[xls]2011 healthcare common procedure coding system ... · web viewhuman breast milk processing,...

PUF___2011_Web_File

HCPC Seq Num RIC A1 00100 7 A2 00100 7 A3 00100 7 A4 00100 7 A5 00100 7 A6 00100 7 A7 00100 7 A8 00100 7 A9 00100 7 AA 00100 7 AD 00100 7 AD 00200 8 AE 00100 7 AF 00100 7 AG 00100 7 AH 00100 7 AI 00100 7 AJ 00100 7 AK 00100 7 AM 00100 7 AP 00100 7 AP 00200 8 AQ 00100 7 AQ 00200 8 AR 00100 7 AS 00100 7 AS 00200 8 AT 00100 7 AT 00200 8 AU 00100 7 AV 00100 7 AW 00100 7 AX 00100 7 AY 00100 7 AY 00200 8 AZ 00100 7 AZ 00200 8 BA 00100 7 BL 00100 7 BO 00100 7 BP 00100 7 BP 00200 8 BR 00100 7 BR 00200 8 BU 00100 7 BU 00200 8 CA 00100 7 CA 00200 8 CB 00100 7 CB 00200 8 CB 00300 8 CC 00100 7 CC 00200 8

PUF___2011_Web_File

CD 00100 7 CD 00200 8 CE 00100 7 CE 00200 8 CE 00300 8 CF 00100 7 CF 00200 8 CG 00100 7 CR 00100 7 CS 00100 7 CS 00200 8 CS 00300 8 CS 00400 8 DA 00100 7 E1 00100 7 E2 00100 7 E3 00100 7 E4 00100 7 EA 00100 7 EA 00200 8 EB 00100 7 EB 00200 8 EC 00100 7 EC 00200 8 ED 00100 7 ED 00200 8 ED 00300 8 EE 00100 7 EE 00200 8 EE 00300 8 EJ 00100 7 EJ 00200 8 EM 00100 7 EP 00100 7 EP 00200 8 ET 00100 7 EY 00100 7 EY 00200 8 F1 00100 7 F2 00100 7 F3 00100 7 F4 00100 7 F5 00100 7 F6 00100 7 F7 00100 7 F8 00100 7 F9 00100 7 FA 00100 7 FB 00100 7 FB 00200 8 FB 00300 8 FC 00100 7 FP 00100 7 G1 00100 7

PUF___2011_Web_File

G2 00100 7 G3 00100 7 G4 00100 7 G5 00100 7 G6 00100 7 G6 00200 8 G7 00100 7 G7 00200 8 G8 00100 7 G8 00200 8 G9 00100 7 G9 00200 8 GA 00100 7 GA 00200 8 GB 00100 7 GB 00200 8 GC 00100 7 GC 00200 8 GD 00100 7 GD 00200 8 GE 00100 7 GE 00200 8 GF 00100 7 GF 00200 8 GF 00300 8 GG 00100 7 GG 00200 8 GH 00100 7 GJ 00100 7 GK 00100 7 GL 00100 7 GL 00200 8 GM 00100 7 GN 00100 7 GO 00100 7 GP 00100 7 GQ 00100 7 GR 00100 7 GR 00200 8 GR 00300 8 GS 00100 7 GS 00200 8 GT 00100 7 GU 00100 7 GV 00100 7 GV 00200 8 GW 00100 7 GX 00100 7 GY 00100 7 GY 00200 8 GZ 00100 7 H9 00100 7 HA 00100 7 HB 00100 7

PUF___2011_Web_File

HC 00100 7 HD 00100 7 HE 00100 7 HF 00100 7 HG 00100 7 HH 00100 7 HI 00100 7 HI 00200 8 HJ 00100 7 HK 00100 7 HL 00100 7 HM 00100 7 HN 00100 7 HO 00100 7 HP 00100 7 HQ 00100 7 HR 00100 7 HS 00100 7 HT 00100 7 HU 00100 7 HV 00100 7 HW 00100 7 HX 00100 7 HY 00100 7 HZ 00100 7 J1 00100 7 J2 00100 7 J2 00200 8 J3 00100 7 J3 00200 8 J4 00100 7 J4 00200 8 JA 00100 7 JB 00100 7 JC 00100 7 JD 00100 7 JW 00100 7 K0 00100 7 K0 00200 8 K0 00300 8 K1 00100 7 K1 00200 8 K1 00300 8 K2 00100 7 K2 00200 8 K2 00300 8 K2 00400 8 K3 00100 7 K3 00200 8 K3 00300 8 K3 00400 8 K3 00500 8 K4 00100 7 K4 00200 8

PUF___2011_Web_File

K4 00300 8 K4 00400 8 KA 00100 7 KB 00100 7 KC 00100 7 KD 00100 7 KE 00100 7 KE 00200 8 KF 00100 7 KG 00100 7 KH 00100 7 KI 00100 7 KJ 00100 7 KJ 00200 8 KK 00100 7 KL 00100 7 KM 00100 7 KN 00100 7 KO 00100 7 KP 00100 7 KQ 00100 7 KR 00100 7 KS 00100 7 KT 00100 7 KT 00200 8 KU 00100 7 KV 00100 7 KV 00200 8 KW 00100 7 KX 00100 7 KY 00100 7 KZ 00100 7 LC 00100 7 LD 00100 7 LL 00100 7 LL 00200 8 LR 00100 7 LS 00100 7 LT 00100 7 M2 00100 7 MS 00100 7 MS 00200 8 NB 00100 7 NR 00100 7 NR 00200 8 NU 00100 7 P1 00100 7 P2 00100 7 P3 00100 7 P4 00100 7 P5 00100 7 P6 00100 7 PA 00100 7 PB 00100 7

PUF___2011_Web_File

PC 00100 7 PI 00100 7 PI 00200 8 PI 00300 8 PL 00100 7 PS 00100 7 PS 00200 8 PS 00300 8 PS 00400 8 PT 00100 7 PT 00200 8 Q0 00100 7 Q0 00200 8 Q1 00100 7 Q1 00200 8 Q2 00100 7 Q3 00100 7 Q4 00100 7 Q5 00100 7 Q5 00200 8 Q6 00100 7 Q7 00100 7 Q8 00100 7 Q9 00100 7 QA 00100 7 QC 00100 7 QD 00100 7 QE 00100 7 QF 00100 7 QF 00200 8 QG 00100 7 QH 00100 7 QJ 00100 7 QJ 00200 8 QJ 00300 8 QK 00100 7 QK 00200 8 QL 00100 7 QM 00100 7 QN 00100 7 QP 00100 7 QP 00200 8 QP 00300 8 QR 00100 7 QS 00100 7 QT 00100 7 QV 00100 7 QW 00100 7 QX 00100 7 QY 00100 7 QY 00200 8 QZ 00100 7 RA 00100 7 RB 00100 7

PUF___2011_Web_File

RB 00200 8 RC 00100 7 RD 00100 7 RE 00100 7 RE 00200 8 RP 00100 7 RP 00200 8 RP 00300 8 RP 00400 8 RR 00100 7 RT 00100 7 SA 00100 7 SB 00100 7 SC 00100 7 SD 00100 7 SD 00200 8 SE 00100 7 SF 00100 7 SF 00200 8 SG 00100 7 SH 00100 7 SJ 00100 7 SK 00100 7 SL 00100 7 SM 00100 7 SN 00100 7 SQ 00100 7 SS 00100 7 ST 00100 7 SU 00100 7 SU 00200 8 SV 00100 7 SW 00100 7 SY 00100 7 SY 00200 8 T1 00100 7 T2 00100 7 T3 00100 7 T4 00100 7 T5 00100 7 T6 00100 7 T7 00100 7 T8 00100 7 T9 00100 7 TA 00100 7 TC 00100 7 TC 00200 8 TC 00300 8 TC 00400 8 TC 00500 8 TC 00600 8 TC 00700 8 TD 00100 7 TE 00100 7

PUF___2011_Web_File

TF 00100 7 TG 00100 7 TH 00100 7 TJ 00100 7 TK 00100 7 TL 00100 7 TM 00100 7 TN 00100 7 TP 00100 7 TQ 00100 7 TR 00100 7 TR 00200 8 TS 00100 7 TT 00100 7 TU 00100 7 TV 00100 7 TW 00100 7 U1 00100 7 U2 00100 7 U3 00100 7 U4 00100 7 U5 00100 7 U6 00100 7 U7 00100 7 U8 00100 7 U9 00100 7 UA 00100 7 UB 00100 7 UC 00100 7 UD 00100 7 UE 00100 7 UF 00100 7 UG 00100 7 UH 00100 7 UJ 00100 7 UK 00100 7 UK 00200 8 UN 00100 7 UP 00100 7 UQ 00100 7 UR 00100 7 US 00100 7 V5 00100 7 V6 00100 7 V7 00100 7 V8 00100 7 V9 00100 7 VP 00100 7A0021 00100 3A0080 00100 3A0080 00200 4A0090 00100 3A0090 00200 4A0100 00100 3

PUF___2011_Web_File

A0110 00100 3A0120 00100 3A0120 00200 4A0130 00100 3A0140 00100 3A0140 00200 4A0160 00100 3A0170 00100 3A0180 00100 3A0190 00100 3A0200 00100 3A0210 00100 3A0225 00100 3A0380 00100 3A0382 00100 3A0384 00100 3A0384 00200 4A0384 00300 4A0390 00100 3A0392 00100 3A0392 00200 4A0394 00100 3A0396 00100 3A0398 00100 3A0420 00100 3A0422 00100 3A0424 00100 3A0424 00200 4A0425 00100 3A0426 00100 3A0426 00200 4A0427 00100 3A0427 00200 4A0428 00100 3A0429 00100 3A0430 00100 3A0431 00100 3A0432 00100 3A0432 00200 4A0432 00300 4A0433 00100 3A0434 00100 3A0435 00100 3A0436 00100 3A0888 00100 3A0888 00200 4A0998 00100 3A0999 00100 3A4206 00100 3A4207 00100 3A4208 00100 3A4209 00100 3A4210 00100 3A4211 00100 3

PUF___2011_Web_File


PUF___2011_Web_File

A9579 00200 4A9580 00100 3A9581 00100 3A9582 00100 3A9583 00100 3A9600 00100 3A9604 00100 3A9604 00200 4A9605 00100 3A9698 00100 3A9699 00100 3A9700 00100 3A9900 00100 3A9900 00200 4A9901 00100 3A9999 00100 3B4034 00100 3B4034 00200 4B4035 00100 3B4035 00200 4B4036 00100 3B4036 00200 4B4081 00100 3B4082 00100 3B4083 00100 3B4086 00100 3B4086 00200 4B4087 00100 3B4088 00100 3B4100 00100 3B4102 00100 3B4102 00200 4B4103 00100 3B4103 00200 4B4104 00100 3B4149 00100 3B4149 00200 4B4149 00300 4B4150 00100 3B4150 00200 4B4150 00300 4B4152 00100 3B4152 00200 4B4152 00300 4B4152 00400 4B4153 00100 3B4153 00200 4B4153 00300 4B4153 00400 4B4154 00100 3B4154 00200 4B4154 00300 4B4154 00400 4B4155 00100 3

PUF___2011_Web_File

B4155 00200 4B4155 00300 4B4155 00400 4B4157 00100 3B4157 00200 4B4157 00300 4B4157 00400 4B4158 00100 3B4158 00200 4B4158 00300 4B4158 00400 4B4159 00100 3B4159 00200 4B4159 00300 4B4159 00400 4B4160 00100 3B4160 00200 4B4160 00300 4B4160 00400 4B4161 00100 3B4161 00200 4B4161 00300 4B4162 00100 3B4162 00200 4B4162 00300 4B4162 00400 4B4164 00100 3B4164 00200 4B4168 00100 3B4172 00100 3B4172 00200 4B4176 00100 3B4176 00200 4B4178 00100 3B4178 00200 4B4180 00100 3B4180 00200 4B4185 00100 3B4189 00100 3B4189 00200 4B4189 00300 4B4193 00100 3B4193 00200 4B4193 00300 4B4197 00100 3B4197 00200 4B4197 00300 4B4199 00100 3B4199 00200 4B4199 00300 4B4216 00100 3B4216 00200 4B4220 00100 3B4222 00100 3

PUF___2011_Web_File

B4224 00100 3B5000 00100 3B5000 00200 4B5000 00300 4B5100 00100 3B5100 00200 4B5100 00300 4B5200 00100 3B5200 00200 4B5200 00300 4B9000 00100 3B9002 00100 3B9004 00100 3B9006 00100 3B9998 00100 3B9999 00100 3C1300 00100 3C1713 00100 3C1714 00100 3C1715 00100 3C1716 00100 3C1717 00100 3C1718 00100 3C1719 00100 3C1720 00100 3C1721 00100 3C1722 00100 3C1724 00100 3C1725 00100 3C1725 00200 4C1726 00100 3C1727 00100 3C1728 00100 3C1729 00100 3C1730 00100 3C1730 00200 4C1731 00100 3C1731 00200 4C1732 00100 3C1733 00100 3C1733 00200 4C1749 00100 3C1750 00100 3C1751 00100 3C1751 00200 4C1752 00100 3C1753 00100 3C1754 00100 3C1755 00100 3C1756 00100 3C1757 00100 3C1758 00100 3C1759 00100 3C1760 00100 3

PUF___2011_Web_File

C1762 00100 3C1763 00100 3C1764 00100 3C1765 00100 3C1766 00100 3C1766 00200 4C1767 00100 3C1768 00100 3C1769 00100 3C1770 00100 3C1771 00100 3C1772 00100 3C1773 00100 3C1776 00100 3C1777 00100 3C1778 00100 3C1779 00100 3C1780 00100 3C1781 00100 3C1782 00100 3C1783 00100 3C1784 00100 3C1785 00100 3C1786 00100 3C1787 00100 3C1788 00100 3C1789 00100 3C1813 00100 3C1814 00100 3C1815 00100 3C1816 00100 3C1817 00100 3C1818 00100 3C1819 00100 3C1820 00100 3C1820 00200 4C1821 00100 3C1874 00100 3C1875 00100 3C1876 00100 3C1877 00100 3C1878 00100 3C1879 00100 3C1880 00100 3C1881 00100 3C1882 00100 3C1883 00100 3C1884 00100 3C1885 00100 3C1887 00100 3C1888 00100 3C1891 00100 3C1892 00100 3C1892 00200 4

PUF___2011_Web_File


PUF___2011_Web_File

C9801 00200 4C9802 00100 3C9802 00200 4C9898 00100 3C9899 00100 3C9899 00200 4E0100 00100 3E0105 00100 3E0105 00200 4E0110 00100 3E0110 00200 4E0111 00100 3E0111 00200 4E0112 00100 3E0112 00200 4E0113 00100 3E0114 00100 3E0114 00200 4E0116 00100 3E0116 00200 4E0117 00100 3E0118 00100 3E0130 00100 3E0135 00100 3E0140 00100 3E0141 00100 3E0143 00100 3E0144 00100 3E0144 00200 4E0147 00100 3E0148 00100 3E0149 00100 3E0153 00100 3E0154 00100 3E0155 00100 3E0156 00100 3E0157 00100 3E0158 00100 3E0159 00100 3E0160 00100 3E0161 00100 3E0161 00200 4E0162 00100 3E0163 00100 3E0165 00100 3E0167 00100 3E0168 00100 3E0168 00200 4E0170 00100 3E0171 00100 3E0172 00100 3E0175 00100 3E0181 00100 3E0181 00200 4

PUF___2011_Web_File

E0182 00100 3E0184 00100 3E0185 00100 3E0186 00100 3E0187 00100 3E0188 00100 3E0189 00100 3E0190 00100 3E0190 00200 4E0191 00100 3E0193 00100 3E0194 00100 3E0196 00100 3E0197 00100 3E0198 00100 3E0199 00100 3E0200 00100 3E0202 00100 3E0203 00100 3E0205 00100 3E0210 00100 3E0215 00100 3E0217 00100 3E0218 00100 3E0220 00100 3E0221 00100 3E0225 00100 3E0230 00100 3E0231 00100 3E0231 00200 4E0232 00100 3E0232 00200 4E0235 00100 3E0236 00100 3E0238 00100 3E0239 00100 3E0240 00100 3E0241 00100 3E0242 00100 3E0243 00100 3E0244 00100 3E0245 00100 3E0246 00100 3E0247 00100 3E0248 00100 3E0249 00100 3E0250 00100 3E0251 00100 3E0255 00100 3E0256 00100 3E0260 00100 3E0260 00200 4E0261 00100 3E0261 00200 4

PUF___2011_Web_File


PUF___2011_Web_File

E2623 00100 3E2623 00200 4E2624 00100 3E2624 00200 4E2625 00100 3E2625 00200 4E8000 00100 3E8000 00200 4E8001 00100 3E8001 00200 4E8002 00100 3E8002 00200 4G0008 00100 3G0009 00100 3G0010 00100 3G0027 00100 3G0101 00100 3G0102 00100 3G0103 00100 3G0104 00100 3G0105 00100 3G0106 00100 3G0106 00200 4G0108 00100 3G0108 00200 4G0109 00100 3G0109 00200 4G0117 00100 3G0117 00200 4G0118 00100 3G0118 00200 4G0120 00100 3G0120 00200 4G0121 00100 3G0121 00200 4G0122 00100 3G0123 00100 3G0123 00200 4G0123 00300 4G0124 00100 3G0124 00200 4G0124 00300 4G0127 00100 3G0128 00100 3G0128 00200 4G0128 00300 4G0129 00100 3G0129 00200 4G0129 00300 4G0130 00100 3G0130 00200 4G0141 00100 3G0141 00200 4G0143 00100 3

PUF___2011_Web_File

G0143 00200 4G0143 00300 4G0144 00100 3G0144 00200 4G0144 00300 4G0145 00100 3G0145 00200 4G0145 00300 4G0147 00100 3G0147 00200 4G0148 00100 3G0148 00200 4G0151 00100 3G0151 00200 4G0152 00100 3G0152 00200 4G0153 00100 3G0153 00200 4G0154 00100 3G0154 00200 4G0155 00100 3G0155 00200 4G0156 00100 3G0156 00200 4G0157 00100 3G0157 00200 4G0158 00100 3G0158 00200 4G0159 00100 3G0159 00200 4G0159 00300 4G0160 00100 3G0160 00200 4G0160 00300 4G0161 00100 3G0161 00200 4G0161 00300 4G0162 00100 3G0162 00200 4G0162 00300 4G0162 00400 4G0163 00100 3G0163 00200 4G0163 00300 4G0163 00400 4G0163 00500 4G0164 00100 3G0164 00200 4G0166 00100 3G0168 00100 3G0173 00100 3G0173 00200 4G0175 00100 3G0175 00200 4

PUF___2011_Web_File


PUF___2011_Web_File

G9147 00200 4G9147 00300 4G9147 00400 4H0001 00100 3H0002 00100 3H0002 00200 4H0003 00100 3H0003 00200 4H0004 00100 3H0005 00100 3H0006 00100 3H0007 00100 3H0008 00100 3H0009 00100 3H0010 00100 3H0010 00200 4H0011 00100 3H0011 00200 4H0012 00100 3H0012 00200 4H0013 00100 3H0013 00200 4H0014 00100 3H0015 00100 3H0015 00200 4H0015 00300 4H0015 00400 4H0016 00100 3H0016 00200 4H0017 00100 3H0017 00200 4H0018 00100 3H0018 00200 4H0019 00100 3H0019 00200 4H0019 00300 4H0020 00100 3H0020 00200 4H0021 00100 3H0021 00200 4H0022 00100 3H0023 00100 3H0023 00200 4H0024 00100 3H0024 00200 4H0025 00100 3H0025 00200 4H0026 00100 3H0026 00200 4H0027 00100 3H0027 00200 4H0027 00300 4H0028 00100 3H0028 00200 4

PUF___2011_Web_File

H0028 00300 4H0029 00100 3H0029 00200 4H0030 00100 3H0031 00100 3H0032 00100 3H0033 00100 3H0034 00100 3H0035 00100 3H0036 00100 3H0037 00100 3H0038 00100 3H0039 00100 3H0040 00100 3H0041 00100 3H0042 00100 3H0043 00100 3H0044 00100 3H0045 00100 3H0046 00100 3H0047 00100 3H0048 00100 3H0048 00200 4H0049 00100 3H0050 00100 3H1000 00100 3H1001 00100 3H1002 00100 3H1003 00100 3H1004 00100 3H1005 00100 3H1010 00100 3H1011 00100 3H1011 00200 4H2000 00100 3H2001 00100 3H2010 00100 3H2011 00100 3H2012 00100 3H2013 00100 3H2014 00100 3H2015 00100 3H2016 00100 3H2017 00100 3H2018 00100 3H2019 00100 3H2020 00100 3H2021 00100 3H2022 00100 3H2023 00100 3H2024 00100 3H2025 00100 3H2026 00100 3H2027 00100 3

PUF___2011_Web_File

H2028 00100 3H2029 00100 3H2030 00100 3H2031 00100 3H2032 00100 3H2033 00100 3H2034 00100 3H2035 00100 3H2036 00100 3H2037 00100 3H2037 00200 4J0120 00100 3J0128 00100 3J0129 00100 3J0130 00100 3J0132 00100 3J0133 00100 3J0135 00100 3J0150 00100 3J0150 00200 4J0152 00100 3J0152 00200 4J0170 00100 3J0171 00100 3J0180 00100 3J0190 00100 3J0200 00100 3J0205 00100 3J0207 00100 3J0210 00100 3J0215 00100 3J0220 00100 3J0256 00100 3J0270 00100 3J0270 00200 4J0270 00300 4J0275 00100 3J0275 00200 4J0275 00300 4J0278 00100 3J0280 00100 3J0282 00100 3J0285 00100 3J0287 00100 3J0288 00100 3J0289 00100 3J0290 00100 3J0295 00100 3J0300 00100 3J0330 00100 3J0348 00100 3J0350 00100 3J0360 00100 3J0364 00100 3

PUF___2011_Web_File

J0365 00100 3J0380 00100 3J0390 00100 3J0395 00100 3J0400 00100 3J0456 00100 3J0460 00100 3J0461 00100 3J0470 00100 3J0475 00100 3J0476 00100 3J0480 00100 3J0500 00100 3J0515 00100 3J0520 00100 3J0530 00100 3J0530 00200 4J0540 00100 3J0540 00200 4J0550 00100 3J0550 00200 4J0558 00100 3J0559 00100 3J0560 00100 3J0561 00100 3J0570 00100 3J0580 00100 3J0583 00100 3J0585 00100 3J0586 00100 3J0587 00100 3J0592 00100 3J0594 00100 3J0595 00100 3J0597 00100 3J0598 00100 3J0600 00100 3J0610 00100 3J0620 00100 3J0630 00100 3J0636 00100 3J0637 00100 3J0638 00100 3J0640 00100 3J0641 00100 3J0670 00100 3J0690 00100 3J0692 00100 3J0694 00100 3J0696 00100 3J0697 00100 3J0698 00100 3J0702 00100 3J0704 00100 3

PUF___2011_Web_File


PUF___2011_Web_File

J9226 00100 3J9230 00100 3J9245 00100 3J9250 00100 3J9260 00100 3J9261 00100 3J9263 00100 3J9264 00100 3J9265 00100 3J9266 00100 3J9268 00100 3J9270 00100 3J9280 00100 3J9290 00100 3J9291 00100 3J9293 00100 3J9300 00100 3J9302 00100 3J9303 00100 3J9305 00100 3J9307 00100 3J9310 00100 3J9315 00100 3J9320 00100 3J9328 00100 3J9330 00100 3J9340 00100 3J9350 00100 3J9351 00100 3J9355 00100 3J9357 00100 3J9360 00100 3J9370 00100 3J9375 00100 3J9380 00100 3J9390 00100 3J9395 00100 3J9600 00100 3J9999 00100 3K0001 00100 3K0002 00100 3K0003 00100 3K0004 00100 3K0005 00100 3K0006 00100 3K0007 00100 3K0009 00100 3K0010 00100 3K0011 00100 3K0011 00200 4K0011 00300 4K0012 00100 3K0014 00100 3K0015 00100 3

PUF___2011_Web_File

K0017 00100 3K0018 00100 3K0019 00100 3K0020 00100 3K0037 00100 3K0038 00100 3K0039 00100 3K0040 00100 3K0041 00100 3K0042 00100 3K0043 00100 3K0044 00100 3K0045 00100 3K0046 00100 3K0047 00100 3K0050 00100 3K0051 00100 3K0052 00100 3K0053 00100 3K0056 00100 3K0056 00200 4K0065 00100 3K0069 00100 3K0070 00100 3K0071 00100 3K0072 00100 3K0073 00100 3K0077 00100 3K0098 00100 3K0105 00100 3K0108 00100 3K0195 00100 3K0455 00100 3K0455 00200 4K0462 00100 3K0552 00100 3K0553 00100 3K0553 00200 4K0554 00100 3K0555 00100 3K0601 00100 3K0601 00200 4K0602 00100 3K0602 00200 4K0603 00100 3K0603 00200 4K0604 00100 3K0604 00200 4K0605 00100 3K0605 00200 4K0606 00100 3K0606 00200 4K0607 00100 3K0607 00200 4

PUF___2011_Web_File


PUF___2011_Web_File

K0858 00100 3K0858 00200 4K0859 00100 3K0859 00200 4K0860 00100 3K0860 00200 4K0861 00100 3K0861 00200 4K0862 00100 3K0862 00200 4K0863 00100 3K0863 00200 4K0864 00100 3K0864 00200 4K0868 00100 3K0868 00200 4K0869 00100 3K0869 00200 4K0870 00100 3K0870 00200 4K0871 00100 3K0871 00200 4K0877 00100 3K0877 00200 4K0878 00100 3K0878 00200 4K0879 00100 3K0879 00200 4K0880 00100 3K0880 00200 4K0884 00100 3K0884 00200 4K0885 00100 3K0885 00200 4K0886 00100 3K0886 00200 4K0890 00100 3K0890 00200 4K0891 00100 3K0891 00200 4K0898 00100 3K0899 00100 3L0112 00100 3L0112 00200 4L0113 00100 3L0113 00200 4L0120 00100 3L0130 00100 3L0140 00100 3L0150 00100 3L0150 00200 4L0160 00100 3L0170 00100 3L0172 00100 3

PUF___2011_Web_File

L0174 00100 3L0174 00200 4L0180 00100 3L0190 00100 3L0190 00200 4L0200 00100 3L0200 00200 4L0210 00100 3L0220 00100 3L0430 00100 3L0430 00200 4L0450 00100 3L0450 00200 4L0450 00300 4L0450 00400 4L0452 00100 3L0452 00200 4L0452 00300 4L0454 00100 3L0454 00200 4L0454 00300 4L0454 00400 4L0454 00500 4L0456 00100 3L0456 00200 4L0456 00300 4L0456 00400 4L0456 00500 4L0456 00600 4L0458 00100 3L0458 00200 4L0458 00300 4L0458 00400 4L0458 00500 4L0458 00600 4L0458 00700 4L0460 00100 3L0460 00200 4L0460 00300 4L0460 00400 4L0460 00500 4L0460 00600 4L0460 00700 4L0462 00100 3L0462 00200 4L0462 00300 4L0462 00400 4L0462 00500 4L0462 00600 4L0462 00700 4L0464 00100 3L0464 00200 4L0464 00300 4L0464 00400 4

PUF___2011_Web_File


PUF___2011_Web_File

L8622 00100 3L8622 00200 4L8623 00100 3L8623 00200 4L8624 00100 3L8624 00200 4L8627 00100 3L8628 00100 3L8629 00100 3L8629 00200 4L8630 00100 3L8631 00100 3L8631 00200 4L8631 00300 4L8641 00100 3L8642 00100 3L8658 00100 3L8659 00100 3L8659 00200 4L8659 00300 4L8670 00100 3L8680 00100 3L8681 00100 3L8681 00200 4L8682 00100 3L8683 00100 3L8683 00200 4L8684 00100 3L8684 00200 4L8685 00100 3L8685 00200 4L8686 00100 3L8686 00200 4L8687 00100 3L8687 00200 4L8688 00100 3L8688 00200 4L8689 00100 3L8689 00200 4L8690 00100 3L8691 00100 3L8692 00100 3L8692 00200 4L8692 00300 4L8693 00100 3L8695 00100 3L8695 00200 4L8699 00100 3L9900 00100 3L9900 00200 4M0064 00100 3M0064 00200 4M0064 00300 4M0075 00100 3

PUF___2011_Web_File

M0076 00100 3M0100 00100 3M0300 00100 3M0301 00100 3P2028 00100 3P2029 00100 3P2031 00100 3P2033 00100 3P2038 00100 3P3000 00100 3P3000 00200 4P3001 00100 3P3001 00200 4P7001 00100 3P9010 00100 3P9011 00100 3P9012 00100 3P9016 00100 3P9017 00100 3P9017 00200 4P9019 00100 3P9020 00100 3P9021 00100 3P9022 00100 3P9023 00100 3P9031 00100 3P9032 00100 3P9033 00100 3P9034 00100 3P9035 00100 3P9036 00100 3P9037 00100 3P9038 00100 3P9039 00100 3P9040 00100 3P9041 00100 3P9043 00100 3P9044 00100 3P9045 00100 3P9046 00100 3P9047 00100 3P9048 00100 3P9050 00100 3P9051 00100 3P9052 00100 3P9053 00100 3P9054 00100 3P9054 00200 4P9055 00100 3P9056 00100 3P9057 00100 3P9057 00200 4P9058 00100 3P9059 00100 3

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P9060 00100 3P9603 00100 3P9603 00200 4P9603 00300 4P9604 00100 3P9604 00200 4P9604 00300 4P9612 00100 3P9612 00200 4P9615 00100 3Q0035 00100 3Q0081 00100 3Q0083 00100 3Q0083 00200 4Q0084 00100 3Q0085 00100 3Q0085 00200 4Q0091 00100 3Q0091 00200 4Q0092 00100 3Q0111 00100 3Q0112 00100 3Q0113 00100 3Q0114 00100 3Q0115 00100 3Q0138 00100 3Q0138 00200 4Q0139 00100 3Q0139 00200 4Q0144 00100 3Q0163 00100 3Q0163 00200 4Q0163 00300 4Q0164 00100 3Q0164 00200 4Q0164 00300 4Q0165 00100 3Q0165 00200 4Q0165 00300 4Q0166 00100 3Q0166 00200 4Q0166 00300 4Q0167 00100 3Q0167 00200 4Q0167 00300 4Q0168 00100 3Q0168 00200 4Q0168 00300 4Q0169 00100 3Q0169 00200 4Q0169 00300 4Q0170 00100 3Q0170 00200 4Q0170 00300 4

PUF___2011_Web_File

Q0171 00100 3Q0171 00200 4Q0171 00300 4Q0172 00100 3Q0172 00200 4Q0172 00300 4Q0173 00100 3Q0173 00200 4Q0173 00300 4Q0174 00100 3Q0174 00200 4Q0174 00300 4Q0175 00100 3Q0175 00200 4Q0175 00300 4Q0176 00100 3Q0176 00200 4Q0176 00300 4Q0177 00100 3Q0177 00200 4Q0177 00300 4Q0178 00100 3Q0178 00200 4Q0178 00300 4Q0179 00100 3Q0179 00200 4Q0179 00300 4Q0180 00100 3Q0180 00200 4Q0180 00300 4Q0181 00100 3Q0181 00200 4Q0181 00300 4Q0478 00100 3Q0478 00200 4Q0479 00100 3Q0479 00200 4Q0480 00100 3Q0481 00100 3Q0481 00200 4Q0482 00100 3Q0482 00200 4Q0483 00100 3Q0483 00200 4Q0484 00100 3Q0484 00200 4Q0485 00100 3Q0485 00200 4Q0486 00100 3Q0486 00200 4Q0487 00100 3Q0487 00200 4Q0488 00100 3Q0488 00200 4

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Q9964 00200 4Q9965 00100 3Q9966 00100 3Q9967 00100 3Q9968 00100 3Q9968 00200 4R0070 00100 3R0070 00200 4R0075 00100 3R0075 00200 4R0076 00100 3S0012 00100 3S0014 00100 3S0017 00100 3S0020 00100 3S0021 00100 3S0023 00100 3S0028 00100 3S0030 00100 3S0032 00100 3S0034 00100 3S0039 00100 3S0040 00100 3S0073 00100 3S0074 00100 3S0077 00100 3S0078 00100 3S0080 00100 3S0081 00100 3S0088 00100 3S0090 00100 3S0091 00100 3S0091 00200 4S0092 00100 3S0093 00100 3S0104 00100 3S0106 00100 3S0108 00100 3S0109 00100 3S0117 00100 3S0122 00100 3S0126 00100 3S0128 00100 3S0132 00100 3S0136 00100 3S0137 00100 3S0138 00100 3S0139 00100 3S0140 00100 3S0141 00100 3S0142 00100 3S0142 00200 4S0143 00100 3S0143 00200 4

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S0145 00100 3S0146 00100 3S0147 00100 3S0148 00100 3S0155 00100 3S0156 00100 3S0157 00100 3S0160 00100 3S0161 00100 3S0162 00100 3S0164 00100 3S0166 00100 3S0167 00100 3S0169 00100 3S0170 00100 3S0171 00100 3S0172 00100 3S0174 00100 3S0174 00200 4S0175 00100 3S0176 00100 3S0177 00100 3S0178 00100 3S0179 00100 3S0180 00100 3S0181 00100 3S0181 00200 4S0182 00100 3S0183 00100 3S0183 00200 4S0187 00100 3S0189 00100 3S0190 00100 3S0191 00100 3S0194 00100 3S0195 00100 3S0195 00200 4S0196 00100 3S0196 00200 4S0197 00100 3S0199 00100 3S0199 00200 4S0199 00300 4S0199 00400 4S0201 00100 3S0207 00100 3S0207 00200 4S0208 00100 3S0209 00100 3S0215 00100 3S0220 00100 3S0220 00200 4S0220 00300 4S0221 00100 3

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PUF___2011_Web_File

S9590 00100 3S9590 00200 4S9590 00300 4S9590 00400 4S9810 00100 3S9810 00200 4S9810 00300 4S9900 00100 3S9900 00200 4S9900 00300 4S9970 00100 3S9975 00100 3S9976 00100 3S9977 00100 3S9981 00100 3S9982 00100 3S9986 00100 3S9986 00200 4S9988 00100 3S9989 00100 3S9989 00200 4S9990 00100 3S9991 00100 3S9992 00100 3S9992 00200 4S9992 00300 4S9994 00100 3S9994 00200 4S9996 00100 3S9999 00100 3T1000 00100 3T1001 00100 3T1002 00100 3T1003 00100 3T1004 00100 3T1005 00100 3T1006 00100 3T1007 00100 3T1007 00200 4T1009 00100 3T1009 00200 4T1010 00100 3T1010 00200 4T1012 00100 3T1013 00100 3T1014 00100 3T1015 00100 3T1016 00100 3T1017 00100 3T1018 00100 3T1019 00100 3T1019 00200 4T1019 00300 4T1019 00400 4

PUF___2011_Web_File

T1020 00100 3T1020 00200 4T1020 00300 4T1020 00400 4T1021 00100 3T1022 00100 3T1022 00200 4T1023 00100 3T1023 00200 4T1023 00300 4T1024 00100 3T1024 00200 4T1025 00100 3T1025 00200 4T1025 00300 4T1026 00100 3T1026 00200 4T1026 00300 4T1027 00100 3T1028 00100 3T1028 00200 4T1029 00100 3T1029 00200 4T1030 00100 3T1031 00100 3T1502 00100 3T1502 00200 4T1503 00100 3T1503 00200 4T1505 00100 3T1505 00200 4T1999 00100 3T1999 00200 4T2001 00100 3T2002 00100 3T2003 00100 3T2004 00100 3T2005 00100 3T2007 00100 3T2007 00200 4T2010 00100 3T2010 00200 4T2011 00100 3T2011 00200 4T2012 00100 3T2013 00100 3T2014 00100 3T2015 00100 3T2016 00100 3T2017 00100 3T2018 00100 3T2019 00100 3T2020 00100 3T2021 00100 3

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T2022 00100 3T2023 00100 3T2024 00100 3T2025 00100 3T2026 00100 3T2027 00100 3T2028 00100 3T2029 00100 3T2030 00100 3T2031 00100 3T2032 00100 3T2033 00100 3T2034 00100 3T2035 00100 3T2035 00200 4T2036 00100 3T2037 00100 3T2038 00100 3T2039 00100 3T2040 00100 3T2041 00100 3T2042 00100 3T2043 00100 3T2044 00100 3T2045 00100 3T2046 00100 3T2048 00100 3T2048 00200 4T2048 00300 4T2049 00100 3T2101 00100 3T4521 00100 3T4522 00100 3T4523 00100 3T4524 00100 3T4525 00100 3T4525 00200 4T4526 00100 3T4526 00200 4T4527 00100 3T4527 00200 4T4528 00100 3T4528 00200 4T4529 00100 3T4529 00200 4T4530 00100 3T4531 00100 3T4531 00200 4T4532 00100 3T4532 00200 4T4533 00100 3T4534 00100 3T4535 00100 3T4536 00100 3

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T4537 00100 3T4538 00100 3T4539 00100 3T4540 00100 3T4541 00100 3T4542 00100 3T4543 00100 3T5001 00100 3T5999 00100 3V2020 00100 3V2025 00100 3V2100 00100 3V2101 00100 3V2102 00100 3V2103 00100 3V2103 00200 4V2104 00100 3V2104 00200 4V2105 00100 3V2105 00200 4V2106 00100 3V2106 00200 4V2107 00100 3V2107 00200 4V2108 00100 3V2108 00200 4V2109 00100 3V2109 00200 4V2110 00100 3V2110 00200 4V2111 00100 3V2111 00200 4V2112 00100 3V2112 00200 4V2113 00100 3V2113 00200 4V2114 00100 3V2115 00100 3V2118 00100 3V2121 00100 3V2199 00100 3V2200 00100 3V2201 00100 3V2202 00100 3V2203 00100 3V2203 00200 4V2204 00100 3V2204 00200 4V2205 00100 3V2205 00200 4V2206 00100 3V2206 00200 4V2207 00100 3V2207 00200 4

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V2208 00100 3V2208 00200 4V2209 00100 3V2209 00200 4V2210 00100 3V2210 00200 4V2211 00100 3V2211 00200 4V2212 00100 3V2212 00200 4V2213 00100 3V2213 00200 4V2214 00100 3V2215 00100 3V2218 00100 3V2219 00100 3V2220 00100 3V2221 00100 3V2299 00100 3V2300 00100 3V2301 00100 3V2302 00100 3V2303 00100 3V2303 00200 4V2304 00100 3V2304 00200 4V2305 00100 3V2305 00200 4V2306 00100 3V2306 00200 4V2307 00100 3V2307 00200 4V2308 00100 3V2308 00200 4V2309 00100 3V2309 00200 4V2310 00100 3V2310 00200 4V2311 00100 3V2311 00200 4V2312 00100 3V2312 00200 4V2313 00100 3V2313 00200 4V2314 00100 3V2315 00100 3V2318 00100 3V2319 00100 3V2320 00100 3V2321 00100 3V2399 00100 3V2410 00100 3V2430 00100 3V2499 00100 3

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V5260 00100 3V5261 00100 3V5262 00100 3V5263 00100 3V5264 00100 3V5265 00100 3V5266 00100 3V5267 00100 3V5268 00100 3V5269 00100 3V5270 00100 3V5271 00100 3V5272 00100 3V5273 00100 3V5274 00100 3V5275 00100 3V5298 00100 3V5299 00100 3V5336 00100 3V5336 00200 4V5362 00100 3V5363 00100 3V5364 00100 3

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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 PSYCHOLOGISTPRINCIPAL PHYSICIAN OF RECORDCLINICAL 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 OR SERVICE FURNISHED TO AN ESRD PATIENT THAT IS NOT FOR THE TREATMENT OFESRDPHYSICIAN PROVIDING A SERVICE IN A DENTAL HEALTH PROFESSIONAL SHORTAGE AREA FORTHE PURPOSE OF AN ELECTRONIC HEALTH RECORD INCENTIVE PAYMENTITEM 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)

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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 BILLABLEPOLICY CRITERIA APPLIEDCATASTROPHE/DISASTER RELATEDITEM OR SERVICE RELATED, IN WHOLE OR IN PART, TO AN ILLNESS, INJURY, ORCONDITION THAT WAS CAUSED BY OR EXACERBATED BY THE EFFECTS, DIRECT OR INDIRECT,OF THE 2010 OIL SPILL IN THE GULF OF MEXICO, INCLUDING BUT NOT LIMITED TOSUBSEQUENT CLEAN-UP ACTIVITIEORAL HEALTH ASSESSMENT BY A LICENSED HEALTH PROFESSIONAL OTHER THAN A DENTISTUPPER 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 60

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MOST 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 ISSUED AS REQUIRED BY PAYER POLICY, INDIVIDUALCASECLAIM 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 SERVICESTHIS 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 SYSTEMSWAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYER POLICY, ROUTINE NOTICEATTENDING PHYSICIAN NOT EMPLOYED OR PAID UNDER ARRANGEMENT BY THE PATIENT'SHOSPICE PROVIDERSERVICE NOT RELATED TO THE HOSPICE PATIENT'S TERMINAL CONDITIONNOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICYITEM 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 GERIATRIC

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ADULT 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 ASWRITTEN, REIMBURSED UNDER AVERAGE SALES PRICE METHODOLOGYDMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM THAT IS FURNISHED BYA HOSPITAL UPON DISCHARGEADMINISTERED 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, EXHIBITING

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HIGH 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 IMPLANTLEFT 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 WARRANTYNEBULIZER SYSTEM, ANY TYPE, FDA-CLEARED FOR USE WITH SPECIFIC DRUGNEW 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 PURPOSESSURGICAL OR OTHER INVASIVE PROCEDURE ON WRONG BODY PARTSURGICAL OR OTHER INVASIVE PROCEDURE ON WRONG PATIENT

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WRONG SURGERY OR OTHER INVASIVE PROCEDURE ON PATIENTPOSITRON EMISSION TOMOGRAPHY (PET) OR PET/COMPUTED TOMOGRAPHY (CT) TO INFORMTHE INITIAL TREATMENT STRATEGY OF TUMORS THAT ARE BIOPSY PROVEN OR STRONGLYSUSPECTED OF BEING CANCEROUS BASED ON OTHER DIAGNOSTIC TESTINGPROGRESSIVE ADDITION LENSESPOSITRON EMISSION TOMOGRAPHY (PET) OR PET/COMPUTED TOMOGRAPHY (CT) TO INFORMTHE SUBSEQUENT TREATMENT STRATEGY OF CANCEROUS TUMORS WHEN THE BENEFICIARY'STREATING PHYSICIAN DETERMINES THAT THE PET STUDY IS NEEDED TO INFORM SUBSEQUENTANTI-TUMOR STRATEGYCOLORECTAL CANCER SCREENING TEST; CONVERTED TO DIAGNOSTIC TEST OR OTHERPROCEDUREINVESTIGATIONAL 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 EXEMPTIONSINGLE 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.ITEM OR SERVICE PROVIDED IN A MEDICARE SPECIFIED STUDYMONITORED ANESTHESIA CARE SERVICERECORDING AND STORAGE ON TAPE BY AN ANALOG TAPE RECORDERITEM 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, ORTHOTIC OR PROSTHETIC ITEMREPLACEMENT OF A PART OF A DME, ORTHOTIC OR PROSTHETIC ITEM FURNISHED AS PART

