| HCPCS Code | HCPCS Long Description | HCPCS Short Description | HCPCS Pricing Indicator Code (1) | HCPCS Pricing Indicator Code (2) | HCPCS Multiple Pricing Indicator Code | Coverage Issues Manual Ref. Section Number(s) (HCPCS) | Medicare Carriers Manual Ref. Section Number(s) (HCPCS) | HCPCS Statute Number | HCPCS Lab Certification Code (1) | HCPCS Lab Certification Code (2) | HCPCS Cross Reference Code | HCPCS Coverage Code | ASC Payment Group Code (HCPCS) | ASC Payment Group Eff Date (HCPCS) | MOG Payment Group Code (HCPCS) | MOG Payment Policy Indicator (HCPCS) | MOG Payment Group Effective Date (HCPCS) | Processing Note Number (HCPCS) | BETOS Code (HCPCS) | HCPCS Type Of Service Code | HCPCS Code Added Date | HCPCS Action Effective Date | HCPCS Termination Date | HCPCS Action Code |
|---|
| S0141 | ZALCITABINE (DDC), 0.375 MG | Zalcitabine, 0.375 mg | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 9 | 04/01/2003 | 10/01/2008 | 10/01/2008 | D |
| S0088 | IMATINIB, 100 MG | Imatinib 100 mg | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | 88 | 0 = Service not separately priced by part B | 9 | 01/01/2002 | 01/01/2003 | | N |
| J1752 | INJECTION, IRON DEXTRAN 267, 50 MG | Iron dextran 267 injection | 51 = Drugs | 51 = Drugs | A | ; ; | ; ; | | | | | 51 = Drugs | YY | 01/01/2008 | | | | 123 | 51 = Drugs | 1 | 01/01/2006 | 04/01/2008 | | N |
| J1751 | INJECTION, IRON DEXTRAN 165, 50 MG | Iron dextran 165 injection | 51 = Drugs | 51 = Drugs | A | ; ; | ; ; | | | | | 51 = Drugs | YY | 01/01/2008 | | | | 123 | 51 = Drugs | 1 | 01/01/2006 | 04/01/2008 | | N |
| J7603 | ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION,; FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT; DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL) | Albuterol inh non-comp u d | 51 = Drugs | 51 = Drugs | A | ; ; | ; ; | | | | | 51 = Drugs | | | | | | 135 | 51 = Drugs | 1 | 01/01/2008 | 04/01/2008 | | A |
| J7602 | ALBUTEROL, 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 inh non-comp con | 51 = Drugs | 51 = Drugs | A | ; ; | ; ; | | | | | 51 = Drugs | | | | | | 135 | 51 = Drugs | 1 | 01/01/2008 | 04/01/2008 | | A |
| G0300 | INSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR DUAL CHAMBER PACING; CARDIOVERTER DEFIBRILLATOR AND INSERTION OF PULSE GENERATOR | Insert reposit lead dual+gen | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 10/01/2003 | 01/01/2008 | 12/31/2007 | D |
| C8926 | TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST FOR CONGENITAL CARDIAC; ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND; REPORT | Cong TEE w/contr, int/rept | 53 = Statute | 53 = Statute | A | ; ; | ; ; | 430 BIPA | | | | 53 = Statute | | | | | | | 53 = Statute | 4 | 01/01/2008 | 04/01/2008 | | C |
| C8927 | TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST FOR MONITORING PURPOSES,; INCLUDING PROBE PLACEMENT, REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND; INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY; TIME BASIS; CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE | TEE w/contrast; monitor | 53 = Statute | 53 = Statute | A | ; ; | ; ; | 430 BIPA | | | | 53 = Statute | | | | | | | 53 = Statute | 4 | 01/01/2008 | 04/01/2008 | | C |
| C8925 | TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, REAL TIME WITH IMAGE; DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE; PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT | 2D TEE w/contrast, int/rept | 53 = Statute | 53 = Statute | A | ; ; | ; ; | 430 BIPA | | | | 53 = Statute | | | | | | | 53 = Statute | 4 | 01/01/2008 | 04/01/2008 | | C |
| C8928 | TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, REAL-TIME WITH IMAGE; DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING, DURING REST AND; CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR; PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT | 2D transtho w/contr; stress | 53 = Statute | 53 = Statute | A | ; ; | ; ; | 430 BIPA | | | | 53 = Statute | | | | | | | 53 = Statute | 4 | 01/01/2008 | 04/01/2008 | | C |
| C8923 | TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, REAL-TIME WITH IMAGE; DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; COMPLETE | 2D com transtho echo w/contr | 53 = Statute | 53 = Statute | A | ; ; | ; ; | 430 BIPA | | | | 53 = Statute | | | | | | | 53 = Statute | 4 | 01/01/2008 | 04/01/2008 | | C |
| C8921 | TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST FOR CONGENITAL CARDIAC ANOMALIES;; COMPLETE | Comp transtho echo w/contr | 53 = Statute | 53 = Statute | A | ; ; | ; ; | 430 BIPA | | | | 53 = Statute | | | | | | | 53 = Statute | 4 | 01/01/2008 | 04/01/2008 | | C |
