License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

Print | Bookmark | Font Size: + | –

DME MAC Jurisdiction C

Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees

Effective 01/01/2007 through 03/31/2007

The absence or presence of a HCPCS code and the fee in this list does not indicate Medicare coverage of the drug.

HCPCS CODE / NDC NUMBER	DESCRIPTION	DOSAGE	FEE
G0333	PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY		$57.000
J0133	INJECTION, ACYCLOVIR	5 MG	$0.470
J0285	AMPHOTERICIN B	50 MG	$10.280
J0287	AMPHOTERICIN B LIPID COMPLEX	10 MG	$21.850
J0288	AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX	10 MG	$15.200
J0289	AMPHOTERICIN B LIPOSOME	10 MG	$35.800
J0882	INJECTION, DARBEPOETIN ALFA, (FOR ESRD ON DIALYSIS)	1 MCG	$3.093
J0886	INJECTION, EPOETIN ALFA, (FOR ESRD ON DIALYSIS)	1000 UNITS	$9.574
J0895	DEFEROXAMINE MESYLATE	500 MG / 5 CC	$15.630
J1170	HYDROMORPHONE	4 MG	$1.490
J1250	DOBUTAMINE HYDROCHLORIDE	250 MG	$4.740
J1265	INJECTION, DOPAMINE HCL	40 MG	$0.620
J1325	EPOPROSTENOL	.5 MG	$12.640
J1455	FOSCARNET SODIUM	1000 MG	$13.070
J1562	INJECTION, IMMUNE GLOBULIN, SUBCUTANEOUS	100 MG	$11.400
J1566	INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER)	500 MG	$25.605
J1567	INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)	500 MG	$30.443
J1570	GANCICLOVIR SODIUM	500 MG	$35.250
J1644AX	INJECTION, HEPARIN SODIUM (FOR ESRD)	1000 UNITS	$0.225
J1815	INSULIN	5 UNITS	$0.239
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP)	50 UNITS	$2.800
J2175	MEPERIDINE HYDROCHLORIDE	100 MG	$0.560
J2260	MILRINONE LACTATE	5 ML	$51.580
J2270	MORPHINE SULFATE	10 MG	$0.710
J2271	MORPHINE SULFATE	100 MG	$11.070
J2275	MORPHINE SULFATE, PRESERVATIVE FREE STERILE SOL	10 MG	$4.390
J2545	PENTAMIDINE FOR AEROSOL INHALER FOR PNEUMOCYSTIS	300 MG	$44.732
J2920	METHYLPREDNISOLONE SODIUM SUCCINATE	40 MG	$1.948
J2930	METHYLPREDNISOLONE SODIUM SUCCINATE	125 MG	$2.476
J3010	FENTANYL CITRATE	2 ML	$0.700
J3285	INJECTION, TREPROSTINIL	1 MG	$61.750
J7500	AZATHIOPRINE, ORAL	50 MG	$0.274
J7501	AZATHIOPRINE, PARENTERAL	100 MG	$49.587
J7502	CYCLOSPORINE, ORAL	100 MG	$3.541
J7504	LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL	250 MG	$317.148
J7505	MUROMONAB-CD3 PARENTERAL	5 MG	$876.832
J7506	PREDNISONE, ORAL	5 MG	$0.191
J7507	TACROLIMUS, ORAL	1 MG	$3.540
J7509	METHYLPREDNISOLONE, ORAL	4 MG	$0.072
J7510	PREDNISOLONE, ORAL	5 MG	$0.071
J7511	LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL	25 MG	$331.070
J7513	DACLIZUMAB, PARENTERAL	25 MG	$314.587
J7515	CYCLOSPORINE, ORAL	25 MG	$0.952
J7516	CYCLOSPORINE, PARENTERAL	250 MG	$20.635
J7517	MYCOPHENOLATE MOFETIL, ORAL	250 MG	$2.547
J7518	MYCOPHENOLIC ACID, ORAL	180 MG	$2.140
J7520	SIROLIMUS, ORAL	1 MG	$7.224
J7525	TACROLIMUS, PARENTERAL	5 MG	$140.386
J7607	LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	0.5 MG	TBD*
J7608KO	ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 GM	$2.395
J7609KO	ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7609KP	ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7609KQ	ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7610	ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7611	ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$0.071
