Diagnostics
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 16714055601 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 16714099701 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 23155025831 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 23155025832 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 25021031802 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 25021031804 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 55150019201 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 55150019301 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 63323065100 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 63323065101 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 63323065102 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 63323065104 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 63323065120 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 63323065130 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 67457085400 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 67457085404 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 67457085500 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 67457085502 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 67457085620 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 67457085730 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 71288020720 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 71288020721 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 71288020830 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 72078003300 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 72078003302 | ADENOSINE | adenosine | VIAL | 3 mg/mL | Y | |||
| 59137023101 | GLEOLAN | aminolevulinic acid HCl | SOLN RECON | 30 mg/mL | Y | |||
| 00224062306 | EPI-STAT-57 | barium sulfate | ORAL SUSP | 57 % | Y | |||
| 00224062307 | EPI-STAT-57 | barium sulfate | ORAL SUSP | 57 % | Y | |||
| 00224062319 | EPI-STAT-57 | barium sulfate | ORAL SUSP | 57 % | Y | |||
| 00224062406 | EPI-STAT-61 | barium sulfate | ORAL SUSP | 61 % | Y | |||
| 00224062407 | EPI-STAT-61 | barium sulfate | ORAL SUSP | 61 % | Y | |||
| 00224062419 | EPI-STAT-61 | barium sulfate | ORAL SUSP | 61 % | Y | |||
| 00224062106 | BAROSPERSE | barium sulfate | POWDER | 95 % | Y | |||
| 00224062690 | BAROSPERSE-110 | barium sulfate | POWDER | 95 % | Y | |||
| 53885029901 | ONE TOUCH/ONE TOUCH II | blood sugar diagnostic | KIT | Y | N | |||
| 69945006401 | DETECTNET | copper Cu-64 dotatate | VIAL | 148 MBq/4 mL (4 mCi/4 mL) | Y | |||
| 31722001912 | DIATRIZOATE MEGLUMINE-SODIUM | diatrizoate meglumine, sodium | SOLUTION | 66 %-10 % | Y | |||
| 31722001930 | DIATRIZOATE MEGLUMINE-SODIUM | diatrizoate meglumine, sodium | SOLUTION | 66 %-10 % | Y | |||
| 31722001931 | DIATRIZOATE MEGLUMINE-SODIUM | diatrizoate meglumine, sodium | SOLUTION | 66 %-10 % | Y | |||
| 31722001932 | DIATRIZOATE MEGLUMINE-SODIUM | diatrizoate meglumine, sodium | SOLUTION | 66 %-10 % | Y | |||
| 00409204302 | DIPYRIDAMOLE | dipyridamole | AMPUL | 5 mg/mL | Y | |||
| 11994000525 | PERSANTINE I.V. | dipyridamole | AMPUL | 5 mg/mL | Y | |||
| 00641256941 | DIPYRIDAMOLE | dipyridamole | VIAL | 5 mg/mL | Y | |||
| 00641256944 | DIPYRIDAMOLE | dipyridamole | VIAL | 5 mg/mL | Y | |||
| 59338070355 | FERIDEX I.V. | ferumoxides | VIAL | 11.2 mg iron/mL | Y | |||
| 24338031010 | FERABRIGHT | ferumoxytol | VIAL | 300 mg/10 mL (31 nm to 43 nm) | Y | |||
| 24338051017 | FERABRIGHT | ferumoxytol | VIAL | 510 mg/17 mL (31 nm to 43 nm) | Y | |||
| 54828000101 | NEURACEQ | florbetaben F-18 | VIAL | 8.1 mCi (300 MBq) | Y | |||
| 54828000150 | NEURACEQ | florbetaben F-18 | VIAL | 8.1 mCi (300 MBq) | Y | |||
| 00002120001 | AMYVID | florbetapir F-18 | VIAL | 10 mCi (370 MBq) | Y | |||
| 00002120048 | AMYVID | florbetapir F-18 | VIAL | 10 mCi (370 MBq) | Y | |||
| 00002120050 | AMYVID | florbetapir F-18 | VIAL | 10 mCi (370 MBq) | Y | |||
| 74725033830 | PIXCLARA | floretyrosine F-18 | VIAL | 185 MBq/mL to 11,100 MBq/mL (5 mCi/mL to 300 mCi/mL) | Y | |||
| 00002122001 | TAUVID PATIENT READY DOSE | flortaucipir F-18 | VIAL | 370 MBq (10 mCi) | Y | |||
| 69932000201 | POSLUMA | flotufolastat F 18 gallium | VIAL | 296 MBq/mL to 5,846 MBq/mL (8 mCi/mL to 158 mCi/mL) | Y | |||
| 69932000250 | POSLUMA | flotufolastat F 18 gallium | VIAL | 296 MBq/mL to 5,846 MBq/mL (8 mCi/mL to 158 mCi/mL) | Y | |||
| 69932000101 | AXUMIN | fluciclovine F-18 | VIAL | 10 mCi (370 MBq) | Y | |||
| 69932000130 | AXUMIN | fluciclovine F-18 | VIAL | 10 mCi (370 MBq) | Y | |||