| C8922 | TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST FOR CONGENITAL CARDIAC ANOMALIES;; FOLLOW-UP OR LIMITED STUDY | Limit transtho echo w/contr | 53 = Statute | 53 = Statute | A | ; ; | ; ; | 430 BIPA | | | | 53 = Statute | | | | | | | 53 = Statute | 4 | 01/01/2008 | 04/01/2008 | | C |
| C8924 | TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, REAL-TIME WITH IMAGE; DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR LIMITED STUDY | 2D lim transtho echo w/contr | 53 = Statute | 53 = Statute | A | ; ; | ; ; | 430 BIPA | | | | 53 = Statute | | | | | | | 53 = Statute | 4 | 01/01/2008 | 04/01/2008 | | C |
| C8920 | MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,; PELVIS | MRA w/o fol w/cont, pelvis | 53 = Statute | 53 = Statute | A | ; ; | ; ; | 430 BIPA | | | | 53 = Statute | YY | 01/01/2008 | | | | | 53 = Statute | 4 | 07/01/2003 | 04/01/2008 | | C |
| J7612 | LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,; ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG | Levalbuterol non-comp con | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 1 | 01/01/2005 | 04/01/2008 | | D |
| J7614 | LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,; ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG | Levalbuterol non-comp unit | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 1 | 01/01/2005 | 04/01/2008 | | D |
| J7613 | ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,; ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG | Albuterol non-comp unit | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 1 | 01/01/2005 | 04/01/2008 | | D |
| J7611 | ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,; ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MG | Albuterol non-comp con | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 1 | 01/01/2005 | 04/01/2008 | | D |
| G0297 | INSERTION OF SINGLE CHAMBER PACING CARDIOVERTER DEFIBRILLATOR PULSE GENERATOR | Insert single chamber/cd | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 10/01/2003 | 04/14/2008 | 12/31/2007 | D |
| G0377 | ADMINISTRATION OF VACCINE FOR PART D DRUG | Administra Part D vaccine | 11 = Price established using national rvu's (Physician Fee Schedule) | 11 = Price established using national rvu's (Physician Fee Schedule) | A | ; ; | ; ; | 1861s10B | | | | 11 = Price established using national rvu's (Physician Fee Schedule) | | | | | | | 11 = Price established using national rvu's (Physician Fee Schedule) | 1 | 01/01/2007 | 04/15/2008 | 12/31/2007 | D |
| A4455 | ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE | Adhesive remover per ounce | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | A | ; ; | 2130; ; | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | | | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | P | 01/01/1989 | 01/01/1995 | | N |
| A4461 | SURGICAL DRESSING HOLDER, NON-REUSABLE, EACH | Surgicl dress hold non-reuse | 35 = Surgical dressings (price subject to floors and ceilings) | 35 = Surgical dressings (price subject to floors and ceilings) | A | ; ; | ; ; | | | | | 35 = Surgical dressings (price subject to floors and ceilings) | | | | | | | 35 = Surgical dressings (price subject to floors and ceilings) | S | 01/01/2007 | 01/01/2007 | | N |
| A4462 | ABDOMINAL DRESSING HOLDER, EACH | Abdmnl drssng holder/binder | 35 = Surgical dressings (price subject to floors and ceilings) | 35 = Surgical dressings (price subject to floors and ceilings) | A | ; ; | 2079; ; | | | | | 35 = Surgical dressings (price subject to floors and ceilings) | | | | | | | 35 = Surgical dressings (price subject to floors and ceilings) | S | 01/01/1998 | 01/01/2007 | 12/31/2006 | N |
| A4463 | SURGICAL DRESSING HOLDER, REUSABLE, EACH | Surgical dress holder reuse | 35 = Surgical dressings (price subject to floors and ceilings) | 35 = Surgical dressings (price subject to floors and ceilings) | A | ; ; | ; ; | | | | | 35 = Surgical dressings (price subject to floors and ceilings) | | | | | | | 35 = Surgical dressings (price subject to floors and ceilings) | S | 01/01/2007 | 01/01/2007 | | N |
| A4470 | GRAVLEE JET WASHER | Gravlee jet washer | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | 50-4; ; | 2320; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | P | 01/01/1986 | 01/01/2001 | | N |
| A4480 | VABRA ASPIRATOR | Vabra aspirator | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | 50-10; ; | 2320; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | P | 01/01/1986 | 01/01/2001 | | N |
| A4481 | TRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE, EACH | Tracheostoma filter | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | A | ; ; | 2130; ; | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | | | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | P | 01/01/1997 | 01/01/2003 | | N |
