophosphamide lyo, brand 20040101 20060101Cytarabine hcl inj, brand 20040101 20060101Dacarbazine inj, brand 20040101 20060101Daunorubicin, brand 20040101 20060101Etoposide inj, brand 20040101 20060101Floxuridine inj, brand 20040101 20060101Ifosfamide inj, brand 20040101 20060101Mesna injection, brand 20040101 20060101Idarubicin hcl inj, brand 20040101 20060101Leuprolide acetate inj, bran 20040101 20060101Paclitaxel inj, brand 20040101 20060101Mitomycin inj, brand 20040101 20060101Thiotepa inj, brand 20040101 20060101Gonadorelin hydroch, brand 20050101 20060101Azathioprine parenteral,brnd 20050101 20060101

Query_110708

Page 358

Carmus bischl nitro inj 20050101 20060101Cyclosporine oral, brand 20040101 20060101Diethylstilbestrol injection 20050101 20060101Vinorelbine tar,brand 20050101 20060101Inj inert subs upper GI 20040101 20060101

Non-contact laser vap prosta 20040401 20060101

Radiofrequency energy to anu 20040701 20040701Kyphoplasty, first vertebra 20050101 20060101Kyphoplasty, each addl 20050101 20060101

HE ESW tx, tennis elbow 20050101 20060101

HE ESW tx, plantar fasciitis 20050101 20060101

KV imaging w/IR tracking 20050101 20060101

Dyn IR Perf Img 20050401 20090101EPS gast cardia plic 20050401 20050401

Place endorectal app 20051001 20051001

Rxt breast appl place/remov 20060101 20060101

Insert palate implants 20061001 20061001Place device/marker, non pro 20070701 20070701

Inpnt stay radiolabeled item 20080101 20081001Inpt implant pros dev,no cov 20090101 20090101

Periodic oral evaluation 19820101 20070101Limit oral eval problm focus 19960101 19960101Oral evaluation, pt < 3yrs 20070101 20070101

Comprehensve oral evaluation 19960101 20030101Extensv oral eval prob focus 19960101 19960101Re-eval,est pt,problem focus 20000101 20000101

Comp periodontal evaluation 20030101 20030101Intraor complete film series 19820101 19960101Intraoral periapical first f 19840101 19960101Intraoral periapical ea add 19840101 19960101Intraoral occlusal film 19840101 19930101Extraoral first film 19840101 19930101Extraoral ea additional film 19820101 19930101Dental bitewing single film 19820101 19930101Dental bitewings two films 19820101 19930101Bitewings - three films 20070101 20070101Dental bitewings four films 19820101 19930101Vert bitewings-sev to eight 20000101 20000101Dental film skull/facial bon 19820101 19960101Dental saliography 19860101 19960101Dental tmj arthrogram incl i 19860101 19960101Dental other tmj films 19840101 19960101Dental tomographic survey 19920101 19960101Dental panoramic film 19840101 19960101Dental cephalometric film 19820101 19960101

Query_110708

Page 359

Oral/facial photo images 20000101 20050101Cone beam ct 20070101 20070101Cone beam, two dimensional 20070101 20070101

Cone beam, three dimensional 20070101 20070101

Collection of microorganisms 19920101 20050101Viral culture 20050101 20050101Collect & prep saliva sample 20090101 20090101Analysis of saliva sample 20090101 20090101Gen tst suscept oral disease 20050101 20050101Caries susceptibility test 19920101 19970101Diag tst detect mucos abnorm 20050101 20050101

Pulp vitality test 19820101 19930101Diagnostic casts 19820101 19960101Gross exam, prep & report 20000101 20000101

Micro exam, prep & report 20000101 20000101

Micro w exam of surg margins 20000101 20000101

Decalcification procedure 20050101 20050101Spec stains for microorganis 20050101 20050101Spec stains not for microorg 20050101 20050101Immunohistochemical stains 20050101 20050101Tissue in-situ hybridization 20050101 20050101Cytopath smear prep & report 20000101 20070101

Electron microscopy diagnost 20050101 20050101Direct immunofluorescence 20050101 20050101Indirect immunofluorescence 20050101 20050101Consult slides prep elsewher 20050101 20050101Consult inc prep of slides 20050101 20050101

Accession of brush biopsy 20070101 20090101

Other oral pathology procedu 19860101 19930101Unspecified diagnostic proce 19840101 19930101Dental prophylaxis adult 19840101 19960101Dental prophylaxis child 19840101 19960101Topical fluor w prophy child 19840101 20070101Topical app fluoride child 19860101 20090101Topical app fluoride adult 19860101 20090101Topical fluoride w/ prophy a 19920101 20070101Topical fluoride varnish 20070101 20070101

Nutri counsel-control caries 19820101 19960101Tobacco counseling 19960101 19960101Oral hygiene instruction 19820101 19960101Dental sealant per tooth 19850101 19960101Space maintainer fxd unilat 19840101 19930101Fixed bilat space maintainer 19840101 19930101Remove unilat space maintain 19840101 19930101Remove bilat space maintain 19840101 19930101Recement space maintainer 19820101 19930101Remove fix space maintainer 20070101 20070101Amalgam one surface permanen 19820101 20030101Amalgam two surfaces permane 19820101 20030101

Query_110708

Page 360

Amalgam three surfaces perma 19820101 20030101Amalgam 4 or > surfaces perm 19820101 20030101Resin one surface-anterior 19840101 19960101Resin two surfaces-anterior 19840101 19960101Resin three surfaces-anterio 19840101 19960101Resin 4/> surf or w incis an 19840101 19960101Ant resin-based cmpst crown 20030101 20030101Post 1 srfc resinbased cmpst 20030101 20030101Post 2 srfc resinbased cmpst 20030101 20030101Post 3 srfc resinbased cmpst 20030101 20030101Post >=4srfc resinbase cmpst 20030101 20030101Dental gold foil one surface 19820101 19960101Dental gold foil two surface 19820101 19960101Dental gold foil three surfa 19820101 19960101Dental inlay metalic 1 surf 19840101 19960101Dental inlay metallic 2 surf 19840101 19960101Dental inlay metl 3/more sur 19840101 19960101Dental onlay metallic 2 surf 20000101 20000101Dental onlay metallic 3 surf 19960101 19960101Dental onlay metl 4/more sur 19960101 19960101Inlay porcelain/ceramic 1 su 19840101 19960101Inlay porcelain/ceramic 2 su 19860101 19960101Dental onlay porc 3/more sur 19860101 19960101Dental onlay porcelin 2 surf 19960101 19960101Dental onlay porcelin 3 surf 19960101 19960101Dental onlay porc 4/more sur 19960101 19960101Inlay composite/resin one su 19920101 20000101Inlay composite/resin two su 19920101 20000101Dental inlay resin 3/mre sur 19920101 20000101Dental onlay resin 2 surface 19960101 20000101Dental onlay resin 3 surface 19960101 20000101Dental onlay resin 4/mre sur 19960101 20000101Crown resin-based indirect 19840101 20050101Crown 3/4 resin-based compos 20050101 20050101Crown resin w/ high noble me 19840101 19960101Crown resin w/ base metal 19840101 19960101Crown resin w/ noble metal 19840101 19960101Crown porcelain/ceramic subs 19840101 19960101Crown porcelain w/ h noble m 19840101 19960101Crown porcelain fused base m 19860101 19960101Crown porcelain w/ noble met 19840101 19960101Crown 3/4 cast hi noble met 20000101 20000101Crown 3/4 cast base metal 20000101 20000101Crown 3/4 cast noble metal 20000101 20000101Crown 3/4 porcelain/ceramic 20000101 20000101Crown full cast high noble m 19840101 19960101Crown full cast base metal 19840101 19960101Crown full cast noble metal 19840101 19960101Crown-titanium 20050101 20050101Provisional crown 20000101 20000101Recement inlay onlay or part 19840101 20050101Recement cast or prefab post 20050101 20050101Dental recement crown 19840101 19960101Prefab stnlss steel crwn pri 19860101 19960101Prefab stnlss steel crown pe 19860101 19960101Prefabricated resin crown 19860101 19960101Prefab stainless steel crown 19920101 19960101Prefab steel crown primary 20050101 20050101Dental sedative filling 19840101 19960101Core build-up incl any pins 19860101 19960101Tooth pin retention 19860101 19960101

Query_110708

Page 361

Post and core cast + crown 19860101 20070101Each addtnl cast post 20000101 20070101Prefab post/core + crown 19860101 19960101Post removal 19960101 19960101Each addtnl prefab post 20000101 20000101Laminate labial veneer 19850101 19960101Lab labial veneer resin 19920101 19960101Lab labial veneer porcelain 19920101 19960101Temp crown (fractured tooth) 20041231 20070101Add proc construct new crown 20050101 20050101

Coping 20050101 20050101Crown repair 19860101 19960101Dental unspec restorative pr 19860101 19930101Pulp cap direct 19820101 19960101Pulp cap indirect 19840101 19960101Therapeutic pulpotomy 19840101 20000101

Gross pulpal debridement 20000101 20030101Part pulp for apexogenesis 20090101 20090101

Pulpal therapy anterior prim 19960101 19960101

Pulpal therapy posterior pri 19960101 19960101

End thxpy, anterior tooth 19840101 20090101End thxpy, bicuspid tooth 19840101 20090101End thxpy, molar 19840101 20090101Non-surg tx root canal obs 20000101 20000101Incomplete endodontic tx 20000101 20050101Internal root repair 20000101 20000101Retreat root canal anterior 19920101 19960101Retreat root canal bicuspid 19920101 19960101Retreat root canal molar 19920101 19960101Apexification/recalc initial 19920101 19960101

Apexification/recalc interim 19920101 19960101

Apexification/recalc final 19920101 19960101

Apicoect/perirad surg anter 19840101 19960101Root surgery bicuspid 19920101 19960101Root surgery molar 19920101 19960101Root surgery ea add root 19920101 19960101Retrograde filling 19840101 19960101Root amputation 19840101 19960101Endodontic endosseous implan 19840101 19930101Intentional replantation 19920101 19960101Isolation- tooth w rubb dam 19820101 19960101Tooth splitting 19840101 19960101Canal prep/fitting of dowel 19820101 19960101Endodontic procedure 19840101 19930101Gingivectomy/plasty per quad 19850101 20090101

Gingivectomy/plasty per toot 19860101 20090101

Ana crown exp 4 or> per quad 20070101 20070101Ana crown exp 1-3 per quad 20070101 20070101Gingival flap proc w/ planin 19840101 20090101

Gngvl flap w rootplan 1-3 th 20030101 20090101

Query_110708

Page 362

Apically positioned flap 20000101 20000101Crown lengthen hard tissue 19920101 19960101Osseous surgery per quadrant 19850101 20090101

Osseous surgl-3teethperquad 20030101 20090101

Bone replce graft first site 19960101 19960101Bone replce graft each add 19960101 19960101Bio mtrls to aid soft/os reg 20030101 20030101Guided tiss regen resorble 19960101 20000101Guided tiss regen nonresorb 19960101 20000101

Surgical revision procedure 20000101 20000101Pedicle soft tissue graft pr 19840101 19930101Free soft tissue graft proc 19840101 19960101Subepithelial tissue graft 19960101 20050101Distal/proximal wedge proc 19960101 19960101

Soft tissue allograft 20030101 20030101Con tissue w dble ped graft 20030101 20050101Provision splnt intracoronal 19840101 19960101Provisional splint extracoro 19840101 19960101Periodontal scaling & root 19850101 20050101Periodontal scaling 1-3teeth 20030101 20030101Full mouth debridement 19960101 20030101Localized delivery antimicro 19960101 20050101

Periodontal maint procedures 19840101 20030101Unscheduled dressing change 19840101 19960101Unspecified periodontal proc 19840101 19960101Dentures complete maxillary 19820101 19960101Dentures complete mandible 19820101 19960101Dentures immediat maxillary 19820101 19960101Dentures immediat mandible 19820101 19960101Dentures maxill part resin 19840101 19960101Dentures mand part resin 19840101 19960101Dentures maxill part metal 19840101 19960101

Dentures mandibl part metal 19840101 19960101

Maxillary part denture flex 20050101 20050101

Mandibular part denture flex 20050101 20050101

Removable partial denture 19840101 19960101

Dentures adjust cmplt maxil 19840101 19960101Dentures adjust cmplt mand 19860101 19960101Dentures adjust part maxill 19840101 19960101Dentures adjust part mandbl 19840101 19960101Dentur repr broken compl bas 19860101 19960101Replace denture teeth complt 19860101 19960101Dentures repair resin base 19840101 19960101Rep part denture cast frame 19840101 19960101Rep partial denture clasp 19840101 19960101Replace part denture teeth 19840101 19960101Add tooth to partial denture 19840101 19960101Add clasp to partial denture 19840101 19960101Replc tth&acrlc on mtl frmwk 20030101 20030101Replc tth&acrlc mandibular 20030101 20030101

Query_110708

Page 363

Dentures rebase cmplt maxil 19840101 19960101Dentures rebase cmplt mand 19860101 19960101Dentures rebase part maxill 19840101 19960101Dentures rebase part mandbl 19860101 19960101Denture reln cmplt maxil ch 19840101 19960101Denture reln cmplt mand chr 19860101 19960101Denture reln part maxil chr 19840101 19960101Denture reln part mand chr 19860101 19960101Denture reln cmplt max lab 19840101 19960101Denture reln cmplt mand lab 19860101 19960101Denture reln part maxil lab 19840101 19960101Denture reln part mand lab 19860101 19960101Denture interm cmplt maxill 19840101 19960101Denture interm cmplt mandbl 19840101 19960101Denture interm part maxill 19840101 19960101Denture interm part mandbl 19840101 19960101Denture tiss conditn maxill 19840101 19960101Denture tiss condtin mandbl 19920101 19960101Overdenture complete 19840101 19960101Overdenture partial 19840101 19960101Precision attachment 19860101 19960101Replacement of precision att 20000101 20000101

Prosthesis modification 20000101 20000101Removable prosthodontic proc 19860101 19960101Facial moulage sectional 19850101 19930101Facial moulage complete 19850101 19930101Nasal prosthesis 19850101 19960101Auricular prosthesis 19850101 19960101Orbital prosthesis 19850101 19960101Ocular prosthesis 19850101 19960101Facial prosthesis 19850101 19960101Nasal septal prosthesis 19920101 19960101Ocular prosthesis interim 19920101 19960101Cranial prosthesis 19920101 19960101Facial augmentation implant 19920101 19960101Replacement nasal prosthesis 19920101 19960101Auricular replacement 19920101 19960101Orbital replacement 19920101 19960101Facial replacement 19920101 19960101Surgical obturator 19850101 19960101Postsurgical obturator 19850101 19960101Refitting of obturator 19850101 19960101Mandibular flange prosthesis 19850101 19960101Mandibular denture prosth 19850101 19960101Temp obturator prosthesis 19920101 19960101Trismus appliance 19920101 19960101Feeding aid 19850101 19930101Pediatric speech aid 19850101 19960101Adult speech aid 19850101 19960101Superimposed prosthesis 19850101 19960101Palatal lift prosthesis 19850101 19960101Intraoral con def inter plt 19920101 19960101Intraoral con def mod palat 19920101 19960101Modify speech aid prosthesis 19920101 19960101Surgical stent 19850101 19960101Radiation applicator 19850101 19930101Radiation shield 19850101 19930101Radiation cone locator 19850101 19930101Fluoride applicator 19850101 19960101Commissure splint 19920101 19960101

Query_110708

Page 364

Surgical splint 19920101 19960101Topical medicament carrier 20090101 20090101Maxillofacial prosthesis 19860101 19960101Odontics endosteal implant 19960101 19960101Endosteal implant 20070101 20070101

Odontics eposteal implant 19920101 19960101Odontics transosteal implnt 19920101 19960101Implnt/abtmnt spprt remv dnt 20030101 20030101Implnt/abtmnt spprt remvprtl 20030101 20030101Implant connecting bar 19920101 19960101Prefabricated abutment 20000101 20050101Custom abutment 20000101 20050101Abutment supported crown 20000101 20000101Abutment supported mtl crown 20000101 20000101Abutment supported mtl crown 20000101 20000101Abutment supported mtl crown 20000101 20000101Abutment supported mtl crown 20000101 20000101Abutment supported mtl crown 20000101 20000101Abutment supported mtl crown 20000101 20000101Implant supported crown 20000101 20000101Implant supported mtl crown 20000101 20000101

Implant supported mtl crown 20000101 20000101Abutment supported retainer 20000101 20000101Abutment supported retainer 20000101 20000101Abutment supported retainer 20000101 20000101

Abutment supported retainer 20000101 20000101Abutment supported retainer 20000101 20000101Abutment supported retainer 20000101 20000101Abutment supported retainer 20000101 20000101Implant supported retainer 20000101 20000101Implant supported retainer 20000101 20000101

Implant supported retainer 20000101 20000101

Implnt/abut suprtd fixd dent 20000101 20000101Implnt/abut suprtd fixd dent 20000101 20000101Implant maintenance 19920101 19960101

Repair implant 19920101 19960101Repl semi/precision attach 20070101 20070101

Recement supp crown 20070101 20070101Recement supp part denture 20070101 20070101Abut support crown titanium 20050101 20050101Odontics repr abutment 19960101 19960101Removal of implant 19920101 19960101Radio/surgical implant index 20050101 20050101Abut support retainer titani 20050101 20050101Implant procedure 19920101 19960101Pontic-indirect resin based 20050101 20050101Prosthodont high noble metal 19840101 19960101Bridge base metal cast 19840101 19960101Bridge noble metal cast 19840101 19960101Pontic titanium 20050101 20050101Bridge porcelain high noble 19840101 19960101Bridge porcelain base metal 19840101 19960101Bridge porcelain nobel metal 19840101 19960101Bridge porcelain/ceramic 20000101 20000101

Query_110708

Page 365

Bridge resin w/high noble 19840101 19960101Bridge resin base metal 19840101 19960101Bridge resin w/noble metal 19840101 19960101Provisional pontic 20030101 20030101Dental retainr cast metl 19840101 19960101Porcelain/ceramic retainer 20000101 20000101Porcelain/ceramic inlay 2srf 20030101 20030101Porc/ceram inlay >= 3 surfac 20030101 20030101Cst hgh nble mtl inlay 2 srf 20030101 20030101Cst hgh nble mtl inlay >=3sr 20030101 20030101Cst bse mtl inlay 2 surfaces 20030101 20030101Cst bse mtl inlay >= 3 surfa 20030101 20030101Cast noble metal inlay 2 sur 20030101 20030101Cst noble mtl inlay >=3 surf 20030101 20030101Onlay porc/crmc 2 surfaces 20030101 20030101Onlay porc/crmc >=3 surfaces 20030101 20030101Onlay cst hgh nbl mtl 2 srfc 20030101 20030101Onlay cst hgh nbl mtl >=3srf 20030101 20030101Onlay cst base mtl 2 surface 20030101 20030101Onlay cst base mtl >=3 surfa 20030101 20030101Onlay cst nbl mtl 2 surfaces 20030101 20030101Onlay cst nbl mtl >=3 surfac 20030101 20030101Inlay titanium 20050101 20050101Onlay titanium 20050101 20050101Crown-indirect resin based 20050101 20050101Retain crown resin w hi nble 19840101 19960101Crown resin w/base metal 19860101 19960101Crown resin w/noble metal 19840101 19960101Crown porcelain/ceramic 20000101 20000101Crown porcelain high noble 19840101 19960101Crown porcelain base metal 19840101 19960101Crown porcelain noble metal 19840101 19960101Crown 3/4 high noble metal 19840101 19960101Crown 3/4 cast based metal 20000101 20000101Crown 3/4 cast noble metal 20000101 20000101Crown 3/4 porcelain/ceramic 20000101 20000101Crown full high noble metal 19840101 19960101Crown full base metal cast 19840101 19960101Crown full noble metal cast 19840101 19960101Provisional retainer crown 20030101 20030101Crown titanium 20050101 20050101Dental connector bar 19960101 19960101Dental recement bridge 19820101 19960101Stress breaker 19820101 19960101Precision attachment 19820101 19960101Post & core plus retainer 19860101 20070101

Cast post bridge retainer 19860101 20070101Prefab post & core plus reta 19860101 19960101Core build up for retainer 19920101 19960101Coping metal 19920101 19960101Each addtnl cast post 20000101 20070101Each addtl prefab post 20000101 20000101Bridge repair 19860101 19960101Pediatric partial denture fx 20030101 20030101Fixed prosthodontic proc 19840101 19960101Extraction coronal remnants 20030101 20050101Extraction erupted tooth/exr 20030101 20030101Rem imp tooth w mucoper flp 19840101 19930101

Impact tooth remov soft tiss 19840101 19930101

Query_110708

Page 366

Impact tooth remov part bony 19840101 19930101Impact tooth remov comp bony 19840101 19930101Impact tooth rem bony w/comp 19840101 19930101Tooth root removal 19840101 19930101Oral antral fistula closure 19840101 19930101Primary closure sinus perf 20030101 20030101Tooth reimplantation 19840101 20030101

Tooth transplantation 19820101 19960101

Exposure impact tooth orthod 19840101 20030101Mobilize erupted/malpos toot 20030101 20030101Place device impacted tooth 20050101 20050101Biopsy of oral tissue hard 19840101 20000101Biopsy of oral tissue soft 19840101 20050101Exfoliative cytolog collect 20030101 20050101Brush biopsy 20050101 20050101Repositioning of teeth 19820101 19960101Transseptal fiberotomy 19860101 20030101Screw retained plate 20070101 20070101

Temp anchorage dev w flap 20070101 20070101Temp anchorage dev w/o flap 20070101 20070101Alveoplasty w/ extraction 19840101 20070101

Alveoloplasty w/extract 1-3 20050101 20050101

Alveoplasty w/o extraction 19840101 20070101

Alveoloplasty not w/extracts 20050101 20050101

Vestibuloplasty ridge extens 19840101 19960101Vestibuloplasty exten graft 19840101 19960101

Rad exc lesion up to 1.25 cm 19820101 20030101Excision benign lesion>1.25c 20030101 20030101Excision benign lesion compl 20030101 20030101Excision malig lesion<=1.25c 20030101 20030101Excision malig lesion>1.25cm 20030101 20030101Excision malig les complicat 20030101 20030101Malig tumor exc to 1.25 cm 19840101 19960101Malig tumor > 1.25 cm 19840101 19960101Rem odontogen cyst to 1.25cm 19840101 20030101Rem odontogen cyst > 1.25 cm 19840101 20030101Rem nonodonto cyst to 1.25cm 19840101 20030101Rem nonodonto cyst > 1.25 cm 19840101 20030101

Lesion destruction 19840101 19960101Rem exostosis any site 20000101 20030101Removal of torus palatinus 20030101 20030101Remove torus mandibularis 20030101 20030101Surg reduct osseoustuberosit 20030101 20030101Maxilla or mandible resectio 19820101 20050101I&d absc intraoral soft tiss 19840101 19960101Incision/drain abscess intra 20050101 20050101

I&d abscess extraoral 19840101 19960101Incision/drain abscess extra 20050101 20050101

Removal fb skin/areolar tiss 19840101 20030101

Query_110708

Page 367

Removal of fb reaction 19840101 19960101Removal of sloughed off bone 19820101 20030101Maxillary sinusotomy 19820101 19960101Maxilla open reduct simple 19840101 19960101Clsd reduct simpl maxilla fx 19840101 19960101Open red simpl mandible fx 19840101 19960101Clsd red simpl mandible fx 19840101 19960101Open red simp malar/zygom fx 19840101 19960101Clsd red simp malar/zygom fx 19840101 19960101Closd rductn splint alveolus 19840101 20030101Alveolus open reduction 20030101 20030101Reduct simple facial bone fx 19820101 19960101

Maxilla open reduct compound 19840101 19960101Clsd reduct compd maxilla fx 19840101 19960101Open reduct compd mandble fx 19840101 19960101Clsd reduct compd mandble fx 19840101 19960101Open red comp malar/zygma fx 19840101 19960101Clsd red comp malar/zygma fx 19840101 19960101Open reduc compd alveolus fx 19840101 20030101Alveolus clsd reduc stblz te 20030101 20030101Reduct compnd facial bone fx 19820101 19960101

Tmj open reduct-dislocation 19820101 19960101Closed tmp manipulation 19820101 19960101Tmj manipulation under anest 19820101 19960101Removal of tmj condyle 19820101 19960101Tmj meniscectomy 19840101 19960101Tmj repair of joint disc 19920101 19960101Tmj excisn of joint membrane 19920101 19960101Tmj cutting of a muscle 19920101 19960101Tmj reconstruction 19920101 19960101Tmj cutting into joint 19820101 19960101Tmj reshaping components 19920101 19960101Tmj aspiration joint fluid 19820101 19960101Lysis + lavage w catheters 20000101 20000101Tmj diagnostic arthroscopy 19920101 19960101Tmj arthroscopy lysis adhesn 19920101 19960101Tmj arthroscopy disc reposit 19920101 19960101Tmj arthroscopy synovectomy 19920101 19960101Tmj arthroscopy discectomy 19920101 19960101Tmj arthroscopy debridement 19920101 19960101Occlusal orthotic appliance 19860101 19960101Tmj unspecified therapy 19920101 19960101Dent sutur recent wnd to 5cm 19840101 19960101Dental suture wound to 5 cm 19840101 19960101Suture complicate wnd > 5 cm 19840101 19960101Dental skin graft 19840101 19960101Reshaping bone orthognathic 19820101 19930101Bone cutting ramus closed 19840101 20000101Cutting ramus open w/graft 19840101 20000101Bone cutting segmented 19840101 20070101Bone cutting body mandible 19840101 19960101Reconstruction maxilla total 19840101 19960101Reconstruct maxilla segment 19840101 19960101Reconstruct midface no graft 19840101 19960101

Reconstruct midface w/graft 19840101 19960101Mandible graft 19840101 20070101

Sinus aug w bone/bone sup 20070101 20070101

Query_110708

Page 368

Bone replacement graft 20050101 20050101Repair maxillofacial defects 19820101 20050101Frenulectomy/frenulotomy 19840101 19960101Frenuloplasty 20050101 20050101Excision hyperplastic tissue 19840101 19960101Excision pericoronal gingiva 19860101 19960101Surg redct fibrous tuberosit 20030101 20030101Sialolithotomy 19820101 19960101Excision of salivary gland 19820101 19960101Sialodochoplasty 19840101 19960101Closure of salivary fistula 19820101 19960101Emergency tracheotomy 19820101 19960101Dental coronoidectomy 19850101 19960101Synthetic graft facial bones 19960101 19960101Implant mandible for augment 19960101 19960101Appliance removal 20000101 20000101

Intraoral place of fix dev 20070101 20070101Oral surgery procedure 19840101 19960101Limited dental tx primary 19960101 19960101Limited dental tx transition 19960101 19960101Limited dental tx adolescent 19960101 19960101Limited dental tx adult 19960101 19960101Intercep dental tx primary 19960101 19960101Intercep dental tx transitn 19960101 19960101Compre dental tx transition 19960101 19960101Compre dental tx adolescent 19960101 19960101Compre dental tx adult 19960101 19960101Orthodontic rem appliance tx 19820101 19960101Fixed appliance therapy habt 19840101 19960101Preorthodontic tx visit 19960101 19960101Periodic orthodontc tx visit 19960101 19960101Orthodontic retention 19960101 19960101

Orthodontic treatment 19960101 19960101Repair ortho appliance 20000101 20000101Replacement retainer 20000101 20000101Rebond/cement/repair retain 20070101 20070101Orthodontic procedure 19840101 19960101Tx dental pain minor proc 19840101 19960101Fix partial denture section 20070101 20070101Dent anesthesia w/o surgery 19840101 19960101Regional block anesthesia 19820101 19960101Trigeminal block anesthesia 19850101 19960101Local anesthesia 19850101 19960101General anesthesia 19820101 20030101General anesthesia ea ad 15m 19920101 20030101Analgesia 19820101 20000101Intravenous sedation 20000101 20030101IV sedation ea ad 30 m 20000101 20030101Sedation (non-iv) 20000101 20000101Dental consultation 19820101 20070101

Dental house call 19840101 20000101Hospital call 19840101 19960101Office visit during hours 19840101 19960101

Office visit after hours 19840101 19960101Case presentation tx plan 20030101 20030101Dent therapeutic drug inject 19840101 20070101Thera par drugs 2 or > admin 20070101 20070101

Query_110708

Page 369

Other drugs/medicaments 19840101 19930101Dent appl desensitizing med 19850101 19960101Appl desensitizing resin 20000101 20000101Behavior management 19860101 19960101Treatment of complications 19840101 19930101Dental occlusal guard 19860101 19960101Fabrication athletic guard 19860101 19960101Repair/reline occlusal guard 20050101 20050101Occlusion analysis 19840101 19930101Limited occlusal adjustment 19860101 19930101Complete occlusal adjustment 19860101 19930101Enamel microabrasion 19960101 19960101Odontoplasty 1-2 teeth 20000101 20000101Extrnl bleaching per arch 20000101 20000101Extrnl bleaching per tooth 20000101 20000101Intrnl bleaching per tooth 20000101 20000101Adjunctive procedure 19840101 19960101Cane adjust/fixed with tip 19860101 19960101Cane adjust/fixed quad/3 pro 19860101 19960101

Crutch forearm pair 19860101 19960101

Crutch forearm each 19860101 19960101

Crutch underarm pair wood 19860101 19960101

Crutch underarm each wood 19860101 19960101Crutch underarm pair no wood 19860101 19970101

Crutch underarm each no wood 19860101 20060101

Underarm springassist crutch 20030101 20030101Crutch substitute 20040101 20040401Walker rigid adjust/fixed ht 19860101 19960101Walker folding adjust/fixed 19860101 19960101Walker w trunk support 20040101 20040101Rigid wheeled walker adj/fix 19860101 20040101Walker folding wheeled w/o s 19860101 20040101Enclosed walker w rear seat 20000101 20071005

Walker variable wheel resist 19860101 20040101Heavyduty walker no wheels 20010101 20010101Heavy duty wheeled walker 20010101 20040101Forearm crutch platform atta 19860101 19960101Walker platform attachment 19860101 19960101Walker wheel attachment,pair 19860101 20000101Walker seat attachment 19860101 19960101Walker crutch attachment 19860101 19960101Walker leg extenders set of4 19860101 20000101Brake for wheeled walker 19970101 19980101Sitz type bath or equipment 19860101 19960101Sitz bath/equipment w/faucet 19860101 19960101

Sitz bath chair 19860101 19960101Commode chair with fixed arm 19860101 20070101Commode chair mobile fixed a 19860101 20070101Commode chair with detacharm 19860101 20070101Commode chair mobile detach 19860101 20070101Commode chair pail or pan 19860101 20070101Heavyduty/wide commode chair 20010101 20010101

Query_110708

Page 370

Seatlift incorp commodechair 20020101 20060101Commode chair electric 20060101 20060101Commode chair non-electric 20060101 20060101Seat lift mechanism toilet 20060101 20060101Commode chair foot rest 19860101 19960101Press pad alternating w pump 19860101 20070101Press pad alternating w/ pum 19860101 20070101

Replace pump, alt press pad 19860101 20070101Dry pressure mattress 19860101 19960101Gel pressure mattress pad 19860101 19980101Air pressure mattress 19860101 19960101Water pressure mattress 19860101 19960101Synthetic sheepskin pad 19860101 20010101Lambswool sheepskin pad 19860101 20010101Positioning cushion 20040101 20070101

Protector heel or elbow 19860101 19960101Powered air flotation bed 19900101 19930101Air fluidized bed 19910101 19910101Gel pressure mattress 19910101 19910101Air pressure pad for mattres 19910101 19980101Water pressure pad for mattr 19910101 19980101Dry pressure pad for mattres 19910101 19980101Heat lamp without stand 19860101 19960101Phototherapy light w/ photom 19850101 19960101Therapeutic lightbox tabletp 20030101 20050101Heat lamp with stand 19860101 19960101Electric heat pad standard 19860101 20030101Electric heat pad moist 19860101 19960101Water circ heat pad w pump 19970101 19970101Water circ cold pad w pump 19970101 19970101Hot water bottle 19860101 19960101Infrared heating pad system 20020101 20070101Hydrocollator unit 19860101 19960101Ice cap or collar 19860101 19960101Wound warming device 20020101 20020701