J7612	LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM	0.5 MG	$0.989
J7613KO	ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	$0.065
J7614KO	LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE	0.5 MG	$1.391
J7615KO	LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	0.5 MG	TBD*
J7615KP	LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	0.5 MG	TBD*
J7615KQ	LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	0.5 MG	TBD*
J7620	ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME	1 UNIT	$1.052
J7622KO	BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7622KP	BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7622KQ	BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7624KO	BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7624KP	BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7624KQ	BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7626KO	BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM	UP TO 0.5 MG	$4.590
J7627KO	BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	UP TO 0.5 MG	TBD*
J7627KP	BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	UP TO 0.5 MG	TBD*
J7627KQ	BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	UP TO 0.5 MG	TBD*
J7628	BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7629KO	BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7629KP	BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7629KQ	BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7631KO	CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM	10 MG	$0.069
J7634	BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	0.25 MG	TBD*
J7635	ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$0.266
J7636KO	ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.338
J7636KP	ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.338
J7636KQ	ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.266
J7637	DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$0.124
J7638KO	DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.160
J7638KP	DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.160
J7638KQ	DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.124
J7639KO	DORNASE ALPHA, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$19.864
J7641KO	FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7641KP	FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7641KQ	FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE	1 MG	TBD*
J7642	GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$1.525
J7643KO	GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$1.705
J7643KP	GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$1.705
J7643KQ	GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$1.525
J7644KO	IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.213
