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May 16, 2006

Payment Allowance Limits for Medicare Part B Drugs

Effective April 1, 2006 through June 30, 2006

Note 1: Payment allowance limits subject to the ASP methodology are based on 4Q05 ASP data.

Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor processing the claim.

Note 3: ** -carrier priced

HCPCS Code Short Description HCPCS Code Dosage Payment Limit Vaccine AWP% Vaccine Limit Infusion AWP% DME Infusion Limit Blood AWP% Blood Limit Notes
90371 Hep b ig, im 1 ML $119.736              
90375 Rabies ig, im/sc 150 IU $64.591              
90376 Rabies ig, heat treated 150 IU $69.231              
90385 Rh ig, minidose, im 50 MCG $4.928              
90396** varicella-zoster immune globulin 125 U / 1.25 ML $145.749              
90396** varicella-zoster immune globulin 625 U / 6.25 ML $716.994              
90585 Bcg vaccine, percut 50 MG $116.558              
90586 Bcg vaccine, intravesical 1 EACH $111.537              
90632 Hep a vaccine, adult im 1 ML $46.827              
90633 Hep a vacc, ped/adol, 2 dose 1 ML $23.829              
90634 Hep a vacc, ped/adol, 3 dose 3 EACH $23.855              
90645 Hib vaccine, hboc, im 1 EACH $21.524              
90647 Hib vaccine, prp-omp, im 0.5 ML $21.524              
90648 Hib vaccine, prp-t, im 0.5 ML $21.782              
90655 Flu vaccine no preserv 6-35m 0.25 ML $14.678 95% $14.678          
90656 Flu vaccine no preserv 3 & > 0.50 ML $15.818 95% $15.818          
90657 Flu vaccine, 6-35 mo, im 0.25 ML $6.028 95% $6.028          
90658 Flu vaccine age 3 & over, im 0.5 ML $12.056 95% $12.056          
90660 Flu vaccine, nasal 0.5 ML $21.176 95% $21.176          
90675 Rabies vaccine, im 1 ML $156.732              
90691 Typhoid vaccine, im 0.5 ML $50.679              
90700 Dtap vaccine, < 7 yrs, im 0.5 ML $23.466              
90702 Dt vaccine < 7, im 0.5 ML $18.300              
90703 Tetanus vaccine, im 0.5 ML $18.337              
90704 Mumps vaccine, sc 0.5 ML $19.144              
90705 Measles vaccine, sc 0.5 ML $14.518              
90706 Rubella vaccine, sc 0.5 ML $16.161              
90707 Mmr vaccine, sc 0.5 ML $38.586              
90713 Poliovirus, ipv, sc/im 0.5 ML $24.888              
90714 Td vaccine no prsrv >/= 7 im 0.5 ML $18.266              
90716 Chicken pox vaccine, sc 0.5 ML $67.475              
90717 Yellow fever vaccine, sc 0.5 ML $54.440              
90718 Td vaccine > 7, im 0.5 ML $18.266              
90721 Dtap/hib vaccine, im 1 EACH $41.724              
90732 Pneumococcal vaccine 0.5 ML $27.028 95% $27.028          
90733 Meningococcal vaccine, sc 0.5 ML $84.460              
90735 Encephalitis vaccine, sc 1 ML $100.099              
90740 Hepb vacc, ill pat 3 dose im 40 MCG $113.914 95% $113.914          
90743 Hep b vacc, adol, 2 dose, im 10 MCG $57.551 95% $57.551          
90744 Hepb vacc ped/adol 3 dose im 1 DOSE $68.381 95% $68.381          
90746 Hep b vaccine, adult, im 1 EACH $56.957 95% $56.957          
90747 Hepb vacc, ill pat 4 dose im 40 MCG $113.914 95% $113.914          
J0128 Abarelix injection 10 MG $66.833              
J0130 Abciximab injection 10 MG $457.273              
J0132 Acetylcysteine injection 100 MG $1.874              
J0133 Acyclovir injection 5 MG $0.026              
J0135 Adalimumab injection 20 MG $307.302              
J0150 Injection adenosine 6 MG 6 MG $30.189              
J0152 Adenosine injection 30 MG $70.071              
J0170 Adrenalin epinephrin inject 1 ML $0.570              
J0180 Agalsidase beta injection 1 MG $127.200              
J0200** Alatrofloxacin mesylate 100 MG $16.992              
J0205 Alglucerase injection 10 UNITS $39.220              
J0207 Amifostine 500 MG $452.684              
J0210 Methyldopate hcl injection 250 MG $9.950              