| 69932000150 | AXUMIN | fluciclovine F-18 | VIAL | 10 mCi (370 MBq) | Y | |||
| 00065078112 | FLUORESCEIN SODIUM | fluorescein sodium | DROPS | 2 % | Y | |||
| 51801000301 | GLOSTRIPS | fluorescein sodium | STRIP | 0.6 mg | Y | |||
| 51801000340 | GLOSTRIPS | fluorescein sodium | STRIP | 0.6 mg | Y | |||
| 51801000350 | GLOSTRIPS | fluorescein sodium | STRIP | 0.6 mg | Y | |||
| 24208039183 | FLUOR-I-STRIP AT | fluorescein sodium | STRIP | 1 mg | Y | |||
| 51801000901 | GLOSTRIPS | fluorescein sodium | STRIP | 1 mg | Y | |||
| 51801000940 | GLOSTRIPS | fluorescein sodium | STRIP | 1 mg | Y | |||
| 14789012305 | FLUORESCEIN SODIUM | fluorescein sodium | VIAL | 500 mg/2 mL (25 %) | Y | |||
| 14789012307 | FLUORESCEIN SODIUM | fluorescein sodium | VIAL | 500 mg/2 mL (25 %) | Y | |||
| 81298866001 | AK-FLUOR | fluorescein sodium | VIAL | 500 mg/5 mL (10 %) | Y | |||
| 81298866003 | AK-FLUOR | fluorescein sodium | VIAL | 500 mg/5 mL (10 %) | Y | |||
| 14789012205 | FLUORESCEIN SODIUM | fluorescein sodium | VIAL | 500 mg/5 mL (10 %) | Y | |||
| 14789012207 | FLUORESCEIN SODIUM | fluorescein sodium | VIAL | 500 mg/5 mL (10 %) | Y | |||
| 70710204501 | FLUORESCEIN SODIUM | fluorescein sodium | VIAL | 500 mg/5 mL (10 %) | Y | |||
| 70710204509 | FLUORESCEIN SODIUM | fluorescein sodium | VIAL | 500 mg/5 mL (10 %) | Y | |||
| 00065009265 | FLUORESCITE | fluorescein sodium | VIAL | 500 mg/5 mL (10 %) | Y | |||
| 72874000101 | CERIANNA | fluoroestradiol F-18 | VIAL | 148 MBq/mL to 3,700 MBq/mL (4 mCi/mL to 100 mCi/mL) | Y | |||
| 00407878701 | FLYRCADO | flurpiridaz F-18 | VIAL | 190 MBq/mL to 2,050 MBq/mL (5 mCi/mL to 55 mCi/mL) | Y | |||
| 17156006730 | VIZAMYL | flutemetamol F-18 | VIAL | 185 MBq (5 mCi) | Y | |||
| 50419032528 | GADAVIST | gadobutrol | SYRINGE | 10 mmol/10 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032529 | GADAVIST | gadobutrol | SYRINGE | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032521 | GADAVIST | gadobutrol | SYRINGE | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032527 | GADAVIST | gadobutrol | SYRINGE | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032508 | GADAVIST | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 50419032509 | GADAVIST | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 50419032514 | GADAVIST | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 50419032515 | GADAVIST | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 50419032518 | GADAVIST | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 50419032519 | GADAVIST | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 65219028710 | GADOBUTROL | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 65219028730 | GADOBUTROL | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 65219028910 | GADOBUTROL | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 65219028965 | GADOBUTROL | gadobutrol | VIAL | 1 mmol/mL (604.72 mg/mL) | Y | |||
| 50419032502 | GADAVIST | gadobutrol | VIAL | 10 mmol/10 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032512 | GADAVIST | gadobutrol | VIAL | 10 mmol/10 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 65219028108 | GADOBUTROL | gadobutrol | VIAL | 10 mmol/10 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 65219028110 | GADOBUTROL | gadobutrol | VIAL | 10 mmol/10 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70710206501 | GADOBUTROL | gadobutrol | VIAL | 10 mmol/10 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70710206506 | GADOBUTROL | gadobutrol | VIAL | 10 mmol/10 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 00407106610 | PIXXOSCAN | gadobutrol | VIAL | 10 mmol/10 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032503 | GADAVIST | gadobutrol | VIAL | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032513 | GADAVIST | gadobutrol | VIAL | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 65219028105 | GADOBUTROL | gadobutrol | VIAL | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 65219028115 | GADOBUTROL | gadobutrol | VIAL | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70436021434 | GADOBUTROL | gadobutrol | VIAL | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70436021454 | GADOBUTROL | gadobutrol | VIAL | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70710206601 | GADOBUTROL | gadobutrol | VIAL | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70710206606 | GADOBUTROL | gadobutrol | VIAL | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 00407106615 | PIXXOSCAN | gadobutrol | VIAL | 15 mmol/15 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032507 | GADAVIST | gadobutrol | VIAL | 2 mmol/2 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032537 | GADAVIST | gadobutrol | VIAL | 2 mmol/2 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 65219028100 | GADOBUTROL | gadobutrol | VIAL | 2 mmol/2 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 65219028102 | GADOBUTROL | gadobutrol | VIAL | 2 mmol/2 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 00407106602 | PIXXOSCAN | gadobutrol | VIAL | 2 mmol/2 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032501 | GADAVIST | gadobutrol | VIAL | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 50419032511 | GADAVIST | gadobutrol | VIAL | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 65219028103 | GADOBUTROL | gadobutrol | VIAL | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 65219028107 | GADOBUTROL | gadobutrol | VIAL | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70436021232 | GADOBUTROL | gadobutrol | VIAL | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70436021254 | GADOBUTROL | gadobutrol | VIAL | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70710206401 | GADOBUTROL | gadobutrol | VIAL | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 70710206406 | GADOBUTROL | gadobutrol | VIAL | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 00407106608 | PIXXOSCAN | gadobutrol | VIAL | 7.5 mmol/7.5 mL (1 mmol/mL = 604.72 mg/mL) | Y | |||
| 00407069020 | OMNISCAN | gadodiamide | VIAL | 10 mmol/20 mL (287 mg/mL) | Y | |||
| 00407069010 | OMNISCAN | gadodiamide | VIAL | 5 mmol/10 mL (287 mg/mL) | Y | |||
| 00407069015 | OMNISCAN | gadodiamide | VIAL | 7.5 mmol/15 mL (287 mg/mL) | Y | |||
| 50419033001 | AMBELVIST | gadoquatrane | SYRINGE | 0.75 mmol/7.5 mL (0.1 mmol/mL) | Y | |||
| 50419033011 | AMBELVIST | gadoquatrane | SYRINGE | 0.75 mmol/7.5 mL (0.1 mmol/mL) | Y | |||
| 50419033101 | AMBELVIST | gadoquatrane | SYRINGE | 1 mmol/10 mL (0.1 mmol/mL) | Y | |||
| 50419033111 | AMBELVIST | gadoquatrane | SYRINGE | 1 mmol/10 mL (0.1 mmol/mL) | Y | |||
| 50419033201 | AMBELVIST | gadoquatrane | SYRINGE | 1.5 mmol/15 mL (0.1 mmol/mL) | Y | |||
| 50419033211 | AMBELVIST | gadoquatrane | SYRINGE | 1.5 mmol/15 mL (0.1 mmol/mL) | Y | |||
| 50419032101 | AMBELVIST | gadoquatrane | VIAL | 0.2 mmol/2 mL (0.1 mmol/mL) | Y | |||
| 50419032111 | AMBELVIST | gadoquatrane | VIAL | 0.2 mmol/2 mL (0.1 mmol/mL) | Y | |||
| 50419032201 | AMBELVIST | gadoquatrane | VIAL | 0.75 mmol/7.5 mL (0.1 mmol/mL) | Y | |||
| 50419032211 | AMBELVIST | gadoquatrane | VIAL | 0.75 mmol/7.5 mL (0.1 mmol/mL) | Y | |||
| 50419032301 | AMBELVIST | gadoquatrane | VIAL | 1 mmol/10 mL (0.1 mmol/mL) | Y | |||
| 50419032311 | AMBELVIST | gadoquatrane | VIAL | 1 mmol/10 mL (0.1 mmol/mL) | Y | |||
| 50419032401 | AMBELVIST | gadoquatrane | VIAL | 1.5 mmol/15 mL (0.1 mmol/mL) | Y | |||
| 50419032411 | AMBELVIST | gadoquatrane | VIAL | 1.5 mmol/15 mL (0.1 mmol/mL) | Y | |||
| 50419032601 | AMBELVIST | gadoquatrane | VIAL | 3 mmol/30 mL (0.1 mmol/mL) | Y | |||
| 50419032611 | AMBELVIST | gadoquatrane | VIAL | 3 mmol/30 mL (0.1 mmol/mL) | Y | |||
| 50419032801 | AMBELVIST | gadoquatrane | VIAL | 3 mmol/30 mL (0.1 mmol/mL) | Y | |||
| 50419032811 | AMBELVIST | gadoquatrane | VIAL | 3 mmol/30 mL (0.1 mmol/mL) | Y | |||
| 50419032701 | AMBELVIST | gadoquatrane | VIAL | 6.5 mmol/65 mL (0.1 mmol/mL) | Y | |||
| 50419032711 | AMBELVIST | gadoquatrane | VIAL | 6.5 mmol/65 mL (0.1 mmol/mL) | Y | |||
| 50419032901 | AMBELVIST | gadoquatrane | VIAL | 6.5 mmol/65 mL (0.1 mmol/mL) | Y | |||
| 50419032911 | AMBELVIST | gadoquatrane | VIAL | 6.5 mmol/65 mL (0.1 mmol/mL) | Y | |||
| 00407294322 | CLARISCAN | gadoterate meglumine | SYRINGE | 10 mmol/20 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 00407294312 | CLARISCAN | gadoterate meglumine | SYRINGE | 5 mmol/10 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 00407294317 | CLARISCAN | gadoterate meglumine | SYRINGE | 7.5 mmol/15 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 00407294305 | CLARISCAN | gadoterate meglumine | VIAL | 10 mmol/20 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008601 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 10 mmol/20 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008620 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 10 mmol/20 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 70436012335 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 10 mmol/20 