J7645KO	IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7645KP	IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7645KQ	IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7647	ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7650KO	ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7650KP	ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7650KQ	ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7657	ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7660KO	ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7660KP	ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7660KQ	ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7667	METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, CONCENTRATED FORM	10 MG	TBD*
J7669KO	METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM	10 MG	$0.238
J7670KO	METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7670KP	METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7670KQ	METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7680	TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	TBD*
J7681KO	TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7681KP	TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7681KQ	TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	TBD*
J7682KO	TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, UNIT DOSE FORM, ADMINISTERED THROUGH DME	300 MG	$57.313
J7683	TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM	1 MG	$0.121
J7684KO	TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.157
J7684KP	TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.157
J7684KQ	TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	1 MG	$0.121
J7685KO	TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	300 MG	TBD*
J7685KP	TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	300 MG	TBD*
J76855KQ	TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM	300 MG	TBD*
J8501	APREPITANT, ORAL	5 MG	$5.035
J8520	CAPECITABINE, ORAL	150 MG	$3.959
J8521	CAPECITABINE, ORAL	500 MG	$13.181
J8530	CYCLOPHOSPHAMIDE; ORAL	25 MG	$0.978
J8540	DEXAMETHASONE, ORAL	0.25 MG	$0.257
J8610	METHOTREXATE; ORAL	2.5 MG	$0.218
J8650	NABILONE, ORAL	1 MG	$16.000
J9000	DOXORUBICIN HCL	10 MG	$12.540
J9001	DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULTAIONS	10 MG	$393.480
J9040	BLEOMYCIN SULFATE	15 UNITS	$289.370
J9065	CLADRIBINE	1 MG	$61.720
J9070	CYCLOPHOSPHAMIDE	100 MG	$5.730
J9080	CYCLOPHOSPHAMIDE	200 MG	$10.890
J9100	CYTARABINE	100 MG	$8.190
J9110	CYTARABINE	500 MG	$8.550
J9150	DAUNORUBICIN HYDROCHLORIDE	10 MG	$74.230
J9181	ETOPOSIDE	10 MG	$1.710
J9182	ETOPOSIDE	100 MG	$17.100
J9190	FLUOROURACIL	500 MG	$2.070
J9200	FLOXURIDINE	500 MG	$136.800
J9208	IFOSFAMIDE	1 GM	$150.380
J9263	OXALIPLATIN	0.5 MG	$9.446
J9265	PACLITAXEL	30 MG	$162.170
J9280	MITOMYCIN	5 MG	$127.400
J9290	MITOMYCIN	20 MG	$323.200
J9293	MITOXANTRONE HYDROCHLORIDE	5 MG	$359.350
J9350	TOPOTECAN	4 MG	$798.650
J9355	TRASTUZUMAB	10 MG	$58.130
J9360	VINBLASTINE SULFATE	1 MG	$4.100
J9370	VINCRISTINE SULFATE	1 MG	$33.980
J9375	VINCRISTINE SULFATE	2 MG	$67.960
J9380	VINCRISTINE SULFATE	5 MG	$169.910
J9390	VINORELBINE TARTRATE	10 MG	$109.000
Q0163	DIPHENHYDRAMINE HYDROCHLORIDE, ORAL	50 MG	$0.034
Q0164	PROCHLORPERAZINE MALEATE, ORAL	5MG	$0.029
