Code	Description	Effective date start	Effective date end	Allowance																																									
A4642	"Indium In-111 satumomab pendetide, diagnostic, per study dose, up to 6 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9500	"	Technetium Tc-99m sestamibi, diagnostic, per study dose"	1/1/2025	12/31/2025	134.67																																									
A9501	"	Technetium Tc-99m teboroxime, diagnostic, per study dose"	1/1/2025	12/31/2025	INVOICE																																									
A9502	"	Technetium Tc-99m tetrofosmin, diagnostic, per study dose"	1/1/2025	12/31/2025	129.61																																									
A9503	"Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9504	"	Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9505	"Thallium Tl-201 thallous chloride, diagnostic, per mCi"	1/1/2025	12/31/2025	77.23																																									
A9507	"	Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries"	1/1/2025	12/31/2025	INVOICE																																									
A9508	"Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9509	"Iodine I-123 sodium iodide, diagnostic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9510	"Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9512	"Technetium Tc-99m pertechnetate, diagnostic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9513	"	Lutetium Lu 177, dotatate, therapeutic, 1 mCi"	1/1/2025	1/13/2025	"318.61

"																																									
A9513	"	Lutetium Lu 177, dotatate, therapeutic, 1 mCi"	1/14/2025	12/31/2025	"340.91
"																																									
A9515	"Choline C-11, diagnostic, per study dose up to 20 mCi"	1/1/2025	12/31/2025	5700.00																																									
A9516	"Iodine I-123 sodium iodide, diagnostic, per 100 mcCi, up to 999 mcCi"	1/1/2025	12/31/2025	INVOICE																																									
A9517	"	Iodine I-131 sodium iodide capsule(s), therapeutic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9520	"	Technetium Tc-99m, tilmanocept, diagnostic, up to 0.5 mCi"	1/1/2025	12/31/2025	535.42																																									
A9521	"	Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 mCi"	1/1/2025	12/31/2025	1742.80																																									
A9524	"Iodine I-131 iodinated serum albumin, diagnostic, per 5 mcCi"	1/1/2025	12/31/2025	141.09																																									
A9526	"Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9527	"	Iodine I-125, sodium iodide solution, therapeutic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9528	"Iodine I-131 sodium iodide capsule(s), diagnostic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9529	"Iodine I-131 sodium iodide solution, diagnostic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9530	"	Iodine I-131 sodium iodide solution, therapeutic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9531	"	Iodine I-131 sodium iodide, diagnostic, per mcCi (up to 100 mcCi)"	1/1/2025	12/31/2025	INVOICE																																									
A9532	"Iodine I-125 serum albumin, diagnostic, per 5 mcCi"	1/1/2025	12/31/2025	INVOICE																																									
A9536	"Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35 mCi "	1/1/2025	12/31/2025	INVOICE																																									
A9537	"	Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 mCi"	1/1/2025	12/31/2025	9.45																																									
A9538	"Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9539	"Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9540	"	Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9541	"Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9542	"Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9543	"Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 mCi"	10/1/2024	12/31/2025	73939.13																																									
A9546	"Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 mcCi"	1/1/2025	12/31/2025	INVOICE																																									
A9547	"	Indium In-111 oxyquinoline, diagnostic, per 0.5 mCi"	1/1/2025	12/31/2025	2399.68																																									
A9548	"Indium In-111 pentetate, diagnostic, per 0.5 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9550	"	Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9551	"Technetium Tc-99m succimer, diagnostic, per study dose, up to 10 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9552	"	Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9553	"Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to 250 mcCi"	1/1/2025	12/31/2025	INVOICE																																									
A9554	"Iodine I-125 sodium iothalamate, diagnostic, per study dose, up to 10 mcCi"	1/1/2025	12/31/2025	33.25																																									
A9555	"	Rubidium Rb-82, diagnostic, per study dose, up to 60 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9556	"	Gallium Ga-67 citrate, diagnostic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9557	"Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9558	"	Xenon Xe-133 gas, diagnostic, per 10 mCi"	1/1/2025	12/31/2025	290.82																																									
A9559	"	Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 mcCi"	1/1/2025	12/31/2025	INVOICE																																									