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 00407294306 | CLARISCAN | gadoterate meglumine | VIAL | 2.5 mmol/5 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008001 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 2.5 mmol/5 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008005 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 2.5 mmol/5 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 70436012331 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 2.5 mmol/5 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 00407294301 | CLARISCAN | gadoterate meglumine | VIAL | 5 mmol/10 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008201 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 5 mmol/10 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008210 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 5 mmol/10 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 70436012333 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 5 mmol/10 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 00407294370 | CLARISCAN | gadoterate meglumine | VIAL | 50 mmol/100 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008806 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 50 mmol/100 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008850 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 50 mmol/100 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 70436012340 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 50 mmol/100 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 70436012356 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 50 mmol/100 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 00407294302 | CLARISCAN | gadoterate meglumine | VIAL | 7.5 mmol/15 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008401 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 7.5 mmol/15 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 65219008415 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 7.5 mmol/15 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 70436012334 | GADOTERATE MEGLUMINE | gadoterate meglumine | VIAL | 7.5 mmol/15 mL (0.5 mmol/mL = 376.9 mg/mL) | Y | |||
| 70436012131 | GADOTERIDOL | gadoteridol | VIAL | 279.3 mg/mL | Y | |||
| 70436012133 | GADOTERIDOL | gadoteridol | VIAL | 279.3 mg/mL | Y | |||
| 70436012134 | GADOTERIDOL | gadoteridol | VIAL | 279.3 mg/mL | Y | |||
| 70436012135 | GADOTERIDOL | gadoteridol | VIAL | 279.3 mg/mL | Y | |||
| 50419032005 | EOVIST | gadoxetate disodium | VIAL | 2.5 mmol/10 mL (181.43 mg/mL) | Y | |||
| 50419032015 | EOVIST | gadoxetate disodium | VIAL | 3.75 mmol/15 mL (181.43 mg/mL) | Y | |||
| 69945018006 | GALLIUM CITRATE GA-67 | gallium-67 citrate | VIAL | 74 MBq/mL (2 mCi/mL) | Y | |||
| 69945018012 | GALLIUM CITRATE GA-67 | gallium-67 citrate | VIAL | 74 MBq/mL (2 mCi/mL) | Y | |||
| 00517290101 | GVOKE VIALDX | glucagon | VIAL | 1 mg/0.2 mL | Y | |||
| 00517290110 | GVOKE VIALDX | glucagon | VIAL | 1 mg/0.2 mL | Y | |||
| 25021084005 | BLUDIGO | indigotindisulfonate sodium | AMPUL | 8 mg/mL (0.8 %) | Y | |||
| 81284031500 | BLUDIGO | indigotindisulfonate sodium | AMPUL | 8 mg/mL (0.8 %) | Y | |||
| 81284031505 | BLUDIGO | indigotindisulfonate sodium | AMPUL | 8 mg/mL (0.8 %) | Y | |||
| 17156002101 | INDIUM IN-111 OXYQUINOLINE | indium In-111 oxyquinoline | VIAL | 1 mCi/mL (37 MBq/mL) (1 mL) | Y | |||
| 45567075503 | INDIUM IN-111 CL-PENTETREOTIDE | indium-111 chlor/pentetreotide | KIT | 3 mCi/mL-10 mcg | Y | |||
| 69945005040 | OCTREOSCAN | indium-111 chlor/pentetreotide | KIT | 3 mCi/mL-10 mcg | Y | |||
| 69945013206 | INDIUM IN-111 CHLORIDE | indium-111 chloride | VIAL | 5 mCi/0.5 mL (185 MBq) | Y | |||
| 25021084110 | ZYOGREEN | indocyanine green | AMPUL | 25 mg/10 mL (2.5 mg/mL) | Y | |||
| 70710201803 | INDOCYANINE GREEN | indocyanine green | VIAL | 25 mg | Y | |||
| 70710203101 | INDOCYANINE GREEN | indocyanine green | VIAL | 25 mg | Y | |||
| 17156023501 | ADREVIEW | iobenguane sulfate I-123 | VIAL | 10 mCi/5 mL (370 MBq/5 mL) | Y | |||
| 65219038103 | IODIXANOL | iodixanol | INFUS. BTL | 270 mg iodine/mL | Y | |||
| 65219038105 | IODIXANOL | iodixanol | INFUS. BTL | 270 mg iodine/mL | Y | |||
| 65219038110 | IODIXANOL | iodixanol | INFUS. BTL | 270 mg iodine/mL | Y | |||
| 65219038150 | IODIXANOL | iodixanol | INFUS. BTL | 270 mg iodine/mL | Y | |||
| 00407222216 | VISIPAQUE | iodixanol | INFUS. BTL | 270 mg iodine/mL | Y | |||
| 00407222217 | VISIPAQUE | iodixanol | INFUS. BTL | 270 mg iodine/mL | Y | |||
