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Pr ior Authorization and Investigational Services List

Services Requiring Prior Authorization (Revised August 2021) Please note: The terms prior authorization, prior approval, predetermination, advance notice, precertification, preauthorization and prior notification all refer to the same process.

SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) Care Management Web: http://navinet.force.com

Ambulance Services Non-emergency air ambulance transportation All contracted providers need to submit via the web. Only non-contracted providers can submit via fax.

Abdominoplasty/Panniculectomy Blepharoplasty, Brow Lift and Blepharoptosis Repair Care Management Reconstruction and Related Procedures Web: http://navinet.force.com Laser for Treatment of Rosacea Or (Bilateral Prophylactic) Fax: 1-877-321-6664 Cosmetic/Reconstructive Prior Approval Form Procedures* Otoplasty Reduction Mammoplasty All contracted providers need to submit via the web. Only Septoplasty non-contracted providers can Surgical Repair of Pectus Deformities submit via fax. Surgical Treatment of Gynecomastia

Air Fluidized Bed New requirement! Prior approval required effective 7/1/2020 Growth Stimulation: Electrical and Ultrasonic Continuous Glucose Monitoring Systems Cranial Orthosis for Plagiocephaly DME Misc. Items >$1,000 Care Management Functional Electrical Stimulation Web: http://navinet.force.com High Frequency Chest Wall Oscillation System Or Durable Medical INR Monitoring System Fax: 1-877-321-6664 Equipment Knee Braces (Custom Fabricated) Prior Approval Form (DME)/Prosthetics/ Mechanical Insufflation-Exsufflation Therapy Orthotics* Motorized Wheelchairs, Power Accessories and Power All contracted providers need Operated Vehicles to submit via the web. Only Pneumatic Compression Device non-contracted providers can Pressure Reducing Support Surfaces submit via fax. Prosthetics (microprocessor systems) Pulse Oximeter (home use) Speech-Generating Devices Tumor Treating (Treatment) Fields for Multiforme Wearable Cardioverter Defibrillator (WED)

X9158-CMT R8/21 (Revised August 2021) Page 1 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY)

* All Genetic Testing, Gene Expression Testing and Microarray Analysis testing requires prior authorization (unless specified as not required). Prior to testing for hereditary conditions Genetic Counseling is required. Care Management

Web: http://navinet.force.com Susceptibility 1 (BRCA1) Or Breast Cancer Susceptibility 2 (BRCA2) Fax: 1-877-321-6664 Genetic Testing/Gene Breast Cancer Susceptibility 1 and 2 Large Rearrangement Prior Approval Form Expression/Microarray Testing

Analysis* All contracted providers need Chromosomal Microarray Analysis to submit via the web. Only Gene Expression Assays for the Management of Breast non-contracted providers can Cancer submit via fax. Genetic Testing for Susceptibility Genetic Testing for Inherited Disorders Surrogate Markers for Detection of Heart Transplant Rejection – Gene Expression Profiling (e.g., AlloMap)

Abatacept (Orencia IV and SC) (Humira)

Adalimumab-afzb (Abrilada) Ado- emtansine (Kadcyla®) (AduhelmTM) [New PA requirement effective 7/30/2021] Afamelanotide (Scenesse)

Aflibercept (Eylea®)

Agalsidase beta (Fabrazyme®) (Lemtrada®) (when utilized for treatment of multiple sclerosis) (Lumizyme®, Myozyme®) (Praluent®) Alpha1-proteinase inhibitors (Aralast NP™, Glassia™,

Prolastin®, Prolastin®-C, Zemaira™)

Amivantamab-vmjw (RybrevantTM) [New PA requirement Medical Management effective 8/13/2021] Web: ih.magellanrx.com Injectables* (Kineret®) Fax: 1-888-656-1948 -FNIA (SaphneloTM) [New PA requirement effective Phone: 1-800-424-7698 8/13/2021] (Trisenox) Prior Approval Form

Asparaginase Erwinia chrysanthemi (Erwinaze)

Asparaginase Erwinia chyrsanthemi (recombinant)-rwyn (RylazeTM) [New PA requirement effective 8/13/2021] (Tecentriq®) Avalgucosidase alfa-ngpt (Nexviazyme TM) [New PA requirement effective 8/13/2021] (Bavencio®)