Q0165	PROCHLORPERAZINE MALEATE, ORAL	10 MG	$0.045
Q0166	GRANISETRON HYDROCHLORIDE	1 MG	$44.174
Q0167	DRONABINOL, ORAL	2.5 MG	$4.646
Q0168	DRONABINOL, ORAL	5 MG	$10.051
Q0169	PROMETHAZINE HYDROCHLORIDE, ORAL	12.5 MG	TBD*
Q0170	PROMETHAZINE HYDROCHLORIDE, ORAL	25 MG	$0.392
Q0171	CHLORPROMAZINE HYDROCHLORIDE, ORAL	10 MG	$0.021
Q0172	CHLORPROMAZINE HYDROCHLORIDE, ORAL	25 MG	$0.047
Q0173	TRIMETHOBENZAMIDE HYDROCHLORIDE, ORAL	250 MG	$0.326
Q0174	THIETHYLPERAZINE MALEATE, ORAL	10 MG	TBD*
Q0175	PERPHENAZINE, ORAL	4 MG	$0.191
Q0176	PERPHENAZINE, ORAL	8 MG	$0.213
Q0177	HYDROXYZINE PAMOATE, ORAL	25 MG	$0.062
Q0178	HYDROXYZINE PAMOATE, ORAL	50 MG	$0.064
Q0179	ONDANSETRON HYDROCHLORIDE, ORAL	8 MG	$36.829
Q0180	DOLASETRON MESYLATE, ORAL	100 MG	$48.707
Q0510	PHARMACY SUPPLY FEE FOR INITIAL IMMUNOSUPPRESSIVE DRUG(S), FIRST MONTH FOLLOWING TRANSPLANT		$50.000
Q0511	PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR THE FIRST PRESCRIPTION IN A 30-DAY PERIOD		$24.000
Q0512	PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE DRUG(S); FOR A SUBSEQUENT PRESCRIPTION IN A 30-DAY PERIOD		$16.000
Q0513	PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 30 DAYS		$33.000
Q0514	PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 90 DAYS		$66.000
Q4080	ILOPROST, INHALATION SOLUTION, ADMINISTERED THROUGH DME	20 MCG	$34.238
Q4081	INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS)		$0.957
00173-0713-25	BUSULFAN, ORAL	2 MG	$2.123
00004-1100-13	CAPECITABINE, ORAL	150 MG	$3.959
00004-1100-20	CAPECITABINE, ORAL	150 MG	$3.959
00004-1100-22	CAPECITABINE, ORAL	150 MG	$3.959
00004-1100-51	CAPECITABINE, ORAL	150 MG	$3.959
54868-4143-00	CAPECITABINE, ORAL	150 MG	$3.959
54868-4143-02	CAPECITABINE, ORAL	150 MG	$3.959
54868-4143-03	CAPECITABINE, ORAL	150 MG	$3.959
00004-1101-13	CAPECITABINE, ORAL	500 MG	$13.181
00004-1101-16	CAPECITABINE, ORAL	500 MG	$13.181
00004-1101-50	CAPECITABINE, ORAL	500 MG	$13.181
00004-1101-51	CAPECITABINE, ORAL	500 MG	$13.181
54569-5717-00	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-00	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-01	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-02	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-03	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-04	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-05	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-06	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-07	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-08	CAPECITABINE, ORAL	500 MG	$13.181
54868-5260-09	CAPECITABINE, ORAL	500 MG	$13.181
00015-0504-01	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.978
00054-4129-25	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.978
00054-8089-25	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.978
54569-5712-00	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.978
54868-5218-00	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.978
54868-5218-01	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.978
54868-5218-02	CYCLOPHOSPHAMIDE, ORAL	25 MG	$0.978