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OF A REPAIRRIGHT CORONARY ARTERYDRUG 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/LVN

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INTERMEDIATE 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 VEHICLEBASIC 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 SERVEDVASCULAR CATHETER (ALONE OR WITH ANY OTHER VASCULAR ACCESS)ARTERIOVENOUS GRAFT (OR OTHER VASCULAR ACCESS NOT INCLUDING A VASCULAR CATHETER)ARTERIOVENOUS FISTULA ONLY (IN USE WITH TWO NEEDLES)INFECTION PRESENTNO INFECTION PRESENTAPHAKIC 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; TAXI

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NON-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)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 MILENONCOVERED 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 INJECTIONS

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NON-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 PINTBETADINE 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 50STRIPSPLATFORMS 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 100CERVICAL CAP FOR CONTRACEPTIVE USETEMPORARY, ABSORBABLE LACRIMAL DUCT IMPLANT, EACHPERMANENT, LONG TERM, NON-DISSOLVABLE LACRIMAL DUCT IMPLANT, EACHPERMANENT IMPLANTABLE CONTRACEPTIVE INTRATUBAL OCCLUSION DEVICE(S) AND DELIVERYSYSTEMPARAFFIN, 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, REPLACEMENT

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POLYCARBONATE 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, EACHURINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, EACHURINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACHINCONTINENCE SUPPLY; MISCELLANEOUSINCONTINENCE SUPPLY, URETHRAL INSERT, ANY TYPE, EACHINDWELLING 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 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 OR

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WITHOUT TUBE, EACHURINARY DRAINAGE BAG, LEG OR ABDOMEN, VINYL, WITH OR WITHOUT TUBE, WITH STRAPS,EACHDISPOSABLE EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE, WITH PAD AND/ORPOUCH, 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-INCONVEXITY (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, WITH OR WITHOUT BRUSHOSTOMY IRRIGATION SETLUBRICANT, PER OUNCEOSTOMY RING, EACHOSTOMY SKIN BARRIER, NON-PECTIN BASED, PASTE, PER OUNCE

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OSTOMY 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, WITHFAUCET-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 OUNCE

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ADHESIVE REMOVER, WIPES, ANY TYPE, EACHENEMA BAG WITH TUBING, REUSABLESURGICAL DRESSING HOLDER, NON-REUSABLE, EACHSURGICAL DRESSING HOLDER, REUSABLE, EACHNON-ELASTIC BINDER FOR EXTREMITYGARMENT, BELT, SLEEVE OR OTHER COVERING, ELASTIC OR SIMILAR STRETCHABLEMATERIAL, ANY TYPE, EACHGRAVLEE 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 TYPESLINGSSHOULDER SLING OR VEST DESIGN, ABDUCTION RESTRAINER, WITH OR WITHOUT SWATHECONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSPLINTTOPICAL 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, EACH

PUF___2011_Web_File

SPACER, BAG OR RESERVOIR, WITH OR WITHOUT MASK, FOR USE WITH METERED DOSEINHALEROROPHARYNGEAL SUCTION CATHETER, EACHTRACHEOSTOMY CARE KIT FOR ESTABLISHED TRACHEOSTOMYREPLACEMENT BATTERIES, MEDICALLY NECESSARY, TRANSCUTANEOUS ELECTRICALSTIMULATOR, OWNED BY PATIENTREPLACEMENT 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 6MILLICURIESTISSUE MARKER, IMPLANTABLE, ANY TYPE, EACHSURGICAL SUPPLY; MISCELLANEOUSIMPLANTABLE RADIATION DOSIMETER, EACHCALIBRATED MICROCAPILLARY TUBE, EACHMICROCAPILLARY TUBE SEALANTPERITONEAL DIALYSIS CATHETER ANCHORING DEVICE, BELT, 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 DIALYSIS

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DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN5999CC, FOR PERITONEAL DIALYSISDIALYSATE SOLUTION, NON-DEXTROSE CONTAINING, 500 MLFISTULA 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 DRAINAGE BAG, LEG OR ABDOMEN, LATEX, WITH OR WITHOUT TUBE, WITH STRAPS,EACHLEG STRAP; LATEX, REPLACEMENT ONLY, PER SETLEG STRAP; FOAM OR FABRIC, REPLACEMENT ONLY, PER SETSKIN BARRIER, WIPES OR SWABS, EACHSKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, EACHSKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, EACH

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ADHESIVE 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-SHELFDEPTH-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, COMPRESSION MOLDED TO PATIENT'S FOOT WITHOUTEXTERNAL HEAT SOURCE, MULTIPLE-DENSITY INSERT(S) PREFABRICATED, 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, 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, EACHDRESSING

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COMPOSITE 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 DRESSINGCONTACT 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 DRESSING

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GAUZE, 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 DRESSINGHYDROGEL 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, 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, ANY TYPE, ANY SIZEWOUND FILLER, GEL/PASTE, PER FLUID OUNCE, NOT OTHERWISE SPECIFIEDWOUND FILLER, DRY FORM, PER GRAM, NOT OTHERWISE SPECIFIEDGAUZE, IMPREGNATED, OTHER THAN WATER, NORMAL SALINE, OR ZINC PASTE, STERILE,ANY WIDTH, PER LINEAR YARD

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GAUZE, 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 THREEINCHES, 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 FABRICATED

PUF___2011_Web_File

COMPRESSION 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/SLEEVE, NOT OTHERWISE SPECIFIEDWOUND CARE SET, FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, INCLUDESALL SUPPLIES AND ACCESSORIESCANISTER, 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,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 COMPRESSOR OR ULTRASONIC GENERATORFILTER, 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 MLINTERFACE FOR COUGH STIMULATING DEVICE, INCLUDES ALL COMPONENTS, REPLACEMENTONLYHIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, REPLACEMENT FOR USE WITHPATIENT OWNED EQUIPMENT, EACH

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HIGH 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, EACHTRACHEOSTOMY/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 ACCESSORIES

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HELMET, 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 SERVICEHOT WATER BOTTLE, ICE CAP OR COLLAR, HEAT AND/OR COLD WRAP, ANY TYPEEXTERNAL 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 DOSETECHNETIUM 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 MILLICURIESTECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIEIODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999MICROCURIESIODINE I-131 SODIUM IODIDE CAPSULE(S), THERAPEUTIC, PER MILLICURIETECHNETIUM TC-99M EXAMETAZIME, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIESIODINE I-131 IODINATED SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIESNITROGEN 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)

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IODINE I-125 SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIESINJECTION, 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 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 1MICROCURIETECHNETIUM 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 OTHERWISE

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SPECIFIED (NOS), PER MLSODIUM FLUORIDE F-18, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIESINJECTION, GADOXETATE DISODIUM, 1 MLIODINE I-123 IOBENGUANE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIESINJECTION, GADOFOSVESET TRISODIUM, 1 MLSTRONTIUM SR-89 CHLORIDE, THERAPEUTIC, PER MILLICURIESAMARIUM SM-153 LEXIDRONAM, THERAPEUTIC, PER TREATMENT DOSE, UP TO 150MILLICURIESSAMARIUM 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 DAY, INCLUDES BUT NOT LIMITED TOFEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPEENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY, INCLUDES BUT NOT LIMITED TOFEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPEENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAY, INCLUDES BUT NOT LIMITED TOFEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPENASOGASTRIC 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 = 1UNITENTERAL 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 SPECIFIC

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NUTRIENTS, 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, PER 10 GRAMS LIPIDSPARENTERAL 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 DAYPARENTERAL NUTRITION SUPPLY KIT; PREMIX, PER DAYPARENTERAL NUTRITION SUPPLY KIT; HOME MIX, PER DAY

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PARENTERAL 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 SUPPLIESHYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVALANCHOR/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 FEWERELECTRODES)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-TIPENDOSCOPE, RETROGRADE IMAGING/ILLUMINATION COLONOSCOPE DEVICE (IMPLANTABLE)CATHETER, 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)

PUF___2011_Web_File

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)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 SYSTEMMATERIAL 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-AWAY

PUF___2011_Web_File

INTRODUCER/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 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,ABDOMENMAGNETIC 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;

PUF___2011_Web_File

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), INCLUDES M-MODERECORDING, WHEN PERFORMED, COMPLETE, WITHOUT SPECTRAL OR COLOR DOPPLERECHOCARDIOGRAPHYTRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BYWITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODERECORDING, WHEN PERFORMED, 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), INCLUDES M-MODERECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USINGTREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITHINTERPRETATION 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 SUPERVISIONMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,SPINAL CANAL AND CONTENTSMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS

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MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,SPINAL CANAL AND CONTENTSMAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITYMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITYMAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,UPPER EXTREMITYINTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION(MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMPPALIVIZUMAB-RSV-IGM, PER 50 MGINJECTION, PANTOPRAZOLE SODIUM, PER VIALINJECTION, ARGATROBAN, PER 5 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 MGINJECTION, ROMIPLOSTIM, 10 MCGINJECTION, GADOXETATE DISODIUM, PER MLIOBENGUANE, I-123, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIESINJECTION, CLEVIDIPINE BUTYRATE, 1 MGINJECTION, CERTOLIZUMAB PEGOL, 1 MGHUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2MLINJECTION, C1 ESTERASE INHIBITOR (HUMAN), 10 UNITSINJECTION, PLERIXAFOR, 1 MGINJECTION, TEMOZOLOMIDE, 1 MGINJECTION, LACOSAMIDE, 1 MGINJECTION, PALIPERIDONE PALMITATE, 1 MGINJECTION, DEXAMETHASONE INTRAVITREAL IMPLANT, 0.1 MGINJECTION, BEVACIZUMAB, 0.25 MGINJECTION, TELAVANCIN, 10 MGINJECTION, PRALATREXATE, 1 MGINJECTION, OFATUMUMAB, 10 MGINJECTION, USTEKINUMAB, 1 MGFLUDARABINE PHOSPHATE, ORAL, 1 MGINJECTION, ECALLANTIDE, 1 MGINJECTION, TOCILIZUMAB, 1 MGINJECTION, ROMIDEPSIN, 1 MGINJECTION, COLLAGENASE CLOSTRIDIUM HISTOLYTICUM, 0.1 MGINJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, PER 100 IU VWF: RCOCAPSAICIN, PATCH, 10CM2INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITSINJECTION, IMMUNE GLOBULIN (GAMMAPLEX), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MGINJECTION, VELAGLUCERASE ALFA, 100 UNITSINJECTION, DENOSUMAB, 1 MGSIPULEUCEL-T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS ACTIVATED WITH

PUF___2011_Web_File

PAP-GM-CSF, INCLUDING LEUKAPHERESIS AND ALL OTHER PREPARATORY PROCEDURES, PERINFUSIONCROTALIDAE POLYVALENT IMMUNE FAB (OVINE), 1 VIALINJECTION, HEXAMINOLEVULINATE HYDROCHLORIDE, 100 MG, PER STUDY DOSEINJECTION, CABAZITAXEL, 1 MGINJECTION, ALGLUCOSIDASE ALFA (LUMIZYME), 1 MGINJECTION, INCOBOTULINUMTOXIN A, 1 UNITINJECTION, IBUPROFEN, 100 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, FETAL BOVINE ORIGIN(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 CCDERMAL SUBSTITUTE, NATIVE, NON-DENATURED COLLAGEN, NEONATAL BOVINE ORIGIN(SURGIMEND COLLAGEN MATRIX), PER 0.5 SQUARE CENTIMETERSCOLLAGEN MATRIX NERVE WRAP (NEUROMEND COLLAGEN NERVE WRAP), PER 0.5 CENTIMETERLENGTHPOROUS PURIFIED COLLAGEN MATRIX BONE VOID FILLER (INTEGRA MOZAIKOSTEOCONDUCTIVE SCAFFOLD STRIP), PER 0.5 CCSKIN SUBSTITUTE, INTEGRA MESHED BILAYER WOUND MATRIX, PER SQUARE CENTIMETERPORCINE IMPLANT, PERMACOL, PER SQUARE CENTIMETERSKIN SUBSTITUTE, ENDOFORM DERMAL TEMPLATE, PER SQUARE CENTIMETERUNCLASSIFIED DRUGS OR BIOLOGICALSCREATIONS OF THERMAL ANAL LESIONS BY RADIOFREQUENCY ENERGYDYNAMIC 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), FOR OTHER THAN THE FOLLOWING SITES (ANYAPPROACH): ABDOMEN, PELVIS, PROSTATE, RETROPERITONEUM, THORAX, SINGLE ORMULTIPLEDERMAL INJECTION PROCEDURE(S) FOR FACIAL LIPODYSTROPHY SYNDROME (LDS) ANDPROVISION OF RADIESSE OR SCULPTRA DERMAL FILLER, INCLUDING ALL ITEMS ANDSUPPLIESSMOKING AND TOBACCO CESSATION COUNSELING VISIT FOR THE ASYMPTOMATIC PATIENT;

PUF___2011_Web_File

INTERMEDIATE, GREATER THAN 3 MINUTES, UP TO 10 MINUTESSMOKING AND TOBACCO CESSATION COUNSELING VISIT FOR THE ASYMPTOMATIC PATIENT;INTENSIVE, GREATER THAN 10 MINUTESRADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAYIMPLANTED PROSTHETIC DEVICE, PAYABLE ONLY FOR INPATIENTS WHO DO NOT HAVEINPATIENT COVERAGECANE, 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 OR STATIONARY, 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, EACHCOMMODE 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, EACHPOWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,INCLUDES HEAVY DUTY

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PUMP 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 UNIT, FOR REPLACEMENT ONLYHOSPITAL 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 SIDERAILS, WITHOUT MATTRESS

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HOSPITAL 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 MATTRESS

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LENGTH 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, ANDTUBINGSTATIONARY 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; HOME LIQUEFIER USED TO FILL PORTABLELIQUID OXYGEN CONTAINERS, INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER,HUMIDIFIER, CANNULA OR MASK AND TUBING, WITH OR WITHOUT SUPPLY RESERVOIR ANDCONTENTS GAUGEPORTABLE 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, ANDTUBINGSTATIONARY OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNITSTATIONARY OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNITPORTABLE OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNITPORTABLE OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNITOXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELYTOPICAL OXYGEN DELIVERY SYSTEM, NOT OTHERWISE SPECIFIED, INCLUDES ALL SUPPLIESAND ACCESSORIESVOLUME 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 RATE

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FEATURE, 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 ACCESSORIESIPPB 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 HEATERRESPIRATORY 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-ELECTRIC

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SEPARATE 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 PRESSURENON-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, DEVICE OR ACCESSORY, ANY TYPETRANSFER 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/ORTRAINER

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NEUROMUSCULAR 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 IMPLANTEDELECTRONIC SALIVARY REFLEX STIMULATOR (INTRA-ORAL/NON-INVASIVE)OSTEOGENESIS 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 PROGRAMFDA 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 BAR

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FRACTURE 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, 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, EACHMANUAL 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, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY,EACHMANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACHWHEELCHAIR 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, EACHWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLYWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEARREDUCTIONWHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEARREDUCTION

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WHEELCHAIR 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,EACHRESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIRWHEELCHAIR 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 GIVER, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 LBSMULTI-POSITIONAL PATIENT TRANSFER SYSTEM, EXTRA-WIDE, WITH INTEGRATED SEAT,OPERATED BY CAREGIVER, PATIENT WEIGHT CAPACITY GREATER THAN 300 LBSTRANSPORT 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 DETACHABLE

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FOOTRESTHIGH 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 ELEVATINGLEGRESTSAMPUTEE 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 FOOTRESTWHEELCHAIR; 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 SEATINGSYSTEM

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WHEELCHAIR, 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 CONSTRUCTIONWHIRLPOOL, 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 10

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UNIPUNCTURE 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 INTERFACEMATERIALSTATIC 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 INTERFACEMATERIALSTATIC PROGRESSIVE STRETCH TOE DEVICE, EXTENSION AND/OR FLEXION, WITH ORWITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIESDYNAMIC ADJUSTABLE SHOULDER FLEXION / ABDUCTION / ROTATION DEVICE, INCLUDESSOFT INTERFACE MATERIALSTATIC PROGRESSIVE STRETCH SHOULDER DEVICE, WITH OR WITHOUT RANGE OF MOTIONADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES

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COMMUNICATION 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, EACHMANUAL 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 SYSTEM

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POWER 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 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 HARDWAREPOWER 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,

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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, EACHPOWER 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 ALL

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RELATED 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 HARDWARESKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES,ANY DEPTH

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SKIN 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 DEPTHGAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES ANDCOMPONENTSGAIT 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 HUHNERCERVICAL 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 ENEMADIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, INDIVIDUAL, PER 30MINUTESDIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, GROUP SESSION (2 ORMORE), PER 30 MINUTESGLAUCOMA 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 PHYSICIANTRIMMING 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), COLLECTED

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IN 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 PERFORMED BY A QUALIFIED PHYSICAL THERAPIST IN THE HOME HEALTH ORHOSPICE SETTING, EACH 15 MINUTESSERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST IN THE HOME HEALTH ORHOSPICE SETTING, EACH 15 MINUTESSERVICES PERFORMED BY A QUALIFIED SPEECH-LANGUAGE PATHOLOGIST IN THE HOMEHEALTH OR HOSPICE SETTING, EACH 15 MINUTESDIRECT SKILLED NURSING SERVICES OF A LICENSED NURSE (LPN OR RN) IN THE HOMEHEALTH OR HOSPICE SETTING, EACH 15 MINUTESSERVICES OF CLINICAL SOCIAL WORKER IN HOME HEALTH OR HOSPICE SETTINGS, EACH 15MINUTESSERVICES OF HOME HEALTH/HOSPICE AIDE IN HOME HEALTH OR HOSPICE SETTINGS, EACH15 MINUTESSERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST ASSISTANT IN THE HOMEHEALTH OR HOSPICE SETTING, EACH 15 MINUTESSERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST ASSISTANT IN THE HOMEHEALTH OR HOSPICE SETTING, EACH 15 MINUTESSERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST, IN THE HOME HEALTHSETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE THERAPYMAINTENANCE PROGRAM, EACH 15 MINUTESSERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST, IN THE HOME HEALTHSETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE THERAPYMAINTENANCE PROGRAM, EACH 15 MINUTESSERVICES PERFORMED BY A QUALIFIED SPEECH-LANGUAGE PATHOLOGIST, IN THE HOMEHEALTH SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVETHERAPY MAINTENANCE PROGRAM, EACH 15 MINUTESSKILLED SERVICES BY A REGISTERED NURSE (RN) IN THE DELIVERY OF MANAGEMENT &EVALUATION OF THE PLAN OF CARE; EACH 15 MINUTES (THE PATIENT'S UNDERLYINGCONDITION OR COMPLICATION REQUIRES AN RN TO ENSURE THAT ESSENTIAL NON-SKILLEDCARE ACHIEVE ITS PURPOSE IN THE HOME HEALTH OR HOSPICE SETTING)SKILLED SERVICES OF A LICENSED NURSE (LPN OR RN) IN THE DELIVERY OF OBSERVATION& ASSESSMENT OF THE PATIENT'S CONDITION, EACH 15 MINUTES (WHEN THE LIKELIHOODOF CHANGE IN THE PATIENT'S CONDITION REQUIRES SKILLED NURSING PERSONNEL TOIDENTIFY AND EVALUATE THE PATIENT'S NEED FOR POSSIBLE MODIFICATION OF TREATMENTIN THE HOME HEALTH OR HOSPICE SETTING)SKILLED SERVICES OF A LICENSED NURSE, IN THE TRAINING AND/OR EDUCATION OF APATIENT OR FAMILY MEMBER, IN THE HOME HEALTH OR HOSPICE 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 PRESENT

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ACTIVITY 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)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; MELANOMA FOR NON-COVERED INDICATIONSPET 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)INITIAL 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 WITH

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DIABETIC 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 INITIATION 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'S ABILITY TOPERFORM TESTING AND REPORT RESULTSPROVISION 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;TESTING NOT OCCURRING MORE FREQUENTLY THAN ONCE A WEEK; TESTING MATERIALS,BILLING UNITS OF SERVICE INCLUDE 4 TESTSPHYSICIAN REVIEW, INTERPRETATION, AND PATIENT MANAGEMENT OF HOME INR TESTINGFOR PATIENT WITH EITHER MECHANICAL HEART VALVE(S), CHRONIC ATRIAL FIBRILLATION,OR VENOUS THROMBOEMBOLISM WHO MEETS MEDICARE COVERAGE CRITERIA; TESTING NOTOCCURRING MORE FREQUENTLY THAN ONCE A WEEK; BILLING UNITS OF SERVICE INCLUDE 4TESTSLINEAR 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)CURRENT 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 FACILITYINJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPYINJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROIDAND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHYCRYOPRESERVATION, 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, MEDICAL

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CONDITION 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)ELECTRICAL 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 USESINSERTION 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 SERVICES

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POST-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 OFPARENTS; 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 OFPARENTS

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END 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)PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS ABENEFICIARYHOSPICE EVALUATION AND COUNSELING SERVICES, PRE-ELECTIONIMAGE-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 ENROLLMENTBONE 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 AUTOGENOUSHEMODIALYSIS 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 EXAMINATION

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INTERPRETATION AND REPORT ONLY, PERFORMED AS A COMPONENT OF THE INITIALPREVENTIVE EXAMINATIONPHYSICIAN SERVICE REQUIRED TO ESTABLISH AND DOCUMENT THE NEED FOR A POWERMOBILITY DEVICESMOKING 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 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 IMMEDIATELY

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PRECEDING 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 TELEHEALTH

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SOCIAL 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)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 SPECIMENSFACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEYDISEASE; INDIVIDUAL, PER SESSION, PER ONE HOURFACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEYDISEASE; GROUP, PER SESSION, PER ONE HOURINTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG MONITORINGWITH EXERCISE, PER SESSIONINTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG MONITORING;WITHOUT EXERCISE, PER SESSIONPULMONARY REHABILITATION, INCLUDING EXERCISE (INCLUDES MONITORING), ONE HOUR,PER SESSION, UP TO TWO SESSIONS PER DAYINITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 30 MINUTES COMMUNICATINGWITH THE PATIENT VIA TELEHEALTHINITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 50 MINUTES COMMUNICATINGWITH THE PATIENT VIA TELEHEALTHINITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 70 MINUTES OR MORECOMMUNICATING WITH THE PATIENT VIA TELEHEALTHCOLLAGEN MENISCUS IMPLANT PROCEDURE FOR FILLING MENISCAL DEFECTS (E.G., CMI,COLLAGEN SCAFFOLD, MENAFLEX)DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME(LDS) (E.G., AS A RESULT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY)DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES OTHER THAN CHROMATOGRAPHICMETHOD, EACH PROCEDUREDRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES BY HIGH COMPLEXITY TEST METHOD(E.G., IMMUNOASSAY, ENZYME ASSAY), PER PATIENT ENCOUNTERINFECTIOUS AGENT ANTIBODY DETECTION BY ENZYME IMMUNOASSAY (EIA) TECHNIQUE,

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HIV-1 AND/OR HIV-2, SCREENINGINFECTIOUS AGENT ANTIBODY DETECTION BY ENZYME-LINKED IMMUNOSORBENT ASSAY(ELISA) TECHNIQUE, HIV-1 AND/OR HIV-2, SCREENINGDRUG SCREEN, OTHER THAN CHROMATOGRAPHIC; ANY NUMBER OF DRUG CLASSES, BY CLIAWAIVED TEST OR MODERATE COMPLEXITY TEST, PER PATIENT ENCOUNTERINFECTIOUS AGENT ANTIBODY DETECTION BY RAPID ANTIBODY TEST, HIV-1 AND/OR HIV-2,SCREENINGSMOKING AND TOBACCO CESSATION COUNSELING VISIT FOR THE ASYMPTOMATIC PATIENT;INTERMEDIATE, GREATER THAN 3 MINUTES, UP TO 10 MINUTESSMOKING AND TOBACCO CESSATION COUNSELING VISIT FOR THE ASYMPTOMATIC PATIENT;INTENSIVE, GREATER THAN 10 MINUTESANNUAL WELLNESS VISIT; INCLUDES A PERSONALIZED PREVENTION PLAN OF SERVICE(PPS), INITIAL VISITANNUAL WELLNESS VISIT, INCLUDES A PERSONALIZED PREVENTION PLAN OF SERVICE(PPS), SUBSEQUENT VISITAPPLICATION OF TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE OR DERMAL SUBSTITUTE;FOR USE ON LOWER LIMB, INCLUDES THE SITE PREPARATION AND DEBRIDEMENT IFPERFORMED; FIRST 25 SQ CM OR LESSAPPLICATION OF TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE OR DERMAL SUBSTITUTE;FOR USE ON LOWER LIMB, INCLUDES THE SITE PREPARATION AND DEBRIDEMENT IFPERFORMED; EACH ADDITIONAL 25 SQ CMADMINISTRATION 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 MEASURE

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CLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC PATIENT FOR THE REQUIRED TIMEFOR LOW-DENSITY LIPOPROTEIN MEASURE (12 MONTHS)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 MEASURE

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PATIENT 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 ELIGIBLECANDIDATE 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 FOR

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MAMMOGRAPHY 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 PHASEPATIENT 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 CLOPIDOGREL

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CLINICIAN 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 ANTIBIOTICCLINICIAN 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 TIME

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CLINICIAN 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 DISCHARGEPATIENT 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 MEASUREMENT

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NOT 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 RECORDPATIENT 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 INCONTINENCE

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CLINICIAN 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 PRESCRIBEDCOPD 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 SPECIFIC

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TARGET 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 MEASUREMENTPATIENT DOCUMENTED TO HAVE RECEIVED DILATED MACULAR OR FUNDUS EXAM WITH LEVELOF SEVERITY OF RETINOPATHY AND THE PRESENCE OR ABSENCE OF MACULAR EDEMADOCUMENTED

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PATIENT 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 RECEIVE

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ASPIRINPATIENT DOCUMENTED TO HAVE HAD ECG PERFORMEDPATIENT NOT DOCUMENTED TO HAVE HAD ECGCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ECGPATIENT 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 STORES

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PRIOR 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 PERFORMEDPATIENT 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 (INCLUDES PRESCRIPTION, OVER-THE-COUNTER, HERBALS,VITAMIN/MINERAL/DIETARY [NUTRITIONAL] SUPPLEMENTS) DOCUMENTED BY THE PROVIDER,INCLUDING DRUG NAME, DOSAGE, FREQUENCY AND ROUTECURRENT MEDICATIONS (INCLUDES PRESCRIPTION, OVER-THE-COUNTER, HERBALS,VITAMIN/MINERAL/DIETARY [NUTRITIONAL] SUPPLEMENTS) WITH DRUG NAME, DOSAGE,

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FREQUENCY AND ROUTE NOT DOCUMENTED BY THE PROVIDER, REASON NOT SPECIFIEDINCOMPLETE 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 REPRESENTATIVENO 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 THERAPY OR DOCUMENTATION OF THE ABSENCE OFPAIN 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 THERAPYDOCUMENTATION 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 AN EHR SYSTEM THAT HAS BEEN CERTIFIED BYAN AUTHORIZED TESTING AND CERTIFICATION BODY (ATCB)PATIENT ENCOUNTER WAS DOCUMENTED USING A PQRI QUALIFIED EHR OR OTHER ACCEPTABLESYSTEMSPATIENT 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 THERAPY

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BETA-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 REMISSIONDOCUMENTATION 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 SPECIFIED

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CLINICIAN 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 PATIENTALL 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 THERAPY OR DOCUMENTATION OF THE ABSENCE OFPAIN AS A RESULT OF ASSESSMENT THROUGH DISCUSSION WITH THE PATIENT INCLUDINGTHE USE OF A STANDARDIZED TOOL; NO DOCUMENTATION OF A FOLLOW-UP PLAN, PATIENT

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NOT ELIGIBLEDOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY ANDDESCRIPTION) PRIOR TO INITIATION OF THERAPY OR DOCUMENTATION OF THE ABSENCE OFPAIN 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 SPECIFIEDAUTOGENOUS 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 NOTSPECIFIED

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DOCUMENTATION 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 GROUPI INTEND TO REPORT THE HEPATITIS C MEASURES GROUPI INTEND TO REPORT THE COMMUNITY-ACQUIRED PNEUMONIA (CAP) MEASURES GROUPI INTEND TO REPORT THE ISCHEMIC VASCULAR DISEASE (IVD) MEASURES GROUPI INTEND TO REPORT THE HEART FAILURE (HF) MEASURES GROUPALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE HEPATITIS C MEASURESGROUP HAVE BEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE COMMUNITY-ACQUIREDPNEUMONIA (CAP) MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE HEART FAILURE (HF)MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENTALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE ISCHEMIC VASCULARDISEASE (IVD) MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENTAT LEAST ONE PRESCRIPTION CREATED DURING THE ENCOUNTER WAS GENERATED ANDTRANSMITTED ELECTRONICALLY USING A QUALIFIED ERX SYSTEMREFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN DISORDERS OFTHE EAR) FOR AN OTOLOGIC EVALUATIONPATIENT IS NOT ELIGIBLE FOR THE REFERRAL FOR OTOLOGIC EVALUATION MEASURENOT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN DISORDERSOF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIEDPATIENT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING INDISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATIONPATIENT HAS A HISTORY OF ACTIVE DRAINAGE FROM THE EAR WITHIN THE PREVIOUS 90DAYSPATIENT IS NOT ELIGIBLE FOR THE REFERRAL FOR OTOLOGIC EVALUATION FOR PATIENTSWITH A HISTORY OF ACTIVE DRAINAGE MEASUREPATIENT DOES NOT HAVE A HISTORY OF ACTIVE DRAINAGE FROM THE EAR WITHIN THEPREVIOUS 90 DAYSPATIENT NOT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING INDISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIEDPATIENT WAS REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING INDISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIED)VERIFICATION AND DOCUMENTATION OF SUDDEN OR RAPIDLY PROGRESSIVE HEARING LOSSPATIENT IS NOT ELIGIBLE FOR THE "REFERRAL FOR OTOLOGIC EVALUATION FOR SUDDEN ORRAPIDLY PROGRESSIVE HEARING LOSS" MEASUREPATIENT DOES NOT HAVE VERIFICATION AND DOCUMENTATION OF SUDDEN OR RAPIDLYPROGRESSIVE HEARING LOSSPATIENT WAS NOT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAININGIN DISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIED)PROLONGED INTUBATION (>24 HRS) REQUIREDPROLONGED INTUBATION (>24 HRS) NOT REQUIREDDEVELOPMENT OF DEEP STERNAL WOUND INFECTION WITHIN 30 DAYS POSTOPERATIVELYNO DEEP STERNAL WOUND INFECTIONSTROKE/CBA FOLLOWING ISOLATED CABG SURGERY

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NO STROKE/CVA FOLLOWING ISOLATED CABG SURGERYDEVELOPED POSTOPERATIVE RENAL INSUFFICIENCY OR REQUIRED DIALYSISNO POSTOPERATIVE RENAL INSUFFICIENCY/DIALYSIS NOT REQUIREDREOPERATION REQUIRED DUE TO BLEEDING/TAMPONADE, GRAFT OCCLUSION OR OTHERCARDIAC REASONREOPERATION NOT REQUIRED DUE TO BLEEDING/TAMPONADE, GRAFT OCCLUSION OR OTHERCARDIAC REASONANTIPLATELET MEDICATION AT DISCHARGEANTIPLATELET MEDICATION CONTRAINDICATED/NOT INDICATEDNO ANTIPLATELET MEDICATION AT DISCHARGEBETA-BLOCKER AT DISCHARGEBETA-BLOCKER CONTRAINDICATED/NOT INDICATEDNO BETA-BLOCKER AT DISCHARGEANTI-LIPID TREATMENT AT DISCHARGEANTI-LIPID TREATMENT CONTRAINDICATED/NOT INDICATEDNO ANTI-LIPID TREATMENT AT DISCHARGEMOST RECENT SYSTOLIC BLOOD PRESSURE < 140 MMHGMOST RECENT SYSTOLIC BLOOD PRESSURE >= 140 MMHGMOST RECENT DIASTOLIC BLOOD PRESSURE < 90 MMHGMOST RECENT DIASTOLIC BLOOD PRESSURE >= 90 MMHGNO DOCUMENTATION OF BLOOD PRESSURE MEASUREMENTLIPID PROFILE RESULTS DOCUMENTED AND REVIEWED (MUST INCLUDE TOTAL CHOLESTEROL,HDL-C, TRIGLYCERIDES AND CALCULATED LDL-C)LIPID PROFILE NOT PERFORMED, REASON NOT OTHERWISE SPECIFIEDMOST RECENT LDL-C < 100 MG/DLLDL-C WAS NOT PERFORMEDMOST RECENT LDL-C >= 100 MG/DLASPIRIN OR ANOTHER ANTITHROMBOTIC THERAPY USEDASPIRIN OR ANOTHER ANTITHROMBOTIC THERAPY NOT USED, REASON NOT OTHERWISESPECIFIEDIV T-PA INITIATED WITHIN THREE HOURS (<= 180 MINUTES) OF TIME LAST KNOWN WELLIV T-PA NOT INITIATED WITHIN THREE HOURS (<= 180 MINUTES) OF TIME LAST KNOWNWELL FOR REASONS DOCUMENTED BY CLINICIANIV T-PA NOT INITIATED WITHIN THREE HOURS (<= 180 MINUTES) OF TIME LAST KNOWNWELL, REASON NOT SPECIFIEDSCORE ON THE SPOKEN LANGUAGE COMPREHENSION FUNCTIONAL COMMUNICATION MEASURE ATDISCHARGE WAS HIGHER THAN AT ADMISSIONSCORE ON THE SPOKEN LANGUAGE COMPREHENSION FUNCTIONAL COMMUNICATION MEASURE ATDISCHARGE WAS NOT HIGHER THAN AT ADMISSION, REASON NOT SPECIFIEDPATIENT WAS NOT SCORED ON THE SPOKEN LANGUAGE COMPREHENSION FUNCTIONALCOMMUNICATION MEASURE EITHER AT ADMISSION OR AT DISCHARGESCORE ON THE ATTENTION FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS HIGHERTHAN AT ADMISSIONSCORE ON THE ATTENTION FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOTHIGHER THAN AT ADMISSION, REASON NOT SPECIFIEDPATIENT WAS NOT SCORED ON THE ATTENTION FUNCTIONAL COMMUNICATION MEASURE EITHERAT ADMISSION OR AT DISCHARGESCORE ON THE MEMORY FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS HIGHERTHAN AT ADMISSIONSCORE ON THE MEMORY FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOTHIGHER THAN AT ADMISSION, REASON NOT SPECIFIEDPATIENT WAS NOT SCORED ON THE MEMORY FUNCTIONAL COMMUNICATION MEASURE AT EITHERADMISSION OR AT DISCHARGESCORE ON THE MOTOR SPEECH FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS

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HIGHER THAN AT ADMISSIONSCORE ON THE MOTOR SPEECH FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOTHIGHER THAN AT ADMISSION, REASON NOT SPECIFIEDPATIENT WAS NOT SCORED ON THE MOTOR SPEECH FUNCTIONAL COMMUNICATION MEASUREEITHER AT ADMISSION OR AT DISCHARGESCORE ON THE READING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS HIGHERTHAN AT ADMISSIONSCORE ON THE READING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOTHIGHER THAN AT ADMISSION, REASON NOT SPECIFIEDPATIENT WAS NOT SCORED ON THE READING FUNCTIONAL COMMUNICATION MEASURE EITHERAT ADMISSION OR AT DISCHARGESCORE ON THE SPOKEN LANGUAGE EXPRESSION FUNCTIONAL COMMUNICATION MEASURE ATDISCHARGE WAS HIGHER THAN AT ADMISSIONSCORE ON THE SPOKEN LANGUAGE EXPRESSION FUNCTIONAL COMMUNICATION MEASURE ATDISCHARGE WAS NOT HIGHER THAN AT ADMISSION, REASON NOT SPECIFIEDPATIENT WAS NOT SCORED ON THE SPOKEN LANGUAGE EXPRESSION FUNCTIONALCOMMUNICATION MEASURE EITHER AT ADMISSION OR AT DISCHARGESCORE ON THE WRITING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS HIGHERTHAN AT ADMISSIONSCORE ON THE WRITING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOTHIGHER THAN AT ADMISSION, REASON NOT SPECIFIEDPATIENT WAS NOT SCORED ON THE WRITING FUNCTIONAL COMMUNICATION MEASURE EITHERAT ADMISSION OR AT DISCHARGESCORE ON THE SWALLOWING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WASHIGHER THAN AT ADMISSIONSCORE ON THE SWALLOWING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOTHIGHER THAN AT ADMISSION, REASON NOT SPECIFIEDPATIENT WAS NOT SCORED ON THE SWALLOWING FUNCTIONAL COMMUNICATION MEASURE ATADMISSION OR AT DISCHARGESURGICAL PROCEDURE PERFORMED WITHIN 30 DAYS FOLLOWING CATARACT SURGERY FORMAJOR COMPLICATIONS (E.G. RETAINED NUCLEAR FRAGMENTS, ENDOPHTHALMITIS,DISLOCATED OR WRONG POWER IOL, RETINAL DETACHMENT, OR WOUND DEHISCENCE)SURGICAL PROCEDURE NOT PERFORMED WITHIN 30 DAYS FOLLOWING CATARACT SURGERY FORMAJOR COMPLICATIONS (E.G. RETAINED NUCLEAR FRAGMENTS, ENDOPHTHALMITIS,DISLOCATED OR WRONG POWER IOL, RETINAL DETACHMENT, OR WOUND DEHISCENCE)DOCUMENTATION OF ORDER FOR PROPHYLACTIC PARENTERAL ANTIBIOTIC TO BE GIVENWITHIN ONE HOUR (IF FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICALINCISION (OR START OF PROCEDURE WHEN NO INCISION IS REQUIRED)DOCUMENTATION THAT ADMINISTRATION OF PROPHYLACTIC PARENTERAL ANTIBIOTICS WASINITIATED WITHIN ONE HOUR (IF FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIORTO SURGICAL INCISION (OR START OF PROCEDURE WHEN NO INCISION IS REQUIRED), ASORDEREDCLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ORDERINGPROPHYLACTIC PARENTERAL ANTIBIOTICS TO BE GIVEN WITHIN ONE HOUR (IFFLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR STARTOF PROCEDURE WHEN NO INCISION IS REQUIRED)PROPHYLACTIC PARENTERAL ANTIBIOTICS WERE NOT ORDERED TO BE GIVEN OR GIVENWITHIN ONE HOUR (IF FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO THESURGICAL INCISION (OR START OF PROCEDURE WHEN NO INCISION IS REQUIRED), REASONNOT OTHERWISE SPECIFIED)PHARMACOLOGIC THERAPY (OTHER THAN MINIERALS/VITAMINS) FOR OSTEOPOROSISPRESCRIBEDCLINICIAN DOCUMENTED PATIENT NOT AN ELIGIBLE CANDIDATE TO RECEIVE PHARMACOLOGICTHERAPY FOR OSTEOPOROSIS

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PHARMACOLOGIC THERAPY FOR OSTEOPOROSIS WAS NOT PRESCRIBED, REASON NOT OTHERWISESPECIFIEDINFLUENZA IMMUNIZATION ADMINISTERED OR PREVIOUSLY RECEIVEDCLINICIAN DOCUMENTED THAT PATIENT IS NOT ELIGIBLE TO RECEIVE THE INFLUENZAIMMUNIZATIONINFLUENZA IMMUNIZATION NOT ADMINISTERED OR PREVIOUSLY RECEIVED, REASON NOTOTHERWISE SPECIFIEDINFLUENZA IMMUNIZATION WAS ADMINISTERED OR PREVIOUSLY RECEIVEDCLINICIAN HAS DOCUMENTED THAT PATIENT IS NOT ELIGIBLE TO RECEIVE THE INFLUENZAIMMUNIZATIONINFLUENZA IMMUNIZATION WAS NOT ADMINISTERED OR PREVIOUSLY RECEIVED, REASON NOTOTHERWISE SPECIFIEDTHE ELIGIBLE PROFESSIONAL PRACTICES IN A RURAL AREA WITHOUT SUFFICIENT HIGHSPEED INTERNET ACCESS AND REQUESTS A HARDSHIP EXEMPTION FROM THE APPLICATION OFTHE PAYMENT ADJUSTMENT UNDER SECTION 1848(A)(5)(A) OF THE SOCIAL SECURITY ACTTHE ELIGIBLE PROFESSIONAL PRACTICES IN AN AREA WITHOUT SUFFICIENT AVAILABLEPHARMACIES FOR ELECTRONIC PRESCRIBING AND REQUESTS A HARDSHIP EXEMPTION FOR THEAPPLICATION OF THE PAYMENT ADJUSTMENT UNDER SECTION 1848(A)(5)(A) OF THE SOCIALSECURITY ACTELIGIBLE PROFESSIONAL DOES NOT HAVE PRESCRIBING PRIVILEGESI INTEND TO REPORT THE ASTHMA MEASURES GROUPALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE ASTHMA MEASURES GROUPHAVE BEEN PERFORMED FOR THIS PATIENTRISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE KNEE SUCCESSFULLYCALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE KNEE SUCCESSFULLYCALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE KNEE NOTMEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ONADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOTELIGIBLE/NOT APPROPRIATERISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE KNEE NOTMEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ONADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIEDRISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE HIP SUCCESSFULLYCALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE HIP SUCCESSFULLYCALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE HIP NOT MEASUREDBECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSIONAND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT ELIGIBLE/NOTAPPROPRIATERISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE HIP NOT MEASUREDBECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSIONAND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIEDRISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LOWER LEG, FOOTOR ANKLE SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATERTHAN ZERO(>0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LOWER LEG, FOOTOR ANKLE SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LOWER LEG, FOOTOR ANKLE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONALINTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOTELIGIBLE/NOT APPROPRIATE

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RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LOWER LEG, FOOTOR ANKLE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONALINTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOTSPECIFIEDRISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LUMBAR SPINESUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THANZERO (>0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LUMBAR SPINESUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LUMBAR SPINE NOTMEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ONADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOTELIGIBLE/NOT APPROPRIATERISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LUMBAR SPINE NOTMEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ONADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIEDRISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE SHOULDERSUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THANZERO (>0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE SHOULDERSUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE SHOULDER NOTMEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ONADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOTELIGIBLE/NOT APPROPRIATERISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE SHOULDER NOTMEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ONADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIEDRISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE ELBOW, WRIST ORHAND SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATERTHAN ZERO (>0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE ELBOW, WRIST ORHAND SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE ELBOW, WRIST ORHAND NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKEON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOTELIGIBLE/NOT APPROPRIATERISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE ELBOW, WRIST ORHAND NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKEON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIEDRISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE NECK, CRANIUM,MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENTSUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THANZERO (>0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE NECK, CRANIUM,MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENTSUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE NECK, CRANIUM,MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT NOTMEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ONADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOTELIGIBLE/NOT APPROPRIATERISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE NECK, CRANIUM,MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT NOT