Warming card for NWT 20020101 20020701

Paraffin bath unit portable 19860101 19960101Pump for water circulating p 19860101 19960101Heat pad non-electric moist 19860101 19960101Hydrocollator unit portable 19860101 19960101Bath/shower chair 20040101 20060101Bath tub wall rail 19860101 19960101Bath tub rail floor 19860101 19960101Toilet rail 19860101 19960101Toilet seat raised 19860101 19960101Tub stool or bench 19860101 19960101Transfer tub rail attachment 19860101 19960101Trans bench w/wo comm open 20040101 20040101HDtrans bench w/wo comm open 20040101 20040101Pad water circulating heat u 19860101 19960101Hosp bed fixed ht w/ mattres 19860101 19910101Hosp bed fixd ht w/o mattres 19860101 19910101Hospital bed var ht w/ mattr 19860101 19910101Hospital bed var ht w/o matt 19910101 19910101Hosp bed semi-electr w/ matt 19860101 19910101

Hosp bed semi-electr w/o mat 19910101 19910101

Query_110708

Page 371

Hosp bed total electr w/ mat 19860101 19910101

Hosp bed total elec w/o matt 19860101 19910101

Hospital bed institutional t 19860101 19930101

Mattress innerspring 19860101 19930101Mattress foam rubber 19860101 19930101Bed board 19860101 19890101Over-bed table 19860101 19890101Bed pan standard 19860101 19960101Bed pan fracture 19860101 19960101Powered pres-redu air mattrs 19920101 19980101Bed cradle 19860101 19890101Hosp bed fx ht w/o rails w/m 19910101 19910101Hosp bed fx ht w/o rail w/o 19910101 19910101Hosp bed var ht w/o rail w/o 19910101 19910101Hosp bed var ht w/o rail w/ 19910101 19910101Hosp bed semi-elect w/ mattr 19910101 19910101

Hosp bed semi-elect w/o matt 19910101 19910101

Hosp bed total elect w/ matt 19910101 19920101

Hosp bed total elect w/o mat 19910101 19910101

Enclosed ped crib hosp grade 20040101 20040101HD hosp bed, 350-600 lbs 20040101 20040101

Ex hd hosp bed > 600 lbs 20040101 20040101

Hosp bed hvy dty xtra wide 20040101 20040101

Hosp bed xtra hvy dty x wide 20040101 20040101

Rails bed side half length 19860101 19900101Rails bed side full length 19860101 19900101Bed accessory brd/tbl/supprt 19860101 19970101Bed safety enclosure 20020101 20020101Urinal male jug-type 19860101 19960101Urinal female jug-type 19860101 19960101Ped hospital bed, manual 20080101 20080101

Ped hospital bed semi/elect 20080101 20080101

Control unit bowel system 19950101 19950101Disposable pack w/bowel syst 19950101 19950101

Air elevator for heel 19970101 19980101Nonpower mattress overlay 19980101 19980101

Powered air mattress overlay 19980101 19980101Nonpowered pressure mattress 19980101 19980101Stationary compressed gas 02 19930101 20010101

Query_110708

Page 372

Gas system stationary compre 19860101 19930101

Oxygen system gas portable 19860101 19930101

Portable gaseous 02 19930101 20010101

Portable liquid 02 19930101 19930101

Oxygen system liquid portabl 19860101 19930101

Stationary liquid 02 19930101 20010101

Oxygen system liquid station 19860101 19930101

Oxygen contents, gaseous 19930101 20030101

Oxygen contents, liquid 19930101 20030101

Portable 02 contents, gas 19930101 20030101

Portable 02 contents, liquid 19930101 20030101

Oximeter non-invasive 20030101 20030101Vol control vent invasiv int 19850101 20050101

Oxygen tent excl croup/ped t 19860101 19900101Chest shell 19900101 20010101Chest wrap 19900101 19960101Neg press vent portabl/statn 19900101 19960101Vol control vent noninv int 20030101 20050101

Rocking bed w/ or w/o side r 19900101 19960101Press supp vent invasive int 20050101 20050101

Press supp vent noninv int 20050101 20050101

RAD w/o backup non-inv intfc 20040101 20040101

RAD w/backup non inv intrfc 20040101 20060401

RAD w backup invasive intrfc 20040101 20060401

Percussor elect/pneum home m 19860101 19960101Intrpulmnry percuss vent sys 20020101 20020701Cough stimulating device 20020101 20020101Chest compression gen system 20030101 20030101

Non-elec oscillatory pep dvc 20030101 20030101Oral device/appliance prefab 20060101 20060101

Oral device/appliance cusfab 20060101 20060101

Electronic spirometer 20090101 20090101

Query_110708

Page 373

Ippb all types 19860101 19960101

Humidif extens supple w ippb 19860101 20050701

Humidifier for use w/ regula 19860101 19960101

Humidifier supplemental w/ i 19860101 20050701

Humidifier nonheated w PAP 20040101 20040101Humidifier heated used w PAP 20040101 20040101Compressor air power source 19820101 19960101

Nebulizer with compression 19860101 19960101Aerosol compressor for svneb 20010101 20010101Aerosol compressor adjust pr 20010101 20010101Ultrasonic generator w svneb 20010101 20030101Nebulizer ultrasonic 19860101 20010101Nebulizer for use w/ regulat 19860101 19980101

Nebulizer w/ compressor & he 19860101 19960101Dispensing fee dme neb drug 20000101 20060101Suction pump portab hom modl 19860101 20020101Cont airway pressure device 19880101 19960101Manual breast pump 20000101 20020101Electric breast pump 20020101 20020101Hosp grade elec breast pump 20020101 20080101Vaporizer room type 19860101 19960101Drainage board postural 19860101 19960101Blood glucose monitor home 19860101 19960101Pacemaker monitr audible/vis 19860101 19960101

Pacemaker monitr digital/vis 19860101 19960101

Cardiac event recorder 20000101 20050401Automatic ext defibrillator 20010101 20010101Apnea monitor 20030101 20030101Apnea monitor w recorder 20030101 20030101Cap bld skin piercing laser 20020101 20020101Patient lift sling or seat 19860101 19960101Patient lift bathroom or toi 19860101 20050101Seat lift incorp lift-chair 19920101 19960101Seat lift for pt furn-electr 19920101 19960101Seat lift for pt furn-non-el 19920101 19960101Patient lift hydraulic 19860101 20080101

Patient lift electric 19860101 19960101PT support & positioning sys 20030101 20030101

Combination sit to stand sys 20040101 20060101

Standing frame sys 20040101 20060101

Moveable patient lift system 20050101 20070101

Fixed patient lift system 20050101 20070101Multi-position stnd fram sys 20060101 20060101

Dynamic standing frame 20060101 20060101Pneuma compresor non-segment 19860101 19960101Pneum compressor segmental 19880101 19960101Pneum compres w/cal pressure 19880101 19960101

Query_110708

Page 374

Pneumatic appliance half arm 19860101 19960101Segmental pneumatic trunk 20090101 20090101Segmental pneumatic chest 20090101 20090101Pneumatic appliance full leg 19860101 19960101Pneumatic appliance full arm 19860101 19960101Pneumatic appliance half leg 19860101 19960101Seg pneumatic appl full leg 19880101 19960101Seg pneumatic appl full arm 19880101 19960101Seg pneumatic appli half leg 19940101 19940101Pressure pneum appl full leg 19950101 19950101Pressure pneum appl full arm 19950101 19950101Pressure pneum appl half leg 19950101 19950101Pneumatic compression device 20040101 20040101

Inter limb compress dev NOS 20070101 20070101

Uvl pnl 2 sq ft or less 20030101 20030101

Uvl sys panel 4 ft 20030101 20030101

Uvl sys panel 6 ft 20030101 20030101

Uvl md cabinet sys 6 ft 20030101 20030101

Safety equipment 19860101 19960101Helmet w face guard prefab 20030101 20070101Transfer device 20060101 20080101Restraints any type 19860101 19960101Tens two lead 19860101 20070101

Tens four lead 19860101 20070101

Conductive garment for tens/ 19890101 19960101

Incontinence treatment systm 19860101 20010401

Neuromuscular stim for scoli 19890101 19960101Neuromuscular stim for shock 19860101 19960101Electromyograph biofeedback 19890101 19960101Elec osteogen stim not spine 19860101 19970101

Elec osteogen stim spinal 19960101 19970101Elec osteogen stim implanted 19860101 20000701Neurostimulator electrode 20020101 20060101Pulsegenerator pt programmer 20020101 20060101

Electronic salivary reflex s 19900101 19950401Implantable pulse generator 20010101 20060101Implantable RF receiver 20010101 20060101External RF transmitter 20010101 20060101

Replace rdfrquncy transmittr 20020101 20060101

Osteogen ultrasound stimltor 19970101 20010101Nontherm electromgntc device 20030101 20050101

Trans elec jt stim dev sys 20060101 20060101

Functional neuromuscularstim 20060101 20090101

Query_110708

Page 375

Nerve stimulator for tx n&v 20010101 20010101

Electric wound treatment dev 20050101 20050101

Functional electric stim NOS 20090101 20090101

Iv pole 19850101 19950401Amb infusion pump mechanical 20000101 20000101Mech amb infusion pump <8hrs 20000101 20000101External ambulatory infus pu 19870101 20000701

Non-programble infusion pump 19860101 20030101

Programmable infusion pump 19950101 19980101

Ext amb infusn pump insulin 19960101 20000701Replacement impl pump cathet 19990101 19990101

Implantable pump replacement 20010101 20010101

Parenteral infusion pump sta 19890101 19960101Ambulatory traction device 20010101 20010101Tract frame attach headboard 19840101 19940101Cervical pneum trac equip 20050101 20050101

Traction stand free standing 19820101 19940101Cervical traction equipment 19980101 19980101Cervic collar w air bladder 20080101 20080101Tract equip cervical tract 19860101 19890101Tract frame attach footboard 19860101 19940101Trac stand free stand extrem 19860101 19940101Traction frame attach pelvic 19860101 19940101Trac stand free stand pelvic 19860101 19940101Trapeze bar attached to bed 19860101 19840101HD trapeze bar attach to bed 20060101 20060101

HD trapeze bar free standing 20060101 20060101

Fracture frame attached to b 19860101 19890101Fracture frame free standing 19860101 19890101Cont pas motion exercise dev 19860101 20060101CPM device, other than knee 20070101 20070101Trapeze bar free standing 19860101 19890101Gravity assisted traction de 19860101 19890101Cervical head harness/halter 19860101 19860101Pelvic belt/harness/boot 19850101 19960101Belt/harness extremity 19850101 19960101Fracture frame dual w cross 19860101 19890101Fracture frame attachmnts pe 19860101 19890101Fracture frame attachmnts ce 19860101 19890101Tray 19860101 20040101Loop heel 19860101 20050101Toe loop/holder, each 19860101 20050101Pneumatic tire 19860101 20060101Wheelchair semi-pneumatic ca 19860101 20060101Cushioned headrest 20040101 20050101

W/c lateral trunk/hip suppor 20040101 20050101

W/c medial thigh support 20040101 20050101

Query_110708

Page 376

Whlchr att- conv 1 arm drive 19860101 20040101Amputee adapter 19860101 20040101W/c shoulder harness/straps 20040101 20040101

Wheelchair brake extension 19860101 20040101Wheelchair head rest extensi 19860101 20040101Manual wc hand rim w project 19860101 20070101Wheelchair commode seat 19860101 19890101Wheelchair narrowing device 19860101 19890101Wheelchair no. 2 footplates 19860101 20010401Wheelchair anti-tipping devi 19860101 20060101Transfer board or device 19860101 20060101W/Ch access det adj armrest 19860101 20040101

W/Ch access anti-rollback 19860101 20040101Wheelchair wedge cushion 19860101 20070101W/C acc,saf belt pelv strap 19860101 20050101Wheelchair safety vest 19860101 19890101Seat upholstery, replacement 20040101 20040101Back upholstery, replacement 20040101 20040101Add pwr joystick 20040101 20040101

Add pwr tiller 20040101 20040101

W/c seat lift mechanism 20040101 20040101Man w/c push-rim pow assist 20040101 20050101Wheelchair elevating leg res 19860101 20040101Wheelchair solid seat insert 19860101 20040101Wheelchair arm rest 19860101 19890101Wheelchair calf rest 19860101 20040101Wheelchair tire solid 19860101 20060101Wheelchair caster w/ a fork 19860101 20070101Wheelchair caster w/o a fork 19860101 20070101Wheelchr pneumatic tire w/wh 19860101 20070101Wheelchair tire pneumatic ca 19860101 20060101Wheelchair wheel 19860101 20060101Pwr seat tilt 20040101 20040101Pwr seat recline 20040101 20040101

Pwr seat recline mech 20040101 20040101

Pwr seat recline pwr 20040101 20040101

Pwr seat combo w/o shear 20040101 20040101

Pwr seat combo w/shear 20040101 20040101

Pwr seat combo pwr shear 20040101 20040101

Add mech leg elevation 20040101 20040101

Add pwr leg elevation 20040101 20050101

Ped wc modify width adjustm 20030101 20050101

Reclining back add ped w/c 20030101 20050101Shock absorber for man w/c 20030101 20030101Shock absorber for power w/c 20030101 20030101HD shck absrbr for hd man wc 20030101 20030101

HD shck absrber for hd powwc 20030101 20030101

Query_110708

Page 377

HD feature power seat 20040101 20060101

Residual limb support system 20030101 20030101Ex hd feature power seat 20040101 20060101

Pedwc lat/thor sup nocontour 20030101 20060101

Pedwc contoured lat/thor sup 20030101 20060101

Ped wc lat/ant support 20030101 20060101W/c manual swingaway 20040101 20040101

W/c vent tray fixed 20040101 20040101W/c vent tray gimbaled 20040101 20040101Rollabout chair with casters 19900101 19900101Patient transfer system 20010101 20030101

Transport chair, ped size 20030101 20030101Transport chair pt wt<=300lb 20030101 20060101

Transport chair pt wt >300lb 20050101 20060101

Whelchr fxd full length arms 19860101 19840101

Wheelchair detachable arms 19860101 19890101

Wheelchair detachable foot r 19860101 19890101

Hemi-wheelchair fixed arms 19860101 19890101

Hemi-wheelchair detachable a 19860101 19890101

Hemi-wheelchair fixed arms 19860101 20010401Hemi-wheelchair detachable a 19860101 20010401

Wheelchair lightwt fixed arm 19860101 19890101

Wheelchair lightweight det a 19860101 19890101

Wheelchair lightwt fixed arm 19860101 20010401

Wheelchair lightweight det a 19860101 20010401

Wheelchair wide w/ leg rests 19860101 19890101

Wheelchair wide w/ foot rest 19860101 19890101

Whchr s-recl fxd arm leg res 19860101 19880101

Wheelchair semi-recl detach 19860101 19890101

Whlchr stand fxd arm ft rest 19860101 20010401

Wheelchair standard detach a 19860101 20010401

Wheelchair standard w/ leg r 19860101 19890101

Wheelchair fixed arms 19860101 19890101Manual adult wc w tiltinspac 20030101 20030101Whlchr ampu fxd arm leg rest 19860101 19890101

Query_110708

Page 378

Wheelchair amputee w/o leg r 19860101 19890101Wheelchair amputee detach ar 19860101 19890101

Wheelchair amputee w/ foot r 19860101 19890101

Wheelchair amputee w/ leg re 19860101 19890101

Wheelchair amputee heavy dut 19860101 19890101

Wheelchair amputee fixed arm 19860101 19890101Whlchr moto ful arm leg rest 19860101 20060101

Wheelchair motorized w/ det 19880101 20060101

Wheelchair motorized w full 19880101 20060101Wheelchair motorized w/ det 19880101 20060101

Whlchr special size/constrc 19860101 19900101

Wheelchair spec size w foot 19860101 19900101Wheelchair spec size w/ leg 19860101 19900101Wheelchair spec size w foot 19860101 19900101Wheelchair spec size w/ leg 19860101 19900101Manual semi-reclining back 19860101 20050101

Manual fully reclining back 19860101 20050101

Wheelchair spec sz spec ht a 19860101 19900101Wheelchair spec sz spec ht b 19860101 19900101Pediatric wheelchair NOS 20050101 20050101Power operated vehicle 19860101 19910101

Rigid ped w/c tilt-in-space 20030101 20090101

Folding ped wc tilt-in-space 20030101 20090101

Rig ped wc tltnspc w/o seat 20030101 20090101

Fld ped wc tltnspc w/o seat 20030101 20090101

Rigid ped wc adjustable 20030101 20090101Folding ped wc adjustable 20030101 20090101Rgd ped wc adjstabl w/o seat 20030101 20090101Fld ped wc adjstabl w/o seat 20030101 20090101Ped power wheelchair NOS 20050101 20050101Whchr litwt det arm leg rest 19860101 19890101

Wheelchair lightwt fixed arm 19860101 20010401Wheelchair lightwt foot rest 19860101 20010401

Wheelchair lightweight leg r 19860101 19890101

Whchr h-duty det arm leg res 19860101 19890101Wheelchair heavy duty fixed 19860101 20010401Wheelchair hvy duty detach a 19860101 20010401

Wheelchair heavy duty fixed 19860101 19890101Wheelchair special seat heig 19860101 19890101Wheelchair special seat dept 19860101 19890101Wheelchair spec seat depth/w 19860101 19890101

Query_110708

Page 379

Whirlpool portable 19860101 19960101Whirlpool non-portable 19860101 19960101Repair for DME, per 15 min 19970101 19970101

Oxygen supplies regulator 19860101 20090101Wheeled cart, port cyl/conc 20090101 20090101

Oxygen supplies stand/rack 19860101 20090101Batt pack/cart, port conc 20090101 20090101

Battery charger, port conc 20090101 20090101

DC power adapter, port conc 20090101 20090101

Oxy suppl heater for nebuliz 19860101 19960101Oxygen concentrator 20000101 20040101

Oxygen concentrator, dual 20040101 20040101

Portable oxygen concentrator 20060101 20060101Durable medical equipment mi 19860101 19960101O2/water vapor enrich w/heat 19880101 19900101O2/water vapor enrich w/o he 19880101 19900101Centrifuge 20020101 20020101Kidney dialysate delivry sys 19860101 20020101

Heparin infusion pump 19860101 20020101Replacement air bubble detec 19860101 20020101Replacement pressure alarm 19860101 20020101Bath conductivity meter 19860101 20020101Replace blood leak detector 19860101 20020101Adjustable chair for esrd pt 19860101 20020101Transducer protect/fld bar 19860101 20020101Unipuncture control system 19860101 20020101Hemodialysis machine 19860101 20020101Auto interm peritoneal dialy 19860101 20020101Cycler dialysis machine 19860101 20020101Deli/install chrg hemo equip 19860101 20020101Reverse osmosis h2o puri sys 19860101 20020101Deionizer H2O puri system 19860101 20020101Replacement blood pump 19860101 20020101Water softening system 19860101 20020101Reciprocating peritoneal dia 19860101 20020101Wearable artificial kidney 19860101 20020101Peritoneal dialysis clamp 20040101 20040101Compact travel hemodialyzer 19860101 20020101Sorbent cartridges per 10 19860101 20020101Hemostats for dialysis, each 20020101 20030101Dialysis scale 20020101 20030101Dialysis equipment noc 19860101 20020101Jaw motion rehab system 19930101 19971020Repl cushions for jaw motion 19930101 19960101Repl measr scales jaw motion 19930101 19960101Adjust elbow ext/flex device 19960101 20020101

SPS elbow device 20020101 20080101

Adjst forearm pro/sup device 20030101 20030101

Adjust wrist ext/flex device 19960101 20020101

Query_110708

Page 380

SPS wrist device 20020101 20080101

Adjust knee ext/flex device 19960101 20020101

SPS knee device 20020101 20080101

Knee ext/flex w act res ctrl 20060101 20060101Adjust ankle ext/flex device 19960101 20020101

SPS ankle device 20020101 20080101

SPS forearm device 20020101 20080101

Soft interface material 19960101 20020101Replacement interface SPSD 20020101 20020101

Adjust finger ext/flex devc 19960101 20020101

Adjust toe ext/flex device 19960101 20020101

Adj shoulder ext/flex device 20020101 20020101

Static str shldr dev rom adj 20050101 20080101

AAC non-electronic board 20020101 20020101

Gastric suction pump hme mdl 20020101 20020101Bld glucose monitor w voice 20020101 20020101Bld glucose monitor w lance 20020101 20020101Pulse gen sys tx endolymp fl 20040101 20040101Man w/ch acc seat w>=20”<24” 20040101 20040101

Seat width 24-27 in 20040101 20040101Frame depth less than 22 in 20040101 20040101

Frame depth 22 to 25 in 20040101 20040101Manual wc accessory, handrim 20050101 20080101

Complete wheel lock assembly 20050101 20050101Crutch and cane holder 20060101 20060101Cylinder tank carrier 20060101 20060101Arm trough each 20060101 20070101Wheelchair bearings 20060101 20060101Pneumatic propulsion tire 20060101 20060101Pneumatic prop tire tube 20060101 20060101Pneumatic prop tire insert 20060101 20060101

Pneumatic caster tire each 20060101 20060101Pneumatic caster tire tube 20060101 20060101Foam filled propulsion tire 20060101 20060101Foam filled caster tire each 20060101 20060101Foam propulsion tire each 20060101 20060101Foam caster tire any size ea 20060101 20060101Solid propulsion tire each 20060101 20060101

Solid caster tire each 20060101 20060101

Solid caster integrated whl 20060101 20060101

Valve replacement only each 20060101 20060101

Query_110708

Page 381

Propulsion whl excludes tire 20060101 20060101Caster wheel excludes tire 20060101 20060101

Caster fork replacement only 20060101 20060101Gear reduction drive wheel 20080101 20080101Mwc acc, wheelchair brake 20080101 20080101Manual standing system 20090101 20090101Solid seat support base 20090101 20090101

Planar back for ped size wc 20050101 20060101Planar seat for ped size wc 20050101 20060101Contour back for ped size wc 20050101 20060101

Contour seat for ped size wc 20050101 20060101

Ped dynamic seating frame 20090101 20090101

Pwr seat elevation sys 20040101 20040101Pwr standing 20040101 20090101Electro connect btw control 20040101 20040101

Electro connect btw 2 sys 20040101 20040101

Mini-prop remote joystick 20080101 20080101

PWC harness, expand control 20080101 20080101

Hand chin control 20040101 20070101

Hand interface joystick 20040101 20040101

Mult mech switches 20040101 20040101

Special joystick handle 20040101 20040101

Chin cup interface 20040101 20040101Sip and puff interface 20040101 20040101

Breath tube kit 20040101 20040101Head control interface mech 20040101 20040101

Head/extremity control inter 20040101 20040101

Head control nonproportional 20040101 20040101

Head control proximity switc 20040101 20040101

Attendant control 20040101 20040101

Query_110708

Page 382

W/c wdth 20-23 in seat frame 20040101 20040101W/c wdth 24-27 in seat frame 20040101 20040101W/c dpth 20-21 in seat frame 20040101 20040101W/c dpth 22-25 in seat frame 20040101 20040101Electronic SGD interface 20040101 20040101

22nf nonsealed leadacid 20040101 2004010122nf sealed leadacid battery 20040101 20040101

Gr24 nonsealed leadacid 20040101 20040101Gr24 sealed leadacid battery 20040101 20040101

U1nonsealed leadacid battery 20040101 20040101U1 sealed leadacid battery 20040101 20040101

Battery charger, single mode 20040101 20040101

Battery charger, dual mode 20040101 20040101

Power wc motor replacement 20050101 20050101Pwr wc gear box replacement 20050101 20050101Pwr wc motor/gear box combo 20050101 20050101Gr27 sealed leadacid battery 20060101 20060101

Gr27 non-sealed leadacid 20060101 20060101Hand/chin ctrl spec joystick 20070101 20080101

Hand/chin ctrl std joystick 20070101 20070101

Non-expandable controller 20070101 20070101

Expandable controller, repl 20070101 20070101

Expandable controller, initl 20070101 20070101

Pneum drive wheel tire 20070101 20070101

Tube, pneum wheel drive tire 20070101 20070101

Insert, pneum wheel drive 20070101 20070101

Pneumatic caster tire 20070101 20070101

Tube, pneumatic caster tire 20070101 20070101

Foam filled drive wheel tire 20070101 20070101

Foam filled caster tire 20070101 20070101

Foam drive wheel tire 20070101 20070101

Foam caster tire 20070101 20070101Solid drive wheel tire 20070101 20070101

Solid caster tire 20070101 20070101

Solid caster tire, integrate 20070101 20070101

Valve, pneumatic tire tube 20070101 20070101

Query_110708

Page 383

Drive wheel excludes tire 20070101 20070101

Caster wheel excludes tire 20070101 20070101

Caster fork 20070101 20070101Pwc acc, lith-based battery 20080101 20080101Noc interface 20040101 20040101

Neg press wound therapy pump 20040101 20040101SGD digitized pre-rec <=8min 20040101 20040101

SGD prerec msg >8min <=20min 20040101 20040101

SGD prerec msg>20min <=40min 20040101 20040101

SGD prerec msg > 40 min 20040101 20040101

SGD spelling phys contact 20040101 20040101

SGD w multi methods msg/accs 20040101 20040101

SGD sftwre prgrm for PC/PDA 20040101 20040101

SGD accessory, mounting sys 20040101 20040101SGD accessory noc 20040101 20040101Gen w/c cushion wdth < 22 in 20050101 20050101Gen w/c cushion wdth >=22 in 20050101 20050101Skin protect wc cus wd <22in 20050101 20050101Skin protect wc cus wd>=22in 20050101 20050101Position wc cush wdth <22 in 20050101 20050101Position wc cush wdth>=22 in 20050101 20050101Skin pro/pos wc cus wd <22in 20050101 20050101

Skin pro/pos wc cus wd>=22in 20050101 20050101

Custom fabricate w/c cushion 20050101 20050101Powered w/c cushion 20050101 20050101Gen use back cush wdth <22in 20050101 20050101

Gen use back cush wdth>=22in 20050101 20050101

Position back cush wd <22in 20050101 20050101

Position back cush wd>=22in 20050101 20050101

Pos back post/lat wdth <22in 20050101 20050101

Pos back post/lat wdth>=22in 20050101 20050101

Custom fab w/c back cushion 20050101 20050101

Wc acc solid seat supp base 20050101 20080101

Replace cover w/c seat cush 20050101 20050101WC planar back cush wd <22in 20050101 20050101

WC planar back cush wd>=22in 20050101 20050101

Posterior gait trainer 20050101 20050101

Query_110708

Page 384

Upright gait trainer 20050101 20050101

Anterior gait trainer 20050101 20050101

Admin influenza virus vac 19940101 19960101Admin pneumococcal vaccine 19940101 19960101Admin hepatitis b vaccine 19940101 19960101Semen analysis 19950101 20031001PET imaging prev PET single 19950101 20050401

PET imaging prev PET multple 19950101 20050401

PET follow SPECT 78464 singl 19950101 20050401

PET follow SPECT 78464 mult 19950101 20050401

PET follow SPECT 76865 singl 19950101 20050401

PET follow SPECT 78465 mult 19950101 20050401

PET follow cornry angio sing 19950101 20050401

PET follow cornry angio mult 19950101 20050401

PET follow myocard perf sing 19950101 20050401

PET follow myocard perf mult 19950101 20050401

PET follow stress echo singl 19950101 20050401

PET follow stress echo mult 19950101 20050401

PET follow ventriculogm sing 19950101 20050401

PET follow ventriculogm mult 19950101 20050401

PET following rest ECG singl 19950101 20050401

PET following rest ECG mult 19950101 20050401

PET follow stress ECG singl 19950101 20050401

PET follow stress ECG mult 19950101 20050401

CA screen;pelvic/breast exam 19980101 19980101Prostate ca screening; dre 20000101 20000101PSA screening 20000101 20070101CA screen;flexi sigmoidscope 19980101 19980101Colorectal scrn; hi risk ind 19980101 19980101Colon CA screen;barium enema 19980101 19980101

CA screen; fecal blood test 19980101 20070101

Diab manage trn per indiv 19980701 20010101

Diab manage trn ind/group 19980701 20010101

Nett pulm-rehab educ; ind 19970801 20060101Nett pulm-rehab educ; group 19970801 20060101

Query_110708

Page 385

Nett;nutrition guid, initial 19970801 20060101Nett;nutrition guid,subseqnt 19970801 20060101Nett; psychosocial consult 19970801 20060101Nett; psychological testing 19970801 20060101Nett; psychosocial counsel 19970801 20060101Glaucoma scrn hgh risk direc 20020101 20031001

Glaucoma scrn hgh risk direc 20020101 20031001

Colon ca scrn; barium enema 19980101 19980101

Colon ca scrn not hi rsk ind 19980101 20010701

Colon ca scrn; barium enema 19980101 19980101Screen cerv/vag thin layer 19980401 19980401

Screen c/v thin layer by MD 19980401 19980401

PET image pulmonary nodule 19971218 20050401Trim nail(s) 19980101 19980101CORF skilled nursing service 19980401 19980401

Partial hosp prog service 20000401 20080401

Single energy x-ray study 19980701 19980701

Scr c/v cyto,autosys and md 19990101 19990101

Scr c/v cyto,thinlayer,rescr 19990101 19990101



Scr c/v cyto, automated sys 19990101 19990101

Scr c/v cyto, autosys, rescr 19990101 19990101

HHCP-serv of pt,ea 15 min 19990701 19990701HHCP-serv of ot,ea 15 min 19990701 19990701HHCP-svs of s/l path,ea 15mn 19990701 19990701

HHCP-svs of rn,ea 15 min 19990701 19990701HHCP-svs of csw,ea 15 min 19990701 19990701HHCP-svs of aide,ea 15 min 19990701 19990701Extrnl counterpulse, per tx 20000101 20000101Wound closure by adhesive 20000101 20000101Linear acc stereo radsur com 20000801 20050101

OPPS Service,sched team conf 20000701 20000701

OPPS/PHP;activity therapy 20010101 20010101

Query_110708

Page 386

OPPS/PHP; train & educ serv 20010101 20010101

MD recertification HHA PT 20010101 20010101

MD certification HHA patient 20001001 20001001

Home health care supervision 20010101 20010101

Hospice care supervision 20010101 20010101

Dstry eye lesn,fdr vssl tech 20010101 20010101

Screeningmammographydigital 20010401 20010401Diagnosticmammographydigital 20010401 20030101Diagnosticmammographydigital 20010401 20030101PET img wholebody dxlung 20010701 20050401PET img wholbody init lung 20010701 20050401

PET img wholebod restag lung 20010701 20050401PET img wholbody dx 20010701 20050401PET img wholebod init 20010701 20050401PETimg wholebod restag 20010701 20050401PET img wholebod dx melanoma 20010701 20050401PET img wholebod init melan 20010701 20050401PET img wholebod restag mela 20010701 20050401PET img wholbod melano nonco 20010701 20010701PET img wholebod dx lymphoma 20010701 20050401PET imag wholbod init lympho 20010701 20050401PET imag wholbod resta lymph 20010701 20050401PET imag wholbod reg dx head 20010701 20050401

PET imag wholbod reg ini hea 20010701 20050401

PET whol restag headneckonly 20010701 20050401

PET img wholbody dx esophagl 20010701 20050401PET img wholbod ini esophage 20010701 20050401PET img wholbod restg esopha 20010701 20050401PET img metaboloc brain pres 20010701 20050401

PET myocard viability post 20010701 20050401

Query_110708

Page 387

PET WhBD colorec; gamma cam 20020101 20050401

PET whbd lymphoma; gamma cam 20020101 20050401

PET whbd melanoma; gamma cam 20020101 20050401

PET WhBD pulm nod; gamma cam 20020101 20050401

PET not otherwise specified 20060101 20060101Therapeutic procd strg endur 20020101 20041001