Axicabtagene ciloleucel (Yescarta®)

Belantamab (Blenrep) (Benlysta IV and SC) (Treanda, Belrapzo, Bendeka™) (Fasenra) (Avastin, Bevacizumab-awwb (mvasi), Bevacizumab-bvzr (Zirabev) (prior approval is required for all conditions except diabetic , macular edema

following retinal vein occlusion, or neovascular (wet) age-

Revised August 2021 Page 2 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) related ) Bivigam (Blincyto®) (Velcade)

Botulinum Toxin Type A and B Bremelanotide (Vyleesi) (Adcetris®) Brexucabtagene autoleucel (Tecartus) (Siliq ™) -dbll (Beovu)

Burosumab (Crysvita) (Jevtana) Cabotegravir/ rilpivirine (Cabenuva) [New PA requirement effective 2/1/2021] Calaspargase Pegol-mknl (Asparlas) (Ilaris®) -yhdp (Cablivi)

Carfilzomib (Kyprolis®) (Amondys 45) [New PA requirement effective 3/1/2021] -rwlc (Libtayo) Cerliponase alfa (Brineura®) (Cimzia)

Cetuximab (Erbitux®)

C1 esterase inhibitor (Berinert) C1 esterase inhibitor (Cinryze) Medical Drug Management Injectables* C1 esterase inhibitor (Haegarda) Web: ih.magellanrx.com (Aliqopa®) Fax: 1-888-656-1948 Crisanlizumab-tmca (Adakveo) Phone: 1-800-424-7698 Cuvitru (immune globulin subcutaneous 20% solution) Prior Approval Form

Daratumumab (Darzalex™) hyaluronidase-fihj (Darzalex Faspro) Darbepoetin alfa (Aranesp®) / (Vyxeos®) (Xgeva®) -gxly (Jemperli) [New PA requirement effective

5/1/2021]

Dupilumab (Dupixent®) (Imfinzi®) Ecallantide (Kalbitor) (Soliris®) Edaravone(Radicava®) Elapegademase-lvlr (Revcovi™)

Elosulfase alfa (Vimizim) (Empliciti™) -lzsg (Gamifant) Emicizumab-kxwh (Hemlibra) -ejfv (Padcev) Replacement Therapy for Gaucher Disease

(, , )

Epoprostenol (Flolan, Veletri) -jjmr (Vyepti)

Revised August 2021 Page 3 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) -aooe (Aimovig™) mesylate (Halaven®) alfa (Epogen®, Procrit®, Retacrit) Esketamine (Spravato™)

Etanercept (Enbrel) (Exondys51) -dgnb (Evkeeza) [New PA requirement effective 2/1/2021] (Repatha®) (Neupogen®)

Filgrastim-aafi (Nivestym™) Fligrastim-sndz (Zarxio™) Flebogamma DIF Fosdenopterin (NulibryTM) [New PA requirement effective 4/1/2021] ™) -vfrm (Ajovy Fulvestrant (Faslodex®)

Galcanezumab-gnlm (Emgality™) Galsulfase (Naglazyme®) Gammagard (all forms) Gammaked Gammaplex Gamunex (all forms)

Gemtuzumab Ozogamicin (Mylotarg®)

Glatiramer acetate (Copaxone, Glatopa) Medical Drug Management New Drug Prior Approval Policy (Global Prior Approval) Web: ih.magellanrx.com Injectables* (Givlaari) Fax: 1-888-656-1948 (Simponi ARIA and SC) Phone: 1-800-424-7698 (Vyondys 53) Prior Approval Form Growth Stimulating

Guselkumab (Tremfya) Hizentra -uiyk (Trogarzo) Icatibant (Firazyr®) TM Idecabtagene vicleucel (Abecma ) [New PA requirement effective 5/1/2021]

Idursulfase (Elaprase®)

Iloprost (Ventavis) Immune globulins (administered intravenous and subcutaneous) -cdon (Uplinza) (Remicade) Infliximab-dyyb (Inflectra®)