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MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ONADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIEDMOST RECENT SYSTOLIC BLOOD PRESSURE >= 140 MM HGMOST RECENT DIASTOLIC BLOOD PRESSURE >= 90 MM HGMOST RECENT SYSTOLIC BLOOD PRESSURE < 130 MM HGMOST RECENT SYSTOLIC BLOOD PRESSURE 130 TO 139 MM HGMOST RECENT DIASTOLIC BLOOD PRESSURE < 80 MM HGMOST RECENT DIASTOLIC BLOOD PRESSURE 80 - 89 MM HGPATIENT HOSPITALIZED WITH PRINCIPAL DIAGNOSIS OF HEART FAILURE DURING THEMEASUREMENT PERIODLEFT VENTRICULAR FUNCTION TESTING PERFORMED DURING THE MEASUREMENT PERIODCLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR LEFTVENTRICULAR FUNCTION TESTING DURING THE MEASUREMENT PERIODPATIENT NOT HOSPITALIZED WITH PRINCIPAL DIAGNOSIS OF HEART FAILURE DURING THEMEASUREMENT PERIODLEFT VENTRICULAR FUNCTION TESTING NOT PERFORMED DURING THE MEASUREMENT PERIOD,REASON NOT SPECIFIEDCURRENTLY A TOBACCO SMOKER OR CURRENT EXPOSURE TO SECONDHAND SMOKECURRENTLY A TOBACCO NON-USER AND NO EXPOSURE TO SECONDHAND SMOKECURRENTLY A SMOKELESS TOBACCO USER (EG, CHEW, SNUFF) AND NO EXPOSURE TOSECONDHAND SMOKETOBACCO USE NOT ASSESSED, REASON NOT OTHERWISE SPECIFIEDCURRENT TOBACCO SMOKER OR CURRENT EXPOSURE TO SECONDHAND SMOKECURRENT TOBACCO NON-USER AND NO EXPOSURE TO SECONDHAND SMOKECURRENT SMOKELESS TOBACCO USER (EG, CHEW, SNUFF) AND NO EXPOSURE TO SECONDHANDSMOKETOBACCO USE NOT ASSESSED, REASON NOT SPECIFIEDCOORDINATED 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)AMANTADINE HYDROCHLORIDE, ORAL BRAND, PER 100 MG (FOR USE IN AMEDICARE-APPROVED DEMONSTRATION PROJECT)

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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)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 OTHER

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REASON(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 INCLUDEDUCTAL 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)

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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; 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)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 NO

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EVIDENCE 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,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)

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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; 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-APPROVED

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DEMONSTRATION 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; 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-APPROVEDDEMONSTRATION 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 HOURSINFLUENZA A (H1N1) IMMUNIZATION ADMINISTRATION (INCLUDES THE PHYSICIANCOUNSELING THE PATIENT/FAMILY)INFLUENZA A (H1N1) VACCINE, ANY ROUTE OF ADMINISTRATIONWARFARIN RESPONSIVENESS TESTING BY GENETIC TECHNIQUE USING ANY METHOD, ANYNUMBER OF SPECIMEN(S)OUTPATIENT INTRAVENOUS INSULIN TREATMENT (OIVIT) EITHER PULSATILE OR

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CONTINUOUS, BY ANY MEANS, GUIDED BY THE RESULTS OF MEASUREMENTS FOR:RESPIRATORY QUOTIENT; AND/OR, URINE UREA NITROGEN (UUN); AND/OR, ARTERIAL,VENOUS OR CAPILLARY GLUCOSE; AND/OR POTASSIUM CONCENTRATIONALCOHOL 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)ALCOHOL AND/OR DRUG PREVENTION PROBLEM IDENTIFICATION AND REFERRAL SERVICE(E.G. STUDENT ASSISTANCE AND EMPLOYEE ASSISTANCE PROGRAMS), DOES NOT INCLUDE

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ASSESSMENTALCOHOL 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 MINUTES

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SEXUAL 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 MINUTESMULTISYSTEMIC 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, ADRENALIN, EPINEPHRINE, 0.1 MGINJECTION, 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 MG

PUF___2011_Web_File

INJECTION, 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, ATROPINE SULFATE, 0.01 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 MGINJECTION, 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 AND PENICILLIN G PROCAINE, 100,000 UNITSINJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, 2500 UNITSINJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITSINJECTION, PENICILLIN G BENZATHINE, 100,000 UNITSINJECTION, PENICILLIN G BENZATHINE, UP TO 1,200,000 UNITSINJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 UNITSINJECTION, BIVALIRUDIN, 1 MGINJECTION, ONABOTULINUMTOXINA, 1 UNITINJECTION, ABOBOTULINUMTOXINA, 5 UNITSINJECTION, RIMABOTULINUMTOXINB, 100 UNITSINJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, BUSULFAN, 1 MGINJECTION, BUTORPHANOL TARTRATE, 1 MGINJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITSINJECTION, C-1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 UNITSINJECTION, 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, CANAKINUMAB, 1 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 MG

PUF___2011_Web_File

INJECTION, CAFFEINE CITRATE, 5MGINJECTION, CEPHAPIRIN SODIUM, UP TO 1 GMINJECTION, CEFTAZIDIME, PER 500 MGINJECTION, CEFTIZOXIME SODIUM, PER 500 MGINJECTION, CERTOLIZUMAB PEGOL, 1 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, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MGINJECTION, PROCHLORPERAZINE, UP TO 10 MGINJECTION, CORTICORELIN OVINE TRIFLUTATE, 1 MICROGRAMINJECTION, CORTICOTROPIN, UP TO 40 UNITSINJECTION, COSYNTROPIN, NOT OTHERWISE SPECIFIED, 0.25 MGINJECTION, COSYNTROPIN (CORTROSYN), 0.25 MGINJECTION, COSYNTROPIN, PER 0.25 MGINJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIALINJECTION, DAPTOMYCIN, 1 MGINJECTION, 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 MGINJECTION, 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 MG

PUF___2011_Web_File

INJECTION, 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, ECALLANTIDE, 1 MGINJECTION, 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 CCINJECTION, 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, IMMUNE GLOBULIN (HIZENTRA), 100 MGINJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CCINJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED (E.G.LIQUID), 500 MGINJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MGINJECTION, RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN, INTRAVENOUS, 50 MG

PUF___2011_Web_File

INJECTION, 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, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), NOTOTHERWISE SPECIFIED, 500 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, HUMAN FIBRINOGEN CONCENTRATE, 100 MGINJECTION, 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, IMIGLUCERASE, 10 UNITSINJECTION, DROPERIDOL, UP TO 5 MGINJECTION, PROPRANOLOL HCL, UP TO 1 MGINJECTION, 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-1A, 30 MCG

PUF___2011_Web_File

INJECTION 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, 0.1 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, OLANZAPINE, LONG-ACTING, 1 MGINJECTION, ORPHENADRINE CITRATE, UP TO 60 MGINJECTION, PHENYLEPHRINE HCL, UP TO 1 MLINJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML

PUF___2011_Web_File

INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MGINJECTION, OXYMORPHONE HCL, UP TO 1 MGINJECTION, PALIFERMIN, 50 MICROGRAMSINJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, 1 MGINJECTION, 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, PLERIXAFOR, 1 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, RILONACEPT, 1 MGINJECTION, RISPERIDONE, LONG ACTING, 0.5 MGINJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MGINJECTION, ROMIPLOSTIM, 10 MICROGRAMSINJECTION, METHOCARBAMOL, UP TO 10 MLINJECTION, SINCALIDE, 5 MICROGRAMS

PUF___2011_Web_File

INJECTION, THEOPHYLLINE, PER 40 MGINJECTION, SARGRAMOSTIM (GM-CSF), 50 MCGINJECTION, SECRETIN, SYNTHETIC, HUMAN, 1 MICROGRAMINJECTION, AUROTHIOGLUCOSE, UP TO 50 MGINJECTION, 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 MGINJECTION, 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, TELEVANCIN, 10 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, TOCILIZUMAB, 1 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, USTEKINUMAB, 1 MGINJECTION, DIAZEPAM, UP TO 5 MGINJECTION, UROKINASE, 5000 IU VIALINJECTION, IV, UROKINASE, 250,000 I.U. VIALINJECTION, VANCOMYCIN HCL, 500 MGINJECTION, VELAGLUCERASE ALFA, 100 UNITS

PUF___2011_Web_File

INJECTION, 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 B17UNCLASSIFIED 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 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, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, PER 100 IU VWF:RCOINJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I.U.INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN),PER FACTOR VIII I.U.INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCOFACTOR 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., NOT OTHERWISESPECIFIEDFACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.FACTOR IX, COMPLEX, PER I.U.FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.INJECTION, ANTITHROMBIN RECOMBINANT, 50 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 MG

PUF___2011_Web_File

CONTRACEPTIVE 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)METHYL AMINOLEVULINATE (MAL) FOR TOPICAL ADMINISTRATION, 16.8%, 1 GRAMGANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANTFLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANTINJECTION, DEXAMETHASONE, INTRAVITREAL IMPLANT, 0.1 MGHYALURONAN (SODIUM HYALURONATE) OR DERIVATIVE, INTRA-ARTICULAR INJECTION, PERINJECTIONHYALURONAN 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 DOSEHYALURONAN OR DERIVATIVE, SYNVISC OR SYNVISC-ONE, FOR INTRA-ARTICULARINJECTION, 1 MGAUTOLOGOUS CULTURED CHONDROCYTES, IMPLANTCAPSAICIN 8% PATCH, PER 10 SQUARE CENTIMETERSDERMAL 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 OTHERBIOENGINEERED 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 CENTIMETERAZATHIOPRINE, ORAL, 50 MGAZATHIOPRINE, PARENTERAL, 100 MGCYCLOSPORINE, ORAL, 100 MGLYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL, 250 MG

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MUROMONAB-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 MGLEVALBUTEROL, 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 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 MG

PUF___2011_Web_File

BITOLTEROL 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, ADMINISTEREDTHROUGH 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 MILLIGRAMS

PUF___2011_Web_File

METAPROTERENOL 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 MILLIGRAMSTREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, UNIT DOSE FORM, 1.74 MGNOC 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 MGFLUDARABINE PHOSPHATE, ORAL, 10 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 MGINJECTION, BEVACIZUMAB, 10 MG

PUF___2011_Web_File

INJECTION, BLEOMYCIN SULFATE, 15 UNITSINJECTION, BORTEZOMIB, 0.1 MGINJECTION, CARBOPLATIN, 50 MGINJECTION, CARMUSTINE, 100 MGINJECTION, CETUXIMAB, 10 MGINJECTION, CISPLATIN, POWDER OR S0LUTION, 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, DEGARELIX, 1 MGINJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMSINJECTION, DIETHYLSTILBESTROL DIPHOSPHATE, 250 MGINJECTION, DOCETAXEL, 20 MGINJECTION, DOCETAXEL, 1 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 MG

PUF___2011_Web_File

HISTRELIN 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 MGINJECTION, 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, OFATUMUMAB, 10 MGINJECTION, PANITUMUMAB, 10 MGINJECTION, PEMETREXED, 10 MGINJECTION, PRALATREXATE, 1 MGINJECTION, RITUXIMAB, 100 MGINJECTION, ROMIDEPSIN, 1 MGINJECTION, STREPTOZOCIN, 1 GRAMINJECTION, TEMOZOLOMIDE, 1 MGINJECTION, TEMSIROLIMUS, 1 MGINJECTION, THIOTEPA, 15 MGINJECTION, TOPOTECAN, 4 MGINJECTION, TOPOTECAN, 0.1 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, EACH

PUF___2011_Web_File

DETACHABLE, 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 HIGHSTRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIRSPOKE PROTECTORS, 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,EACHFRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACHDRIVE BELT FOR POWER WHEELCHAIRIV HANGER, EACHWHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIEDELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE)INFUSION 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, PAIRREPLACEMENT 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,GARMENT TYPEREPLACEMENT BATTERY FOR AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENT TYPE ONLY,EACH

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REPLACEMENT GARMENT FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR, EACHREPLACEMENT ELECTRODES FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENTTYPE ONLY, EACHWHEELCHAIR ACCESSORY, WHEELCHAIR SEAT OR BACK CUSHION, DOES NOT MEET SPECIFICCODE CRITERIA OR NO WRITTEN CODING VERIFICATION FROM DME PDACADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL COMPONENTS,REPLACEMENT ONLY, EACHCONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEMPOWER 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 TUBINGREPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL EQUIPMENT OTHER THAN OXYGENEQUIPMENT REQUIRING THE SKILL OF A TECHNICIAN, LABOR COMPONENT, PER 15 MINUTESREPAIR OR NONROUTINE SERVICE FOR OXYGEN EQUIPMENT REQUIRING THE SKILL OF ATECHNICIAN, LABOR COMPONENT, PER 15 MINUTESPOWER 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 POUNDSPOWER 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 POUNDS

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POWER 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 POUNDS

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POWER 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,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 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 PIECE

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CERVICAL, 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 EXTENSIONTHORACIC, 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 INTERVERTEBRAL 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 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, 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,

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AND TRANSVERSE 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 ANDADJUSTMENTTLSO, 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 TRANSVERSE PLANES, PROVIDESINTRACAVITARY 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 JUNCTION

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AND 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 THESAGITTAL 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 INTRACAVITARY

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PRESSURE 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 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/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 AND

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POSTERIOR 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 PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIALTORSO SUPPORT, POST SURGICAL SUPPORT, PADS FOR POST SURGICAL SUPPORTTLSO, CORSET FRONTLSO, CORSET FRONTTLSO, FULL CORSETLSO, FULL CORSETAXILLARY CRUTCH EXTENSIONPERONEAL 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, OUTRIGGER

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ADDITION 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 ADJUSTMENTHIP 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-FABRICATED

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LEGG 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-FABRICATEDKNEE 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 ANDADJUSTMENT

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ANKLE 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 FABRICATEDHIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL ROTATION STRAPS,PELVIC BAND/BELT, CUSTOM FABRICATED

PUF___2011_Web_File

HIP 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/LINED

PUF___2011_Web_File

OR MALLEOLUS PADADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION,PADDED/LINEDADDITION 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 THRUST

PUF___2011_Web_File

BEARING, 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, UNILATERALADDITION 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, EACHADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSIONSTYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, 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, EACH

PUF___2011_Web_File

FOOT, 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, INFANTSURGICAL 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 WEDGE

PUF___2011_Web_File

SOLE 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 COUNTERORTHOPEDIC 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 JOINT 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, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENTAND SUPPORT BAR, WITH OR WITHOUT NONTORSION JOINT/TURNBUCKLE, MAY INCLUDE SOFT

PUF___2011_Web_File

INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ORTHOSIS, VEST TYPE ABDUCTION RESTRAINER, CANVAS WEBBING TYPE OREQUAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFTINTERFACE, STRAPS, PREFABRICATED, INCLUDES FITTING 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),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 CONTROL

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WHFO, 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, EACHADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLETORSION STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, 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, 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, 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 ADJUSTMENTHAND 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 ADJUSTMENT

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WRIST 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 ANDADJUSTMENTSHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, ERBS PALSEY DESIGN,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTSHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,

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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

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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 OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL,ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTFOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM,ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHERMATERIAL, INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATEDPARTIAL 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 FOOT

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BELOW 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 RIGIDDRESSING, 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 TOMODEL

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PREPARATORY, 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, SYMESADDITION 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,

PUF___2011_Web_File

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, ELASTOMERICOR 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 KNEE

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CUSTOM 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)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, PNEUMATIC

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SWING 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, POLYCENTRIC HIP JOINT, PNEUMATIC OR HYDRAULICCONTROL, ROTATION CONTROL, WITH OR WITHOUT FLEXION AND/OR EXTENSION CONTROLADDITION, 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 FOOTALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL (SACH) FOOT,REPLACEMENT ONLYALL LOWER EXTREMITY PROSTHESES, FLEXIBLE KEEL FOOT (SAFE, STEN, BOCK DYNAMIC OREQUAL)ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXIONAND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCEALL 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 SYSTEM

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ALL 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 ELBOWIMMEDIATE 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 ANDREALIGNMENT

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IMMEDIATE 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 ELBOW

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UPPER EXTREMITY ADDITION, HEAVY DUTY FEATURE, ANY ELBOWUPPER EXTREMITY ADDITIONS, SHOULDER ABDUCTION JOINT, PAIRUPPER 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, PASSIVE HAND/MITT, ANY MATERIAL, ANY SIZETERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY MATERIAL, ANY SIZE

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TERMINAL 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, 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 UNLINEDADDITION TO TERMINAL DEVICE, MODIFIER WRIST UNITADDITION TO TERMINAL DEVICE, PRECISION PINCH DEVICEAUTOMATIC 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, ANYMATERIAL, 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 DEVICE

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ELBOW 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, ADULTPREHENSILE 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,

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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 FORMBREAST PROSTHESIS, SILICONE OR EQUAL, WITHOUT INTEGRAL ADHESIVEBREAST PROSTHESIS, SILICONE OR EQUAL, WITH INTEGRAL ADHESIVENIPPLE PROSTHESIS, REUSABLE, ANY TYPE, EACHCUSTOM 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-PHYSICIAN

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TRUSS, 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, OREQUAL, 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 AND CONTROLLER, INTEGRATED SYSTEM,REPLACEMENTZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT, EACH

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ALKALINE 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, EACHCOCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR, COMPONENT, REPLACEMENTCOCHLEAR IMPLANT, EXTERNAL CONTROLLER COMPONENT, REPLACEMENTTRANSMITTING COIL AND CABLE, INTEGRATED, FOR USE WITH COCHLEAR IMPLANT DEVICE,REPLACEMENTMETACARPOPHALANGEAL 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, REPLACEMENTAUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, USED WITHOUTOSSEOINTEGRATION, BODY WORN, INCLUDES HEADBAND OR OTHER MEANS OF EXTERNALATTACHMENTAUDITORY OSSEOINTEGRATED DEVICE ABUTMENT, ANY LENGTH, REPLACEMENT ONLYEXTERNAL RECHARGING SYSTEM FOR BATTERY (EXTERNAL) FOR USE WITH IMPLANTABLENEUROSTIMULATOR, 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 THERAPY

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PROLOTHERAPYINTRAGASTRIC 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 UNITFRESH FROZEN PLASMA BETWEEN 8-24 HOURS OF COLLECTION, EACH UNIT

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FRESH 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, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRDUSE)INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (FOR ESRDON DIALYSIS)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 REGIMEN

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CHLORPROMAZINE 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-EMETICAT 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 REGIMENPOWER ADAPTER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSISTDEVICE, VEHICLE TYPEPOWER MODULE FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSISTDEVICE, REPLACEMENT ONLYDRIVER 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, REPLACEMENTONLY

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POWER 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, OTHER THAN LITHIUM-ION, FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATICVENTRICULAR ASSIST DEVICE, REPLACEMENT ONLYBATTERY CLIPS FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSISTDEVICE, REPLACEMENT ONLYHOLSTER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE,REPLACEMENT ONLYBELT/VEST/BAG FOR USE TO CARRY EXTERNAL PERIPHERAL COMPONENTS OF ANY TYPEVENTRICULAR ASSIST DEVICE, 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 DEVICEBATTERY, LITHIUM-ION, FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULARASSIST DEVICE, REPLACEMENT ONLYPHARMACY 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 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 NOTICEIRRIGATION SOLUTION FOR TREATMENT OF BLADDER CALCULI, FOR EXAMPLE RENACIDIN,PER 500 MLINJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENTINJECTION, TENIPOSIDE, 50 MGINJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I.U.INJECTION, BEVACIZUMAB, 0.25 MGFLUDARABINE PHOSPHATE, ORAL, 1 MGINJECTION, RADIESSE, 0.1 MLINJECTION, SCULPTRA, 0.1 ML

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INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARSOF AGE AND OLDER, FOR INTRAMUSCULAR USE (AFLURIA)INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARSOF AGE AND OLDER, FOR INTRAMUSCULAR USE (FLULAVAL)INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARSOF AGE AND OLDER, FOR INTRAMUSCULAR USE (FLUVIRIN)INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARSOF AGE AND OLDER, FOR INTRAMUSCULAR USE (FLUZONE)INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARSOF AGE AND OLDER, FOR INTRAMUSCULAR USE (NOT OTHERWISE SPECIFIED)RADIOELEMENTS FOR BRACHYTHERAPY, ANY TYPE, EACHTELEHEALTH ORIGINATING SITE FACILITY FEEINJECTION, 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), PLASTER

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CAST 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 +), PLASTERCAST 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)ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 20 MICROGRAMSINJECTION, 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,

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NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMSSKIN SUBSTITUTE, NOT OTHERWISE SPECIFIEDAPLIGRAF, PER SQUARE CENTIMETEROASIS WOUND MATRIX, PER SQUARE CENTIMETEROASIS BURN MATRIX, PER SQUARE CENTIMETERINTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQUARE CENTIMETERINTEGRA DERMAL REGENERATION TEMPLATE (DRT), PER SQUARE CENTIMETERDERMAGRAFT, PER SQUARE CENTIMETERGRAFTJACKET, PER SQUARE CENTIMETERINTEGRA MATRIX, PER SQUARE CENTIMETERSKIN SUBSTITUTE, TISSUEMEND, PER SQUARE CENTIMETERPRIMATRIX, PER SQUARE CENTIMETERGAMMAGRAFT, PER SQUARE CENTIMETERCYMETRA, INJECTABLE, 1CCGRAFTJACKET XPRESS, INJECTABLE, 1CCINTEGRA FLOWABLE WOUND MATRIX, INJECTABLE, 1CCALLOSKIN, PER SQUARE CENTIMETERALLODERM, PER SQUARE CENTIMETERHYALOMATRIX, PER SQUARE CENTIMETERMATRISTEM MICROMATRIX, 1 MGMATRISTEM WOUND MATRIX, PER SQUARE CENTIMETERMATRISTEM BURN MATRIX, PER SQUARE CENTIMETERTHERASKIN, PER SQUARE CENTIMETERHOSPICE 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)HOSPICE HOME CARE PROVIDED IN A HOSPICE FACILITYLOW 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, PER

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MLLOW 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 MLINJECTION, NON-RADIOACTIVE, NON-CONTRAST, VISUALIZATION ADJUNCT (E.G.,METHYLENE BLUE, ISOSULFAN BLUE), 1 MGTRANSPORTATION 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, 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 GRAMSINJECTION, OFLOXACIN, 400 MGINJECTION, SULFAMETHOXAZOLE AND TRIMETHOPRIM, 10 MLINJECTION, TICARCILLIN DISODIUM AND CLAVULANATE POTASSIUM, 3.1 GRAMSINJECTION, 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 TABLETSMERCAPTOPURINE, ORAL, 50 MGMETHADONE, ORAL, 5 MGTRETINOIN, TOPICAL, 5 GRAMSINJECTION, MENOTROPINS, 75 IUINJECTION, FOLLITROPIN ALFA, 75 IUINJECTION, FOLLITROPIN BETA, 75 IUINJECTION, GANIRELIX ACETATE, 250 MCGCLOZAPINE, 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, PERGRAM

PUF___2011_Web_File

INJECTION, PEGYLATED INTERFERON ALFA-2A, 180 MCG PER MLINJECTION, PEGYLATED INTERFERON ALFA-2B, 10 MCG PER 0.5 MLINJECTION, ALGLUCOSIDASE ALFA, 20 MGINJECTION, PEGYLATED INTERFERON ALFA-2B, 10 MCGSTERILE DILUTANT FOR EPOPROSTENOL, 50MLEXEMESTANE, 25 MGBECAPLERMIN GEL 0.01%, 0.5 GMDEXTROAMPHETAMINE SULFATE, 5 MGCALCITROL, 0.25 MGINJECTION, EFALIZUMAB, 125 MGINJECTION, PANTOPRAZOLE SODIUM, 40 MGINJECTION, OLANZAPINE, 2.5 MGINJECTION, APOMORPHINE HYDROCHLORIDE, 1 MGCALCITROL, 0.25 MICROGRAMANASTROZOLE, ORAL, 1MGINJECTION, BUMETANIDE, 0.5MGCHLORAMBUCIL, ORAL, 2MGDOLASETRON MESYLATE, ORAL 50MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARESTATUTE, 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 SUPPLYMEDICALLY 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 HEALTH

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PROFESSIONALS 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 ARRANGEMENTMEDICAL HOME PROGRAM, COMPREHENSIVE CARE COORDINATION AND PLANNING, INITIAL PLANMEDICAL HOME PROGRAM, COMPREHENSIVE CARE COORDINATION AND PLANNING, MAINTENANCEOF PLANCOMPLETED 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 APPROPRIATEEVALUATION 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 VISIT

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IMPRESSION 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, MALE, 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 ANDREPORTREMOVAL 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)

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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)ADJUSTMENT OF GASTRIC BAND DIAMETER VIA SUBCUTANEOUS PORT BY INJECTION ORASPIRATION OF SALINETRANSCATHETER 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 TREATMENTARTHROSCOPY, 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 OF

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PRE-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 DEVICEMYRINGOTOMY, 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 WEEKSINDUCED 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 CORDNASAL 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)

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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)GASTROINTESTINAL FAT ABSORPTION STUDYCIRCULATING TUMOR CELL TESTKRAS MUTATION ANALYSIS TESTINGGENETIC 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 BREASTAND 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; MSH2 GENECOMPLETE MLH1 AND MSH2 GENE SEQUENCE ANALYSIS FOR HEREDITARY NONPOLYPOSISCOLORECTAL CANCER (HNPCC) GENETIC TESTINGSINGLE-MUTATION ANALYSIS (IN INDIVIDUAL WITH A KNOWN MLH1 AND MSH2 MUTATION INTHE FAMILY) FOR HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (HNPCC) GENETICTESTING

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COMPLETE 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 LABORATORYCOMPREHENSIVE GENE SEQUENCE ANALYSIS FOR HYPERTROPHIC CARDIOMYOPATHYGENETIC ANALYSIS FOR A SPECIFIC GENE MUTATION FOR HYPERTROPHIC CARDIOMYOPATHY(HCM) IN AN INDIVIDUAL WITH A KNOWN HCM MUTATION IN THE FAMILYCOMPARATIVE GENOMIC HYBRIZATION (CGH) MICROARRAY TESTING FOR DEVELOPMENTALDELAY, AUTISM SPECTRUM DISORDER AND/OR MENTAL RETARDATIONDNA 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

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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 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 MINUTES

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COMPANION 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 MINUTESUNSKILLED 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 UNITS

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INSULIN 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 SIZESCLERAL 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 NOTPERFORM THE ULTRASOUND, GUIDANCE IS INCLUDED IN THE CPT CODE FOR MULTIFETALPREGNANCY REDUCTION - 59866)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)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 TRAPMANDIBULAR 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, ROLLSPLINT, PREFABRICATED, DIGIT (SPECIFY DIGIT BY USE OF MODIFIER)SPLINT, PREFABRICATED, WRIST OR ANKLESPLINT, PREFABRICATED, ELBOWCAMISOLE, POST-MASTECTOMYINSULIN SYRINGES (100 SYRINGES, ANY SIZE)

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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 MONITORINGPARANASAL 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), INCLUDING

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ADMINISTRATIVE 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)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 DIEM

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HOME 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);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 NURSING

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VISITS 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, CARECOORDINATION, 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,

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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 SESSIONDIABETIC 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 DIEM

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HOME 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 DIEMHOME 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 DIEM

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HOME 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 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)

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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 VISITELECTRONIC MEDICATION COMPLIANCE MANAGEMENT DEVICE, INCLUDES ALL COMPONENTS ANDACCESSORIES, NOT OTHERWISE CLASSIFIEDMISCELLANEOUS 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 VANTRANSPORTATION 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 MINUTES

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CASE MANAGEMENT, PER MONTHTARGETED CASE MANAGEMENT; PER MONTHSERVICE ASSESSMENT/PLAN OF CARE DEVELOPMENT, WAIVERWAIVER SERVICES; NOT OTHERWISE SPECIFIED (NOS)SPECIALIZED CHILDCARE, WAIVER; PER DIEMSPECIALIZED 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, EACH

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INCONTINENCE 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 LENSSPHERE, 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 LENS

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SPHEROCYLINDER, 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)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 TYPE

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CONTACT 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 SHELLFABRICATION 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 LENS

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PROCESSING, 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 EARHEARING 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, ITC

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HEARING 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

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Short Description PI1 PI2 PI3 PI4 MPIDressing 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 9 or more woundAnesthesia perf by anesgstMD supervision, >4 anes proc

Registered dieticianSpecialty physicianPrimary physicianClinical psychologistPrincipal physician of recClinical social workerNon participating physicianPhysician, team member svcNo dtmn of refractive state

Physician service HPSA area

Physician scarcity areaAssistant at surgery service

Acute treatment

Uro, ostomy or trach itemItem w prosthetic/orthoticItem w a surgical dressingItem w dialysis servicesItem/service not for ESRD tx

Physician serv in dent HPSA

Item w pen servicesSpec acquisition blood prodsNutrition oral admin no tubeBene electd to purchase item

Bene elected to rent item

Bene undecided on purch/rent

Procedure payable inpatient

ESRD bene part a snf-sep pay

Procedure code change

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AMCC test for ESRD or MCP MD

Med neces AMCC tst sep reimb

AMCC tst not composite rate

Policy criteria appliedCatastrophe/disaster relatedGulf Oil 2010 Spill Related

Oral health assess, not dentUpper left eyelidLower left eyelidUpper right eyelidLower right eyelidESA, anemia, chemo-induced

ESA, anemia, radio-induced

ESA, anemia, non-chemo/radio

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

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

Subsequent claim

Emer reserve supply (ESRD)Medicaid EPSDT program svc

Emergency ServicesNo md order for item/service

Left 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

Part credit, replaced deviceSvc part of family plan pgmURR reading of less than 60

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URR reading of 60 to 64.9URR reading of 65 to 69.9URR reading of 70 to 74.9URR reading of 75 or greaterESRD patient <6 dialysis/mth

Payment limits do not apply

Monitored anesthesia care

MAC for at risk patient

Liability waiver ind case

Claim resubmitted

Resident/teaching phys serv

Unit of service > MUE value

Resident prim care exception

Nonphysician serv c a hosp

Payment screen mam + diagmam

Diag mammo to screening mamoOpt out provider of er srvcActual item/service orderedUpgraded item, no charge

Multiple transportsOP speech language serviceOP occupational therapy servOP PT servicesTelehealth store and forwardService by va resident

Epo/darbepoietin reduced 25%

InteractiveTelecommunicationLiability waiver rout noticeAttending phys not hospice

Service unrelated to term coVoluntary liability noticeStatutorily excluded

Not reasonable and necessaryCourt-orderedChild/adolescent programAdult program non-geriatric

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Adult program geriatricPregnant/parenting programMental health programSubstance abuse programOpioid addiction tx programMental hlth/substance abs prM hlth/m retrdtn/dev dis pro

Employee assistance programSpec hgh rsk mntl hlth pop pinternLess than bachelor degree lvBachelors degree levelMasters degree levelDoctoral levelGroup settingFamily/couple w client prsntFamily/couple w/o client prsMulti-disciplinary teamChild welfare agency fundedFunded state addiction agncyState mntl hlth agncy fundedCounty/local agency fundedFunded by juvenile justiceCriminal justice agncy fundCAP no-pay for prescript numCAP restock of emerg drugs

CAP drug unavail thru cap

DMEPOS comp bid furn by hosp

Administered intravenouslyAdministered subcutaneouslySkin substitute graftSkin sub not used as a graftDiscarded drug not administeLwr ext prost functnl lvl 0

Lwr ext prost functnl lvl 1




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Wheelchair add-on option/acc>4 modifiers on claimRepl special pwr wc intrfaceDrug/biological DME infusedBid under round 1 DMEPOS CB

FDA class III deviceDMEPOS comp bid prgm no 1DMEPOS ini clm, pur/1 mo rntDMEPOS 2nd or 3rd mo rentalDMEPOS PEN pmp or 4-15mo rnt

DMEPOS comp bid prgm no 2DMEPOS mailorder comp bidRplc facial prosth new impRplc facial prosth old modSingle drug unit dose formFirst drug of multi drug u d2nd/subsqnt drg multi drg udRental item partial monthGlucose monitor supplyItem from noncontract supply

DMEPOS comp bid prgm no 3DMEPOS item, profession serv

DMEPOS comp bid prgm no 4Documentation on fileDMEPOS comp bid prgm no 5New cov not implement by m+cLft circum coronary arteryLeft ant des coronary arteryLease/rental (appld to pur)

Laboratory round tripFDA-monitored IOL implantLeft sideMedicare secondary payer6-mo maint/svc fee parts/lbr

Drug specific nebulizerNew when rented

New equipmentNormal healthy patientPatient w/mild syst diseasePatient w/severe sys diseasePt w/sev sys dis threat lifePt not expect surv w/o operBrain-dead pt organs removedSurgery, wrong body partSurgery, wrong patient

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Wrong surgery on patientPET tumor init tx strat

Progressive addition lensesPET tumor subsq tx strategy

Clrctal screen to diagn

Invest clinical research

Routine clinical research

HCFA/ORD demo procedure/svcLive donor surgery/servicesSvc exempt - ordrg/rfrng MDSubst MD svc, recip bill arr

Locum tenens MD serviceOne Class A findingTwo Class B findings1 Class B & 2 Class C fndngsFDA investigational deviceSingle channel monitoringRcrdg/strg in sld st memoryPrescribed oxygen < 1 LPMPrscrbd oxygen >4 LPM & port

Prescribed oxygen > 4 LPMOxygen cnsrvg dvc w del sysPatient in state/locl custod

Med dir 2-4 cncrnt anes proc

Patient died after amb callAmbulance arr by providerAmbulance furn by providerIndividually ordered lab tst

Item/serv in medicare studyMonitored anesthesia careRcrdg/strg tape analog recdrItem or service providedCLIA waived testCRNA svc w/ MD med directionMedically directed CRNA

CRNA svc w/o med dir by MDReplacement of DME itemReplacement part, DME item

PUF___2011_Web_File

Right coronary arteryDrug admin not incident-toFurnish full compliance REMS

Replacement & repair(DMEPOS)

Rental (DME)Right sideNurse practitioner w physiciNurse midwifeMedically necessary serv/supServ by home infusion RN

State/fed funded program/ser2nd opinion ordered by PRO

ASC facility service2nd concurrent infusion ther3rd concurrent infusion therHigh risk populationState supplied vaccineSecond opinionThird opinionItem ordered by home healthHIT in infusion suiteRelated to trauma or injuryPerformed in phys office

Drugs delivered not usedServ by cert diab educatorContact w/high-risk pop

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

RNLPN/LVN

PUF___2011_Web_File

Intermediate level of careComplex/High Tech level careOB TX/Srvcs prenatl/postpartChild/adolescent program gpExtra patient or passengerEarly intervention IFSPIndividualized ed prgrm(IEP)Rural/out of service areaMed transprt unloaded vehiclBLS by volunteer amb providrSchool-based IEP out of dist

Follow-up serviceAdditional patientOvertime payment rateHoliday/weekend payment rateBack-up equipmentM/caid care lev 1 state defM/caid care lev 2 state defM/caid care lev 3 state defM/caid care lev 4 state defM/caid care lev 5 state defM/caid care lev 6 state defM/caid care lev 7 state defM/caid care lev 8 state defM/caid care lev 9 state defM/caid care lev 10 state defM/caid care lev 11 state defM/caid care lev 12 state defM/caid care lev 13 state defUsed durable med equipmentServices provided, morningServices provided, afternoonServices provided, eveningServices provided, nightSvc on behalf client-collat

Two patients servedThree patients servedFour patients servedFive patients servedSix or more patients servedVascular catheterArteriovenous graftArteriovenous fistulaInfection presentNo infection presentAphakic patientOutside state ambulance serv 00 9Noninterest escort in non er 00 9

Interest escort in non er 00 9

Nonemergency transport taxi 00 9

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Nonemergency transport bus 00 9Noner transport mini-bus 00 9

Noner transport wheelch van 00 9Nonemergency transport air 00 9

Noner transport case worker 00 9Transport parking fees/tolls 00 9Noner transport lodgng recip 00 9Noner transport meals recip 00 9Noner transport lodgng escrt 00 9Noner transport meals escort 00 9Neonatal emergency transport 00 9Basic life support mileage 00 9Basic support routine suppls 52 ABls defibrillation supplies 52 A

Advanced life support mileag 00 9Als defibrillation supplies 52 A

Als IV drug therapy supplies 52 AAls esophageal intub suppls 52 AAls routine disposble suppls 52 AAmbulance waiting 1/2 hr 52 AAmbulance 02 life sustaining 52 AExtra ambulance attendant 52 A

Ground mileage 52 AAls 1 52 A

ALS1-emergency 52 A

bls 52 ABLS-emergency 52 AFixed wing air transport 52 ARotary wing air transport 52 API volunteer ambulance co 52 A

als 2 52 ASpecialty care transport 52 AFixed wing air mileage 52 ARotary wing air mileage 52 ANoncovered ambulance mileage 00 9

Ambulance response/treatment 00 9Unlisted ambulance service 57 A1 CC sterile syringe&needle 00 92 CC sterile syringe&needle 00 93 CC sterile syringe&needle 00 95+ CC sterile syringe&needle 00 9Nonneedle injection device 00 9Supp for self-adm injections 00 9

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Non coring needle or stylet 57 A20+ CC syringe only 00 9Sterile needle 00 9Sterile water/saline, 10 ml 37 ASterile water/saline, 500 ml 37 ASterile saline or water 51 AInfusion pump refill kit 57 AMaint drug infus cath per wk 34 A

Infusion supplies with pump 34 A

Infusion supplies w/o pump 00 9

Infus insulin pump non needl 34 AInfusion insulin pump needle 34 ASyringe w/needle insulin 3cc 00 9Alkalin batt for glucose mon 36 A

J-cell batt for glucose mon 36 A

Lithium batt for glucose mon 36 A

Silvr oxide batt glucose mon 36 A

Alcohol or peroxide per pint 00 9Alcohol wipes per box 00 9Betadine/phisohex solution 00 9Betadine/iodine swabs/wipes 00 9Chlorhexidine antisept 52 AUrine reagent strips/tablets 00 9Blood ketone test or strip 00 9Blood glucose/reagent strips 32 A

Glucose monitor platforms 34 ACalibrator solution/chips 34 AReplace Lensshield Cartridge 34 ALancet device each 34 ALancets per box 34 ACervical cap contraceptive 00 9Temporary tear duct plug 00 9Permanent tear duct plug 11 AIntratubal occlusion device 00 9

Paraffin 34 ADiaphragm 00 9Male condom 00 9Female condom 00 9Spermicide 00 9Disposable endoscope sheath 00 9Brst prsths adhsv attchmnt 38 AReplacement breastpump tube 00 9Replacement breastpump adpt 00 9Replacement breastpump cap 00 9Replcmnt breast pump shield 00 9

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Replcmnt breast pump bottle 00 9Replcmnt breastpump lok ring 00 9Sacral nerve stim test lead 00 9Cath impl vasc access portal 11 A

Implantable access syst perc 00 9

Drug delivery system >=50 ML 00 9Drug delivery system <=50 ml 00 9Insert tray w/o bag/cath 37 ACatheter w/o bag 2-way latex 37 A

Cath w/o bag 2-way silicone 37 A

Catheter w/bag 3-way 37 A

Cath w/drainage 2-way latex 37 A

Cath w/drainage 2-way silcne 37 A

Cath w/drainage 3-way 37 A

Irrigation tray 37 ACath therapeutic irrig agent 37 AIrrigation syringe 37 AMale external catheter 37 AFem urinary collect dev cup 37 AFem urinary collect pouch 37 AStool collection pouch 37 AExtension drainage tubing 37 A

Lube sterile packet 37 AUrinary cath anchor device 37 AUrinary cath leg strap 37 AIncontinence supply 46 AUrethral insert 37 AIndwelling catheter latex 37 A

Indwelling catheter special 37 ACath indw foley 2 way silicn 37 ACath indw foley 3 way 37 ADisposable male external cat 37 AStraight tip urine catheter 37 A

Coude tip urinary catheter 37 A

Intermittent urinary cath 37 ACath insertion tray w/bag 37 ABladder irrigation tubing 37 A

Ext ureth clmp or compr dvc 37 A

Bedside drainage bag 37 A

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Urinary leg or abdomen bag 37 A

Disposable ext urethral dev 37 A

Ostomy face plate 37 ASolid skin barrier 37 AOstomy clamp, replacement 37 AAdhesive, liquid or equal 37 AAdhesive remover wipes 37 AOstomy vent 37 AOstomy belt 37 AOstomy filter 37 ASkin barrier liquid per oz 37 ASkin barrier powder per oz 37 ASkin barrier solid 4x4 equiv 37 A

Skin barrier with flange 37 A

Drainable plastic pch w fcpl 37 ADrainable rubber pch w fcplt 37 ADrainable plstic pch w/o fp 37 ADrainable rubber pch w/o fp 37 AUrinary plastic pouch w fcpl 37 AUrinary rubber pouch w fcplt 37 AUrinary plastic pouch w/o fp 37 AUrinary hvy plstc pch w/o fp 37 AUrinary rubber pouch w/o fp 37 AOstomy faceplt/silicone ring 37 AOst skn barrier sld ext wear 37 A

Ost clsd pouch w att st barr 37 A

Drainable pch w ex wear barr 37 ADrainable pch w st wear barr 37 A

Drainable pch ex wear convex 37 A

Urinary pouch w ex wear barr 37 AUrinary pouch w st wear barr 37 A

Urine pch w ex wear bar conv 37 A

Ostomy pouch liq deodorant 37 A

Ostomy pouch solid deodorant 37 APeristomal hernia supprt blt 37 AIrrigation supply sleeve 37 AOstomy irrigation bag 37 AOstomy irrig cone/cath w brs 37 AOstomy irrigation set 37 ALubricant per ounce 37 AOstomy ring each 37 ANonpectin based ostomy paste 37 A

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Pectin based ostomy paste 37 AExt wear ost skn barr <=4sq" 37 A

Ext wear ost skn barr >4sq" 37 A

Ost skn barr convex <=4 sq i 37 A

Ost skn barr extnd >4 sq 37 A

Ost skn barr extnd =4sq 37 A

Ost pouch drain high output 37 A

2 pc drainable ost pouch 37 A

Ost sknbar w/o conv<=4 sq in 37 A

Ost skn barr w/o conv >4 sqi 37 A

Ost pch clsd w barrier/filtr 37 AOst pch w bar/bltinconv/fltr 37 A

Ost pch clsd w/o bar w filtr 37 AOst pch for bar w flange/flt 37 A

Ost pch clsd for bar w lk fl 37 AOstomy supply misc 00 9Ost pouch absorbent material 37 A