Oth resp proc, indiv 20020101 20041001

Oth resp proc, group 20020101 20041001

Multisource photon ster plan 20020101 20060101

Multisour photon stero treat 20020101 20070101

Observ care by facility topt 20020101 20060101

Initial foot exam pt lops 20020701 20020701

Followup eval of foot pt lop 20020701 20020701

Routine footcare pt w lops 20020701 20030701

Demonstrate use home inr mon 20020701 20080319

Provide INR test mater/equip 20020701 20080319

MD INR test revie inter mgmt 20020701 20080319

Query_110708

Page 388

Linear acc based stero radio 20020401 20020401

PET imaging initial dx 20021001 20021001

PET image brst dection recur 20021001 20050401

PET image brst eval to tx 20021001 20050401

Current percep threshold tst 20021001 20021001

Unsched dialysis ESRD pt hos 20030101 20030101

IV infusion during obs stay 20020401 20060101

Inject for sacroiliac joint 20030101 20030101Inj for sacroiliac jt anesth 20030101 20041001

Adm with CHF, CP, asthma 20030101 20060101

Assmt otr CHF, CP, asthma 20030101 20060101

Cryopresevation Freeze+stora 20030101 20080101

Thawing + expansion froz cel 20030101 20080101Bone marrow or psc harvest 20030101 20080101

Removal of impacted wax md 20030101 20030101

Occlusive device in vein art 20030101 20030101

MNT subs tx for change dx 20030101 20030101

Group MNT 2 or more 30 mins 20030101 20030101

Renal angio, cardiac cath 20030101 20080101

Iliac art angio,cardiac cath 20030101 20080101

Excorp shock tx, elbow epi 20030101 20060101

Query_110708

Page 389

Excorp shock tx other than 20030101 20060101

Elec stim unattend for press 20030401 20030401

Elect stim wound care not pd 20030401 20030401

Elec stim other than wound 20030101 20030101

Recon, CTA for surg plan 20030101 20060101

Arthro, loose body + chondro 20030101 20030101

Drug-eluting stents, single 20030101 20030101

Drug-eluting stents,each add 20030101 20030101

Non-cov surg proc,clin trial 20030101 20030101

Non-cov proc, clinical trial 20030101 20030101

Electromagnetic therapy onc 20030401 20040701

PET imge restag thyrod cance 20031001 20050401

Insert single chamber/cd 20031001 20080101Insert dual chamber/cd 20031001 20080101Inser/repos single icd+leads 20031001 20080101

Insert reposit lead dual+gen 20031001 20080101

Pre-op service LVRS complete 20040101 20040101

Pre-op service LVRS 10-15dos 20040101 20040101

Pre-op service LVRS 1-9 dos 20040101 20040101

Post op service LVRS min 6 20040101 20040101

CBC/diffwbc w/o platelet 20040101 20040101

CBC without platelet 20040101 20040101ESRD related svc 4+mo < 2yrs 20040101 20090101

ESRD related svc 2-3mo <2yrs 20040101 20090101

ESRD related svc 1 vst <2yrs 20040101 20090101

ESRD related svs 4+mo 2-11yr 20040101 20090101

Query_110708

Page 390

ESRD relate svs 2-3 mo 2-11y 20040101 20090101

ESRD related svs 1 mon 2-11y 20040101 20090101

ESRD related svs 4+ mo 12-19 20040101 20090101

ESRD related svs 2-3mo/12-19 20040101 20090101

ESRD related svs 1vis/12-19y 20040101 20090101

ESRD related svs 4+mo 20+yrs 20040101 20090101

ESRD related svs 2-3 mo 20+y 20040101 20090101

ESRD related svs 1visit 20+y 20040101 20090101

ESD related svs home undr 2 20040101 20090101

ESRDrelatedsvs home mo 2-11y 20040101 20090101

ESRD related svs hom mo12-19 20040101 20090101

ESRD related svs home mo 20+ 20040101 20090101

ESRD related serv/dy, 2y 20040101 20090101

ESRD relate serv/dy 2-11yr 20040101 20090101

ESRD relate serv/dy 12-19y 20040101 20090101

ESRD relate serv/dy 20+yrs 20040101 20090101

Fecal blood scrn immunoassay 20040101 20040101

Electromagntic tx for ulcers 20040701 20040701

Preadmin IV immunoglobulin 20060101 20090101

Query_110708

Page 391

Dispense fee initial 30 day 20060101 20060101

PET imaging brain alzheimers 20040915 20050401

Hospice evaluation preelecti 20050101 20050101Linear accelerator stero pln 20040101 20060101

Robot lin-radsurg com, first 20040101 20040101

Robt lin-radsurg fractx 2-5 20040101 20040101

Percutaneous islet celltrans 20041001 20041001

Laparoscopy islet cell trans 20041001 20041001

Laparotomy islet cell transp 20041001 20041001

Initial preventive exam 20050101 20090101

IV infuse hydration, initial 20050101 20060101Each additional infuse hour 20050101 20060101

IV infusion therapy/diagnost 20050101 20060101

Each additional hr up to 8hr 20050101 20060101

Additional sequential infuse 20050101 20060101

Concurrent infusion 20050101 20060101

Therapeutic/diagnostic injec 20050101 20060101

IV push,single orinitial dru 20050101 20060101Each addition sequential IV 20050101 20060101

Chemo adminisrate subcut/IM 20050101 20060101

Hormonal anti-neoplastic 20050101 20060101IV push single/initial subst 20050101 20060101IV push each additional drug 20050101 20060101

Chemotherapy IV one hr initi 20050101 20060101

Each additional hr 1-8 hrs 20050101 20060101

Prolong chemo infuse>8hrs pu 20050101 20060101

Each add sequential infusion 20050101 20060101

Irrigate implanted venous de 20050101 20060101

Bone marrow aspirate &biopsy 20050101 20050101

Vessel mapping hemo access 20050101 20050101

Query_110708

Page 392

EKG for initial prevent exam 20050101 20090101

EKG tracing for initial prev 20050101 20090101

EKG interpret & report preve 20050101 20090101

Pharm fee 1st month transpla 20050101 20060101

Pharmacy fee oral cancer etc 20050101 20060101

Pharm dispense inhalation 30 20050101 20060101MD service required for PMD 20051025 20051025

Pharm dispense inhalation 90 20050101 20060101Smoke/tobacco counselng 3-10 20050323 20080101

Smoke/tobacco counseling >10 20050323 20080101

Administra Part D vaccine 20070101 20080101Hospital observation per hr 20060101 20060101Direct admit hospital observ 20060101 20060101Lev 1 hosp type B ED visit 20070101 20080101

Lev 2 hosp type B ED visit 20070101 20080101



Query_110708

Page 393


Ultrasound exam AAA screen 20070101 20070101

Trauma Respons w/hosp criti 20070101 20070101AV fistula or graft arterial 20070101 20070101

AV fistula or graft venous 20070101 20070101

Blood occult test,colorectal 20070101 20090101

Alcohol/subs interv 15-30mn 20080101 20080101

Alcohol/subs interv >30 min 20080101 20080101

Home sleep test/type 2 Porta 20080313 20080313



Initial preventive exam 20090101 20090101

EKG for initial prevent exam 20090101 20090101

EKG tracing for initial prev 20090101 20090101

EKG interpret & report preve 20090101 20090101

Telhealth inpt consult 15min 20090101 20090101

Telheath inpt consult 25min 20090101 20090101

Telhealth inpt consult 35min 20090101 20090101

CORF related serv 15 mins ea 20090101 20090101

Query_110708

Page 394

Grp psych partial hosp 45-50 20090101 20090101

Inter active grp psych parti 20090101 20090101

Open tx iliac spine uni/bil 20090101 20090101

Pelvic ring fracture uni/bil 20090101 20090101

Pelvic ring fx treat int fix 20090101 20090101

Open tx post pelvic fxcture 20090101 20090101

Sat biopsy prostate 1-20 spc 20090101 20090101

Sat biopsy prostate 21-40 20090101 20090101

Sat biopsy prostate 41-60 20090101 20090101

Sat biopsy prostate: >60 20090101 20090101

Admin + supply, tositumomab 20030701 20030701AMI pt recd aspirin at arriv 20060101 20060101

AMI pt did not receiv aspiri 20060101 20060101

AMI pt ineligible for aspiri 20060101 20060101

AMI pt recd Bblock at arr 20060101 20060101

AMI pt did not rec bblock 20060101 20060101

AMI pt inelig Bbloc at arriv 20060101 20060101

Pneum pt recv antibiotic 4 h 20060101 20060101

Pneum pt w/o antibiotic 4 hr 20060101 20060101

Pneum pt not elig antibiotic 20060101 20060101

Diabetic pt w/ HBA1c>9% 20060101 20060101

Diabetic pt w/ HBA1c<or=9% 20060101 20060101

DM pt inelig for HBA1c measu 20060101 20060101

Care not provided for HbA1c 20060101 20060101

Diabetic pt w/LDL>= 100mg/dl 20060101 20060101

Diab pt w/LDL< 100mg/dl 20060101 20060101

Diab pt inelig for LDL meas 20060101 20060101

Care not provided for LDL 20060101 20060101

Query_110708

Page 395

DM pt w BP>=140/80 20060101 20060101

Diabetic pt wBP<140/80 20060101 20060101

Diabetic pt inelig for BP me 20060101 20060101

Diabet pt w no care re BP me 20060101 20060101

HF p w/LVSD on ACE-I/ARB 20060101 20060101

HF pt w/LVSD not on ACE-I/AR 20060101 20060101

HF pt not elig for ACE-I/ARB 20060101 20060101

HF pt w/LVSD on Bblocker 20060101 20060101

HF pt w/LVSD not on Bblocker 20060101 20060101

HF pt not elig for Bblocker 20060101 20060101

PMI-CAD pt on Bblocker 20060101 20060101

PMI-CAD pt not on Bblocker 20060101 20060101

PMI-CAD pt inelig Bblocker 20060101 20060101

AMI-CAD pt doc on antiplatel 20060101 20060101AMI-CAD pt not docu on antip 20060101 20060101AMI-CAD inelig antiplate mea 20060101 20060101

CAD pt w/LDL>100mg/dl 20060101 20060101

CAD pt w/LDL<or=100mg/dl 20060101 20060101

CAD pt not eligible for LDL 20060101 20060101

Osteoporosis assess 20060101 20060101Osteopor pt not assess 20060101 20060101Pt inelig for osteopor meas 20060101 20060101

Falls assess not docum 12 mo 20060101 20060101Falls assess w/ 12 mon 20060101 20060101Not elig for falls assessmen 20060101 20060101

Hearing assess receive 20060101 20060101Pt w/o hearing assess 20060101 20060101Pt inelig for hearing assess 20060101 20060101

Urinary incont pt assess 20060101 20060101Pt not assess for urinary in 20060101 20060101Pt not elig for urinary inco 20060101 20060101

ESRD pt w/ dialy of URR>=65% 20060101 20060101

ESRD pt w/ dialy of URR<65% 20060101 20060101

ESRD pt not elig for URR/KtV 20060101 20060101

Query_110708

Page 396

ESRD pt w/Hct>or=33 20060101 20060101

ESRD pt w/Hct<33 20060101 20060101

ESRD pt inelig for HCT/Hgb 20060101 20060101

ESRD pt w/ auto AV fistula 20060101 20060101

ESRD pt w other fistula 20060101 20060101

ESRD PT inelig auto AV FISTU 20060101 20060101

COPD pt rec smoking cessat 20060101 20060101

COPD pt w/o smoke cessat int 20060101 20060101

Osteopo pt given Ca+VitD sup 20060101 20060101

Osteop pt inelig for Ca+VitD 20060101 20060101

New dx osteo pt w/antiresorp 20060101 20060101

Osteo pt inelig for antireso 20060101 20060101

Bone dens meas test perf 20060101 20060101

Bone dens meas test inelig 20060101 20060101

Pt receiv influenza vacc 20060101 20060101

Pt w/o influenza vacc 20060101 20060101

Pt inelig for influenza vacc 20060101 20060101

Pt receiv mammogram 20060101 20060101

Pt not doc mammogram 20060101 20060101

Pt ineligible mammography 20060101 20060101

Care not provided for mamogr 20060101 20060101

Pt receiv pneumo vacc 20060101 20060101Pt did not rec pneumo vacc 20060101 20060101Pt was inelig for pneumo vac 20060101 20060101

Pt treat w/antidepress12wks 20060101 20060101

Pt not treat w/antidepres12w 20060101 20060101

Pt inelig for antidepres med 20060101 20060101

Pt treat w/antidepres for 6m 20060101 20060101

Query_110708

Page 397

Pt not treat w/antidepres 6m 20060101 20060101

Pt inelig for antidepres med 20060101 20060101

Pt w/AB 1 hr prior to incisi 20060101 20060101

Pt not doc for AB 1 hr prior 20060101 20060101

Pt ineligi for AB therapy 20060101 20060101

Pt recd thromboemb prophylax 20060101 20060101Pt did not rec thromboembo 20060101 20060101Pt ineligi for thrombolism 20060101 20060101

Pt recd CABG w/ IMA 20060101 20070701

Pt w/CABG w/o IMA 20060101 20060101

Pt inelig for CABG w/IMA 20060101 20070701

Iso CABG pt rec preop bblock 20060101 20070701

Iso CABG pt w/o preop Bblock 20060101 20060101

Iso CABG pt inelig for preo 20060101 20070701

Iso CABG pt w/prolng intub 20060101 20060101

Iso CABG pt w/o prolng intub 20060101 20060101

Iso CABG req surg rexpo 20060101 20060101

Iso CABG w/o surg explo 20060101 20060101

CEA/ext bypass pt on aspirin 20060101 20060101

Pt w/carot endarct/ext bypas 20060101 20060101

CEA/ext bypass pt not on asp 20060101 20060101

CAD pt care not prov LDL 20060101 20060101

HF/atrial fib pt on warfarin 20060101 20060101

HF/atrial fib pt inelig warf 20060101 20060101

Osteoarth pt w/ assess pain 20060101 20060101

Osteoarth pt inelig assess 20060101 20060101

Antibiotic given prior surg 20070101 20070701

Antib given prior surg incis 20070101 20070701

Antibio not doc prior surg 20070101 20070101

Pt not elig for antibiotic 20070101 20070701

Query_110708

Page 398

Antibiotic given prior surg 20070101 20070701

Antibio not docum prior surg 20070101 20070101

Antib order prior to surg 20070101 20070701

Cefazolin documented ordered 20070101 20070701

Cefazolin given prophylaxis 20070101 20070701

Cefazolin not docum prophy 20070101 20070101Pt not eligi for cefazolin 20070101 20070701

Order given to d/c antibio 20070101 20070701

Antib was D/C 24hrs surg tim 20070101 20070701

MD not doc order to d/c anti 20070101 20070101

Pt not eligi for proph antib 20070101 20070701

MD doc prophylactic AB given 20070101 20070701Clini doc order to D/C antib 20070101 20070701

Clini doc AB was D/C 48 h 20070101 20070701

Clinician did not doc 20070101 20070101

Clini doc pt ineligib anti 20070101 20070701

Clini doc proph AB giv 20070101 20070701Clini order given for VTE 20070101 20070701

Clini given VTE prop 20070101 20070701

Clini not doc order VTE 20070101 20070101

Clini doc pt inelig VTE 20070101 20070701

Pt received DVT prophylaxis 20070101 20070701Pt not received DVT proph 20070101 20070101Pt inelig DVT prophylaxis 20070101 20070701

Received DVT proph day 2 20070101 20070101Pt not rec DVT proph day 2 20070101 20070101Pt inelig for DVT proph 20070101 20070101

Pt prescribe platelet at D/C 20070101 20070701Pt not doc for presc antipla 20070101 20070101

Pt inelig for antiplat proph 20070101 20070701

Pt prescrib anticoag at D/C 20070101 20070701

Query_110708

Page 399

Pt no prescr anticoa at D/C 20070101 20070101

Pt not doc to have perm/AF 20070101 20070701

Clin pt inelig anticoag D/C 20070101 20070701

Pt doc to have admin t-PA 20070101 20070701Pt inelig t-PA isch strok>3h 20070101 20070701

Pt not doc for admin t-PA 20070101 20070101

Pt received dysphagia screen 20070101 20070701

Pt not doc dysphagia screen 20070101 20070101Pt received NPO 20070101 20070701

Pt inelig dysphagia screen 20070101 20070701

Pt doc rec rehab serv 20070101 20070701

Pt not doc to rec rehab serv 20070101 20070101

Inter carotid stenosis <30% 20070101 20070701

Inter carotid stenosis30-99% 20070101 20070101

Pt inelig candidate ito meas 20070101 20070701

Pt doc to have CT/MRI w/les 20070101 20070701

Pt not doc MRI/CT w/o lesion 20070101 20070101

Clini doc prese/abs alarm 20070101 20070701Pt inelig hx w new/chg mole 20070101 20070101

Pt w/alarm symp upper endo 20070101 20070701

Pt w/one alarm symp not doc 20070101 20070101

Pt inelig for upper endo 20070101 20070701

Pt w/Barretts esoph endo re 20070101 20070701

Pt not doc w/Barretts, endo 20070101 20070101

Pt inelig for esophag biop 20070101 20070701

Pt rec order for barium 20070101 20070701Pt w/no doc order for barium 20070101 20070101Clini doc pt inelig bar swal 20070101 20070701

Clini doc rev D/C meds w/med 20070101 20070701

Pt not doc rev meds D/C 20070101 20070101

Query_110708

Page 400

Pt inelig for d/c meds rev 20070101 20070701Pt doc to hav decision maker 20070101 20070701

Pt not doc to have dec maker 20070101 20070101

Clin doc pt inelig dec maker 20070101 20070701

Pt doc assess uriny incon 20070101 20070701

Pt not doc assess urinary in 20070101 20070101

Pt inelig assess urinary inc 20070101 20070701

Pt doc rec charc urin incon 20070101 20070701Pt not doc charc urin incon 20070101 20070101Pt doc rec plan urinary inco 20070101 20070701Pt not doc rec care urin inc 20070101 20070101Clin not prov care urin inco 20070101 20070701

Pt receiv screen for fall 20070101 20070701

Pt no doc screen fall 20070101 20070101

Clin doc pt inelig fall risk 20070101 20070701

Clin not prov care scre fall 20070101 20070701

Clini not doc pres/abs alarm 20070101 20070101Pt hx w/ new moles 20070101 20070701

Pt not doc mole change 20070101 20070101

Pt inelig for assess mole 20070101 20070701

Pt doc rec PE skin 20070101 20070701Pt not doc rec PE 20070101 20070101Pt inelig PE skin 20070101 20070701

Pt rec counsel for self-exam 20070101 20070701Pt not doc to rec couns 20070101 20070101Pt inelig for counsel 20070101 20070701Pt doc to rec pres osteo 20070101 20070701

Pt did not rec pres osteo 20070101 20070101Pt inelig to rec pres osteo 20070101 20070701

Clin not prov care for pharm 20070101 20070701

Pt doc rec Ca/Vit D 20070101 20070701

Pt not doc rec Ca/Vit D 20070101 20070101

Clin doc pt inelig Ca/Vit D 20070101 20070701

Clin no pro care pt Ca/Vit D 20070101 20070701

COPD pt w/spir results 20070101 20070701COPD pt w/o spir results 20070101 20070101COPD pt inelig spir results 20070101 20070701COPD pt doc bronch ther 20070101 20070701COPD pt not doc bronch ther 20070101 20070101

Query_110708

Page 401

COPD pt inelig bronch therap 20070101 20070701Pt doc optic nerve eval 20070101 20070101Pt not doc optic nerv eval 20070101 20070101Pt inelig for optic nerv eva 20070101 20070701

Clin not prov care POAG 20070101 20070701

Pt doc w/ target IOP 20070101 20070101Pt not doc w/ IOP 20070101 20070101Clin doc pt inelig IOP 20070101 20070101

Clin not prov care POAG 20070101 20070101

POAG w/ IOP rec care plan 20070101 20070101

POAG w/ IOP no care plan 20070101 20070101

POAG w/ IOP not doc plan 20070101 20070101

Pt doc rec antioxidant 20070101 20070701

Pt not doc rec antiox 20070101 20070101

Pt inelig for antioxidant 20070101 20070701

Clin no prov care for antiox 20070101 20070701

Pt doc rec macular exam 20070101 20070701

Pt not doc to rec mac exam 20070101 20070101

Clin doc pt inelig mac exam 20070101 20070701

Clin no pro care for mac deg 20070101 20070701

Pt doc to have visual func 20070101 20070701Pt doc not have visual func 20070101 20070101Pt inelig for vis func stat 20070101 20070701

Clin not prov care catarac 20070101 20070701

Pt doc to pre axial leng 20070101 20070701

Pt not doc pre axial leng 20070101 20070101

Pt inelig for pre surg axial 20070101 20070701

Clin not prov care for IOL 20070101 20070701

Pt rec fund exam prior surg 20070101 20070701

Pt not doc rec fundus exam 20070101 20070101

Pt inelig for pre surg fundu 20070101 20070701Clin not prov care fund eval 20070101 20070701

Query_110708

Page 402

Pt doc rec dilated macular 20070101 20070701

Pt not doc rec dilated mac 20070101 20070101

Pt inelig dilate fundus 20070101 20070701

Clin prov no care diabetic r 20070101 20070701

Pt doc to have macular exam 20070101 20070701

Doc of macular not giv MD 20070101 20070101

Clin doc pt inelig macular 20070101 20070701

Clin did not pro care diabet 20070101 20070701

Clin doc pt was test osteo 20070101 20070701

Clin not doc pt test osteo 20070101 20070101

Pt inelig for test osteo 20070101 20070701

Pt doc have DEXA 20070101 20070701

Pt not doc for DEXA 20070101 20070101

Clin doc pt inelig DEXA 20070101 20070701

Clin not prov care DEXA 20070101 20070701

Pt doc have DEXA perform 20070101 20070701

Pt not doc have DEXA 20070101 20070101

Clin doc pt inelig DEXA 20070101 20070701

Clin not prov care DEXA 20070101 20070701

Int carotid stenosis meas 20070101 20070701

Pt inelig for doc of alarm 20070101 20070701

Pt doc 12 lead ECG 20070101 20070701Pt not doc ECG 20070101 20070101Pt inelig for ECG 20070101 20070701Pt doc rec aspirin 24hrs ER 20070101 20070701

Pt not rec aspirin prior ER 20070101 20070101

Clin doc pt inelig aspirin 20070101 20070701

Pt doc to have ECG 20070101 20070701Pt not doc to have ECG 20070101 20070101Clin doc pt inelig ECG 20070101 20070701

Query_110708

Page 403

Pt doc vital signs recorded 20070101 20070701Pt not doc vital signs recor 20070101 20070101Pt doc to have 02 SAT assess 20070101 20070701Pt not doc 02 SAT assess 20070101 20070101Clin doc pt inelig 02 SAT 20070101 20070701

Pt doc mental status assess 20070101 20070701Pt not doc mental status 20070101 20070101Pt doc to have empiric AB 20070101 20070701Pt not doc have empiric AB 20070101 20070101Clin doc pt inelig empiri AB 20070101 20070701

Asthma pt w survey not docum 20070701 20070701

Chemother not rec stg3 colon 20070701 20070701

Chemother rec stg3 colon ca 20070701 20070701

Chemo plan documen prior che 20070701 20070701Chemo plan not doc prior che 20070701 20070701CLL pt w/o doc flow cytometr 20070701 20070701

Brst ca pt inelig tamoxifen 20070701 20070701

MD doc colon ca pt inelig ch 20070701 20070701

MD doc pt inelig radiation 20070701 20070701

Doc radiat tx recom 12mo ov 20070701 20070701

Pt w stgIC-3Brst ca not rec 20070701 20070701

Pt w stgIC-3Brst ca rec tam 20070701 20070701

MM pt w/o doc IV bisphophon 20070701 20070701

No doc radiation rec 12mo ov 20070701 20070701

Base cytogen test MDS notper 20070701 20070701

Diabet pt no do Hgb A1c 12m 20070701 20070701

Diabet pt nodoc LDLiprotei 20070701 20070701

ESRD pt w Hct/Hgb not docume 20070701 20070701ESRD pt w URR/Ktv notdoc eli 20070701 20070701

MDS pt no doc FE st prio EPO 20070701 20070701

Diabetic w/o document BP 12m 20070701 20070701

Pt w asthma no doc med or tx 20070701 20070701

LVEF>=40% doc normal or mild 20080101 20080101

LVEF not performed 20080101 20080101Dil macula/fundus exam/w doc 20080101 20080101

Dil macular/fundus not perfo 20080101 20080101

Query_110708

Page 404

Pt w/DXA document or order 20080101 20080101

Pt w/DXA no document or orde 20080101 20080101

Pt inelig osteo screen measu 20080101 20080101

Smoke preven interven counse 20080101 20080101Smoke preven nocounsel 20080101 20080101Low extemity neur exam docum 20080101 20080101Low extemity neur not perfor 20080101 20080101Pt inelig lower extrem neuro 20080101 20080101

ABI documented 20080101 20080101ABI not documented 20080101 20080101Pt inelig for ABI measure 20080101 20080101

Eval on foot documented 20080101 20080101Eval on foot not performed 20080101 20080101Pt inelig footwear evaluatio 20080101 20080101

Calc BMI abv up param f/u 20080101 20090101

Calc BMI blw low param f/u 20080101 20090101

Calc BMI out nrm param nof/u 20080101 20090101

Calc BMI norm parameters 20080101 20090101BMI not calculated 20080101 20080101Pt inelig BMI calculation 20080101 20080101Pt screen flu vac & counsel 20080101 20080101

Flu vaccine not screen 20080101 20080101Flu vaccine screen not curre 20080101 20080101

Pt not approp screen & counc 20080101 20080101

Doc meds verified w/pt or re 20080101 20090101

Meds document w/o verifica 20080101 20090101

Incomplete doc pt on meds 20080101 20090101

Pt inelig med check 20080101 20090101Pos clin depres scrn f/u doc 20080101 20090101

Clin depression screen not d 20080101 20080101Pt inelig; scrn clin dep 20080101 20090101

Cognitive impairment screen 20080101 20080101Cognitive screen not documen 20080101 20080101Pt inelig for cognitive impa 20080101 20080101Care plan develop & document 20080101 20090101

Query_110708

Page 405

Pt inelig for devlp care pln 20080101 20090101

Care plan develp & not docum 20080101 20090101

Pain assess f/u pln document 20080101 20090101

No document of pain assess 20080101 20080101

Pt inelig pain assessment 20080101 20080101Prescription by E-Prescrib s 20080101 20080101

Prescrip not gen at encounte 20080101 20080101

Some prescrib print or call 20080101 20090101

Pt vis doc use CCHIT cer EHR 20080101 20090101Pt vis doc w/non-CCHIT EHR 20080101 20090101Pt not doc w/EMR due to syst 20080101 20080101

Beta-bloc rx pt w/abn lvef 20080101 20080101

Pt w/abn lvef inelig b-bloc 20080101 20080101

Pt w/abn lvef b-bloc no rx 20080101 20080101

Tob use cess int counsel 20080101 20080101Tob use cess int no counsel 20080101 20080101Current tobacco smoker 20080101 20080101Smokeless tobacco user 20080101 20080101Cur tobacco non-user 20080101 20090101Pt inelig geno no antvir tx 20080101 20080101

Doc pt rec antivir treat 20080101 20080101

Pt inelig RNA no antvir tx 20080101 20080101

Pt rec antivir treat hep c 20080101 20080101Pt inelig couns no antvir tx 20080101 20080101

Pt rec antiviral treat doc 20080101 20080101Pt inelig; lo to no dter rsk 20080101 20080101

High risk recurrence pro ca 20080101 20080101Pt inelig suic; MDD remis 20080101 20080101

Query_110708

Page 406

New dx init/rec episode MDD 20080101 20080101

ACE/ARB rx pt w/abn lvef 20080101 20080101

Pt w/abn lvef inelig ACE/ARB 20080101 20080101

Pt w/ normal lvef 20080101 20080101

LVEF not performed/doc 20080101 20080101ACE/ARB no rx pt w/abn lvef 20080101 20080101

ACE/ARB thxpy rx’d 20080101 20080101

ACE/ARB not rx’d; doc reas 20080101 20080101

ACE/ARB thxpy not rx’d 20080101 20080101

BP sys <130 and dias <80 20080101 20080101

BP sys>=130 and/or dias >=80 20080101 20080101

BP not performed/doc 20080101 20080101MD rx’d ACE/ARB thxpy 20080101 20080101

Pt inelig ACE/ARB thxpy 20080101 20080101

MD not rx’d ACE/ARB thxpy 20080101 20080101

Flu immunize order/admin 20080101 20080101Flu imm no ord/admin doc rea 20080101 20080101

Flu immunize no order/admin 20080101 20080101Report, Diabetes measures 20080701 20080701Report, Prev Care Measures 20080701 20080701Report CKD Measures 20080701 20080701Report ESRD Measures 20080701 20080701CAD measures grp 20090101 20090101RA measures grp 20090101 20090101HIV/AIDS measures grp 20090101 20090101Prev Care measures grp 20090101 20090101Back pain measures grp 20090101 20090101DM meas qual act perform 20090101 20090101

CKD meas qual act perform 20090101 20090101

PC meas qual act perform 20090101 20090101

CABG meas qual act perform 20090101 20090101

CAD meas qual act perform 20090101 20090101

RA meas qual act perform 20090101 20090101

HIV meas qual act perform 20090101 20090101

Query_110708

Page 407

Perio meas qual act perform 20090101 20090101

BP meas qual act perform 20090101 20090101

Doc proph antibx w/in 1 hr 20090101 20090101

Doc ord pro antbx w/in 1 hr 20090101 20090101

No doc proph antibx w/in 1hr 20090101 20090101

Pt rec ACE/ARB 20090101 20090101

Pt inelig pt verif meds 20090101 20090101

Pt inelig; pain asses no f/u 20090101 20090101

Pain assess no f/u pln doc 20090101 20090101

Pt inelig neg scrn depres 20090101 20090101

Clin depres scrn no f/u doc 20090101 20090101

Pain sev quant present 20090101 20090101ABI meas & doc 20090101 20090101PT inelig; ABI measure 20090101 20090101

No ABI measurement 20090101 20090101Scrn fal rsk >2 fal or w/inj 20090101 20090101

Scrn fall rsk; <2 falls 20090101 20090101

Clin stg b/f lun/eso ca surg 20090101 20090101

Pt in; clin ca stg b/f surg 20090101 20090101

Clin stg b/f surg not doc 20090101 20090101

Antplt recd 48 hrs & disch 20090101 20090101

Pt inelig; antiplt therapy 20090101 20090101

Antplt not recd reas no spec 20090101 20090101

Patch closure conv CEA 20090101 20090101No patch closure CEA 20090101 20090101No patch closure conv CEA 20090101 20090101

Doc ord antimic prophy 20090101 20090101Pt inelig; proph antibiot 20090101 20090101

No doc ord antimic prophy 20090101 20090101

Query_110708

Page 408

Auto AV fistula recd 20090101 20090101Pt inelig; auto AV fistula 20090101 20090101

No auto AV fistula; no reas 20090101 20090101

Partic in clin data base reg 20090101 20090101

Doc elder mal scrn f/u plan 20090101 20090101Pt inelig no eld mal scrn 20090101 20090101No doc elder mal scrn 20090101 20090101Pt inelig eldmal scrn no f/u 20090101 20090101

Eld mal scrn no f/u pln 20090101 20090101

Cur funct assess & care pln 20090101 20090101

Pt inelig funct assess 20090101 20090101

No doc cur funct assess 20090101 20090101

Pt inelig func asses no pln 20090101 20090101

Cur funct asses; no care pln 20090101 20090101

CABG measures grp 20090101 20090101MCCD, initial rate 20001001 20001001MCCD,maintenance rate 20001001 20001001MCCD, risk adj hi, initial 20001001 20001001MCCD, risk adj lo, initial 20001001 20001001MCCD, risk adj, maintenance 20001001 20001001MCCD, Home monitoring 20001001 20001001MCCD, sch team conf 20001001 20001001Mccd,phys coor-care ovrsght 20001001 20001001MCCD, risk adj, level 3 20011001 20011001MCCD, risk adj, level 4 20011001 20011001MCCD, risk adj, level 5 20011001 20011001Other Specified Case Mgmt 20011001 20011001ESRD demo bundle level I 20040701 20040701ESRD demo bundle-level II 20040701 20040701Demo-smoking cessation coun 20010101 20010101

