| G0235 | Pet imaging, any site, not otherwise specified |
| L8039 | Breast prosthesis, not otherwise specified |
| Q4100 | Skin substitute, not otherwise specified |
| S9977 | Meals, per diem, not otherwise specified |
| T5999 | Supply, not otherwise specified |
| L0999 | Addition to spinal orthosis, not otherwise specified |
| J0220 | Injection, alglucosidase alfa, 10 mg, not otherwise specified |
| J8498 | Antiemetic drug, rectal/suppository, not otherwise specified |
| J8597 | Antiemetic drug, oral, not otherwise specified |
| V5267 | Hearing aid or assistive listening device/supplies/accessories, not otherwise specified |
| V5274 | Assistive listening device, not otherwise specified |
| V5287 | Assistive listening device, personal fm/dm receiver, not otherwise specified |
| G9699 | Long-acting inhaled bronchodilator not prescribed, reason not otherwise specified |
| A4100 | Skin substitute, fda cleared as a device, not otherwise specified |
| T2032 | Residential care, not otherwise specified (nos), waiver; per month |
| A9153 | Multiple vitamins, with or without minerals and trace elements, oral, per dose, not otherwise specified |
| E1229 | Wheelchair, pediatric size, not otherwise specified |
| L8699 | Prosthetic implant, not otherwise specified |
| G9743 | Psychiatric symptoms not assessed, reason not otherwise specified |
| T2033 | Residential care, not otherwise specified (nos), waiver; per diem |
| A9152 | Single vitamin/mineral/trace element, oral, per dose, not otherwise specified |
| L1499 | Spinal orthosis, not otherwise specified |
| L3999 | Upper limb orthosis, not otherwise specified |
| A6262 | Wound filler, dry form, per gram, not otherwise specified |
| A6261 | Wound filler, gel/paste, per fluid ounce, not otherwise specified |
