HCPCS Range Diagnostic and Therapeutic Radiopharmaceuticals

• 1 Technetium Tc-99m sestamibi, diagnostic, per study dose ( A9500 )

• 2 Technetium Tc-99m teboroxime, diagnostic, per study dose ( A9501 )

• 3 Technetium Tc-99m tetrofosmin, diagnostic, per study dose ( A9502 )

• 4 Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 millicuries ( A9503 )

• 5 Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20 millicuries ( A9504 )

• 6 Thallium Tl-201 thallous chloride, diagnostic, per millicurie ( A9505 )

• 7 Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries ( A9507 )

• 8 Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 millicurie ( A9508 )

• 9 Iodine I-123 sodium iodide, diagnostic, per millicurie ( A9509 )

• 10 Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 millicuries ( A9510 )

• 11 Technetium Tc-99m pertechnetate, diagnostic, per millicurie ( A9512 )

• 12 Iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries ( A9516 )

• 13 Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie ( A9517 )

• 14 Technetium Tc-99m, tilmanocept, diagnostic, up to 0.5 millicuries ( A9520 )

• 15 Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 millicuries ( A9521 )

• 16 Iodine I-131 iodinated serum albumin, diagnostic, per 5 microcuries ( A9524 )

• 17 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries ( A9526 )

• 18 Iodine I-125, sodium iodide solution, therapeutic, per millicurie ( A9527 )

• 19 Iodine I-131 sodium iodide capsule(s), diagnostic, per millicurie ( A9528 )

• 20 Iodine I-131 sodium iodide solution, diagnostic, per millicurie ( A9529 )

• 21 Iodine I-131 sodium iodide solution, therapeutic, per millicurie ( A9530 )

• 22 Iodine I-131 sodium iodide, diagnostic, per microcurie (up to 100 microcuries) ( A9531 )

• 23 Iodine I-125 serum albumin, diagnostic, per 5 microcuries ( A9532 )

• 24 Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35 millicuries ( A9536 )

• 25 Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries ( A9537 )

• 26 Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries ( A9538 )

• 27 Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 millicuries ( A9539 )

• 28 Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 millicuries ( A9540 )

• 29 Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries ( A9541 )

• 30 Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries ( A9542 )

• 31 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries ( A9543 )

• 32 Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 microcurie ( A9546 )

• 33 Indium In-111 oxyquinoline, diagnostic, per 0.5 millicurie ( A9547 )

• 34 Indium In-111 pentetate, diagnostic, per 0.5 millicurie ( A9548 )

• 35 Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 millicurie ( A9550 )

• 36 Technetium Tc-99m succimer, diagnostic, per study dose, up to 10 millicuries ( A9551 )

• 37 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries ( A9552 )

• 38 Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to 250 microcuries ( A9553 )

• 39 Iodine I-125 sodium iothalamate, diagnostic, per study dose, up to 10 microcuries ( A9554 )

• 40 Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries ( A9555 )

• 41 Gallium Ga-67 citrate, diagnostic, per millicurie ( A9556 )

• 42 Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25 millicuries ( A9557 )

• 43 Xenon Xe-133 gas, diagnostic, per 10 millicuries ( A9558 )

• 44 Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 microcurie ( A9559 )

• 45 Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries ( A9560 )

• 46 Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30 millicuries ( A9561 )

• 47 Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries ( A9562 )

• 48 Sodium phosphate P-32, therapeutic, per millicurie ( A9563 )

• 49 Chromic phosphate P-32 suspension, therapeutic, per millicurie ( A9564 )

• 50 Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 25 millicuries ( A9566 )

• 51 Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 millicuries ( A9567 )

• 52 Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 45 millicuries ( A9568 )

• 53 Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose ( A9569 )

• 54 Indium In-111 labeled autologous white blood cells, diagnostic, per study dose ( A9570 )

• 55 Indium In-111 labeled autologous platelets, diagnostic, per study dose ( A9571 )

• 56 Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 millicuries ( A9572 )

• 57 Injection, gadoterate meglumine, 0.1 ml ( A9575 )

• 58 Injection, gadoteridol, (ProHance multipack), per ml ( A9576 )

• 59 Injection, gadobenate dimeglumine (MultiHance), per ml ( A9577 )

• 60 Injection, gadobenate dimeglumine (MultiHance multipack), per ml ( A9578 )

• 61 Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml ( A9579 )

• 62 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries ( A9580 )

• 63 Injection, gadoxetate disodium, 1 ml ( A9581 )

• 64 Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries ( A9582 )

• 65 Injection, gadofosveset trisodium, 1 ml ( A9583 )

• 66 Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries ( A9584 )

• 67 Injection, gadobutrol, 0.1 ml ( A9585 )

• 68 Florbetapir F18, diagnostic, per study dose, up to 10 millicuries ( A9586 )

• 69 Strontium Sr-89 chloride, therapeutic, per millicurie ( A9600 )

• 70 Samarium Sm-153 lexidronam, therapeutic, per treatment dose, up to 150 millicuries ( A9604 )

• 71 Non-radioactive contrast imaging material, not otherwise classified, per study ( A9698 )

• 72 Radiopharmaceutical, therapeutic, not otherwise classified ( A9699 )

• 73 Supply of injectable contrast material for use in echocardiography, per study ( A9700 )

• 74 Choline c-11, diagnostic, per study dose up to 20 millicuries ( A9515 )

• 75 Piflufolastat f-18, diagnostic, 1 millicurie ( A9595 )

• 76 Fluoroestradiol f 18, diagnostic, 1 millicurie ( A9591 )

• 77 Injection, pafolacianine, 0.1 mg ( A9603 )

• 78 Radium Ra-223 dichloride, therapeutic, per microcurie ( A9606 )

• 79 Gallium ga-68, dotatate, diagnostic, 0.1 millicurie ( A9587 )

• 80 Fluciclovine f-18, diagnostic, 1 millicurie ( A9588 )

• 81 Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified ( A9597 )

• 82 Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified ( A9598 )

• 83 Lutetium lu 177, dotatate, therapeutic, 1 millicurie ( A9513 )

• 84 Instillation, hexaminolevulinate hydrochloride, 100 mg ( A9589 )

• 85 Iodine i-131, iobenguane, 1 millicurie ( A9590 )

• 86 Copper cu-64, dotatate, diagnostic, 1 millicurie ( A9592 )

• 87 Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie ( A9593 )

• 88 Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie ( A9594 )

• 89 Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie ( A9596 )

• 90 Flortaucipir f 18 injection, diagnostic, 1 millicurie ( A9601 )

• 91 Fluorodopa f-18, diagnostic, per millicurie ( A9602 )

• 92 Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie ( A9607 )

• 93 Gallium ga-68 gozetotide, diagnostic, (locametz), 1 millicurie ( A9800 )

• 94 Injection, gadopiclenol, 1 ml ( A9573 )

• 95 Injection, carboxydextran-coated superparamagnetic iron oxide, per study dose ( A9697 )

• 96 Flotufolastat f 18, diagnostic, 1 millicurie ( A9608 )

• 97 Fludeoxyglucose f18 up to 15 millicuries ( A9609 )

• 98 Graphite crucible for preparation of technetium tc 99m-labeled carbon aerosol, one crucible ( A9506 )