J0215 Alefacept 0.5 MG $26.279              
J0256 Alpha 1 proteinase inhibitor 10 MG $3.242              
J0270 Alprostadil for injection 1.25 MCG $1.815              
J0275 Alprostadil urethral suppos 125 MCG $21.995              
J0278 Amikacin sulfate injection 100 MG $1.346              
J0280 Aminophyllin 250 MG inj 250 MG $0.414              
J0282 Amiodarone HCl 30 MG $0.193              
J0285 Amphotericin B 50 MG $9.307     95% $10.280      
J0287 Amphotericin b lipid complex 10 MG $11.205     95% $21.850      
J0288 Ampho b cholesteryl sulfate 10 MG $12.000     95% $15.200      
J0289 Amphotericin b liposome inj 10 MG $17.566     95% $35.800      
J0290 Ampicillin 500 MG inj 500 MG $1.781              
J0295 Ampicillin sodium per 1.5 gm 1.5 GM $4.518              
J0300 Amobarbital 125 MG inj 125 MG $2.145              
J0330 Succinycholine chloride inj 20 MG $0.140              
J0350 Injection anistreplase 30 u 30 UNITS $2,265.460              
J0360 Hydralazine hcl injection 20 MG $5.106              
J0365 Aprotonin, 10,000 kiu 10000 KIU $2.347              
J0380** metaraminol bitartrate, inj 10 MG $1.362              
J0390** Chloroquine injection 250 MG $17.270              
J0395** Arbutamine HCl injection 1 MG Invoice              
J0456 Azithromycin 500 MG $25.324              
J0460 Atropine sulfate injection 0.3 MG $0.227              
J0470 Dimecaprol injection 100 MG $21.834              
J0475 Baclofen 10 MG injection 10 MG $193.322     95% $215.180      
J0476 Baclofen intrathecal trial 50 MCG $70.872     95% $79.800      
J0480 Basiliximab 20 MG $1,402.038              
J0500 Dicyclomine injection 20 MG $15.112              
J0520** Bethanechol chloride Oral drug considered part of procedure in physician's office.                
J0515 Inj benztropine mesylate 1 MG $4.774              
J0530 Penicillin g benzathine inj 600000 UNITS $13.069              
J0540 Penicillin g benzathine inj 1200000 UNITS $25.889              
J0550 Penicillin g benzathine inj 2400000 UNITS $32.597              
J0560 Penicillin g benzathine inj 600000 UNITS $19.463              
J0570 Penicillin g benzathine inj 1200000 UNITS $33.827              
J0580 Penicillin g benzathine inj 2400000 UNITS $68.507              
J0583 Bivalirudin 1 MG $1.635              
J0585 Botulinum toxin a per unit 1 UNIT $4.901              
J0587 Botulinum toxin type B 100 UNITS $7.929              
J0592 Buprenorphine hydrochloride 0.1 MG $0.747              
J0595 Butorphanol tartrate 1 mg 1 MG $0.839              
J0600 Edetate calcium disodium inj 1000 MG $40.179              
J0610 Calcium gluconate injection 10 ML $0.545              
J0620** calcium glycerophosphate/calcium lactate 10 ML $11.847              
J0630 Calcitonin salmon injection 400 UNITS $37.810              
J0636 Inj calcitriol per 0.1 mcg 0.1 MCG $0.462              
J0637 Caspofungin acetate 5 MG $32.496              
J0640 Leucovorin calcium injection 50 MG $0.913              
J0670 Inj mepivacaine HCL/10 ml 10 ML $1.362              
J0690 Cefazolin sodium injection 500 MG $1.310              
J0692 Cefepime HCl for injection 500 MG $7.818              
J0694 Cefoxitin sodium injection 1 GM $7.516              
J0696 Ceftriaxone sodium injection 250 MG $3.369              
J0697 Sterile cefuroxime injection 750 MG $1.770              
J0698 Cefotaxime sodium injection 1 GM $4.317              
J0702 Betamethasone acet&sod phosp 3 MG $5.068              
J0704 Betamethasone sod phosp/4 MG 4 MG $0.907              
J0706 Caffeine citrate injection 5 MG $3.369              
J0713 Inj ceftazidime per 500 mg 500 MG $4.073              
J0715 Ceftizoxime sodium / 500 MG 500 MG $3.559              
J0720 Chloramphenicol sodium injec 1 GM $12.039              