Amantadine HCL 100mg oral 20041201 20041201

Zanamivir,inhalation pwd 10m 20041201 20041201

Oseltamivir phosphate 75mg 20041201 20041201

Rimantadine HCL 100mg oral 20041201 20041201

Chemo assess nausea vomit L1 20050101 20060101




Query_110708

Page 409

Chemo assessment pain level1 20050101 20060101




Chemo assess for fatigue L1 20050101 20060101




Amantadine HCL oral brand 20041201 20041201

Zanamivir, inh pwdr, brand 20041201 20041201

Oseltamivir phosp, brand 20041201 20041201

Rimantadine HCL, brand 20041201 20041201

Low vision rehab occupationa 20060101 20060101

Low vision rehab orient/mobi 20060101 20060101

Low vision lowvision therapi 20060101 20060101

Low vision rehabilate teache 20060101 20060101

Oncology work-up evaluation 20060101 20070101

Oncology tx decision-mgmt 20060101 20070101

Onc surveillance for disease 20060101 20070101

Onc expectant management pt 20060101 20070101

Onc supervision palliative 20060101 20070101

Query_110708

Page 410

Onc visit unspecified NOS 20060101 20070101

Onc prac mgmt adheres guide 20060101 20070101

Onc pract mgmt differs trial 20060101 20070101

Onc prac mgmt disagree w/gui 20060101 20070101

Onc prac mgmt pt opt alterna 20060101 20070101

Onc prac mgmt dif pt comorb 20060101 20070101

Onc prac cond noadd by guide 20060101 20070101

Onc prac guide differs nos 20060101 20070101

Onc dx nsclc stgI no progres 20060101 20070101

Onc dx nsclc stg2 no progres 20060101 20070101

Onc dx nsclc stg3A no progre 20060101 20070101

Onc dx nsclc stg3B-4 metasta 20060101 20070101

Onc dx nsclc dx unknown nos 20060101 20070101

Onc dx sclc/nsclc limited 20060101 20070101

Onc dx sclc/nsclc ext at dx 20060101 20070101

Onc dx sclc/nsclc ext unknwn 20060101 20070101

Onc dx brst stg1-2B HR,nopro 20060101 20070101

Onc dx brst stg1-2 noprogres 20060101 20070101

Onc dx brst stg3-HR, no pro 20060101 20070101

Query_110708

Page 411

Onc dx brst stg3-noprogress 20060101 20070101

Onc dx brst metastic/ recur 20060101 20070101

Onc dx brst unknown NOS 20060101 20070101

Onc dx prostate T1no progres 20060101 20070101

Onc dx prostate T2no progres 20060101 20070101

Onc dx prostate T3b-T4noprog 20060101 20070101

Onc dx prostate w/rise PSA 20060101 20070101

Onc dx prostate mets no cast 20060101 20070101

Onc dx prostate castrate met 20060101 20070101

Onc dx prostate unknwn nos 20060101 20070101

Onc dx colon t1-3,n1-2,no pr 20060101 20070101

Onc dx colon T4, N0 w/o prog 20060101 20070101

Onc dx colon T1-4 no dx prog 20060101 20070101

Onc dx colon metas evid dx 20060101 20070101

Onc dx colon metas noevid dx 20060101 20070101

Query_110708

Page 412

Onc dx colon extent unknown 20060101 20070101

Onc dx rectal T1-2 no progr 20060101 20070101

Onc dx rectal T3 N0 no prog 20060101 20070101

Onc dx rectal T1-3,N1-2noprg 20060101 20070101

Onc dx rectal T4,N,M0 no prg 20060101 20070101

Onc dx rectal M1 w/mets prog 20060101 20070101

Onc dx rectal extent unknwn 20060101 20070101

Onc dx esophag T1-T3 noprog 20060101 20070101

Onc dx esophageal T4 no prog 20060101 20070101

Onc dx esophageal mets recur 20060101 20070101

Onc dx esophageal unknown 20060101 20070101

Onc dx gastric no recurrence 20060101 20070101

Onc dx gastric p R1-R2noprog 20060101 20070101

Onc dx gastric unresectable 20060101 20070101

Onc dx gastric recurrent 20060101 20070101

Query_110708

Page 413

Onc dx gastric unknown NOS 20060101 20070101

Onc dx pancreatc p R0 res no 20060101 20070101

Onc dx pancreatc p R1/R2 no 20060101 20070101

Onc dx pancreatic unresectab 20060101 20070101

Onc dx pancreatic unknwn NOS 20060101 20070101

Onc dx head/neck T1-T2no prg 20060101 20070101

Onc dx head/neck T3-4 noprog 20060101 20070101

Onc dx head/neck M1 mets rec 20060101 20070101

Onc dx head/neck ext unknown 20060101 20070101

Onc dx ovarian stg1A-B no pr 20060101 20070101

Onc dx ovarian stg1A-B or 2 20060101 20070101

Onc dx ovarian stg3/4 noprog 20060101 20070101

Onc dx ovarian recurrence 20060101 20070101

Onc dx ovarian unknown NOS 20060101 20070101

Onc NHLstg 1-2 no relap no 20060101 20070101

Onc dx NHL stg 3-4 not relap 20060101 20070101

Onc dx NHL trans to lg Bcell 20060101 20070101

Query_110708

Page 414

Onc dx NHL relapse/refractor 20060101 20070101

Onc dx NHL stg unknown 20060101 20070101

Onc dx CML chronic phase 20060101 20070101

Onc dx CML acceler phase 20060101 20070101

Onc dx CML blast phase 20060101 20070101

Onc dx CML remission 20060101 20070101

Onc dx CML dx status unknown 20060101 20070101

Onc dx multi myeloma stage I 20060101 20070101

Onc dx mult myeloma stg2 hig 20060101 20070101

Onc dx multi myeloma unknown 20060101 20070101

Onc dx brst unknown NOS 20070101 20070101

Onc dx prostate mets no cast 20070101 20070101

Onc dx prostate clinical met 20070101 20070101

Onc NHLstg 1-2 no relap no 20070101 20070101

Onc dx NHL stg 3-4 not relap 20070101 20070101

Onc dx NHL trans to lg Bcell 20070101 20070101

Onc dx NHL relapse/refractor 20070101 20070101

Onc dx NHL stg unknown 20070101 20070101

Query_110708

Page 415

Onc dx CML dx status unknown 20070101 20070101

Frontier extended stay demo 20071001 20071001

Alcohol and/or drug assess 20010101 20010101Alcohol and/or drug screenin 20010101 20030101

Alcohol and/or drug screenin 20010101 20010101

Alcohol and/or drug services 20010101 20030101Alcohol and/or drug services 20010101 20010101Alcohol and/or drug services 20010101 20010101Alcohol and/or drug services 20010101 20010101Alcohol and/or drug services 20010101 20010101Alcohol and/or drug services 20010101 20010101Alcohol and/or drug services 20010101 20010101

Alcohol and/or drug services 20010101 20010101



Alcohol and/or drug services 20010101 20010101Alcohol and/or drug services 20010101 20010101






Alcohol and/or drug training 20010101 20010101

Alcohol and/or drug interven 20010101 20010101Alcohol and/or drug outreach 20010101 20030101

Alcohol and/or drug preventi 20010101 20030101




Query_110708

Page 416



Alcohol and/or drug hotline 20010101 20030101MH health assess by non-md 20030101 20030101MH svc plan dev by non-md 20030101 20030101Oral med adm direct observe 20030101 20030101Med trng & support per 15min 20030101 20030101MH partial hosp tx under 24h 20030101 20030101Comm psy face-face per 15min 20030101 20030101Comm psy sup tx pgm per diem 20030101 20030101Self-help/peer svc per 15min 20030101 20030101Asser com tx face-face/15min 20030101 20030101Assert comm tx pgm per diem 20030101 20030101Fos c chld non-ther per diem 20030101 20030101Fos c chld non-ther per mon 20030101 20030101Supported housing, per diem 20030101 20030101Supported housing, per month 20030101 20030101Respite not-in-home per diem 20030101 20030101Mental health service, nos 20030101 20030101Alcohol/drug abuse svc nos 20030101 20030101Spec coll non-blood:a/d test 20030101 20030101

Alcohol/drug screening 20070101 20070101Alcohol/drug service 15 min 20070101 20070101Prenatal care atrisk assessm 20020101 20020101Antepartum management 20020101 20020101Carecoordination prenatal 20020101 20020101Prenatal at risk education 20020101 20020101Follow up home visit/prental 20020101 20020101Prenatalcare enhanced srv pk 20020101 20020101Nonmed family planning ed 20030101 20030101Family assessment 20030101 20030101

Comp multidisipln evaluation 20030101 20030101Rehabilitation program 1/2 d 20030101 20030101Comprehensive med svc 15 min 20030401 20030401Crisis interven svc, 15 min 20030401 20030401Behav hlth day treat, per hr 20030401 20030401Psych hlth fac svc, per diem 20030401 20030401Skills train and dev, 15 min 20030401 20030401Comp comm supp svc, 15 min 20030401 20030401Comp comm supp svc, per diem 20030401 20030401Psysoc rehab svc, per 15 min 20030401 20030401Psysoc rehab svc, per diem 20030401 20030401Ther behav svc, per 15 min 20030401 20030401Ther behav svc, per diem 20030401 20030401Com wrap-around sv, 15 min 20030401 20030401Com wrap-around sv, per diem 20030401 20030401Supported employ, per 15 min 20030401 20030401Supported employ, per diem 20030401 20030401Supp maint employ, 15 min 20030401 20030401Supp maint employ, per diem 20030401 20030401Psychoed svc, per 15 min 20030401 20030401Sex offend tx svc, 15 min 20030401 20030401Sex offend tx svc, per diem 20030401 20030401MH clubhouse svc, per 15 min 20030401 20030401MH clubhouse svc, per diem 20030401 20030401Activity therapy, per 15 min 20030401 20030401

Query_110708

Page 417

Multisys ther/juvenile 15min 20030401 20030401A/D halfway house, per diem 20030401 20030401A/D tx program, per hour 20030401 20030401A/D tx program, per diem 20030401 20030401Dev delay prev dp ch, 15 min 20030401 20030401

Tetracyclin injection 19860101 19970101Abarelix injection 20050101 20050101Abatacept injection 20070101 20070101Abciximab injection 19990101 19990101Acetylcysteine injection 20060101 20060101Acyclovir injection 20060101 20060101Adalimumab injection 20050101 20050101Injection adenosine 6 MG 19940101 20050101

Adenosine injection 20040101 20050101

Adrenalin epinephrin inject 19860101 19970101Agalsidase beta injection 20050101 20050101Inj biperiden lactate/5 mg 19820101 19970101Alatrofloxacin mesylate 20000101 20000101Alglucerase injection 19930101 19970101Amifostine 19980101 19980101Methyldopate hcl injection 19840101 19970101Alefacept 20040101 20040101Alglucosidase alfa injection 20080101 20080101Alpha 1 proteinase inhibitor 19890101 19990101Alprostadil for injection 19970101 20000101

Alprostadil urethral suppos 19990101 20000101

Amikacin sulfate injection 20060101 20060101Aminophyllin 250 MG inj 19840101 19970101Amiodarone HCl 20010101 20010101Amphotericin B 19990101 19990101Amphotericin b lipid complex 20030101 20030101Ampho b cholesteryl sulfate 20030101 20030101Amphotericin b liposome inj 20030101 20030101Ampicillin 500 MG inj 19840101 20000101Ampicillin sodium per 1.5 gm 19950101 19970101Amobarbital 125 MG inj 19820101 19970101Succinycholine chloride inj 19860101 19970101Anidulafungin injection 20070101 20090101Injection anistreplase 30 u 19860101 19970101Hydralazine hcl injection 19860101 19970101Apomorphine hydrochloride 20070101 20070101Aprotonin, 10,000 kiu 20060101 20060101Inj metaraminol bitartrate 19820101 19970101Chloroquine injection 19860101 19970101Arbutamine hcl injection 19990101 20090101Aripiprazole injection 20080101 20080101Azithromycin 20000101 20000101Atropine sulfate injection 19820101 19970101Dimecaprol injection 19820101 19970101Baclofen 10 MG injection 19940101 19970101Baclofen intrathecal trial 19990101 19990101Basiliximab 20060101 20060101Dicyclomine injection 19860101 19970101Inj benztropine mesylate 19820101 19970101

Query_110708

Page 418

Bethanechol chloride inject 19840101 19970101Penicillin g benzathine inj 19820101 19970101

Penicillin g benzathine inj 19820101 19970101

Penicillin g benzathine inj 19820101 19970101

Penicillin g benzathine inj 19820101 19970101Penicillin g benzathine inj 19820101 19970101Penicillin g benzathine inj 19820101 19970101Bivalirudin 20040101 20040101Botulinum toxin a per unit 19910101 19970101Botulinum toxin type B 20020101 20020101Buprenorphine hydrochloride 20030101 20030101Busulfan injection 20070101 20070101Butorphanol tartrate 1 mg 20040101 20040101Edetate calcium disodium inj 19820101 19970101Calcium gluconate injection 19820101 19970101Calcium glycer & lact/10 ML 19820101 19970101Calcitonin salmon injection 19820101 19970101Inj calcitriol per 0.1 mcg 20030101 20030101Caspofungin acetate 20030101 20030101Leucovorin calcium injection 19820101 19970101Levoleucovorin injection 20090101 20090101Inj mepivacaine HCL/10 ml 19860101 19970101Cefazolin sodium injection 19820101 20000101Cefepime HCl for injection 20020101 20020101Cefoxitin sodium injection 19920101 19970101Ceftriaxone sodium injection 19900101 19970101Sterile cefuroxime injection 19900101 19970101Cefotaxime sodium injection 19910101 19970101Betamethasone acet&sod phosp 19950101 20080101Betamethasone sod phosp/4 MG 19950101 19970101Caffeine citrate injection 20020101 20020101Cephapirin sodium injection 19820101 19970101Inj ceftazidime per 500 mg 19960101 19970101Ceftizoxime sodium / 500 MG 19950101 19970101Chloramphenicol sodium injec 19820101 19970101Chorionic gonadotropin/1000u 19860101 19970101Clonidine hydrochloride 19980101 19980101Cidofovir injection 19980101 19980101Cilastatin sodium injection 19930101 19970101Ciprofloxacin iv 20020101 20020101Inj codeine phosphate /30 MG 19860101 19970101Colchicine injection 19820101 19970101Colistimethate sodium inj 19820101 19970101Prochlorperazine injection 19840101 19970101Corticorelin ovine triflutal 20060101 20060101Corticotropin injection 19820101 19970101Inj cosyntropin per 0.25 MG 19950101 19970101Cytomegalovirus imm IV /vial 19820101 19970101Daptomycin injection 20050101 20050101Darbepoetin alfa injection 20030101 20060101Darbepoetin alfa, non-esrd 20060101 20060101Darbepoetin alfa, esrd use 20060101 20060101Epoetin alfa, non-esrd 20060101 20060101Epoetin alfa 1000 units ESRD 20060101 20070101Decitabine injection 20070101 20070101Deferoxamine mesylate inj 19920101 20010101Testosterone enanthate inj 19820101 19970101Brompheniramine maleate inj 19820101 19970101

Query_110708

Page 419

Estradiol valerate injection 19820101 19970101Depo-estradiol cypionate inj 19820101 19970101Methylprednisolone 20 MG inj 19820101 19970101Methylprednisolone 40 MG inj 19820101 19970101Methylprednisolone 80 MG inj 19820101 19970101Medroxyprogesterone inj 20030101 20030101Medrxyprogester acetate inj 19940101 19970101MA/EC contraceptiveinjection 20020101 20030101Testosterone cypionate 1 ML 19820101 19970101Testosterone cypionat 100 MG 19820101 19970101Testosterone cypionat 200 MG 19820101 19970101Inj dexamethasone acetate 20030101 20030101Dexamethasone sodium phos 19820101 20010101Inj dihydroergotamine mesylt 19820101 19970101Acetazolamid sodium injectio 19820101 19970101Digoxin injection 19820101 19970101Digoxin immune fab (ovine) 20060101 20060101Phenytoin sodium injection 19820101 19970101Hydromorphone injection 19820101 19970101Dyphylline injection 19820101 19970101Dexrazoxane HCl injection 19970101 19970101Diphenhydramine hcl injectio 19820101 19970101Chlorothiazide sodium inj 19820101 19970101Dimethyl sulfoxide 50% 50 ML 19860101 19970101Methadone injection 19820101 19970101Dimenhydrinate injection 19840101 19970101Dipyridamole injection 19930101 19980101Inj dobutamine HCL/250 mg 19960101 19970101Dolasetron mesylate 19990101 20000101Dopamine injection 20060101 20060101Doripenem injection 20090101 20090101Injection, doxercalciferol 20020101 20020101Eculizumab injection 20080101 20080101Amitriptyline injection 19820101 19970101Enfuvirtide injection 20070101 20070101Epoprostenol injection 19980101 19980101Eptifibatide injection 20000101 20000101Ergonovine maleate injection 19860101 19970101Ertapenem injection 20040101 20040101Erythro lactobionate /500 MG 19950101 19970101Estradiol valerate 10 MG inj 19820101 19970101Estradiol valerate 20 MG inj 19820101 19970101Inj estrogen conjugate 25 MG 19820101 19970101Ethanolamine oleate 100 mg 20060101 20060101Injection estrone per 1 MG 19820101 19970101Etidronate disodium inj 19900101 19970101Etanercept injection 20000101 20000101

Filgrastim 300 mcg injection 19940101 19970101Filgrastim 480 mcg injection 19940101 19970101Fluconazole 20000101 20000101Fomepizole, 15 mg 20060101 20060101Intraocular Fomivirsen na 20010101 20010101Fosaprepitant injection 20090101 20090101Foscarnet sodium injection 19930101 19970101Gallium nitrate injection 20050101 20050101Galsulfase injection 20070101 20070101Inj IVIG privigen 500 mg 20090101 20090101

Gamma globulin 1 CC inj 19840101 19970101

Query_110708

Page 420

Gamma globulin 2 CC inj 19840101 19970101Gamma globulin 3 CC inj 19850101 19970101Gamma globulin 4 CC inj 19840101 19970101Gamma globulin 5 CC inj 19840101 19970101Gamma globulin 6 CC inj 19840101 19970101Gamma globulin 7 CC inj 19840101 19970101Gamma globulin 8 CC inj 19840101 19970101Gamma globulin 9 CC inj 19840101 19970101Gamma globulin 10 CC inj 19840101 19970101Gamma globulin > 10 CC inj 19840101 19970101Gamunex injection 20080101 20080101

Vivaglobin, inj 20070101 20080101IV immune globulin 20010101 20060101Immune globulin 10 mg 20030101 20060101RSV-ivig 19980101 19980101Immune globulin, powder 20060101 20080101

Immune globulin, liquid 20060101 20080101Octagam injection 20080101 20080101

Gammagard liquid injection 20080101 20080101

Ganciclovir sodium injection 19940101 19970101Hepagam b im injection 20080101 20090101Flebogamma injection 20080101 20090101

Hepagam b intravenous, inj 20080101 20090101Garamycin gentamicin inj 19840101 19970101Gatifloxacin injection 20020101 20020101Injection glatiramer acetate 20040101 20040101Gold sodium thiomaleate inj 19820101 19970101Glucagon hydrochloride/1 MG 19860101 19970101Gonadorelin hydroch/ 100 mcg 19820101 19970101Granisetron hcl injection 19980101 20090101Haloperidol injection 19860101 19970101Haloperidol decanoate inj 19890101 19970101Hemin, 1 mg 20060101 20060101Inj heparin sodium per 10 u 19950101 19970101Inj heparin sodium per 1000u 19950101 20030101Dalteparin sodium 19970101 20020701Inj enoxaparin sodium 19960101 20040101Fondaparinux sodium 20030101 20030101Tinzaparin sodium injection 20020101 20020701Tetanus immune globulin inj 19860101 19970101Histrelin acetate 20060101 20060101Hydrocortisone acetate inj 19820101 19970101Hydrocortisone sodium ph inj 19820101 19970101Hydrocortisone sodium succ i 19820101 19970101Diazoxide injection 19820101 19970101Ibandronate sodium injection 20070101 20070101Ibutilide fumarate injection 19980101 19980101Idursulfase injection 20080101 20080101Infliximab injection 20000101 20000101Inj iron dextran 20051231 20090101Iron dextran 165 injection 20060101 20090101Iron dextran 267 injection 20060101 20090101Iron sucrose injection 20030101 20030101Injection imiglucerase /unit 19950101 19970101Droperidol injection 19820101 19970101Propranolol injection 19820101 19970101

Query_110708

Page 421

Droperidol/fentanyl inj 19820101 19970101Insulin injection 20030101 20030101Insulin for insulin pump use 20030101 20030101Interferon beta-1a 19980101 20030101Interferon beta-1b / .25 MG 19820101 20000101

Itraconazole injection 20020101 20020101Kanamycin sulfate 500 MG inj 19820101 19970101Kanamycin sulfate 75 MG inj 19820101 19970101Ketorolac tromethamine inj 19930101 19970101Cephalothin sodium injection 19820101 19970101Lanreotide injection 20090101 20090101Laronidase injection 20050101 20050101Furosemide injection 19820101 19970101Lepirudin 20060101 20060101Leuprolide acetate /3.75 MG 19860101 19970101Levetiracetam injection 20090101 20090101Inj levocarnitine per 1 gm 19960101 19970101Levofloxacin injection 19990101 19990101Levorphanol tartrate inj 19820101 19970101Hyoscyamine sulfate inj 19820101 19970101Chlordiazepoxide injection 19820101 19970101Lidocaine injection 20040101 20040101Lincomycin injection 19820101 19970101Linezolid injection 20020101 20020101Lorazepam injection 19820101 19970101Mannitol injection 19860101 19970101Mecasermin injection 20070101 20070101Meperidine hydrochl /100 MG 19860101 19970101Meperidine/promethazine inj 19820101 19970101Meropenem 20040101 20040101Methylergonovin maleate inj 19820101 19970101Micafungin sodium injection 20070101 20070101Inj midazolam hydrochloride 19960101 19970101Inj milrinone lactate / 5 MG 19860101 20010101Morphine sulfate injection 19820101 19970101Morphine so4 injection 100mg 19990101 20010101Morphine sulfate injection 19930101 20010101Ziconotide injection 20060101 20060101Inj, moxifloxacin 100 mg 20040101 20040101Inj nalbuphine hydrochloride 19960101 19970101Inj naloxone hydrochloride 19960101 19970101Naltrexone, depot form 20070101 20070101Nandrolone decanoate 50 MG 19860101 19970101Nandrolone decanoate 100 MG 19870101 19970101Nandrolone decanoate 200 MG 19870101 19970101Natalizumab injection 20080101 20080101Nesiritide 20030101 20060101Nesiritide injection 20060101 20060101Octreotide injection, depot 20040101 20040101Octreotide inj, non-depot 20040101 20040101

Oprelvekin injection 19990101 19990101Omalizumab injection 20050101 20050101Orphenadrine injection 19820101 19970101Phenylephrine hcl injection 19820101 19970101Chloroprocaine hcl injection 19860101 19970101Ondansetron hcl injection 19930101 19970101Oxymorphone hcl injection 19820101 19970101Palifermin injection 20060101 20060101

Query_110708

Page 422

Pamidronate disodium /30 MG 19820101 19970101Papaverin hcl injection 19860101 19970101Oxytetracycline injection 19820101 19970101Palonosetron hcl 20050101 20090101Paricalcitol 20030101 20030101Pegaptanib sodium injection 20060101 20060101Pegademase bovine, 25 iu 20060101 20060101Injection, pegfilgrastim 6mg 20040101 20040101Penicillin g procaine inj 19820101 19970101Pentastarch 10% solution 20060101 20060101Pentobarbital sodium inj 19820101 19970101Penicillin g potassium inj 19820101 19970101Piperacillin/tazobactam 20000101 20010101

Pentamidine non-comp unit 19920101 20080101

Promethazine hcl injection 19820101 19970101Phenobarbital sodium inj 19820101 19970101Oxytocin injection 19860101 19970101Inj desmopressin acetate 19960101 19970101Prednisolone acetate inj 19820101 19970101Totazoline hcl injection 19860101 19970101Inj progesterone per 50 MG 19860101 20020701Fluphenazine decanoate 25 MG 19820101 19970101Procainamide hcl injection 19820101 19970101Oxacillin sodium injeciton 19820101 19970101Neostigmine methylslfte inj 19820101 19970101Inj protamine sulfate/10 MG 19820101 19970101Protein c concentrate 20080101 20090101Inj protirelin per 250 mcg 19950101 19970101Pralidoxime chloride inj 19860101 19970101Phentolaine mesylate inj 19820101 19970101Metoclopramide hcl injection 19820101 19970101Quinupristin/dalfopristin 20010101 20010101Ranibizumab injection 20080101 20080101Ranitidine hydrochloride inj 20000101 20000101Rasburicase 20040101 20040101Regadenoson injection 20090101 20090101Rho d immune globulin 50 mcg 20030101 20090101Rho d immune globulin inj 19860101 20090101Rhophylac injection 20080101 20080101

Rho(D) immune globulin h, sd 19990101 19990101Risperidone, long acting 20050101 20050101Ropivacaine HCl injection 20010101 20010101Methocarbamol injection 19820101 19970101Sincalide injection 20060101 20060101Inj theophylline per 40 MG 19820101 19970101Sargramostim injection 19820101 19980101Inj secretin synthetic human 20060101 20060101Aurothioglucose injeciton 19820101 19970101Sodium chloride injection 19860101 20070101Na ferric gluconate complex 20030101 20030101Methylprednisolone injection 19820101 19970101Methylprednisolone injection 19840101 19970101Somatrem injection 20020101 20020101Somatropin injection 20020101 20020101Promazine hcl injection 19820101 19970101Reteplase injection 20010101 20010101Inj streptokinase /250000 IU 19860101 19970101Alteplase recombinant 20010101 20010101

Query_110708

Page 423

Streptomycin injection 19820101 19970101Fentanyl citrate injeciton 19820101 20010101Sumatriptan succinate / 6 MG 19860101 20000101

Pentazocine injection 19820101 20030101Tenecteplase injection 20020101 20090101Tenecteplase injection 20090101 20090101Terbutaline sulfate inj 19870101 19970101Teriparatide injection 20050101 20050101Testosterone enanthate inj 19820101 19970101Testosterone enanthate inj 19820101 19970101Testosterone suspension inj 19820101 19970101Testosteron propionate inj 19820101 19970101Chlorpromazine hcl injection 19820101 19970101Thyrotropin injection 19860101 20030101Tigecycline injection 20070101 20070101Tirofiban HCl 20050101 20050101Trimethobenzamide hcl inj 19820101 19970101Tobramycin sulfate injection 19820101 19970101Injection torsemide 10 mg/ml 19960101 19970101Thiethylperazine maleate inj 19820101 19970101Treprostinil injection 20060101 20060101Triamcinolone A inj PRS-free 20090101 20090101Triamcinolone acet inj NOS 19910101 20090101Triamcinolone diacetate inj 19910101 19970101Triamcinolone hexacetonl inj 19910101 19970101Inj trimetrexate glucoronate 19960101 19970101Perphenazine injeciton 19820101 19970101Triptorelin pamoate 20030101 20030101Spectinomycn di-hcl inj 19820101 19970101Urea injection 19860101 19970101Urofollitropin, 75 iu 20060101 20060101Diazepam injection 19820101 19970101Urokinase 5000 IU injection 19930101 19970101Urokinase 250,000 IU inj 19920101 19970101Vancomycin hcl injection 19860101 20000101Verteporfin injection 20050101 20050101Triflupromazine hcl inj 19820101 19970101Hydroxyzine hcl injection 19820101 19970101Thiamine hcl 100 mg 20040101 20040101Pyridoxine hcl 100 mg 20040101 20040101Vitamin b12 injection 19860101 19970101Vitamin k phytonadione inj 19820101 19970101Injection, voriconazole 20040101 20040101Hyaluronidase injection 19820101 19970101Ovine, up to 999 USP units 20060101 20060101

Ovine, 1000 USP units 20060101 20060101Hyaluronidase recombinant 20070101 20070101Inj magnesium sulfate 19960101 19970101Inj potassium chloride 19960101 19970101Zidovudine 20010101 20010101Ziprasidone mesylate 20040101 20040101Zoledronic acid 20030101 20080101Reclast injection 20080101 20080101Drugs unclassified injection 19860101 19970101Edetate disodium per 150 mg 19860101 19960101Nasal vaccine inhalation 19860101 19970101Metered dose inhaler drug 19940101 19970101Laetrile amygdalin vit B17 19860101 19960101

Query_110708

Page 424

Unclassified biologics 20030101 20030101Normal saline solution infus 19820101 19970101Normal saline solution infus 19840101 199701015% dextrose/normal saline 19840101 19970101Normal saline solution infus 19820101 19970101Sterile saline/water 19940101 200601015% dextrose/water 19850101 19970101D5w infusion 19820101 19970101Dextran 40 infusion 19820101 19970101Dextran 75 infusion 19820101 19970101Ringers lactate infusion 19820101 19970101Hypertonic saline solution 19840101 19970101Antihemophilic viii/vwf comp 20090101 20090101

Humate-P, inj 20070101 20080101Inj Vonwillebrand factor iu 20060101 20070101Factor viia 20060101 20060101Factor viii 19860101 19990101Factor VIII (porcine) 19960101 19980101Factor viii recombinant 19940101 19990101Factor IX non-recombinant 20020101 20020101Factor ix complex 19860101 19980101Factor IX recombinant 20020101 20020101Antithrombin iii injection 19920101 19970101Anti-inhibitor 20000101 20000101Hemophilia clot factor noc 20000101 20000101Intraut copper contraceptive 19860101 19950401Levonorgestrel iu contracept 20020101 20020101Contraceptive vaginal ring 20040101 20040101Contraceptive hormone patch 20050101 20050101Levonorgestrel implant sys 20060101 20060101Etonogestrel implant system 20080101 20080101Aminolevulinic acid hcl top 20020101 20040101

Ganciclovir long act implant 19970101 19970101Fluocinolone acetonide implt 20070101 20070101Sodium hyaluronate injection 20030101 20070101Sodium Hyaluronate Injection 20070101 20070401

Hylan G-F 20 injection 19990101 20070101Hyalgan/supartz inj per dose 20080101 20080101

Synvisc inj per dose 20080101 20080101Euflexxa inj per dose 20080101 20080101Orthovisc inj per dose 20080101 20080101Cultured chondrocytes implnt 20010101 20020701Metabolic active D/E tissue 20020101 20090101

Non-human, metabolic tissue 20060101 20090101

Metabolically active tissue 20030101 20090101

Nonmetabolic act d/e tissue 20050101 20090101

Nonmetabolic active tissue 20050101 20090101

Non-human, non-metab tissue 20070101 20080101

Query_110708

Page 425

Injectable human tissue 20070101 20090101

Integra matrix tissue 20080101 20090101

Tissuemend tissue 20080101 20090101

Primatrix tissue 20080101 20090101

Injectable human tissue 20030101 20070101

Azathioprine oral 50mg 19880101 20000101Azathioprine parenteral 19880101 20000101Cyclosporine oral 100 mg 20000101 20000101Lymphocyte immune globulin 19880101 20020101Monoclonal antibodies 19880101 20010101Prednisone oral 19890101 20000101Tacrolimus oral per 1 MG 19950101 20000101Methylprednisolone oral 19960101 20000101Prednisolone oral per 5 mg 19960101 20000101Antithymocyte globuln rabbit 20020101 20020101Daclizumab, parenteral 19990101 20000101Cyclosporine oral 25 mg 20000101 20000101Cyclosporin parenteral 250mg 20000101 20000101Mycophenolate mofetil oral 20000101 20000101Mycophenolic acid 20050101 20050101Sirolimus, oral 20010101 20010101Tacrolimus injection 20010101 20010101Immunosuppressive drug noc 19960101 20000101Albuterol inh non-comp con 20080101 20090101