Ost pch for bar w lk fl/fltr 37 A

Ost pch drain w bar & filter 37 AOst pch drain for barrier fl 37 A

Ost pch drain 2 piece system 37 A

Ost pch drain/barr lk flng/f 37 A

Urine ost pouch w faucet/tap 37 A

Urine ost pouch w bltinconv 37 A

Ost urine pch w b/bltin conv 37 A

Ost pch urine w barrier/tapv 37 A

Os pch urine w bar/fange/tap 37 A

Urine ost pch bar w lock fln 37 AOst pch urine w lock flng/ft 37 A

Non-waterproof tape 37 AWaterproof tape 37 AAdhesive remover per ounce 37 A

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Adhesive remover, wipes 37 AReusable enema bag 00 9Surgicl dress hold non-reuse 35 ASurgical dress holder reuse 35 ANon-elastic extremity binder 00 9Elastic garment/covering 00 9

Gravlee jet washer 00 9Vabra aspirator 00 9Tracheostoma filter 37 AMoisture exchanger 37 AAbove knee surgical stocking 00 9Thigh length surg stocking 00 9Below knee surgical stocking 00 9Full length surg stocking 00 9Incontinence garment anytype 00 9Surgical trays 11 ADisposable underpads 00 9Electrodes, pair 34 ALead wires, pair 34 AConductive gel or paste 34 A

Coupling gel or paste 34 APessary rubber, any type 38 APessary, non rubber,any type 38 ASlings 52 AShould sling/vest/abrestrain 00 9

Splint 52 AHyperbaric o2 chamber disps 00 9Cast supplies (plaster) 00 9Special casting material 00 9TENS suppl 2 lead per month 34 ASleeve, inter limb comp dev 32 ALith ion batt, non-pros use 32 ATubing with heating element 32 A

Trach suction cath close sys 32 AOxygen probe used w oximeter 00 9Transtracheal oxygen cath 00 9Heavy duty battery 32 ABattery cables 32 ABattery charger 32 AHand-held PEFR meter 46 ACannula nasal 00 9Tubing (oxygen) per foot 00 9Mouth piece 00 9Breathing circuits 32 AFace tent 33 AVariable concentration mask 00 9Tracheostomy inner cannula 37 ATracheal suction tube 32 ATrach care kit for new trach 37 ATracheostomy cleaning brush 37 A

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Spacer bag/reservoir 00 9

Oropharyngeal suction cath 32 ATracheostomy care kit 37 ARepl bat t.e.n.s. own by pt 32 A

Uvl replacement bulb 32 AReplacement bulb th lightbox 00 9Underarm crutch pad 32 AHandgrip for cane etc 32 ARepl tip cane/crutch/walker 32 ARepl batt pulse gen sys 32 AInfrared ht sys replcmnt pad 32 AAlternating pressure pad 32 A

Radiopharm dx agent noc 51 AIn111 satumomab 51 A

Implantable tissue marker 57 ASurgical supplies 46 AImplant radiation dosimeter 57 ACalibrated microcap tube 52 AMicrocapillary tube sealant 52 APD catheter anchor belt 52 ASyringe w/wo needle 52 ASphyg/bp app w cuff and stet 52 ADialysis blood pressure cuff 52 AAutomatic bp monitor, dial 00 9Disposable cycler set 52 ADrainage ext line, dialysis 52 AExt line w easy lock connect 52 AChem/antisept solution, 8oz 52 A

Activated carbon filter, ea 52 ADialyzer, each 52 ABicarbonate conc sol per gal 52 ABicarbonate conc pow per pac 52 AAcetate conc sol per gallon 52 AAcid conc sol per gallon 52 ATreated water per gallon 52 A

"Y set" tubing 52 ADialysat sol fld vol > 249cc 52 A

Dialysat sol fld vol > 999cc 52 A

Dialys sol fld vol > 1999cc 52 A




PUF___2011_Web_File


Dialysate solution, non-dex 52 AFistula cannulation set, ea 52 ATopical anesthetic, per gram 52 AInj anesthetic per 10 ml 52 AShunt accessory 52 AArt or venous blood tubing 52 AComb art/venous blood tubing 52 ADialysate sol test kit, each 52 ADialysate conc pow per pack 52 ADialysate conc sol add 10 ml 52 ABlood collection tube/vacuum 52 ASerum clotting time tube 52 ABlood glucose test strips 52 AOccult blood test strips 52 AAmmonia test strips 52 AProtamine sulfate per 50 mg 52 ADisposable catheter tips 52 APlumb/elec wk hm hemo equip 52 ARepair/maint cont hemo equip 52 ADrain bag/bottle 52 AMisc dialysis supplies noc 52 AVenous pressure clamp 52 ANon-sterile gloves 52 ASurgical mask 52 ATourniquet for dialysis, ea 52 ASterile, gloves per pair 52 AReusable oral thermometer 52 AReusable rectal thermometer 00 9Pouch clsd w barr attached 37 AClsd ostomy pouch w/o barr 37 AClsd ostomy pouch faceplate 37 AClsd ostomy pouch w/flange 37 AStoma cap 37 APouch drainable w barrier at 37 ADrnble ostomy pouch w/o barr 37 ADrain ostomy pouch w/flange 37 AUrinary pouch w/barrier 37 AUrinary pouch w/o barrier 37 AUrinary pouch on barr w/flng 37 AContinent stoma plug 37 AContinent stoma catheter 37 AStoma absorptive cover 37 AOstomy accessory convex inse 37 ABedside drain btl w/wo tube 37 AUrinary suspensory 37 AUrinary leg bag 37 A

Latex leg strap 37 AFoam/fabric leg strap 37 ASkin barrier, wipe or swab 37 ASolid skin barrier 6x6 37 ASolid skin barrier 8x8 37 A

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Disk/foam pad +or- adhesive 37 AAppliance cleaner 37 APercutaneous catheter anchor 37 ADiab shoe for density insert 38 A

Diabetic custom molded shoe 38 A

Diabetic shoe w/roller/rockr 38 A

Diabetic shoe with wedge 38 A

Diab shoe w/metatarsal bar 38 A

Diabetic shoe w/off set heel 38 A

Modification diabetic shoe 38 A

Diabetic deluxe shoe 38 A

Compression form shoe insert 38 A

Multi den insert direct form 38 A

Multi den insert custom mold 38 A

Wound warming wound cover 00 9

Collagen based wound filler 35 ACollagen gel/paste wound fil 35 ACollagen dressing <=16 sq in 35 ACollagen drsg>16<=48 sq in 35 A

Collagen dressing >48 sq in 35 ACollagen dsg wound filler 35 ASilicone gel sheet, each 00 9

Wound pouch each 35 AAlginate dressing <=16 sq in 35 A

Alginate drsg >16 <=48 sq in 35 A

alginate dressing > 48 sq in 46 A

Alginate drsg wound filler 35 ACompos drsg <=16 no border 00 9

PUF___2011_Web_File

Compos drsg >16<=48 no bdr 00 9

Compos drsg >48 no border 00 9

Composite drsg <= 16 sq in 35 A

Composite drsg >16<=48 sq in 35 A

Composite drsg > 48 sq in 46 A

Contact layer <= 16 sq in 46 AContact layer >16<= 48 sq in 35 A

Contact layer > 48 sq in 46 AFoam drsg <=16 sq in w/o bdr 35 A

Foam drg >16<=48 sq in w/o b 35 A

Foam drg > 48 sq in w/o brdr 35 A

Foam drg <=16 sq in w/border 35 A

Foam drg >16<=48 sq in w/bdr 46 A

Foam drg > 48 sq in w/border 35 A

Foam dressing wound filler 46 ANon-sterile gauze<=16 sq in 35 A

Non-sterile gauze>16<=48 sq 35 A

Non-sterile gauze > 48 sq in 46 A

Gauze <= 16 sq in w/border 35 A

Gauze >16 <=48 sq in w/bordr 35 A

Gauze > 48 sq in w/border 46 A

Gauze <=16 in no w/sal w/o b 35 A

Gauze >16<=48 no w/sal w/o b 35 A

Gauze > 48 in no w/sal w/o b 35 A

Gauze <= 16 sq in water/sal 46 A

Gauze >16<=48 sq in watr/sal 35 A

Gauze > 48 sq in water/salne 46 A

Hydrogel dsg<=16 sq in 35 A

PUF___2011_Web_File

Hydrogel dsg>16<=48 sq in 35 A

Hydrogel dressing >48 sq in 35 A

Hydrocolld drg <=16 w/o bdr 35 A

Hydrocolld drg >16<=48 w/o b 35 A

Hydrocolld drg > 48 in w/o b 35 A

Hydrocolld drg <=16 in w/bdr 35 A

Hydrocolld drg >16<=48 w/bdr 35 A

Hydrocolld drg > 48 in w/bdr 46 A

Hydrocolld drg filler paste 35 AHydrocolloid drg filler dry 35 AHydrogel drg <=16 in w/o bdr 35 A

Hydrogel drg >16<=48 w/o bdr 35 A

Hydrogel drg >48 in w/o bdr 35 A

Hydrogel drg <= 16 in w/bdr 35 A

Hydrogel drg >16<=48 in w/b 35 A

Hydrogel drg > 48 sq in w/b 35 A

Hydrogel drsg gel filler 35 ASkin seal protect moisturizr 00 9Absorpt drg <=16 sq in w/o b 35 A

Absorpt drg >16 <=48 w/o bdr 35 A

Absorpt drg > 48 sq in w/o b 35 A

Absorpt drg <=16 sq in w/bdr 35 A

Absorpt drg >16<=48 in w/bdr 35 A

Absorpt drg > 48 sq in w/bdr 46 A

Transparent film <= 16 sq in 35 ATransparent film >16<=48 in 35 A

Transparent film > 48 sq in 35 AWound cleanser any type/size 00 9Wound filler gel/paste /oz 46 AWound filler dry form / gram 46 AImpreg gauze no h20/sal/yard 35 A

PUF___2011_Web_File

Sterile gauze <= 16 sq in 35 A

Sterile gauze>16 <= 48 sq in 35 A

Sterile gauze > 48 sq in 35 A

Packing strips, non-impreg 35 A

Sterile eye pad 35 ANon-sterile eye pad 35 AOcclusive eye patch 00 9Adhesive bandage, first-aid 00 9Pad band w>=3" <5"/yd 35 A

Conform band n/s w<3"/yd 35 A

Conform band n/s w>=3"<5"/yd 35 A

Conform band n/s w>=5"/yd 35 A

Conform band s w <3"/yd 35 A

Conform band s w>=3" <5"/yd 35 A

Conform band s w >=5"/yd 35 A

Lt compres band <3"/yd 35 A

Lt compres band >=3" <5"/yd 35 A

Lt compres band >=5"/yd 35 A

Mod compres band w>=3"<5"/yd 35 A

High compres band w>=3"<5"yd 35 A

Self-adher band w <3"/yd 35 A

Self-adher band w>=3" <5"/yd 35 A

Self-adher band >=5"/yd 35 A

Zinc paste band w >=3"<5"/yd 35 A

Tubular dressing 35 ACompres burngarment bodysuit 35 ACompres burngarment chinstrp 35 ACompres burngarment facehood 35 ACmprsburngarment glove-wrist 35 ACmprsburngarment glove-elbow 35 ACmprsburngrmnt glove-axilla 35 ACmprs burngarment foot-knee 35 A

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Cmprs burngarment foot-thigh 35 ACompres burn garment jacket 35 A

Compres burn garment leotard 35 A

Compres burn garment panty 35 A

Compres burn garment, noc 35 ACompress burn mask face/neck 00 9Compression stocking BK18-30 00 9Compression stocking BK30-40 35 ACompression stocking BK40-50 35 AGc stocking thighlngth 18-30 00 9Gc stocking thighlngth 30-40 00 9Gc stocking thighlngth 40-50 00 9Gc stocking full lngth 18-30 00 9Gc stocking full lngth 30-40 00 9Gc stocking full lngth 40-50 00 9Gc stocking waistlngth 18-30 00 9Gc stocking waistlngth 30-40 00 9Gc stocking waistlngth 40-50 00 9Gc stocking custom made 00 9Gc stocking lymphedema 00 9Gc stocking garter belt 00 9Grad comp non-elastic BK 35 AG compression stocking 00 9Neg pres wound ther drsg set 34 A

Disposable canister for pump 32 ANondisposable pump canister 32 ATubing used w suction pump 32 ANebulizer administration set 32 A

Disposable nebulizer sml vol 32 ANondisposable nebulizer set 32 A

Filtered nebulizer admin set 32 ALg vol nebulizer disposable 32 ADisposable nebulizer prefill 32 ANebulizer reservoir bottle 32 ADisposable corrugated tubing 32 ANondispos corrugated tubing 46 ANebulizer water collec devic 32 ADisposable compressor filter 32 ACompressor nondispos filter 32 AAerosol mask used w nebulize 32 ANebulizer dome & mouthpiece 32 ANebulizer not used w oxygen 32 A

Water distilled w/nebulizer 32 AInterface, cough stim device 32 A

Replace chest compress vest 32 A

PUF___2011_Web_File

Replace chst cmprss sys hose 32 A

Combination oral/nasal mask 32 A

Repl oral cushion combo mask 32 ARepl nasal pillow comb mask 32 ACPAP full face mask 32 AReplacement facemask interfa 32 AReplacement nasal cushion 32 AReplacement nasal pillows 32 ANasal application device 32 A

Pos airway press headgear 32 APos airway press chinstrap 32 APos airway pressure tubing 32 APos airway pressure filter 32 AFilter, non disposable w pap 32 AOne way chest drain valve 38 AWater seal drain container 38 AImplanted pleural catheter 38 AVacuum drainagebottle/tubing 38 APAP oral interface 32 ARepl exhalation port for PAP 32 A

Repl water chamber, PAP dev 32 A

Tracheostoma valve w diaphra 37 AReplacement diaphragm/fplate 37 AHMES filter holder or cap 37 A

Tracheostoma HMES filter 37 AHMES or trach valve housing 37 A

HMES/trachvalve adhesivedisk 37 A

Integrated filter & holder 37 A

Housing & Integrated Adhesiv 37 A

Heat & moisture exchange sys 37 A

Trach/laryn tube non-cuffed 37 A

Trach/laryn tube cuffed 37 A

Trach/laryn tube stainless 37 A

Tracheostomy shower protect 37 ATracheostoma stent/stud/bttn 37 ATracheostomy mask 37 ATracheostomy tube collar 37 ATrach/laryn tube plug/stop 37 ASoft protect helmet prefab 32 AHard protect helmet prefab 32 A

PUF___2011_Web_File

Soft protect helmet custom 45 A

Hard protect helmet custom 45 A

Repl soft interface, helmet 32 AMisc/exper non-prescript dru 57 ASingle vitamin nos 00 9Multi-vitamin nos 00 9

Artificial saliva 57 ALice treatment, topical 00 9

Non-covered item or service 00 9Hot/cold h2obot/cap/col/wrap 00 9Ext amb insulin delivery sys 00 9

Disp home glucose monitor 00 9Disposable sensor, CGM sys 00 9

External transmitter, CGM 00 9

External receiver, CGM sys 00 9

Monitoring feature/deviceNOC 00 9

Alert device, noc 00 9Reaching/grabbing device 00 9Wig any type 00 9Foot press off load supp dev 00 9Non-electronic spirometer 00 9Exercise equipment 00 9Tc99m sestamibi 57 ATechnetium TC-99m teboroxime 57 ATc99m tetrofosmin 57 ATc99m medronate 57 ATc99m apcitide 57 ATL201 thallium 57 AIn111 capromab 57 A

I131 iodobenguate, dx 51 AIodine I-123 sod iodide mil 57 ATc99m disofenin 51 ATc99m pertechnetate 57 AIodine I-123 sod iodide mic 57 A

I131 iodide cap, rx 57 ATc99m exametazime 57 AI131 serum albumin, dx 57 ANitrogen N-13 ammonia 53 AIodine I-125 sodium iodide 57 AIodine I-131 iodide cap, dx 57 AI131 iodide sol, dx 57 AI131 iodide sol, rx 57 AI131 max 100uCi 57 A

PUF___2011_Web_File

I125 serum albumin, dx 57 AInjection, methylene blue 51 ATc99m depreotide 57 ATc99m mebrofenin 57 ATc99m pyrophosphate 57 A

Tc99m pentetate 57 ATc99m MAA 57 A

Tc99m sulfur colloid 57 A

In111 ibritumomab, dx 51 A

Y90 ibritumomab, rx 51 A

I131 tositumomab, dx 57 AI131 tositumomab, rx 57 ACo57/58 53 AIn111 oxyquinoline 53 AIn111 pentetate 53 ATc99m gluceptate 53 A

Tc99m succimer 53 AF18 fdg 53 ACr51 chromate 53 A

I125 iothalamate, dx 53 A

Rb82 rubidium 99 9Ga67 gallium 57 ATc99m bicisate 57 AXe133 xenon 10mci 57 ACo57 cyano 57 A

Tc99m labeled rbc 57 A

Tc99m oxidronate 57 ATc99m mertiatide 57 AP32 Na phosphate 57 AP32 chromic phosphate 57 AIn111 pentetreotide 57 ATc99m fanolesomab 57 ATechnetium TC-99m aerosol 57 A

Technetium tc99m arcitumomab 53 ATechnetium TC-99m auto WBC 57 A

Indium In-111 auto WBC 57 AIndium IN-111 auto platelet 57 AIndium In-111 pentetreotide 57 AInj prohance multipack 51 AInj multihance 51 AInj multihance multipack 51 AGad-base MR contrast NOS,1ml 51 A

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Sodium fluoride F-18 57 AGadoxetate disodium inj 51 AIodine I-123 iobenguane 51 AGadofosveset trisodium inj 51 ASr89 strontium 57 ASm 153 lexidronam 57 A

Sm 153 lexidronm 57 ANon-rad contrast materialNOC 51 ARadiopharm rx agent noc 57 AEchocardiography Contrast 57 ASupply/accessory/service 46 A

Delivery/set up/dispensing 46 ADME supply or accessory, nos 46 AEnter feed supkit syr by day 39 A

Enteral feed supp pump per d 39 A

Enteral feed sup kit grav by 39 A

Enteral ng tubing w/ stylet 39 AEnteral ng tubing w/o stylet 39 AEnteral stomach tube levine 39 AGastrostomy/jejunostomy tube 39 A

Gastro/jejuno tube, std 39 AGastro/jejuno tube, low-pro 39 AFood thickener oral 00 9EF adult fluids and electro 39 A

EF ped fluid and electrolyte 46 A

Additive for enteral formula 00 9EF blenderized foods 39 A

EF complet w/intact nutrient 39 A

EF calorie dense>/=1.5Kcal 39 A

EF hydrolyzed/amino acids 39 A

EF spec metabolic noninherit 39 A

EF incomplete/modular 39 A

PUF___2011_Web_File

EF special metabolic inherit 39 A

EF ped complete intact nut 46 A

EF ped complete soy based 46 A

EF ped caloric dense>/=0.7kc 46 A

EF ped hydrolyzed/amino acid 46 A

EF ped specmetabolic inherit 46 A

Parenteral 50% dextrose solu 39 A

Parenteral sol amino acid 3. 39 AParenteral sol amino acid 5. 39 A

Parenteral sol amino acid 7- 39 A

Parenteral sol amino acid > 39 A

Parenteral sol carb > 50% 39 A

Parenteral sol 10 gm lipids 39 AParenteral sol amino acid & 39 A

Parenteral sol 52-73 gm prot 39 A

Parenteral sol 74-100 gm pro 39 A

Parenteral sol > 100gm prote 39 A

Parenteral nutrition additiv 39 A

Parenteral supply kit premix 39 AParenteral supply kit homemi 39 A

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Parenteral administration ki 39 AParenteral sol renal-amirosy 39 A

Parenteral sol hepatic-fream 39 A

Parenteral sol stres-brnch c 39 A

Enter infusion pump w/o alrm 39 AEnteral infusion pump w/ ala 39 AParenteral infus pump portab 39 AParenteral infus pump statio 39 AEnteral supp not otherwise c 57 AParenteral supp not othrws c 57 AHYPERBARIC Oxygen 53 AAnchor/screw bn/bn,tis/bn 53 ACath, trans atherectomy, dir 53 ABrachytherapy needle 53 ABrachytx, non-str, Gold-198 53 ABrachytx, non-str,HDR Ir-192 53 ABrachytx source, Iodine 125 53 ABrachytx, NS, Non-HDRIr-192 53 ABrachytx sour, Palladium 103 53 AAICD, dual chamber 53 AAICD, single chamber 53 ACath, trans atherec,rotation 53 ACath, translumin non-laser 53 A

Cath, bal dil, non-vascular 53 ACath, bal tis dis, non-vas 53 ACath, brachytx seed adm 53 ACath, drainage 53 ACath, EP, 19 or few elect 53 A

Cath, EP, 20 or more elec 53 A

Cath, EP, diag/abl, 3D/vect 53 ACath, EP, othr than cool-tip 53 A

Endo, colon, retro imaging 53 ACath, hemodialysis,long-term 53 ACath, inf, per/cent/midline 53 A

Cath,hemodialysis,short-term 53 ACath, intravas ultrasound 53 ACatheter, intradiscal 53 ACatheter, intraspinal 53 ACath, pacing, transesoph 53 ACath, thrombectomy/embolect 53 ACatheter, ureteral 53 ACath, intra echocardiography 53 AClosure dev, vasc 53 A

PUF___2011_Web_File

Conn tiss, human(inc fascia) 53 AConn tiss, non-human 53 AEvent recorder, cardiac 53 AAdhesion barrier 53 AIntro/sheath,strble,non-peel 53 A

Generator, neuro non-recharg 53 AGraft, vascular 53 AGuide wire 53 AImaging coil, MR, insertable 53 ARep dev, urinary, w/sling 53 AInfusion pump, programmable 53 ARet dev, insertable 53 AJoint device (implantable) 53 ALead, AICD, endo single coil 53 ALead, neurostimulator 53 ALead, pmkr, transvenous VDD 53 ALens, intraocular (new tech) 53 AMesh (implantable) 53 AMorcellator 53 AOcular imp, aqueous drain de 53 AOcular dev, intraop, det ret 53 APmkr, dual, rate-resp 53 APmkr, single, rate-resp 53 APatient progr, neurostim 53 APort, indwelling, imp 53 AProsthesis, breast, imp 53 AProsthesis, penile, inflatab 53 ARetinal tamp, silicone oil 53 APros, urinary sph, imp 53 AReceiver/transmitter, neuro 53 ASeptal defect imp sys 53 AIntegrated keratoprosthesis 53 ATissue localization-excision 53 AGenerator neuro rechg bat sy 53 A

Interspinous implant 53 AStent, coated/cov w/del sys 53 AStent, coated/cov w/o del sy 53 AStent, non-coa/non-cov w/del 53 AStent, non-coat/cov w/o del 53 AMatrl for vocal cord 53 ATissue marker, implantable 53 AVena cava filter 53 ADialysis access system 53 AAICD, other than sing/dual 53 AAdapt/ext, pacing/neuro lead 53 AEmbolization Protect syst 53 ACath, translumin angio laser 53 ACatheter, guiding 53 AEndovas non-cardiac abl cath 53 AInfusion pump,non-prog, perm 53 AIntro/sheath,fixed,peel-away 53 A

PUF___2011_Web_File

Intro/sheath, fixed,non-peel 53 A

Intro/sheath, non-laser 53 A

Lead, AICD, endo dual coil 53 ALead, AICD, non sing/dual 53 A

Lead, neurostim test kit 53 ALead, pmkr, other than trans 53 ALead, pmkr/AICD combination 53 ALead, coronary venous 53 AProbe, perc lumb disc 53 ASealant, pulmonary, liquid 53 ABrachytx, non-str,Yttrium-90 53 AStent, non-cor, tem w/o del 53 AProbe, cryoablation 53 APmkr, dual, non rate-resp 53 APmkr, single, non rate-resp 53 APmkr, other than sing/dual 53 AProsthesis, penile, non-inf 53 AStent, non-cor, tem w/del sy 53 AInfusion pump, non-prog,temp 53 ACath, suprapubic/cystoscopic 53 ACatheter, occlusion 53 AIntro/sheath, laser 53 ACath, EP, cool-tip 53 A

Rep dev, urinary, w/o sling 53 ABrachytx source, Cesium-131 53 ABrachytx, non-str, HA, I-125 53 A

Brachytx, non-str, HA, P-103 53 A

Brachy linear, non-str,P-103 53 ABrachy,non-str,Ytterbium-169 53 ABrachytx, stranded, I-125 53 ABrachytx, non-stranded,I-125 53 ABrachytx, stranded, P-103 53 ABrachytx, non-stranded,P-103 53 ABrachytx, stranded, C-131 53 ABrachytx, non-stranded,C-131 53 ABrachytx, stranded, NOS 53 ABrachytx, non-stranded, NOS 53 AMRA w/cont, abd 53 AMRA w/o cont, abd 53 AMRA w/o fol w/cont, abd 53 A

MRI w/cont, breast, uni 53 AMRI w/o cont, breast, uni 53 AMRI w/o fol w/cont, brst, un 53 A

MRI w/cont, breast, bi 53 AMRI w/o cont, breast, bi 53 AMRI w/o fol w/cont, breast, 53 A

PUF___2011_Web_File

MRA w/cont, chest 53 AMRA w/o cont, chest 53 AMRA w/o fol w/cont, chest 53 A

MRA w/cont, lwr ext 53 AMRA w/o cont, lwr ext 53 AMRA w/o fol w/cont, lwr ext 53 A

MRA w/cont, pelvis 53 AMRA w/o cont, pelvis 53 AMRA w/o fol w/cont, pelvis 53 A

TTE w or w/o fol w/cont, com 53 A

TTE w or w/o fol w/cont, f/u 53 A

2D TTE w or w/o fol w/con,co 53 A

2D TTE w or w/o fol w/con,fu 53 A

2D TEE w or w/o fol w/con,in 53 A

TEE w or w/o fol w/cont,cong 53 A

TEE w or w/o fol w/cont, mon 53 A

TTE w or w/o fol w/con,stres 53 A

TTE w or wo fol wcon,Doppler 53 A

TTE w or w/o contr, cont ECG 53 A

MRA, w/dye, spinal canal 53 A

MRA, w/o dye, spinal canal 53 A

PUF___2011_Web_File

MRA, w/o&w/dye, spinal canal 53 A

MRA, w/dye, upper extremity 53 AMRA, w/o dye, upper extr 53 AMRA, w/o&w/dye, upper extr 53 A

Prolonged IV inf, req pump 99 9

Palivizumab, per 50 mg 53 AInj pantoprazole sodium, via 53 AInjection, argatroban 53 AInjection, idursulfase 53 AInjection, ranibizumab 53 AInj, alglucosidase alfa 53 AInjection, panitumumab 53 AInjection, eculizumab 53 AInj, lanreotide acetate 53 AInj, levetiracetam 53 AInj, temsirolimus 53 AInjection, ixabepilone 53 AInjection, doripenem 53 AInjection, fosaprepitant 53 AInjection, bendamustine hcl 53 AInjection, regadenoson 53 AInjection, romiplostim 53 AInj, gadoxetate disodium 53 AInj, iobenguane, I-123, dx 53 AInj, clevidipine butyrate 53 AInj, certolizumab pegol 53 AArtiss fibrin sealant 53 AInj, C1 esterase inhibitor 53 AInjection, plerixafor 53 AInjection, temozolomide 53 AInjection, lacosamide 53 APaliperidone palmitate inj 53 ADexamethasone intravitreal 53 ABevacizumab injection 53 ATelavancin injection 53 APralatrexate injection 53 AOfatumumab injection 53 AUstekinumab injection 53 AFludarabine phosphate, oral 53 AEcallantide injection 53 ATocilizumab injection 53 ARomidepsin injection 53 ACollagenase clostridum histo 53 AInjection, Wilate 53 ACapsaicin patch 53 AC-1 esterase, berinert 53 AGammaplex IVIG 53 A

Velaglucerase alfa 53 AInj, denosumab 53 ASipuleucel-T, per infusion 53 A

PUF___2011_Web_File

Crotalidae Poly Immune Fab 53 AHexaminolevulinate HCl 53 ACabazitaxel injection 53 ALumizyme, 1 mg 53 AIncobotulinumtoxin A 53 AInjection, ibuprofen 53 APorous collagen tube per cm 53 AAcellular derm tissue percm2 53 A

Neuragen nerve guide, per cm 53 A

Neurawrap nerve protector,cm 53 A

Veritas collagen matrix, cm2 53 A

Neuromatrix nerve cuff, cm 53 ATenoGlide tendon prot, cm2 53 A

Flowable wound matrix, 1 cc 53 A

SurgiMend, fetal 53 A

Implnt,bon void filler-putty 53 A

SurgiMend, neonatal 53 A

NeuroMend nerve wrap 53 A

Implnt,bon void filler-strip 53 A

Integra Meshed Bil Wound Mat 53 APorcine implant, Permacol 53 AEndoform Dermal Template 53 AUnclassified drugs or biolog 53 ARadiofrequency energy to anu 53 ADyn IR Perf Img 53 AEPS gast cardia plic 53 A

Place endorectal app 53 A

Rxt breast appl place/remov 53 A

Insert palate implants 53 APlace device/marker, non pro 53 A

Dermal filler inj px/suppl 53 A

Tobacco-use counsel 3-10 min 53 A

PUF___2011_Web_File

Tobacco-use counsel >10min 53 A

Inpnt stay radiolabeled item 00 9Inpt implant pros dev,no cov 53 A

Cane adjust/fixed with tip 32 ACane adjust/fixed quad/3 pro 32 A

Crutch forearm pair 32 A

Crutch forearm each 32 A

Crutch underarm pair wood 32 A

Crutch underarm each wood 32 ACrutch underarm pair no wood 32 A

Crutch underarm each no wood 32 A

Underarm springassist crutch 32 ACrutch substitute 32 AWalker rigid adjust/fixed ht 32 AWalker folding adjust/fixed 32 AWalker w trunk support 32 ARigid wheeled walker adj/fix 32 AWalker folding wheeled w/o s 32 AEnclosed walker w rear seat 32 A

Walker variable wheel resist 32 AHeavyduty walker no wheels 32 AHeavy duty wheeled walker 32 AForearm crutch platform atta 32 AWalker platform attachment 32 AWalker wheel attachment,pair 32 AWalker seat attachment 32 AWalker crutch attachment 32 AWalker leg extenders set of4 32 ABrake for wheeled walker 32 ASitz type bath or equipment 32 ASitz bath/equipment w/faucet 32 A

Sitz bath chair 32 ACommode chair with fixed arm 32 ACommode chair with detacharm 36 ACommode chair pail or pan 32 AHeavyduty/wide commode chair 32 A

Commode chair electric 36 ACommode chair non-electric 36 ASeat lift mechanism toilet 00 9Commode chair foot rest 32 APress pad alternating w/ pum 36 A

PUF___2011_Web_File

Replace pump, alt press pad 36 ADry pressure mattress 32 AGel pressure mattress pad 32 AAir pressure mattress 36 AWater pressure mattress 36 ASynthetic sheepskin pad 32 ALambswool sheepskin pad 32 APositioning cushion 00 9

Protector heel or elbow 32 APowered air flotation bed 36 AAir fluidized bed 36 AGel pressure mattress 36 AAir pressure pad for mattres 32 AWater pressure pad for mattr 32 ADry pressure pad for mattres 32 AHeat lamp without stand 32 APhototherapy light w/ photom 36 ATherapeutic lightbox tabletp 00 9Heat lamp with stand 32 AElectric heat pad standard 32 AElectric heat pad moist 32 AWater circ heat pad w pump 32 AWater circ cold pad w pump 36 AHot water bottle 32 AInfrared heating pad system 00 9Hydrocollator unit 32 AIce cap or collar 32 AWound warming device 00 9

Warming card for NWT 00 9

Paraffin bath unit portable 36 APump for water circulating p 36 AHeat pad non-electric moist 32 AHydrocollator unit portable 32 ABath/shower chair 00 9Bath tub wall rail 00 9Bath tub rail floor 00 9Toilet rail 00 9Toilet seat raised 00 9Tub stool or bench 00 9Transfer tub rail attachment 00 9Trans bench w/wo comm open 00 9HDtrans bench w/wo comm open 00 9Pad water circulating heat u 32 AHosp bed fixed ht w/ mattres 36 AHosp bed fixd ht w/o mattres 36 AHospital bed var ht w/ mattr 36 AHospital bed var ht w/o matt 36 AHosp bed semi-electr w/ matt 36 A

Hosp bed semi-electr w/o mat 36 A

PUF___2011_Web_File

Hosp bed total electr w/ mat 36 A

Hosp bed total elec w/o matt 36 A

Hospital bed institutional t 00 9

Mattress innerspring 32 AMattress foam rubber 32 ABed board 00 9Over-bed table 00 9Bed pan standard 32 ABed pan fracture 32 APowered pres-redu air mattrs 36 ABed cradle 32 AHosp bed fx ht w/o rails w/m 36 AHosp bed fx ht w/o rail w/o 36 AHosp bed var ht w/o rail w/o 36 AHosp bed var ht w/o rail w/ 36 AHosp bed semi-elect w/ mattr 36 A

Hosp bed semi-elect w/o matt 36 A

Hosp bed total elect w/ matt 36 A

Hosp bed total elect w/o mat 36 A

Enclosed ped crib hosp grade 32 AHD hosp bed, 350-600 lbs 36 A

Ex hd hosp bed > 600 lbs 36 A

Hosp bed hvy dty xtra wide 36 A

Hosp bed xtra hvy dty x wide 36 A

Rails bed side half length 36 ARails bed side full length 32 ABed accessory brd/tbl/supprt 00 9Bed safety enclosure 36 AUrinal male jug-type 32 AUrinal female jug-type 32 APed hospital bed, manual 36 A

Ped hospital bed semi/elect 36 A

Control unit bowel system 57 ADisposable pack w/bowel syst 57 A

Air elevator for heel 00 9Nonpower mattress overlay 36 A

PUF___2011_Web_File

Powered air mattress overlay 36 ANonpowered pressure mattress 36 AStationary compressed gas 02 33 A

Gas system stationary compre 00 9

Oxygen system gas portable 00 9

Portable gaseous 02 33 A

Portable liquid oxygen sys 33 A

Portable liquid 02 33 A

Oxygen system liquid portabl 00 9

Stationary liquid 02 33 A

Oxygen system liquid station 00 9

Stationary O2 contents, gas 33 AStationary O2 contents, liq 33 APortable 02 contents, gas 33 APortable 02 contents, liquid 33 AOximeter non-invasive 00 9Topical Ox Deliver sys, nos 00 9

Vol control vent invasiv int 31 A

Oxygen tent excl croup/ped t 33 AChest shell 32 AChest wrap 36 ANeg press vent portabl/statn 31 AVol control vent noninv int 31 A

Rocking bed w/ or w/o side r 36 APress supp vent invasive int 31 A

Press supp vent noninv int 31 A

RAD w/o backup non-inv intfc 36 A

RAD w/backup non inv intrfc 36 A

RAD w backup invasive intrfc 36 A

PUF___2011_Web_File

Percussor elect/pneum home m 36 AIntrpulmnry percuss vent sys 00 9Cough stimulating device 36 AChest compression gen system 36 A

Non-elec oscillatory pep dvc 32 AOral device/appliance prefab 32 A

Oral device/appliance cusfab 32 A

Electronic spirometer 00 9Ippb all types 31 A

Humidif extens supple w ippb 33 A

Humidifier for use w/ regula 33 A

Humidifier supplemental w/ i 33 A

Humidifier nonheated w PAP 32 AHumidifier heated used w PAP 32 ACompressor air power source 36 A

Nebulizer with compression 36 AAerosol compressor for svneb 36 AAerosol compressor adjust pr 36 AUltrasonic generator w svneb 36 ANebulizer ultrasonic 31 ANebulizer for use w/ regulat 32 A

Nebulizer w/ compressor & he 36 ASuction pump portab hom modl 36 ACont airway pressure device 36 AManual breast pump 32 AElectric breast pump 00 9Hosp grade elec breast pump 00 9Vaporizer room type 32 ADrainage board postural 36 ABlood glucose monitor home 32 APacemaker monitr audible/vis 32 A

Pacemaker monitr digital/vis 32 A

Cardiac event recorder 00 9Automatic ext defibrillator 36 AApnea monitor 00 9Apnea monitor w recorder 00 9Cap bld skin piercing laser 32 APatient lift sling or seat 32 APatient lift bathroom or toi 00 9Seat lift incorp lift-chair 32 ASeat lift for pt furn-electr 32 A

PUF___2011_Web_File

Seat lift for pt furn-non-el 32 APatient lift hydraulic 36 A

Patient lift electric 36 APT support & positioning sys 36 A

Combination sit to stand sys 32 A

Standing frame sys 00 9

Moveable patient lift system 00 9

Fixed patient lift system 00 9Multi-position stnd fram sys 00 9

Dynamic standing frame 00 9Pneuma compresor non-segment 32 APneum compressor segmental 32 APneum compres w/cal pressure 32 APneumatic appliance half arm 32 ASegmental pneumatic trunk 32 ASegmental pneumatic chest 32 APneumatic appliance full leg 32 APneumatic appliance full arm 32 APneumatic appliance half leg 32 ASeg pneumatic appl full leg 32 ASeg pneumatic appl full arm 32 ASeg pneumatic appli half leg 32 APressure pneum appl full leg 32 APressure pneum appl full arm 32 APressure pneum appl half leg 32 APneumatic compression device 36 A

Inter limb compress dev NOS 00 9

Uvl pnl 2 sq ft or less 32 A

Uvl sys panel 4 ft 32 A

Uvl sys panel 6 ft 32 A

Uvl md cabinet sys 6 ft 32 A

Safety equipment 00 9Transfer device 32 ARestraints any type 57 ATens two lead 32 A

Tens four lead 32 A

Conductive garment for tens/ 34 A

Incontinence treatment systm 32 A

PUF___2011_Web_File

Neuromuscular stim for scoli 36 ANeuromuscular stim for shock 36 AElectromyograph biofeedback 52 AElec osteogen stim not spine 32 A

Elec osteogen stim spinal 32 AElec osteogen stim implanted 36 AElectronic salivary reflex s 52 AOsteogen ultrasound stimltor 32 ANontherm electromgntc device 00 9

Trans elec jt stim dev sys 36 A

Functional neuromuscularstim 32 A

Nerve stimulator for tx n&v 32 A

Electric wound treatment dev 00 9

Functional electric stim NOS 46 A

Iv pole 32 AAmb infusion pump mechanical 36 AMech amb infusion pump <8hrs 32 AExternal ambulatory infus pu 36 A

Non-programble infusion pump 32 A

Programmable infusion pump 32 A

Ext amb infusn pump insulin 36 AReplacement impl pump cathet 32 A

Implantable pump replacement 32 A

Parenteral infusion pump sta 36 AAmbulatory traction device 00 9Tract frame attach headboard 32 ACervical pneum trac equip 32 A

Traction stand free standing 32 ACervical traction equipment 32 ACervic collar w air bladder 32 ATract equip cervical tract 32 ATract frame attach footboard 32 ATrac stand free stand extrem 32 ATraction frame attach pelvic 32 ATrac stand free stand pelvic 32 ATrapeze bar attached to bed 36 AHD trapeze bar attach to bed 36 A

HD trapeze bar free standing 36 A

PUF___2011_Web_File

Fracture frame attached to b 36 AFracture frame free standing 36 ACont pas motion exercise dev 31 ACPM device, other than knee 00 9Trapeze bar free standing 36 AGravity assisted traction de 36 ACervical head harness/halter 32 APelvic belt/harness/boot 32 ABelt/harness extremity 32 AFracture frame dual w cross 36 AFracture frame attachmnts pe 32 AFracture frame attachmnts ce 32 ATray 00 9Loop heel 00 9Toe loop/holder, each 00 9Cushioned headrest 32 A

W/c lateral trunk/hip suppor 32 A

W/c medial thigh support 32 A

Whlchr att- conv 1 arm drive 00 9Amputee adapter 00 9W/c shoulder harness/straps 32 A

Wheelchair brake extension 00 9Wheelchair head rest extensi 00 9Manual wc hand rim w project 32 AWheelchair commode seat 36 AWheelchair narrowing device 32 AWheelchair no. 2 footplates 00 9Wheelchair anti-tipping devi 00 9W/Ch access det adj armrest 00 9

W/Ch access anti-rollback 00 9W/C acc,saf belt pelv strap 32 AWheelchair safety vest 32 ASeat upholstery, replacement 32 ABack upholstery, replacement 32 AAdd pwr joystick 36 A

Add pwr tiller 32 A

W/c seat lift mechanism 32 AMan w/c push-rim pow assist 32 AWheelchair elevating leg res 00 9Wheelchair solid seat insert 32 AWheelchair arm rest 32 AWheelchair calf rest 00 9Pwr seat tilt 32 APwr seat recline 32 A

Pwr seat recline mech 32 A

PUF___2011_Web_File

Pwr seat recline pwr 32 A

Pwr seat combo w/o shear 32 A

Pwr seat combo w/shear 32 A

Pwr seat combo pwr shear 32 A

Add mech leg elevation 32 A

Add pwr leg elevation 32 A

Ped wc modify width adjustm 32 A

Reclining back add ped w/c 32 AShock absorber for man w/c 32 AShock absorber for power w/c 32 AHD shck absrbr for hd man wc 32 A

HD shck absrber for hd powwc 32 A

Residual limb support system 32 AW/c manual swingaway 32 A

W/c vent tray fixed 32 AW/c vent tray gimbaled 32 ARollabout chair with casters 36 APatient transfer system <300 36 A

Patient transfer system >300 36 A

Transport chair, ped size 36 ATransport chair pt wt<=300lb 36 A

Transport chair pt wt >300lb 36 A

Whelchr fxd full length arms 36 A

Wheelchair detachable arms 36 A

Wheelchair detachable foot r 36 A

Hemi-wheelchair fixed arms 36 A

Hemi-wheelchair detachable a 36 A

Hemi-wheelchair fixed arms 00 9Hemi-wheelchair detachable a 00 9

Wheelchair lightwt fixed arm 36 A

Wheelchair lightweight det a 36 A

Wheelchair lightwt fixed arm 00 9

PUF___2011_Web_File

Wheelchair lightweight det a 00 9

Wheelchair wide w/ leg rests 36 A

Wheelchair wide w/ foot rest 36 A

Whchr s-recl fxd arm leg res 36 A

Wheelchair semi-recl detach 36 A

Whlchr stand fxd arm ft rest 00 9

Wheelchair standard detach a 00 9

Wheelchair standard w/ leg r 36 A

Wheelchair fixed arms 36 AManual adult wc w tiltinspac 32 AWhlchr ampu fxd arm leg rest 36 A

Wheelchair amputee w/o leg r 36 AWheelchair amputee detach ar 36 A

Wheelchair amputee w/ foot r 36 A

Wheelchair amputee w/ leg re 36 A

Wheelchair amputee heavy dut 36 A

Wheelchair amputee fixed arm 36 AWhlchr special size/constrc 45 A

Wheelchair spec size w foot 36 AWheelchair spec size w/ leg 36 AWheelchair spec size w foot 36 AWheelchair spec size w/ leg 36 AManual semi-reclining back 36 A

Manual fully reclining back 00 9

Wheelchair spec sz spec ht a 32 AWheelchair spec sz spec ht b 36 APediatric wheelchair NOS 32 APower operated vehicle 32 A

