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NDC | HCPCS | HCPCS Description | NDC Label | Route of Administration |
|---|---|---|---|---|
63323-0399-23 | J0290 | INJECTION, AMPICILLIN SODIUM, 500 MG | AMPICILLIN SODIUM (VIAL) 2 GM | IJ |
63323-0400-05 | J1953 | INJECTION, LEVETIRACETAM, 10 MG | LEVETIRACETAM (SINGLE USE,LATEX-FREE) 100 MG/1 ML | IV |
63323-0400-44 | J1953 | INJECTION, LEVETIRACETAM, 10 MG | PREMIERPRO RX LEVETIRACETAM (LATEX-FREE) 100 MG/1 ML | IV |
63323-0401-20 | J0457 | INJECTION, AZTREONAM, 100 MG | AZTREONAM (SDV,USP,SODIUM-FREE) 1 GM | IJ |
63323-0401-24 | J0457 | INJECTION, AZTREONAM, 100 MG | PREMIERPRO RX AZTREONAM (SDV,USP,SODIUM-FREE) 1 GM | IJ |
63323-0401-26 | J0457 | INJECTION, AZTREONAM, 100 MG | AZTREONAM NOVAPLUS (SDV,USP,LATEX-FREE) 1 GM | IJ |
63323-0402-20 | J0457 | INJECTION, AZTREONAM, 100 MG | AZTREONAM (SDV,USP,SODIUM-FREE) 2 GM | IJ |
63323-0402-24 | J0457 | INJECTION, AZTREONAM, 100 MG | PREMIERPRO RX AZTREONAM (SDV,USP,SODIUM-FREE) 2 GM | IJ |
63323-0402-30 | J0457 | INJECTION, AZTREONAM, 100 MG | AZTREONAM NOVAPLUS (SDV,USP,LATEX-FREE) 2 GM | IJ |
63323-0404-00 | J0290 | INJECTION, AMPICILLIN SODIUM, 500 MG | AMPICILLIN (BULK PACKAGE,LATEX-FREE) 10 GM | IV |
63323-0407-03 | J0706 | INJECTION, CAFFEINE CITRATE, 5MG | CAFFEINE CITRATE (USP,SDV,PF) 20 MG/ML | IV |
63323-0411-10 | J2250 | INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG | MIDAZOLAM HCL (M.D.V.) 1 MG/ML | IJ |
HCPCS Code | Description | Billing Unit | SA Type |
|---|---|---|---|
A7507 | Filter holder and integrated filter without adhesive, for use in tracheostoma heat and moisture exchange system, each | Each | N |
A7520 | TracheOstomy/laryngectomy tube, non-cuffed, polyvinylchloride (PVC), silicone or equal, each | Each | N |
A7521 | Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each | Each | N |
A7522 | Tracheostomy/laryngectomy tube, stainless steel or equal, (sterilizable and reusable), each | Each | N |
A7524 | Tracheostomy stent/stud/button, each | Each | N |
A7525 | Tracheostomy Mask | Each | N |
A7526 | Tracheostomy tube collar/holder, each | Each | N |
A7527 | Tracheostomy/larngectomy tube plug/stop, each | Each | N |
E0424 RR | Stationary compressed gaseous oxygen system, rental, includes container, contents, regulator, flowmeter, humidifier, nebulizer, 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 |
E0430 | Portable Gaseous Oxygen System, purchase, Includes Regulator, flowmeter, humidifier, cannula or mask, and tubing | Each | Y |
E0431 RR | Portable Gaseous Oxygen System, rental, Includes Regulator, flowmeter, humidifier, 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 |
E0431 RR U1 | Portable Gaseous Oxygen System, rental, Includes Regulator, flowmeter, humidifier, 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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