J0725 Chorionic gonadotropin/1000u 1000 UNITS $3.132              
J0735 Clonidine hydrochloride 1 MG $63.311              
J0740 Cidofovir injection 375 MG $764.239              
J0743 Cilastatin sodium injection 250 MG $13.205              
J0744 Ciprofloxacin iv 200 MG $8.320              
J0745 Inj codeine phosphate /30 MG 30 MG $0.950              
J0760 Colchicine injection 1 MG $4.543              
J0770 Colistimethate sodium inj 150 MG $25.080              
J0780 Prochlorperazine injection 10 MG $2.284              
J0795 Corticorelin ovine triflutal 1 MCG $4.260              
J0800 Corticotropin injection 40 UNITS $109.884              
J0835 Inj cosyntropin per 0.25 MG 0.25 MG $64.155              
J0850 Cytomegalovirus imm IV /vial PER VIAL $762.988              
J0878 Daptomycin injection 1 MG $0.313              
J0881 Darbepoetin alfa, non-esrd 1 MCG $3.033              
J0882 Darbepoetin alfa, esrd use 1 MCG $3.033              
J0885 Epoetin alfa, non-esrd 1000 UNITS $9.339              
J0886 Epoetin alfa, esrd 1000 UNITS $9.334              
J0895 Deferoxamine mesylate inj 500 MG $14.912     95% $15.630      
J0900 Testosterone enanthate inj 1 CC $1.379              
J0945 Brompheniramine maleate inj 10 MG $0.732              
J0970 Estradiol valerate injection 40 MG $32.524              
J1000 Depo-estradiol cypionate inj 5 MG $5.303              
J1020 Methylprednisolone 20 MG inj 20 MG $2.803              
J1030 Methylprednisolone 40 MG inj 40 MG $5.231              
J1040 Methylprednisolone 80 MG inj 80 MG $9.421              
J1051 Medroxyprogesterone inj 50 MG $5.234              
J1056 MA/EC contraceptiveinjection 5 MG $22.885              
J1060 Testosterone cypionate 1 ML 1 ML $4.142              
J1070 Testosterone cypionat 100 MG 100 MG $5.156              
J1080 Testosterone cypionat 200 MG 200 MG $12.517              
J1094 Inj dexamethasone acetate 1 MG $0.230              
J1100 Dexamethasone sodium phos 1 MG $0.127              
J1110 Inj dihydroergotamine mesylt 1 MG $25.271              
J1120 Acetazolamid sodium injectio 500 MG $14.946              
J1160 Digoxin injection 0.5 MG $1.034              
J1162 Digoxin immune fab (ovine) PER VIAL $532.483              
J1165 Phenytoin sodium injection 50 MG $0.844              
J1170 Hydromorphone injection 4 MG $1.765     95% $1.490      
J1180 Dyphylline injection 500 MG $8.045              
J1190 Dexrazoxane HCl injection 250 MG $181.330              
J1200 Diphenhydramine hcl injectio 50 MG $0.791              
J1205 Chlorothiazide sodium inj 500 MG $12.815              
J1212 Dimethyl sulfoxide 50% 50 ML 50 ML $42.103              
J1230 Methadone injection 10 MG $3.485     95% $0.750      
J1240 Dimenhydrinate injection 50 MG $3.779              
J1245 Dipyridamole injection 10 MG $1.706              
J1250 Inj dobutamine HCL/250 mg 250 MG $4.779     95% $4.740      
J1260 Dolasetron mesylate 10 MG $6.824              
J1265 Dopamine injection 40 MG $0.729              
J1270 Injection, doxercalciferol 1 MCG $3.167              
J1320 Amitriptyline injection 20 MG $2.237              
J1325 Epoprostenol injection 0.5 MG $13.200     95% $12.640      
J1327 Eptifibatide injection 5 MG $13.440              
J1335 Ertapenem injection 500 MG $23.172              
J1364 Erythro lactobionate /500 MG 500 MG $5.602              
J1380 Estradiol valerate 10 MG inj 10 MG $11.974              
J1390 Estradiol valerate 20 MG inj 20 MG $16.262              
J1410 Inj estrogen conjugate 25 MG 25 MG $58.332              
J1430 Ethanolamine oleate 100 mg 100 MG $72.252              
J1435 Injection estrone per 1 MG 1 MG $0.138              
J1436 Etidronate disodium inj 300 MG $71.407              
J1438 Etanercept injection 25 MG $155.584              