Albuterol inh non-comp u d 20080101 20090101

Acetylcysteine comp unit 20080101 20080101

Arformoterol non-comp unit 20080101 20080101

Formoterol fumarate, inh 20090101 20090101

Levalbuterol comp con 20070101 20070101

Acetylcysteine non-comp unit 20000101 20080101

Albuterol comp unit 20070101 20070101

Albuterol comp con 20070101 20070101

Albuterol non-comp con 20050101 20080401

Levalbuterol non-comp con 20050101 20080401

Albuterol non-comp unit 20050101 20080401

Query_110708

Page 426

Levalbuterol non-comp unit 20050101 20080401

Levalbuterol comp unit 20070101 20070101

Albuterol compound solution 20050101 20060101

Levalbuterol compounded sol 20050101 20060101

Albuterol ipratrop non-comp 20060101 20070101

Beclomethasone comp unit 20020101 20070101

Betamethasone comp unit 20020101 20070101

Budesonide non-comp unit 20020101 20070101

Budesonide comp unit 20060101 20070101

Bitolterol mesylate comp con 20000101 20070101

Bitolterol mesylate comp unt 20000101 20070101

Cromolyn sodium noncomp unit 20000101 20080101

Cromolyn sodium comp unit 20080101 20080101

Budesonide non-comp con 20030101 20070101

Budesonide comp con 20070101 20070101

Atropine comp con 20000101 20070101

Atropine comp unit 20000101 20070101

Dexamethasone comp con 20000101 20070101

Dexamethasone comp unit 20000101 20070101

Dornase alfa non-comp unit 20000101 20090101

Formoterol comp unit 20060101 20070101

Flunisolide comp unit 20020101 20070101

Glycopyrrolate comp con 20000101 20070101

Glycopyrrolate comp unit 20000101 20070101

Ipratropium bromide non-comp 20000101 20070101

Ipratropium bromide comp 20070101 20070101

Isoetharine comp con 20070101 20070101

Isoetharine non-comp con 20000101 20070101

Isoetharine non-comp unit 20000101 20070101

Isoetharine comp unit 20070101 20070101

Isoproterenol comp con 20070101 20070101

Query_110708

Page 427

Isoproterenol non-comp con 20000101 20070101

Isoproterenol non-comp unit 20000101 20070101

Isoproterenol comp unit 20070101 20070101

Metaproterenol comp con 20070101 20070101

Metaproterenol non-comp con 20000101 20070101

Metaproterenol non-comp unit 20000101 20070101

Metaproterenol comp unit 20070101 20070101

Methacholine chloride, neb 20050101 20050101

Pentamidine comp unit dose 20080101 20080101

Terbutaline sulf comp con 20000101 20070101

Terbutaline sulf comp unit 20000101 20070101

Tobramycin non-comp unit 20000101 20070101

Triamcinolone comp con 20000101 20070101

Triamcinolone comp unit 20000101 20070101

Tobramycin comp unit 20070101 20070101

Inhalation solution for DME 19930101 20070101Non-inhalation drug for DME 19930101 20020701Antiemetic rectal/supp NOS 20060101 20060101Oral prescrip drug non chemo 19950101 19970101Oral aprepitant 20050101 20050101Oral busulfan 20000101 20000101Cabergoline, oral 0.25mg 20060101 20060101Capecitabine, oral, 150 mg 20000101 20000101Capecitabine, oral, 500 mg 20000101 20000101Cyclophosphamide oral 25 MG 19950101 19970831Oral dexamethasone 20060101 20060101Etoposide oral 50 MG 19950101 19970101Gefitinib oral 20050101 20050101Antiemetic drug oral NOS 20060101 20060101Melphalan oral 2 MG 19950101 19970101Methotrexate oral 2.5 MG 19950101 19970831Nabilone oral 20070101 20070101Temozolomide 20010101 20010101Topotecan oral 20090101 20090101Oral prescription drug chemo 19950101 19970101Doxorubicin hcl injection 19840101 20090101Doxorubicin hcl liposome inj 20000101 20090101Alemtuzumab injection 20030101 20090101Aldesleukin injection 19960101 20090101Arsenic trioxide injection 20020101 20090101Asparaginase injection 19840101 20090101Azacitidine injection 20060101 20060101Clofarabine injection 20060101 20060101Bcg live intravesical vac 19910101 19970101Bendamustine injection 20090101 20090101

Query_110708

Page 428

Bevacizumab injection 20050101 20050101Bleomycin sulfate injection 19840101 20090101Bortezomib injection 20050101 20050101Carboplatin injection 19900101 20090101Carmustine injection 19840101 20090101Cetuximab injection 20050101 20050101Cisplatin 10 MG injection 19840101 19970101Cisplatin 50 MG injection 19820101 19970101Inj cladribine per 1 MG 19950101 19970101Cyclophosphamide 100 MG inj 19840101 19970101Cyclophosphamide 200 MG inj 19940101 19970101Cyclophosphamide 500 MG inj 19940101 19970101Cyclophosphamide 1.0 grm inj 19940101 19970101Cyclophosphamide 2.0 grm inj 19940101 19970101Cyclophosphamide lyophilized 19880101 19970101Cyclophosphamide lyophilized 19940101 19970101Cyclophosphamide lyophilized 19940101 19970101Cyclophosphamide lyophilized 19940101 19970101Cyclophosphamide lyophilized 19940101 19970101Cytarabine liposome inj 20040101 20090101Cytarabine hcl 100 MG inj 19860101 20090101Cytarabine hcl 500 MG inj 19940101 20090101Dactinomycin injection 19840101 20090101Dacarbazine 100 mg inj 19860101 20040101Dacarbazine 200 MG inj 19940101 19970101Daunorubicin injection 19860101 20090101Daunorubicin citrate inj 19990101 20090101Denileukin diftitox inj 20010101 20090101Diethylstilbestrol injection 19880101 20090101Docetaxel injection 19980101 20090101Elliotts b solution per ml 20060101 20060101Inj, epirubicin hcl, 2 mg 20040101 20040101Etoposide injection 19870101 20090101Etoposide 100 MG inj 19870101 20090101Fludarabine phosphate inj 19940101 20090101Fluorouracil injection 19840101 20090101Floxuridine injection 19840101 20090101Gemcitabine hcl injection 19980101 20090101Goserelin acetate implant 19910101 19970101Irinotecan injection 19980101 20090101Ixabepilone injection 20090101 20090101Ifosfomide injection 19900101 20090101Mesna injection 19900101 20090101Idarubicin hcl injection 19930101 20090101Interferon alfacon-1 inj 19990101 20090101Interferon alfa-2a inj 19930101 20090101Interferon alfa-2b inj 19930101 20090101Interferon alfa-n3 inj 19930101 20090101Interferon gamma 1-b inj 19930101 20090101Leuprolide acetate suspnsion 19910101 19970101Leuprolide acetate injeciton 19900101 19970101Leuprolide acetate implant 20010101 20010101Vantas implant 20060101 20080101Supprelin LA implant 20080101 20080101Mechlorethamine hcl inj 19860101 20090101Inj melphalan hydrochl 50 MG 19950101 19970101Methotrexate sodium inj 19940101 19970101Methotrexate sodium inj 19840101 19970101Nelarabine injection 20070101 20070101Oxaliplatin 20040101 20040101Paclitaxel protein bound 20060101 20070101

Query_110708

Page 429

Paclitaxel injection 19940101 20090101Pegaspargase injection 19960101 20090101Pentostatin injection 19940101 20090101Plicamycin (mithramycin) inj 19840101 20090101Mitomycin 5 MG inj 19860101 19970101Mitomycin 20 MG inj 19940101 19970101Mitomycin 40 MG inj 19890101 19970101Mitoxantrone hydrochl / 5 MG 19900101 19970101Gemtuzumab ozogamicin inj 20020101 20090101Panitumumab injection 20080101 20080101Pemetrexed injection 20050101 20050101Rituximab injection 19990101 20090101Streptozocin injection 19860101 20090101Temsirolimus injection 20090101 20090101Thiotepa injection 19840101 20090101Topotecan injection 19980101 20090101Trastuzumab injection 20000101 20090101Valrubicin injection 20000101 20090101Vinblastine sulfate inj 19860101 20090101Vincristine sulfate 1 MG inj 19860101 19970101Vincristine sulfate 2 MG inj 19880101 19970101Vincristine sulfate 5 MG inj 19940101 19970101Vinorelbine tartrate inj 19960101 20090101Injection, Fulvestrant 20040101 20040101Porfimer sodium injection 19980101 20090101Chemotherapy drug 19860101 19970101Standard wheelchair 19940101 19940101Stnd hemi (low seat) whlchr 19940101 19940101Lightweight wheelchair 19940101 19940101High strength ltwt whlchr 19940101 19940101Ultralightweight wheelchair 19940101 19940101Heavy duty wheelchair 19940101 19940101Extra heavy duty wheelchair 19940101 19940101Other manual wheelchair/base 19940101 19940101Stnd wt frame power whlchr 19940101 19970505Stnd wt pwr whlchr w control 19940101 19970505

Ltwt portbl power whlchr 19940101 19970505Other power whlchr base 19940101 20010101Detach non-adjus hght armrst 19940101 19940101Detach adjust armrest base 19940101 19940101Detach adjust armrst upper 19940101 19940101Arm pad each 19940101 19940101Fixed adjust armrest pair 19940101 19940101High mount flip-up footrest 19940101 19940101Leg strap each 19940101 19940101Leg strap h style each 19940101 19940101Adjustable angle footplate 19940101 19940101Large size footplate each 19940101 19940101Standard size footplate each 19940101 19940101Ftrst lower extension tube 19940101 19940101Ftrst upper hanger bracket 19940101 19940101Footrest complete assembly 19940101 19940101Elevat legrst low extension 19940101 19940101Elevat legrst up hangr brack 19940101 19940101Ratchet assembly 19940101 19940101Cam relese assem ftrst/lgrst 19940101 19940101Swingaway detach footrest 19940101 19940101Elevate footrest articulate 19940101 19940101Seat ht <17 or >=21 ltwt wc 19940101 19990101

Query_110708

Page 430

Zero pressure tube flat free 19940101 20060101Spoke protectors 19940101 20000101Solid tire any size each 19940101 20060101Pneumatic tire any size each 19940101 20060101Pneumatic tire tube each 19940101 20060101Rear whl complete solid tire 19940101 19940101Rear whl compl pneum tire 19940101 19940101Front castr compl pneum tire 19940101 19940101Frnt cstr cmpl sem-pneum tir 19940101 19940101Caster pin lock each 19940101 19940101Pneumatic caster tire each 19940101 20060101Semi-pneumatic caster tire 19940101 20060101Solid caster tire each 19940101 20060101Front caster assem complete 19940101 19940101Pneumatic caster tire tube 19940101 20060101Rear tire power wheelchair 19940101 20070101Rear tire tube power whlchr 19940101 20070101

Rear assem cmplt powr whlchr 19940101 20070101Rear zero pressure tire tube 19940101 20070101

Wheel tire for power base 19940101 20070101Wheel tire tube each base 19940101 20070101Wheel assem powr base complt 19940101 20070101Wheel zero presure tire tube 19940101 20070101Drive belt power wheelchair 19940101 19940101Pwr wheelchair front caster 19940101 20070101Crutch and cane holder 19940101 20060101Cylinder tank carrier 19940101 20060101Iv hanger 19940101 20000101Arm trough each 19940101 20060101W/c component-accessory NOS 19940101 19990701Elevating whlchair leg rests 19930101 19930101RX antiemetic drg, oral NOS 19960101 20060101

Rx antiemetic drg,rectal NOS 19960101 20060101

Wheelchair bearings 19970101 20060101Pump uninterrupted infusion 19980101 20030701

Temporary replacement eqpmnt 19980701 19980701Supply/ext inf pump syr type 20030701 20030701Combination oral/nasal mask 20070701 20080101

Repl oral cushion combo mask 20070701 20080101Repl nasal pillow comb mask 20070701 20080101Functional neuromuscularstim 20030401 20060101

Repl batt silver oxide 1.5 v 20030401 20030401

Repl batt silver oxide 3 v 20030401 20030401

Repl batt alkaline 1.5 v 20030401 20030401

Repl batt lithium 3.6 v 20030401 20030401

Repl batt lithium 4.5 v 20030401 20030401

AED garment w elec analysis 20030701 20030701

Query_110708

Page 431

Repl batt for AED 20030701 20030701

Repl garment for AED 20030701 20030701Repl electrode for AED 20030701 20030701

TLSO 2 piece rigid shell 20030701 20060101


Tubular elastic dressing 20030701 20060101Multi den insert direct form 20040401 20060101

Multi den insert custom mold 20040401 20060101

SIO flex pelvisacral prefab 20040401 20060101

SIO flex pelvisacral custom 20040401 20060101

SIO panel prefab 20040401 20060101

SIO panel custom 20040401 20060101

LO flexibl L1-below L5 pre 20040401 20060101

LO sag stays/panels pre-fab 20040401 20060101

LO sagitt rigid panel prefab 20040401 20060101

LO flex w/o rigid stays pre 20040401 20060101

Query_110708

Page 432

LSO flex w/rigid stays cust 20040401 20060101

LSO post rigid panel pre 20040401 20060101

LSO sag-coro rigid frame pre 20040401 20060101

LSO sag-cor rigid frame cust 20040401 20060101

LSO flexion control prefab 20040401 20060101

LSO flexion control custom 20040401 20060101

LSO sagit rigid panel prefab 20040401 20060101

LSO sagittal rigid panel cus 20040401 20060101

LSO sag-coronal panel prefab 20040401 20060101

LSO sag-coronal panel custom 20040401 20060101

LSO s/c shell/panel prefab 20040401 20060101

Query_110708

Page 433

LSO s/c shell/panel custom 20040401 20060101

Seat/back cus no sadmerc ver 20040701 20090101

Stance phase only 20050401 20060101

Portable oxygen concentrator 20050401 20060101Removable soft interface LE 20080401 20080401

Ctrl dose inh drug deliv sys 20050701 20050701Lith ion bat CID non-ear lvl 20050701 20060101

Lith ion batt CID ear level 20050701 20060101

12-24hr sealed lead acid 20060701 20060701

Adj skin pro w/c cus wd<22in 20060701 20060701

Adj skin pro wc cus wd>=22in 20060701 20060701

Adj skin pro/pos wc cus<22in 20060701 20060701

Adj skin pro/pos wc cus>=22" 20060701 20060701

Portable gas oxygen system 20061001 20061001

POV group 1 std up to 300lbs 20061001 20061001

POV group 1 hd 301-450 lbs 20061001 20061001

POV group 1 vhd 451-600 lbs 20061001 20061001

POV group 2 std up to 300lbs 20061001 20061001

POV group 2 hd 301-450 lbs 20061001 20061001

POV group 2 vhd 451-600 lbs 20061001 20061001

Power operated vehicle NOC 20061001 20061001PWC gp 1 std port seat/back 20061001 20061001

PWC gp 1 std port cap chair 20061001 20061001

PWC gp 1 std seat/back 20061001 20061001

PWC gp 1 std cap chair 20061001 20061001

PWC gp 2 std port seat/back 20061001 20061001

PWC gp 2 std port cap chair 20061001 20061001

Query_110708

Page 434



PWC gp 2 hd seat/back 20061001 20061001

PWC gp 2 hd cap chair 20061001 20061001

PWC gp 2 vhd seat/back 20061001 20061001

PWC gp vhd cap chair 20061001 20061001

PWC gp 2 xtra hd seat/back 20061001 20061001

PWC gp 2 xtra hd cap chair 20061001 20061001

PWC gp2 std seat elevate s/b 20061001 20061001

PWC gp2 std seat elevate cap 20061001 20061001

PWC gp2 std sing pow opt s/b 20061001 20061001

PWC gp2 std sing pow opt cap 20061001 20061001

PWC gp 2 hd sing pow opt s/b 20061001 20061001

PWC gp 2 hd sing pow opt cap 20061001 20061001

PWC gp2 vhd sing pow opt s/b 20061001 20061001

PWC gp2 xhd sing pow opt s/b 20061001 20061001

PWC gp2 std mult pow opt s/b 20061001 20061001

PWC gp2 std mult pow opt cap 20061001 20061001

PWC gp2 hd mult pow opt s/b 20061001 20061001




PWC gp 3 hd cap chair 20061001 20061001


PWC gp 3 vhd cap chair 20061001 20061001

PWC gp 3 xhd seat/back 20061001 20061001

PWC gp 3 xhd cap chair 20061001 20061001



PWC gp3 hd sing pow opt s/b 20061001 20061001

PWC gp3 hd sing pow opt cap 20061001 20061001

Query_110708

Page 435



PWC gp3 hd mult pow opt s/b 20061001 20061001

PWC gp3 vhd mult pow opt s/b 20061001 20061001

PWC gp3 xhd mult pow opt s/b 20061001 20061001







PWC gp4 hd sing pow opt s/b 20061001 20061001



PWC gp4 std mult pow opt cap 20061001 20061001

PWC gp4 hd mult pow s/b 20061001 20061001

PWC gp5 ped sing pow opt s/b 20061001 20061001

PWC gp5 ped mult pow opt s/b 20061001 20061001

Power wheelchair NOC 20061001 20061001Pow mobil dev no SADMERC 20061001 20090101Cranial orthosis/helmet mold 19820101 20070101

Cranial orthosis/helmet nonm 19820101 20070101Cranial cervical orthosis 20040101 20040101

Cranial cervical torticollis 20090101 20090101

Cerv flexible non-adjustable 19820101 19960101Flex thermoplastic collar mo 19840101 19960101Cervical semi-rigid adjustab 19820101 19960101Cerv semi-rig adj molded chn 19820101 19960101

Cerv semi-rig wire occ/mand 19820101 19960101Cervical collar molded to pt 19860101 19960101Cerv col thermplas foam 2 pi 19880101 19960101Cerv col foam 2 piece w thor 19880101 19960101

Cer post col occ/man sup adj 19840101 19960101Cerv collar supp adj cerv ba 19820101 19960101

Cerv col supp adj bar & thor 19840101 19960101

Query_110708

Page 436

Thoracic rib belt 19820101 19960101Thor rib belt custom fabrica 19820101 19960101Dewall posture protector 19880101 20050101

TLSO flex prefab thoracic 20030101 20030101

tlso flex custom fab thoraci 20030101 20030101

TLSO flex prefab sacrococ-T9 20030101 20030101

TLSO flex prefab 20030101 20030101

TLSO 2Mod symphis-xipho pre 20030101 20030101

TLSO2Mod symphysis-stern pre 20030101 20030101

TLSO 3Mod sacro-scap pre 20030101 20030101

TLSO 4Mod sacro-scap pre 20030101 20030101

TLSO rigid frame pre soft ap 20030101 20030101

TLSO rigid frame prefab pelv 20030101 20030101

Query_110708

Page 437

TLSO rigid frame pre subclav 20030101 20030101

TLSO rigid frame hyperex pre 20030101 20030101

TLSO rigid plastic custom fa 20030101 20040101

TLSO rigid lined custom fab 20030101 20030101

TLSO rigid plastic cust fab 20030101 20030101

TLSO rigidlined cust fab two 20030101 20030101

TLSO rigid lined pre one pie 20030101 20030101

TLSO rigid plastic pre one 20030101 20030101



Query_110708

Page 438

SIO flex pelvisacral prefab 20060101 20060101

SIO flex pelvisacral custom 20060101 20060101

SIO panel prefab 20060101 20060101

SIO panel custom 20060101 20060101

LO flexibl L1-below L5 pre 20060101 20060101

LO sag stays/panels pre-fab 20060101 20060101

LO sagitt rigid panel prefab 20060101 20060101

LO flex w/o rigid stays pre 20060101 20060101

LSO flex w/rigid stays cust 20060101 20060101

LSO post rigid panel pre 20060101 20060101

LSO sag-coro rigid frame pre 20060101 20070101

LSO sag rigid frame cust 20060101 20060101

LSO flexion control prefab 20060101 20060101

Query_110708

Page 439

LSO flexion control custom 20060101 20060101

LSO sagit rigid panel prefab 20060101 20060101

LSO sagittal rigid panel cus 20060101 20060101

LSO sag-coronal panel prefab 20060101 20060101

LSO sag-coronal panel custom 20060101 20060101

LSO s/c shell/panel prefab 20060101 20060101

LSO s/c shell/panel custom 20060101 20060101

Ctlso a-p-l control molded 19840101 19960101

Ctlso a-p-l control w/ inter 19840101 19960101

Halo cervical into jckt vest 19860101 19960101Halo cervical into body jack 19860101 19960101Halo cerv into milwaukee typ 19860101 19960101MRI compatible system 20060101 20060101

Magnetic resonanc image comp 19890101 20060101Halo repl liner/interface 20040101 20040101Post surgical support pads 19860101 20080101Tlso corset front 19820101 19960101Lso corset front 19820101 19960101Tlso full corset 19820101 19960101Lso full corset 19820101 19960101Axillary crutch extension 19820101 19960101

Query_110708

Page 440

Peroneal straps pair 19860101 19960101Stocking supp grips set of f 19820101 19960101Protective body sock each 19940101 19960101Add to spinal orthosis NOS 19980101 19980101Ctlso milwauke initial model 19860101 19960101

CTLSO infant immobilizer 20070101 20070101

Tension based scoliosis orth 20020101 20020101

Ctlso axilla sling 19860101 19960101

Kyphosis pad 19860101 19960101Kyphosis pad floating 19880101 19960101Lumbar bolster pad 19860101 19960101Lumbar or lumbar rib pad 19860101 19960101Sternal pad 19860101 19960101Thoracic pad 19860101 19960101Trapezius sling 19860101 19960101Outrigger 19860101 19960101Outrigger bil w/ vert extens 19880101 19960101

Lumbar sling 19860101 19960101Ring flange plastic/leather 19860101 19960101Ring flange plas/leather mol 19860101 19960101

Covers for upright each 19860101 19960101Furnsh initial orthosis only 19860101 19960101

Lateral thoracic extension 19860101 19960101Anterior thoracic extension 19860101 19960101Milwaukee type superstructur 19860101 19960101Lumbar derotation pad 19880101 19960101Anterior asis pad 19880101 19960101Anterior thoracic derotation 19880101 19960101Abdominal pad 19880101 19960101Rib gusset (elastic) each 19880101 19960101Lateral trochanteric pad 19880101 19960101Body jacket mold to patient 19860101 19960101Post-operative body jacket 19860101 19960101Spinal orthosis NOS 19820101 19980101Thkao mobility frame 19860101 19960101

Thkao standing frame 19820101 20020101Thkao swivel walker 19820101 19960101Abduct hip flex frejka w cvr 19860101 20010101

Abduct hip flex frejka covr 19820101 20010101

Abduct hip flex pavlik harne 19820101 20010101

Abduct control hip semi-flex 19820101 20010101

Pelv band/spread bar thigh c 19820101 20010101

HO abduction hip adjustable 19820101 20010101

HO bi thighcuffs w sprdr bar 20030101 20030101

HO abduction static plastic 19820101 20010101

Query_110708

Page 441

Pelvic & hip control thigh c 19820101 20010101

Post-op hip abduct custom fa 19880101 20010101

HO post-op hip abduction 19890101 20010101

Combination bilateral HO 19990101 20010101

Leg perthes orth toronto typ 19820101 20010101Legg perthes orth newington 19820101 20010101Legg perthes orthosis trilat 19850101 20010101Legg perthes orth scottish r 19820101 20010101Legg perthes sling 19820101 20060101

Legg perthes patten bottom t 19880101 20010101Knee orthoses elas w stays 19860101 20010101

Ko elastic with joints 19820101 20010101

Elastic with condylar pads 19880101 20010101

Ko elas w/ condyle pads & jo 19860101 20050101

Ko elastic knee cap 19850101 20010101Ko immobilizer canvas longit 19860101 20010101

Knee orth pos locking joint 20040101 20040101

KO adj jnt pos rigid support 19890101 20060101

Ko w/0 joint rigid molded to 19890101 20010101Rigid KO wo joints 20030101 20030101

Ko derot ant cruciate custom 19860101 20010101

KO single upright custom fit 19980101 20060101

Ko w/adj jt rot cntrl molded 19930101 20060101

Ko w/ adj flex/ext rotat cus 19880101 20060101

Ko w adj flex/ext rotat mold 19880101 20060101

KO adjustable w air chambers 19990101 20010101

Ko swedish type 19820101 20010101Ko plas doub upright jnt mol 19880101 20080101

Ko polycentric pneumatic pad 19880101 20080101

Ko supracondylar socket mold 19820101 20010101

Ko doub upright lacers molde 19820101 20080101

Query_110708

Page 442

Ko doub upright cuffs/lacers 19820101 20080101

Afo sprng wir drsflx calf bd 19860101 20010101

Prefab ankle orthosis 20030101 20030101

Afo ankle gauntlet 19880101 20010101

Afo molded ankle gauntlet 19880101 20010101Afo multiligamentus ankle su 19880101 20010101

AFO supramalleolar custom 20040101 20040101

Afo sing bar clasp attach sh 19820101 20010101

Afo sing upright w/ adjust s 19820101 20010101

Afo plastic 19820101 20020101

Afo rig ant tib prefab TCF/= 20050101 20050101

Afo molded to patient plasti 19820101 20020101Afo molded plas rig ant tib 19890101 20010101

Afo spiral molded to pt plas 19820101 20040101

AFO spiral prefabricated 20040101 20040101

Afo pos solid ank plastic mo 19820101 20010101Afo plastic molded w/ankle j 19820101 20010101AFO w/ankle joint, prefab 20040101 20040101

Afo sing solid stirrup calf 19820101 20010101

Afo doub solid stirrup calf 19820101 20010101

Kafo sing fre stirr thi/calf 19850101 20010101

KAFO sng/dbl mechanical act 20050101 20050101

Kafo sng solid stirrup w/o j 19860101 20010101

Kafo dbl solid stirrup band/ 19850101 20010101

Kafo dbl solid stirrup w/o j 19860101 20010101

KAFO pla sin up w/wo k/a cus 20060101 20060101

KAFO plastic pediatric size 19980101 20050101

Kafo plas doub free knee mol 19880101 20060101

Kafo plas sing free knee mol 19890101 20060101

Kafo w/o joint multi-axis an 19890101 20060101

KAFO,plstic,medlat rotat con 19970101 20060101

Query_110708

Page 443

Hkafo torsion bil rot straps 19860101 20010101

Hkafo torsion cable hip pelv 19820101 20010101

Hkafo torsion ball bearing j 19820101 20010101

Hkafo torsion unilat rot str 19820101 20010101

Hkafo unilat torsion cable 19860101 20010101

Hkafo unilat torsion ball br 19840101 20010101

Afo tib fx cast plaster mold 19880101 20010101

Afo tib fx cast molded to pt 19880101 20010101

Afo tibial fracture soft 19880101 20010101

Afo tib fx semi-rigid 19880101 20010101

Afo tibial fracture rigid 19880101 20010101

Kafo fem fx cast thermoplas 19880101 20010101

Kafo fem fx cast molded to p 19880101 20010101

Kafo femoral fx cast soft 19880101 20010101

Kafo fem fx cast semi-rigid 19880101 20010101

Kafo femoral fx cast rigid 19880101 20010101

Plas shoe insert w ank joint 19880101 19960101

Drop lock knee 19880101 19960101Limited motion knee joint 19880101 19960101Adj motion knee jnt lerman t 19880101 19960101

Quadrilateral brim 19880101 19960101Waist belt 19880101 19960101Pelvic band & belt thigh fla 19880101 19960101

Limited ankle motion ea jnt 19860101 19960101Dorsiflexion assist each joi 19860101 19960101

Dorsi & plantar flex ass/res 19860101 19960101

Split flat caliper stirr & p 19860101 19960101Rocker bottom, contact AFO 20050101 20050101

Round caliper and plate atta 19860101 19960101Foot plate molded stirrup at 19860101 19960101

Reinforced solid stirrup 19860101 19960101Long tongue stirrup 19890101 19960101Varus/valgus strap padded/li 19860101 19960101

Plastic mod low ext pad/line 19940101 19960101

Query_110708

Page 444

Molded inner boot 19860101 19960101Abduction bar jointed adjust 19860101 19960101

Abduction bar-straight 19860101 19960101Non-molded lacer 19860101 20050101

Lacer molded to patient mode 19860101 20050101

Anterior swing band 19880101 19960101Pre-tibial shell molded to p 19860101 19960101Prosthetic type socket molde 19860101 19960101

Extended steel shank 19860101 19960101Patten bottom 19880101 19960101Torsion ank & half solid sti 19880101 19960101

Torsion straight knee joint 19880101 19960101Straight knee joint heavy du 19880101 19960101Add LE poly knee custom KAFO 20060101 20060101

Offset knee joint each 19880101 19960101Offset knee joint heavy duty 19880101 19960101Suspension sleeve lower ext 19940101 19960101Knee joint drop lock ea jnt 19880101 20060101Knee joint cam lock each joi 19880101 20020101

Knee disc/dial lock/adj flex 19880101 19960101

Knee jnt ratchet lock ea jnt 19970101 19970101

Knee lift loop drop lock rin 19880101 19960101Thi/glut/ischia wgt bearing 19860101 19960101

Th/wght bear quad-lat brim m 19860101 19960101

Th/wght bear quad-lat brim c 19860101 19960101

Th/wght bear nar m-l brim mo 19890101 19960101

Th/wght bear nar m-l brim cu 19890101 19960101

Thigh/wght bear lacer non-mo 19860101 19960101Thigh/wght bear lacer molded 19860101 19960101

Thigh/wght bear high roll cu 19860101 19960101Hip clevis type 2 posit jnt 19860101 19960101

Pelvic control pelvic sling 19860101 19960101Hip clevis/thrust bearing fr 19860101 19960101

Hip clevis/thrust bearing lo 19860101 19960101

Pelvic control hip heavy dut 19860101 19960101Hip joint adjustable flexion 19880101 19960101Hip adj flex ext abduct cont 19880101 19960101

Plastic mold recipro hip & c 19890101 19960101

Metal frame recipro hip & ca 19890101 19960101

Pelvic control band & belt u 19860101 19960101

Query_110708

Page 445

Pelvic control band & belt b 19860101 19960101Pelv & thor control gluteal 19860101 19960101Thoracic control thoracic ba 19860101 19960101Thorac cont paraspinal uprig 19860101 19960101Thorac cont lat support upri 19860101 19960101Plating chrome/nickel pr bar 19860101 19960101Carbon graphite lamination 19970101 20050101

Extension per extension per 19860101 19960101

Ortho sidebar disconnect 20020101 20020101Low ext orthosis per bar/jnt 19860101 19960101Non-corrosive finish 19860101 19960101Drop lock retainer each 19880101 19960101Knee control full kneecap 19880101 19960101Knee cap medial or lateral p 19880101 20050101

Knee control condylar pad 19880101 19960101Soft interface below knee se 19880101 19960101

Soft interface above knee se 19880101 19960101

Tibial length sock fx or equ 19890101 19960101

Femoral lgth sock fx or equa 19890101 19960101

Torsion mechanism knee/ankle 19950101 20090101

Lower extremity orthosis NOS 19820101 19980101Ft insert ucb berkeley shell 19820101 19970101

Foot insert remov molded spe 19840101 19970101Foot insert plastazote or eq 19840101 19970101Foot insert silicone gel eac 19840101 19970101Foot longitudinal arch suppo 19820101 19970101

Foot longitud/metatarsal sup 19860101 19970101

Foot arch support remov prem 19860101 19970101Foot lamin/prepreg composite 20040101 20050101

Ft arch suprt premold longit 19820101 19970101Foot arch supp premold metat 19820101 19970101Foot arch supp longitud/meta 19820101 19970101Arch suprt att to sho longit 19840101 19970101Arch supp att to shoe metata 19840101 19970101Arch supp att to shoe long/m 19840101 19970101