00015-0503-01	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.956
00015-0503-02	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.956
00054-4130-25	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.956
00054-8130-25	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.956
54569-5713-00	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.956
54868-5005-00	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.956
54868-5005-01	CYCLOPHOSPHAMIDE, ORAL	50 MG	$1.956
00015-3091-45	ETOPOSIDE, ORAL	50 MG	$30.533
00378-3266-94	ETOPOSIDE, ORAL	50 MG	$30.533
51079-0965-05	ETOPOSIDE, ORAL	50 MG	$30.533
54569-5718-00	ETOPOSIDE, ORAL	50 MG	$30.533
54868-5355-00	ETOPOSIDE, ORAL	50 MG	$30.533
54868-5355-02	ETOPOSIDE, ORAL	50 MG	$30.533
00081-0045-35	MELPHALAN, ORAL	2 MG	$4.336
00173-0045-35	MELPHALAN, ORAL	2 MG	$4.336
54868-4339-00	MELPHALAN, ORAL	2 MG	$4.336
54868-4339-01	MELPHALAN, ORAL	2 MG	$4.336
54868-4339-02	MELPHALAN, ORAL	2 MG	$4.336
54868-4339-03	MELPHALAN, ORAL	2 MG	$4.336
59572-0302-50	MELPHALAN, ORAL	2 MG	$4.336
00005-4507-04	METHOTREXATE, ORAL	2.5 MG	$0.218
00005-4507-05	METHOTREXATE, ORAL	2.5 MG	$0.218
00005-4507-07	METHOTREXATE, ORAL	2.5 MG	$0.218
00005-4507-09	METHOTREXATE, ORAL	2.5 MG	$0.218
00005-4507-23	METHOTREXATE, ORAL	2.5 MG	$0.218
00005-4507-91	METHOTREXATE, ORAL	2.5 MG	$0.218
00054-4550-15	METHOTREXATE, ORAL	2.5 MG	$0.218
00054-4550-25	METHOTREXATE, ORAL	2.5 MG	$0.218
00054-8550-03	METHOTREXATE, ORAL	2.5 MG	$0.218
00054-8550-05	METHOTREXATE, ORAL	2.5 MG	$0.218
00054-8550-06	METHOTREXATE, ORAL	2.5 MG	$0.218
00054-8550-07	METHOTREXATE, ORAL	2.5 MG	$0.218
00054-8550-10	METHOTREXATE, ORAL	2.5 MG	$0.218
00054-8550-25	METHOTREXATE, ORAL	2.5 MG	$0.218
00182-1539-01	METHOTREXATE, ORAL	2.5 MG	$0.218
00182-1539-95	METHOTREXATE, ORAL	2.5 MG	$0.218
00364-2499-01	METHOTREXATE, ORAL	2.5 MG	$0.218
00364-2499-36	METHOTREXATE, ORAL	2.5 MG	$0.218
00378-0014-01	METHOTREXATE, ORAL	2.5 MG	$0.218
00378-0014-50	METHOTREXATE, ORAL	2.5 MG	$0.218
00536-3998-01	METHOTREXATE, ORAL	2.5 MG	$0.218
00536-3998-36	METHOTREXATE, ORAL	2.5 MG	$0.218
00555-0572-02	METHOTREXATE, ORAL	2.5 MG	$0.218
00555-0572-35	METHOTREXATE, ORAL	2.5 MG	$0.218
00555-0572-45	METHOTREXATE, ORAL	2.5 MG	$0.218
00555-0572-46	METHOTREXATE, ORAL	2.5 MG	$0.218
00555-0572-47	METHOTREXATE, ORAL	2.5 MG	$0.218
00555-0572-48	METHOTREXATE, ORAL	2.5 MG	$0.218
00555-0572-49	METHOTREXATE, ORAL	2.5 MG	$0.218
00603-4499-21	METHOTREXATE, ORAL	2.5 MG	$0.218
00677-1610-01	METHOTREXATE, ORAL	2.5 MG	$0.218
00781-1076-01	METHOTREXATE, ORAL	2.5 MG	$0.218
00781-1076-36	METHOTREXATE, ORAL	2.5 MG	$0.218
00904-1749-60	METHOTREXATE, ORAL	2.5 MG	$0.218
00904-1749-73	METHOTREXATE, ORAL	2.5 MG	$0.218
49999-0380-24	METHOTREXATE, ORAL	2.5 MG	$0.218
51079-0670-05	METHOTREXATE, ORAL	2.5 MG	$0.218
51285-0509-02	METHOTREXATE, ORAL	2.5 MG	$0.218
51432-0522-03	METHOTREXATE, ORAL	2.5 MG	$0.218
52959-0244-00	METHOTREXATE, ORAL	2.5 MG	$0.218
54569-1818-08	METHOTREXATE, ORAL	2.5 MG	$0.218
54868-3826-03	METHOTREXATE, ORAL	2.5 MG	$0.218
54868-3826-04	METHOTREXATE, ORAL	2.5 MG	$0.218
54868-3826-05	METHOTREXATE, ORAL	2.5 MG	$0.218