| 00407222219 | VISIPAQUE | iodixanol | INFUS. BTL | 270 mg iodine/mL | Y | |||
| 00407222221 | VISIPAQUE | iodixanol | INFUS. BTL | 270 mg iodine/mL | Y | |||
| 65219038302 | IODIXANOL | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 65219038304 | IODIXANOL | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 65219038305 | IODIXANOL | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 65219038306 | IODIXANOL | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 65219038308 | IODIXANOL | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 65219038310 | IODIXANOL | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 65219038350 | IODIXANOL | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 65219038370 | IODIXANOL | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 00407222316 | VISIPAQUE | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 00407222317 | VISIPAQUE | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 00407222319 | VISIPAQUE | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 00407222321 | VISIPAQUE | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 00407222323 | VISIPAQUE | iodixanol | INFUS. BTL | 320 mg iodine/mL | Y | |||
| 17156021001 | DATSCAN | ioflupane I 123 | VIAL | 5 mCi/2.5 mL (185 MBq/2.5 mL) | Y | |||
| 69945016605 | IOFLUPANE I-123 | ioflupane I 123 | VIAL | 5 mCi/2.5 mL (185 MBq/2.5 mL) | Y | |||
| 00407140152 | OMNIPAQUE | iohexol | INFUS. BTL | 140 mg iodine/mL | Y | |||
| 00407141227 | OMNIPAQUE | iohexol | INFUS. BTL | 240 mg iodine/mL | Y | |||
| 00407141228 | OMNIPAQUE | iohexol | INFUS. BTL | 240 mg iodine/mL | Y | |||
| 00407141230 | OMNIPAQUE | iohexol | INFUS. BTL | 240 mg iodine/mL | Y | |||
| 00407141233 | OMNIPAQUE | iohexol | INFUS. BTL | 240 mg iodine/mL | Y | |||
| 00407141282 | OMNIPAQUE | iohexol | INFUS. BTL | 240 mg iodine/mL | Y | |||
| 80830246701 | IOHEXOL | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 80830246702 | IOHEXOL | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 80830246801 | IOHEXOL | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 80830246802 | IOHEXOL | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 00407141355 | OMNIPAQUE | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 00407141356 | OMNIPAQUE | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 00407141359 | OMNIPAQUE | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 00407141361 | OMNIPAQUE | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 00407141363 | OMNIPAQUE | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 00407141365 | OMNIPAQUE | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 00407141372 | OMNIPAQUE | iohexol | INFUS. BTL | 300 mg iodine/mL | Y | |||
| 00407141472 | OMNIPAQUE | iohexol | INFUS. BTL | 350 mg iodine/mL | Y | |||
| 00407141489 | OMNIPAQUE | iohexol | INFUS. BTL | 350 mg iodine/mL | Y | |||
| 00407141490 | OMNIPAQUE | iohexol | INFUS. BTL | 350 mg iodine/mL | Y | |||
| 00407141491 | OMNIPAQUE | iohexol | INFUS. BTL | 350 mg iodine/mL | Y | |||
| 00407141493 | OMNIPAQUE | iohexol | INFUS. BTL | 350 mg iodine/mL | Y | |||
| 00407141494 | OMNIPAQUE | iohexol | INFUS. BTL | 350 mg iodine/mL | Y | |||
| 00407141270 | OMNIPAQUE | iohexol | PLAST. BAG | 240 mg iodine/mL | Y | |||
| 00407141275 | OMNIPAQUE | iohexol | PLAST. BAG | 240 mg iodine/mL | Y | |||
| 00407141285 | OMNIPAQUE | iohexol | PLAST. BAG | 240 mg iodine/mL | Y | |||
| 00407141286 | OMNIPAQUE | iohexol | PLAST. BAG | 240 mg iodine/mL | Y | |||
| 00407141344 | OMNIPAQUE | iohexol | PLAST. BAG | 300 mg iodine/mL | Y | |||
| 00407141380 | OMNIPAQUE | iohexol | PLAST. BAG | 300 mg iodine/mL | Y | |||
| 00407141612 | OMNIPAQUE | iohexol | SOLUTION | 12 mg iodine/mL | Y | |||
| 00407141509 | OMNIPAQUE | iohexol | SOLUTION | 9 mg iodine/mL | Y | |||
| 00407141110 | OMNIPAQUE | iohexol | VIAL | 180 mg iodine/mL | Y | |||
| 00407141210 | OMNIPAQUE | iohexol | VIAL | 240 mg iodine/mL | Y | |||
| 00407141220 | OMNIPAQUE | iohexol | VIAL | 240 mg iodine/mL | Y | |||
| 00407141283 | OMNIPAQUE | iohexol | VIAL | 240 mg iodine/mL | Y | |||
| 00407141310 | OMNIPAQUE | iohexol | VIAL | 300 mg iodine/mL | Y | |||
| 00407141340 | OMNIPAQUE | iohexol | VIAL | 300 mg iodine/mL | Y | |||
| 00074753123 | IOPAMIDOL | iopamidol | INFUS. BTL | 300 mg iodine/mL (61 %) | Y | |||
| 00074753124 | IOPAMIDOL | iopamidol | INFUS. BTL | 300 mg iodine/mL (61 %) | Y | |||
| 70436012433 | IOPAMIDOL | iopamidol | VIAL | 200 mg iodine/mL (41 %) | Y | |||
| 70436012435 | IOPAMIDOL | iopamidol | VIAL | 200 mg iodine/mL (41 %) | Y | |||