Infliximab-abda (Renflexis®) Infliximab-axxq (Avsola) Inotersen (Tegsedi) (Besponsa®) beta-1a (Avonex®, Plegridy™, Rebif®) Interferon beta-1b (Betaseron®, Extavia®)

Ipilimumab (Yervoy®)

Iobenguane I 131 (Azedra®) liposomal (Onivyde®)

Revised August 2021 Page 4 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) -irfc (Sarclissa) (Ixempra®) (Taltz®) (Takhzyro®)

Laronidase (Aldurazyme®) Levoleucovorin (Fusilev, Khapzory) [New PA requirement effective 1/1/2021] Lisocabtagene maraleucel (Breyanzi) [New PA requirement effective 2/1/2021} -lpyl (Zynlonta) [New PA requirement

effective 5/1/2021] Lumasiran (Oxlumo) [New PA requirement effective 12/1/2020] Lurbinectedin (Zepzelca) Luspatarcept-aamt (Reblozyl) Lutetium Lu 177 dotatate (Lutathera®) flufenamide (Pepaxto) [New PA requirement effective 3/1/2021]

Mepolizumab (Nucala®) Mitomycin (Jelmyto) Methoxy polyethylene glycol-epoetin beta (Mircera®) -kpkc (Poteligeo®) -tdfk (Lumoxiti) (Tysabri)

Naxitamab-gpgk (Danyelza) [New PA requirement effective

12/1/2020] Medical Drug Management (Portrazza™) Web: ih.magellanrx.com Injectables* (Arranon) Fax: 1-888-656-1948 (Opdivo®) Phone: 1-800-424-7698 (Spinraza®) Prior Approval Form (Gazyva®)

Ocrelizumab (Ocrevus®)

Octagam (Arzerra) Ofatumumab (Kesimpta) [New PA requirement effective 10/9/2020]

Omacetaxine mepesuccinate (Synribo®) (Xolair®)

Onasemnogene abeparvovec (Zolgensma®) albumin-bound (Abraxane®) Panzyga (IVIG) Management (Vectibix®)

Patisirin (Onpattro®) sodium (Macugen®)

Pegaspargase (Oncaspar) Pegcetacoplan (Empaveli) [New PA requirement effective 6/1/2021] (Neulasta®)

Pegfilgrastim-bmez (Ziextenzo) Pegfilgrastim-jmdb (Fulphila™)

Pegfilgrastim-apgf (Nyvepria) Pegfilgrastim-cbqv) (Udenyca)

Revised August 2021 Page 5 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) Peginterferon alfa-2b (Sylatron™) Pegloticase (KRYSTEXXA) -pqpz (Palynziq) (Keytruda®)

Pemetrexed (Alimta®) (Perjeta®) Pertuzumab, Transtuzumab, hyaluronidase-zzxf (Phesgo) Plasminogen, human-tvmh (RyplazimTM) [New PA requirement effective 7/1/2021]

Polatuzumab vedotin-piiq (Polivy)

Privigen (Cyramza®) (Lucentis®) -cwvz (Ultomiris) Recombinant C1 esterase inhibitor (Ruconest®)

Repository Corticotropin Injection (H.P. Acthar Gel)

Reslizumab (Cinqair®)

Risankizumab-rzaa (Skyrizi) (Rituxan) Rituximab-abbs (Truxima) Rituximab-pvvr (Ruxience) Rituximab and Hyaluronidase (Rituxan Hycela) Medical Drug Management (Istodax®) Web: ih.magellanrx.com

Romiplostim (Nplate®) Fax: 1-888-656-1948 ™ -aqqg (Evenity ) Phone: 1-800-424-7698 Injectables* -hziy (Trodelvy) Prior Approval Form (Leukine®) (Kevzara®) (Enspryng)

Sebelipase alfa (Kanuma) (Cosentyx™) Setmelanotide (Imcivree) [New PA requirement effective 12/1/2020] (Sylvant®) Sipuleucel-T (Provenge) Synagis (Palivizumab) and RSV IVIG Respirgam -cxix (Monjuvi) Tagraxofusp-erzs (Elzonris) Taliglucerase alfa (Elelyso) Talimogene laherparepvic (Imlygic®) TBO-Filgrastim (Granix™) -trbw (Tepezza) cypionate (Depo®-Testosterone) Testosterone enanthate (Delatestryl®, Xyosted®) Testosterone pellet (Testopel®) Testosterone undecanoate (Aveed®) -asmn (Ilumya™) Tisagenlecleucel (Kymriah®) (Actemra IV and SC) (Yondelis®) Trastuzumab (Herceptin®) Trastuzumab-dkst (Ogivri™)