Hallus-valgus nght dynamic s 19850101 19970101Abduction rotation bar shoe 19820101 19970101Abduct rotation bar w/o shoe 19840101 19970101Shoe styled positioning dev 19860101 19950101Foot plastic heel stabilizer 19840101 20060101Oxford w supinat/pronat inf 19840101 19970101Oxford w/ supinat/pronator c 19840101 19970101Oxford w/ supinator/pronator 19840101 19970101Hightop w/ supp/pronator inf 19840101 19970101Hightop w/ supp/pronator chi 19840101 19970101Hightop w/ supp/pronator jun 19840101 19970101Surgical boot each infant 19840101 19960101

Query_110708

Page 446

Surgical boot each child 19840101 19960101Surgical boot each junior 19840101 19960101Benesch boot pair infant 19840101 19960101Benesch boot pair child 19840101 19960101Benesch boot pair junior 19840101 19960101Orthopedic ftwear ladies oxf 19840101 20060101Orthoped ladies shoes dpth i 19840101 20060101Ladies shoes hightop depth i 19840101 20060101Orthopedic mens shoes oxford 19840101 20060101Orthopedic mens shoes dpth i 19840101 20060101Mens shoes hightop depth inl 19840101 20060101Woman's shoe oxford brace 19950101 19950101

Man's shoe oxford brace 19950101 19950101

Custom shoes depth inlay 19840101 20060101Custom mold shoe remov prost 19840101 19970101

Shoe molded to pt silicone s 19840101 19970101Shoe molded plastazote cust 19840101 19970101

Shoe molded plastazote cust 19840101 19970101Orth foot non-stndard size/w 19840101 19970101Orth foot non-standard size/ 19840101 19970101Orth foot add charge split s 19880101 19970101Ambulatory surgical boot eac 19840101 20030101Plastazote sandal each 19840101 19960101Sho lift taper to metatarsal 19860101 19970101Shoe lift elev heel/sole neo 19860101 19970101Shoe lift elev heel/sole cor 19860101 19970101Lifts elevation metal extens 19860101 19970101Shoe lifts tapered to one-ha 19860101 19970101Shoe lifts elevation heel /i 19860101 19970101Shoe wedge sach 19820101 19970101Shoe heel wedge 19820101 19970101Shoe sole wedge outside sole 19840101 19970101Shoe sole wedge between sole 19840101 19970101Shoe clubfoot wedge 19820101 19970101Shoe outflare wedge 19820101 19970101Shoe metatarsal bar wedge ro 19840101 19970101Shoe metatarsal bar between 19840101 19970101Full sole/heel wedge btween 19840101 19970101Sho heel count plast reinfor 19850101 19970101Heel leather reinforced 19840101 19970101Shoe heel sach cushion type 19840101 19970101Shoe heel new leather standa 19840101 19970101Shoe heel new rubber standar 19840101 19970101Shoe heel thomas with wedge 19840101 19970101Shoe heel thomas extend to b 19840101 19970101Shoe heel pad & depress for 19840101 19970101Shoe heel pad removable for 19840101 19970101Ortho shoe add leather insol 19860101 19990101Orthopedic shoe add rub insl 19860101 19990101O shoe add felt w leath insl 19860101 19990101Ortho shoe add half sole 19860101 19990101Ortho shoe add full sole 19860101 19990101O shoe add standard toe tap 19860101 19990101O shoe add horseshoe toe tap 19860101 19990101O shoe add instep extension 19860101 19990101O shoe add instep velcro clo 19860101 19990101O shoe convert to sof counte 19860101 19990101

Query_110708

Page 447

Ortho shoe add march bar 19860101 19990101Trans shoe calip plate exist 19860101 19970101Trans shoe caliper plate new 19860101 19970101Trans shoe solid stirrup exi 19860101 19970101Trans shoe solid stirrup new 19860101 19970101Shoe dennis browne splint bo 19860101 19970101

Orthopedic shoe modifica NOS 19820101 19990101Shlder fig 8 abduct restrain 19860101 20010101

Prefab shoulder orthosis 20030101 20030101

Prefab dbl shoulder orthosis 20030101 20030101

Abduct restrainer canvas&web 19820101 20010101

Acromio/clavicular canvas&we 19820101 20010101

SO cap design w/o jnts CF 20060101 20060101

SO airplane w/o jnts CF 20060101 20060101

SO airplane w/joint CF 20060101 20060101

Canvas vest SO 19990101 20010101

SO hard plastic stabilizer 20020101 20020101

Elbow orthoses elas w stays 19820101 20010101

Prefab elbow orthosis 20030101 20030101

EO w/o joints CF 20060101 20060101

Elbow elastic with metal joi 19860101 20010101

Forearm/arm cuffs free motio 19840101 20010101

Forearm/arm cuffs ext/flex a 19820101 20010101

Cuffs adj lock w/ active con 19820101 20010101

EO withjoint, Prefabricated 20010101 20010101

Rigid EO wo joints 20030101 20030101

EWHO rigid w/o jnts CF 20060101 20060101

EWHO w/joint(s) CF 20060101 20060101

EWHFO rigid w/o jnts CF 20060101 20060101

EWHFO w/joint(s) CF 20060101 20060101

Whfo short opponen no attach 19820101 20080101Whfo long opponens no attach 19820101 20080101WHFO w/joint(s) custom fab 20070101 20080101

Query_110708

Page 448

WHFO,no joint, prefabricated 20000101 20010101

WHFO, rigid w/o joints 20070101 20070101

Whfo thumb abduction bar 19860101 20080101Whfo second m.p. abduction a 19860101 20080101Whfo ip ext asst w/ mp ext s 19860101 20080101

Whfo m.p. extension stop 19860101 20080101Whfo m.p. extension assist 19860101 20080101Whfo m.p. spring extension a 19860101 20080101Whfo spring swivel thumb 19860101 20080101Whfo thumb ip ext ass w/ mp 19860101 20080101

Action wrist w/ dorsiflex as 19860101 20080101Whfo adj m.p. flexion contro 19860101 20080101Whfo adj m.p. flex ctrl & i. 19860101 20080101

Torsion mechanism wrist/elbo 19950101 20090101

Hinge extension/flex wrist/f 19860101 20010101

Hinge ext/flex wrist finger 19840101 20010101

Whfo ext power compress gas 19850101 20070101Whfo electric custom fitted 19820101 20010101WHO w/nontorsion jnt(s) CF 20060101 20060101

WHO w/o joints CF 19860101 20060101

Whfo wrst gauntlt thmb spica 19880101 20080101Wrist cock-up non-molded 19860101 20010101

Prefab wrist orthosis 20030101 20030101

Whfo swanson design 19820101 20080101

Prefab hand finger orthosis 20030101 20030101

Flex glove w/elastic finger 19820101 20010101

HFO w/o joints CF 20060101 20060101

WHO wrist extension cock-up 19860101 20070101

WHO w nontor jnt(s) prefab 20070101 20070101

Whfo wrist extens w/ outrigg 19860101 20080101

Prefab metacarpl fx orthosis 20040101 20040101

HFO knuckle bender 19820101 20080101

HO w/o joints CF 20060101 20060101

Knuckle bender with outrigge 19820101 20080101

Query_110708

Page 449

HFO w/joint(s) CF 20060101 20060101

Knuckle bend 2 seg to flex j 19820101 20080101

HFO w/o joints PF 20010101 20060101

Oppenheimer 19820101 20080101

FO pip/dip with joint/spring 20080101 20080101

Thomas suspension 19820101 20080101

FO pip/dip w/o joint/spring 20080101 20080101

Finger extension w/ clock sp 19820101 20080101

HFO nontorsion joint, prefab 20080101 20080101

Finger extension with wrist 19820101 20080101

WHFO nontorsion joint prefab 20080101 20080101

Safety pin spring wire 19820101 20080101

FO w/o joints CF 20060101 20060101

Safety pin modified 19820101 20080101

FO nontorsion joint CF 20060101 20060101

Palmer 19820101 20080101

Dorsal wrist 19820101 20080101

Dorsal wrist w/ outrigger at 19820101 20080101

Reverse knuckle bender 19820101 20080101

Reverse knuckle bend w/ outr 19820101 20080101

HFO composite elastic 19820101 20080101

Finger knuckle bender 19820101 20080101

Oppenheimer w/ knuckle bend 19820101 20080101

Oppenheimer w/ rev knuckle 2 19820101 20080101

Spreading hand 19820101 20080101

Add joint upper ext orthosis 19970101 19970101Sewho airplan desig abdu pos 19860101 20010101

SEWHO cap design w/o jnts CF 20060101 20060101

Query_110708

Page 450

Sewho erbs palsey design abd 19820101 20010101

Molded w/ articulating elbow 19880101 20060101

Seo mobile arm sup att to wc 19860101 20010101

Arm supp att to wc rancho ty 19840101 20010101

Mobile arm supports reclinin 19860101 20010101

SEWHO airplane w/o jnts CF 20060101 20060101

Friction dampening arm supp 19860101 20010101

Monosuspension arm/hand supp 19880101 20010101

Elevat proximal arm support 19860101 19980101SEWHO cap design w/jnt(s) CF 20060101 20060101

Offset/lat rocker arm w/ ela 19860101 19980101

SEWHO airplane w/jnt(s) CF 20060101 20060101

Mobile arm support supinator 19860101 19980101SEWHFO cap design w/o jnt CF 20060101 20060101

SEWHFO airplane w/o jnts CF 20060101 20060101

SEWHFO cap desgn w/jnt(s) CF 20060101 20060101

SEWHFO airplane w/jnt(s) CF 20060101 20060101

Upp ext fx orthosis humeral 19820101 20010101

Upper ext fx orthosis rad/ul 19840101 20010101

Upper ext fx orthosis wrist 19820101 20010101

Forearm hand fx orth w/ wr h 19880101 20080101

Humeral rad/ulna wrist fx or 19840101 20080101

Sock fracture or equal each 19890101 19960101Upper limb orthosis NOS 19820101 19980101Repl girdle milwaukee orth 19850101 20020101Replace strap, any orthosis 20050101 20050101Replace trilateral socket br 19850101 19960101Replace quadlat socket brim 19850101 19960101Replace socket brim cust fit 19850101 19960101Replace molded thigh lacer 19850101 20050101

Query_110708

Page 451

Replace non-molded thigh lac 19880101 20050101Replace molded calf lacer 19850101 20050101Replace non-molded calf lace 19880101 20050101Replace high roll cuff 19850101 19960101Replace prox & dist upright 19860101 19960101Repl met band kafo-afo prox 19860101 19960101Repl met band kafo-afo calf/ 19850101 19960101Repl leath cuff kafo prox th 19860101 19960101Repl leath cuff kafo-afo cal 19850101 19960101Replace pretibial shell 19840101 19960101Ortho dvc repair per 15 min 19970101 19970101Orth dev repair/repl minor p 19850101 19960101Ankle control orthosi prefab 19890101 20040101

Pneumati walking boot prefab 19890101 20090101

Pneumatic full leg splint 19890101 20030101Pneumatic knee splint 19890101 20030101Non-pneum walk boot prefab 20030101 20040101

Replace AFO soft interface 19970101 20010101Replace foot drop spint 19970101 19970101Static AFO 19970101 20020101

Foot drop splint recumbent 19970101 20010101

Sho insert w arch toe filler 19820101 19960101Mold socket ank hgt w/ toe f 19820101 19960101Tibial tubercle hgt w/ toe f 19820101 19960101Ank symes mold sckt sach ft 19850101 19960101Symes met fr leath socket ar 19850101 19960101Molded socket shin sach foot 19820101 19960101Plast socket jts/thgh lacer 19890101 19960101Mold sckt ext knee shin sach 19820101 19960101

Mold socket bent knee shin s 19820101 19960101

Kne sing axis fric shin sach 19820101 19960101No knee/ankle joints w/ ft b 19820101 19960101

No knee joint with artic ali 19820101 19960101

Fem focal defic constant fri 19820101 19960101

Hip canad sing axi cons fric 19820101 19960101

Tilt table locking hip sing 19820101 19960101

Hemipelvect canad sing axis 19820101 19960101

BK mold socket SACH ft endo 20020101 20020101Knee disart, SACH ft, endo 20020101 20020101

AK open end SACH 20020101 20020101

Hip disart canadian SACH ft 20020101 20020101

Hemipelvectomy canadian SACH 20020101 20020101

Postop dress & 1 cast chg bk 19820101 19960101

Query_110708

Page 452

Postop dsg bk ea add cast ch 19860101 19960101

Postop dsg & 1 cast chg ak/d 19820101 19960101

Postop dsg ak ea add cast ch 19860101 19960101

Postop app non-wgt bear dsg 19820101 19960101

Postop app non-wgt bear dsg 19820101 19960101

Init bk ptb plaster direct 19860101 19960101

Init ak ischal plstr direct 19860101 19960101

Prep BK ptb plaster molded 19860101 19960101

Perp BK ptb thermopls direct 19860101 19960101

Prep BK ptb thermopls molded 19860101 19960101

Prep BK ptb open end socket 19890101 19960101

Prep BK ptb laminated socket 19860101 19960101

Prep AK ischial plast molded 19860101 19960101

Prep AK ischial direct form 19860101 19960101

Prep AK ischial thermo mold 19860101 19960101

Prep AK ischial open end 19880101 19960101

Prep AK ischial laminated 19860101 19960101

Hip disartic sach thermopls 19890101 19960101

Hip disart sach laminat mold 19890101 19960101

Above knee hydracadence 19860101 19960101

Ak 4 bar link w/fric swing 19890101 19960101

Ak 4 bar ling w/hydraul swig 19890101 19960101

4-bar link above knee w/swng 19940101 19960101

Ak univ multiplex sys frict 19860101 19960101

AK/BK self-aligning unit ea 19960101 19960101

Test socket symes 19860101 19960101

Query_110708

Page 453

Test socket below knee 19860101 19960101Test socket knee disarticula 19860101 19960101Test socket above knee 19860101 19960101Test socket hip disarticulat 19860101 19960101Test socket hemipelvectomy 19860101 19960101Below knee acrylic socket 19890101 19960101Syme typ expandabl wall sckt 19860101 19960101Ak/knee disartic acrylic soc 19890101 19960101Symes type ptb brim design s 19860101 19960101Symes type poster opening so 19860101 19960101Symes type medial opening so 19860101 19960101Below knee total contact 19890101 19960101Below knee leather socket 19860101 19960101Below knee wood socket 19890101 19960101Knee disarticulat leather so 19860101 19960101Above knee leather socket 19860101 19960101Hip flex inner socket ext fr 19880101 19960101

Above knee wood socket 19860101 19960101Bk flex inner socket ext fra 19880101 20001213Below knee cushion socket 19860101 20040101

Below knee suction socket 19880101 19960101Above knee cushion socket 19860101 20040101

Isch containmt/narrow m-l so 19880101 19960101Tot contact ak/knee disart s 19860101 19960101

Ak flex inner socket ext fra 19880101 19960101Suction susp ak/knee disart 19860101 19960101

Knee disart expand wall sock 19860101 19960101Socket insert symes 19860101 19960101

Socket insert below knee 19860101 19960101

Socket insert knee articulat 19860101 19960101

Socket insert above knee 19860101 19960101

Multi-durometer symes 19880101 19960101Multi-durometer below knee 19880101 19960101Below knee cuff suspension 19860101 19960101Socket insert w/o lock lower 19860101 19960101Bk molded supracondylar susp 19860101 19960101

BK/AK locking mechanism 20020101 20020101

Bk removable medial brim sus 19860101 19960101Socket insert w lock mech 20040101 20040101

Bk knee joints single axis p 19860101 19960101Bk knee joints polycentric p 19880101 19960101Bk joint covers pair 19840101 19960101Socket insert w/o lock mech 20040101 20040101

Bk thigh lacer non-molded 19860101 19960101Intl custm cong/latyp insert 20040101 20040101

Query_110708

Page 454

Bk thigh lacer glut/ischia m 19860101 19960101Initial custom socket insert 20040101 20040101

Bk fork strap 19860101 19960101Below knee sus/seal sleeve 20050101 20050101

Bk back check 19860101 19960101Bk waist belt webbing 19860101 19960101Bk waist belt padded and lin 19860101 19960101Ak pelvic control belt light 19860101 19960101Ak pelvic control belt pad/l 19860101 19960101Ak sleeve susp neoprene/equa 19890101 19960101

Ak/knee disartic pelvic join 19860101 19960101Ak/knee disartic pelvic band 19860101 19960101Ak/knee disartic silesian ba 19860101 19960101

Shoulder harness 19860101 19960101Replace socket below knee 19940101 19940101Replace socket above knee 19940101 19940101

Replace socket hip 19940101 19940101

Symes ankle w/o (SACH) foot 20060101 20060101

Custom shape cover BK 19940101 20020101Custom shape cover AK 19940101 20020101Custom shape cvr knee disart 19940101 20020101Custom shape cvr hip disart 19940101 20020101Kne-shin exo sng axi mnl loc 19860101 19960101Knee-shin exo mnl lock ultra 19880101 19960101

Knee-shin exo frict swg & st 19860101 19960101

Knee-shin exo variable frict 19860101 19960101

Knee-shin exo mech stance ph 19860101 19960101

Knee-shin exo frct swg & sta 19860101 19960101

Knee-shin pneum swg frct exo 19860101 19960101

Knee-shin exo fluid swing ph 19860101 19960101Knee-shin ext jnts fld swg e 19860101 19960101

Knee-shin fluid swg & stance 19860101 19960101

Knee-shin pneum/hydra pneum 19860101 19960101

Lower limb pros vacuum pump 20030101 20030101

HD low limb pros vacuum pump 20030101 20030101

Exoskeletal bk ultralt mater 19880101 19960101

Exoskeletal ak ultra-light m 19880101 19960101

Query_110708

Page 455

Exoskel hip ultra-light mate 19880101 19960101

Endoskel knee-shin mnl lock 19880101 19960101Endo knee-shin mnl lck ultra 19880101 19960101

Endo knee-shin frct swg & st 19880101 19960101

Endo knee-shin hydral swg ph 19970101 19970101

Endo knee-shin polyc mch sta 19880101 19960101

Endo knee-shin frct swg & st 19880101 19960101

Endo knee-shin pneum swg frc 19880101 19960101

Endo knee-shin fluid swing p 19880101 19960101Miniature knee joint 19980101 19990101

Endo knee-shin fluid swg/sta 19880101 19960101

Endo knee-shin pneum/swg pha 19880101 19960101

Multi-axial knee/shin system 19940101 19990101

Knee-shin sys stance flexion 19960101 19960101Knee-shin sys hydraul stance 20030101 20070101

Endo ak/hip knee extens assi 19880101 19960101

Mech hip extension assist 19940101 19950101

Elec knee-shin swing/stance 20050101 20050101

Elec knee-shin swing only 20050101 20050101

Stance phase only 20060101 20060101

Endo below knee alignable sy 19880101 19960101Endo ak/hip alignable system 19880101 19960101

Above knee manual lock 19940101 20000101

High activity knee frame 19960101 19960101Endo bk ultra-light material 19880101 19960101

Endo ak ultra-light material 19880101 19960101

Endo hip ultra-light materia 19880101 19960101

Below knee flex cover system 19940101 19940101

Above knee flex cover system 19940101 19940101

Hip flexible cover system 19940101 19940101

Multiaxial ankle w dorsiflex 19990101 20000101

Foot external keel sach foot 19890101 19960101

Query_110708

Page 456

SACH foot, replacement 20060101 20060101

Flexible keel foot 19890101 19960101

Foot single axis ankle/foot 19890101 19960101Combo ankle/foot prosthesis 19990101 19990101

Energy storing foot 19890101 19960101

Ft prosth multiaxial ankl/ft 19890101 19960101Multi-axial ankle/ft prosth 19940101 20010101

Flex foot system 19890101 19960101Flex-walk sys low ext prosth 19940101 19940101Exoskeletal axial rotation u 19890101 19960101Endoskeletal axial rotation 19890101 20040101

Lwr ext dynamic prosth pylon 19960101 19960101Multi-axial rotation unit 19890101 19960101Shank ft w vert load pylon 19970101 19970101Vertical shock reducing pylo 19990101 20000101User adjustable heel height 20020101 20020101Heavy duty feature, foot 20070101 20090101

Heavy duty feature, knee 20070101 20090101

Lower ext pros heavyduty fea 20030101 20090101

Lowr extremity prosthes NOS 19820101 19980101Par hand robin-aids thum rem 19820101 19960101Hand robin-aids little/ring 19820101 19960101Part hand robin-aids no fing 19820101 19960101Part hand disart myoelectric 20030101 20030101

Wrst MLd sck flx hng tri pad 19820101 19960101Wrst mold sock w/exp interfa 19880101 19960101

Elb mold sock flex hinge pad 19820101 19960101Elbow mold sock suspension t 19820101 19960101Elbow mold doub splt soc ste 19820101 19960101Elbow stump activated lock h 19820101 19960101

Elbow mold outsid lock hinge 19820101 19960101Elbow molded w/ expand inter 19880101 19960101

Elbow inter loc elbow forarm 19820101 19960101Shlder disart int lock elbow 19820101 19960101

Shoulder passive restor comp 19820101 19960101Shoulder passive restor cap 19820101 19960101Thoracic intern lock elbow 19840101 19960101

Thoracic passive restor comp 19860101 19960101Thoracic passive restor cap 19860101 19960101Postop dsg cast chg wrst/elb 19880101 19960101

Postop dsg cast chg elb dis/ 19880101 19960101

Query_110708

Page 457

Postop dsg cast chg shlder/t 19880101 19960101

Postop ea cast chg & realign 19880101 19960101

Postop applicat rigid dsg on 19880101 19960101Below elbow prosth tiss shap 19820101 19960101

Elb disart prosth tiss shap 19820101 19960101

Above elbow prosth tiss shap 19820101 19960101

Shldr disar prosth tiss shap 19840101 19960101

Scap thorac prosth tiss shap 19840101 19960101

Wrist/elbow bowden cable mol 19880101 19960101

Wrist/elbow bowden cbl dir f 19880101 19960101

Elbow fair lead cable molded 19880101 19960101

Elbow fair lead cable dir fo 19880101 19960101

Shdr fair lead cable molded 19880101 19960101

Shdr fair lead cable direct 19880101 19960101

Polycentric hinge pair 19820101 19960101Single pivot hinge pair 19820101 19960101Flexible metal hinge pair 19820101 19960101Additional switch, ext power 20070101 20070101

Disconnect locking wrist uni 19860101 19960101Disconnect insert locking wr 19890101 19960101

Flexion/extension wrist unit 19860101 20040101

Flex/ext wrist w/wo friction 20060101 20060101

Spring-ass rot wrst w/ latch 19880101 19960101

Flex/ext/rotation wrist unit 20070101 20070101Rotation wrst w/ cable lock 19860101 19960101Quick disconn hook adapter o 19880101 19960101Lamination collar w/ couplin 19880101 19960101

Stainless steel any wrist 19860101 19960101Latex suspension sleeve each 19880101 19960101Lift assist for elbow 19860101 19960101Nudge control elbow lock 19880101 19960101Elec lock on manual pw elbow 20030101 20030101

Heavy duty elbow feature 20070101 20070101Shoulder abduction joint pai 19820101 19960101

Query_110708

Page 458

Excursion amplifier pulley t 19880101 19960101Excursion amplifier lever ty 19880101 19960101Shoulder flexion-abduction j 19860101 19960101Multipo locking shoulder jnt 20030101 20030101

Shoulder lock actuator 20030101 20030101Ext pwrd shlder lock/unlock 20030101 20030101Shoulder universal joint 19860101 19960101Standard control cable extra 19860101 19960101Heavy duty control cable 19860101 19960101Teflon or equal cable lining 19860101 19960101Hook to hand cable adapter 19860101 19960101Harness chest/shlder saddle 19860101 19960101Harness figure of 8 sing con 19860101 20040101

Harness figure of 8 dual con 19860101 20040101

UE triple control harness 20060101 20060101

Test sock wrist disart/bel e 19860101 19960101Test sock elbw disart/above 19860101 19960101Test socket shldr disart/tho 19860101 19960101

Suction socket 19880101 19960101Frame typ socket bel elbow/w 19880101 19960101

Frame typ sock above elb/dis 19880101 19960101

Frame typ socket shoulder di 19880101 19960101Frame typ sock interscap-tho 19880101 19960101Removable insert each 19880101 19960101Silicone gel insert or equal 19890101 19960101Lockingelbow forearm cntrbal 19990101 20000101Elbow socket ins use w/lock 20050101 20050101

Elbow socket ins use w/o lck 20050101 20050101

Cus elbo skt in for con/atyp 20050101 20050101

Cus elbo skt in not con/atyp 20050101 20050101

Below/above elbow lock mech 20050101 20050101

Terminal device model #3 19860101 20070101Term dev, passive hand mitt 20070101 20070101Term dev, sport/rec/work att 20070101 20070101Terminal device model #5 19860101 20070101Term dev mech hook vol open 20070101 20070101

Term dev mech hook vol close 20070101 20070101

Term dev mech hand vol open 20070101 20070101Term dev mech hand vol close 20070101 20070101Terminal device model #5x 19860101 20070101

Query_110708

Page 459

Ped term dev, hook, vol open 20090101 20090101

Ped term dev, hook, vol clos 20090101 20090101

Ped term dev, hand, vol open 20090101 20090101

Ped term dev, hand, vol clos 20090101 20090101

Terminal device model #5xa 19860101 20070101Terminal device model #6 19860101 20070101Hook/hand, hvy dty, vol open 20090101 20090101

Hook/hand, hvy dty, vol clos 20090101 20090101

Terminal device model #7 19860101 20070101Terminal device model #7lo 19860101 20070101Terminal device model #8 19860101 20070101Terminal device model #8x 19860101 20070101Terminal device model #88x 19860101 20070101Terminal device model #10p 19860101 20070101Terminal device model #10x 19860101 20070101Terminal device model #12p 19860101 20070101Terminal device model #99x 19860101 20070101Terminal device model#555 19860101 20070101Terminal device model #ss555 19860101 20070101Hooks-accu hook or equal 19860101 20070101Hooks-2 load or equal 19860101 20070101Hooks-aprl vc or equal 19860101 20070101Term dev modifier wrist unit 19850101 20070101Trs grip vc or equal 19880101 20070101Term device grip1/2 or equal 19880101 20070101Term device infant or child 19880101 20070101Trs super sport passive 19880101 20070101Term dev precision pinch dev 19880101 20070101Hands dorrance vo 19820101 20070101Hand aprl vc 19860101 20070101Hand sierra vo 19860101 20070101Hand becker imperial 19860101 20070101Hand becker lock grip 19860101 20070101Term dvc-hand becker plylite 19860101 20070101Hand robin-aids vo 19860101 20070101Hand robin-aids vo soft 19860101 20070101Hand passive hand 19860101 20070101Hand detroit infant hand 19880101 20070101Passive inf hand steeper/hos 19880101 20070101Hand child mitt 19860101 20070101Hand nyu child hand 19880101 20070101Hand mech inf steeper or equ 19880101 20070101Hand bock vc 19860101 20070101Hand bock vo 19860101 20070101Term dev auto grasp feature 20020101 20070101

Microprocessor control uplmb 20020101 20020101

Replc sockt below e/w disa 20060101 20060101

Replc sockt above elbow disa 20060101 20070101

Replc sockt shldr dis/interc 20060101 20060101

Prefab glove for term device 19860101 20050101

Query_110708

Page 460

Custom glove for term device 19860101 20050101

Hand restorat thumb/1 finger 19820101 19960101

Hand restoration multiple fi 19860101 19960101

Hand restoration no fingers 19820101 19960101

Hand restoration replacmnt g 19820101 19960101

Wrist disarticul switch ctrl 19880101 19960101

Wrist disart myoelectronic c 19880101 19960101

Below elbow switch control 19880101 19960101

Below elbow myoelectronic ct 19880101 19960101

Elbow disarticulation switch 19880101 19960101

Elbow disart myoelectronic c 19880101 19960101

Above elbow switch control 19880101 19960101

Above elbow myoelectronic ct 19880101 19960101

Shldr disartic switch contro 19880101 19960101

Shldr disartic myoelectronic 19880101 19960101

Interscapular-thor switch ct 19880101 19960101

Interscap-thor myoelectronic 19880101 19960101

Adult electric hand 20070101 20070101Pediatric electric hand 20070101 20070101Adult electric hook 20070101 20070101Hand otto back steeper/eq sw 19880101 20070101Hand sys teknik village swit 19880101 20070101Electronic greifer switch ct 19880101 20070101Electron hand myoelectronic 19880101 20070101Hand sys teknik vill myoelec 19880101 20070101

Electron greifer myoelectro 19880101 20070101

Query_110708

Page 461

Prehensile actuator 19880101 20070101Pediatric electric hook 19880101 20070101Electronic elbow hosmer swit 19880101 19960101Electronic elbow sequential 19880101 20050101Electronic elbo simultaneous 20050101 20050101

Electron elbow adolescent sw 19880101 19960101Electron elbow child switch 19890101 19960101Elbow adolescent myoelectron 19880101 19960101

Elbow child myoelectronic ct 19890101 19960101Electron wrist rotator otto 19880101 19960101Electron wrist rotator utah 19880101 19960101Servo control steeper or equ 19880101 19960101Analogue control unb or equa 19880101 19960101Proportional ctl 12 volt uta 19880101 19970101Six volt bat otto bock/eq ea 19880101 20080101Battery chrgr six volt otto 19880101 20080101Twelve volt battery utah/equ 19880101 20080101Battery chrgr 12 volt utah/e 19880101 20080101Replacemnt lithium ionbatter 20030101 20030101Lithium ion battery charger 20030101 20030101Add UE prost be/wd, ultlite 20060101 20060101

Add UE prost a/e ultlite mat 20060101 20060101

Add UE prost s/d ultlite mat 20060101 20060101

Add UE prost b/e acrylic 20060101 20060101

Add UE prost a/e acrylic 20060101 20060101

Add UE prost s/d acrylic 20060101 20060101

Upper extremity prosthes NOS 19850101 19980101Prosthetic dvc repair hourly 19820101 19960101

Prosthetic device repair rep 19850101 20030101Repair prosthesis per 15 min 19970101 20000101Prosthetic donning sleeve 20060101 20060101Ped term dev, hook, vol open 20080101 20090101

Ped term dev, hook, vol clos 20080101 20090101

Ped term dev, hand, vol open 20080101 20090101

Ped term dev, hand, vol clos 20080101 20090101

Hook/hand, hvy dty, vol open 20080101 20090101

Hook/hand, hvy dty, vol clos 20080101 20090101

Male vacuum erection system 19970101 20030101Mastectomy bra 19860101 19960101Breast prosthesis bra & form 20020101 20020101

Brst prsth bra & bilat form 20020101 20020101

Mastectomy sleeve 19860101 20050401Ext breastprosthesis garment 19990101 19990101Mastectomy form 19860101 19960101

Query_110708

Page 462

Breast prosthesis silicone/e 19890101 19960101Custom breast prosthesis 19990101 19990101Breast prosthesis NOS 19980101 19980101Nasal prosthesis 20010101 20010101Midfacial prosthesis 20010101 20010101Orbital prosthesis 20010101 20010101Upper facial prosthesis 20010101 20010101Hemi-facial prosthesis 20010101 20010101Auricular prosthesis 20010101 20010101Partial facial prosthesis 20010101 20010101Nasal septal prosthesis 20010101 20010101Unspec maxillofacial prosth 20010101 20010101Repair maxillofacial prosth 20010101 20010101

Compression stocking BK18-30 19860101 20060101Compression stocking BK30-40 19860101 20060101Compression stocking BK40-50 19860101 20060101Gc stocking thighlngth 18-30 19860101 20060101Gc stocking thighlngth 30-40 19860101 20060101Gc stocking thighlngth 40-50 19860101 20060101Gc stocking full lngth 18-30 19860101 20060101Gc stocking full lngth 30-40 19860101 20060101Gc stocking full lngth 40-50 19860101 20060101Gc stocking waistlngth 18-30 19860101 20060101Gc stocking waistlngth 30-40 19990101 20060101Gc stocking waistlngth 40-50 19860101 20060101Gc stocking custom made 19860101 20060101Gc stocking lymphedema 19860101 20060101Gc stocking garter belt 19860101 20060101G compression stocking NOS 19980101 20060101Truss single w/ standard pad 19860101 19960101Truss double w/ standard pad 19860101 19960101Truss addition to std pad wa 19860101 19960101Truss add to std pad scrotal 19860101 19960101Sheath below knee 19820101 19960101Sheath above knee 19820101 19960101Sheath upper limb 19880101 19960101Pros sheath/sock w gel cushn 19970101 19970101