| A4490 | SURGICAL STOCKINGS ABOVE KNEE LENGTH, EACH | Above knee surgical stocking | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | 60-9; ; | 2079; 2100; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | P | 01/01/1986 | 01/01/2003 | | N |
| A4495 | SURGICAL STOCKINGS THIGH LENGTH, EACH | Thigh length surg stocking | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | 60-9; ; | 2079; 2100; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | P | 01/01/1986 | 01/01/2003 | | N |
| A4500 | SURGICAL STOCKINGS BELOW KNEE LENGTH, EACH | Below knee surgical stocking | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | 60-9; ; | 2079; 2100; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | P | 01/01/1986 | 01/01/2003 | | N |
| A4510 | SURGICAL STOCKINGS FULL LENGTH, EACH | Full length surg stocking | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | 60-9; ; | 2079; 2100; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | P | 01/01/1986 | 01/01/2003 | | N |
| A4521 | ADULT-SIZED INCONTINENCE PRODUCT, DIAPER, SMALL SIZE, EACH | Adult size diaper sm each | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | 60-9; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 9 | 01/01/2003 | 01/01/2005 | 12/31/2004 | N |
| A4522 | ADULT-SIZED INCONTINENCE PRODUCT, DIAPER, MEDIUM SIZE, EACH | Adult size diaper med each | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | 60-9; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 9 | 01/01/2003 | 01/01/2005 | 12/31/2004 | N |
| A4616 | TUBING (OXYGEN), PER FOOT | Tubing (oxygen) per foot | 34 = DME supplies (price subject to floors and ceilings) | 34 = DME supplies (price subject to floors and ceilings) | A | 60-4; ; | 3312; ; | | | | | 34 = DME supplies (price subject to floors and ceilings) | | | | | | | 34 = DME supplies (price subject to floors and ceilings) | P | 01/01/1990 | 04/01/2007 | | P |
| A4617 | MOUTH PIECE | Mouth piece | 34 = DME supplies (price subject to floors and ceilings) | 34 = DME supplies (price subject to floors and ceilings) | A | 60-4; ; | 3312; ; | | | | | 34 = DME supplies (price subject to floors and ceilings) | | | | | | | 34 = DME supplies (price subject to floors and ceilings) | P | 01/01/1990 | 04/01/2007 | | P |
| A4619 | FACE TENT | Face tent | 33 = Oxygen and oxygen equipment (price subject to floors and ceilings) | 33 = Oxygen and oxygen equipment (price subject to floors and ceilings) | A | 60-4; ; | 3312; ; | | | | | 33 = Oxygen and oxygen equipment (price subject to floors and ceilings) | | | | | | | 33 = Oxygen and oxygen equipment (price subject to floors and ceilings) | P | 01/01/1990 | 01/01/1996 | | N |
| A4620 | VARIABLE CONCENTRATION MASK | Variable concentration mask | 34 = DME supplies (price subject to floors and ceilings) | 34 = DME supplies (price subject to floors and ceilings) | A | 60-4; ; | 3312; ; | | | | | 34 = DME supplies (price subject to floors and ceilings) | | | | | | | 34 = DME supplies (price subject to floors and ceilings) | P | 01/01/1990 | 04/01/2007 | | P |
| A4623 | TRACHEOSTOMY, INNER CANNULA | Tracheostomy inner cannula | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | A | 65-16; ; | 2130; ; | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | | | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | P | 01/01/1990 | 01/01/2004 | | N |
| A4625 | TRACHEOSTOMY CARE KIT FOR NEW TRACHEOSTOMY | Trach care kit for new trach | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | A | ; ; | 2130; ; | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | | | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | P | 01/01/1990 | 01/01/2003 | | N |
| A4626 | TRACHEOSTOMY CLEANING BRUSH, EACH | Tracheostomy cleaning brush | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | A | ; ; | 2130; ; | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | | | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | P | 01/01/1990 | 01/01/2003 | | N |
| A4627 | SPACER, BAG OR RESERVOIR, WITH OR WITHOUT MASK, FOR USE WITH METERED DOSE; INHALER | Spacer bag/reservoir | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | 2100; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 9 | 01/01/1991 | 01/01/1997 | | N |
| A4628 | OROPHARYNGEAL SUCTION CATHETER, EACH | Oropharyngeal suction cath | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | ; ; | ; ; | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | | | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 01/01/1996 | 01/01/1996 | | N |
| A4629 | TRACHEOSTOMY CARE KIT FOR ESTABLISHED TRACHEOSTOMY | Tracheostomy care kit | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | A | ; ; | 2130; ; | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | | | | | | | 37 = Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) | P | 01/01/1996 | 01/01/2003 | | N |