Revised August 2021 Page 6 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) Trastuzumab-dttb (Ontruzant) Trastuzumab-pkrb (Herzuma) Trastuzumab-qyyp (Trazimera) Trastuzumab-anns (Kanjinti) Trastuzumab/hyaluronidase-oysk (Herceptin Hylecta™) Treprostinil (Remodulin, Tyvaso) Triamcinolone acetonide extended-release injectable (ZilrettaTM) (Cosela) [New PA requirement effective 2/1/2021] (Stelara IV and SC) (Entyvio®) Velaglucerase alfa (Vpriv) (Visudyne) [New PA requirement effective 1/1/2021] Vestronidase alfa-vjbk (Mepsevii) (Viltepso liposomal (Marqibo®) Viscosupplementation Injections (e.g., Euflexxa, Gel-One, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz, Supartz FX, Synvisc, Synvisc-One, Gel-Syn, Durolane, Trivisc, Synojoynt, Triluron, Viscos 3) Voretigene Neparvovec-rzyl (Luxturna) Ziv- (Zaltrap)

SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY)

Medical/Surgical Admissions Acute Care Medical/Surgical MMO Contracting Providers Prior approval of normal deliveries is not required unless the Submit through: length of stay for the mother or child exceeds 48 hours from https://Reviewlink.mmoh.com the date of a vaginal delivery or 96 hours from the date of a C-section. For all other providers please Acute Physical Rehabilitation fax clinical information to 1-800- Long Term Acute Care (LTAC) 517-2583 Inpatient Services Skilled Nursing Facility (SNF)

MMO Contracting Providers submit through: Behavioral Health Admissions http://navinet.force.com Acute Care Psychiatric/Substance Abuse Residential Inpatient For all other providers, please fax clinical information to 1-800- 524-9817

Imaging Submit through eviCore Computed Tomography (CT) Healthcare Magnetic Resonance Imaging/Angiography (MRI/MRA) Web: https://www.evicore.com/page Outpatient Services Myocardial perfusion (SPECT/PET) and cardiac blood pool imaging s/providerlogin.aspx Other Nuclear Medicine Or Position Emission Tomography (PET) Phone: 1-888-693-3211 Fax: 1-888-693-3210

Revised August 2021 Page 7 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) Please find full listing by procedure at: https://www.evicore.com/healthplan/MedMutualOH

Submit through eviCore Therapy Healthcare Not all plans require prior approval for therapy services (i.e., Web: Mutual Health Services). Please contact the For Providers https://www.evicore.com/page number on the back of the Covered Person’s ID card. s/providerlogin.aspx Phone: 1-877-531-9139 Chiropractic/Osteopathic Manipulative Therapy Fax: 1-855-774-1319 Occupational Therapy Physical Therapy Therapy Authorization Forms: Speech Therapy Physical, Occupational, Chiropractic or Speech Therapy Outpatient Services

Care Management Web: http://navinet.force.com Or Fax: 1-877-321-6664 Behavioral Therapy Prior Approval Form Applied Behavioral Analysis (ABA) Therapy All contracted providers need to submit via the web. Only non-contracted providers can submit via fax.

Nursing Private Duty Nursing 1-800-258-3175

Artificial Anal Sphincter for Treatment of Fecal Incontinence Artificial Intervertebral Disc Replacement Auditory Brainstem Implant Autologous Chondrocyte Implantation Bariatric for obesity Bone Anchored Hearing Device (BAHA) Capsule (Wireless) Endoscopy – Esophagus through Ileum Care Management Other Medical/Surgical/ Carotid Artery Stenting Web: http://navinet.force.com Diagnostic Services Cochlear Implant Or Electrical Stimulation and Electromagnetic Therapy for the Fax: 1-877-321-6664 (furnished in a physician Treatment of Chronic Dermal Ulcers Prior Approval Form office, certified Electromagnetic Navigational

ambulatory surgery Endoscopic Thoracic Sympathectomy for Treatment of All contracted providers need center, inpatient or Hyperhidrosis to submit via the web. Only outpatient hospital, or Gastric Electrical Stimulation for Treatment of Gastroparesis non-contracted providers can any other location) Gender Dysphoria Treatment submit via fax. Implantable Miniature Telescope – End Stage Age-Related

