HCPCS	Descriptor	ALLOWANCE
A4642	"Indium In-111 satumomab pendetide, diagnostic, per study dose up to 6 millicuries"	invoice
A9500	"Technetium Tc-99m sestamibi, diagnostic, per study dose"	$116.28
A9501	"Technetium Tc-99m teboroxime, diagnostic, per study dose"	invoice
A9502	"Technetium Tc-99m tetrofosmin, diagnostic, per study dose"	$462.94
A9503	"Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 mCi"	invoice
A9504	"Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20 mCi"	invoice
A9505	"Thallium Tl-201 thallous chloride, diagnostic, per mCi"	$77.23
A9507	"Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries"	invoice
A9508	"Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 mCi"	invoice
A9509	"Iodine I-123 sodium iodide, diagnostic, per mCi"	invoice
A9510	"Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 mCi"	invoice
A9512	"Technetium Tc-99m pertechnetate, diagnostic, per mCi"	invoice
A9513	"Lutetium Lu 177, dotatate, therapeutic, 1 mCi"	$312.60
A9515	"Choline C-11, diagnostic, per study dose up to 20 mCi"	"$5,700.00"
A9516	"Iodine I-123 sodium iodide, diagnostic, per 100 mcCi, up to 999 mcCi"	invoice
A9517	"Iodine I-131 sodium iodide capsule(s), therapeutic, per mCi"	invoice
A9520	"Technetium Tc-99m, tilmanocept, diagnostic, up to 0.5 mCi"	$669.47
A9521	"Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 mCi"	"$1,742.80"
A9524	"	Iodine I-131 iodinated serum albumin, diagnostic, per 5 mcCi"	$107.35
A9526	"Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 mCi"	invoice
A9527	"Iodine I-125, sodium iodide solution, therapeutic, per mCi"	invoice
A9528	"Iodine I-131 sodium iodide capsule(s), diagnostic, per mCi"	invoice
A9529	"Iodine I-131 sodium iodide solution, diagnostic, per mCi"	invoice
A9530	"Iodine I-131 sodium iodide solution, therapeutic, per mCi"	invoice
A9531	"Iodine I-131 sodium iodide, diagnostic, per mcCi (up to 100 mcCi)"	invoice
A9532	"Iodine I-125 serum albumin, diagnostic, per 5 mcCi"	invoice
A9536	"Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35 mCi"	invoice
A9537	"Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 mCi"	$9.45
A9538	"Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 mCi"	invoice
A9539	"Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 mCi"	invoice
A9540	"Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 mCi"	invoice
A9541	"Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 mCi"	invoice
A9542	"Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 mCi"	invoice
A9543	"Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 mCi"	"$70,418.21"
A9546	"Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 mcCi"	invoice
A9547	"Indium In-111 oxyquinoline, diagnostic, per 0.5 mCi"	"$2,221.92"
A9548	"Indium In-111 pentetate, diagnostic, per 0.5 mCi"	$890.19
A9550	"Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 mCi"	invoice
A9551	"Technetium Tc-99m succimer, diagnostic, per study dose, up to 10 mCi"	"$1,742.78"
A9552	"Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 mCi"	$527.67
A9553	"Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to 250 mcCi"	invoice
A9554	"Iodine I-125 sodium iothalamate, diagnostic, per study dose, up to 10 mcCi"	$33.25
A9555	"Rubidium Rb-82, diagnostic, per study dose, up to 60 mCi"	$412.06
A9556	"Gallium Ga-67 citrate, diagnostic, per mCi"	$50.80
A9557	"Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25 mCi"	invoice
A9558	"Xenon Xe-133 gas, diagnostic, per 10 mCi	"	"253.63
"
A9559	"Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 mcCi"	invoice
A9560	"Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 mCi"	invoice
A9561	"Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30 mCi"	invoice
A9562	"Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 mCi"	invoice
A9563	"Sodium phosphate P-32, therapeutic, per mCi"	invoice
A9564	"Chromic phosphate P-32 suspension, therapeutic, per mCi"	invoice
A9566	"Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 25 mCi"	invoice
A9567	"Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 mCi"	invoice
A9568	"Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 45 mCi"	"$1,235.00"
A9569	"Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose"	invoice
A9570	"Indium In-111 labeled autologous white blood cells, diagnostic, per study dose"	invoice
A9571	"Indium In-111 labeled autologous platelets, diagnostic, per study dose"	invoice
A9572	"Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 mCi"	invoice
A9575	"Injection, gadoterate meglumine, 0.1 ml"	CMS Priced
A9576	"Injection, gadoteridol, (ProHance multipack), per ml"	CMS Priced
A9577	"	Injection, gadobenate dimeglumine (MultiHance), per ml"	CMS Priced
A9578	"Injection, gadobenate dimeglumine (MultiHance multipack), per ml"	CMS Priced
A9579	"Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml"	CMS Priced
A9580	"Sodium fluoride F-18, diagnostic, per study dose, up to 30 mCi"	invoice
A9581	"Injection, gadoxetate disodium, 1 ml"	CMS Priced
A9582	"Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 mCi"	"$5,135.43"
A9583	"Injection, gadofosveset trisodium, 1 ml"	invoice
A9584	"Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 mCi"	"$2,813.52"
A9585	"Injection, gadobutrol, 0.1 ml"	-
A9586	"Florbetapir F18, diagnostic, per study dose, up to 10 mCi"	invoice
A9587	"Gallium Ga-68, dotatate, diagnostic, 0.1 mCi"	$63.33
A9588	"	Fluciclovine F-18, diagnostic, 1 mCi"	invoice
A9589	"Instillation, hexaminolevulinate HCl, 100 mg"	CMS Priced
A9590	"Iodine I-131, iobenguane, 1 mCi"	invoice
A9591	"Fluoroestradiol f 18, diagnostic, 1 mCi"	$762.85
A9592	"Copper Cu-64, dotatate, diagnostic, 1 mCi"	"$4,218.00"
A9593	"Gallium Ga-68 PSMA-11, diagnostic, (UCSF), 1 mCi"	"$1,026.00"
A9594	"Gallium Ga-68 PSMA-11, diagnostic, (UCLA), 1 mCi"	"$1,004.57"
A9595	"	Piflufolastat f-18, diagnostic, 1 mCi"	$624.15
A9596	"Gallium Ga-68 gozetotide, diagnostic, (Illuccix), 1 mCi"	"$1,071.60"
A9597	"Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified"	invoice
A9598	"Positron emission tomography radiopharmaceutical, diagnostic, for nontumor identification, not otherwise classified"	invoice
A9600	"Strontium Sr-89 chloride, therapeutic, per mCi"	"$2,200.10"
A9601	"Flortaucipir F 18 injection, diagnostic, 1 mCi"	invoice
A9602	"Fluorodopa f-18, diagnostic, per mCi"	invoice
A9604	"	Samarium Sm-153 lexidronam, therapeutic, per treatment dose, up to 150 mCi"	"$18,562.49"
A9606	"Radium RA-223 dichloride, therapeutic, per UCI"	$167.81
A9607	"Lutetium Lu 177 vipivotide tetraxetan, therapeutic, 1 mCi"	$247.10
A9698	"Nonradioactive contrast imaging material, not otherwise classified, per study"	invoice
A9699	"Radiopharmaceutical, therapeutic, not otherwise classified"	invoice
A9700	"Supply of injectable contrast material for use in echocardiography, per study"	invoice
A9800	"Gallium Ga-68 gozetotide, diagnostic, (Locametz), 1 mCi"	$939.36