| 70436012452 | IOPAMIDOL | iopamidol | VIAL | 200 mg iodine/mL (41 %) | Y | |||
| 70436012482 | IOPAMIDOL | iopamidol | VIAL | 200 mg iodine/mL (41 %) | Y | |||
| 70436021137 | IOPAMIDOL | iopamidol | VIAL | 200 mg iodine/mL (41 %) | Y | |||
| 70436012537 | IOPAMIDOL | iopamidol | VIAL | 250 mg iodine/mL (51 %) | Y | |||
| 70436012582 | IOPAMIDOL | iopamidol | VIAL | 250 mg iodine/mL (51 %) | Y | |||
| 70436012634 | IOPAMIDOL | iopamidol | VIAL | 300 mg iodine/mL (61 %) | Y | |||
| 70436012682 | IOPAMIDOL | iopamidol | VIAL | 300 mg iodine/mL (61 %) | Y | |||
| 70436021936 | IOPAMIDOL | iopamidol | VIAL | 300 mg iodine/mL (61 %) | Y | |||
| 70436021937 | IOPAMIDOL | iopamidol | VIAL | 300 mg iodine/mL (61 %) | Y | |||
| 70436021940 | IOPAMIDOL | iopamidol | VIAL | 300 mg iodine/mL (61 %) | Y | |||
| 70436021952 | IOPAMIDOL | iopamidol | VIAL | 300 mg iodine/mL (61 %) | Y | |||
| 70436021962 | IOPAMIDOL | iopamidol | VIAL | 300 mg iodine/mL (61 %) | Y | |||
| 70436021982 | IOPAMIDOL | iopamidol | VIAL | 300 mg iodine/mL (61 %) | Y | |||
| 70436012740 | IOPAMIDOL | iopamidol | VIAL | 370 mg iodine/mL (76 %) | Y | |||
| 70436012782 | IOPAMIDOL | iopamidol | VIAL | 370 mg iodine/mL (76 %) | Y | |||
| 50419034215 | ULTRAVIST | iopromide | VIAL | 240 mg iodine/mL | Y | |||
| 50419034220 | ULTRAVIST | iopromide | VIAL | 240 mg iodine/mL | Y | |||
| 50419034405 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034410 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034412 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034415 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034421 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034422 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034423 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034450 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034458 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034460 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034461 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034463 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034464 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034465 | ULTRAVIST | iopromide | VIAL | 300 mg iodine/mL | Y | |||
| 50419034605 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034610 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034615 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034620 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034625 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034627 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034628 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034633 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034650 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034658 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034660 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034661 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034662 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034665 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034813 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 50419034820 | ULTRAVIST | iopromide | VIAL | 370 mg iodine/mL | Y | |||
| 72078006901 | ISOSULFAN BLUE | isosulfan blue | SYRINGE | 1 % (10 mg/mL) | Y | |||
| 72078007003 | ISOSULFAN BLUE | isosulfan blue | SYRINGE | 1 % (30 mg/3 mL) | Y | |||
| 67457022000 | ISOSULFAN BLUE | isosulfan blue | VIAL | 1 % (10 mg/mL) | Y | |||
| 67457022005 | ISOSULFAN BLUE | isosulfan blue | VIAL | 1 % (10 mg/mL) | Y | |||
| 67457058600 | ISOSULFAN BLUE | isosulfan blue | VIAL | 1 % (10 mg/mL) | Y | |||
| 67457058605 | ISOSULFAN BLUE | isosulfan blue | VIAL | 1 % (10 mg/mL) | Y | |||
| 72205019501 | ISOSULFAN BLUE | isosulfan blue | VIAL | 1 % (10 mg/mL) | Y | |||
| 72205019502 | ISOSULFAN BLUE | isosulfan blue | VIAL | 1 % (10 mg/mL) | Y | |||
| 73043009301 | ISOSULFAN BLUE | isosulfan blue | VIAL | 1 % (10 mg/mL) | Y | |||
| 73043009306 | ISOSULFAN BLUE | isosulfan blue | VIAL | 1 % (10 mg/mL) | Y | |||
| 69488000140 | NETSPOT | kit for prep of Ga 68/dotatate | VIAL | 40 mcg | Y | |||
| 69945013910 | PULMOTECH MAA | kit for prep of Tc-99m/albumin | VIAL | 2 mg | Y | |||
| 69945013920 | PULMOTECH MAA | kit for prep of Tc-99m/albumin | VIAL | 2 mg | Y | |||
| 69945013940 | PULMOTECH MAA | kit for prep of Tc-99m/albumin | VIAL | 2 mg | Y | |||
| 45567045501 | TC99M MEBROFENIN PREP | kit for prep Tc-99m/mebrofenin | VIAL | 45 mg | Y | |||
| 45567045502 | TC99M MEBROFENIN PREP | kit for prep Tc-99m/mebrofenin | VIAL | 45 mg | Y | |||