A9560	"	Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9561	"Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9562	"Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9563	"	Sodium phosphate P-32, therapeutic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9564	"	Chromic phosphate P-32 suspension, therapeutic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9566	"	Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 25 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9567	"Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9568	"Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 45 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9569	"	Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose"	1/1/2025	12/31/2025	INVOICE																																									
A9570	"	Indium In-111 labeled autologous white blood cells, diagnostic, per study dose"	1/1/2025	12/31/2025	INVOICE																																									
A9571	"	Indium In-111 labeled autologous platelets, diagnostic, per study dose"	1/1/2025	12/31/2025	INVOICE																																									
A9572	"Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9580	"	Sodium fluoride F-18, diagnostic, per study dose, up to 30 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9582	"	Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 mCi"	1/1/2025	12/31/2025	5823.59																																									
A9583	"Injection, gadofosveset trisodium, 1 ml"	1/1/2025	12/31/2025	INVOICE																																									
A9584	"	Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 mCi"	1/1/2025	12/31/2025	2813.52																																									
A9586	"	Florbetapir F18, diagnostic, per study dose, up to 10 mCi"	1/1/2025	12/31/2025	3257.44																																									
A9587	"	Gallium Ga-68, dotatate, diagnostic, 0.1 mCi"	1/1/2025	12/31/2025	63.33																																									
A9588	"	Fluciclovine F-18, diagnostic, 1 mCi"	1/1/2025	12/31/2025	588.98																																									
A9590	"	Iodine I-131, iobenguane, 1 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9591	"	Fluoroestradiol F-18, diagnostic, 1 mCi"	12/1/2024	12/31/2025	876.85																																									
A9592	"	Copper Cu-64, dotatate, diagnostic, 1 mCi"	1/1/2025	12/31/2025	1097.25																																									
A9593	"Gallium Ga-68 PSMA-11, diagnostic, (UCSF), 1 mCi"	1/1/2025	12/31/2025	1241.46																																									
A9594	"Gallium Ga-68 PSMA-11, diagnostic, (UCLA), 1 mCi"	1/1/2025	12/31/2025	1215.52																																									
A9595	"	Piflufolastat F-18, diagnostic, 1 mCi"	1/1/2025	1/31/2025	661.54																																									
A9595	"	Piflufolastat F-18, diagnostic, 1 mCi"	2/1/2025	12/31/2025	701.17																																									
A9596	"Gallium Ga-68 gozetotide, diagnostic, (Illuccix), 1 mCi"	1/1/2025	12/31/2025	1177.85																																									
A9597	"Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified"	1/1/2025	12/31/2025	INVOICE																																									
A9598	"	Positron emission tomography radiopharmaceutical, diagnostic, for nontumor identification, not otherwise classified"	1/1/2025	12/31/2025	INVOICE																																									
A9600	"	Strontium Sr-89 chloride, therapeutic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9601	"	Flortaucipir F 18 injection, diagnostic, 1 mCi"	1/1/2025	12/31/2025	399.00																																									
A9602	"Fluorodopa F-18, diagnostic, per mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9604	"	Samarium Sm-153 lexidronam, therapeutic, per treatment dose, up to 150 mCi"	1/1/2025	12/31/2025	18562.49																																									
A9606	"	Radium RA-223 dichloride, therapeutic, per UCI"	7/1/2024	12/31/2025	187.07																																									
A9607	"	Lutetium Lu 177 vipivotide tetraxetan, therapeutic, 1 mCi"	1/1/2025	1/13/2025	"259.45

"																																									
A9607	"	Lutetium Lu 177 vipivotide tetraxetan, therapeutic, 1 mCi"	1/14/2025	12/31/2025	277.61																																									
A9608	"	Flotufolastat F18, diagnostic, 1 mCi"	1/1/2025	12/31/2025	721.88																																									
A9609	"	Fludeoxyglucose F18, up to 15 mCi"	1/1/2025	12/31/2025	INVOICE																																									
A9698	"	Nonradioactive contrast imaging material, not otherwise classified, per study"	1/1/2025	12/31/2025	INVOICE																																									
A9699	"	Radiopharmaceutical, therapeutic, not otherwise classified"	1/1/2025	12/31/2025	INVOICE																																									
A9700	"Supply of injectable contrast material for use in echocardiography, per study"	1/1/2025	12/31/2025	INVOICE																																									
A9800	"Gallium Ga-68 gozetotide, diagnostic, (Locametz), 1 mCi"	1/1/2025	12/31/2025	"939.36

"																																									
A9603	"	Injection, pafolacianine, 0.1 mg"	1/1/2025	12/31/2025	INVOICE																																									
A9697	"	Injection, carboxydextran-coated superparamagnetic iron oxide, per study dose"	1/1/2025	12/31/2025	INVOICE																																									