| A4630 | REPLACEMENT BATTERIES, MEDICALLY NECESSARY, TRANSCUTANEOUS ELECTRICAL; STIMULATOR, OWNED BY PATIENT | Repl bat t.e.n.s. own by pt | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 65-8; ; | ; ; | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | | | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 01/01/1991 | 01/01/2006 | | N |
| A4632 | REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP, ANY TYPE, EACH | Infus pump rplcemnt battery | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | A | 01/01/2003 | 01/01/2007 | 12/31/2006 | N |
| A4633 | REPLACEMENT BULB/LAMP FOR ULTRAVIOLET LIGHT THERAPY SYSTEM, EACH | Uvl replacement bulb | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | ; ; | ; ; | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | | | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 01/01/2003 | 01/01/2003 | | N |
| A4634 | REPLACEMENT BULB FOR THERAPEUTIC LIGHT BOX, TABLETOP MODEL | Replacement bulb th lightbox | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 9 | 01/01/2003 | 01/01/2003 | | N |
| A4635 | UNDERARM PAD, CRUTCH, REPLACEMENT, EACH | Underarm crutch pad | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 60-9; ; | ; ; | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | | | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 01/01/1991 | 01/01/1996 | | N |
| A4250 | URINE TEST OR REAGENT STRIPS OR TABLETS (100 TABLETS OR STRIPS) | Urine reagent strips/tablets | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | 2100; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 9 | 01/01/1990 | 01/01/1997 | | N |
| A4252 | BLOOD KETONE TEST OR REAGENT STRIP, EACH | Blood ketone test or strip | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | 1861(n) | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | P | 01/01/2008 | 01/01/2008 | | A |
| A4254 | REPLACEMENT BATTERY, ANY TYPE, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD; GLUCOSE MONITOR OWNED BY PATIENT, EACH | Battery for glucose monitor | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 60-11; ; | ; ; | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | | | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 01/01/1996 | 01/01/2006 | 12/31/2005 | N |
| A4255 | PLATFORMS FOR HOME BLOOD GLUCOSE MONITOR, 50 PER BOX | Glucose monitor platforms | 34 = DME supplies (price subject to floors and ceilings) | 34 = DME supplies (price subject to floors and ceilings) | A | 60-11; ; | ; ; | | | | | 34 = DME supplies (price subject to floors and ceilings) | | | | | | | 34 = DME supplies (price subject to floors and ceilings) | P | 01/01/1997 | 01/01/2002 | | N |
| A4256 | NORMAL, LOW AND HIGH CALIBRATOR SOLUTION / CHIPS | Calibrator solution/chips | 34 = DME supplies (price subject to floors and ceilings) | 34 = DME supplies (price subject to floors and ceilings) | A | 60-11; ; | ; ; | | | | | 34 = DME supplies (price subject to floors and ceilings) | | | | | | | 34 = DME supplies (price subject to floors and ceilings) | P | 01/01/1985 | 01/01/2002 | | N |
| A4257 | REPLACEMENT LENS SHIELD CARTRIDGE FOR USE WITH LASER SKIN PIERCING DEVICE, EACH | Replace Lensshield Cartridge | 34 = DME supplies (price subject to floors and ceilings) | 34 = DME supplies (price subject to floors and ceilings) | A | ; ; | ; ; | | | | | 34 = DME supplies (price subject to floors and ceilings) | | | | | | | 34 = DME supplies (price subject to floors and ceilings) | P | 01/01/2002 | 01/01/2002 | | N |
| D7220 | REMOVAL OF IMPACTED TOOTH-SOFT TISSUE | Impact tooth remov soft tiss | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | A | ; ; | 2336; 2136; | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | | | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 2 | 01/01/1984 | 01/01/1993 | | N |
| D7230 | REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY | Impact tooth remov part bony | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | A | ; ; | 2336; 2136; | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | | | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 2 | 01/01/1984 | 01/01/1993 | | N |
| D7240 | REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY | Impact tooth remov comp bony | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | A | ; ; | 2336; 2136; | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | | | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 2 | 01/01/1984 | 01/01/1993 | | N |
| D7241 | REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS | Impact tooth rem bony w/comp | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | A | ; ; | 2336; 2136; | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | | | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 2 | 01/01/1984 | 01/01/1993 | | N |