54868-3826-06	METHOTREXATE, ORAL	2.5 MG	$0.218
54868-3826-07	METHOTREXATE, ORAL	2.5 MG	$0.218
55289-0924-30	METHOTREXATE, ORAL	2.5 MG	$0.218
58469-3998-30	METHOTREXATE, ORAL	2.5 MG	$0.218
59911-5874-01	METHOTREXATE, ORAL	2.5 MG	$0.218
62701-0940-36	METHOTREXATE, ORAL	2.5 MG	$0.218
62701-0940-99	METHOTREXATE, ORAL	2.5 MG	$0.218
63629-1472-01	METHOTREXATE, ORAL	2.5 MG	$0.218
67253-0320-10	METHOTREXATE, ORAL	2.5 MG	$0.218
67253-0580-42	METHOTREXATE, ORAL	2.5 MG	$0.218
67253-0580-43	METHOTREXATE, ORAL	2.5 MG	$0.218
67253-0580-44	METHOTREXATE, ORAL	2.5 MG	$0.218
67253-0580-45	METHOTREXATE, ORAL	2.5 MG	$0.218
67253-0580-46	METHOTREXATE, ORAL	2.5 MG	$0.218
68115-0632-00	METHOTREXATE, ORAL	2.5 MG	$0.218
00555-0927-01	METHOTREXATE, ORAL	5 MG	$0.436
51285-0366-01	METHOTREXATE, ORAL	5 MG	$0.436
00555-0928-01	METHOTREXATE, ORAL	7.5 MG	$0.654
51285-0367-01	METHOTREXATE, ORAL	7.5 MG	$0.654
00555-0929-01	METHOTREXATE, ORAL	10 MG	$0.872
51285-0368-01	METHOTREXATE, ORAL	10 MG	$0.872
00555-0945-01	METHOTREXATE, ORAL	15 MG	$1.308
51285-0369-01	METHOTREXATE, ORAL	15 MG	$1.308
00085-1248-01	TEMOZOLOMIDE, ORAL	5 MG	$7.415
00085-1248-02	TEMOZOLOMIDE, ORAL	5 MG	$7.415
00085-1248-03	TEMOZOLOMIDE, ORAL	5 MG	$7.415
54569-5836-00	TEMOZOLOMIDE, ORAL	5 MG	$7.415
54569-5837-00	TEMOZOLOMIDE, ORAL	5 MG	$7.415
54868-5348-00	TEMOZOLOMIDE, ORAL	5 MG	$7.415
54868-5348-01	TEMOZOLOMIDE, ORAL	5 MG	$7.415
00085-1244-01	TEMOZOLOMIDE, ORAL	20 MG	$29.660
00085-1244-02	TEMOZOLOMIDE, ORAL	20 MG	$29.660
00085-1425-01	TEMOZOLOMIDE, ORAL	20 MG	$29.660
00085-1425-02	TEMOZOLOMIDE, ORAL	20 MG	$29.660
00085-1430-01	TEMOZOLOMIDE, ORAL	20 MG	$29.660
00085-1430-02	TEMOZOLOMIDE, ORAL	20 MG	$29.660
00085-1519-01	TEMOZOLOMIDE, ORAL	20 MG	$29.660
00085-1519-02	TEMOZOLOMIDE, ORAL	20 MG	$29.660
54569-5838-00	TEMOZOLOMIDE, ORAL	20 MG	$29.660
54569-5839-00	TEMOZOLOMIDE, ORAL	20 MG	$29.660
54868-4142-00	TEMOZOLOMIDE, ORAL	20 MG	$29.660
54868-4142-02	TEMOZOLOMIDE, ORAL	20 MG	$29.660
54868-4142-03	TEMOZOLOMIDE, ORAL	20 MG	$29.660
54868-4142-04	TEMOZOLOMIDE, ORAL	20 MG	$29.660
54868-4142-06	TEMOZOLOMIDE, ORAL	20 MG	$29.660
00085-1259-01	TEMOZOLOMIDE, ORAL	100 MG	$148.300
00085-1259-02	TEMOZOLOMIDE, ORAL	100 MG	$148.300
00085-1366-01	TEMOZOLOMIDE, ORAL	100 MG	$148.300
00085-1366-02	TEMOZOLOMIDE, ORAL	100 MG	$148.300
54569-5842-00	TEMOZOLOMIDE, ORAL	100 MG	$148.300
54569-5843-00	TEMOZOLOMIDE, ORAL	100 MG	$148.300
54868-5350-01	TEMOZOLOMIDE, ORAL	100 MG	$148.300
54868-5350-02	TEMOZOLOMIDE, ORAL	100 MG	$148.300
54868-5350-03	TEMOZOLOMIDE, ORAL	100 MG	$148.300
54868-5350-04	TEMOZOLOMIDE, ORAL	100 MG	$148.300
00085-1252-01	TEMOZOLOMIDE, ORAL	250 MG	$370.750
00085-1252-02	TEMOZOLOMIDE, ORAL	250 MG	$370.750
00085-1417-01	TEMOZOLOMIDE, ORAL	250 MG	$370.750
54569-5844-00	TEMOZOLOMIDE, ORAL	250 MG	$370.750
54569-5845-00	TEMOZOLOMIDE, ORAL	250 MG	$370.750
54868-5354-00	TEMOZOLOMIDE, ORAL	250 MG	$370.750

*To Be Developed (TBD) is used for HCPCS codes where there was no fee on the ASP file and we were unable to locate published WAC pricing, therefore we will develop for an invoice on this drug.