J1440 Filgrastim 300 mcg injection 300 MCG $184.266              
J1441 Filgrastim 480 mcg injection 480 MCG $292.346              
J1450 Fluconazole 200 MG $11.853              
J1451 Fomepizole, 15 mg 15 MG $11.933              
J1452 Intraocular Fomivirsen na 1.65 MG $212.000              
J1455 Foscarnet sodium injection 1000 MG $10.791     95% $13.070      
J1457 Gallium nitrate injection 1 MG $1.247              
J1460 Gamma globulin 1 CC inj 1 CC $10.686              
J1470 Gamma globulin 2 CC inj 2 CC $21.372              
J1480 Gamma globulin 3 CC inj 3CC $32.053              
J1490 Gamma globulin 4 CC inj 4 CC $42.744              
J1500 Gamma globulin 5 CC inj 5 CC $53.430              
J1510 Gamma globulin 6 CC inj 6 CC $64.134              
J1520 Gamma globulin 7 CC inj 7 CC $74.758              
J1530 Gamma globulin 8 CC inj 8 CC $85.487              
J1540 Gamma globulin 9 CC inj 9 CC $96.218              
J1550 Gamma globulin 10 CC inj 10 CC $106.859              
J1560 Gamma globulin > 10 CC inj 10 CC $106.859              
J1565 RSV-ivig 50 MG $16.176              
J1566 Immune globulin, powder 500 MG $22.261              
J1567 Immune globulin, liquid 500 MG $29.090              
J1570 Ganciclovir sodium injection 500 MG $37.175     95% $35.250      
J1580 Garamycin gentamicin inj 80 MG $1.680              
J1590 Gatifloxacin injection 10 MG $0.445              
J1595 Injection glatiramer acetate 20 MG $41.647              
J1600 Gold sodium thiomaleate inj 50 MG $3.974              
J1610 Glucagon hydrochloride/1 MG 1 MG $63.019              
J1620 Gonadorelin hydroch/ 100 mcg 100 MCG $180.295              
J1626 Granisetron HCl injection 100 MCG $6.865              
J1630 Haloperidol injection 5 MG $1.287              
J1631 Haloperidol decanoate inj 50 MG $5.869              
J1640 Hemin, 1 mg 1 MG $6.651              
J1642 Inj heparin sodium per 10 u 10 UNITS $0.059              
J1644 Inj heparin sodium per 1000u 1000 UNITS $0.121              
J1645 Dalteparin sodium 2500 IU $10.535              
J1650 Inj enoxaparin sodium 10 MG $5.442              
J1652 Fondaparinux sodium 0.5 MG $5.344              
J1655 Tinzaparin sodium injection 1000 IU $2.196              
J1670 Tetanus immune globulin inj 250 UNITS $91.573              
J1700** Hydrocortisone acetate inj 25 MG $0.342              
J1710** Hydrocortisone sodium ph inj 50 MG $4.685              
J1720 Hydrocortisone sodium succ i 100 MG $1.904              
J1730 Diazoxide injection 300 MG $111.936              
J1742 Ibutilide fumarate injection 1 MG $251.379              
J1745 Infliximab injection 10 MG $54.242              
J1751 Iron dextran 165 injection 50 MG $12.420              
J1752 Iron dextran 267 injection 50 MG $10.270              
J1756 Iron sucrose injection 1 MG $0.361              
J1785 Injection imiglucerase /unit 1 UNIT $3.908              
J1790 Droperidol injection 5 MG $1.080              
J1800 Propranolol injection 1 MG $4.741              
J1810 Droperidol/fentanyl inj 2 ML $5.944              
J1815 Insulin injection 5 UNITS $0.239              
J1817 Insulin for insulin pump use 50 UNITS $2.440     95% $2.800      
J1830 Interferon beta-1b / .25 MG 0.25 MG $92.214              
J1835 Itraconazole injection 50 MG $36.572              
J1840 Kanamycin sulfate 500 MG inj 500 MG $4.340              
J1850 Kanamycin sulfate 75 MG inj 75 MG $0.654              
J1885 Ketorolac tromethamine inj 15 MG $0.501              
J1890** Cephalothin sodium injection 1 G $8.640              
J1931 Laronidase injection 0.1 MG $23.868              
J1940 Furosemide injection 20 MG $0.433              
J1945 Lepirudin 50 MG $147.772              
J1950 Leuprolide acetate /3.75 MG 3.75 MG $444.553              
J1955 Inj levocarnitine per 1 gm 1 GM $8.038              