| D7250 | SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) | Tooth root removal | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | A | ; ; | 2336; 2136; | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | | | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 2 | 01/01/1984 | 01/01/1993 | | N |
| D7260 | ORAL ANTRAL FISTULA CLOSURE | Oral antral fistula closure | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | A | ; ; | 2336; 2136; | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | | | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 2 | 01/01/1984 | 01/01/1993 | | N |
| D7270 | TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED OR DISPLACED; TOOTH | Tooth reimplantation | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | 1862a(12) | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/2003 | | N |
| D7272 | TOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION FROM ONE SITE TO ANOTHER AND; SPLINTING AND/OR STABILIZATION) | Tooth transplantation | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | 1862a(12) | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1982 | 01/01/1996 | | N |
| D7280 | SURGICAL ACCESS OF AN UNERUPTED TOOTH | Exposure impact tooth orthod | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | 1862a(12) | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/2003 | | N |
| D7282 | MOBILIZATION OF ERUPTED OR MALPOSITIONED TOOTH TO AID ERUPTION | Mobilize erupted/malpos toot | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | 1862a(12) | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2003 | 01/01/2003 | | N |
| D7283 | PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPACTED TOOTH | Place device impacted tooth | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 9 | 01/01/2005 | 01/01/2005 | | N |
| D7285 | BIOPSY OF ORAL TISSUE - HARD (BONE, TOOTH) | Biopsy of oral tissue hard | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | 20220 | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/2000 | | N |
| D7286 | BIOPSY OF ORAL TISSUE - SOFT | Biopsy of oral tissue soft | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | 40808 | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/2005 | | N |
| D7287 | EXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTION | Exfoliative cytolog collect | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2003 | 01/01/2005 | | N |
| D7288 | BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION | Brush biopsy | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2005 | 01/01/2005 | | N |
| D7290 | SURGICAL REPOSITIONING OF TEETH | Repositioning of teeth | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | 1862a(12) | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1982 | 01/01/1996 | | N |
| D7291 | TRANSSEPTAL FIBEROTOMY/SUPRA CRESTAL FIBEROTOMY, BY REPORT | Transseptal fiberotomy | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | A | ; ; | 2136; 2336; | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | | | | | | | 13 = Price established by carriers (e.G., not otherwise classified, individual determination, Clinical Lab Fee Schedule) | 2 | 01/01/1986 | 01/01/2003 | | N |
| D7292 | SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE [SCREW RETAINED PLATE] REQUIRING; SURGICAL FLAP | Screw retained plate | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | 1862a(12) | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2007 | 01/01/2007 | | N |
| D7293 | SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE REQUIRING SURGICAL FLAP | Temp anchorage dev w flap | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | 1862a(12) | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2007 | 01/01/2007 | | N |
| D7294 | SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE WITHOUT SURGICAL FLAP | Temp anchorage dev w/o flap | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | 1862a(12) | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2007 | 01/01/2007 | | N |
| D7310 | ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH; SPACES, PER QUADRANT | Alveoplasty w/ extraction | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | 41874 | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/2007 | | N |
| D7320 | ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH; SPACES, PER QUADRANT | Alveoplasty w/o extraction | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | 41870 | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/2007 | | N |
| D7321 | ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH; SPACES, PER QUADRANT | Alveoloplasty not w/extracts | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2005 | 01/01/2005 | | N |
| D7340 | VESTIBULOPLASTY-RIDGE EXTENSION (SECOND EPITHELIALIZATION) | Vestibuloplasty ridge extens | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | 40840 | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/1996 | | N |
