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NDC | HCPCS | HCPCS Description | NDC Label | Route of Administration |
|---|---|---|---|---|
65862-0831-05 | J0604 | CINACALCET, ORAL, 1 MG, (FOR ESRD ON DIALYSIS) | CINACALCET HYDROCHLORIDE (FILM COATED) 30 MG | PO |
65862-0831-30 | J0604 | CINACALCET, ORAL, 1 MG, (FOR ESRD ON DIALYSIS) | CINACALCET HYDROCHLORIDE (FILM COATED) 30 MG | PO |
65862-0832-05 | J0604 | CINACALCET, ORAL, 1 MG, (FOR ESRD ON DIALYSIS) | CINACALCET HYDROCHLORIDE (FILM COATED) 60 MG | PO |
65862-0832-30 | J0604 | CINACALCET, ORAL, 1 MG, (FOR ESRD ON DIALYSIS) | CINACALCET HYDROCHLORIDE (FILM COATED) 60 MG | PO |
65862-0833-05 | J0604 | CINACALCET, ORAL, 1 MG, (FOR ESRD ON DIALYSIS) | CINACALCET HYDROCHLORIDE (FILM COATED) 90 MG | PO |
65862-0833-30 | J0604 | CINACALCET, ORAL, 1 MG, (FOR ESRD ON DIALYSIS) | CINACALCET HYDROCHLORIDE (FILM COATED) 90 MG | PO |
65862-0942-03 | J7612 | LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG | LEVALBUTEROL (CONCENTRATE,PF) 1.25 MG/0.5 ML | IH |
65862-0943-24 | J7614 | LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG | LEVALBUTEROL (PF) 0.31 MG/3 ML | IH |
65862-0943-24 | J7614 | LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG | LEVALBUTEROL (PF) 0.31 MG/3 ML | IH |
65862-0944-24 | J7614 | LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG | LEVALBUTEROL (2X12 POUCHES,PF) 0.63 MG/3 ML | IH |
65862-0944-24 | J7614 | LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG | LEVALBUTEROL (2X12 POUCHES,PF) 0.63 MG/3 ML | IH |
65862-0945-24 | J7614 | LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG | LEVALBUTEROL (2X12 POUCHES,PF) 1.25 MG/3 ML | IH |
HCPCS Code | Description | Billing Unit | SA Type |
|---|---|---|---|
S8096 | Portable peek flow meter | Each | N |
S8120 | Oxygen contents, gaseous, 1 unit equals 1 cubic foot | Each | Y |
S8121 | Oxygen contents, liquid, 1 unit equals 1 pound | Each | Y |
S8999 | Resuscitation bag (for use by patient on artificial respiration during power failure or other catastrophic event) | Each | Y |
A4216 | Sterile water, saline and/or dextrose, diluent/flush, 10 ml | Each | N |
A4217 | Sterile water/saline 500 ml | Each | N |
A4244 | Alcohol or peroxide, per pint | Per Pint | N |
A4246 | Betadine or pHisoHex solution, per pint | Pint | N |
A4247 | Betadine or iodine swabs/wipes, per box | Box of 50 | N |
A4450 | Tape, non-waterproof, per 18 square inches | 1 unit = 18 sq inches | N |
E0434 RR | Portable liquid oxygen system, rental, includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula or mask, and tubing (Coverage of home oxygen must be preauthorized by DMAS for members with arterial PO2 levels at or above 60 mm Hg or whose arterial blood oxygen saturation is at or above 90% (or at or above 95% for children.) The practitioner must submit documentation, in addition to the CMN, which specifies why oxygen is medically necessary.) | Day | N See note for exception on Service auth |
E0434 RR U1 | Portable liquid oxygen system, rental, includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula or mask, and tubing (Coverage of home oxygen must be preauthorized by DMAS for members with arterial PO2 levels at or above 60 mm Hg or whose arterial blood oxygen saturation is at or above 90% (or at or above 95% for children.) The practitioner must submit documentation, in addition to the CMN, which specifies why oxygen is medically necessary.) High Intensity code must have O2 rate above 4 LPM | Day | Y |
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