Rigid ped w/c tilt-in-space 32 A

Folding ped wc tilt-in-space 32 A

Rig ped wc tltnspc w/o seat 32 A

Fld ped wc tltnspc w/o seat 32 A

PUF___2011_Web_File

Rigid ped wc adjustable 32 AFolding ped wc adjustable 32 ARgd ped wc adjstabl w/o seat 32 AFld ped wc adjstabl w/o seat 32 APed power wheelchair NOS 36 AWhchr litwt det arm leg rest 36 A

Wheelchair lightwt fixed arm 00 9Wheelchair lightwt foot rest 00 9

Wheelchair lightweight leg r 36 A

Whchr h-duty det arm leg res 36 AWheelchair heavy duty fixed 00 9Wheelchair hvy duty detach a 00 9

Wheelchair heavy duty fixed 36 AWheelchair special seat heig 32 AWheelchair special seat dept 32 AWheelchair spec seat depth/w 32 AWhirlpool portable 00 9Whirlpool non-portable 32 ARepair for DME, per 15 min 00 9

Oxygen supplies regulator 00 9Wheeled cart, port cyl/conc 00 9

Oxygen supplies stand/rack 00 9Batt pack/cart, port conc 00 9

Battery charger, port conc 00 9

DC power adapter, port conc 00 9

Oxy suppl heater for nebuliz 32 AOxygen concentrator 33 A

Oxygen concentrator, dual 33 A

Portable oxygen concentrator 33 ADurable medical equipment mi 46 AO2/water vapor enrich w/heat 33 AO2/water vapor enrich w/o he 33 ACentrifuge 52 AKidney dialysate delivry sys 52 A

Heparin infusion pump 52 AReplacement air bubble detec 52 AReplacement pressure alarm 52 ABath conductivity meter 52 AReplace blood leak detector 52 AAdjustable chair for esrd pt 52 ATransducer protect/fld bar 52 A

PUF___2011_Web_File

Unipuncture control system 52 AHemodialysis machine 52 AAuto interm peritoneal dialy 52 ACycler dialysis machine 52 ADeli/install chrg hemo equip 52 AReverse osmosis h2o puri sys 52 ADeionizer H2O puri system 52 AReplacement blood pump 52 AWater softening system 52 AReciprocating peritoneal dia 52 AWearable artificial kidney 52 APeritoneal dialysis clamp 52 ACompact travel hemodialyzer 52 ASorbent cartridges per 10 52 AHemostats for dialysis, each 52 ADialysis scale 52 ADialysis equipment noc 52 AJaw motion rehab system 32 ARepl cushions for jaw motion 34 ARepl measr scales jaw motion 34 AAdjust elbow ext/flex device 36 A

SPS elbow device 36 A

Adjst forearm pro/sup device 36 A

Adjust wrist ext/flex device 36 A

SPS wrist device 36 A

Adjust knee ext/flex device 36 A

SPS knee device 36 A

Knee ext/flex w act res ctrl 36 AAdjust ankle ext/flex device 36 A

SPS ankle device 36 A

SPS forearm device 36 A

Soft interface material 32 AReplacement interface SPSD 32 A

Adjust finger ext/flex devc 36 A

Adjust toe ext/flex device 36 A

Static str toe dev ext/flex 36 A

Adj shoulder ext/flex device 36 A

Static str shldr dev rom adj 36 A

PUF___2011_Web_File

AAC non-electronic board 00 9

Gastric suction pump hme mdl 36 ABld glucose monitor w voice 32 ABld glucose monitor w lance 32 APulse gen sys tx endolymp fl 36 AMan w/ch acc seat w>=20"<24" 32 A

Seat width 24-27 in 32 AFrame depth less than 22 in 32 A

Frame depth 22 to 25 in 32 AManual wc accessory, handrim 32 A

Complete wheel lock assembly 32 ACrutch and cane holder 32 ACylinder tank carrier 32 AArm trough each 32 AWheelchair bearings 32 APneumatic propulsion tire 32 APneumatic prop tire tube 32 APneumatic prop tire insert 32 A

Pneumatic caster tire each 32 APneumatic caster tire tube 32 AFoam filled propulsion tire 32 AFoam filled caster tire each 32 AFoam propulsion tire each 32 AFoam caster tire any size ea 32 ASolid propulsion tire each 32 A

Solid caster tire each 32 A

Solid caster integrated whl 32 A

Valve replacement only each 32 APropulsion whl excludes tire 32 ACaster wheel excludes tire 32 A

Caster fork replacement only 32 AGear reduction drive wheel 32 AMwc acc, wheelchair brake 32 AManual standing system 00 9Solid seat support base 32 A

Planar back for ped size wc 32 APlanar seat for ped size wc 32 AContour back for ped size wc 32 A

Contour seat for ped size wc 32 A

Ped dynamic seating frame 32 A

Pwr seat elevation sys 32 A

PUF___2011_Web_File

Pwr standing 00 9Electro connect btw control 32 A

Electro connect btw 2 sys 32 A

Mini-prop remote joystick 32 A

PWC harness, expand control 32 A

Hand interface joystick 32 A

Mult mech switches 32 A

Special joystick handle 32 A

Chin cup interface 32 ASip and puff interface 32 A

Breath tube kit 32 AHead control interface mech 32 A

Head/extremity control inter 32 A

Head control nonproportional 32 A

Head control proximity switc 32 A

Attendant control 32 A

W/c wdth 20-23 in seat frame 32 AW/c wdth 24-27 in seat frame 32 AW/c dpth 20-21 in seat frame 32 AW/c dpth 22-25 in seat frame 32 AElectronic SGD interface 32 A

22nf nonsealed leadacid 32 A22nf sealed leadacid battery 32 A

Gr24 nonsealed leadacid 32 AGr24 sealed leadacid battery 32 A

U1nonsealed leadacid battery 32 AU1 sealed leadacid battery 32 A

PUF___2011_Web_File

Battery charger, single mode 32 A

Battery charger, dual mode 32 A

Power wc motor replacement 32 APwr wc gear box replacement 32 APwr wc motor/gear box combo 32 AGr27 sealed leadacid battery 32 A

Gr27 non-sealed leadacid 32 AHand/chin ctrl spec joystick 32 A

Hand/chin ctrl std joystick 32 A

Non-expandable controller 32 A

Expandable controller, repl 32 A

Expandable controller, initl 32 A

Pneum drive wheel tire 32 A

Tube, pneum wheel drive tire 32 A

Insert, pneum wheel drive 32 A

Pneumatic caster tire 32 A

Tube, pneumatic caster tire 32 A

Foam filled drive wheel tire 32 A

Foam filled caster tire 32 A

Foam drive wheel tire 32 A

Foam caster tire 32 ASolid drive wheel tire 32 A

Solid caster tire 32 A

Solid caster tire, integrate 32 A

Valve, pneumatic tire tube 32 A

Drive wheel excludes tire 32 A

Caster wheel excludes tire 32 A

Caster fork 32 APwc acc, lith-based battery 32 ANoc interface 32 A

PUF___2011_Web_File

Neg press wound therapy pump 36 ASGD digitized pre-rec <=8min 32 A

SGD prerec msg >8min <=20min 32 A

SGD prerec msg>20min <=40min 32 A

SGD prerec msg > 40 min 32 A

SGD spelling phys contact 32 A

SGD w multi methods msg/accs 32 A

SGD sftwre prgrm for PC/PDA 32 A

SGD accessory, mounting sys 32 ASGD accessory noc 32 AGen w/c cushion wdth < 22 in 32 AGen w/c cushion wdth >=22 in 32 ASkin protect wc cus wd <22in 32 ASkin protect wc cus wd>=22in 32 APosition wc cush wdth <22 in 32 APosition wc cush wdth>=22 in 32 ASkin pro/pos wc cus wd <22in 32 A

Skin pro/pos wc cus wd>=22in 32 A

Custom fabricate w/c cushion 32 APowered w/c cushion 32 AGen use back cush wdth <22in 32 A

Gen use back cush wdth>=22in 32 A

Position back cush wd <22in 32 A

Position back cush wd>=22in 32 A

Pos back post/lat wdth <22in 32 A

Pos back post/lat wdth>=22in 32 A

Custom fab w/c back cushion 32 A

Wc acc solid seat supp base 32 A

Replace cover w/c seat cush 32 AWC planar back cush wd <22in 32 A

WC planar back cush wd>=22in 32 A

Adj skin pro w/c cus wd<22in 32 A

PUF___2011_Web_File

Adj skin pro wc cus wd>=22in 32 A

Adj skin pro/pos cus<22in 32 A

Adj skin pro/pos wc cus>=22 32 A

Posterior gait trainer 00 9

Upright gait trainer 00 9

Anterior gait trainer 00 9

Admin influenza virus vac 54 AAdmin pneumococcal vaccine 54 AAdmin hepatitis b vaccine 54 ASemen analysis 21 ACA screen;pelvic/breast exam 11 AProstate ca screening; dre 11 APSA screening 21 ACA screen;flexi sigmoidscope 11 AColorectal scrn; hi risk ind 11 AColon CA screen;barium enema 11 A

Diab manage trn per indiv 11 A

Diab manage trn ind/group 11 A

Glaucoma scrn hgh risk direc 11 A

Glaucoma scrn hgh risk direc 11 A

Colon ca scrn; barium enema 11 A

Colon ca scrn not hi rsk ind 11 A

Colon ca scrn; barium enema 00 9Screen cerv/vag thin layer 21 A

Screen c/v thin layer by MD 11 21 C

Trim nail(s) 11 ACORF skilled nursing service 99 9

Partial hosp prog service 00 9

Single energy x-ray study 11 A

Scr c/v cyto,autosys and md 11 A

Scr c/v cyto,thinlayer,rescr 21 A

PUF___2011_Web_File



Scr c/v cyto, automated sys 21 A

Scr c/v cyto, autosys, rescr 21 A

HHCP-serv of pt,ea 15 min 00 9

HHCP-serv of ot,ea 15 min 00 9

HHCP-svs of s/l path,ea 15mn 00 9

HHCP-svs of rn,ea 15 min 00 9

HHCP-svs of csw,ea 15 min 00 9

HHCP-svs of aide,ea 15 min 00 9

HHC PT assistant ea 15 00 9

HHC OT assistant ea 15 00 9

HHC PT maint ea 15 min 00 9

HHC Occup Therapy ea 15 00 9

HHC SLP ea 15 min 00 9

HHC RN E&M plan svs, 15 min 00 9

HHC LPN/RN obs/asses ea 15 00 9

HHC lis nurse train ea 15 00 9

Extrnl counterpulse, per tx 11 AWound closure by adhesive 00 9Linear acc stereo radsur com 00 9

OPPS Service,sched team conf 00 9

PUF___2011_Web_File

OPPS/PHP;activity therapy 00 9

OPPS/PHP; train & educ serv 00 9

MD recertification HHA PT 11 A

MD certification HHA patient 11 A

Home health care supervision 11 A

Hospice care supervision 11 A

Dstry eye lesn,fdr vssl tech 00 9

Screeningmammographydigital 11 ADiagnosticmammographydigital 11 ADiagnosticmammographydigital 11 APET img wholbod melano nonco 00 9PET not otherwise specified 00 9Therapeutic procd strg endur 11 A

Oth resp proc, indiv 11 A

Oth resp proc, group 11 A

Initial foot exam pt lops 11 A

Followup eval of foot pt lop 11 A

PUF___2011_Web_File

Routine footcare pt w lops 11 A

Demonstrate use home inr mon 11 A

Provide INR test mater/equip 11 A

MD INR test revie inter mgmt 11 A

Linear acc based stero radio 00 9

PET imaging initial dx 00 9

Current percep threshold tst 00 9

Unsched dialysis ESRD pt hos 00 9

Inject for sacroiliac joint 00 9Inj for sacroiliac jt anesth 00 9

Cryopresevation Freeze+stora 13 A

Thawing + expansion froz cel 11 ABone marrow or psc harvest 11 A

Removal of impacted wax md 11 A

Occlusive device in vein art 00 9

MNT subs tx for change dx 11 A

PUF___2011_Web_File

Group MNT 2 or more 30 mins 11 A

Renal angio, cardiac cath 11 A

Iliac art angio,cardiac cath 11 A

Elec stim unattend for press 11 A

Elect stim wound care not pd 00 9

Elec stim other than wound 11 A

Recon, CTA for surg plan 11 A

Arthro, loose body + chondro 11 A

Drug-eluting stents, single 00 9

Drug-eluting stents,each add 00 9

Non-cov surg proc,clin trial 00 9

Non-cov proc, clinical trial 00 9

Electromagnetic therapy onc 00 9

Insert single chamber/cd 00 9Insert dual chamber/cd 00 9Inser/repos single icd+leads 00 9

Insert reposit lead dual+gen 00 9

Pre-op service LVRS complete 00 9

Pre-op service LVRS 10-15dos 00 9

Pre-op service LVRS 1-9 dos 00 9

PUF___2011_Web_File

Post op service LVRS min 6 00 9

CBC/diffwbc w/o platelet 00 9

CBC without platelet 00 9ESRD related svc 4+mo < 2yrs 11 A

ESRD related svc 2-3mo <2yrs 11 A

ESRD related svc 1 vst <2yrs 11 A

ESRD related svs 4+mo 2-11yr 11 A

ESRD relate svs 2-3 mo 2-11y 11 A

ESRD related svs 1 mon 2-11y 11 A

ESRD related svs 4+ mo 12-19 11 A

ESRD related svs 2-3mo/12-19 11 A

ESRD related svs 1vis/12-19y 11 A

ESRD related svs 4+mo 20+yrs 11 A

ESRD related svs 2-3 mo 20+y 11 A

ESRD related svs 1visit 20+y 11 A

ESD related svs home undr 2 11 A

PUF___2011_Web_File

ESRDrelatedsvs home mo 2-11y 11 A

ESRD related svs hom mo12-19 11 A

ESRD related svs home mo 20+ 11 A

ESRD related serv/dy, 2y 11 A

ESRD relate serv/dy 2-11yr 11 A

ESRD relate serv/dy 12-19y 11 A

ESRD relate serv/dy 20+yrs 11 A

Fecal blood scrn immunoassay 21 A

Electromagntic tx for ulcers 00 9

Preadmin IV immunoglobulin 13 A

Dispense fee initial 30 day 46 A

Hospice evaluation preelecti 11 ARobot lin-radsurg com, first 00 9

Robt lin-radsurg fractx 2-5 00 9

Percutaneous islet celltrans 13 A

Laparoscopy islet cell trans 13 A

Laparotomy islet cell transp 13 A

Initial preventive exam 11 A

Bone marrow aspirate &biopsy 11 A

Vessel mapping hemo access 11 A

EKG for initial prevent exam 11 A

EKG tracing for initial prev 11 A

PUF___2011_Web_File

EKG interpret & report preve 11 A

MD service required for PMD 13 A

Smoke/tobacco counselng 3-10 13 A

Smoke/tobacco counseling >10 13 A

Administra Part D vaccine 11 AHospital observation per hr 00 9Direct refer hospital observ 00 9Lev 1 hosp type B ED visit 00 9

Lev 2 hosp type B ED visit 00 9



PUF___2011_Web_File


Ultrasound exam AAA screen 13 A

Trauma Respons w/hosp criti 00 9AV fistula or graft arterial 13 A

AV fistula or graft venous 13 A

Blood occult test,colorectal 21 A

Alcohol/subs interv 15-30mn 11 A

Alcohol/subs interv >30 min 11 A

Home sleep test/type 2 Porta 13 A



Initial preventive exam 11 A

EKG for initial prevent exam 11 A

EKG tracing for initial prev 11 A

EKG interpret & report preve 11 A

Telhealth inpt consult 15min 13 A

Telheath inpt consult 25min 11 A

Telhealth inpt consult 35min 11 A

PUF___2011_Web_File

CORF related serv 15 mins ea 13 A

Grp psych partial hosp 45-50 13 A

Inter active grp psych parti 13 A

Open tx iliac spine uni/bil 13 A

Pelvic ring fracture uni/bil 13 A

Pelvic ring fx treat int fix 13 A

Open tx post pelvic fxcture 13 A

Sat biopsy prostate 1-20 spc 13 A

Sat biopsy prostate 21-40 13 A

Sat biopsy prostate 41-60 13 A

Sat biopsy prostate: >60 13 A

Ed svc CKD ind per session 11 A

Ed svc CKD grp per session 11 A

Intens cardiac rehab w/exerc 11 A

Intens cardiac rehab no exer 11 A

Pulmonary rehab w exer 11 A

Inpt telehealth consult 30m 13 A

Inpt telehealth consult 50m 13 A

Inpt telehealth con 70/>m 13 A

Collagen Meniscus Implant 00 9

Dermal filler injection(s) 13 A

Drug screen multi class 13 A

Drug screen multip class 13 A

EIA HIV-1/HIV-2 screen 21 A

PUF___2011_Web_File

ELISA HIV-1/HIV-2 screen 21 A

Drug screen multi drug class 21 A

Oral HIV-1/HIV-2 screen 21 A

Tobacco-use counsel 3-10 min 13 A

Tobacco-use counsel>10min 13 A

PPPS, initial visit 13 A

PPPS, subseq visit 13 A

Skin/dermal subs init 25or< 13 A

Skin/dermal subs each additi 13 A

Admin + supply, tositumomab 13 AAMI pt recd aspirin at arriv 00 9

AMI pt did not receiv aspiri 00 9

AMI pt ineligible for aspiri 00 9

AMI pt recd Bblock at arr 00 9

AMI pt did not rec bblock 00 9

AMI pt inelig Bbloc at arriv 00 9

Pneum pt recv antibiotic 4 h 00 9

Pneum pt w/o antibiotic 4 hr 00 9

Pneum pt not elig antibiotic 00 9

Diabetic pt w/ HBA1c>9% 00 9

Diabetic pt w/ HBA1c<or=9% 00 9

DM pt inelig for HBA1c measu 00 9

Care not provided for HbA1c 00 9

Diabetic pt w/LDL>= 100mg/dl 00 9

Diab pt w/LDL< 100mg/dl 00 9

Diab pt inelig for LDL meas 00 9

PUF___2011_Web_File

Care not provided for LDL 00 9

DM pt w BP>=140/80 00 9

Diabetic pt wBP<140/80 00 9

Diabetic pt inelig for BP me 00 9

Diabet pt w no care re BP me 00 9

HF p w/LVSD on ACE-I/ARB 00 9

HF pt w/LVSD not on ACE-I/AR 00 9

HF pt not elig for ACE-I/ARB 00 9

HF pt w/LVSD on Bblocker 00 9

HF pt w/LVSD not on Bblocker 00 9

HF pt not elig for Bblocker 00 9

PMI-CAD pt on Bblocker 00 9

PMI-CAD pt not on Bblocker 00 9

PMI-CAD pt inelig Bblocker 00 9

AMI-CAD pt doc on antiplatel 00 9AMI-CAD pt not docu on antip 00 9AMI-CAD inelig antiplate mea 00 9

CAD pt w/LDL>100mg/dl 00 9

CAD pt w/LDL<or=100mg/dl 00 9

CAD pt not eligible for LDL 00 9

Osteoporosis assess 00 9Osteopor pt not assess 00 9Pt inelig for osteopor meas 00 9

Falls assess not docum 12 mo 00 9Falls assess w/ 12 mon 00 9Not elig for falls assessmen 00 9

Hearing assess receive 00 9Pt w/o hearing assess 00 9Pt inelig for hearing assess 00 9

PUF___2011_Web_File

Urinary incont pt assess 00 9Pt not assess for urinary in 00 9Pt not elig for urinary inco 00 9

ESRD pt w/ dialy of URR>=65% 00 9

ESRD pt w/ dialy of URR<65% 00 9

ESRD pt not elig for URR/KtV 00 9

ESRD pt w/Hct>or=33 00 9

ESRD pt w/Hct<33 00 9

ESRD pt inelig for HCT/Hgb 00 9

ESRD pt w/ auto AV fistula 00 9

ESRD pt w other fistula 00 9

ESRD PT inelig auto AV FISTU 00 9

COPD pt rec smoking cessat 00 9

COPD pt w/o smoke cessat int 00 9

Osteopo pt given Ca+VitD sup 00 9

Osteop pt inelig for Ca+VitD 00 9

New dx osteo pt w/antiresorp 00 9

Osteo pt inelig for antireso 00 9

Bone dens meas test perf 00 9

Bone dens meas test inelig 00 9

Pt receiv influenza vacc 00 9

Pt w/o influenza vacc 00 9

Pt inelig for influenza vacc 00 9

Pt receiv mammogram 00 9

Pt not doc mammogram 00 9

Pt ineligible mammography 00 9

PUF___2011_Web_File

Care not provided for mamogr 00 9

Pt receiv pneumo vacc 00 9Pt did not rec pneumo vacc 00 9Pt was inelig for pneumo vac 00 9

Pt treat w/antidepress12wks 00 9

Pt not treat w/antidepres12w 00 9

Pt inelig for antidepres med 00 9

Pt treat w/antidepres for 6m 00 9

Pt not treat w/antidepres 6m 00 9

Pt inelig for antidepres med 00 9

Pt w/AB 1 hr prior to incisi 00 9

Pt not doc for AB 1 hr prior 00 9

Pt ineligi for AB therapy 00 9

Pt recd thromboemb prophylax 00 9Pt did not rec thromboembo 00 9Pt ineligi for thrombolism 00 9

Pt recd CABG w/ IMA 00 9

Pt w/CABG w/o IMA 00 9

Pt inelig for CABG w/IMA 00 9

Iso CABG pt rec preop bblock 00 9

Iso CABG pt w/o preop Bblock 00 9

Iso CABG pt inelig for preo 00 9

Iso CABG pt w/prolng intub 00 9

Iso CABG pt w/o prolng intub 00 9

Iso CABG req surg rexpo 00 9

Iso CABG w/o surg explo 00 9

CEA/ext bypass pt on aspirin 00 9

Pt w/carot endarct/ext bypas 00 9

PUF___2011_Web_File

CEA/ext bypass pt not on asp 00 9

CAD pt care not prov LDL 00 9

HF/atrial fib pt on warfarin 00 9

HF/atrial fib pt inelig warf 00 9

Osteoarth pt w/ assess pain 00 9

Osteoarth pt inelig assess 00 9

Antibiotic given prior surg 00 9

Antib given prior surg incis 00 9

Antibio not doc prior surg 00 9

Pt not elig for antibiotic 00 9

Antibiotic given prior surg 00 9

Antibio not docum prior surg 00 9

Antib order prior to surg 00 9

Cefazolin documented ordered 00 9

Cefazolin given prophylaxis 00 9

Cefazolin not docum prophy 00 9Pt not eligi for cefazolin 00 9

Order given to d/c antibio 00 9

Antib was D/C 24hrs surg tim 00 9

MD not doc order to d/c anti 00 9

Pt not eligi for proph antib 00 9

MD doc prophylactic AB given 00 9Clini doc order to D/C antib 00 9

Clini doc AB was D/C 48 h 00 9

Clinician did not doc 00 9

PUF___2011_Web_File

Clini doc pt ineligib anti 00 9

Clini doc proph AB giv 00 9Clini order given for VTE 00 9

Clini given VTE prop 00 9

Clini not doc order VTE 00 9

Clini doc pt inelig VTE 00 9

Pt received DVT prophylaxis 00 9Pt not received DVT proph 00 9Pt inelig DVT prophylaxis 00 9

Received DVT proph day 2 00 9Pt not rec DVT proph day 2 00 9Pt inelig for DVT proph 00 9

Pt prescribe platelet at D/C 00 9Pt not doc for presc antipla 00 9

Pt inelig for antiplat proph 00 9

Pt prescrib anticoag at D/C 00 9Pt no prescr anticoa at D/C 00 9

Pt not doc to have perm/AF 00 9

Clin pt inelig anticoag D/C 00 9

Pt doc to have admin t-PA 00 9Pt inelig t-PA isch strok>3h 00 9

Pt not doc for admin t-PA 00 9

Pt received dysphagia screen 00 9

Pt not doc dysphagia screen 00 9Pt received NPO 00 9

Pt inelig dysphagia screen 00 9

Pt doc rec rehab serv 00 9

Pt not doc to rec rehab serv 00 9

Inter carotid stenosis <30% 00 9

PUF___2011_Web_File

Inter carotid stenosis30-99% 00 9

Pt inelig candidate ito meas 00 9

Pt doc to have CT/MRI w/les 00 9

Pt not doc MRI/CT w/o lesion 00 9

Clini doc prese/abs alarm 00 9Pt inelig hx w new/chg mole 00 9

Pt w/alarm symp upper endo 00 9

Pt w/one alarm symp not doc 00 9

Pt inelig for upper endo 00 9

Pt w/Barretts esoph endo re 00 9

Pt not doc w/Barretts, endo 00 9

Pt inelig for esophag biop 00 9

Pt rec order for barium 00 9Pt w/no doc order for barium 00 9Clini doc pt inelig bar swal 00 9

Clini doc rev D/C meds w/med 00 9

Pt not doc rev meds D/C 00 9

Pt inelig for d/c meds rev 00 9Pt doc to hav decision maker 00 9

Pt not doc to have dec maker 00 9

Clin doc pt inelig dec maker 00 9

Pt doc assess uriny incon 00 9

Pt not doc assess urinary in 00 9

Pt inelig assess urinary inc 00 9

Pt doc rec charc urin incon 00 9Pt not doc charc urin incon 00 9Pt doc rec plan urinary inco 00 9Pt not doc rec care urin inc 00 9

PUF___2011_Web_File

Clin not prov care urin inco 00 9

Pt receiv screen for fall 00 9

Pt no doc screen fall 00 9

Clin doc pt inelig fall risk 00 9

Clin not prov care scre fall 00 9

Clini not doc pres/abs alarm 00 9Pt hx w/ new moles 00 9

Pt not doc mole change 00 9

Pt inelig for assess mole 00 9

Pt doc rec PE skin 00 9Pt not doc rec PE 00 9Pt inelig PE skin 00 9

Pt rec counsel for self-exam 00 9Pt not doc to rec couns 00 9Pt inelig for counsel 00 9Pt doc to rec pres osteo 00 9

Pt did not rec pres osteo 00 9Pt inelig to rec pres osteo 00 9

Clin not prov care for pharm 00 9

Pt doc rec Ca/Vit D 00 9

Pt not doc rec Ca/Vit D 00 9

Clin doc pt inelig Ca/Vit D 00 9

Clin no pro care pt Ca/Vit D 00 9

COPD pt w/spir results 00 9COPD pt w/o spir results 00 9COPD pt inelig spir results 00 9COPD pt doc bronch ther 00 9COPD pt not doc bronch ther 00 9COPD pt inelig bronch therap 00 9Pt doc optic nerve eval 00 9Pt not doc optic nerv eval 00 9Pt inelig for optic nerv eva 00 9

Clin not prov care POAG 00 9

Pt doc w/ target IOP 00 9Pt not doc w/ IOP 00 9Clin doc pt inelig IOP 00 9

PUF___2011_Web_File

Clin not prov care POAG 00 9

POAG w/ IOP rec care plan 00 9

POAG w/ IOP no care plan 00 9

POAG w/ IOP not doc plan 00 9

Pt doc rec antioxidant 00 9

Pt not doc rec antiox 00 9

Pt inelig for antioxidant 00 9

Clin no prov care for antiox 00 9

Pt doc rec macular exam 00 9

Pt not doc to rec mac exam 00 9

Clin doc pt inelig mac exam 00 9

Clin no pro care for mac deg 00 9

Pt doc to have visual func 00 9Pt doc not have visual func 00 9Pt inelig for vis func stat 00 9

Clin not prov care catarac 00 9

Pt doc to pre axial leng 00 9

Pt not doc pre axial leng 00 9

Pt inelig for pre surg axial 00 9

Clin not prov care for IOL 00 9

Pt rec fund exam prior surg 00 9

Pt not doc rec fundus exam 00 9

Pt inelig for pre surg fundu 00 9Clin not prov care fund eval 00 9

Pt doc rec dilated macular 00 9

PUF___2011_Web_File

Pt not doc rec dilated mac 00 9

Pt inelig dilate fundus 00 9

Clin prov no care diabetic r 00 9

Pt doc to have macular exam 00 9

Doc of macular not giv MD 00 9

Clin doc pt inelig macular 00 9

Clin did not pro care diabet 00 9

Clin doc pt was test osteo 00 9

Clin not doc pt test osteo 00 9

Pt inelig for test osteo 00 9

Pt doc have DEXA 00 9

Pt not doc for DEXA 00 9

Clin doc pt inelig DEXA 00 9

Clin not prov care DEXA 00 9

Pt doc have DEXA perform 00 9

Pt not doc have DEXA 00 9

Clin doc pt inelig DEXA 00 9

Clin not prov care DEXA 00 9

Int carotid stenosis meas 00 9

Pt inelig for doc of alarm 00 9

Pt doc 12 lead ECG 00 9Pt not doc ECG 00 9Pt inelig for ECG 00 9Pt doc rec aspirin 24hrs ER 00 9

Pt not rec aspirin prior ER 00 9

Clin doc pt inelig aspirin 00 9

PUF___2011_Web_File

Pt doc to have ECG 00 9Pt not doc to have ECG 00 9Clin doc pt inelig ECG 00 9Pt doc vital signs recorded 00 9Pt not doc vital signs recor 00 9Pt doc to have 02 SAT assess 00 9Pt not doc 02 SAT assess 00 9Clin doc pt inelig 02 SAT 00 9

Pt doc mental status assess 00 9Pt not doc mental status 00 9Pt doc to have empiric AB 00 9Pt not doc have empiric AB 00 9Clin doc pt inelig empiri AB 00 9

Asthma pt w survey not docum 00 9

Chemother not rec stg3 colon 00 9

Chemother rec stg3 colon ca 00 9

Chemo plan documen prior che 00 9Chemo plan not doc prior che 00 9CLL pt w/o doc flow cytometr 00 9

Brst ca pt inelig tamoxifen 00 9

MD doc colon ca pt inelig ch 00 9

MD doc pt inelig radiation 00 9

Doc radiat tx recom 12mo ov 00 9

Pt w stgIC-3Brst ca not rec 00 9

Pt w stgIC-3Brst ca rec tam 00 9

MM pt w/o doc IV bisphophon 00 9

No doc radiation rec 12mo ov 00 9

Base cytogen test MDS notper 00 9

Diabet pt no do Hgb A1c 12m 00 9

Diabet pt nodoc LDLiprotei 00 9

ESRD pt w Hct/Hgb not docume 00 9ESRD pt w URR/Ktv notdoc eli 00 9

MDS pt no doc FE st prio EPO 00 9

PUF___2011_Web_File

Diabetic w/o document BP 12m 00 9

Pt w asthma no doc med or tx 00 9

LVEF>=40% doc normal or mild 00 9

LVEF not performed 00 9Dil macula/fundus exam/w doc 00 9

Dil macular/fundus not perfo 00 9Pt w/DXA document or order 00 9

Pt w/DXA no document or orde 00 9

Pt inelig osteo screen measu 00 9

Smoke preven interven counse 00 9Smoke preven nocounsel 00 9Low extemity neur exam docum 00 9Low extemity neur not perfor 00 9Pt inelig lower extrem neuro 00 9

ABI documented 00 9ABI not documented 00 9Pt inelig for ABI measure 00 9

Eval on foot documented 00 9Eval on foot not performed 00 9Pt inelig footwear evaluatio 00 9

Calc BMI abv up param f/u 00 9

Calc BMI blw low param f/u 00 9

Calc BMI out nrm param nof/u 00 9

Calc BMI norm parameters 00 9BMI not calculated 00 9Pt inelig BMI calculation 00 9Pt screen flu vac & counsel 00 9

Flu vaccine not screen 00 9Flu vaccine screen not curre 00 9

Pt not approp screen & counc 00 9

Doc cur meds by prov 00 9

Cur meds not document 00 9

PUF___2011_Web_File

Incomplete doc pt on meds 00 9

Pt inelig med check 00 9Pos clin depres scrn f/u doc 00 9

Clin depression screen not d 00 9Pt inelig; scrn clin dep 00 9

Cognitive impairment screen 00 9Cognitive screen not documen 00 9Pt inelig for cognitive impa 00 9Care plan develop & document 00 9

Pt inelig for devlp care pln 00 9

Care plan develp & not docum 00 9

Pain assess f/u pln document 00 9

No document of pain assess 00 9

Pt inelig pain assessment 00 9Prescription by E-Prescrib s 00 9

Prescrip not gen at encounte 00 9

Some prescrib print or call 00 9

Pt vis doc use EHR cer ATCB 00 9

Pt vis doc w/PQRI qual EHR 00 9

Pt not doc w/EMR due to syst 00 9

Beta-bloc rx pt w/abn lvef 00 9

Pt w/abn lvef inelig b-bloc 00 9

PUF___2011_Web_File

Pt w/abn lvef b-bloc no rx 00 9

Tob use cess int counsel 00 9Tob use cess int no counsel 00 9Current tobacco smoker 00 9Current smkless tobacco user 00 9Cur tobacco non-user 00 9Pt inelig geno no antvir tx 00 9

Doc pt rec antivir treat 00 9

Pt inelig RNA no antvir tx 00 9

Pt rec antivir treat hep c 00 9Pt inelig couns no antvir tx 00 9

Pt rec antiviral treat doc 00 9Pt inelig; lo to no dter rsk 00 9

High risk recurrence pro ca 00 9Pt inelig suic; MDD remis 00 9

New dx init/rec episode MDD 00 9

ACE/ARB rx pt w/abn lvef 00 9

Pt w/abn lvef inelig ACE/ARB 00 9

Pt w/ normal lvef 00 9

LVEF not performed/doc 00 9ACE/ARB no rx pt w/abn lvef 00 9

ACE/ARB thxpy rx'd 00 9

ACE/ARB not rx'd; doc reas 00 9

ACE/ARB thxpy not rx'd 00 9

BP sys <130 and dias <80 00 9

BP sys>=130 and/or dias >=80 00 9

BP not performed/doc 00 9

PUF___2011_Web_File

MD rxÆd ACE/ARB thxpy 00 9

Pt inelig ACE/ARB thxpy 00 9

MD not rxÆd ACE/ARB thxpy 00 9

Flu immunize order/admin 00 9Flu imm no ord/admin doc rea 00 9

Flu immunize no order/admin 00 9Report, Diabetes measures 00 9Report, Prev Care Measures 00 9Report CKD Measures 00 9Report ESRD Measures 00 9CAD measures grp 00 9RA measures grp 00 9HIV/AIDS measures grp 00 9Periop Care measures grp 00 9Back pain measures grp 00 9DM meas qual act perform 00 9

CKD meas qual act perform 00 9

Prev Care MG qual act perfrm 00 9

CABG meas qual act perform 00 9

CAD meas qual act perform 00 9

RA meas qual act perform 00 9

HIV meas qual act perform 00 9

Perio meas qual act perform 00 9

Back Pain MG qual act perfrm 00 9

Doc proph antibx w/in 1 hr 00 9

Doc ord pro antbx w/in 1 hr 00 9

No doc proph antibx w/in 1hr 00 9

Pt rec ACE/ARB 00 9

Pt inelig pt verif meds 00 9

Pt inelig; pain asses no f/u 00 9

PUF___2011_Web_File

Pain assess no f/u pln doc 00 9

Pt inelig neg scrn depres 00 9

Clin depres scrn no f/u doc 00 9

Pain sev quant present 00 9ABI meas & doc 00 9PT inelig; ABI measure 00 9

No ABI measurement 00 9Scrn fal rsk >2 fal or w/inj 00 9

Scrn fall rsk; <2 falls 00 9

Clin stg b/f lun/eso ca surg 00 9

Pt in; clin ca stg b/f surg 00 9

Clin stg b/f surg not doc 00 9

Antplt recd 48 hrs & disch 00 9

Pt inelig; antiplt therapy 00 9

Antplt not recd reas no spec 00 9

Patch closure conv CEA 00 9No patch closure CEA 00 9No patch closure conv CEA 00 9

Doc ord antimic prophy 00 9Pt inelig; proph antibiot 00 9

No doc ord antimic prophy 00 9

Auto AV fistula recd 00 9Pt inelig; auto AV fistula 00 9

No auto AV fistula; no reas 00 9

Partic in clin data base reg 00 9

Doc elder mal scrn f/u plan 00 9Pt inelig no eld mal scrn 00 9No doc elder mal scrn 00 9Pt inelig eldmal scrn no f/u 00 9

Eld mal scrn no f/u pln 00 9

PUF___2011_Web_File

Cur funct assess & care pln 00 9

Pt inelig funct assess 00 9

No doc cur funct assess 00 9

Pt inelig func asses no pln 00 9

Cur funct asses; no care pln 00 9

CABG measures grp 00 9HepC measures grp 00 9CAP measures grp 00 9IVD measures grp 00 9HF measures grp 00 9HepC MG qual act perform 00 9

CAP MG qual act perform 00 9

HF MG qual act perform 00 9

IVD MG qual act perform 00 9

1 Rx via qualified eRx sys 00 9

Ref to doc otolog eval 00 9

Pt inelig ref otolog eval 00 9No ref to doc otolog eval 00 9

Pt ref doc oto eval 00 9

Pt hx act drain prev 90 days 00 9

Pt inelig for ref oto eval 00 9

Pt no hx act drain 90 d 00 9

Pt no ref oto reas no spec 00 9

Pt ref oto eval 00 9

Ver doc hear loss 00 9Pt inelig ref oto eval 00 9

Pt no doc hear loss 00 9

Pt no ref otolo no spec 00 9

Prol intubation req 00 9No prol intub req 00 9Ster wd ifx 30 d postop 00 9No ster wd ifx 00 9Stk/CVA CABG 00 9

PUF___2011_Web_File

No strk/CVA CABG 00 9Postop ren insuf 00 9No postop ren insuf 00 9Reop req bld grft oth 00 9

No reop req bld grft oth 00 9

Antplt med disch 00 9Antplt med contraind 00 9no antplt med disch 00 9Bblock disch 00 9Bblock contraind 00 9No bblock disch 00 9Antilipid treat disch 00 9Antlip disch contra 00 9No antlipid treat disch 00 9Sys BP <140 00 9Sys BP >= 140 00 9Dia BP < 90 00 9Dia BP >= 90 00 9No BP measure 00 9Lipid pn results 00 9

No lipid prof perf 00 9Ldl < 100 00 9No LDL perf 00 9Ldl >= 100 00 9Asp therp used 00 9No asp therp used 00 9

tPA initi w/in 3 hrs 00 9No elig tPA init w/in 3 hrs 00 9

No tPA init w/in 3 hrs 00 9

Spok lang comp score 00 9

No high score spok lang 00 9

No spok lang comp score 00 9

Attention score 00 9

No high score attention 00 9

No attention score 00 9

Memory score 00 9

No high score memory 00 9

No memory score 00 9

Moto speech score 00 9

PUF___2011_Web_File

No high score moto speech 00 9

No moto speech score 00 9

Reading score 00 9

No high score reading 00 9

No reading score 00 9

Spok lang exp score 00 9

No high score spok lang exp 00 9

No spok lang exp score 00 9

Writing score 00 9

No high score writing 00 9

No writing score 00 9

Swallowing score 00 9

No high score swallowing 00 9

No swallowing score 00 9

Surg proc w/in 30 days 00 9

No surg proc w/in 30 days 00 9

Doc antibio order b/4 surg 00 9

Doc antibio given b/4 surg 00 9

Pt no elg 4 order antbi give 00 9

Doc no antibi order b/4 surg 00 9

Pharm ther osteo rx 00 9

Pt no elg phar ther osteo 00 9

PUF___2011_Web_File

No pharm ther osteo rx 00 9

Flu immun admin/prev rec 00 9Pt no elg receiv flu immun 00 9

Flu immun no admin/prev rec 00 9

Flu immun admin or prev rec 00 9Pt no elg rec flu immun 00 9

Flu immun not admin/pre rec 00 9

Hrdshp rural w/o internet 00 9

Hrdshp w/o suff pharm w/eRx 00 9

EP no prescribe priv 00 9Asthma measures grp 00 9Asthma MG qual act perform 00 9

Fun stat score knee >= 0 00 9

Fun stat score knee < 0 00 9

Fun stat score knee pt noelg 00 9

Fun stat score knee not done 00 9

Fun stat score hip >= 0 00 9

Fun stat score hip < 0 00 9

Fun stat score hip pt no elg 00 9

Fun stat score hip not done 00 9

Fun stat score LE >= 0 00 9

Fun stat score LE < 0 00 9

Fun stat score LE pt no elg 00 9

PUF___2011_Web_File

Fun stat score LE not done 00 9

Fun stat score LS >= 0 00 9

Fun stat score LS < 0 00 9

Fun stat score LS pt no elg 00 9

Fun stat score LS not done 00 9

Fun stat score shdl >=0 00 9

Fun stat score shdl < 0 00 9

Fun stat score shdl pt no el 00 9

Fun stat score shdl not done 00 9

Fun stat score UE >=0 00 9

Fun stat score UE < 0 00 9

Fun stat score UE pt no elg 00 9

Fun stat score UE not done 00 9

Fun stat score neck/TS >=0 00 9

Fun stat score neck/TS < 0 00 9

Fun stat scor nek/TS pt no e 00 9

Fun stat scor nek/TS not don 00 9

PUF___2011_Web_File

BP Syst >= 140 mmHg 00 9BP Diast >= 90 mmHg 00 9BP Syst < 130 mmHg 00 9BP Syst >=130 - 139 mmHg 00 9BP Diast < 80 mmHg 00 9BP Diast 80-89 mmHg 00 9Pt hosp w/HF 00 9

LVG test perf 00 9Pt not elig for LVF test 00 9

Pt not hosp w/HF 00 9

LVF test not perf 00 9

Toba smkr curr or 2 hand exp 00 9No tob smkr cur no 2 hnd exp 00 9Smkls tob cur; no 2 hnd exp 00 9

Toba use not assess 00 9Curr toba smkr or 2 hand exp 00 9No cur tob smkr no 2 hnd exp 00 9Curr smkls tob; no 2 hnd exp 00 9

Tobacco no assess 00 9MCCD, initial rate 00 9MCCD,maintenance rate 00 9MCCD, risk adj hi, initial 00 9MCCD, risk adj lo, initial 00 9MCCD, risk adj, maintenance 00 9MCCD, Home monitoring 00 9MCCD, sch team conf 00 9Mccd,phys coor-care ovrsght 00 9MCCD, risk adj, level 3 00 9MCCD, risk adj, level 4 00 9MCCD, risk adj, level 5 00 9Other Specified Case Mgmt 00 9ESRD demo bundle level I 00 9ESRD demo bundle-level II 00 9Demo-smoking cessation coun 00 9