Prosthetic sock multi ply BK 19820101 19990101Prosthetic sock multi ply AK 19820101 19990101Pros sock multi ply upper lm 19880101 20000101Shrinker below knee 19820101 19960101Shrinker above knee 19820101 19960101Shrinker upper limb 19880101 19960101Pros sock single ply BK 19820101 19990101Pros sock single ply AK 19820101 19990101Pros sock single ply upper l 19940101 19990101Unlisted misc prosthetic ser 19820101 20020101Artificial larynx 19900101 19960101Tracheostomy speaking valve 19900101 19960101Artificial larynx, accessory 20020101 20020101Trach-esoph voice pros pt in 20020101 20020101Trach-esoph voice pros md in 20020101 20020101

Voice amplifier 20020101 20020101Indwelling trach insert 20040101 20040101

Gel cap for trach voice pros 20040101 20040101

Trach pros cleaning device 20040101 20040101

Query_110708

Page 463

Repl trach puncture dilator 20040101 20040101Gel cap app device for trach 20050101 20050101

Implant breast silicone/eq 19920101 19971001Collagen imp urinary 2.5 ml 19950101 20010101

Dextranomer/hyaluronic acid 20090101 20090101

Synthetic implnt urinary 1ml 20010101 20010101

Artificial cornea 20060101 20060101Ocular implant 19920101 19971001Aqueous shunt prosthesis 19920101 19971001Ossicular implant 19920101 19971001Cochlear device 19920101 20070101Coch implant headset replace 20050101 20050101Coch implant microphone repl 20050101 20050101Coch implant trans coil repl 20050101 20050101Coch implant tran cable repl 20050101 20050101Replace cochlear processor 19960101 19960916Repl lithium ion battery 20050101 20060101Repl zinc air battery 20050101 20050101Repl alkaline battery 20050101 20050101

Lith ion batt CID,non-earlvl 20060101 20060101

Lith ion batt CID, ear level 20060101 20060101

Metacarpophalangeal implant 19920101 19971001MCP joint repl 2 pc or more 20040101 20040101

Metatarsal joint implant 19920101 19971001Hallux implant 19920101 19971001Interphalangeal joint spacer 19920101 20040101Interphalangeal joint repl 20040101 20040101

Vascular graft, synthetic 19920101 19971001Implt neurostim elctr each 20060101 20060101Pt prgrm for implt neurostim 20060101 20090101

Implt neurostim radiofq rec 20060101 20060101Radiofq trsmtr for implt neu 20060101 20060101

Radiof trsmtr implt scrl neu 20060101 20060101

Implt nrostm pls gen sng rec 20060101 20060101

Implt nrostm pls gen sng non 20060101 20060101

Implt nrostm pls gen dua rec 20060101 20060101

Implt nrostm pls gen dua non 20060101 20060101

External recharg sys intern 20060101 20090101

Aud osseo dev, int/ext comp 20070101 20070101Aud osseo dev ext snd proces 20070101 20070101External recharg sys extern 20070101 20090101

Query_110708

Page 464

Prosthetic implant NOS 19980101 19980101O&P supply/accessory/service 20000101 20000101

Visit for drug monitoring 19920101 19960101

Cellular therapy 19860101 19960101Prolotherapy 19860101 19960101Intragastric hypothermia 19860101 20040101IV chelationtherapy 19860101 19960101Fabric wrapping of aneurysm 19860101 20040101Cephalin floculation test 19860101 19900101Congo red blood test 19860101 19900101Hair analysis 19860101 19890101Blood thymol turbidity 19860101 19900101Blood mucoprotein 19860101 19930101Screen pap by tech w md supv 19920101 19950101

Screening pap smear by phys 19920101 20020101

Culture bacterial urine 19860101 19960101Whole blood for transfusion 19870101 19870101Blood split unit 19870101 20070101Cryoprecipitate each unit 19870101 20010101RBC leukocytes reduced 19870101 20010101Plasma 1 donor frz w/in 8 hr 19870101 20040101

Platelets, each unit 19870101 20010101Plaelet rich plasma unit 19870101 20010101Red blood cells unit 19870101 20010101Washed red blood cells unit 19870101 19870101Frozen plasma, pooled, sd 20000101 20010101Platelets leukocytes reduced 20010101 20010101Platelets, irradiated 20010101 20010101Platelets leukoreduced irrad 20010101 20010101Platelets, pheresis 20010101 20010101Platelet pheres leukoreduced 20010101 20010101Platelet pheresis irradiated 20010101 20010101Plate pheres leukoredu irrad 20010101 20010101RBC irradiated 20010101 20010101RBC deglycerolized 20010101 20010101RBC leukoreduced irradiated 20010101 20010101Albumin (human),5%, 50ml 20010101 20010101Plasma protein fract,5%,50ml 20010101 20010101Cryoprecipitatereducedplasma 20010101 20010101Albumin (human), 5%, 250 ml 20020101 20020101Albumin (human), 25%, 20 ml 20020101 20020101Albumin (human), 25%, 50ml 20020101 20020101Plasmaprotein fract,5%,250ml 20020101 20020101Granulocytes, pheresis unit 20020101 20020101Blood, l/r, cmv-neg 20040101 20040101Platelets, hla-m, l/r, unit 20040101 20040101Plt, pher, l/r cmv-neg, irr 20040101 20040101Blood, l/r, froz/degly/wash 20040101 20040101

Plt, aph/pher, l/r, cmv-neg 20040101 20040101Blood, l/r, irradiated 20040101 20040101RBC, frz/deg/wsh, l/r, irrad 20040101 20040101

RBC, l/r, cmv-neg, irrad 20040101 20040101

Query_110708

Page 465

Plasma, frz between 8-24hour 20040101 20040101Fr frz plasma donor retested 20040101 20040101One-way allow prorated miles 19870101 19920101

One-way allow prorated trip 19870101 19920101

Catheterize for urine spec 19990101 19990101

Urine specimen collect mult 19850101 19920101Cardiokymography 19890101 19910101Infusion ther other than che 19920101 19960101Chemo by other than infusion 19920101 19960101

Chemotherapy by infusion 19920101 19960101Chemo by both infusion and o 19920101 19960101

Obtaining screen pap smear 19920101 19960701

Set up port xray equipment 19930101 19960101Wet mounts/ w preparations 19940101 19940101Potassium hydroxide preps 19940101 19940101Pinworm examinations 19940101 19940101Fern test 19940101 19940101Post-coital mucous exam 19940101 19940101Non esrd epoetin alpha inj 20001231 20010101Darbepoetin alfa, non-esrd 20040101 20060101Azithromycin dihydrate, oral 19960701 20020701Diphenhydramine HCl 50mg 19980401 19980401

Prochlorperazine maleate 5mg 19980401 19980401

Prochlorperazine maleate10mg 19980401 19980401

Granisetron hcl 1 mg oral 19980401 20090101

Dronabinol 2.5mg oral 19980401 19980401

Dronabinol 5mg oral 19980401 19980401

Promethazine HCl 12.5mg oral 19980401 19980401

Promethazine HCl 25 mg oral 19980401 19980401

Chlorpromazine HCl 10mg oral 19980401 19980401

Chlorpromazine HCl 25mg oral 19980401 19980401

Trimethobenzamide HCl 250mg 19980401 19980401

Query_110708

Page 466

Thiethylperazine maleate10mg 19980401 19980401

Perphenazine 4mg oral 19980401 19980401

Perphenazine 8mg oral 19980401 19980401

Hydroxyzine pamoate 25mg 19980401 19980401

Hydroxyzine pamoate 50mg 19980401 19980401

Ondansetron hcl 8 mg oral 19980401 20090101

Dolasetron mesylate oral 19980401 19980401

Unspecified oral anti-emetic 19980401 19980401

Factor viia recombinant 20000101 20060101Driver pneumatic vad, rep 20051001 20051001Microprcsr cu elec vad, rep 20051001 20051001

Microprcsr cu combo vad, rep 20051001 20051001

Monitor elec vad, rep 20051001 20051001

Monitor elec or comb vad rep 20051001 20051001

Monitor cable elec vad, rep 20051001 20051001

Mon cable elec/pneum vad rep 20051001 20051001

Leads any type vad, rep only 20051001 20051001

Pwr pack base elec vad, rep 20051001 20051001

Pwr pck base combo vad, rep 20051001 20051001

Emr pwr source elec vad, rep 20051001 20051001

Emr pwr source combo vad rep 20051001 20051001

Emr pwr cbl elec vad, rep 20051001 20051001

Emr pwr cbl combo vad, rep 20051001 20051001

Emr hd pmp elec/combo, rep 20051001 20051001

Charger elec/combo vad, rep 20051001 20051001

Battery elec/combo vad, rep 20051001 20051001

Bat clps elec/comb vad, rep 20051001 20051001

Query_110708

Page 467

Holster elec/combo vad, rep 20051001 20051001

Belt/vest elec/combo vad rep 20051001 20051001

Filters elec/combo vad, rep 20051001 20051001

Shwr cov elec/combo vad, rep 20051001 20051001

Mobility cart pneum vad, rep 20051001 20051001Battery pneum vad replacemnt 20051001 20051001Pwr adpt pneum vad, rep veh 20051001 20051001

Miscl supply/accessory vad 20051001 20051001Dispens fee immunosupressive 20060101 20060101

Sup fee antiem,antica,immuno 20060101 20060101

Px sup fee anti-can sub pres 20060101 20090101

Disp fee inhal drugs/30 days 20060101 20060101Disp fee inhal drugs/90 days 20060101 20060101Sermorelin acetate injection 20060101 20060101Ntiol category 1 19990701 20050701

Ntiol category 2 19990701 20050701

Ntiol category 3 19990701 20060227Ntiol category 4 19990701 20031001Ntiol category 5 19990701 20031001Oral cabergoline 0.5 mg 20000701 20060101Elliotts b solution per ml 20000701 20060101Aprotinin, 10,000 kiu 20000701 20060101Bladder calculi irrig sol 20000701 20070101

Corticorelin ovine triflutat 20000701 20060101Digoxin immune fab (ovine) 20000701 20060101Ethanolamine oleate 100 mg 20000701 20060101Fomepizole, 15 mg 20000701 20060101Fosphenytoin, 50 mg 20000701 20070101Hemin, per 1 mg 20000701 20060101Pegademase bovine, 25 iu 20000701 20060101Pentastarch 10% solution 20000701 20060101Sermorelin acetate, 0.5 mg 20000701 20060101Teniposide, 50 mg 20000701 20070101Urofollitropin, 75 iu 20000701 20060101Basiliximab 20000701 20060101Histrelin acetate 20000701 20060101Lepirudin 20000701 20060101VonWillebrandFactrCmplxperIU 20000701 20060101Rubidium RB-82 20030101 20060101Brachytherapy Radioelements 20000701 20050101Gallium ga 67 20000701 20060101Technetium tc99m bicisate 20000701 20060101

Xenon xe 133 20000701 20060101Technetium tc99m mertiatide 20000701 20060101

Technetium tc99m glucepatate 20000701 20060101

Sodium phosphate p32 20000701 20060101

Query_110708

Page 468

Indium 111-in pentetreotide 20000701 20060101

Technetium tc99m oxidronate 20000701 20060101

Technetium tc99mlabeledrbcs 20000701 20060101

Chromic phosphate p32 20000701 20060101

Cyanocobalamin cobalt co57 20000701 20060101

Telehealth facility fee 20011001 20011001ALS emer trans no ALS serv 20020401 20060401ALS nonemer trans no ALS ser 20020401 20060401IM inj interferon beta 1-a 20030101 20030101Subc inj interferon beta-1a 20030101 20030101Collagen skin test 20030401 20041001Cast sup body cast plaster 20010701 20010701Cast sup body cast fiberglas 20010701 20010701Cast sup shoulder cast plstr 20010701 20010701Cast sup shoulder cast fbrgl 20010701 20010701Cast sup long arm adult plst 20010701 20010701Cast sup long arm adult fbrg 20010701 20010701Cast sup long arm ped plster 20010701 20010701Cast sup long arm ped fbrgls 20010701 20010701Cast sup sht arm adult plstr 20010701 20010701Cast sup sht arm adult fbrgl 20010701 20010701Cast sup sht arm ped plaster 20010701 20010701Cast sup sht arm ped fbrglas 20010701 20010701Cast sup gauntlet plaster 20010701 20010701

Cast sup gauntlet fiberglass 20010701 20010701

Cast sup gauntlet ped plster 20010701 20010701

Cast sup gauntlet ped fbrgls 20010701 20010701

Cast sup lng arm splint plst 20010701 20010701Cast sup lng arm splint fbrg 20010701 20010701Cast sup lng arm splnt ped p 20010701 20010701Cast sup lng arm splnt ped f 20010701 20010701Cast sup sht arm splint plst 20010701 20010701Cast sup sht arm splint fbrg 20010701 20010701Cast sup sht arm splnt ped p 20010701 20010701Cast sup sht arm splnt ped f 20010701 20010701Cast sup hip spica plaster 20010701 20010701Cast sup hip spica fiberglas 20010701 20010701Cast sup hip spica ped plstr 20010701 20010701Cast sup hip spica ped fbrgl 20010701 20010701Cast sup long leg plaster 20010701 20010701Cast sup long leg fiberglass 20010701 20010701Cast sup lng leg ped plaster 20010701 20010701Cast sup lng leg ped fbrgls 20010701 20010701Cast sup lng leg cylinder pl 20010701 20010701Cast sup lng leg cylinder fb 20010701 20010701Cast sup lngleg cylndr ped p 20010701 20010701Cast sup lngleg cylndr ped f 20010701 20010701Cast sup shrt leg plaster 20010701 20010701Cast sup shrt leg fiberglass 20010701 20010701Cast sup shrt leg ped plster 20010701 20010701Cast sup shrt leg ped fbrgls 20010701 20010701Cast sup lng leg splnt plstr 20010701 20010701

Query_110708

Page 469

Cast sup lng leg splnt fbrgl 20010701 20010701Cast sup lng leg splnt ped p 20010701 20010701Cast sup lng leg splnt ped f 20010701 20010701Cast sup sht leg splnt plstr 20010701 20010701Cast sup sht leg splnt fbrgl 20010701 20010701Cast sup sht leg splnt ped p 20010701 20010701Cast sup sht leg splnt ped f 20010701 20010701Finger splint, static 20010701 20010701Cast supplies unlisted 20010701 20010701Splint supplies misc 20010701 20010701

Darbepoetin alfa, esrd use 20040101 20060101Epoetin alfa, esrd use 20040101 20060101Acyclovir, 5 mg 20031001 20060101Dopamine hcl, 40 mg 20031001 20060101Treprostinil, 1 mg 20031001 20060101Natalizumab injection 20050101 20080101Iloprost non-comp unit dose 20050701 20080101

Epoetin alfa, 100 units ESRD 20070101 20070101Drug/bio NOC part B drug CAP 20070101 20070101

Hyalgan/supartz inj per dose 20070101 20080101

Synvisc inj per dose 20070101 20080101Euflexxa inj per dose 20070101 20080101Orthovisc inj per dose 20070101 20080101Octagam injection 20070701 20080101

Gammagard liquid injection 20070701 20080101

Rhophylac injection 20070701 20080101

HepaGam B IM injection 20070701 20080101Flebogamma injection 20070701 20080101

Gamunex injection 20070701 20080101

Albuterol inh non-comp con 20070701 20080101

Albuterol inh non-comp u d 20070701 20080101

Reclast injection 20070701 20080101VWF complex, NOS 20080401 20090101

Inj IVIG privigen 500 mg 20080401 20090101

Inj iron dextran 20080401 20090101Formoterol fumarate, inh 20080401 20090101

Skin substitute, NOS 20090101 20090101Apligraf skin sub 20090101 20090101Oasis wound matrix skin sub 20090101 20090101Oasis burn matrix skin sub 20090101 20090101Integra BMWD skin sub 20090101 20090101

Integra DRT skin sub 20090101 20090101

Dermagraft skin sub 20090101 20090101

Query_110708

Page 470

Graftjacket skin sub 20090101 20090101Integra matrix skin sub 20090101 20090101Tissuemend skin sub 20090101 20090101Primatrix skin sub 20090101 20090101Gammagraft skin sub 20090101 20090101Cymetra allograft 20090101 20090101Graftjacket express allograf 20090101 20090101Integra flowable wound matri 20090101 20090101Hospice in patient home 20070101 20070101Hospice in assisted living 20070101 20070101Hospice in LT/non-skilled NF 20070101 20070101

Hospice in SNF 20070101 20070101Hospice, inpatient hospital 20070101 20070101Hospice in hospice facility 20070101 20070101Hospice in LTCH 20070101 20070101Hospice in inpatient psych 20070101 20070101Hospice care, NOS 20070101 20070101IVIG lyophil 1G 20050401 20060101IVIG lyophil 10 mg 20050401 20060101IVIG non-lyophil 1G 20050401 20060101IVIG non-lyophil 10 mg 20050401 20060101LOCM <=149 mg/ml iodine, 1ml 20050401 20080101LOCM 150-199mg/ml iodine,1ml 20050401 20080101LOCM 200-249mg/ml iodine,1ml 20050401 20080101LOCM 250-299mg/ml iodine,1ml 20050401 20080101LOCM 300-349mg/ml iodine,1ml 20050401 20080101LOCM 350-399mg/ml iodine,1ml 20050401 20080101LOCM >= 400 mg/ml iodine,1ml 20050401 20050401Inj Gad-base MR contrast,1ml 20050401 20080101Inj Fe-based MR contrast,1ml 20050401 20050401Oral MR contrast, 100 ml 20050401 20050401Inj perflexane lip micros,ml 20050401 20050401Inj octafluoropropane mic,ml 20050401 20050401Inj perflutren lip micros,ml 20050401 20050401HOCM <=149 mg/ml iodine, 1ml 20050701 20050701HOCM 150-199mg/ml iodine,1ml 20050701 20050701HOCM 200-249mg/ml iodine,1ml 20050701 20050701HOCM 250-299mg/ml iodine,1ml 20050701 20050701HOCM 300-349mg/ml iodine,1ml 20050701 20050701HOCM 350-399mg/ml iodine,1ml 20050701 20050701HOCM>= 400mg/ml iodine, 1ml 20050701 20050701

LOCM 100-199mg/ml iodine,1ml 20080101 20080101LOCM 200-299mg/ml iodine,1ml 20080101 20080101LOCM 300-399mg/ml iodine,1ml 20080101 20080101Transport portable x-ray 19820101 19980101

Transport port x-ray multipl 19860101 19980101

Transport portable EKG 19840101 19980101Butorphanol tartrate, nasal 20000101 20000101Tacrine hydrochloride, 10 mg 20000101 20000101Injection, amikacin sulfate 20000101 20050401Injection, aminocaproic acid 20000101 20000101Injection, bupivicaine hydro 20000101 20000101Injection, cefoperazone sod 20000101 20000101Injection, cimetidine hydroc 20000101 20000101Injection, famotidine, 20 mg 20000101 20000101Injection, metronidazole 20000101 20000101Injection, nafcillin sodium 20000101 20000101

Query_110708

Page 471

Injection, ofloxacin, 400 mg 20000101 20000101Injection, sulfamethoxazole 20000101 20000101Injection, ticarcillin disod 20000101 20000101Injection, acyclovir sodium 20000101 20060101Injection, amikacin sulfate 20000101 20060101Injection, aztreonam, 500 mg 20000101 20000101Injection, cefotetan disodiu 20000101 20000101Injection, clindamycin phosp 20000101 20000101Injection, fosphenytoin sodi 20000101 20000101Injection, pentamidine iseth 20000101 20000101Injection, piperacillin sodi 20000101 20000101Imatinib 100 mg 20020101 20081001Sildenafil citrate, 25 mg 20000101 20000101Granisetron 1mg 20020101 20010701

Hydromorphone 250 mg 20020101 20010701Morphine 500 mg 20020101 20010701Zidovudine, oral, 100 mg 20021001 20021001Bupropion HCL SR 60 tablets 20020401 20020401Inj, omalizumab 25 mg 20040101 20050401Mercaptopurine 50 mg 20020401 20020401Methadone oral 5mg 20041001 20041001Inj treprostinil 0.5 mg 20030101 20060101Bevacizumab 100 mg 20040701 20060701Tretinoin topical 5 g 20040701 20040701Ziconotide inthrathecal 1mcg 20050701 20060101Inj menotropins 75 iu 20020401 20020401Inj follitropin alfa 75 iu 20020401 20020401Inj follitropin beta 75 iu 20020401 20020401Inj ganirelix acetat 250 mcg 20020401 20020401Histrelin implant 20050701 20060401Clozapine, 25 mg 20030401 20030401Didanosine, 25 mg 20030401 20030401Finasteride, 5 mg 20030401 20030401Minoxidil, 10 mg 20030401 20030401Saquinavir, 200 mg 20030401 20030401Zalcitabine, 0.375 mg 20030401 20081001Colistimethate inh sol mg 20050401 20050401

Aztreonam, inh sol gram 20050401 20090101

Peg interferon alfa-2A/180 20050701 20050701Peg interferon alfa-2b/10 20050701 20050701Alglucosidase alfa 20 mg 20061001 20080101Epoprostenol dilutant 20020101 20020101Exemestane, 25 mg 20010101 20010101Becaplermin gel 1%, 0.5 gm 20010101 20010101Injection laronidase 20040401 20050401Injection agalsidase 20040401 20050401Dextroamphetamine 20040401 20040401Calcitrol 20040401 20040401Injection efalizumab 20040401 20040401Injection pantroprazole 20040401 20040401Inj olanzapine 2.5mg 20041001 20041001Inj apomorphine HCl 1mg 20041001 20070401Inj azacitidine 100mg 20041001 20060101Anastrozole 1 mg 20020101 20020101Bumetanide 0.5 mg 20020101 20020101Chlorambucil 2 mg 20020101 20020101Dexamethasone 4 mg 20020101 20060101Dolasetron 50 mg 20020101 20020101

Query_110708

Page 472

Flutamide 125 mg 20020101 20020101Hydroxyurea 500 mg 20020101 20020101Levamisole 50 mg 20020101 20020101Lomustine 10 mg 20020101 20020101Megestrol 20 mg 20020101 20020101Etonogestrel implant system 20070101 20080101Ondansetron 4 mg 20020101 20020101

Procarbazine 5 mg 20020101 20020101Prochlorperazine 5 mg 20020101 20020101

Tamoxifen 10 mg 20020101 20020101Testosterone pellet 75 mg 20020101 20020101Mifepristone, oral, 200 mg 20010101 20010101Misoprostol, oral, 200 mcg 20010101 20010101Vitamin suppl 100 caps 20040401 20040401Pneumo vaccine 5-9 yrs 20030101 20030101

Poly-l-lactic acid 1ml face 20050101 20050101

Prenatal vitamins 30 day 20050401 20050401Inj pegaptanib 0.3 mg 20050701 20060701Med abortion inc all ex drug 20010101 20010101

Partial hospitalization serv 20021001 20021001Paramedicintercep nonhospals 20021001 20021001

Paramed intrcept nonvol 20020101 20020101WC van mileage per mi 20020101 20020101Nonemerg transp mileage 20020101 20020401Medical conference by physic 20010101 20010101

Medical conference, 60 min 20010101 20010101

Comp geriatr assmt team 20020101 20020101

Hospice refer visit nonmd 20020101 20020101

End of life counseling 20050101 20050101

H&P for surgery 20020101 20020101

Genetic counsel 15 mins 20050701 20050701Home std case rate 30 days 20070401 20070401

Home hospice case 30 days 20070401 20070401

Home episodic case 30 days 20070401 20070401

MD home visit outside cap 20070401 20070401Nurse practr visit outs cap 20070401 20070401Completed EPSDT 20020101 20020101

Hospitalist visit 20020101 20020101

Query_110708

Page 473

Disease management program 20021001 20021001Follow-up/reassessment 20021001 20061001Disease mgmt per diem 20030701 20030701RN telephone calls to DMP 20021001 20021001

Lifestyle mod 1st stage 20020101 20020101

Lifestyle mod 2 or 3 stage 20020101 20020101

Lifestyle mod 4th stage 20020101 20020101

Home ecg monitrng global 24h 20060401 20060401

Home ecg monitrng tech 24hr 20060401 20060401

Home ecg monitrng prof 24hr 20060401 20060401

Rout foot care per visit 20020401 20020401

Impression casting ft 20020101 20020101

Global eswl kidney 20020101 20020101

Dispos cont lens 20010701 20010701Singl prscrp lens 20010701 20010701Bifoc prscp lens 20010701 20010701Trifoc prscrp lens 20010701 20010701Non-prscrp lens 20010701 20010701Daily cont lens 20010701 20010701Color cont lens 20010701 20010701Scleral lens liquid bandage 20041001 20041001Safety frames 20010701 20010701Sunglass frames 20010701 20010701Polycarb lens 20010701 20010701Nonstnd lens 20010701 20010701Misc integral lens serv 20010701 20010701Comp cont lens eval 20010701 20010701New lenses in pts old frame 20050401 20050401Screening proctoscopy 20000101 20000101Digital rectal examination, 20000101 20000101Annual gynecological examina 20000101 20000101Annual gynecological examina 20000101 20000101Ann breast exam 20050701 20050701

Audiometry for hearing aid 20040401 20040401

Routine ophthalmological exa 20000101 20000101Routine ophthalmological exa 20000101 20000101Phys exam for college 20020101 20020101

Digital screening retina 20050401 20050401

Query_110708

Page 474

Removal of sutures 20010101 20010101

Laser in situ keratomileusis 20000101 20000101Photorefractive keratectomy 20000101 20000101Phototherap keratect 20010701 20010701Computerized corneal topogra 20010101 20070401Deluxe item 20010701 20010701Custom item 20010701 20010701IV tubing extension set 20010101 20010101Non-pvc intravenous administ 20010101 20010101

Inhal nitric oxide neonate 20020101 20070401

Gluc monitor purchase 20020101 20020101

Gluc monitor rental 20020101 20020101

Cranial remolding orthosis 20021001 20070101

Transplantation of small int 20000101 20000101Transplantation of multivisc 20000101 20000101Harvesting of donor multivis 20000101 20000101

Lobar lung transplantation 20010101 20010101Donor lobectomy (lung) 20010101 20010101Simult panc kidn trans 20010701 20010701Breast GAP flap reconst 20070701 20070701

Breast ”stacked” DIEP/GAP 20070701 20070701

Breast DIEP or SIEA flap 20060101 20070701

Cysto laser tx ureteral calc 20031001 20031001

Lap inc/vent hernia repair 20051001 20090101Lap umbilical hernia repair 20051001 20090101Lap mesh implant hern rep 20051001 20090101

Lap supracerv hysterectomy 20060101 20070701

Lap esophagomyotomy 20060101 20060101Laup 20020101 20020101Lap adjustable gastric band 20040401 20060101

Adjustment gastric band 20040401 20040401

Open cryosurg renal 20030401 20060101Perc cryosurg renal 20030401 20060101Transcath emboliz microspher 20040101 20040101

Islet cell tissue transplant 20010101 20010101Adrenal tissue transplant 20010101 20010101Adoptive immunotherapy 20020401 20020401

Query_110708

Page 475

Knee arthroscp harv 20010701 20010701Arthrosc sh tenodesis biceps 20051001 20080101Periacetabular osteotomy 20020101 20020101Arthroereisis, subtalar 20051001 20051001Total hip resurfacing 20081001 20081001

Low density lipoprotein(LDL) 20010101 20010101

Neurolysis interspace foot 20040101 20090101

Cord blood harvesting 20010101 20010101Cord blood-derived stem-cell 20010101 20010101BMT harv/transpl 28d pkg 20020101 20040401

Solid organ transpl pkg 20040401 20040401

Echosclerotherapy 20010101 20010101Minimally invasive direct co 20000101 20000101

Minimally invasive direct co 20000101 20000101




Implant gastric stim 20031001 20070401UGI endoscopy inj implant 20041001 20060101

Myringotomy laser-assist 20040101 20040101Implant semi-imp hear 20031001 20031001

Implant auditory brain imp 20031001 20031001Uterine artery emboliz 20020101 20070401Induced abortion 17-24 weeks 20020101 20070101Abortion maternal indic>=25w 20021001 20070101Induced abortion 25-28 wks 20021001 20070101Induced abortion 29-31 wks 20021001 20070101Induced abortion 32 or more 20021001 20070101Insertion vaginal cylinder 20081001 20081001

Arthroscopy, shoulder, surgi 20000101 20000101Hip core decompression 20061001 20061001Chemodenervation of abductor 20010101 20010101Chemodenerv adduct vocal 20020101 20020101

Query_110708

Page 476

Nasal endoscop po debrid 20020101 20020101

Endosc balloon sinuplasty 20070101 20070101

Decompress disc RF lumbar 20050101 20050101

Diskectomy, anterior, with d 20000101 20000101

Diskectomy, anterior, with d 20000101 20000101

Vertebroplast cerv 1st 20020101 20020101

Vertebroplast cerv addl 20020101 20020101

Kyphoplasty, first vertebra 20040101 20060401Kyphoplasty, each addl 20040101 20060401

Fetal surg congen hernia 20020101 20020401

Fetal surg urin trac obstr 20020101 20020101Fetal surg cong cyst malf 20020101 20020101

Fetal surg pulmon sequest 20020101 20020101

Fetal surg myelomeningo 20020101 20020101Fetal surg sacrococ teratoma 20020401 20020401Fetal surg noc 20020101 20020101

Fetoscop laser ther TTTS 20020101 20020101Robotic surgical system 20050701 20050701

Bilat dil retinal exam 20030401 20030401Eval self-assess depression 20050401 20050401Stat lab 20020101 20020101Stat lab home/nf 20020101 20020101

Free beta HCG 20070401 20080101Newborn metabolic screening 20010101 20010101

Maternal triple screen test 20030701 20030701

Maternal serum quad screen 20051001 20051001

PAMG-1 rapid assay for ROM 20080401 20080401

Eosinophil blood count 20020101 20020101HIV-1 antibody testing of or 20000101 20000101Saliva test, hormone level; 20000101 20000101Saliva test, hormone level; 20000101 20000101Antisperm antibodies test 20021001 20021001NMP-22 assay 20020101 20060401Gastrointestinal fat absorpt 20010101 20010101Circulating tumor cell test 20090101 20090101Genetic testing ALS 20070701 20070701BRCA1 gene anal 20010701 20010701BRCA2 gene anal 20010701 20010701Comp BRCA1/BRCA2 20030401 20030401

Query_110708

Page 477

Sing mutation brst/ovar 20030401 20030401

3 mutation brst/ovar 20030401 20030401

Comp MLH1 gene 20030401 20030401Comp MLH2 gene 20030401 20030401Gene test HNPCC comp 20020101 20020101

Gene test HNPCC single 20020101 20020101

Comp APC sequence 20030401 20030401

Sing mutation APC 20030401 20030401

Gene test cystic fibrosis 20020101 20020101Gene test hemochromato 20020101 20020101DNA analysis RET-oncogene 20030701 20030701

Gene test retinoblastoma 20030701 20030701Gene test Hippel-Lindau 20030701 20030701DNA analysis factor v 20030701 20030701DNA analysis deafness 20030701 20030701

Gene test alpha-thalassemia 20030701 20030701Gene test beta-thalassemia 20030701 20030701Gene test Tay-Sachs 20030701 20030701Gene test Gaucher 20030701 20030701Gene test Niemann-Pick 20030701 20030701Gene test sickle cell 20030701 20030701Gene test canavan 20030701 20030701DNA analysis APOE alzheimer 20030701 20030701Gene test myo musclr dyst 20040101 20040101Gene profile panel breast 20060101 20060101

Gene test presenilin-1 gene 20070101 20070101Genet test cardiac ion-comp 20081001 20081001