Macular Degeneration Treatment

Intensity Modulated Radiation Therapy Interspinous Process Decompression System (X-STOP) Intrastromal Corneal Ring Segments (Intacs) In Utero Fetal Surgery Laser Therapy – Vitiligo Longitudinal Gastrectomy (i.e., sleeve gastrectomy) Lumbar Spinal Fusion

Revised August 2021 Page 8 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) Volume Reduction Surgery (LVRS) for Severe Emphysema Neutron Beam Therapy Osteochondral Allografts and Autografts (OATS Mosaicplasty) for the Treatment of Focal Articular Cartilage Defects of the Knee Outpatient Telemetry Systems Phototherapy – Home Treatment of Dermatological Conditions (Other Than Vitiligo) Proton Beam Radiotherapy Psoriasis Laser Treatment Radiofrequency Ablation (RFA) for Treatment of Tumors Radiofrequency Volumetric Tissue Reduction Recombinant Human Bone Morphogenetic Protein-2 and Protein-7 Sacral Nerve Stimulation Sclerotherapy Spinal Cord Stimulation for Treatment of Chronic Pain Stereotactic Body Radiotherapy and Radiosurgery Strabismus Surgery if >11 Years of Age Surrogate Markers for Detection of Heart Transplant Rejection – Gene Expression Profiling (e.g., AlloMap) Transcatheter Valve Replacement/Implantation Transcranial Magnetic Stimulation (TMS) for Treatment of Depression Transurethral Radiofrequency Micro-Remodeling Uterine Artery Embolization for Treatment of Fibroids Uvulectomy Uvulopalatopharyngoplasty Vertebroplasty – Thoracic and Lumbar Virtual Colonoscopy (Computed Tomographic Colonography) – Diagnostic Transplantation – • Blood component (e.g., Stem Cell, ) Care Management Transplants • Solid Organ (Except Corneal) Phone: 1-800-258-3175 • Pancreatic Islet Cell - Autologous

Care Management

Web: http://navinet.force.com Total Artificial

Heart Systems • Total Artificial Heart Systems All contracted providers need Ventricular Assist • Ventricular Assist Devices to submit via the web. Only Devices non-contracted providers can

submit via fax.

All rights in the product names of all third-party products appearing here, whether appearing with the trademark symbol, belong exclusively to their respective owners.

Revised August 2021 Page 9 of 11

Investigational Services (Revised August 2021) The health plan defines investigational procedures, , devices and supplies as services that are not approved by governing bodies OR do not demonstrate comparable or superior outcomes to current practice standards as evidenced by peer-reviewed published literature and/or clinical trials.

Although not all-inclusive, the health plan considers the following services as investigational and not eligible for reimbursement. Additionally, any charge clearly related to an investigational service such as a hospitalization, outpatient service, office visit, diagnostic test, supply or will also be denied as investigational and not eligible for reimbursement.

SUBMIT TO DETAILS (PROVIDER USE ONLY)