J1956 Levofloxacin injection 250 MG $7.593              
J1960** levorphanol tartrate 2 MG $3.604              
J1980 Hyoscyamine sulfate inj 0.25 MG $7.528              
J1990 Chlordiazepoxide injection 100 MG $21.050              
J2001 Lidocaine injection 10 MG $0.015              
J2010 Lincomycin injection 300 MG $3.574              
J2020 Linezolid injection 200 MG $23.726              
J2060 Lorazepam injection 2 MG $1.063              
J2150 Mannitol injection 50 ML $1.001              
J2175 Meperidine hydrochl /100 MG 100 MG $1.621     95% $0.560      
J2180 Meperidine/promethazine inj 50 MG $3.788              
J2185 Meropenem 100 MG $3.793              
J2210 Methylergonovin maleate inj 0.2 MG $4.305              
J2250 Inj midazolam hydrochloride 1 MG $0.283              
J2260 Inj milrinone lactate / 5 MG 5 MG $3.226     95% $51.580      
J2270 Morphine sulfate injection 10 MG $1.409     95% $0.710      
J2271 Morphine so4 injection 100mg 100 MG $3.853     95% $11.070      
J2275 Morphine sulfate injection 10 MG $5.125     95% $4.390      
J2278 Ziconotide injection 1 MCG $6.197              
J2280 Inj, moxifloxacin 100 mg 100 MG $3.909              
J2300 Inj nalbuphine hydrochloride 10 MG $1.081              
J2310 Inj naloxone hydrochloride 1 MG $2.505              
J2320 Nandrolone decanoate 50 MG 50 MG $3.272              
J2321 Nandrolone decanoate 100 MG 100 MG $6.677              
J2322 Nandrolone decanoate 200 MG 200 MG $12.950              
J2325 Nesiritide injection 0.1 MG $30.000              
J2353 Octreotide injection, depot 1 MG $90.354              
J2354 Octreotide inj, non-depot 25 MCG $4.381              
J2355 Oprelvekin injection 5 MG $245.703              
J2357 Omalizumab injection 5 MG $16.491              
J2360 Orphenadrine injection 60 MG $11.916              
J2370 Phenylephrine hcl injection 1 ML $0.500              
J2400 Chloroprocaine hcl injection 30 ML $13.680              
J2405 Ondansetron hcl injection 1 MG $3.724              
J2410 Oxymorphone hcl injection 1 MG $2.243              
J2425 Palifermin injection 50 MCG $11.475              
J2430 Pamidronate disodium /30 MG 30 MG $29.591              
J2440 Papaverin hcl injection 60 MG $0.542              
J2460 Oxytetracycline injection 50 MG $0.936              
J2469 Palonosetron HCl 25 MCG $17.677              
J2501 Paricalcitol 1 MCG $3.796              
J2503 Pegaptanib sodium injection 0.3 MG $1,054.700              
J2504 Pegademase bovine, 25 iu 25 IU $166.067              
J2505 Injection, pegfilgrastim 6mg 6 MG $2,163.195              
J2510 Penicillin g procaine inj 600000 UNITS $8.266              
J2513 Pentastarch 10% solution 100 ML $12.722              
J2515 Pentobarbital sodium inj 50 MG $5.233              
J2540 Penicillin g potassium inj 600000 UNITS $0.704              
J2543 Piperacillin/tazobactam 1.125 GM $4.846              
J2545 Pentamidine isethionte/300mg 300 MG $44.626              
J2550 Promethazine hcl injection 50 MG $2.076              
J2560 Phenobarbital sodium inj 120 MG $2.259              
J2590 Oxytocin injection 10 UNITS $2.223              
J2597 Inj desmopressin acetate 1 MCG $2.252              
J2650 Prednisolone acetate inj 1 ML $0.333              
J2670** Totazoline hcl injection 25 MG $3.440              
J2675 Inj progesterone per 50 MG 50 MG $1.813              
J2680 Fluphenazine decanoate 25 MG 25 MG $1.498              
J2690 Procainamide hcl injection 1 GM $1.863              
J2700 Oxacillin sodium injeciton 250 MG $0.595              
J2710 Neostigmine methylslfte inj 0.5 MG $0.085              
J2720 Inj protamine sulfate/10 MG 10 MG $0.534              
J2725 Inj protirelin per 250 mcg 250 MCG $21.778              
J2730 Pralidoxime chloride inj 1 GM $28.937              