| 17156002405 | MYOVIEW | kit for prep Tc-99m/tetrofosmn | VIAL | 0.23 mg | Y | |||
| 17156002630 | MYOVIEW | kit for prep Tc-99m/tetrofosmn | VIAL | 1.38 mg | Y | |||
| 11994000100 | CARDIOLITE | kit for Tc 99m/sestamibi no.1 | SYRINGE | Y | ||||
| 11994000120 | CARDIOLITE | kit for Tc 99m/sestamibi no.1 | VIAL | Y | ||||
| 11994000155 | CARDIOLITE | kit for Tc 99m/sestamibi no.1 | VIAL | Y | ||||
| 11994000320 | TC99M SESTAMIBI PREP | kit for Tc 99m/sestamibi no.1 | VIAL | Y | ||||
| 45567055501 | TC99M SESTAMIBI PREP | kit for Tc 99m/sestamibi no.1 | VIAL | Y | ||||
| 45567055502 | TC99M SESTAMIBI PREP | kit for Tc 99m/sestamibi no.1 | VIAL | Y | ||||
| 69945009220 | TC99M SESTAMIBI PREP | kit for Tc 99m/sestamibi no.1 | VIAL | Y | ||||
| 69945009240 | TC99M SESTAMIBI PREP | kit for Tc 99m/sestamibi no.1 | VIAL | Y | ||||
| 45567003001 | TC 99M SULFUR COLLOID PREP | kit for Tc 99m/sod thiosulfate | VIAL | 2 mg | Y | |||
| 69945006810 | ULTRATAG RBC | kit for Tc-99m-labeled RBCs | VIAL | Y | ||||
| 69945006820 | ULTRATAG RBC | kit for Tc-99m-labeled RBCs | VIAL | Y | ||||
| 11994000602 | NEUROLITE | kit for Tc-99m/bicisate di-HCl | VIAL | 0.9 mg | Y | |||
| 11994000605 | NEUROLITE | kit for Tc-99m/bicisate di-HCl | VIAL | 0.9 mg | Y | |||
| 45567004001 | TC99M MEDRONATE PREP | kit for Tc-99m/medronate sod | VIAL | 20 mg | Y | |||
| 45567004002 | TC99M MEDRONATE PREP | kit for Tc-99m/medronate sod | VIAL | 20 mg | Y | |||
| 69945009120 | TECHNESCAN HDP | kit for Tc-99m/sod oxidronate | VIAL | 3.15 mg | Y | |||
| 69945009140 | TECHNESCAN HDP | kit for Tc-99m/sod oxidronate | VIAL | 3.15 mg | Y | |||
| 69945009420 | TECHNESCAN PYP | kit for Tc-99m/sod pyrophospht | VIAL | 11.9 mg | Y | |||
| 45567006001 | TC99M PYROPHOSPHATE PREP | kit for Tc-99m/sod pyrophospht | VIAL | 12 mg | Y | |||
| 45567006002 | TC99M PYROPHOSPHATE PREP | kit for Tc-99m/sod pyrophospht | VIAL | 12 mg | Y | |||
| 84552050025 | GOZELLIX | kit prep of Ga-68/gozetotide | VIAL | 25 mcg | Y | |||
| 84552050064 | GOZELLIX | kit prep of Ga-68/gozetotide | VIAL | 25 mcg | Y | |||
| 74725010025 | ILLUCCIX | kit prep of Ga-68/gozetotide | VIAL | 25 mcg | Y | |||
| 74725010064 | ILLUCCIX | kit prep of Ga-68/gozetotide | VIAL | 25 mcg | Y | |||
| 00078122461 | LOCAMETZ | kit prep of Ga-68/gozetotide | VIAL | 25 mcg | Y | |||
| 69945031401 | TC99M PENTETATE PREP | kit prep Tc 99m/pentetic acid | VIAL | 20 mg | Y | |||
| 69945031405 | TC99M PENTETATE PREP | kit prep Tc 99m/pentetic acid | VIAL | 20 mg | Y | |||
| 69945031430 | TC99M PENTETATE PREP | kit prep Tc 99m/pentetic acid | VIAL | 20 mg | Y | |||
| 17156002205 | CERETEC | kit prep Tc-99m/exametazime | VIAL | 0.5 mg | Y | |||
| 45567065501 | TC99M MERTIATIDE PREP | kit Tc-99m/mertiatide (betiat) | VIAL | 1 mg | Y | |||
| 69945009620 | TECHNESCAN MAG3 | kit Tc-99m/mertiatide (betiat) | VIAL | 1 mg | Y | |||
| 67850055201 | ARIDOL | mannitol | CAP W/DEV | 0 mg (1)-5 mg (1)-10 mg (1)-20 mg (1)-40 mg (15) | Y | |||
| 64281011100 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 0 mg/3 mL (0 mg/mL) | Y | |||
| 64281011005 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 0 mg/3mL-0.1875 mg/3mL-0.75 mg/3mL-3mg/3mL-12mg/3mL-48mg/3mL | Y | |||
| 64281011006 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 0 mg/3mL-0.1875 mg/3mL-0.75 mg/3mL-3mg/3mL-12mg/3mL-48mg/3mL | Y | |||
| 64281011200 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 0.1875 mg/3 mL (0.0625 mg/mL) | Y | |||
| 64281011300 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 0.75 mg/3 mL (0.25 mg/mL) | Y | |||
| 64281010000 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 100 mg | Y | |||
| 64281010006 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 100 mg | Y | |||
| 64281011500 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 12 mg/3 mL (4 mg/mL) | Y | |||
| 64281011400 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 3 mg/3 mL (1 mg/mL) | Y | |||
| 64281011600 | PROVOCHOLINE | methacholine chloride | VIAL-NEB | 48 mg/3 mL (16 mg/mL) | Y | |||
| 82292004001 | LUMISIGHT | pegulicianine acetate | VIAL | 39 mg | Y | |||
| 82292004010 | LUMISIGHT | pegulicianine acetate | VIAL | 39 mg | Y | |||
| 17156025108 | INDIUM IN-111 DTPA | pentetate indium disod. In-111 | VIAL | 1.5 mCi/1.5 mL | Y | |||
| 11994001101 | DEFINITY | perflutren lipid microspheres | VIAL | 1.1 mg/mL | Y | |||
| 11994001116 | DEFINITY | perflutren lipid microspheres | VIAL | 1.1 mg/mL | Y | |||
| 00407270703 | OPTISON | perflutren protein-A microsphr | VIAL | 0.22 mg (+/- 0.11) mg/mL | Y | |||