Amantadine HCL 100mg oral 13 A

Zanamivir,inhalation pwd 10m 13 A

Oseltamivir phosphate 75mg 13 A

Rimantadine HCL 100mg oral 13 A

Amantadine HCL oral brand 13 A

PUF___2011_Web_File

Zanamivir, inh pwdr, brand 00 9

Oseltamivir phosp, brand 00 9

Rimantadine HCL, brand 00 9

Low vision rehab occupationa 00 9

Low vision rehab orient/mobi 00 9

Low vision lowvision therapi 00 9

Low vision rehabilate teache 00 9

Oncology work-up evaluation 00 9

Oncology tx decision-mgmt 00 9

Onc surveillance for disease 00 9

Onc expectant management pt 00 9

Onc supervision palliative 00 9

Onc visit unspecified NOS 00 9

Onc prac mgmt adheres guide 00 9

Onc pract mgmt differs trial 00 9

Onc prac mgmt disagree w/gui 00 9

Onc prac mgmt pt opt alterna 00 9

Onc prac mgmt dif pt comorb 00 9

Onc prac cond noadd by guide 00 9

Onc prac guide differs nos 00 9

PUF___2011_Web_File

Onc dx nsclc stgI no progres 00 9

Onc dx nsclc stg2 no progres 00 9

Onc dx nsclc stg3A no progre 00 9

Onc dx nsclc stg3B-4 metasta 00 9

Onc dx nsclc dx unknown nos 00 9

Onc dx sclc/nsclc limited 00 9

Onc dx sclc/nsclc ext at dx 00 9

Onc dx sclc/nsclc ext unknwn 00 9

Onc dx brst stg1-2B HR,nopro 00 9

Onc dx brst stg1-2 noprogres 00 9

Onc dx brst stg3-HR, no pro 00 9

Onc dx brst stg3-noprogress 00 9

Onc dx brst metastic/ recur 00 9

PUF___2011_Web_File

Onc dx prostate T1no progres 00 9

Onc dx prostate T2no progres 00 9

Onc dx prostate T3b-T4noprog 00 9

Onc dx prostate w/rise PSA 00 9

Onc dx prostate unknwn nos 00 9

Onc dx colon t1-3,n1-2,no pr 00 9

Onc dx colon T4, N0 w/o prog 00 9

Onc dx colon T1-4 no dx prog 00 9

Onc dx colon metas evid dx 00 9

Onc dx colon metas noevid dx 00 9

Onc dx colon extent unknown 00 9

Onc dx rectal T1-2 no progr 00 9

Onc dx rectal T3 N0 no prog 00 9

Onc dx rectal T1-3,N1-2noprg 00 9

PUF___2011_Web_File

Onc dx rectal T4,N,M0 no prg 00 9

Onc dx rectal M1 w/mets prog 00 9

Onc dx rectal extent unknwn 00 9

Onc dx esophag T1-T3 noprog 00 9

Onc dx esophageal T4 no prog 00 9

Onc dx esophageal mets recur 00 9

Onc dx esophageal unknown 00 9

Onc dx gastric no recurrence 00 9

Onc dx gastric p R1-R2noprog 00 9

Onc dx gastric unresectable 00 9

Onc dx gastric recurrent 00 9

Onc dx gastric unknown NOS 00 9

Onc dx pancreatc p R0 res no 00 9

PUF___2011_Web_File

Onc dx pancreatc p R1/R2 no 00 9

Onc dx pancreatic unresectab 00 9

Onc dx pancreatic unknwn NOS 00 9

Onc dx head/neck T1-T2no prg 00 9

Onc dx head/neck T3-4 noprog 00 9

Onc dx head/neck M1 mets rec 00 9

Onc dx head/neck ext unknown 00 9

Onc dx ovarian stg1A-B no pr 00 9

Onc dx ovarian stg1A-B or 2 00 9

Onc dx ovarian stg3/4 noprog 00 9

Onc dx ovarian recurrence 00 9

Onc dx ovarian unknown NOS 00 9

Onc dx CML chronic phase 00 9

Onc dx CML acceler phase 00 9

Onc dx CML blast phase 00 9

PUF___2011_Web_File

Onc dx CML remission 00 9

Onc dx multi myeloma stage I 00 9

Onc dx mult myeloma stg2 hig 00 9

Onc dx multi myeloma unknown 00 9

Onc dx brst unknown NOS 00 9

Onc dx prostate mets no cast 00 9

Onc dx prostate clinical met 00 9

Onc NHLstg 1-2 no relap no 00 9

Onc dx NHL stg 3-4 not relap 00 9

Onc dx NHL trans to lg Bcell 00 9

Onc dx NHL relapse/refractor 00 9

Onc dx NHL stg unknown 00 9

Onc dx CML dx status unknown 00 9

Frontier extended stay demo 00 9

Influenza A H1N1,admin w cou 13 A

Influenza A H1N1, vaccine 13 AWarfarin respon genetic test 13 A

Outpt IV insulin tx any mea 00 9

PUF___2011_Web_File

Alcohol and/or drug assess 00 9Alcohol and/or drug screenin 00 9

Alcohol and/or drug screenin 00 9

Alcohol and/or drug services 00 9Alcohol and/or drug services 00 9Alcohol and/or drug services 00 9Alcohol and/or drug services 00 9Alcohol and/or drug services 00 9Alcohol and/or drug services 00 9Alcohol and/or drug services 00 9

Alcohol and/or drug services 00 9



Alcohol and/or drug services 00 9Alcohol and/or drug services 00 9






Alcohol and/or drug training 00 9

Alcohol and/or drug interven 00 9Alcohol and/or drug outreach 00 9

Alcohol and/or drug preventi 00 9





PUF___2011_Web_File


Alcohol and/or drug hotline 00 9MH health assess by non-md 00 9MH svc plan dev by non-md 00 9Oral med adm direct observe 00 9Med trng & support per 15min 00 9MH partial hosp tx under 24h 00 9Comm psy face-face per 15min 00 9Comm psy sup tx pgm per diem 00 9Self-help/peer svc per 15min 00 9Asser com tx face-face/15min 00 9Assert comm tx pgm per diem 00 9Fos c chld non-ther per diem 00 9Fos c chld non-ther per mon 00 9Supported housing, per diem 00 9Supported housing, per month 00 9Respite not-in-home per diem 00 9Mental health service, nos 00 9Alcohol/drug abuse svc nos 00 9Spec coll non-blood:a/d test 00 9

Alcohol/drug screening 00 9Alcohol/drug service 15 min 00 9Prenatal care atrisk assessm 00 9Antepartum management 00 9Carecoordination prenatal 00 9Prenatal at risk education 00 9Follow up home visit/prental 00 9Prenatalcare enhanced srv pk 00 9Nonmed family planning ed 00 9Family assessment 00 9

Comp multidisipln evaluation 00 9Rehabilitation program 1/2 d 00 9Comprehensive med svc 15 min 00 9Crisis interven svc, 15 min 00 9Behav hlth day treat, per hr 00 9Psych hlth fac svc, per diem 00 9Skills train and dev, 15 min 00 9Comp comm supp svc, 15 min 00 9Comp comm supp svc, per diem 00 9Psysoc rehab svc, per 15 min 00 9Psysoc rehab svc, per diem 00 9Ther behav svc, per 15 min 00 9Ther behav svc, per diem 00 9Com wrap-around sv, 15 min 00 9Com wrap-around sv, per diem 00 9Supported employ, per 15 min 00 9Supported employ, per diem 00 9Supp maint employ, 15 min 00 9Supp maint employ, per diem 00 9Psychoed svc, per 15 min 00 9

PUF___2011_Web_File

Sex offend tx svc, 15 min 00 9Sex offend tx svc, per diem 00 9MH clubhouse svc, per 15 min 00 9MH clubhouse svc, per diem 00 9Activity therapy, per 15 min 00 9Multisys ther/juvenile 15min 00 9A/D halfway house, per diem 00 9A/D tx program, per hour 00 9A/D tx program, per diem 00 9Dev delay prev dp ch, 15 min 00 9

Tetracyclin injection 51 AAbarelix injection 51 AAbatacept injection 51 AAbciximab injection 51 AAcetylcysteine injection 51 AAcyclovir injection 51 AAdalimumab injection 51 AInjection adenosine 6 MG 51 A

Adenosine injection 51 A

Adrenalin epinephrin inject 51 AAdrenalin epinephrine inject 51 AAgalsidase beta injection 51 AInj biperiden lactate/5 mg 51 AAlatrofloxacin mesylate 51 AAlglucerase injection 51 AAmifostine 51 AMethyldopate hcl injection 51 AAlefacept 51 AAlglucosidase alfa injection 51 AAlpha 1 proteinase inhibitor 51 AAlprostadil for injection 51 A

Alprostadil urethral suppos 51 A

Amikacin sulfate injection 51 AAminophyllin 250 MG inj 51 AAmiodarone HCl 51 AAmphotericin B 51 AAmphotericin b lipid complex 51 AAmpho b cholesteryl sulfate 51 AAmphotericin b liposome inj 51 AAmpicillin 500 MG inj 51 AAmpicillin sodium per 1.5 gm 51 AAmobarbital 125 MG inj 51 ASuccinycholine chloride inj 51 AAnidulafungin injection 51 AInjection anistreplase 30 u 51 AHydralazine hcl injection 51 AApomorphine hydrochloride 51 A

PUF___2011_Web_File

Aprotonin, 10,000 kiu 51 AInj metaraminol bitartrate 51 AChloroquine injection 51 AArbutamine hcl injection 51 AAripiprazole injection 51 AAzithromycin 51 AAtropine sulfate injection 51 AAtropine sulfate injection 51 ADimecaprol injection 51 ABaclofen 10 MG injection 51 ABaclofen intrathecal trial 51 ABasiliximab 51 ADicyclomine injection 51 AInj benztropine mesylate 51 ABethanechol chloride inject 51 APenicillin g benzathine inj 51 A

Penicillin g benzathine inj 51 A

Penicillin g benzathine inj 51 A

PenG benzathine/procaine inj 51 APenG benzathine/procaine inj 51 APenicillin g benzathine inj 51 APenicillin g benzathine inj 51 APenicillin g benzathine inj 51 APenicillin g benzathine inj 51 ABivalirudin 51 AInjection,onabotulinumtoxinA 51 AAbobotulinumtoxinA 51 AInj, rimabotulinumtoxinB 51 ABuprenorphine hydrochloride 51 ABusulfan injection 51 AButorphanol tartrate 1 mg 51 AC-1 esterase, berinert 51 AC-1 esterase, cinryze 51 AEdetate calcium disodium inj 51 ACalcium gluconate injection 51 ACalcium glycer & lact/10 ML 51 ACalcitonin salmon injection 51 AInj calcitriol per 0.1 mcg 51 ACaspofungin acetate 51 ACanakinumab injection 51 ALeucovorin calcium injection 51 ALevoleucovorin injection 51 AInj mepivacaine HCL/10 ml 51 ACefazolin sodium injection 51 ACefepime HCl for injection 51 ACefoxitin sodium injection 51 ACeftriaxone sodium injection 51 ASterile cefuroxime injection 51 ACefotaxime sodium injection 51 ABetamethasone acet&sod phosp 51 ABetamethasone sod phosp/4 MG 51 A

PUF___2011_Web_File

Caffeine citrate injection 51 ACephapirin sodium injection 51 AInj ceftazidime per 500 mg 51 ACeftizoxime sodium / 500 MG 51 ACertolizumab pegol inj 51 AChloramphenicol sodium injec 51 AChorionic gonadotropin/1000u 51 AClonidine hydrochloride 51 ACidofovir injection 51 ACilastatin sodium injection 51 ACiprofloxacin iv 51 AInj codeine phosphate /30 MG 51 AColchicine injection 51 AColistimethate sodium inj 51 ACollagenase, clost hist inj 51 AProchlorperazine injection 51 ACorticorelin ovine triflutal 51 ACorticotropin injection 51 ACosyntropin injection NOS 51 ACosyntropin cortrosyn inj 51 AInj cosyntropin per 0.25 MG 51 ACytomegalovirus imm IV /vial 51 ADaptomycin injection 51 ADarbepoetin alfa, non-esrd 51 ADarbepoetin alfa, esrd use 57 AEpoetin alfa, non-esrd 51 AEpoetin alfa 1000 units ESRD 57 ADecitabine injection 51 ADeferoxamine mesylate inj 51 ATestosterone enanthate inj 51 ABrompheniramine maleate inj 51 AEstradiol valerate injection 51 ADepo-estradiol cypionate inj 51 AMethylprednisolone 20 MG inj 51 AMethylprednisolone 40 MG inj 51 AMethylprednisolone 80 MG inj 51 AMedroxyprogesterone inj 51 AMedrxyprogester acetate inj 00 9MA/EC contraceptiveinjection 51 ATestosterone cypionate 1 ML 51 ATestosterone cypionat 100 MG 51 ATestosterone cypionat 200 MG 51 AInj dexamethasone acetate 51 ADexamethasone sodium phos 51 AInj dihydroergotamine mesylt 51 AAcetazolamid sodium injectio 51 ADigoxin injection 51 ADigoxin immune fab (ovine) 51 APhenytoin sodium injection 51 AHydromorphone injection 51 ADyphylline injection 51 ADexrazoxane HCl injection 51 ADiphenhydramine hcl injectio 51 AChlorothiazide sodium inj 51 A

PUF___2011_Web_File

Dimethyl sulfoxide 50% 50 ML 51 AMethadone injection 51 ADimenhydrinate injection 51 ADipyridamole injection 51 AInj dobutamine HCL/250 mg 51 ADolasetron mesylate 51 ADopamine injection 51 ADoripenem injection 51 AInjection, doxercalciferol 51 AEcallantide injection 51 AEculizumab injection 51 AAmitriptyline injection 51 AEnfuvirtide injection 51 AEpoprostenol injection 51 AEptifibatide injection 51 AErgonovine maleate injection 51 AErtapenem injection 51 AErythro lactobionate /500 MG 51 AEstradiol valerate 10 MG inj 51 AEstradiol valerate 20 MG inj 51 AInj estrogen conjugate 25 MG 51 AEthanolamine oleate 100 mg 51 AInjection estrone per 1 MG 51 AEtidronate disodium inj 51 AEtanercept injection 51 A

Filgrastim 300 mcg injection 51 AFilgrastim 480 mcg injection 51 AFluconazole 51 AFomepizole, 15 mg 51 AIntraocular Fomivirsen na 51 AFosaprepitant injection 51 AFoscarnet sodium injection 51 AGallium nitrate injection 51 AGalsulfase injection 51 AInj IVIG privigen 500 mg 51 A

Gamma globulin 1 CC inj 51 AGamma globulin 2 CC inj 51 AGamma globulin 3 CC inj 51 AGamma globulin 4 CC inj 51 AGamma globulin 5 CC inj 51 AGamma globulin 6 CC inj 51 AGamma globulin 7 CC inj 51 AGamma globulin 8 CC inj 51 AGamma globulin 9 CC inj 51 AGamma globulin 10 CC inj 51 AHizentra injection 51 AGamma globulin > 10 CC inj 51 AGamunex injection 51 A

Vivaglobin, inj 51 ARSV-ivig 51 A

PUF___2011_Web_File

Immune globulin, powder 51 A

Immune globulin, liquid 00 9Octagam injection 51 A

Gammagard liquid injection 51 A

Ganciclovir sodium injection 51 AHepagam b im injection 51 AFlebogamma injection 51 A

Hepagam b intravenous, inj 51 AGaramycin gentamicin inj 51 AGatifloxacin injection 51 AInjection glatiramer acetate 51 AIvig non-lyophilized, NOS 51 A

Gold sodium thiomaleate inj 51 AGlucagon hydrochloride/1 MG 51 AGonadorelin hydroch/ 100 mcg 51 AGranisetron hcl injection 51 AHaloperidol injection 51 AHaloperidol decanoate inj 51 AHemin, 1 mg 51 AInj heparin sodium per 10 u 51 AInj heparin sodium per 1000u 51 ADalteparin sodium 51 AInj enoxaparin sodium 51 AFondaparinux sodium 51 ATinzaparin sodium injection 51 ATetanus immune globulin inj 51 AHistrelin acetate 51 AHuman fibrinogen conc inj 51 AHydrocortisone acetate inj 51 AHydrocortisone sodium ph inj 51 AHydrocortisone sodium succ i 51 ADiazoxide injection 51 AIbandronate sodium injection 51 AIbutilide fumarate injection 51 AIdursulfase injection 51 AInfliximab injection 51 AInj iron dextran 51 AIron dextran 165 injection 00 9Iron dextran 267 injection 00 9Iron sucrose injection 51 AInjection imiglucerase /unit 51 AImuglucerase injection 51 ADroperidol injection 51 APropranolol injection 51 ADroperidol/fentanyl inj 51 AInsulin injection 51 AInsulin for insulin pump use 51 AInterferon beta-1a 00 9Interferon Beta-1A inj 00 9

PUF___2011_Web_File

Interferon beta-1b / .25 MG 51 A

Itraconazole injection 51 AKanamycin sulfate 500 MG inj 51 AKanamycin sulfate 75 MG inj 51 AKetorolac tromethamine inj 51 ACephalothin sodium injection 51 ALanreotide injection 51 ALaronidase injection 51 AFurosemide injection 51 ALepirudin 51 ALeuprolide acetate /3.75 MG 51 ALevetiracetam injection 51 AInj levocarnitine per 1 gm 51 ALevofloxacin injection 51 ALevorphanol tartrate inj 51 AHyoscyamine sulfate inj 51 AChlordiazepoxide injection 51 ALidocaine injection 51 ALincomycin injection 51 ALinezolid injection 51 ALorazepam injection 51 AMannitol injection 51 AMecasermin injection 51 AMeperidine hydrochl /100 MG 51 AMeperidine/promethazine inj 51 AMeropenem 51 AMethylergonovin maleate inj 51 AMicafungin sodium injection 51 AInj midazolam hydrochloride 51 AInj milrinone lactate / 5 MG 51 AMorphine sulfate injection 51 AMorphine so4 injection 100mg 51 AMorphine sulfate injection 51 AZiconotide injection 51 AInj, moxifloxacin 100 mg 51 AInj nalbuphine hydrochloride 51 AInj naloxone hydrochloride 51 ANaltrexone, depot form 51 ANandrolone decanoate 50 MG 51 ANandrolone decanoate 100 MG 51 ANandrolone decanoate 200 MG 51 ANatalizumab injection 51 ANesiritide injection 51 AOctreotide injection, depot 51 AOctreotide inj, non-depot 51 A

Oprelvekin injection 51 AOmalizumab injection 51 AOlanzapine long-acting inj 51 AOrphenadrine injection 51 APhenylephrine hcl injection 51 AChloroprocaine hcl injection 51 A

PUF___2011_Web_File

Ondansetron hcl injection 51 AOxymorphone hcl injection 51 APalifermin injection 51 APaliperidone palmitate inj 51 APamidronate disodium /30 MG 51 APapaverin hcl injection 51 AOxytetracycline injection 51 APalonosetron hcl 51 AParicalcitol 51 APegaptanib sodium injection 51 APegademase bovine, 25 iu 51 AInjection, pegfilgrastim 6mg 53 APenicillin g procaine inj 51 APentastarch 10% solution 51 APentobarbital sodium inj 51 APenicillin g potassium inj 51 APiperacillin/tazobactam 51 A

Pentamidine non-comp unit 51 A

Promethazine hcl injection 51 APhenobarbital sodium inj 51 APlerixafor injection 51 AOxytocin injection 51 AInj desmopressin acetate 51 APrednisolone acetate inj 51 ATotazoline hcl injection 51 AInj progesterone per 50 MG 51 AFluphenazine decanoate 25 MG 51 AProcainamide hcl injection 51 AOxacillin sodium injeciton 51 ANeostigmine methylslfte inj 51 AInj protamine sulfate/10 MG 51 AProtein c concentrate 51 AInj protirelin per 250 mcg 51 APralidoxime chloride inj 51 APhentolaine mesylate inj 51 AMetoclopramide hcl injection 51 AQuinupristin/dalfopristin 51 ARanibizumab injection 51 ARanitidine hydrochloride inj 51 ARasburicase 51 ARegadenoson injection 51 ARho d immune globulin 50 mcg 51 ARho d immune globulin inj 51 ARhophylac injection 51 A

Rho(D) immune globulin h, sd 51 ARilonacept injection 51 ARisperidone, long acting 51 ARopivacaine HCl injection 51 ARomiplostim injection 51 AMethocarbamol injection 51 ASincalide injection 51 A

PUF___2011_Web_File

Inj theophylline per 40 MG 51 ASargramostim injection 51 AInj secretin synthetic human 51 AAurothioglucose injeciton 51 ANa ferric gluconate complex 51 AMethylprednisolone injection 51 AMethylprednisolone injection 51 ASomatrem injection 51 ASomatropin injection 51 APromazine hcl injection 51 AReteplase injection 51 AInj streptokinase /250000 IU 51 AAlteplase recombinant 51 AStreptomycin injection 51 AFentanyl citrate injeciton 51 ASumatriptan succinate / 6 MG 51 A

Pentazocine injection 51 ATelevancin injection 51 ATenecteplase injection 51 ATenecteplase injection 51 ATerbutaline sulfate inj 51 ATeriparatide injection 51 ATestosterone enanthate inj 51 ATestosterone enanthate inj 51 ATestosterone suspension inj 51 ATestosteron propionate inj 51 AChlorpromazine hcl injection 51 AThyrotropin injection 51 ATigecycline injection 51 ATirofiban HCl 51 ATrimethobenzamide hcl inj 51 ATobramycin sulfate injection 51 ATocilizumab injection 51 AInjection torsemide 10 mg/ml 51 AThiethylperazine maleate inj 51 ATreprostinil injection 51 ATriamcinolone A inj PRS-free 51 ATriamcinolone acet inj NOS 51 ATriamcinolone diacetate inj 51 ATriamcinolone hexacetonl inj 51 AInj trimetrexate glucoronate 51 APerphenazine injeciton 51 ATriptorelin pamoate 51 ASpectinomycn di-hcl inj 51 AUrea injection 51 AUrofollitropin, 75 iu 51 AUstekinumab injection 51 ADiazepam injection 51 AUrokinase 5000 IU injection 51 AUrokinase 250,000 IU inj 51 AVancomycin hcl injection 51 AVelaglucerase alfa 51 A

PUF___2011_Web_File

Verteporfin injection 51 ATriflupromazine hcl inj 51 AHydroxyzine hcl injection 51 AThiamine hcl 100 mg 51 APyridoxine hcl 100 mg 51 AVitamin b12 injection 51 AVitamin k phytonadione inj 51 AInjection, voriconazole 51 AHyaluronidase injection 51 AOvine, up to 999 USP units 51 A

Ovine, 1000 USP units 51 AHyaluronidase recombinant 51 AInj magnesium sulfate 51 AInj potassium chloride 51 AZidovudine 51 AZiprasidone mesylate 51 AZoledronic acid 51 AReclast injection 51 ADrugs unclassified injection 51 AEdetate disodium per 150 mg 00 9Nasal vaccine inhalation 51 AMetered dose inhaler drug 00 9Laetrile amygdalin vit B17 00 9Unclassified biologics 51 ANormal saline solution infus 51 ANormal saline solution infus 51 A5% dextrose/normal saline 51 ANormal saline solution infus 51 A5% dextrose/water 51 AD5w infusion 51 ADextran 40 infusion 51 ADextran 75 infusion 51 ARingers lactate infusion 51 AHypertonic saline solution 51 AWilate injection 51 AXyntha inj 51 AAntihemophilic viii/vwf comp 51 A

Humate-P, inj 51 AFactor viia 51 AFactor viii 51 AFactor VIII (porcine) 51 AFactor viii recombinant NOS 51 A

Factor IX non-recombinant 51 AFactor ix complex 51 AFactor IX recombinant 51 AAntithrombin recombinant 51 AAntithrombin iii injection 51 AAnti-inhibitor 51 AHemophilia clot factor noc 51 AIntraut copper contraceptive 00 9Levonorgestrel iu contracept 00 9

PUF___2011_Web_File

Contraceptive vaginal ring 00 9Contraceptive hormone patch 00 9Levonorgestrel implant sys 00 9Etonogestrel implant system 00 9Aminolevulinic acid hcl top 51 A

Methyl aminolevulinate, top 51 AGanciclovir long act implant 51 AFluocinolone acetonide implt 51 ADexamethasone intra implant 51 ASodium Hyaluronate Injection 00 9

Hyalgan/supartz inj per dose 51 A

Synvisc inj per dose 51 AEuflexxa inj per dose 51 AOrthovisc inj per dose 51 ASynvisc or Synvisc-One 51 A

Cultured chondrocytes implnt 57 ACapsaicin 8% patch 51 AMetabolic active D/E tissue 51 A

Non-human, metabolic tissue 51 A

Metabolically active tissue 46 A

Nonmetabolic act d/e tissue 51 A

Nonmetabolic active tissue 51 A

Non-human, non-metab tissue 51 A

Injectable human tissue 51 A

Integra matrix tissue 51 A

Tissuemend tissue 51 A

Primatrix tissue 51 A

Azathioprine oral 50mg 51 AAzathioprine parenteral 51 ACyclosporine oral 100 mg 57 ALymphocyte immune globulin 51 A

PUF___2011_Web_File

Monoclonal antibodies 51 APrednisone oral 51 ATacrolimus oral per 1 MG 51 AMethylprednisolone oral 51 APrednisolone oral per 5 mg 51 AAntithymocyte globuln rabbit 51 ADaclizumab, parenteral 51 ACyclosporine oral 25 mg 51 ACyclosporin parenteral 250mg 51 AMycophenolate mofetil oral 51 AMycophenolic acid 51 ASirolimus, oral 51 ATacrolimus injection 51 AImmunosuppressive drug noc 51 AAlbuterol inh non-comp con 00 9

Albuterol inh non-comp u d 00 9

Acetylcysteine comp unit 51 A

Arformoterol non-comp unit 51 A

Formoterol fumarate, inh 51 A

Levalbuterol comp con 51 A

Acetylcysteine non-comp unit 51 A

Albuterol comp unit 51 A

Albuterol comp con 51 A

Albuterol non-comp con 00 9

Levalbuterol non-comp con 00 9

Albuterol non-comp unit 00 9

Levalbuterol non-comp unit 00 9

Levalbuterol comp unit 51 A

Albuterol ipratrop non-comp 51 A

Beclomethasone comp unit 51 A

Betamethasone comp unit 51 A

Budesonide non-comp unit 51 A

Budesonide comp unit 51 A

PUF___2011_Web_File

Bitolterol mesylate comp con 51 A

Bitolterol mesylate comp unt 51 A

Cromolyn sodium noncomp unit 51 A

Cromolyn sodium comp unit 51 A

Budesonide non-comp con 51 A

Budesonide comp con 51 A

Atropine comp con 51 A

Atropine comp unit 51 A

Dexamethasone comp con 51 A

Dexamethasone comp unit 51 A

Dornase alfa non-comp unit 51 A

Formoterol comp unit 00 9

Flunisolide comp unit 51 A

Glycopyrrolate comp con 51 A

Glycopyrrolate comp unit 51 A

Ipratropium bromide non-comp 51 A

Ipratropium bromide comp 51 A

Isoetharine comp con 51 A

Isoetharine non-comp con 51 A

Isoetharine non-comp unit 51 A

Isoetharine comp unit 51 A

Isoproterenol comp con 51 A

Isoproterenol non-comp con 51 A

Isoproterenol non-comp unit 51 A

Isoproterenol comp unit 51 A

Metaproterenol comp con 51 A

Metaproterenol non-comp con 51 A

PUF___2011_Web_File

Metaproterenol non-comp unit 51 A

Metaproterenol comp unit 51 A

Methacholine chloride, neb 51 A

Pentamidine comp unit dose 51 A

Terbutaline sulf comp con 51 A

Terbutaline sulf comp unit 51 A

Tobramycin non-comp unit 51 A

Triamcinolone comp con 51 A

Triamcinolone comp unit 51 A

Tobramycin comp unit 51 A

Treprostinil, non-comp unit 51 A

Inhalation solution for DME 51 ANon-inhalation drug for DME 51 AAntiemetic rectal/supp NOS 51 AOral prescrip drug non chemo 00 9Oral aprepitant 51 AOral busulfan 51 ACabergoline, oral 0.25mg 00 9Capecitabine, oral, 150 mg 51 ACapecitabine, oral, 500 mg 51 ACyclophosphamide oral 25 MG 51 AOral dexamethasone 51 AEtoposide oral 50 MG 51 AOral fludarabine phosphate 51 AGefitinib oral 00 9Antiemetic drug oral NOS 51 AMelphalan oral 2 MG 51 AMethotrexate oral 2.5 MG 51 ANabilone oral 51 ATemozolomide 51 ATopotecan oral 51 AOral prescription drug chemo 51 ADoxorubicin hcl injection 51 ADoxorubicin hcl liposome inj 51 AAlemtuzumab injection 51 AAldesleukin injection 51 AArsenic trioxide injection 51 AAsparaginase injection 51 AAzacitidine injection 51 AClofarabine injection 51 ABcg live intravesical vac 51 ABendamustine injection 51 ABevacizumab injection 51 A

PUF___2011_Web_File

Bleomycin sulfate injection 51 ABortezomib injection 51 ACarboplatin injection 51 ACarmustine injection 51 ACetuximab injection 51 ACisplatin 10 MG injection 51 ACisplatin 50 MG injection 51 AInj cladribine per 1 MG 51 ACyclophosphamide 100 MG inj 51 ACyclophosphamide 200 MG inj 51 ACyclophosphamide 500 MG inj 51 ACyclophosphamide 1.0 grm inj 51 ACyclophosphamide 2.0 grm inj 51 ACyclophosphamide lyophilized 51 ACyclophosphamide lyophilized 51 ACyclophosphamide lyophilized 51 ACyclophosphamide lyophilized 51 ACyclophosphamide lyophilized 51 ACytarabine liposome inj 51 ACytarabine hcl 100 MG inj 51 ACytarabine hcl 500 MG inj 51 ADactinomycin injection 51 ADacarbazine 100 mg inj 51 ADacarbazine 200 MG inj 51 ADaunorubicin injection 51 ADaunorubicin citrate inj 51 ADegarelix injection 51 ADenileukin diftitox inj 51 ADiethylstilbestrol injection 51 ADocetaxel injection 51 ADocetaxel injection 51 AElliotts b solution per ml 51 AInj, epirubicin hcl, 2 mg 51 AEtoposide injection 51 AEtoposide 100 MG inj 51 AFludarabine phosphate inj 51 AFluorouracil injection 51 AFloxuridine injection 51 AGemcitabine hcl injection 51 AGoserelin acetate implant 51 AIrinotecan injection 51 AIxabepilone injection 51 AIfosfomide injection 51 AMesna injection 51 AIdarubicin hcl injection 51 AInterferon alfacon-1 inj 51 AInterferon alfa-2a inj 51 AInterferon alfa-2b inj 51 AInterferon alfa-n3 inj 51 AInterferon gamma 1-b inj 51 ALeuprolide acetate suspnsion 51 ALeuprolide acetate injeciton 51 ALeuprolide acetate implant 51 AVantas implant 51 A

PUF___2011_Web_File

Supprelin LA implant 51 AMechlorethamine hcl inj 51 AInj melphalan hydrochl 50 MG 51 AMethotrexate sodium inj 51 AMethotrexate sodium inj 51 ANelarabine injection 51 AOxaliplatin 51 APaclitaxel protein bound 51 APaclitaxel injection 51 APegaspargase injection 51 APentostatin injection 51 APlicamycin (mithramycin) inj 51 AMitomycin 5 MG inj 51 AMitomycin 20 MG inj 51 AMitomycin 40 MG inj 51 AMitoxantrone hydrochl / 5 MG 51 AGemtuzumab ozogamicin inj 51 AOfatumumab injection 51 APanitumumab injection 51 APemetrexed injection 51 APralatrexate injection 51 ARituximab injection 51 ARomidepsin injection 51 AStreptozocin injection 51 ATemozolomide injection 51 ATemsirolimus injection 51 AThiotepa injection 51 ATopotecan injection 51 ATopotecan injection 51 ATrastuzumab injection 51 AValrubicin injection 51 AVinblastine sulfate inj 51 AVincristine sulfate 1 MG inj 51 AVincristine sulfate 2 MG inj 51 AVincristine sulfate 5 MG inj 51 AVinorelbine tartrate inj 51 AInjection, Fulvestrant 51 APorfimer sodium injection 51 AChemotherapy drug 51 AStandard wheelchair 36 AStnd hemi (low seat) whlchr 36 ALightweight wheelchair 36 AHigh strength ltwt whlchr 36 AUltralightweight wheelchair 32 AHeavy duty wheelchair 36 AExtra heavy duty wheelchair 36 AOther manual wheelchair/base 46 AStnd wt frame power whlchr 36 AStnd wt pwr whlchr w control 36 A

Ltwt portbl power whlchr 36 AOther power whlchr base 36 ADetach non-adjus hght armrst 32 A

PUF___2011_Web_File

Detach adjust armrest base 32 ADetach adjust armrst upper 32 AArm pad each 32 AFixed adjust armrest pair 32 AHigh mount flip-up footrest 32 ALeg strap each 32 ALeg strap h style each 32 AAdjustable angle footplate 32 ALarge size footplate each 32 AStandard size footplate each 32 AFtrst lower extension tube 32 AFtrst upper hanger bracket 32 AFootrest complete assembly 32 AElevat legrst low extension 32 AElevat legrst up hangr brack 32 ARatchet assembly 32 ACam relese assem ftrst/lgrst 32 ASwingaway detach footrest 32 AElevate footrest articulate 32 ASeat ht <17 or >=21 ltwt wc 32 A

Spoke protectors 32 ARear whl complete solid tire 32 ARear whl compl pneum tire 32 AFront castr compl pneum tire 32 AFrnt cstr cmpl sem-pneum tir 32 ACaster pin lock each 32 AFront caster assem complete 32 ADrive belt power wheelchair 32 AIv hanger 32 AW/c component-accessory NOS 46 AElevating whlchair leg rests 36 APump uninterrupted infusion 31 A

Temporary replacement eqpmnt 32 ASupply/ext inf pump syr type 34 ACombination oral/nasal mask 32 A

Repl oral cushion combo mask 32 ARepl nasal pillow comb mask 32 ARepl batt silver oxide 1.5 v 32 A

Repl batt silver oxide 3 v 32 A

Repl batt alkaline 1.5 v 32 A

Repl batt lithium 3.6 v 32 A

Repl batt lithium 4.5 v 32 A

AED garment w elec analysis 36 A

Repl batt for AED 32 A

PUF___2011_Web_File

Repl garment for AED 32 ARepl electrode for AED 34 A

Seat/back cus no dmepdac ver 32 A

Removable soft interface LE 38 A

Ctrl dose inh drug deliv sys 32 A12-24hr sealed lead acid 32 A

Adj skin pro w/c cus wd<22in 32 A

Adj skin pro wc cus wd>=22in 32 A

Adj skin pro/pos wc cus<22in 32 A

Adj skin pro/pos wc cus>=22" 32 A

Portable gas oxygen system 33 A

Repair/svc DME non-oxygen eq 46 A

Repair/svc oxygen equipment 00 9

POV group 1 std up to 300lbs 32 A

POV group 1 hd 301-450 lbs 32 A

POV group 1 vhd 451-600 lbs 32 A

POV group 2 std up to 300lbs 32 A

POV group 2 hd 301-450 lbs 32 A

POV group 2 vhd 451-600 lbs 32 A

Power operated vehicle NOC 32 APWC gp 1 std port seat/back 36 A

PWC gp 1 std port cap chair 36 A

PWC gp 1 std seat/back 36 A

PWC gp 1 std cap chair 36 A

PWC gp 2 std port seat/back 36 A

PWC gp 2 std port cap chair 36 A



PUF___2011_Web_File

PWC gp 2 hd seat/back 36 A

PWC gp 2 hd cap chair 36 A

PWC gp 2 vhd seat/back 36 A

PWC gp vhd cap chair 36 A

PWC gp 2 xtra hd seat/back 36 A

PWC gp 2 xtra hd cap chair 36 A

PWC gp2 std seat elevate s/b 36 A

PWC gp2 std seat elevate cap 36 A

PWC gp2 std sing pow opt s/b 36 A

PWC gp2 std sing pow opt cap 36 A

PWC gp 2 hd sing pow opt s/b 36 A

PWC gp 2 hd sing pow opt cap 36 A

PWC gp2 vhd sing pow opt s/b 36 A

PWC gp2 xhd sing pow opt s/b 36 A

PWC gp2 std mult pow opt s/b 36 A

PWC gp2 std mult pow opt cap 36 A

PWC gp2 hd mult pow opt s/b 36 A




PWC gp 3 hd cap chair 36 A


PWC gp 3 vhd cap chair 36 A

PWC gp 3 xhd seat/back 36 A

PWC gp 3 xhd cap chair 36 A



PUF___2011_Web_File

PWC gp3 hd sing pow opt s/b 36 A

PWC gp3 hd sing pow opt cap 36 A



PWC gp3 hd mult pow opt s/b 36 A

PWC gp3 vhd mult pow opt s/b 36 A

PWC gp3 xhd mult pow opt s/b 36 A







PWC gp4 hd sing pow opt s/b 36 A



PWC gp4 std mult pow opt cap 36 A

PWC gp4 hd mult pow s/b 36 A

PWC gp5 ped sing pow opt s/b 36 A

PWC gp5 ped mult pow opt s/b 36 A

Power wheelchair NOC 36 APow mobil dev no dmepdac 36 ACranial cervical orthosis 38 A

Cranial cervical torticollis 38 A

Cerv flexible non-adjustable 38 AFlex thermoplastic collar mo 38 ACervical semi-rigid adjustab 38 ACerv semi-rig adj molded chn 38 A

Cerv semi-rig wire occ/mand 38 ACervical collar molded to pt 38 ACerv col thermplas foam 2 pi 38 A

PUF___2011_Web_File

Cerv col foam 2 piece w thor 38 A

Cer post col occ/man sup adj 38 ACerv collar supp adj cerv ba 38 A

Cerv col supp adj bar & thor 38 A

Thoracic rib belt 38 AThor rib belt custom fabrica 38 ADewall posture protector 38 A

TLSO flex prefab thoracic 38 A

tlso flex custom fab thoraci 38 A

TLSO flex prefab sacrococ-T9 38 A

TLSO flex prefab 38 A

TLSO 2Mod symphis-xipho pre 38 A

TLSO2Mod symphysis-stern pre 38 A

TLSO 3Mod sacro-scap pre 38 A

TLSO 4Mod sacro-scap pre 38 A

PUF___2011_Web_File

TLSO rigid frame pre soft ap 38 A

TLSO rigid frame prefab pelv 38 A

TLSO rigid frame pre subclav 38 A

TLSO rigid frame hyperex pre 38 A

TLSO rigid plastic custom fa 38 A

TLSO rigid lined custom fab 38 A

TLSO rigid plastic cust fab 38 A

TLSO rigidlined cust fab two 38 A

TLSO rigid lined pre one pie 38 A

PUF___2011_Web_File

TLSO rigid plastic pre one 38 A

TLSO 2 piece rigid shell 38 A

TLSO 3 piece rigid shell 38 A

SIO flex pelvisacral prefab 38 A

SIO flex pelvisacral custom 38 A

SIO panel prefab 38 A

SIO panel custom 38 A

LO flexibl L1-below L5 pre 38 A

LO sag stays/panels pre-fab 38 A

LO sagitt rigid panel prefab 38 A

LO flex w/o rigid stays pre 38 A

PUF___2011_Web_File

LSO flex w/rigid stays cust 38 A

LSO post rigid panel pre 38 A

LSO sag-coro rigid frame pre 38 A

LSO sag rigid frame cust 38 A

LSO flexion control prefab 38 A

LSO flexion control custom 38 A

LSO sagit rigid panel prefab 38 A

LSO sagittal rigid panel cus 38 A

LSO sag-coronal panel prefab 38 A

LSO sag-coronal panel custom 38 A

PUF___2011_Web_File

LSO s/c shell/panel prefab 38 A

LSO s/c shell/panel custom 38 A

Ctlso a-p-l control molded 38 A

Ctlso a-p-l control w/ inter 38 A

Halo cervical into jckt vest 38 AHalo cervical into body jack 38 AHalo cerv into milwaukee typ 38 AMRI compatible system 38 A

Halo repl liner/interface 38 APost surgical support pads 38 ATlso corset front 38 ALso corset front 38 ATlso full corset 38 ALso full corset 38 AAxillary crutch extension 38 APeroneal straps pair 38 AStocking supp grips set of f 38 AProtective body sock each 38 AAdd to spinal orthosis NOS 46 ACtlso milwauke initial model 38 A

CTLSO infant immobilizer 38 A

Tension based scoliosis orth 38 A

Ctlso axilla sling 38 A

Kyphosis pad 38 AKyphosis pad floating 38 ALumbar bolster pad 38 ALumbar or lumbar rib pad 38 ASternal pad 38 AThoracic pad 38 ATrapezius sling 38 AOutrigger 38 A

PUF___2011_Web_File

Outrigger bil w/ vert extens 38 A

Lumbar sling 38 ARing flange plastic/leather 38 ARing flange plas/leather mol 38 A

Covers for upright each 38 AFurnsh initial orthosis only 38 A

Lateral thoracic extension 38 AAnterior thoracic extension 38 AMilwaukee type superstructur 38 ALumbar derotation pad 38 AAnterior asis pad 38 AAnterior thoracic derotation 38 AAbdominal pad 38 ARib gusset (elastic) each 38 ALateral trochanteric pad 38 ABody jacket mold to patient 38 APost-operative body jacket 38 ASpinal orthosis NOS 46 AThkao mobility frame 38 A

Thkao standing frame 38 AThkao swivel walker 38 AAbduct hip flex frejka w cvr 38 A

Abduct hip flex frejka covr 38 A

Abduct hip flex pavlik harne 38 A

Abduct control hip semi-flex 38 A

Pelv band/spread bar thigh c 38 A

HO abduction hip adjustable 38 A

HO bi thighcuffs w sprdr bar 38 A

HO abduction static plastic 38 A

Pelvic & hip control thigh c 38 A

Post-op hip abduct custom fa 38 A

HO post-op hip abduction 38 A

Combination bilateral HO 38 A

Leg perthes orth toronto typ 38 ALegg perthes orth newington 38 ALegg perthes orthosis trilat 38 ALegg perthes orth scottish r 38 A

PUF___2011_Web_File

Legg perthes patten bottom t 38 AKnee orthoses elas w stays 38 A

Ko elastic with joints 38 A

Elastic with condylar pads 38 A

Ko elas w/ condyle pads & jo 38 A

Ko elastic knee cap 38 AKo immobilizer canvas longit 38 A

Knee orth pos locking joint 38 A

KO adj jnt pos rigid support 38 A

Ko w/0 joint rigid molded to 38 ARigid KO wo joints 38 A

Ko derot ant cruciate custom 38 A

KO single upright custom fit 38 A

Ko w/adj jt rot cntrl molded 38 A

Ko w/ adj flex/ext rotat cus 38 A

Ko w adj flex/ext rotat mold 38 A

KO adjustable w air chambers 38 A

Ko swedish type 38 AKo plas doub upright jnt mol 38 A

Ko polycentric pneumatic pad 38 A

Ko supracondylar socket mold 38 A

Ko doub upright lacers molde 38 A

Ko doub upright cuffs/lacers 38 A

Afo sprng wir drsflx calf bd 38 A

Prefab ankle orthosis 38 A

Afo ankle gauntlet 38 A

PUF___2011_Web_File

Afo molded ankle gauntlet 38 AAfo multiligamentus ankle su 38 A

AFO supramalleolar custom 38 A

Afo sing bar clasp attach sh 38 A

Afo sing upright w/ adjust s 38 A

Afo plastic 38 A

Afo rig ant tib prefab TCF/= 38 A

Afo molded to patient plasti 38 AAfo molded plas rig ant tib 38 A

Afo spiral molded to pt plas 38 A

AFO spiral prefabricated 38 A

Afo pos solid ank plastic mo 38 AAfo plastic molded w/ankle j 38 AAFO w/ankle joint, prefab 38 A