J2760 Phentolaine mesylate inj 5 MG $23.596              
J2765 Metoclopramide hcl injection 10 MG $0.515              
J2770 Quinupristin/dalfopristin 500 MG $109.056              
J2780 Ranitidine hydrochloride inj 25 MG $0.670              
J2783 Rasburicase 0.5 MG $111.406              
J2788 Rho d immune globulin 50 mcg 50 MCG $14.262              
J2790 Rho d immune globulin inj 300 MCG $98.037              
J2792 Rho(D) immune globulin h, sd 100 IU $13.700              
J2794 Risperidone, long acting 0.5 MG $4.775              
J2795 Ropivacaine HCl injection 1 MG $0.071              
J2800 Methocarbamol injection 10 ML $8.467              
J2805 Sincalide injection 5 MCG $44.565              
J2810 Inj theophylline per 40 MG 40 MG $0.035              
J2820 Sargramostim injection 50 MCG $23.339              
J2850 Inj secretin synthetic human 1 MCG $20.313              
J2910 Aurothioglucose injeciton 50 MG $24.500              
J2912 Sodium chloride injection 2 ML $0.113              
J2916 Na ferric gluconate complex 12.5 MG $5.056              
J2920 Methylprednisolone injection 40 MG $1.418              
J2930 Methylprednisolone injection 125 MG $2.357              
J2940** Somatrem injection Considered self-administered.                
J2941 Somatropin injection 1 MG $44.151              
J2950** Promazine hydrochloride 25 MG $0.353              
J2993 Reteplase injection 18.1 MG $761.899              
J2995 Inj streptokinase /250000 IU 250000 IU $79.500              
J2997 Alteplase recombinant 1 MG $31.355              
J3000 Streptomycin injection 1 GM $6.648              
J3010 Fentanyl citrate injeciton 0.1 MG $0.289     95% $0.700      
J3030 Sumatriptan succinate / 6 MG 6 MG $52.246              
J3070 Pentazocine injection 30 MG $4.841              
J3100 Tenecteplase injection 50 MG $2,078.618              
J3105 Terbutaline sulfate inj 1 MG $7.296              
J3110** Teriparatide injection Considered self-administered.                
J3120 Testosterone enanthate inj 100 MG $7.187              
J3130 Testosterone enanthate inj 200 MG $14.375              
J3140** Testosterone suspension 50 MG $0.657              
J3150** Testosterone propionate 100 MG $0.840              
J3230 Chlorpromazine hcl injection 50 MG $3.121              
J3240 Thyrotropin injection 0.9 MG $773.911              
J3246 Tirofiban HCl 0.25 MG $7.679              
J3250 Trimethobenzamide hcl inj 200 MG $4.618              
J3260 Tobramycin sulfate injection 80 MG $1.748              
J3265 Injection torsemide 10 mg/ml 10 MG $2.356              
J3280** Thiethylperazine maleate, inj 10 MG $5.656              
J3285 Treprostinil injection 1 MG $54.018              
J3301 Triamcinolone acetonide inj 10 MG $1.362              
J3302 Triamcinolone diacetate inj 5 MG $0.280              
J3303 Triamcinolone hexacetonl inj 5 MG $1.300              
J3305 Inj trimetrexate glucoronate 25 MG $145.763              
J3315 Triptorelin pamoate 3.75 MG $303.767              
J3320 Spectinomycn di-hcl inj 2 GM $30.083              
J3355 Urofollitropin, 75 iu 75 IU $49.309              
J3360 Diazepam injection 5 MG $0.754              
J3364 Urokinase 5000 IU injection 5000 IU $9.155              
J3365 Urokinase 250,000 IU inj 250000 IU $457.729              
J3370 Vancomycin hcl injection 500 MG $3.239              
J3396 Verteporfin injection 0.1 MG $8.977              
J3410 Hydroxyzine hcl injection 25 MG $0.398              
J3411 Thiamine hcl 100 mg 100 MG $1.918              
J3415 Pyridoxine hcl 100 mg 100 MG $3.108              
J3420 Vitamin b12 injection 1000 MCG $0.872              
J3430 Vitamin k phytonadione inj 1 MG $3.356              
J3465 Injection, voriconazole 10 MG $4.592              
J3470 Hyaluronidase injection 150 UNITS $17.178              