| 00407270718 | OPTISON | perflutren protein-A microsphr | VIAL | 0.22 mg (+/- 0.11) mg/mL | Y | |||
| 71258002200 | PYLARIFY | piflufolastat F 18 | SYRINGE | 296 MBq to 370 MBq (8 mCi to 10 mCi) | Y | |||
| 71258002201 | PYLARIFY | piflufolastat F 18 | VIAL | 37 MBq/mL to 2,960 MBq/mL (1 mCi/mL to 80 mCi/mL) | Y | |||
| 00469650189 | LEXISCAN | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 00409140101 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 00409140105 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 00641625301 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 36000036401 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 43598061611 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 55150044301 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 60505611600 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 60505628800 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 71288020185 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 76329332100 | REGADENOSON | regadenoson | SYRINGE | 0.4 mg/5 mL | Y | |||
| 72611087401 | REGADENOSON | regadenoson | VIAL | 0.4 mg/5 mL | Y | |||
| 72611087410 | REGADENOSON | regadenoson | VIAL | 0.4 mg/5 mL | Y | |||
| 69945060110 | SODIUM IODIDE I-123 | sodium iodide-123 | CAPSULE | 3.7 MBq (100 microCi) | Y | |||
| 69945060220 | SODIUM IODIDE I-123 | sodium iodide-123 | CAPSULE | 7.4 MBq (200 microCi) | Y | |||
| 11994009101 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009103 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009104 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009105 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009106 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009107 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009109 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009110 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009111 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009112 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009136 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009173 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 11994009192 | TECHNELITE TC-99M GENERATOR | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945001003 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945001504 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945002005 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945002506 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945003007 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945003508 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945005109 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945006010 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945007511 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945011012 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945014013 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945016014 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945019015 | ULTRA-TECHNEKOW V4 | sodium pertechnetate Tc-99m | VIAL | Y | ||||
| 69945012028 | THALLOUS CHLORIDE TL-201 | thallous chloride Tl-201 | VIAL | 37 MBq/mL (1 mCi/mL) | Y | |||
| 69945012056 | THALLOUS CHLORIDE TL-201 | thallous chloride Tl-201 | VIAL | 37 MBq/mL (1 mCi/mL) | Y | |||
| 69945012063 | THALLOUS CHLORIDE TL-201 | thallous chloride Tl-201 | VIAL | 37 MBq/mL (1 mCi/mL) | Y | |||
| 69945012099 | THALLOUS CHLORIDE TL-201 | thallous chloride Tl-201 | VIAL | 37 MBq/mL (1 mCi/mL) | Y | |||
| 10370041494 | REVEAL UTI TEST STRIP | urinary tract infection test | STICK (EA) | Y | ||||
| 69945009711 | XENON XE-133 | xenon 133 in air | GAS (EA) | 370 MBq (10 mCi) | Y | |||
| 69945009713 | XENON XE-133 | xenon 133 in air | GAS (EA) | 370 MBq (10 mCi) | Y | |||
| 69945009715 | XENON XE-133 | xenon 133 in air | GAS (EA) | 370 MBq (10 mCi) | Y | |||
| 69945009821 | XENON XE-133 | xenon 133 in air | GAS (EA) | 740 MBq (20 mCi) | Y | |||
| 69945009823 | XENON XE-133 | xenon 133 in air | GAS (EA) | 740 MBq (20 mCi) | Y | |||
| 69945009825 | XENON XE-133 | xenon 133 in air | GAS (EA) | 740 MBq (20 mCi) | Y | |||
| 11994012711 | XENON XE-133 | xenon 133 in carbon dioxide | GAS (EA) | 370 MBq (10 mCi) | Y | |||
| 11994012715 | XENON XE-133 | xenon 133 in carbon dioxide | GAS (EA) | 370 MBq (10 mCi) | Y | |||
| 11994012821 | XENON XE-133 | xenon 133 in carbon dioxide | GAS (EA) | 740 MBq (20 mCi) | Y | |||
| 11994012825 | XENON XE-133 | xenon 133 in carbon dioxide | GAS (EA) | 740 MBq (20 mCi) | Y |