Afo sing solid stirrup calf 38 A

Afo doub solid stirrup calf 38 A

Kafo sing fre stirr thi/calf 38 A

KAFO sng/dbl mechanical act 38 A

Kafo sng solid stirrup w/o j 38 A

Kafo dbl solid stirrup band/ 38 A

Kafo dbl solid stirrup w/o j 38 A

KAFO pla sin up w/wo k/a cus 38 A

KAFO plastic pediatric size 38 A

Kafo plas doub free knee mol 38 A

Kafo plas sing free knee mol 38 A

Kafo w/o joint multi-axis an 38 A

Hkafo torsion bil rot straps 38 A

PUF___2011_Web_File

Hkafo torsion cable hip pelv 38 A

Hkafo torsion ball bearing j 38 A

Hkafo torsion unilat rot str 38 A

Hkafo unilat torsion cable 38 A

Hkafo unilat torsion ball br 38 A

Afo tib fx cast plaster mold 38 A

Afo tib fx cast molded to pt 38 A

Afo tibial fracture soft 38 A

Afo tib fx semi-rigid 38 A

Afo tibial fracture rigid 38 A

Kafo fem fx cast thermoplas 38 A

Kafo fem fx cast molded to p 38 A

Kafo femoral fx cast soft 38 A

Kafo fem fx cast semi-rigid 38 A

Kafo femoral fx cast rigid 38 A

Plas shoe insert w ank joint 38 A

Drop lock knee 38 ALimited motion knee joint 38 AAdj motion knee jnt lerman t 38 A

Quadrilateral brim 38 AWaist belt 38 APelvic band & belt thigh fla 38 A

Limited ankle motion ea jnt 38 ADorsiflexion assist each joi 38 A

Dorsi & plantar flex ass/res 38 A

Split flat caliper stirr & p 38 ARocker bottom, contact AFO 38 A

Round caliper and plate atta 38 AFoot plate molded stirrup at 38 A

Reinforced solid stirrup 38 ALong tongue stirrup 38 AVarus/valgus strap padded/li 38 A

PUF___2011_Web_File

Plastic mod low ext pad/line 38 A

Molded inner boot 38 AAbduction bar jointed adjust 38 A

Abduction bar-straight 38 ANon-molded lacer 38 A

Lacer molded to patient mode 38 A

Anterior swing band 38 APre-tibial shell molded to p 38 AProsthetic type socket molde 38 A

Extended steel shank 38 APatten bottom 38 ATorsion ank & half solid sti 38 A

Torsion straight knee joint 38 AStraight knee joint heavy du 38 AAdd LE poly knee custom KAFO 38 A

Offset knee joint each 38 AOffset knee joint heavy duty 38 ASuspension sleeve lower ext 38 AKnee joint drop lock ea jnt 38 AKnee joint cam lock each joi 38 A

Knee disc/dial lock/adj flex 38 A

Knee jnt ratchet lock ea jnt 38 A

Knee lift loop drop lock rin 38 AThi/glut/ischia wgt bearing 38 A

Th/wght bear quad-lat brim m 38 A

Th/wght bear quad-lat brim c 38 A

Th/wght bear nar m-l brim mo 38 A

Th/wght bear nar m-l brim cu 38 A

Thigh/wght bear lacer non-mo 38 AThigh/wght bear lacer molded 38 A

Thigh/wght bear high roll cu 38 AHip clevis type 2 posit jnt 38 A

Pelvic control pelvic sling 38 AHip clevis/thrust bearing fr 38 A

Hip clevis/thrust bearing lo 38 A

PUF___2011_Web_File

Pelvic control hip heavy dut 38 AHip joint adjustable flexion 38 AHip adj flex ext abduct cont 38 A

Plastic mold recipro hip & c 38 A

Metal frame recipro hip & ca 38 A

Pelvic control band & belt u 38 APelvic control band & belt b 38 APelv & thor control gluteal 38 AThoracic control thoracic ba 38 AThorac cont paraspinal uprig 38 AThorac cont lat support upri 38 APlating chrome/nickel pr bar 38 ACarbon graphite lamination 38 A

Extension per extension per 38 A

Ortho sidebar disconnect 38 ALow ext orthosis per bar/jnt 38 ANon-corrosive finish 38 ADrop lock retainer each 38 AKnee control full kneecap 38 AKnee cap medial or lateral p 38 A

Knee control condylar pad 38 ASoft interface below knee se 38 A

Soft interface above knee se 38 A

Tibial length sock fx or equ 38 A

Femoral lgth sock fx or equa 38 A

Torsion mechanism knee/ankle 00 9

Torsion mechanism knee/ankle 00 9

Lower extremity orthosis NOS 46 AFt insert ucb berkeley shell 00 9

Foot insert remov molded spe 00 9Foot insert plastazote or eq 00 9Foot insert silicone gel eac 00 9Foot longitudinal arch suppo 00 9

Foot longitud/metatarsal sup 00 9

Foot arch support remov prem 00 9Foot lamin/prepreg composite 00 9

PUF___2011_Web_File

Ft arch suprt premold longit 00 9Foot arch supp premold metat 00 9Foot arch supp longitud/meta 00 9Arch suprt att to sho longit 00 9Arch supp att to shoe metata 00 9Arch supp att to shoe long/m 00 9

Hallus-valgus nght dynamic s 00 9Abduction rotation bar shoe 00 9Abduct rotation bar w/o shoe 00 9Shoe styled positioning dev 00 9Foot plastic heel stabilizer 00 9Oxford w supinat/pronat inf 00 9Oxford w/ supinat/pronator c 00 9Oxford w/ supinator/pronator 00 9Hightop w/ supp/pronator inf 00 9Hightop w/ supp/pronator chi 00 9Hightop w/ supp/pronator jun 00 9Surgical boot each infant 00 9Surgical boot each child 00 9Surgical boot each junior 00 9Benesch boot pair infant 00 9Benesch boot pair child 00 9Benesch boot pair junior 00 9Orthopedic ftwear ladies oxf 00 9Orthoped ladies shoes dpth i 00 9Ladies shoes hightop depth i 00 9Orthopedic mens shoes oxford 00 9Orthopedic mens shoes dpth i 00 9Mens shoes hightop depth inl 00 9Woman's shoe oxford brace 38 A

Man's shoe oxford brace 38 A

Custom shoes depth inlay 00 9Custom mold shoe remov prost 00 9

Shoe molded to pt silicone s 00 9Shoe molded plastazote cust 00 9

Shoe molded plastazote cust 00 9Orth foot non-stndard size/w 00 9Orth foot non-standard size/ 00 9Orth foot add charge split s 00 9Ambulatory surgical boot eac 00 9Plastazote sandal each 00 9Sho lift taper to metatarsal 00 9Shoe lift elev heel/sole neo 00 9Shoe lift elev heel/sole cor 00 9Lifts elevation metal extens 00 9Shoe lifts tapered to one-ha 00 9Shoe lifts elevation heel /i 00 9Shoe wedge sach 00 9Shoe heel wedge 00 9

PUF___2011_Web_File

Shoe sole wedge outside sole 00 9Shoe sole wedge between sole 00 9Shoe clubfoot wedge 00 9Shoe outflare wedge 00 9Shoe metatarsal bar wedge ro 00 9Shoe metatarsal bar between 00 9Full sole/heel wedge btween 00 9Sho heel count plast reinfor 00 9Heel leather reinforced 00 9Shoe heel sach cushion type 00 9Shoe heel new leather standa 00 9Shoe heel new rubber standar 00 9Shoe heel thomas with wedge 00 9Shoe heel thomas extend to b 00 9Shoe heel pad & depress for 00 9Shoe heel pad removable for 00 9Ortho shoe add leather insol 00 9Orthopedic shoe add rub insl 00 9O shoe add felt w leath insl 00 9Ortho shoe add half sole 00 9Ortho shoe add full sole 00 9O shoe add standard toe tap 00 9O shoe add horseshoe toe tap 00 9O shoe add instep extension 00 9O shoe add instep velcro clo 00 9O shoe convert to sof counte 00 9Ortho shoe add march bar 00 9Trans shoe calip plate exist 00 9Trans shoe caliper plate new 00 9Trans shoe solid stirrup exi 00 9Trans shoe solid stirrup new 00 9Shoe dennis browne splint bo 00 9

Orthopedic shoe modifica NOS 00 9Shlder fig 8 abduct restrain 38 A

Prefab shoulder orthosis 38 A

Prefab dbl shoulder orthosis 38 A

Abduct restrainer canvas&web 38 A

Acromio/clavicular canvas&we 38 A

SO cap design w/o jnts CF 38 A

SO airplane w/o jnts CF 38 A

SO airplane w/joint CF 38 A

SO airplane w/wo joint CF 38 A

PUF___2011_Web_File

Canvas vest SO 38 A

SO hard plastic stabilizer 00 9

Elbow orthoses elas w stays 38 A

Prefab elbow orthosis 38 A

EO w/o joints CF 38 A

Elbow elastic with metal joi 38 A

Forearm/arm cuffs free motio 38 A

Forearm/arm cuffs ext/flex a 38 A

Cuffs adj lock w/ active con 38 A

EO withjoint, Prefabricated 38 A

Rigid EO wo joints 38 A

EWHO rigid w/o jnts CF 38 A

EWHO w/joint(s) CF 38 A

EWHFO rigid w/o jnts CF 38 A

EWHFO w/joint(s) CF 38 A

Whfo short opponen no attach 38 AWhfo long opponens no attach 38 AWHFO w/joint(s) custom fab 38 A

WHFO,no joint, prefabricated 38 A

WHFO, rigid w/o joints 38 A

Whfo thumb abduction bar 38 AWhfo second m.p. abduction a 38 AWhfo ip ext asst w/ mp ext s 38 A

Whfo m.p. extension stop 38 AWhfo m.p. extension assist 38 AWhfo m.p. spring extension a 38 AWhfo spring swivel thumb 38 AWhfo thumb ip ext ass w/ mp 38 A

Action wrist w/ dorsiflex as 38 AWhfo adj m.p. flexion contro 38 A

PUF___2011_Web_File

Whfo adj m.p. flex ctrl & i. 38 A

Torsion mechanism wrist/elbo 00 9

Torsion mechanism wrist/elbo 00 9

Hinge extension/flex wrist/f 38 A

Hinge ext/flex wrist finger 38 A

Whfo electric custom fitted 38 AWHO w/nontorsion jnt(s) CF 38 A

WHO w/o joints CF 38 A

Whfo wrst gauntlt thmb spica 38 AWrist cock-up non-molded 38 A

Prefab wrist orthosis 38 A

Whfo swanson design 38 A

Prefab hand finger orthosis 38 A

Flex glove w/elastic finger 38 A

HFO w/o joints CF 38 A

WHO w nontor jnt(s) prefab 38 A

Whfo wrist extens w/ outrigg 38 A

Prefab metacarpl fx orthosis 38 A

HFO knuckle bender 38 A

HO w/o joints CF 38 A

Knuckle bender with outrigge 38 A

HFO w/joint(s) CF 38 A

Knuckle bend 2 seg to flex j 38 A

HFO w/o joints PF 38 A

Oppenheimer 38 A

FO pip/dip with joint/spring 38 A

PUF___2011_Web_File

Thomas suspension 38 A

FO pip/dip w/o joint/spring 38 A

Finger extension w/ clock sp 38 A

HFO nontorsion joint, prefab 38 A

Finger extension with wrist 38 A

WHFO nontorsion joint prefab 38 A

Safety pin spring wire 38 A

FO w/o joints CF 38 A

Safety pin modified 38 A

FO nontorsion joint CF 38 A

Palmer 38 A

Dorsal wrist 38 A

Dorsal wrist w/ outrigger at 38 A

Reverse knuckle bender 38 A

Reverse knuckle bend w/ outr 38 A

HFO composite elastic 38 A

Finger knuckle bender 38 A

Oppenheimer w/ knuckle bend 38 A

Oppenheimer w/ rev knuckle 2 38 A

Spreading hand 38 A

Add joint upper ext orthosis 38 ASewho airplan desig abdu pos 38 A

SEWHO cap design w/o jnts CF 38 A

Sewho erbs palsey design abd 38 A

Seo mobile arm sup att to wc 32 A

Arm supp att to wc rancho ty 32 A

PUF___2011_Web_File

Mobile arm supports reclinin 32 A

SEWHO airplane w/o jnts CF 38 A

Friction dampening arm supp 32 A

Monosuspension arm/hand supp 32 A

Elevat proximal arm support 32 ASEWHO cap design w/jnt(s) CF 38 A

Offset/lat rocker arm w/ ela 32 A

SEWHO airplane w/jnt(s) CF 38 A

Mobile arm support supinator 32 ASEWHFO cap design w/o jnt CF 38 A

SEWHFO airplane w/o jnts CF 38 A

SEWHFO cap desgn w/jnt(s) CF 38 A

SEWHFO airplane w/jnt(s) CF 38 A

Upp ext fx orthosis humeral 38 A

Upper ext fx orthosis rad/ul 38 A

Upper ext fx orthosis wrist 38 A

Forearm hand fx orth w/ wr h 38 A

Humeral rad/ulna wrist fx or 38 A

Sock fracture or equal each 38 AUpper limb orthosis NOS 46 ARepl girdle milwaukee orth 38 AReplace strap, any orthosis 38 AReplace trilateral socket br 38 AReplace quadlat socket brim 38 AReplace socket brim cust fit 38 AReplace molded thigh lacer 38 A

PUF___2011_Web_File

Replace non-molded thigh lac 38 AReplace molded calf lacer 38 AReplace non-molded calf lace 38 AReplace high roll cuff 38 AReplace prox & dist upright 38 ARepl met band kafo-afo prox 38 ARepl met band kafo-afo calf/ 38 ARepl leath cuff kafo prox th 38 ARepl leath cuff kafo-afo cal 38 AReplace pretibial shell 38 AOrtho dvc repair per 15 min 46 AOrth dev repair/repl minor p 46 AAnkle control orthosi prefab 38 A

Pneumati walking boot prefab 38 A

Pneumatic full leg splint 38 APneumatic knee splint 38 ANon-pneum walk boot prefab 38 A

Replace AFO soft interface 38 AReplace foot drop spint 38 AStatic AFO 38 A

Foot drop splint recumbent 38 A

Afo, walk boot type, cus fab 38 A

Sho insert w arch toe filler 38 AMold socket ank hgt w/ toe f 38 ATibial tubercle hgt w/ toe f 38 AAnk symes mold sckt sach ft 38 ASymes met fr leath socket ar 38 AMolded socket shin sach foot 38 APlast socket jts/thgh lacer 38 AMold sckt ext knee shin sach 38 A

Mold socket bent knee shin s 38 A

Kne sing axis fric shin sach 38 ANo knee/ankle joints w/ ft b 38 A

No knee joint with artic ali 38 A

Fem focal defic constant fri 38 A

Hip canad sing axi cons fric 38 A

Tilt table locking hip sing 38 A

Hemipelvect canad sing axis 38 A

PUF___2011_Web_File

BK mold socket SACH ft endo 38 AKnee disart, SACH ft, endo 38 A

AK open end SACH 38 A

Hip disart canadian SACH ft 38 A

Hemipelvectomy canadian SACH 38 A

Postop dress & 1 cast chg bk 38 A

Postop dsg bk ea add cast ch 38 A

Postop dsg & 1 cast chg ak/d 38 A

Postop dsg ak ea add cast ch 38 A

Postop app non-wgt bear dsg 38 A

Postop app non-wgt bear dsg 38 A

Init bk ptb plaster direct 38 A

Init ak ischal plstr direct 38 A

Prep BK ptb plaster molded 38 A

Perp BK ptb thermopls direct 38 A

Prep BK ptb thermopls molded 38 A

Prep BK ptb open end socket 38 A

Prep BK ptb laminated socket 38 A

Prep AK ischial plast molded 38 A

Prep AK ischial direct form 38 A

Prep AK ischial thermo mold 38 A

Prep AK ischial open end 38 A

Prep AK ischial laminated 38 A

PUF___2011_Web_File

Hip disartic sach thermopls 38 A

Hip disart sach laminat mold 38 A

Above knee hydracadence 38 A

Ak 4 bar link w/fric swing 38 A

Ak 4 bar ling w/hydraul swig 38 A

4-bar link above knee w/swng 38 A

Ak univ multiplex sys frict 38 A

AK/BK self-aligning unit ea 38 A

Test socket symes 38 ATest socket below knee 38 ATest socket knee disarticula 38 ATest socket above knee 38 ATest socket hip disarticulat 38 ATest socket hemipelvectomy 38 ABelow knee acrylic socket 38 ASyme typ expandabl wall sckt 38 AAk/knee disartic acrylic soc 38 ASymes type ptb brim design s 38 ASymes type poster opening so 38 ASymes type medial opening so 38 ABelow knee total contact 38 ABelow knee leather socket 38 ABelow knee wood socket 38 AKnee disarticulat leather so 38 AAbove knee leather socket 38 AHip flex inner socket ext fr 38 A

Above knee wood socket 38 ABk flex inner socket ext fra 38 ABelow knee cushion socket 38 A

Below knee suction socket 38 AAbove knee cushion socket 38 A

Isch containmt/narrow m-l so 38 ATot contact ak/knee disart s 38 A

Ak flex inner socket ext fra 38 ASuction susp ak/knee disart 38 A

Knee disart expand wall sock 38 ASocket insert symes 38 A

Socket insert below knee 38 A

Socket insert knee articulat 38 A

PUF___2011_Web_File

Socket insert above knee 38 A

Multi-durometer symes 38 AMulti-durometer below knee 38 ABelow knee cuff suspension 38 ASocket insert w/o lock lower 38 ABk molded supracondylar susp 38 A

BK/AK locking mechanism 38 A

Bk removable medial brim sus 38 ASocket insert w lock mech 38 A

Bk knee joints single axis p 38 ABk knee joints polycentric p 38 ABk joint covers pair 38 ASocket insert w/o lock mech 38 A

Bk thigh lacer non-molded 38 AIntl custm cong/latyp insert 38 A

Bk thigh lacer glut/ischia m 38 AInitial custom socket insert 38 A

Bk fork strap 38 ABelow knee sus/seal sleeve 38 A

Bk back check 38 ABk waist belt webbing 38 ABk waist belt padded and lin 38 AAk pelvic control belt light 38 AAk pelvic control belt pad/l 38 AAk sleeve susp neoprene/equa 38 A

Ak/knee disartic pelvic join 38 AAk/knee disartic pelvic band 38 AAk/knee disartic silesian ba 38 A

Shoulder harness 38 AReplace socket below knee 38 AReplace socket above knee 38 A

Replace socket hip 38 A

Symes ankle w/o (SACH) foot 38 A

Custom shape cover BK 38 A

PUF___2011_Web_File

Custom shape cover AK 38 ACustom shape cvr knee disart 38 ACustom shape cvr hip disart 38 AKne-shin exo sng axi mnl loc 38 AKnee-shin exo mnl lock ultra 38 A

Knee-shin exo frict swg & st 38 A

Knee-shin exo variable frict 38 A

Knee-shin exo mech stance ph 38 A

Knee-shin exo frct swg & sta 38 A

Knee-shin pneum swg frct exo 38 A

Knee-shin exo fluid swing ph 38 AKnee-shin ext jnts fld swg e 38 A

Knee-shin fluid swg & stance 38 A

Knee-shin pneum/hydra pneum 38 A

Lower limb pros vacuum pump 38 A

HD low limb pros vacuum pump 38 A

Exoskeletal bk ultralt mater 38 A

Exoskeletal ak ultra-light m 38 A

Exoskel hip ultra-light mate 38 A

Endoskel knee-shin mnl lock 38 AEndo knee-shin mnl lck ultra 38 A

Endo knee-shin frct swg & st 38 A

Endo knee-shin hydral swg ph 38 A

Endo knee-shin polyc mch sta 38 A

Endo knee-shin frct swg & st 38 A

Endo knee-shin pneum swg frc 38 A

Endo knee-shin fluid swing p 38 AMiniature knee joint 38 A

Endo knee-shin fluid swg/sta 38 A

Endo knee-shin pneum/swg pha 38 A

Multi-axial knee/shin system 38 A

PUF___2011_Web_File

Knee-shin sys stance flexion 38 AKnee-shin sys hydraul stance 38 A

Endo ak/hip knee extens assi 38 A

Mech hip extension assist 38 A

Elec knee-shin swing/stance 38 A

Elec knee-shin swing only 38 A

Stance phase only 38 A

Endo below knee alignable sy 38 AEndo ak/hip alignable system 38 A

Above knee manual lock 38 A

High activity knee frame 38 AEndo bk ultra-light material 38 A

Endo ak ultra-light material 38 A

Endo hip ultra-light materia 38 A

Endo poly hip, pneu/hyd/rot 38 A

Below knee flex cover system 38 A

Above knee flex cover system 38 A

Hip flexible cover system 38 A

Multiaxial ankle w dorsiflex 38 A

Foot external keel sach foot 38 ASACH foot, replacement 38 A

Flexible keel foot 38 A

Ank-foot sys dors-plant flex 38 A

Foot single axis ankle/foot 38 ACombo ankle/foot prosthesis 38 A

Energy storing foot 38 A

Ft prosth multiaxial ankl/ft 38 AMulti-axial ankle/ft prosth 38 A

PUF___2011_Web_File

Flex foot system 38 AFlex-walk sys low ext prosth 38 AExoskeletal axial rotation u 38 AEndoskeletal axial rotation 38 A

Lwr ext dynamic prosth pylon 38 AMulti-axial rotation unit 38 AShank ft w vert load pylon 38 AVertical shock reducing pylo 38 AUser adjustable heel height 38 AHeavy duty feature, foot 38 A

Heavy duty feature, knee 38 A

Lower ext pros heavyduty fea 38 A

Lowr extremity prosthes NOS 46 APar hand robin-aids thum rem 38 AHand robin-aids little/ring 38 APart hand robin-aids no fing 38 APart hand disart myoelectric 38 A

Wrst MLd sck flx hng tri pad 38 AWrst mold sock w/exp interfa 38 A

Elb mold sock flex hinge pad 38 AElbow mold sock suspension t 38 AElbow mold doub splt soc ste 38 AElbow stump activated lock h 38 A

Elbow mold outsid lock hinge 38 AElbow molded w/ expand inter 38 A

Elbow inter loc elbow forarm 38 AShlder disart int lock elbow 38 A

Shoulder passive restor comp 38 AShoulder passive restor cap 38 AThoracic intern lock elbow 38 A

Thoracic passive restor comp 38 AThoracic passive restor cap 38 APostop dsg cast chg wrst/elb 38 A

Postop dsg cast chg elb dis/ 38 A

Postop dsg cast chg shlder/t 38 A

Postop ea cast chg & realign 38 A

PUF___2011_Web_File

Postop applicat rigid dsg on 38 ABelow elbow prosth tiss shap 38 A

Elb disart prosth tiss shap 38 A

Above elbow prosth tiss shap 38 A

Shldr disar prosth tiss shap 38 A

Scap thorac prosth tiss shap 38 A

Wrist/elbow bowden cable mol 38 A

Wrist/elbow bowden cbl dir f 38 A

Elbow fair lead cable molded 38 A

Elbow fair lead cable dir fo 38 A

Shdr fair lead cable molded 38 A

Shdr fair lead cable direct 38 A

Polycentric hinge pair 38 ASingle pivot hinge pair 38 AFlexible metal hinge pair 38 AAdditional switch, ext power 38 A

Disconnect locking wrist uni 38 ADisconnect insert locking wr 38 A

Flexion/extension wrist unit 38 A

Flex/ext wrist w/wo friction 38 A

Spring-ass rot wrst w/ latch 38 A

Flex/ext/rotation wrist unit 38 ARotation wrst w/ cable lock 38 AQuick disconn hook adapter o 38 ALamination collar w/ couplin 38 A

Stainless steel any wrist 38 ALatex suspension sleeve each 38 ALift assist for elbow 38 ANudge control elbow lock 38 AElec lock on manual pw elbow 38 A

PUF___2011_Web_File

Heavy duty elbow feature 38 AShoulder abduction joint pai 38 AExcursion amplifier pulley t 38 AExcursion amplifier lever ty 38 AShoulder flexion-abduction j 38 AMultipo locking shoulder jnt 38 A

Shoulder lock actuator 38 AExt pwrd shlder lock/unlock 38 AShoulder universal joint 38 AStandard control cable extra 38 AHeavy duty control cable 38 ATeflon or equal cable lining 38 AHook to hand cable adapter 38 AHarness chest/shlder saddle 38 AHarness figure of 8 sing con 38 A

Harness figure of 8 dual con 38 A

UE triple control harness 38 A

Test sock wrist disart/bel e 38 ATest sock elbw disart/above 38 ATest socket shldr disart/tho 38 A

Suction socket 38 AFrame typ socket bel elbow/w 38 A

Frame typ sock above elb/dis 38 A

Frame typ socket shoulder di 38 AFrame typ sock interscap-tho 38 ARemovable insert each 38 ASilicone gel insert or equal 38 ALockingelbow forearm cntrbal 38 AElbow socket ins use w/lock 38 A

Elbow socket ins use w/o lck 38 A

Cus elbo skt in for con/atyp 38 A

Cus elbo skt in not con/atyp 38 A

Below/above elbow lock mech 38 A

Term dev, passive hand mitt 38 ATerm dev, sport/rec/work att 38 A

PUF___2011_Web_File

Term dev mech hook vol open 38 A

Term dev mech hook vol close 38 A

Term dev mech hand vol open 38 ATerm dev mech hand vol close 38 APed term dev, hook, vol open 38 A

Ped term dev, hook, vol clos 38 A

Ped term dev, hand, vol open 38 A

Ped term dev, hand, vol clos 38 A

Hook/hand, hvy dty, vol open 38 A

Hook/hand, hvy dty, vol clos 38 A

Term dev modifier wrist unit 38 ATerm dev precision pinch dev 38 ATerm dev auto grasp feature 38 A

Microprocessor control uplmb 38 A

Replc sockt below e/w disa 38 A

Replc sockt above elbow disa 38 A

Replc sockt shldr dis/interc 38 A

Prefab glove for term device 38 A

Custom glove for term device 38 A

Hand restorat thumb/1 finger 38 A

Hand restoration multiple fi 38 A

Hand restoration no fingers 38 A

Hand restoration replacmnt g 38 A

Wrist disarticul switch ctrl 38 A

Wrist disart myoelectronic c 38 A

Below elbow switch control 38 A

Below elbow myoelectronic ct 38 A

PUF___2011_Web_File

Elbow disarticulation switch 38 A

Elbow disart myoelectronic c 38 A

Above elbow switch control 38 A

Above elbow myoelectronic ct 38 A

Shldr disartic switch contro 38 A

Shldr disartic myoelectronic 38 A

Interscapular-thor switch ct 38 A

Interscap-thor myoelectronic 38 A

Adult electric hand 38 APediatric electric hand 38 AAdult electric hook 38 APrehensile actuator 38 APediatric electric hook 38 AElectronic elbow hosmer swit 38 AElectronic elbow sequential 38 AElectronic elbo simultaneous 38 A

Electron elbow adolescent sw 38 AElectron elbow child switch 38 AElbow adolescent myoelectron 38 A

Elbow child myoelectronic ct 38 AElectron wrist rotator otto 38 AElectron wrist rotator utah 38 AServo control steeper or equ 38 AAnalogue control unb or equa 38 AProportional ctl 12 volt uta 38 ASix volt bat otto bock/eq ea 38 ABattery chrgr six volt otto 38 ATwelve volt battery utah/equ 38 ABattery chrgr 12 volt utah/e 38 AReplacemnt lithium ionbatter 38 ALithium ion battery charger 38 AAdd UE prost be/wd, ultlite 38 A

PUF___2011_Web_File

Add UE prost a/e ultlite mat 38 A

Add UE prost s/d ultlite mat 38 A

Add UE prost b/e acrylic 38 A

Add UE prost a/e acrylic 38 A

Add UE prost s/d acrylic 38 A

Upper extremity prosthes NOS 46 AProsthetic dvc repair hourly 46 A

Prosthetic device repair rep 46 ARepair prosthesis per 15 min 46 AProsthetic donning sleeve 00 9Ped term dev, hook, vol open 38 A

Ped term dev, hook, vol clos 38 A

Ped term dev, hand, vol open 38 A

Ped term dev, hand, vol clos 38 A

Hook/hand, hvy dty, vol open 38 A

Hook/hand, hvy dty, vol clos 38 A

Male vacuum erection system 38 AMastectomy bra 38 ABreast prosthesis bra & form 38 A

Brst prsth bra & bilat form 38 A

Mastectomy sleeve 00 9Ext breastprosthesis garment 38 AMastectomy form 38 ABreast prosthes w/o adhesive 38 ABreast prosthesis w adhesive 38 AReusable nipple prosthesis 38 ACustom breast prosthesis 38 ABreast prosthesis NOS 46 ANasal prosthesis 38 AMidfacial prosthesis 38 AOrbital prosthesis 38 AUpper facial prosthesis 38 AHemi-facial prosthesis 38 AAuricular prosthesis 38 APartial facial prosthesis 38 ANasal septal prosthesis 38 AUnspec maxillofacial prosth 46 ARepair maxillofacial prosth 46 A

PUF___2011_Web_File

Truss single w/ standard pad 38 ATruss double w/ standard pad 38 ATruss addition to std pad wa 38 ATruss add to std pad scrotal 38 ASheath below knee 38 ASheath above knee 38 ASheath upper limb 38 APros sheath/sock w gel cushn 38 A

Prosthetic sock multi ply BK 38 AProsthetic sock multi ply AK 38 APros sock multi ply upper lm 38 AShrinker below knee 38 AShrinker above knee 38 AShrinker upper limb 38 APros sock single ply BK 38 APros sock single ply AK 38 APros sock single ply upper l 38 AUnlisted misc prosthetic ser 46 AArtificial larynx 38 ATracheostomy speaking valve 38 AArtificial larynx, accessory 46 ATrach-esoph voice pros pt in 38 ATrach-esoph voice pros md in 38 A

Voice amplifier 38 AIndwelling trach insert 38 A

Gel cap for trach voice pros 38 A

Trach pros cleaning device 38 A

Repl trach puncture dilator 38 AGel cap app device for trach 37 A

Implant breast silicone/eq 38 ACollagen imp urinary 2.5 ml 38 A

Dextranomer/hyaluronic acid 00 9

Synthetic implnt urinary 1ml 38 A

Artificial cornea 38 AOcular implant 38 AAqueous shunt prosthesis 38 AOssicular implant 38 ACochlear device 38 ACoch implant headset replace 38 ACoch implant microphone repl 38 ACoch implant trans coil repl 38 ACoch implant tran cable repl 38 ACoch imp ext proc/contr rplc 38 A

Repl zinc air battery 38 A

PUF___2011_Web_File

Repl alkaline battery 38 A

Lith ion batt CID,non-earlvl 38 A

Lith ion batt CID, ear level 38 A

CID ext speech process repl 38 ACID ext controller repl 38 ACID transmit coil and cable 38 A

Metacarpophalangeal implant 38 AMCP joint repl 2 pc or more 38 A

Metatarsal joint implant 38 AHallux implant 38 AInterphalangeal joint spacer 38 AInterphalangeal joint repl 38 A

Vascular graft, synthetic 38 AImplt neurostim elctr each 38 APt prgrm for implt neurostim 38 A

Implt neurostim radiofq rec 38 ARadiofq trsmtr for implt neu 38 A

Radiof trsmtr implt scrl neu 38 A

Implt nrostm pls gen sng rec 38 A

Implt nrostm pls gen sng non 38 A

Implt nrostm pls gen dua rec 38 A

Implt nrostm pls gen dua non 38 A

External recharg sys intern 38 A

Aud osseo dev, int/ext comp 38 AOsseointegrated snd proc rpl 38 ANon-osseointegrated snd proc 00 9

Aud osseo dev, abutment 38 AExternal recharg sys extern 38 A

Prosthetic implant NOS 46 AO&P supply/accessory/service 46 A

Visit for drug monitoring 11 A

Cellular therapy 00 9

PUF___2011_Web_File

Prolotherapy 00 9Intragastric hypothermia 00 9IV chelationtherapy 00 9Fabric wrapping of aneurysm 00 9Cephalin floculation test 57 ACongo red blood test 57 AHair analysis 00 9Blood thymol turbidity 57 ABlood mucoprotein 21 AScreen pap by tech w md supv 21 A

Screening pap smear by phys 11 21 C

Culture bacterial urine 00 9Whole blood for transfusion 52 ABlood split unit 52 ACryoprecipitate each unit 52 ARBC leukocytes reduced 52 APlasma 1 donor frz w/in 8 hr 52 A

Platelets, each unit 52 APlaelet rich plasma unit 52 ARed blood cells unit 52 AWashed red blood cells unit 52 AFrozen plasma, pooled, sd 52 APlatelets leukocytes reduced 52 APlatelets, irradiated 52 APlatelets leukoreduced irrad 52 APlatelets, pheresis 52 APlatelet pheres leukoreduced 52 APlatelet pheresis irradiated 52 APlate pheres leukoredu irrad 52 ARBC irradiated 52 ARBC deglycerolized 52 ARBC leukoreduced irradiated 52 AAlbumin (human),5%, 50ml 52 APlasma protein fract,5%,50ml 52 ACryoprecipitatereducedplasma 52 AAlbumin (human), 5%, 250 ml 52 AAlbumin (human), 25%, 20 ml 52 AAlbumin (human), 25%, 50ml 52 APlasmaprotein fract,5%,250ml 52 AGranulocytes, pheresis unit 52 ABlood, l/r, cmv-neg 52 APlatelets, hla-m, l/r, unit 52 APlt, pher, l/r cmv-neg, irr 52 ABlood, l/r, froz/degly/wash 52 A

Plt, aph/pher, l/r, cmv-neg 52 ABlood, l/r, irradiated 52 ARBC, frz/deg/wsh, l/r, irrad 52 A

RBC, l/r, cmv-neg, irrad 52 APlasma, frz between 8-24hour 52 A

PUF___2011_Web_File

Fr frz plasma donor retested 52 AOne-way allow prorated miles 22 A

One-way allow prorated trip 22 A

Catheterize for urine spec 57 A

Urine specimen collect mult 57 ACardiokymography 11 AInfusion ther other than che 00 9Chemo by other than infusion 00 9

Chemotherapy by infusion 00 9Chemo by both infusion and o 00 9

Obtaining screen pap smear 11 A

Set up port xray equipment 11 AWet mounts/ w preparations 21 APotassium hydroxide preps 21 APinworm examinations 21 AFern test 21 APost-coital mucous exam 21 AFerumoxytol, non-esrd 51 A

Ferumoxytol, esrd use 51 A

Azithromycin dihydrate, oral 00 9Diphenhydramine HCl 50mg 51 A

Prochlorperazine maleate 5mg 51 A

Prochlorperazine maleate10mg 51 A

Granisetron hcl 1 mg oral 51 A

Dronabinol 2.5mg oral 51 A

Dronabinol 5mg oral 51 A

Promethazine HCl 12.5mg oral 51 A

Promethazine HCl 25 mg oral 51 A

PUF___2011_Web_File

Chlorpromazine HCl 10mg oral 51 A

Chlorpromazine HCl 25mg oral 51 A

Trimethobenzamide HCl 250mg 51 A

Thiethylperazine maleate10mg 51 A

Perphenazine 4mg oral 51 A

Perphenazine 8mg oral 51 A

Hydroxyzine pamoate 25mg 51 A

Hydroxyzine pamoate 50mg 51 A

Ondansetron hcl 8 mg oral 51 A

Dolasetron mesylate oral 51 A

Unspecified oral anti-emetic 51 A

Power adapter, combo vad 38 A

Power module combo vad, rep 38 A

Driver pneumatic vad, rep 38 AMicroprcsr cu elec vad, rep 38 A

Microprcsr cu combo vad, rep 38 A

Monitor elec vad, rep 38 A

Monitor elec or comb vad rep 38 A

Monitor cable elec vad, rep 38 A

Mon cable elec/pneum vad rep 38 A

Leads any type vad, rep only 38 A

Pwr pack base elec vad, rep 38 A

PUF___2011_Web_File

Pwr pck base combo vad, rep 38 A

Emr pwr source elec vad, rep 38 A

Emr pwr source combo vad rep 38 A

Emr pwr cbl elec vad, rep 38 A

Emr pwr cbl combo vad, rep 38 A

Emr hd pmp elec/combo, rep 38 A

Charger elec/combo vad, rep 38 A

Battery elec/combo vad, rep 38 A

Bat clps elec/comb vad, rep 38 A

Holster elec/combo vad, rep 38 A

Belt/vest elec/combo vad rep 38 A

Filters elec/combo vad, rep 38 A

Shwr cov elec/combo vad, rep 38 A

Mobility cart pneum vad, rep 38 ABattery pneum vad replacemnt 38 APwr adpt pneum vad, rep veh 38 A

Miscl supply/accessory vad 38 ALith-ion batt elec/pneum VAD 38 A

Dispens fee immunosupressive 46 A

Sup fee antiem,antica,immuno 46 A

Px sup fee anti-can sub pres 46 A

Disp fee inhal drugs/30 days 46 ADisp fee inhal drugs/90 days 46 ASermorelin acetate injection 51 ANtiol category 3 57 ANtiol category 4 57 ANtiol category 5 57 ABladder calculi irrig sol 51 A

Fosphenytoin inj PE 51 ATeniposide, 50 mg 51 AXyntha, inj 51 ABevacizumab injection 51 AOral fludarabine phosphate 51 ARadiesse injection 51 ASculptra injection 51 A

PUF___2011_Web_File

Afluria vacc, 3 yrs & >, im 54 A

Flulaval vacc, 3 yrs & >, im 54 A

Fluvirin vacc, 3 yrs & >, im 54 A

Fluzone vacc, 3 yrs & >, im 54 A

NOS flu vacc, 3 yrs & >, im 54 A

Brachytherapy Radioelements 57 ATelehealth facility fee 53 AIM inj interferon beta 1-a 51 ASubc inj interferon beta-1a 00 9Collagen skin test 11 ACast sup body cast plaster 52 ACast sup body cast fiberglas 52 ACast sup shoulder cast plstr 52 ACast sup shoulder cast fbrgl 52 ACast sup long arm adult plst 52 ACast sup long arm adult fbrg 52 ACast sup long arm ped plster 52 ACast sup long arm ped fbrgls 52 ACast sup sht arm adult plstr 52 ACast sup sht arm adult fbrgl 52 ACast sup sht arm ped plaster 52 ACast sup sht arm ped fbrglas 52 ACast sup gauntlet plaster 52 A

Cast sup gauntlet fiberglass 52 A

Cast sup gauntlet ped plster 52 A

Cast sup gauntlet ped fbrgls 52 A

Cast sup lng arm splint plst 52 ACast sup lng arm splint fbrg 52 ACast sup lng arm splnt ped p 52 ACast sup lng arm splnt ped f 52 ACast sup sht arm splint plst 52 ACast sup sht arm splint fbrg 52 ACast sup sht arm splnt ped p 52 ACast sup sht arm splnt ped f 52 ACast sup hip spica plaster 52 ACast sup hip spica fiberglas 52 ACast sup hip spica ped plstr 52 ACast sup hip spica ped fbrgl 52 ACast sup long leg plaster 52 ACast sup long leg fiberglass 52 ACast sup lng leg ped plaster 52 ACast sup lng leg ped fbrgls 52 ACast sup lng leg cylinder pl 52 ACast sup lng leg cylinder fb 52 ACast sup lngleg cylndr ped p 52 A

PUF___2011_Web_File

Cast sup lngleg cylndr ped f 52 ACast sup shrt leg plaster 52 ACast sup shrt leg fiberglass 52 ACast sup shrt leg ped plster 52 ACast sup shrt leg ped fbrgls 52 ACast sup lng leg splnt plstr 52 ACast sup lng leg splnt fbrgl 52 ACast sup lng leg splnt ped p 52 ACast sup lng leg splnt ped f 52 ACast sup sht leg splnt plstr 52 ACast sup sht leg splnt fbrgl 52 ACast sup sht leg splnt ped p 52 ACast sup sht leg splnt ped f 52 AFinger splint, static 52 ACast supplies unlisted 57 ASplint supplies misc 57 A

Iloprost non-comp unit dose 51 A

Natalizumab injection 51 AIloprost non-comp unit dose 51 A

Epoetin alfa, 100 units ESRD 57 ADrug/bio NOC part B drug CAP 51 A

Hyalgan/supartz inj per dose 51 A

Synvisc inj per dose 51 AEuflexxa inj per dose 51 AOrthovisc inj per dose 51 AOctagam injection 51 A

Gammagard liquid injection 51 A

Rhophylac injection 51 A

HepaGam B IM injection 51 AFlebogamma injection 51 A

Gamunex injection 51 A

Albuterol inh non-comp con 51 A

Albuterol inh non-comp u d 51 A

Reclast injection 51 AVWF complex, NOS 51 A

Inj IVIG privigen 500 mg 51 A

Inj iron dextran 51 AFormoterol fumarate, inh 51 A

PUF___2011_Web_File

Skin substitute, NOS 51 AApligraf 51 AOasis wound matrix 51 AOasis burn matrix 51 AIntegra BMWD 51 AIntegra DRT 51 ADermagraft 51 AGraftjacket 51 AIntegra matrix 51 ATissuemend skin sub 51 APrimatrix 51 AGammagraft 51 ACymetra injectable 51 AGraftjacket xpress 51 AIntegra flowable wound matri 51 AAlloskin 51 AAlloderm 51 AHyalomatrix 51 AMatristem micromatrix 51 AMatristem wound matrix 51 AMatristem burn matrix 51 ATheraskin 51 AHospice in patient home 00 9Hospice in assisted living 00 9Hospice in LT/non-skilled NF 00 9

Hospice in SNF 00 9Hospice, inpatient hospital 00 9Hospice in hospice facility 00 9Hospice in LTCH 00 9Hospice in inpatient psych 00 9Hospice care, NOS 00 9Hospice home care in hospice 00 9LOCM <=149 mg/ml iodine, 1ml 51 ALOCM 150-199mg/ml iodine,1ml 51 ALOCM 200-249mg/ml iodine,1ml 51 ALOCM 250-299mg/ml iodine,1ml 51 ALOCM 300-349mg/ml iodine,1ml 51 ALOCM 350-399mg/ml iodine,1ml 51 ALOCM >= 400 mg/ml iodine,1ml 51 AInj Gad-base MR contrast,1ml 57 AInj Fe-based MR contrast,1ml 57 AOral MR contrast, 100 ml 57 AInj perflexane lip micros,ml 57 AInj octafluoropropane mic,ml 57 AInj perflutren lip micros,ml 57 AHOCM <=149 mg/ml iodine, 1ml 51 AHOCM 150-199mg/ml iodine,1ml 51 AHOCM 200-249mg/ml iodine,1ml 51 AHOCM 250-299mg/ml iodine,1ml 51 AHOCM 300-349mg/ml iodine,1ml 51 AHOCM 350-399mg/ml iodine,1ml 51 AHOCM>= 400mg/ml iodine, 1ml 51 A