J3471 Ovine, up to 999 USP units 1 USP UNIT $0.112              
J3472 Ovine, 1000 USP units 1000 USP UNITS $135.044              
J3475 Inj magnesium sulfate 500 MG $0.149              
J3480 Inj potassium chloride 2 MEQ $0.023              
J3485 Zidovudine 10 MG $1.007              
J3486 Ziprasidone mesylate 10 MG $19.875              
J3487 Zoledronic acid 1 MG $202.736              
J7030 Normal saline solution infus 1000 CC $0.938              
J7040 Normal saline solution infus 500 ML $0.459              
J7042 5% dextrose/normal saline 500 ML $0.387              
J7050 Normal saline solution infus 250 CC $0.228              
J7060 5% dextrose/water 500 ML $1.264              
J7070 D5w infusion 1000 CC $2.282              
J7100 Dextran 40 infusion 500 ML $14.008              
J7110 Dextran 75 infusion 500 ML $8.609              
J7120 Ringers lactate infusion 1000 CC $0.901              
J7130** Hypertonic saline solution 20 CC $1.345              
J7188 Inj Vonwillebrand factor iu 1 IU $0.877              
J7189 Factor viia 1 MCG $1.091              
J7190 Factor viii 1 IU $0.681              
J7191** Factor VIII (porcine) 1 IU $1.860              
J7192 Factor viii recombinant 1 IU $1.058              
J7193 Factor IX non-recombinant 1 IU $0.888              
J7194 Factor ix complex 1 IU $0.639              
J7195 Factor IX recombinant 1 IU $0.985              
J7197 Antithrombin iii injection 1 IU $1.630              
J7198 Anti-inhibitor 1 IU $1.301              
J7308 Aminolevulinic acid hcl top 354 MG $100.870              
J7310 Ganciclovir long act implant 4.5 MG $4,240.000              
J7317 Sodium hyaluronate injection 20 - 25 MG $113.105              
J7320 Hylan G-F 20 injection 16 MG $198.867              
J7330 Cultured chondrocytes implnt 1 EA $17,414.973              
J7340 Metabolic active D/E tissue 1 SQ CM $27.827              
J7341 Non-human, metabolic tissue 1 SQ CM $1.652              
J7342 Metabolically active tissue 1 SQ CM $15.149              
J7343 Nonmetabolic act d/e tissue 1 SQ CM $15.345              
J7344 Nonmetabolic active tissue 1 SQ CM $67.022              
J7350 Injectable human tissue 10 MG $29.740              
J7500 Azathioprine oral 50mg 50 MG $0.216              
J7501 Azathioprine parenteral 100 MG $49.195              
J7502 Cyclosporine oral 100 mg 100 MG $3.920              
J7504 Lymphocyte immune globulin 250 MG $298.193              
J7505 Monoclonal antibodies 5 MG $869.136              
J7506 Prednisone oral 5 MG $0.230              
J7507 Tacrolimus oral per 1 MG 1 MG $3.434              
J7509 Methylprednisolone oral 4 MG $0.080              
J7510 Prednisolone oral per 5 mg 5 MG $0.073              
J7511 Antithymocyte globuln rabbit 25 MG $304.347              
J7513 Daclizumab, parenteral 25 MG $348.358              
J7515 Cyclosporine oral 25 mg 25 MG $0.995              
J7516 Cyclosporin parenteral 250mg 250 MG $19.370              
J7517 Mycophenolate mofetil oral 250 MG $2.521              
J7518 Mycophenolic acid 180 MG $2.166              
J7520 Sirolimus, oral 1 MG $6.904              
J7525 Tacrolimus injection 5 MG $136.454              
J7608 Acetylcysteine inh sol u d 1 GM $2.248              
J7611 Albuterol concentrated form 1 MG $0.090              
J7612 Levalbuterol concentrated 0.5 MG $0.987              
J7613 Albuterol unit dose 1 MG $0.073              
J7614 Levalbuterol unit dose 0.5 MG $1.413              
J7620 Albuterol non-compounded 2.5 MG/0.5 MG $1.092              
J7622** Beclomethasone inhalatn sol Inhalation solutions are considered part of procedure in physician's office.                
J7624** Betamethasone inhalation sol Inhalation solutions are considered part of procedure in physician's office.                