Genetic test brugada 20081001 20081001

Genet test cardiac ion-spec 20081001 20081001

Fecal DNA analysis 20040401 20040401Surface EMG 20010701 20010701Ballistocardiogram 20010101 20010101Masters two step 20010101 20010101Auto handheld diag nerv test 20070701 20070701

Interim labor facility globa 20020401 20020401IVF package 20020101 20020101

Compl GIFT case rate 20020401 20020401Compl ZIFT case rate 20020401 20020401Complete IVF nos case rate 20020101 20020401

Query_110708

Page 478

Frozen IVF case rate 20020101 20020101IVF canc a stim case rate 20020401 20020401F EMB trns canc case rate 20020101 20020101IVF canc a aspir case rate 20020101 20020101IVF canc p aspir case rate 20020101 20020101Asst oocyte fert case rate 20020101 20020101Incompl donor egg case rate 20020401 20020401Donor serv IVF case rate 20020101 20020101Procure donor sperm 20020101 20020101Store prev froz embryos 20020101 20020101Microsurg epi sperm asp 20020101 20020101Sperm procure init visit 20020101 20020101Sperm procure subs visit 20020101 20020101Stimulated IUI case rate 20020401 20020401Intravag cult case rate 20020401 20070101Cryo embryo transf case rate 20020401 20020401Monit store cryo embryo 30 d 20020401 20020401Ovulation mgmt per cycle 20050101 20050101

Insert levonorgestrel ius 20010701 20010701Contracept IUD 20020101 20020101

Nicotine patch legend 20020101 20020101Nicotine patch nonlegend 20020101 20020101Contraceptive pills for bc 20020401 20020401Smoking cessation gum 20020401 20020401Prescription drug, generic 20010101 20010101Prescription drug,brand name 20010101 200101015% dextrose and 0.45% saline 20010101 200101015% dextrose in lactated ring 20010101 200101015% dextrose with potassium 20010101 200101015%dextrose/0.45%saline1000ml 20010101 20010101

D5W/0.45NS w KCl and MGS04 20010101 20010101

HIT routine device maint 20020101 20020101

HIT device repair 20020101 20020101Adult daycare services 15min 20030101 20030101Adult day care per half day 20030101 20030101Adult day care per diem 20030101 20030101Centerbased day care perdiem 20030101 20030101Homecare train pt 15 min 20030401 20030401Homecare train pt session 20030401 20030401Family homecare training 15m 20030101 20030101Family homecare train/sessio 20030101 20030101Nonfamily homecare train/15m 20030101 20030101Nonfamily HC train/session 20030101 20030101Chore services per 15 min 20030101 20030101Chore services per diem 20030101 20030101Attendant care service /15m 20030101 20030101Attendant care service /diem 20030101 20030101Homaker service nos per 15m 20030101 20030101Homemaker service nos /diem 20030101 20030101Adult companioncare per 15m 20030101 20030101Adult companioncare per diem 20030101 20030101Adult foster care per diem 20030101 20030101Adult foster care per month 20030101 20030101Child fostercare th per diem 20030101 20030101Ther fostercare child /month 20030101 20030101Unskilled respite care /15m 20030101 20030101

Query_110708

Page 479

Unskilled respitecare /diem 20030101 20030101Emer response sys instal&tst 20030101 20030101Emer rspns sys serv permonth 20030101 20030101

Emer rspns system purchase 20030101 20030101Home modifications per serv 20030101 20030101Homedelivered prepared meal 20030101 20030101Laundry serv,ext,prof,/order 20030101 20030101HH respiratory thrpy in eval 20030101 20030101HH respiratory thrpy nos/day 20030101 20030101Med reminder serv per month 20030101 20030101Wellness assessment by nonph 20030101 20030101Personal care item nos each 20030101 20030101HIT cath care noc 20020101 20020101

HIT simple cath care 20020101 20020101

HIT complex cath care 20020101 20020101

HIT interim cath care 20020101 20020101

HIT declotting kit 20020101 20020101

HIT cath repair kit 20020101 20020101HIT picc insert kit 20020101 20020101

HIT midline cath insert kit 20020101 20020101

HIT picc insert no supp 20020101 20020101

HIP midline cath insert kit 20020101 20060701

Insulin rapid 5 u 20031001 20031001Insulin most rapid 5 u 20031001 20031001Insulin intermed 5 u 20031001 20031001Insulin long acting 5 u 20031001 20031001Insulin reuse pen 1.5 ml 20031001 20031001Insulin reuse pen 3 ml 20031001 20031001Insulin cartridge 150 u 20031001 20031001Insulin cartridge 300 u 20031001 20031001Insulin dispos pen 1.5 ml 20031001 20031001Insulin dispos pen 3 ml 20031001 20031001Wholebody radiopharm trgcell 20030101 20050401Tantalum ring application 20020101 20020101

Magnetic source imaging 20000101 20000101mrcp 20010701 20010701Topographic brain mapping 20000101 20000101MRI low field 20020401 20020401Intraoperative radiation the 20000101 20000101Us guidance fetal reduct 20020101 20020101

Query_110708

Page 480

CAD of digital mammogr 20040101 20060701

Scintimammography 20010101 20010101

Fluorine-18 fluorodeoxygluco 20010101 20010101

Electron beam computed tomog 20000101 20000101CT angiography coronary 20041001 20060401Wig (for medically-induced h 20000101 20060101Portable peak flow meter 20000101 20000101Asthma kit 20020101 20020101

Spacer without mask 20020101 20020101Spacer with mask 20020101 20020101Peak expiratory flow rate (p 20000101 20000101O2 contents gas cubic ft 20031001 20031001O2 contents liquid lb 20031001 20031001Flutter device 20020101 20020101Swivel adaptor 20020101 20020101Trach supply noc 20020101 20020101Electronic spirometer 20020101 20020101Mucus trap 20010101 20010101Oral orthotic for treatment 20000101 20060401

Mandib ortho repos device 20020401 20020401Haberman feeder 20020401 20020401Enuresis alarm 20050701 20050701Infect control supplies NOS 20040701 20040701Supplies for home delivery 20020101 20020101Custom gradient sleev/glov 20020101 20020101Ready gradient sleev/glov 20020101 20020101Custom grad sleeve med 20020101 20020101Custom grad sleeve heavy 20020101 20020101Ready gradient sleeve 20020101 20020101Custom grad glove med 20020101 20020101Custom grad glove heavy 20020101 20020101Ready gradient glove 20020101 20020101Ready gradient gauntlet 20020101 20020101Gradient pressure wrap 20020101 20020101Padding for comprssn bdg 20020101 20020101Compression bandage 20020101 20020101Interim splint upper extrem 20050401 20060101Splint digit 20020101 20020101Splint wrist or ankle 20020101 20020101Splint elbow 20020101 20020101Camisole post-mast 20030401 20030401100 insulin syringes 20020101 20020101Hippotherapy per session 20050401 20050401Low-level laser trmt 15 min 20040101 20040101

Complex lymphedema therapy, 20000101 20000101Pt or manip for maint 20030401 20030401

Resuscitation bag 20010101 20010101

Home uterine monitor with or 20000101 20000101Ultrafiltration monitor 20010101 20010101Automated EEG monitoring 20010101 20010101

Query_110708

Page 481

Digital subtraction angiogra 20000101 20060701

Paranasal sinus ultrasound 20000101 20000101Omnicardiogram/cardiointegra 20010101 20010101ESWL for gallstones 20020401 20020401

Procuren or other growth fac 20000101 20000101Coma stimulation per diem 20000101 20000101Medical supplies and equipme 20010101 20020101

Smoking cessation treatment 20000101 20000101Urgent care center global 20020101 20020101Services provided in urgent 20010101 20020101

Vertebral axial decompressio 20000101 20000101Canolith repositioning 20020401 20090101Home visit wound care 20041001 20041001Home phototherapy visit 20020101 20020101

CHF telemonitoring month 20020101 20020101

Back school visit 20020101 20020101Home health aide or certifie 20000101 20000101

Nursing care in home RN 20000101 20040101

Nursing care, in the home; b 20000101 20000101Respite care, in the home, p 20000101 20000101Hospice care, in the home, p 20000101 20000101Social work visit, in the ho 20000101 20000101Speech therapy, in the home, 20000101 20000101Occupational therapy, in the 20000101 20000101PT in the home per diem 20020101 20020101Diabetic Management Program, 20000101 20000101Diabetic Management Program, 20000101 20000101Insulin pump initiation 20020401 20020401Evaluation by ocularist 20020401 20020401Speech therapy, re-eval 20070701 20070701Home mgmt preterm labor 20020101 20020101

Home mgmt PPROM 20020101 20020101

Home mgmt gest hypertension 20020101 20020101

Hm postpar hyper per diem 20020101 20020101

Hm preeclamp per diem 20020101 20020101

Query_110708

Page 482

Hm gest dm per diem 20020101 20020101

HIT pain mgmt per diem 20020101 20020101

HIT cont pain per diem 20020101 20020101

HIT int pain per diem 20020101 20020101

HIT pain imp pump diem 20020101 20020101

HIT chemo per diem 20020101 20020101

HIT cont chem diem 20020101 20020101

HIT intermit chemo diem 20020101 20020101

HT hemodialysis diem 20030701 20030701

HIT cont anticoag diem 20020101 20020101

HIT immunotherapy diem 20020101 20020101

HIT periton dialysis diem 20020101 20020101

HIT enteral per diem 20020101 20020101

HIT enteral grav diem 20020101 20020101

HIT enteral pump diem 20020101 20020101

HIT enteral bolus nurs 20020101 20020101

HIT anti-hemophil diem 20020101 20020101

HIT alpha-1-proteinas diem 20020101 20020101

Query_110708

Page 483

HIT longterm infusion diem 20020101 20030101

HIT sympathomim diem 20020101 20020101

HIT tocolysis diem 20020101 20020101

HIT cont antiemetic diem 20020101 20070401

HIT cont insulin diem 20020101 20020101

HIT chelation diem 20020101 20020101

HIT enzyme replace diem 20020101 20020101

HIT anti-tnf per diem 20020101 20020101

HIT diuretic infus diem 20020101 20020101

HIT anti-spasmotic diem 20020101 20041001

HIT tpn total diem 20020101 20020101

HIT tpn 1 liter diem 20020101 20020101



HIT tpn over 3l diem 20020101 20020101

Query_110708

Page 484

HT inj antiemetic diem 20020101 20020101

HT inj anticoag diem 20020101 20020101

HIT hydra total diem 20020101 20020101

HIT hydra 1 liter diem 20020101 20020101



HIT hydra over 3l diem 20020101 20020101

HIT noc per diem 20020101 20020101

HIT high risk/escort 20020101 20020101

Anticoag clinic per session 20020401 20020401

Pharmacy comp/disp serv 20020401 20020401Medical food oral 100% nutr 20090101 20090101

Mod solid food suppl 20030401 20030401Medical foods for inborn err 20010101 20010101Lamaze class 20020401 20020401Childbirth refresher class 20020401 20020401Cesarean birth class 20020401 20020401VBAC class 20020401 20020401Asthma education 20020101 20020101Birthing class 20020101 20020101Lactation class 20020101 20020101Parenting class 20020401 20020401PT education noc individ 20020101 20020101

PT education noc group 20020101 20020101

Infant safety class 20020401 20020401Weight mgmt class 20020401 20020401Exercise class 20020401 20020401Nutrition class 20020401 20020401Smoking cessation class 20020401 20020401Stress mgmt class 20020401 20020401Diabetic Management Program, 20000101 20000101

Query_110708

Page 485

Diabetic Management Program, 20000101 20000101Diabetic Management Program, 20000101 20000101Nutritional counseling, diet 20000101 20000101Cardiac rehabilitation progr 20000101 20000101Pulmonary rehabilitation pro 20000101 20000101Enterostomal therapy by a re 20000101 20000101

Ambulatory setting substance 20000101 20000101

Vestibular rehab per diem 20031001 20031001Intensive outpatient psychia 20000101 20000101Family stabilization 15 min 20050101 20050101Crisis intervention per hour 20020701 20020701Crisis intervention mental h 20000101 20000101HIT corticosteroid/diem 20020701 20020701

HIT antibiotic total diem 20020101 20020101

HIT antibiotic q3h diem 20020101 20020101






Venipuncture home/snf 20020101 20020101

HT hem horm inj diem 20020101 20020101

HIT blood products diem 20020101 20020101

HT inj noc per diem 20020101 20020101

HT inj growth horm diem 20020101 20020101

Query_110708

Page 486

HIT inj interferon diem 20020101 20020101

HT inj hormone diem 20020101 20020101

HT inj palivizumab diem 20030101 20030101

HT irrigation diem 20030101 20030101

HT pharm per hour 20020101 20020101

Christian Sci Pract visit 20020701 20020701

Health club membership yr 20020401 20020401Transplant related per diem 20020401 20020401Lodging per diem 20040401 20040401Meals per diem 20040401 20040401Med record copy admin 20020101 20020101Med record copy per page 20020101 20020101Not medically necessary svc 20020101 20020101

Serv part of phase I trial 20040401 20040401Services outside US 20020101 20020101

Services provided as part of 20000101 20000101Services provided as part of 20000101 20000101Transportation costs to and 20000101 20000101

Lodging costs (e.g. hotel ch 20000101 20000101

Meals for clinical trial par 20000101 20000101Sales tax 20000101 20000101Private duty/independent nsg 20010701 20010701Nursing assessment/evaluatn 20010701 20010701RN services up to 15 minutes 20010701 20010701LPN/LVN services up to 15min 20010701 20010701Nsg aide service up to 15min 20010701 20010701Respite care service 15 min 20010701 20010701Family/Couple Counseling 20010701 20010701Treatment Plan Development 20010701 20010701

Child Sitting Services 20010701 20010701

Meals when Receive Services 20010701 20010701

Alcohol/Substance Abuse Skil 20010701 20010701Sign Lang/Oral Interpreter 20010701 20030101Telehealth transmit, per min 20010701 20010701Clinic service 20020101 20020101Case management 20020701 20020701Targeted case management 20020701 20020701School-based IEP ser bundled 20020701 20020701Personal care ser per 15 min 20020701 20020701

Query_110708

Page 487

Personal care ser per diem 20020701 20020701

HH Aide or cn aide per visit 20020701 20020701Contracted services per day 20030101 20030101

Program intake assessment 20030101 20030101

Team evaluation & management 20030101 20030101

Ped compr care pkg, per diem 20030101 20030101

Ped compr care pkg, per hour 20030101 20030101

Family training & counseling 20030101 20030101Home environment assessment 20030101 20030101

Dwelling lead investigation 20030101 20030101

RN home care per diem 20030101 20030101LPN home care per diem 20030101 20030101Medication admin visit 20030101 20030101

Med admin, not oral/inject 20070401 20070401

NOC retail items andsupplies 20030101 20030101

N-et; patient attend/escort 20020401 20020401N-et; per diem 20020401 20020401N-et; encounter/trip 20020401 20020401N-et; commerc carrier pass 20020401 20020401N-et; stretcher van 20020401 20040701Amb response & trt, no trans 20020401 20060101Non-emer transport wait time 20030101 20030101

PASRR Level I 20030401 20030401

PASRR Level II 20030401 20030401

Habil ed waiver, per diem 20031001 20031001Habil ed waiver per hour 20031001 20031001Habil prevoc waiver, per d 20031001 20031001Habil prevoc waiver per hr 20031001 20031001Habil res waiver per diem 20031001 20031001Habil res waiver 15 min 20031001 20031001Habil sup empl waiver/diem 20031001 20031001Habil sup empl waiver 15min 20031001 20031001Day habil waiver per diem 20031001 20031001Day habil waiver per 15 min 20031001 20031001Case management, per month 20031001 20031001Targeted case mgmt per month 20031001 20031001Serv asmnt/care plan waiver 20031001 20031001Waiver service, nos 20031001 20031001Special childcare waiver/d 20031001 20031001

Query_110708

Page 488

Spec childcare waiver 15 min 20031001 20031001Special supply, nos waiver 20031001 20031001Special med equip, noswaiver 20031001 20031001Assist living waiver/month 20031001 20031001Assist living waiver/diem 20031001 20031001Res care, nos waiver/month 20031001 20031001Res, nos waiver per diem 20031001 20031001Crisis interven waiver/diem 20031001 20031001Utility services waiver 20031001 20031001

Camp overnite waiver/session 20031001 20031001Camp day waiver/session 20031001 20031001Comm trans waiver/service 20031001 20031001Vehicle mod waiver/service 20031001 20031001Financial mgt waiver/15min 20031001 20031001Support broker waiver/15 min 20031001 20031001Hospice routine home care 20031001 20031001Hospice continuous home care 20031001 20031001Hospice respite care 20031001 20031001Hospice general care 20031001 20031001Hospice long term care, r&b 20031001 20031001Bh ltc res r&b, per diem 20031001 20031001

N-ET; stretcher van, mileage 20040701 20040701Breast milk proc/store/dist 20040101 20040101Adult size brief/diaper sm 20050101 20050101Adult size brief/diaper med 20050101 20050101Adult size brief/diaper lg 20050101 20050101Adult size brief/diaper xl 20050101 20050101Adult size pull-on sm 20050101 20050101

Adult size pull-on med 20050101 20050101

Adult size pull-on lg 20050101 20050101

Adult size pull-on xl 20050101 20050101

Ped size brief/diaper sm/med 20050101 20050101

Ped size brief/diaper lg 20050101 20050101Ped size pull-on sm/med 20050101 20050101

Ped size pull-on lg 20050101 20050101

Youth size brief/diaper 20050101 20050101Youth size pull-on 20050101 20050101Disposable liner/shield/pad 20050101 20050101Reusable pull-on any size 20050101 20050101Reusable underpad bed size 20050101 20050101Diaper serv reusable diaper 20050101 20050101Reuse diaper/brief any size 20050101 20050101Reusable underpad chair size 20050101 20050101Large disposable underpad 20050101 20050101Small disposable underpad 20050101 20050101Disp bariatric brief/diaper 20070101 20070101Position seat spec orth need 20040101 20070101Supply, nos 20040101 20040101Vision svcs frames purchases 19850101 20031001Eyeglasses delux frames 19920101 20031001Lens spher single plano 4.00 19850101 20031001

Query_110708

Page 489

Single visn sphere 4.12-7.00 19850101 20031001Singl visn sphere 7.12-20.00 19850101 20031001Spherocylindr 4.00d/12-2.00d 19850101 20031001

Spherocylindr 4.00d/2.12-4d 19850101 20031001

Spherocylinder 4.00d/4.25-6d 19850101 20031001

Spherocylinder 4.00d/>6.00d 19850101 20031001

Spherocylinder 4.25d/12-2d 19850101 20031001



Spherocylinder 4.25d/over 6d 19850101 20031001

Spherocylindr 7.25d/.25-2.25 19850101 20031001



Spherocylinder over 12.00d 19850101 20031001Lens lenticular bifocal 19850101 20031001Lens aniseikonic single 19850101 20031001Lenticular lens, single 20040101 20040101Lens single vision not oth c 19850101 20031001Lens spher bifoc plano 4.00d 19850101 20031001Lens sphere bifocal 4.12-7.0 19850101 20031001Lens sphere bifocal 7.12-20. 19850101 20031001Lens sphcyl bifocal 4.00d/.1 19850101 20031001

Lens sphcy bifocal 4.00d/2.1 19850101 20031001

Lens sphcy bifocal 4.00d/4.2 19850101 20031001

Lens sphcy bifocal 4.00d/ove 19850101 20031001

Lens sphcy bifocal 4.25-7d/. 19850101 20031001

Lens sphcy bifocal 4.25-7/2. 19850101 20031001

Lens sphcy bifocal 4.25-7/4. 19850101 20031001

Lens sphcy bifocal 4.25-7/ov 19850101 20031001

Lens sphcy bifo 7.25-12/.25- 19850101 20031001

Lens sphcyl bifo 7.25-12/2.2 19850101 20031001

Lens sphcyl bifo 7.25-12/4.2 19850101 20031001

Lens sphcyl bifocal over 12. 19850101 20031001Lens lenticular bifocal 19850101 20031001Lens aniseikonic bifocal 19850101 20031001Lens bifocal seg width over 19850101 20031001Lens bifocal add over 3.25d 19850101 20031001Lenticular lens, bifocal 20040101 20040101Lens bifocal speciality 19850101 20031001

Query_110708

Page 490

Lens sphere trifocal 4.00d 19850101 20031001Lens sphere trifocal 4.12-7. 19850101 20031001Lens sphere trifocal 7.12-20 19850101 20031001Lens sphcy trifocal 4.0/.12- 19850101 20031001

Lens sphcy trifocal 4.0/2.25 19850101 20031001

Lens sphcy trifocal 4.0/4.25 19850101 20031001

Lens sphcyl trifocal 4.00/>6 19850101 20031001

Lens sphcy trifocal 4.25-7/. 19850101 20031001

Lens sphc trifocal 4.25-7/2. 19850101 20031001

Lens sphc trifocal 4.25-7/4. 19850101 20031001

Lens sphc trifocal 4.25-7/>6 19850101 20031001

Lens sphc trifo 7.25-12/.25- 19850101 20031001

Lens sphc trifo 7.25-12/2.25 19850101 20031001

Lens sphc trifo 7.25-12/4.25 19850101 20031001

Lens sphcyl trifocal over 12 19850101 20031001Lens lenticular trifocal 19850101 20031001Lens aniseikonic trifocal 19850101 20031001Lens trifocal seg width > 28 19850101 20031001Lens trifocal add over 3.25d 19850101 20031001Lenticular lens, trifocal 20040101 20040101Lens trifocal speciality 19850101 20031001Lens variab asphericity sing 19840101 20031001Lens variable asphericity bi 19840101 20031001Variable asphericity lens 19840101 20031001Contact lens pmma spherical 19850101 20031001Cntct lens pmma-toric/prism 19850101 20031001Contact lens pmma bifocal 19850101 20031001Cntct lens pmma color vision 19850101 20031001Cntct gas permeable sphericl 19850101 20031001Cntct toric prism ballast 19850101 20031001Cntct lens gas permbl bifocl 19850101 20031001Contact lens extended wear 19850101 20031001Contact lens hydrophilic 19840101 20031001Cntct lens hydrophilic toric 19850101 20031001Cntct lens hydrophil bifocl 19850101 20031001Cntct lens hydrophil extend 19850101 20031001Contact lens gas impermeable 19850101 20031001

Contact lens gas permeable 19960101 20031001

Contact lens/es other type 19850101 20031001Hand held low vision aids 19850101 20031001Single lens spectacle mount 19850101 20031001Telescop/othr compound lens 19850101 20031001

Plastic eye prosth custom 19850101 20031001Polishing artifical eye 19930101 20031001Enlargemnt of eye prosthesis 19930101 20031001Reduction of eye prosthesis 19930101 20031001Scleral cover shell 19930101 20031001

Query_110708

Page 491

Fabrication & fitting 19930101 20031001Prosthetic eye other type 19850101 20031001Anter chamber intraocul lens 19850101 20031001Iris support intraoclr lens 19850101 20031001Post chmbr intraocular lens 19850101 20031001Balance lens 19850101 20031001Deluxe lens feature 20050101 20050101Glass/plastic slab off prism 19850101 20031001Prism lens/es 19850101 20031001Fresnell prism press-on lens 19850101 20031001Special base curve 19850101 20031001Tint photochromatic lens/es 19850101 20031001Tint, any color/solid/grad 20040101 20050101

Anti-reflective coating 19850101 20031001UV lens/es 19850101 20031001Eye glass case 20040101 20070101Scratch resistant coating 19850101 20031001Mirror coating 20040101 20040101Polarization, any lens 20040101 20040101Occluder lens/es 19850101 20031001Oversize lens/es 19850101 20031001Progressive lens per lens 19960101 20031001Lens, 1.54-1.65 p/1.60-1.79g 20040101 20040101

Lens, >= 1.66 p/>=1.80 g 20040101 20040101

Lens polycarb or equal 20040101 20040101Corneal tissue processing 19900101 20031001Occupational multifocal lens 20040101 20040101Astigmatism-correct function 20080101 20080101Presbyopia-correct function 20060101 20060101Amniotic membrane 20010101 20031001Vis item/svc in other code 20040101 20040101Miscellaneous vision service 19850101 20031001Hearing screening 19900101 19950101Assessment for hearing aid 19840101 19950101Hearing aid fitting/checking 19900101 19950101Hearing aid repair/modifying 19900101 19950101Conformity evaluation 19840101 19950101Body-worn hearing aid air 19860101 19950101Body-worn hearing aid bone 19860101 19950101Hearing aid monaural in ear 19820101 20010101Behind ear hearing aid 19820101 19950101Glasses air conduction 19820101 19950101Glasses bone conduction 19820101 19950101Hearing aid dispensing fee 19820101 19950101Implant mid ear hearing pros 20030101 20030101Body-worn bilat hearing aid 19820101 19950101Hearing aid dispensing fee 19820101 19950101Body-worn binaur hearing aid 19820101 19950101In ear binaural hearing aid 19820101 19950101Behind ear binaur hearing ai 19820101 19950101Glasses binaural hearing aid 19820101 19950101Dispensing fee binaural 19820101 19950101Within ear cros hearing aid 19820101 19950101Behind ear cros hearing aid 19820101 19950101Glasses cros hearing aid 19820101 19950101Cros hearing aid dispens fee 19820101 19950101In ear bicros hearing aid 19820101 19950101Behind ear bicros hearing ai 19820101 19950101

Query_110708

Page 492

Glasses bicros hearing aid 19820101 19950101Dispensing fee bicros 19820101 19950101Dispensing fee, monaural 20020101 20020101Hearing aid, monaural, cic 20020101 20020101Hearing aid, monaural, itc 20020101 20020101Hearing aid, prog, mon, cic 20020101 20020101Hearing aid, prog, mon, itc 20020101 20020101Hearing aid, prog, mon, ite 20020101 20020101Hearing aid, prog, mon, bte 20020101 20020101Hearing aid, binaural, cic 20020101 20020101Hearing aid, binaural, itc 20020101 20020101Hearing aid, prog, bin, cic 20020101 20020101Hearing aid, prog, bin, itc 20020101 20020101Hearing aid, prog, bin, ite 20020101 20020101Hearing aid, prog, bin, bte 20020101 20020101Hearing id, digit, mon, cic 20020101 20020101Hearing aid, digit, mon, itc 20020101 20020101Hearing aid, digit, mon, ite 20020101 20020101Hearing aid, digit, mon, bte 20020101 20020101Hearing aid, digit, bin, cic 20020101 20020101Hearing aid, digit, bin, itc 20020101 20020101Hearing aid, digit, bin, ite 20020101 20020101Hearing aid, digit, bin, bte 20020101 20020101Hearing aid, disp, monaural 20020101 20020101Hearing aid, disp, binaural 20020101 20020101Ear mold/insert 20020101 20020101Ear mold/insert, disp 20020101 20020101Battery for hearing device 20020101 20020101Hearing aid supply/accessory 20020101 20020101ALD Telephone Amplifier 20020101 20020101Alerting device, any type 20020101 20020101ALD, TV amplifier, any type 20020101 20020101ALD, TV caption decoder 20020101 20020101Tdd 20020101 20020101ALD for cochlear implant 20020101 20020101ALD unspecified 20020101 20020101Ear impression 20020101 20020101Hearing aid noc 20030101 20030101Hearing service 19820101 19950101Repair communication device 19900101 19910101

Speech screening 19900101 20040101Language screening 19900101 20040101Dysphagia screening 19900101 20040101

Query_110708

Page 493

Term Date Action CodeNNNNNNNNNNN

NNNNNNNN

N

NN

N

NNNNNNNN

N

N

N

N

N

N

N

N

Query_110708

Page 494

ANNNNNN

N

N

N

N

N

NN

NN

NNNNNNNNNNN

NNNNNNNN

N

N

N

NN

N

N

Query_110708

Page 495

N

N

N

NNNN

NNNNNN

N

NN

NN

NNNNNNNNNNN

NNNNNNNNNNNNNNNNNNN

N

Query_110708

Page 496

NNAANN

N

N

N

N

NNNNA

NNNNN

NTNNNNNNNC

NN

NNNNNNN

NN

Query_110708

Page 497

NNN

N

NNNNNNNNN

N

NNNN

NNNN

20071231 N20051231 N

NNNN

NNN

N

NNNN

20051231 N20071231 N

NN

20051231 N20071231 N

NNN

NAAN

Query_110708

Page 498

NA

20081231 D

NNNNNN

NN

NNNNNNNNNNN

NNN

NNNNNNNNNNN

NNNNNNNNNNN

Query_110708

Page 499

NN

NNNNNNNNNNNNNNNNNNNNNNNN

NNNNNNNN

N

NNN

NN

NNNNNNNNNN

NN

Query_110708

Page 500

NNNNNN

NN

N

NNNNN

NNNN

20061231 NN

NNNNNNNNNNNNNNNN

N

N

NNNN

N

N

N

NNN

Query_110708

Page 501

NNNNN

20051231 N

NNNNN

20051231 NNNNNNNNNNNNNNNNNNN

N

NNNN

N

N

N

N

N

NNNNNNNN

N

Query_110708

Page 502

NNNN

NNN

20061231 N

NN

N

NNN

N

N

N

20061231 NNNNNNNNNNNN

N

NNNNNNNNNNN

N

NN

N

NN

Query_110708

Page 503

N

N

NNNNNNNNNNN

N

N

N

N

N

N

N

N

NN

NN

NNN

N

NN

N

N

N

N

N

N

N

Query_110708

Page 504

NN

NNNNN

20061231 NNNNNNNNNNNNNNNNN

NNNNNNNNNNNN

NNPNNNNPPPNNPNNNNN

NN

Query_110708

Page 505

N

20061231 NNNNNNNNN

NN

20051231 N

20051231 N20051231 N20051231 N20051231 N

NNNNNN

20051231 NNNNNNNNN

NNNNNNN

NN

N

N

N

N

N

N

N

Query_110708

Page 506

NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN

20051231 NNNNNNNN

N

N

Query_110708

Page 507

N

N

N

N

N

20051231 N

N

20051231 N

N

N

N

CCCC

CCN

NC

C

C

CF

F

F

C

C

C

CC

Query_110708

Page 508

CC

C

C

C

C

C

CN

N

N

C

C

C

C

C

C

C

C

C

C

C

C

C

C

C

C

C

C

CCC

Query_110708

Page 509

C

C

C

C

C

CNC

C

C

C

C

C

CC

CCCCC

N

N

N

C

NNNNN

N

N

N

N

N

N

N

Query_110708

Page 510

N

N

N

N

N

N

N

N

NNNNNNNNNN

N

N

NNNNNNNNNNNNNNNNNANN

20051231 N

NNNN

Query_110708

Page 511

NN

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Page 512

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Page 513

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Page 516

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Page 520

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Page 521

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Page 522

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Page 548

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Page 549

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Page 550

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Page 551

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Page 553

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Page 554

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Page 555

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Page 556

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Page 558

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Page 560

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Page 561

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Page 562

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Page 563

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Page 564

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Page 565

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Page 566

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Page 567

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Page 568

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Page 569

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Page 570

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Page 571

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Query_110708

Page 572

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Page 573

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Page 574

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Page 575

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Page 576

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Page 577

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Page 578

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Page 579

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Page 580

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Page 581

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Page 582

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Page 583

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Page 584

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Page 585

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Page 586

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Page 587

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Page 588

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Page 589

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Query_110708

Page 590

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Page 591

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Page 592

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Query_110708

Page 593

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Query_110708

Page 594

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Page 595

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Page 596

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Page 597

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Page 598

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Page 599

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Page 600

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Page 601

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Page 602

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Page 603

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Page 604

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Page 605

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Query_110708

Page 606

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Page 607

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Page 609

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Page 610

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Page 611

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Page 615

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Page 618

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Page 619

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Page 621

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Page 623

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Page 626

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Page 627

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Page 632

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Page 634

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Page 647

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Page 649

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Page 653

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Page 654

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Page 655

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Page 656

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€¦ · XLS file · Web view2008-12-02 · supply of additional high dose contrast material(s) during magnetic resonance high dose contrast mri i2d imaging, e.g., gadoteridol injection