Actiography Allergen Specific IgE Quantitative or Semiquantitative, Multiallergen Screen (Dipstick, Disk or Paddle) Allergy – Sublingual Anal Fistula Plug Axial Lumbar Interbody Fusion (AxiaLIF) Biodegradable Capsule with a Radiofrequency Identification Tag to Determine Patency of the Gastrointestinal Tract (e.g., AGILETM Patency System) Bioidentical Hormone Therapy Bioimpedance Spectroscopy BioniCare BIO-1000 System for Treatment of Osteoarthritis of the Knee Breast Cancer Analysis Rearrangement Test (BART) Breast Ductal Lavage Capsule (wireless) Endoscopy – Esophagus Chelation Therapy for Chemical Endarteretomy Coblation Radiofrequency Microtenotomy (TOPAZ) for Treatment of Tendinosis Compounded Drugs Computed Tomographic Colonography-Screening Care Management Computer-Aided Detection Software Systems – Magnetic Resonance Imaging of the Breast Web: http://navinet.force.com Disc Biacuplasty Doppler Velocimetry (Uterine Artery) All contracted providers Electrical Stimulation for Treatment of Dysphagia) need to submit via the web. Electron Beam Computed Tomography Only non-contracted Endobronchial Valve for Lung Volume Reduction Surgery and for Treatment of a providers can submit via fax. Bronchopleural Fistula Endometrial Photodynamic Ablation Endoscopic Disc Decompression Endoscopic Therapy for Gastroesophageal Reflux Disease Endovascular Repair of Aortic Aneurysm Involving Visceral Branches/Vessels Evaluation of Vestibular Disorders Extracorporeal Magnetic Stimulation – Urinary Incontinence Extracorporeal Shock Wave Therapy (ESWT) for Muskuloskeletal Conditions Fiberoptic Fluid-Ventilated Gas-Permeable Contact Lenses Gait Analysis Gastric Bubble (Balloon) Gastric Electrical Stimulation for Treatment of Obesity Hyperbaric (Topical) Infrared Energy Therapy Interferential Stimulation

Revised August 2021 Page 10 of 11

SUBMIT TO DETAILS (PROVIDER USE ONLY)

Intra-Aneurysm Sac Pressure Monitoring Device Intrapulmonary Percussive Ventilation System Intravascular Stent without Distal Embolic Protection In Utero Repair of Myelomeningocele In Utero Tracheal Occlusion for Treatment of Congenital Diaphragmatic Hernia Kyphoplasty – Cervical Laser-assisted Uvulopalatoplasty Laser Discectomy – Nucleoplasty Magnetic Resonance Imaging-Guided High-Intensity Focused Ultrasound Ablation of Uterine Fibroids Manipulation Under Anesthesia of the Ankle, Elbow, Finger, Hip, Pelvis, Sacroiliac Joint, Spine, Temporomandibular Joint, Thumb and Wrist Microcurrent Electrical Therapy Non-Surgical Treatment of Obstructive : Oral Pressure Therapy Nucleoplasty – Laser Discectomy Osteochondral Autograft Transplantation of the Ankle Ovarian Adnexal Mass Assessment Score Test Systems (e.g., OVA1) Pancreatic Islet Cell Transplant – Allogeneic Percutaneous Disc Decompression Percutaneous Intradiscal Radiofrequency Thermocoagulation Percutaneous Neuromodulation Therapy Care Management Percutaneous Tibial Nerve Stimulation Web: http://navinet.force.com Phototherapy – Home Treatment of Vitiligo Pulsed Electrical Stimulation All contracted providers Radiofrequency Microtenotomy Tendinosis need to submit via the web. Radiofrequency Therapy for Treatment of Urinary Incontinence Only non-contracted Robotic Surgical Systems Utilized for any Procedure other than Laparoscopic Prostatectomy providers can submit via fax. Salivary Hormone Testing for Menopause Skin Substitutes for Wound Healing (Acticoat and E-Z Derm) Smooth Pursuit Neck Torsion Testing Suction-assisted Lipectomy Suit Therapy Surface Electrodiagnostic Studies – Lumbar Matrix Scan Surgical Treatment of Migraine Surrogate Markers for Detection of Heart Transplant Rejection – Breath Testing (e.g., Heartsbreath) Sympathetic Peripheral Autonomic Skin Potentialsm (PAP’s) Thermography Total Body Photography Transanal Radiofrequency Therapy for Fecal Incontinence Tumor Chemosenstivity and Chemoresistance Assays (e.g., ChemoFx®) Unicondylar Interpostitional Spacer Vagal Nerve Stimulation for Treatment of Depression Vertebral Axial Decompression Vertebroplasty of the Cervical Spine Vestibular Autorotation Whole-Body Computed Tomography Wireless Gastrointestinal Motility Monitoring System

All rights in the product names of all third-party products appearing here, whether appearing with the trademark symbol, belong exclusively to their respective owners.

Revised August 2021 Page 11 of 11