PUF___2011_Web_File

LOCM 100-199mg/ml iodine,1ml 51 ALOCM 200-299mg/ml iodine,1ml 51 ALOCM 300-399mg/ml iodine,1ml 51 AVisualization adjunct 51 A

Transport portable x-ray 13 A

Transport port x-ray multipl 13 A

Transport portable EKG 13 AButorphanol tartrate, nasal 00 9Tacrine hydrochloride, 10 mg 00 9Injection, aminocaproic acid 00 9Injection, bupivicaine hydro 00 9Injection, cefoperazone sod 00 9Injection, cimetidine hydroc 00 9Injection, famotidine, 20 mg 00 9Injection, metronidazole 00 9Injection, nafcillin sodium 00 9Injection, ofloxacin, 400 mg 00 9Injection, sulfamethoxazole 00 9Injection, ticarcillin disod 00 9Injection, aztreonam, 500 mg 00 9Injection, cefotetan disodiu 00 9Injection, clindamycin phosp 00 9Injection, fosphenytoin sodi 00 9Injection, pentamidine iseth 00 9Injection, piperacillin sodi 00 9Imatinib 100 mg 00 9Sildenafil citrate, 25 mg 00 9Granisetron 1mg 00 9

Hydromorphone 250 mg 00 9Morphine 500 mg 00 9Zidovudine, oral, 100 mg 00 9Bupropion HCL SR 60 tablets 00 9Mercaptopurine 50 mg 00 9Methadone oral 5mg 00 9Tretinoin topical 5 g 00 9Inj menotropins 75 iu 00 9Inj follitropin alfa 75 iu 00 9Inj follitropin beta 75 iu 00 9Inj ganirelix acetat 250 mcg 00 9Clozapine, 25 mg 00 9Didanosine, 25 mg 00 9Finasteride, 5 mg 00 9Minoxidil, 10 mg 00 9Saquinavir, 200 mg 00 9Zalcitabine, 0.375 mg 00 9Colistimethate inh sol mg 00 9

Aztreonam, inh sol gram 00 9

PUF___2011_Web_File

Peg interferon alfa-2A/180 00 9Peg interferon alfa-2b/10 00 9Alglucosidase alfa 20 mg 00 9Peg interferon alfa-2b/10 00 9Epoprostenol dilutant 00 9Exemestane, 25 mg 00 9Becaplermin gel 1%, 0.5 gm 00 9Dextroamphetamine 00 9Calcitrol 00 9Injection efalizumab 00 9Injection pantroprazole 00 9Inj olanzapine 2.5mg 00 9Inj apomorphine HCl 1mg 00 9Calcitrol 00 9Anastrozole 1 mg 00 9Bumetanide 0.5 mg 00 9Chlorambucil 2 mg 00 9Dolasetron 50 mg 00 9

Flutamide 125 mg 00 9Hydroxyurea 500 mg 00 9Levamisole 50 mg 00 9Lomustine 10 mg 00 9Megestrol 20 mg 00 9Etonogestrel implant system 00 9Ondansetron 4 mg 00 9

Procarbazine 5 mg 00 9Prochlorperazine 5 mg 00 9

Tamoxifen 10 mg 00 9Testosterone pellet 75 mg 00 9Mifepristone, oral, 200 mg 00 9Misoprostol, oral, 200 mcg 00 9Vitamin suppl 100 caps 00 9Pneumo vaccine 5-9 yrs 00 9

Poly-l-lactic acid 1ml face 00 9

Prenatal vitamins 30 day 00 9Med abortion inc all ex drug 00 9

Partial hospitalization serv 00 9Paramedicintercep nonhospals 00 9

Paramed intrcept nonvol 00 9WC van mileage per mi 00 9Nonemerg transp mileage 00 9Medical conference by physic 00 9

Medical conference, 60 min 00 9

PUF___2011_Web_File

Comp geriatr assmt team 00 9

Hospice refer visit nonmd 00 9

End of life counseling 00 9

H&P for surgery 00 9

Genetic counsel 15 mins 00 9Home std case rate 30 days 00 9

Home hospice case 30 days 00 9

Home episodic case 30 days 00 9

MD home visit outside cap 00 9Nurse practr visit outs cap 00 9Medical home, initial plan 00 9Medical home, maintenance 00 9

Completed EPSDT 00 9

Hospitalist visit 00 9

Disease management program 00 9Follow-up/reassessment 00 9Disease mgmt per diem 00 9RN telephone calls to DMP 00 9

Lifestyle mod 1st stage 00 9

Lifestyle mod 2 or 3 stage 00 9

Lifestyle mod 4th stage 00 9

Home ecg monitrng global 24h 00 9

Home ecg monitrng tech 24hr 00 9

Home ecg monitrng prof 24hr 00 9

Rout foot care per visit 00 9

PUF___2011_Web_File

Impression casting ft 00 9

Global eswl kidney 00 9

Dispos cont lens 00 9Singl prscrp lens 00 9Bifoc prscp lens 00 9Trifoc prscrp lens 00 9Non-prscrp lens 00 9Daily cont lens 00 9Color cont lens 00 9Scleral lens liquid bandage 00 9Safety frames 00 9Sunglass frames 00 9Polycarb lens 00 9Nonstnd lens 00 9Misc integral lens serv 00 9Comp cont lens eval 00 9New lenses in pts old frame 00 9Screening proctoscopy 00 9Digital rectal examination, 00 9Annual gynecological examina 00 9Annual gynecological examina 00 9Ann breast exam 00 9

Audiometry for hearing aid 00 9

Routine ophthalmological exa 00 9Routine ophthalmological exa 00 9Phys exam for college 00 9

Digital screening retina 00 9

Removal of sutures 00 9

Laser in situ keratomileusis 00 9Photorefractive keratectomy 00 9Phototherap keratect 00 9Computerized corneal topogra 00 9Deluxe item 00 9Custom item 00 9IV tubing extension set 00 9Non-pvc intravenous administ 00 9

Inhal nitric oxide neonate 00 9

Gluc monitor purchase 00 9

Gluc monitor rental 00 9

Cranial remolding orthosis 00 9

PUF___2011_Web_File

Transplantation of small int 00 9Transplantation of multivisc 00 9Harvesting of donor multivis 00 9

Lobar lung transplantation 00 9Donor lobectomy (lung) 00 9Simult panc kidn trans 00 9Breast GAP flap reconst 00 9

Breast "stacked" DIEP/GAP 00 9

Breast DIEP or SIEA flap 00 9

Cysto laser tx ureteral calc 00 9

Lap inc/vent hernia repair 00 9Lap umbilical hernia repair 00 9Lap mesh implant hern rep 00 9

Lap supracerv hysterectomy 00 9

Lap esophagomyotomy 00 9Laup 00 9Adjustment gastric band 00 9

Transcath emboliz microspher 00 9

Islet cell tissue transplant 00 9Adrenal tissue transplant 00 9Adoptive immunotherapy 00 9

Knee arthroscp harv 00 9Arthrosc sh tenodesis biceps 00 9Periacetabular osteotomy 00 9Arthroereisis, subtalar 00 9Total hip resurfacing 00 9

Low density lipoprotein(LDL) 00 9

Neurolysis interspace foot 00 9

Cord blood harvesting 00 9Cord blood-derived stem-cell 00 9BMT harv/transpl 28d pkg 00 9

PUF___2011_Web_File

Solid organ transpl pkg 00 9

Echosclerotherapy 00 9Minimally invasive direct co 00 9

Minimally invasive direct co 00 9




Implant gastric stim 00 9Myringotomy laser-assist 00 9Implant semi-imp hear 00 9

Implant auditory brain imp 00 9Uterine artery emboliz 00 9Induced abortion 17-24 weeks 00 9Induced abortion 25-28 wks 00 9Induced abortion 29-31 wks 00 9Induced abortion 32 or more 00 9Insertion vaginal cylinder 00 9

Arthroscopy, shoulder, surgi 00 9Hip core decompression 00 9Chemodenervation of abductor 00 9Chemodenerv adduct vocal 00 9Nasal endoscop po debrid 00 9

Endosc balloon sinuplasty 00 9

Decompress disc RF lumbar 00 9

Diskectomy, anterior, with d 00 9

Diskectomy, anterior, with d 00 9

Vertebroplast cerv 1st 00 9

Vertebroplast cerv addl 00 9

PUF___2011_Web_File

Fetal surg congen hernia 00 9

Fetal surg urin trac obstr 00 9Fetal surg cong cyst malf 00 9

Fetal surg pulmon sequest 00 9

Fetal surg myelomeningo 00 9Fetal surg sacrococ teratoma 00 9Fetal surg noc 00 9

Fetoscop laser ther TTTS 00 9Robotic surgical system 00 9

Bilat dil retinal exam 00 9Eval self-assess depression 00 9Stat lab 00 9Stat lab home/nf 00 9

Free beta HCG 00 9Newborn metabolic screening 00 9

Maternal triple screen test 00 9

Maternal serum quad screen 00 9

PAMG-1 rapid assay for ROM 00 9

Eosinophil blood count 00 9HIV-1 antibody testing of or 00 9Saliva test, hormone level; 00 9Saliva test, hormone level; 00 9Antisperm antibodies test 00 9Gastrointestinal fat absorpt 00 9Circulating tumor cell test 00 9KRAS mutation analysis 00 9Genetic testing ALS 00 9BRCA1 gene anal 00 9BRCA2 gene anal 00 9Comp BRCA1/BRCA2 00 9

Sing mutation brst/ovar 00 9

3 mutation brst/ovar 00 9

Comp MLH1 gene 00 9Comp MSH2 gene 00 9Gene test HNPCC comp 00 9

Gene test HNPCC single 00 9

PUF___2011_Web_File

Comp APC sequence 00 9

Sing mutation APC 00 9

Gene test cystic fibrosis 00 9Gene test hemochromato 00 9DNA analysis RET-oncogene 00 9

Gene test retinoblastoma 00 9Gene test Hippel-Lindau 00 9DNA analysis factor v 00 9DNA analysis deafness 00 9

Gene test alpha-thalassemia 00 9Gene test beta-thalassemia 00 9Gene test Tay-Sachs 00 9Gene test Gaucher 00 9Gene test Niemann-Pick 00 9Gene test sickle cell 00 9Gene test canavan 00 9DNA analysis APOE alzheimer 00 9Gene test myo musclr dyst 00 9Gene profile panel breast 00 9

Gene test presenilin-1 gene 00 9Genet test cardiac ion-comp 00 9

Genetic test brugada 00 9

Genet test cardiac ion-spec 00 9

Comp genet test hyp cardiomy 00 9Spec gene test hyp cardiomy 00 9

CGH test developmental delay 00 9

Fecal DNA analysis 00 9Surface EMG 00 9Ballistocardiogram 00 9Masters two step 00 9Auto handheld diag nerv test 00 9

Interim labor facility globa 00 9IVF package 00 9

Compl GIFT case rate 00 9Compl ZIFT case rate 00 9Complete IVF nos case rate 00 9

PUF___2011_Web_File

Frozen IVF case rate 00 9IVF canc a stim case rate 00 9F EMB trns canc case rate 00 9IVF canc a aspir case rate 00 9IVF canc p aspir case rate 00 9Asst oocyte fert case rate 00 9Incompl donor egg case rate 00 9Donor serv IVF case rate 00 9Procure donor sperm 00 9Store prev froz embryos 00 9Microsurg epi sperm asp 00 9Sperm procure init visit 00 9Sperm procure subs visit 00 9Stimulated IUI case rate 00 9Cryo embryo transf case rate 00 9Monit store cryo embryo 30 d 00 9Ovulation mgmt per cycle 00 9

Insert levonorgestrel ius 00 9Contracept IUD 00 9

Nicotine patch legend 00 9Nicotine patch nonlegend 00 9Contraceptive pills for bc 00 9Smoking cessation gum 00 9Prescription drug, generic 00 9Prescription drug,brand name 00 95% dextrose and 0.45% saline 00 95% dextrose in lactated ring 00 95% dextrose with potassium 00 95%dextrose/0.45%saline1000ml 00 9

D5W/0.45NS w KCl and MGS04 00 9

HIT routine device maint 00 9

HIT device repair 00 9Adult daycare services 15min 00 9Adult day care per half day 00 9Adult day care per diem 00 9Centerbased day care perdiem 00 9Homecare train pt 15 min 00 9Homecare train pt session 00 9Family homecare training 15m 00 9Family homecare train/sessio 00 9Nonfamily homecare train/15m 00 9Nonfamily HC train/session 00 9Chore services per 15 min 00 9Chore services per diem 00 9Attendant care service /15m 00 9Attendant care service /diem 00 9Homaker service nos per 15m 00 9Homemaker service nos /diem 00 9Adult companioncare per 15m 00 9

PUF___2011_Web_File

Adult companioncare per diem 00 9Adult foster care per diem 00 9Adult foster care per month 00 9Child fostercare th per diem 00 9Ther fostercare child /month 00 9Unskilled respite care /15m 00 9Unskilled respitecare /diem 00 9Emer response sys instal&tst 00 9Emer rspns sys serv permonth 00 9

Emer rspns system purchase 00 9Home modifications per serv 00 9Homedelivered prepared meal 00 9Laundry serv,ext,prof,/order 00 9HH respiratory thrpy in eval 00 9HH respiratory thrpy nos/day 00 9Med reminder serv per month 00 9Wellness assessment by nonph 00 9Personal care item nos each 00 9HIT cath care noc 00 9

HIT simple cath care 00 9

HIT complex cath care 00 9

HIT interim cath care 00 9

HIT declotting kit 00 9

HIT cath repair kit 00 9HIT picc insert kit 00 9

HIT midline cath insert kit 00 9

HIT picc insert no supp 00 9

HIP midline cath insert kit 00 9

Insulin rapid 5 u 00 9Insulin most rapid 5 u 00 9Insulin intermed 5 u 00 9Insulin long acting 5 u 00 9Insulin reuse pen 1.5 ml 00 9Insulin reuse pen 3 ml 00 9Insulin cartridge 150 u 00 9

PUF___2011_Web_File

Insulin cartridge 300 u 00 9Insulin dispos pen 1.5 ml 00 9Insulin dispos pen 3 ml 00 9Tantalum ring application 00 9

Magnetic source imaging 00 9mrcp 00 9Topographic brain mapping 00 9MRI low field 00 9Intraoperative radiation the 00 9Us guidance fetal reduct 00 9

Scintimammography 00 9

Fluorine-18 fluorodeoxygluco 00 9

Electron beam computed tomog 00 9Portable peak flow meter 00 9Asthma kit 00 9

Spacer without mask 00 9Spacer with mask 00 9Peak expiratory flow rate (p 00 9O2 contents gas cubic ft 00 9O2 contents liquid lb 00 9Flutter device 00 9Swivel adaptor 00 9Trach supply noc 00 9Electronic spirometer 00 9Mucus trap 00 9Mandib ortho repos device 00 9Haberman feeder 00 9Enuresis alarm 00 9Infect control supplies NOS 00 9Supplies for home delivery 00 9Custom gradient sleev/glov 00 9Ready gradient sleev/glov 00 9Custom grad sleeve med 00 9Custom grad sleeve heavy 00 9Ready gradient sleeve 00 9Custom grad glove med 00 9Custom grad glove heavy 00 9Ready gradient glove 00 9Ready gradient gauntlet 00 9Gradient pressure wrap 00 9Padding for comprssn bdg 00 9Compression bandage 00 9Splint digit 00 9Splint wrist or ankle 00 9Splint elbow 00 9Camisole post-mast 00 9100 insulin syringes 00 9

PUF___2011_Web_File

Hippotherapy per session 00 9Low-level laser trmt 15 min 00 9

Complex lymphedema therapy, 00 9Pt or manip for maint 00 9

Resuscitation bag 00 9

Home uterine monitor with or 00 9Ultrafiltration monitor 00 9Automated EEG monitoring 00 9Paranasal sinus ultrasound 00 9Omnicardiogram/cardiointegra 00 9ESWL for gallstones 00 9

Procuren or other growth fac 00 9Coma stimulation per diem 00 9Medical supplies and equipme 00 9

Smoking cessation treatment 00 9Urgent care center global 00 9Services provided in urgent 00 9

Vertebral axial decompressio 00 9Canolith repositioning 00 9Home visit wound care 00 9Home phototherapy visit 00 9

CHF telemonitoring month 00 9

Back school visit 00 9Home health aide or certifie 00 9

Nursing care in home RN 00 9

Nursing care, in the home; b 00 9Respite care, in the home, p 00 9Hospice care, in the home, p 00 9Social work visit, in the ho 00 9Speech therapy, in the home, 00 9Occupational therapy, in the 00 9PT in the home per diem 00 9Diabetic Management Program, 00 9Diabetic Management Program, 00 9Insulin pump initiation 00 9Evaluation by ocularist 00 9Speech therapy, re-eval 00 9Home mgmt preterm labor 00 9

Home mgmt PPROM 00 9

PUF___2011_Web_File

Home mgmt gest hypertension 00 9

Hm postpar hyper per diem 00 9

Hm preeclamp per diem 00 9

Hm gest dm per diem 00 9

HIT pain mgmt per diem 00 9

HIT cont pain per diem 00 9

HIT int pain per diem 00 9

HIT pain imp pump diem 00 9

HIT chemo per diem 00 9

HIT cont chem diem 00 9

HIT intermit chemo diem 00 9

HT hemodialysis diem 00 9

HIT cont anticoag diem 00 9

PUF___2011_Web_File

HIT immunotherapy diem 00 9

HIT periton dialysis diem 00 9

HIT enteral per diem 00 9

HIT enteral grav diem 00 9

HIT enteral pump diem 00 9

HIT enteral bolus nurs 00 9

HIT anti-hemophil diem 00 9

HIT alpha-1-proteinas diem 00 9

HIT longterm infusion diem 00 9

HIT sympathomim diem 00 9

HIT tocolysis diem 00 9

HIT cont antiemetic diem 00 9

HIT cont insulin diem 00 9

HIT chelation diem 00 9

HIT enzyme replace diem 00 9

HIT anti-tnf per diem 00 9

PUF___2011_Web_File

HIT diuretic infus diem 00 9

HIT anti-spasmotic diem 00 9

HIT tpn total diem 00 9

HIT tpn 1 liter diem 00 9



HIT tpn over 3l diem 00 9

HT inj antiemetic diem 00 9

HT inj anticoag diem 00 9

HIT hydra total diem 00 9

HIT hydra 1 liter diem 00 9



PUF___2011_Web_File

HIT hydra over 3l diem 00 9

HIT noc per diem 00 9

HIT high risk/escort 00 9

Anticoag clinic per session 00 9

Pharmacy comp/disp serv 00 9Medical food oral 100% nutr 00 9

Mod solid food suppl 00 9Medical foods for inborn err 00 9Lamaze class 00 9Childbirth refresher class 00 9Cesarean birth class 00 9VBAC class 00 9Asthma education 00 9Birthing class 00 9Lactation class 00 9Parenting class 00 9PT education noc individ 00 9

PT education noc group 00 9

Infant safety class 00 9Weight mgmt class 00 9Exercise class 00 9Nutrition class 00 9Smoking cessation class 00 9Stress mgmt class 00 9Diabetic Management Program, 00 9Diabetic Management Program, 00 9Diabetic Management Program, 00 9Nutritional counseling, diet 00 9Cardiac rehabilitation progr 00 9Pulmonary rehabilitation pro 00 9Enterostomal therapy by a re 00 9

Ambulatory setting substance 00 9

Vestibular rehab per diem 00 9Intensive outpatient psychia 00 9Family stabilization 15 min 00 9Crisis intervention per hour 00 9Crisis intervention mental h 00 9HIT corticosteroid/diem 00 9

PUF___2011_Web_File

HIT antibiotic total diem 00 9

HIT antibiotic q3h diem 00 9






Venipuncture home/snf 00 9

HT hem horm inj diem 00 9

HIT blood products diem 00 9

HT inj noc per diem 00 9

HT inj growth horm diem 00 9

HIT inj interferon diem 00 9

HT inj hormone diem 00 9

HT inj palivizumab diem 00 9

PUF___2011_Web_File

HT irrigation diem 00 9

HT pharm per hour 00 9

Christian Sci Pract visit 00 9

Health club membership yr 00 9Transplant related per diem 00 9Lodging per diem 00 9Meals per diem 00 9Med record copy admin 00 9Med record copy per page 00 9Not medically necessary svc 00 9

Serv part of phase I trial 00 9Services outside US 00 9

Services provided as part of 00 9Services provided as part of 00 9Transportation costs to and 00 9

Lodging costs (e.g. hotel ch 00 9

Meals for clinical trial par 00 9Sales tax 00 9Private duty/independent nsg 00 9Nursing assessment/evaluatn 00 9RN services up to 15 minutes 00 9LPN/LVN services up to 15min 00 9Nsg aide service up to 15min 00 9Respite care service 15 min 00 9Family/Couple Counseling 00 9Treatment Plan Development 00 9

Child Sitting Services 00 9

Meals when Receive Services 00 9

Alcohol/Substance Abuse Skil 00 9Sign Lang/Oral Interpreter 00 9Telehealth transmit, per min 00 9Clinic service 00 9Case management 00 9Targeted case management 00 9School-based IEP ser bundled 00 9Personal care ser per 15 min 00 9

PUF___2011_Web_File

Personal care ser per diem 00 9

HH Aide or cn aide per visit 00 9Contracted services per day 00 9

Program intake assessment 00 9

Team evaluation & management 00 9

Ped compr care pkg, per diem 00 9

Ped compr care pkg, per hour 00 9

Family training & counseling 00 9Home environment assessment 00 9

Dwelling lead investigation 00 9

RN home care per diem 00 9LPN home care per diem 00 9Medication admin visit 00 9

Med admin, not oral/inject 00 9

Elec med comp dev, noc 00 9

NOC retail items andsupplies 00 9

N-et; patient attend/escort 00 9N-et; per diem 00 9N-et; encounter/trip 00 9N-et; commerc carrier pass 00 9N-et; stretcher van 00 9Non-emer transport wait time 00 9

PASRR Level I 00 9

PASRR Level II 00 9

Habil ed waiver, per diem 00 9Habil ed waiver per hour 00 9Habil prevoc waiver, per d 00 9Habil prevoc waiver per hr 00 9Habil res waiver per diem 00 9Habil res waiver 15 min 00 9Habil sup empl waiver/diem 00 9Habil sup empl waiver 15min 00 9Day habil waiver per diem 00 9Day habil waiver per 15 min 00 9

PUF___2011_Web_File

Case management, per month 00 9Targeted case mgmt per month 00 9Serv asmnt/care plan waiver 00 9Waiver service, nos 00 9Special childcare waiver/d 00 9Spec childcare waiver 15 min 00 9Special supply, nos waiver 00 9Special med equip, noswaiver 00 9Assist living waiver/month 00 9Assist living waiver/diem 00 9Res care, nos waiver/month 00 9Res, nos waiver per diem 00 9Crisis interven waiver/diem 00 9Utility services waiver 00 9

Camp overnite waiver/session 00 9Camp day waiver/session 00 9Comm trans waiver/service 00 9Vehicle mod waiver/service 00 9Financial mgt waiver/15min 00 9Support broker waiver/15 min 00 9Hospice routine home care 00 9Hospice continuous home care 00 9Hospice respite care 00 9Hospice general care 00 9Hospice long term care, r&b 00 9Bh ltc res r&b, per diem 00 9

N-ET; stretcher van, mileage 00 9Breast milk proc/store/dist 00 9Adult size brief/diaper sm 00 9Adult size brief/diaper med 00 9Adult size brief/diaper lg 00 9Adult size brief/diaper xl 00 9Adult size pull-on sm 00 9

Adult size pull-on med 00 9

Adult size pull-on lg 00 9

Adult size pull-on xl 00 9

Ped size brief/diaper sm/med 00 9

Ped size brief/diaper lg 00 9Ped size pull-on sm/med 00 9

Ped size pull-on lg 00 9

Youth size brief/diaper 00 9Youth size pull-on 00 9Disposable liner/shield/pad 00 9Reusable pull-on any size 00 9

PUF___2011_Web_File

Reusable underpad bed size 00 9Diaper serv reusable diaper 00 9Reuse diaper/brief any size 00 9Reusable underpad chair size 00 9Large disposable underpad 00 9Small disposable underpad 00 9Disp bariatric brief/diaper 00 9Position seat spec orth need 00 9Supply, nos 00 9Vision svcs frames purchases 38 AEyeglasses delux frames 00 9Lens spher single plano 4.00 38 ASingle visn sphere 4.12-7.00 38 ASingl visn sphere 7.12-20.00 38 ASpherocylindr 4.00d/12-2.00d 38 A

Spherocylindr 4.00d/2.12-4d 38 A

Spherocylinder 4.00d/4.25-6d 38 A

Spherocylinder 4.00d/>6.00d 38 A

Spherocylinder 4.25d/12-2d 38 A



Spherocylinder 4.25d/over 6d 38 A

Spherocylindr 7.25d/.25-2.25 38 A



Spherocylinder over 12.00d 38 ALens lenticular bifocal 38 ALens aniseikonic single 38 ALenticular lens, single 38 ALens single vision not oth c 46 ALens spher bifoc plano 4.00d 38 ALens sphere bifocal 4.12-7.0 38 ALens sphere bifocal 7.12-20. 38 ALens sphcyl bifocal 4.00d/.1 38 A

Lens sphcy bifocal 4.00d/2.1 38 A

Lens sphcy bifocal 4.00d/4.2 38 A

Lens sphcy bifocal 4.00d/ove 38 A

Lens sphcy bifocal 4.25-7d/. 38 A

PUF___2011_Web_File

Lens sphcy bifocal 4.25-7/2. 38 A

Lens sphcy bifocal 4.25-7/4. 38 A

Lens sphcy bifocal 4.25-7/ov 38 A

Lens sphcy bifo 7.25-12/.25- 38 A

Lens sphcyl bifo 7.25-12/2.2 38 A

Lens sphcyl bifo 7.25-12/4.2 38 A

Lens sphcyl bifocal over 12. 38 ALens lenticular bifocal 38 ALens aniseikonic bifocal 38 ALens bifocal seg width over 38 ALens bifocal add over 3.25d 38 ALenticular lens, bifocal 38 ALens bifocal speciality 46 ALens sphere trifocal 4.00d 38 ALens sphere trifocal 4.12-7. 38 ALens sphere trifocal 7.12-20 38 ALens sphcy trifocal 4.0/.12- 38 A

Lens sphcy trifocal 4.0/2.25 38 A

Lens sphcy trifocal 4.0/4.25 38 A

Lens sphcyl trifocal 4.00/>6 38 A

Lens sphcy trifocal 4.25-7/. 38 A

Lens sphc trifocal 4.25-7/2. 38 A

Lens sphc trifocal 4.25-7/4. 38 A

Lens sphc trifocal 4.25-7/>6 38 A

Lens sphc trifo 7.25-12/.25- 38 A

Lens sphc trifo 7.25-12/2.25 38 A

Lens sphc trifo 7.25-12/4.25 38 A

Lens sphcyl trifocal over 12 38 ALens lenticular trifocal 38 ALens aniseikonic trifocal 38 ALens trifocal seg width > 28 38 ALens trifocal add over 3.25d 38 ALenticular lens, trifocal 38 ALens trifocal speciality 46 ALens variab asphericity sing 38 ALens variable asphericity bi 38 AVariable asphericity lens 46 A

PUF___2011_Web_File

Contact lens pmma spherical 38 ACntct lens pmma-toric/prism 38 AContact lens pmma bifocal 38 ACntct lens pmma color vision 38 ACntct gas permeable sphericl 38 ACntct toric prism ballast 38 ACntct lens gas permbl bifocl 38 AContact lens extended wear 38 AContact lens hydrophilic 38 ACntct lens hydrophilic toric 38 ACntct lens hydrophil bifocl 38 ACntct lens hydrophil extend 38 AContact lens gas impermeable 38 A

Contact lens gas permeable 38 A

Contact lens/es other type 46 AHand held low vision aids 46 ASingle lens spectacle mount 46 ATelescop/othr compound lens 46 A

Plastic eye prosth custom 38 APolishing artifical eye 38 AEnlargemnt of eye prosthesis 38 AReduction of eye prosthesis 38 AScleral cover shell 38 AFabrication & fitting 38 AProsthetic eye other type 46 AAnter chamber intraocul lens 52 AIris support intraoclr lens 52 APost chmbr intraocular lens 52 ABalance lens 38 ADeluxe lens feature 00 9Glass/plastic slab off prism 38 APrism lens/es 38 AFresnell prism press-on lens 38 ASpecial base curve 38 ATint photochromatic lens/es 38 ATint, any color/solid/grad 38 A

Anti-reflective coating 38 AUV lens/es 38 AEye glass case 00 9Scratch resistant coating 38 AMirror coating 38 APolarization, any lens 38 AOccluder lens/es 38 AOversize lens/es 38 AProgressive lens per lens 00 9Lens, 1.54-1.65 p/1.60-1.79g 38 A

Lens, >= 1.66 p/>=1.80 g 38 A

Lens polycarb or equal 38 A

PUF___2011_Web_File

Corneal tissue processing 46 AOccupational multifocal lens 38 AAstigmatism-correct function 00 9Presbyopia-correct function 00 9Amniotic membrane 57 AVis item/svc in other code 00 9Miscellaneous vision service 46 AHearing screening 00 9Assessment for hearing aid 00 9Hearing aid fitting/checking 00 9Hearing aid repair/modifying 00 9Conformity evaluation 00 9Body-worn hearing aid air 00 9Body-worn hearing aid bone 00 9Hearing aid monaural in ear 00 9Behind ear hearing aid 00 9Glasses air conduction 00 9Glasses bone conduction 00 9Hearing aid dispensing fee 00 9Implant mid ear hearing pros 00 9Body-worn bilat hearing aid 00 9Hearing aid dispensing fee 00 9Body-worn binaur hearing aid 00 9In ear binaural hearing aid 00 9Behind ear binaur hearing ai 00 9Glasses binaural hearing aid 00 9Dispensing fee binaural 00 9Within ear cros hearing aid 00 9Behind ear cros hearing aid 00 9Glasses cros hearing aid 00 9Cros hearing aid dispens fee 00 9In ear bicros hearing aid 00 9Behind ear bicros hearing ai 00 9Glasses bicros hearing aid 00 9Dispensing fee bicros 00 9Dispensing fee, monaural 00 9Hearing aid, monaural, cic 00 9Hearing aid, monaural, itc 00 9Hearing aid, prog, mon, cic 00 9Hearing aid, prog, mon, itc 00 9Hearing aid, prog, mon, ite 00 9Hearing aid, prog, mon, bte 00 9Hearing aid, binaural, cic 00 9Hearing aid, binaural, itc 00 9Hearing aid, prog, bin, cic 00 9Hearing aid, prog, bin, itc 00 9Hearing aid, prog, bin, ite 00 9Hearing aid, prog, bin, bte 00 9Hearing id, digit, mon, cic 00 9Hearing aid, digit, mon, itc 00 9Hearing aid, digit, mon, ite 00 9Hearing aid, digit, mon, bte 00 9Hearing aid, digit, bin, cic 00 9Hearing aid, digit, bin, itc 00 9

PUF___2011_Web_File

Hearing aid, digit, bin, ite 00 9Hearing aid, digit, bin, bte 00 9Hearing aid, disp, monaural 00 9Hearing aid, disp, binaural 00 9Ear mold/insert 00 9Ear mold/insert, disp 00 9Battery for hearing device 00 9Hearing aid supply/accessory 00 9ALD Telephone Amplifier 00 9Alerting device, any type 00 9ALD, TV amplifier, any type 00 9ALD, TV caption decoder 00 9Tdd 00 9ALD for cochlear implant 00 9ALD unspecified 00 9Ear impression 00 9Hearing aid noc 00 9Hearing service 13 ARepair communication device 00 9

Speech screening 00 9Language screening 00 9Dysphagia screening 00 9

PUF___2011_Web_File

CIM1 CIM2 CIM3 MCM1 MCM2 MCM3 Statute Lab Cert1

3350.53350.5

2150 5112

2152 5113

4105.7

PUF___2011_Web_File

4270.2

4270.2

4270.2

4273.2

3045.7

PUF___2011_Web_File

35-99 2005.1

3350.5 4116

4116

4273.1

4175-5

4175-5

2000

PUF___2011_Web_File

65-7

PUF___2011_Web_File

3060.6

3060.7

3350.5

7517.1

15018I

30-1

3350.5

PUF___2011_Web_File

2125

2120.1 2125

60-92049

PUF___2011_Web_File

20492049

60-14

60-1460-1460-14

21001861(n)

60-11

60-1160-11

60-1160-11

1862a1

15030

60-9

PUF___2011_Web_File

2130

21302130

2130

2130

2130

2130

2130

21302130213021302130213021302130

2130213021302130

2130

21302130213021302130

2130

213021302130

2130

2130

PUF___2011_Web_File

2130

21302130

21302130

2130A

213021302130

2130

21302130213021302130213021302130213021302130

2130

21302130

2130

21302130

2130

2130

213021302130213021302130213021302130

PUF___2011_Web_File

21302130

2130

2130

2130

2130

2130

2130

2130

2130

213021302130

PUF___2011_Web_File

2130

50-4 232050-10 2320

21302130

60-9 2079 210060-9 2079 210060-9 2079 210060-9 2079 210060-9

1503060-9

207935-10

20792079

45-25

60-4 331260-4 331260-4 331260-4 331260-4 331260-4 331265-16 2130

21302130

PUF___2011_Web_File

2100

213065-8

60-960-960-9

60-9 4107.6

42704270

427042704270

50-42 42704270427042704270

55-1 427042704270427042704270

55-1 4270

42704270

4270

4270

4270

4270

4270

PUF___2011_Web_File

4270

427042704270427042704270427042704270427042704270427042704270427042702100.4

21302130213021302130

2130213021302130213021302130

2130213021302130

21302130213021302130

PUF___2011_Web_File

2130213021302134

2134

2134

2134

2134

2134

2134

2134

2134

2303

2079207920792079

20792079

20792079

2079

2079

2079

PUF___2011_Web_File

2079

2079

2079

20792079

20792079

2079

2079

2079

2079

2079

20792079

2079

2079

2079

2079

2079

2079

2079

2079

2079

2079

2079

2079

PUF___2011_Web_File

2079

2079

2079

2079

2079

2079

2079

2079

207920792079

2079

2079

2079

2079

2079

207920792079

2079

2079

2079

2079

2079

20792079

20792079207920792079

PUF___2011_Web_File

2079

2079

2079

20792079

1861(s)(5)

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PUF___2011_Web_File


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O1E 9O1E 9O1D 1

PUF___2011_Web_File

O1E 9O1E 4O1D 9O1E 9O1E 9

0093 O1E 1D1A 9D1A 9

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File


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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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M5B 1M5B 1

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M5B 1M5B 1M5B 1

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M5B 10097 Y2 10097 Y2 10097 Y2 10097 Y2 10097 Y2 10097 Y2 10097 Y2 10097 Y2 10096 Y2 10096 Y2 10096 Y2 10096 Y2 10096 Y2 10096 Y2 10096 Y2 1

O1E 1

O1E 1

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O1E 1

O1E 1

PUF___2011_Web_File

O1E 1

O1E 1

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T2D 1

T2D 1

T2D 1

T2D 1

P7B 1

P7B 1

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

Z2 9Z2 9Z2 9Z2 9Z2 9Z2 9Z2 9Z2 9Z2 9Z2 9

O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

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O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1D 1 PO1E 1 PO1E 1 GO1E 1 PO1E 1 PO1E 1

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PUF___2011_Web_File

0095 O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

0095 O1E 1 GO1E 1 PO1E 1 PO1E 1 PO1E 1 P

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0127 O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

PUF___2011_Web_File

O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

0095 O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

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PUF___2011_Web_File

O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1D 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

0095 O1E 1 PO1E 1 PO1E 1 PO1E 1 P

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PUF___2011_Web_File

O1E 1 P

O1E 1 PO1E 1 P

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O1E 1 PO1E 1 PO1E 1 P

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0095 O1E 1 PO1E 1 PO1E 1 L PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

0095 O1E 1 GO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PD1G 1 PO1E 1O1E 1

PUF___2011_Web_File

O1E 1

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0095 O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

0123 O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

PUF___2011_Web_File

O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

0095 O1E 1 P0095 O1E 1 P

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0095 O1E 1 PO1E 1 PO1E 1 PO1E 1 P

0127 D1G 1 P

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O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

PUF___2011_Web_File

O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 GO1E 1 GO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P


0120 O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

0127 O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P


PUF___2011_Web_File

O1E 9O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P

0123 O1E 1 P


0135 O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 P


O1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PO1E 1 PP6C 9P6C 9

PUF___2011_Web_File

Z2 9Z2 9P6C 9Z2 9O1E 1

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PUF___2011_Web_File

O1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 GO1E 1 P

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PUF___2011_Web_File

0135 D1G 1 P

0135 D1G 1 P

0135 D1G 1 P

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0135 D1G 1 P

0135 D1G 1 P

0135 D1G 1 P

0135 D1G 1 P

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0135 D1G 1 P

0135 D1G 1 P

0135 D1G 1 P

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PUF___2011_Web_File

0135 D1G 1 P

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0135 D1G 1 P

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0119 O1E 1 GO1D 1 PO1E 1 PO1D 1 PO1D 1 PO1D 1 G PO1E 1O1D 1 PO1D 9O1E 9O1D 1O1D 1 PO1D 1 G PO1E 1 GO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1E 1 PO1E 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1E 1 PO1D 1 PO1D 1 PO1E 1 P

PUF___2011_Web_File

O1D 1 PO1E 1 PO1D 1 PO1D 1 PO1E 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1E 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1E 1 PO1E 1 PO1D 1 PO1D 1 PO1E 1 P

0095 O1E 1 PO1E 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1E 1 PO1D GO1D GO1D GO1D GO1D 1 P

0014 O1D 1 PO1D 1 PO1D 1 P

PUF___2011_Web_File

O1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1E 1 PO1D 1 PO1E 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1E 1 PO1E 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1E 1 PO1E 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1D 1 PO1E 1 PO1D 1 PO1D 1 PD1D RD1D RD1D RD1D RD1D A P RD1D RD1D RD1D A P RD1D A P RD1D A P R


PUF___2011_Web_File

D1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P RD1D A P R

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PUF___2011_Web_File

D1E A P RD1E P

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0157 D1C 9

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PUF___2011_Web_File

D1D A P R

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PUF___2011_Web_File

D1D A P R

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PUF___2011_Web_File

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PUF___2011_Web_File

D1F P

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PUF___2011_Web_File

D1F P

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

D1F PD1F P

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File


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PUF___2011_Web_File

D1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F P

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File


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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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D1F P

D1F P

PUF___2011_Web_File


D1F P

D1F P

D1F P

D1F P

D1F P

D1F PD1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F PD1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F PD1F P

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D1F P

D1F P

PUF___2011_Web_File

D1F PD1F P

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D1F P

D1F P

D1F P

D1F P

D1F PD1F P

D1F P

D1F PD1F P

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D1F P

D1F P

D1F P

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D1F P

D1F P

D1F PD1F P

D1F P

D1F P

D1F PD1F P

D1F P

D1F PD1F P

PUF___2011_Web_File



D1F P

D1F P


D1F PD1F P


D1F PD1F P

D1F PD1F P

D1F PD1F PD1F P

D1F PD1F PD1F P

D1F P

D1F P

D1F P

PUF___2011_Web_File

D1F PD1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P


D1F PD1F P

D1F P

D1F P

D1F P



PUF___2011_Web_File


D1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F P

D1F P

D1F P

D1F PD1F PD1F P

D1F PD1F P

D1F P


D1F P

D1F P

D1F P

D1F P

D1F PD1F P

PUF___2011_Web_File

D1F P

D1F P

D1F PD1F PD1F P

D1F P

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D1F P

D1F P

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D1F P

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D1F P

D1F P

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PUF___2011_Web_File

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P


D1F PD1F PD1F P


PUF___2011_Web_File

D1F P

D1F P

D1F P

D1F P

D1F P

D1F PD1F P


D1F P

D1F P

D1F P

D1F P

D1F P

D1F PD1F PD1F P

D1F P

D1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F P

PUF___2011_Web_File


D1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F P

D1F PD1F P

D1F P

D1F P

D1F PD1F P

D1F PD1F P

D1F P

D1F P

D1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F PD1F P

D1F P

PUF___2011_Web_File

D1F P

D1F P

D1F P

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D1F PD1F P


D1F PD1F PD1F P

D1F PD1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F P

D1F PD1F PD1F P

D1F PD1F P

D1F PD1F P

M5B 1

Y2 1

PUF___2011_Web_File

Y2 1P1G 1Y2 1P1G 2T1H 5T1H 5T1H 5T1H 5T1H 5

0045 T1H 5

0045 T1G 5

T1H 5T1H 0T1H 0T1H 9T1H 0T1H 9

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T1H 0T1H 9

PUF___2011_Web_File

T1H 90039 Y2 5

0039 Y2 5

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0040 T1H 5T2D 5

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I1F 4T1H 5T1H 5T1H 5T1H 5T1H 5O1E 1 P

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0054 O1E 1O1D 1

O1D 1

O1D 1

O1D 1

O1D 1

O1D 1

O1D 1

O1D 1

PUF___2011_Web_File

O1D 1

O1D 1

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O1D 1

O1D 1

O1D 1

O1D 1

O1D 1

O1D 1

O1D 1

0121 D1F P

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0121 D1F P

PUF___2011_Web_File

0121 D1F P

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0121 D1F P

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O1E 1 PD1F F

0086 D1F F0086 D1F F

O1E 1 P

O1E 1 PO1D 1 PO1E 1 PO1E 1 PO1D 9

0166 O1E 90166 O1E 9

PUF___2011_Web_File

O1G V

O1G V

O1G V

O1G V

O1G V

P7A 1Y2 9O1E 1 PO1E 1 PD1A 5D1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A S

D1A S

D1A S

D1A S

D1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A S

PUF___2011_Web_File

D1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A SD1A S

D1G 1 P

O1E 1 PD1G 1 P

O1E 1 LD1E 1 L

O1E 1

O1E 1O1E 1O1E 1O1E 1 P

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O1E 1 P

O1E 1 PO1E 1 P

O1E 1 P

0135 O1E 1 P

0135 O1E 1 P

0135 O1E 1 PO1E 1 P

O1E 1 P

O1E 1 PD1G 1 P

PUF___2011_Web_File

O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1O1E 1

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PUF___2011_Web_File

I1E 4I1E 4I1E 4I1E 4

I1F 4

I1F 4

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

Z2 9

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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D1F Q

D1F Q

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D1F Q

PUF___2011_Web_File

D1F Q

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

O1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F KO1F 1

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PUF___2011_Web_File

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PUF___2011_Web_File

0 20040101 20040101 N

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0 19910101 20000101 N

0 19910101 19970101 N 0 19870101 19970101 N

0 19840101 20020101 N 0 20030101 20030101 N

0 19950101 19990101 N 0 19950101 19990101 N 0 19950101 19990101 N 0 19950101 19990101 N 0 19950101 19990101 N 0 19950101 19990101 N 0 19950101 19990101 N 0 19950101 19990101 N 0 19950101 19990101 N 0 19950101 19990101 N 0 20060101 20080101 N

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PUF___2011_Web_File

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PUF___2011_Web_File

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PUF___2011_Web_File

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