| D7350 | VESTIBULOPLASTY-RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS, MUSCLE; RE-ATTACHMENTS, REVISION OF SOFT TISSUE ATTACHMENT, AND MANAGEMENT OF; HYPERTROPHIED AND HYPERPLASTIC TISSUE) | Vestibuloplasty exten graft | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | 40845 | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/1996 | | N |
| D7410 | EXCISION OF BENIGN LESION UP TO 1.25 CM | Rad exc lesion up to 1.25 cm | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | CPT | 0 = Service not separately priced by part B | | | | | | 20 | 0 = Service not separately priced by part B | 2 | 01/01/1982 | 01/01/2003 | | N |
| D7412 | EXCISION OF BENIGN LESION, COMPLICATED | Excision benign lesion compl | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2003 | 01/01/2003 | | N |
| D7413 | EXCISION OF MALIGNANT LESION UP TO 1.25 CM | Excision malig lesion<=1.25c | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2003 | 01/01/2003 | | N |
| D7414 | EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM | Excision malig lesion>1.25cm | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2003 | 01/01/2003 | | N |
| D7440 | EXCISION OF MALIGNANT TUMOR-LESION DIAMETER UP TO 1.25 CM | Malig tumor exc to 1.25 cm | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | CPT | 0 = Service not separately priced by part B | | | | | | 21 | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/1996 | | N |
| D7441 | EXCISION OF MALIGNANT TUMOR-LESION DIAMETER GREATER THAN 1.25 CM | Malig tumor > 1.25 cm | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | CPT | 0 = Service not separately priced by part B | | | | | | 21 | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/1996 | | N |
| D7450 | REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER UP T0 1.25 CM | Rem odontogen cyst to 1.25cm | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | CPT | 0 = Service not separately priced by part B | | | | | | 21 | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/2003 | | N |
| D7451 | REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER GREATER THAN 1.25 CM | Rem odontogen cyst > 1.25 cm | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | CPT | 0 = Service not separately priced by part B | | | | | | 21 | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/2003 | | N |
| D7461 | REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER GREATER THAN; 1.25 CM | Rem nonodonto cyst > 1.25 cm | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | CPT | 0 = Service not separately priced by part B | | | | | | 21 | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/2003 | | N |
| D7465 | DESTRUCTION OF LESION(S) BY PHYSICAL OR CHEMICAL METHODS, BY REPORT | Lesion destruction | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | 41850 | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/1984 | 01/01/1996 | | N |
| D7471 | REMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR MANDIBLE) | Rem exostosis any site | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | 21031 | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2000 | 01/01/2003 | | N |
| D7472 | REMOVAL OF TORUS PALATINUS | Removal of torus palatinus | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2003 | 01/01/2003 | | N |
| D7485 | SURGICAL REDUCTION OF OSSEOUS TUBEROSITY | Surg reduct osseoustuberosit | 0 = Service not separately priced by part B | 0 = Service not separately priced by part B | 9 | ; ; | ; ; | | | | | 0 = Service not separately priced by part B | | | | | | | 0 = Service not separately priced by part B | 2 | 01/01/2003 | 01/01/2003 | | N |
| E0746 | ELECTROMYOGRAPHY (EMG), BIOFEEDBACK DEVICE | Electromyograph biofeedback | 52 = Reasonable charge | 52 = Reasonable charge | A | 35-27; ; | ; ; | | | | | 52 = Reasonable charge | | | | | | | 52 = Reasonable charge | A | 01/01/1989 | 01/01/1996 | | N |
| E0747 | OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL; APPLICATIONS | Elec osteogen stim not spine | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 35-48; ; | ; ; | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | | | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 01/01/1986 | 01/01/1997 | | N |
| E0748 | OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, SPINAL APPLICATIONS | Elec osteogen stim spinal | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 35-48; ; | ; ; | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | | | | | | | 32 = Inexpensive & routinely purchased DME (price subject to floors and ceilings) | A | 01/01/1996 | 01/01/1997 | | N |
| E0749 | OSTEOGENESIS STIMULATOR, ELECTRICAL, SURGICALLY IMPLANTED | Elec osteogen stim implanted | |
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