J7626 Budesonide, non-compounded 0.5 MG $4.374              
J7628** Bitolterol mes inhal sol con Inhalation solutions are considered part of procedure in physician's office.                
J7629** Bitolterol mes inh sol u d Inhalation solutions are considered part of procedure in physician's office.                
J7631 Cromolyn sodium inh sol u d 10 MG $0.059              
J7633** Budesonide concentrated sol Inhalation solutions are considered part of procedure in physician's office.                
J7635 Atropine inhal sol con 1 MG $0.116              
J7636 Atropine inhal sol unit dose 1 MG $0.116              
J7637 Dexamethasone inhal sol con 1 MG $0.060              
J7638 Dexamethasone inhal sol u d 1 MG $0.127              
J7639 Dornase alpha inhal sol u d 1 MG $18.757              
J7641** Flunisolide, inhalation sol Inhalation solutions are considered part of procedure in physician's office.                
J7642 Glycopyrrolate inhal sol con 1 MG $1.040              
J7643 Glycopyrrolate inhal sol u d 1 MG $1.040              
J7644 Ipratropium brom inh sol u d 1 MG $0.216              
J7648** Isoetharine hcl inh sol con Inhalation solutions are considered part of procedure in physician's office.                
J7649** Isoetharine hcl inh sol u d Inhalation solutions are considered part of procedure in physician's office.                
J7658** Isoproterenol hcl inh sol con Inhalation solutions are considered part of procedure in physician's office.                
J7659** Isoproterenol hcl inh sol ud Inhalation solutions are considered part of procedure in physician's office.                
J7668** Metaproterenol inh sol con Inhalation solutions are considered part of procedure in physician's office.                
J7669 Metaproterenol inh sol u d 10 MG $0.232              
J7674 Methacholine chloride, neb 1 MG $0.389              
J7680** Terbutaline so4 inh sol con Inhalation solutions are considered part of procedure in physician's office.                
J7681** Terbutaline so4 inh sol u d Inhalation solutions are considered part of procedure in physician's office.                
J7682 Tobramycin inhalation sol 300 MG $53.658              
J7683** Triamcinolone inh sol con Inhalation solutions are considered part of procedure in physician's office.                
J7684** Triamcinolone inh sol u d Inhalation solutions are considered part of procedure in physician's office.                
J8501 Oral aprepitant 5 MG $4.634              
J8510 Oral busulfan 2 MG $1.973              
J8515 Cabergoline, oral 0.25mg 0.25 MG $15.929              
J8520 Capecitabine, oral, 150 mg 150 MG $3.631              
J8521 Capecitabine, oral, 500 mg 500 MG $12.089              
J8530 Cyclophosphamide oral 25 MG 25 MG $0.971              
J8540 Oral dexamethasone 0.25 MG $0.073              
J8560 Etoposide oral 50 MG 50 MG $33.041              
J8600** Melphalan oral 2 MG Oral chemotherapy drug billed to DME Carrier                
J8610 Methotrexate oral 2.5 MG 2.5 MG $0.239              
J8700 Temozolomide 5 MG $7.228              
J9000 Doxorubic hcl 10 MG vl chemo 10 MG $6.285              
J9001 Doxorubicin hcl liposome inj 10 MG $371.060     95% $393.480      
J9010 Alemtuzumab injection 10 MG $530.760              
J9015 Aldesleukin/single use vial 1 EA $741.088              
J9017 Arsenic trioxide 1 MG $33.232              
J9020 Asparaginase injection 10000 UNITS $54.166              
J9025 Azacitidine injection 1 MG $4.127              
J9027 Clofarabine injection 1 MG $116.675              
J9031 Bcg live intravesical vac 1 EA $111.537              
J9035 Bevacizumab injection 10 MG $56.898              
J9040 Bleomycin sulfate injection 15 UNITS $24.592     95% $289.370      
J9041 Bortezomib injection 0.1 MG $30.093              
J9045 Carboplatin injection 50 MG $13.869              
J9050 Carmus bischl nitro inj 100 MG $140.991              
J9055 Cetuximab injection 10 MG $49.860              
J9060 Cisplatin 10 MG injection 10 MG $1.883              
J9062 Cisplatin 50 MG injection 50 MG $11.073              
J9065 Inj cladribine per 1 MG 1 MG $38.642     95% $61.720      
J9070 Cyclophosphamide 100 MG inj 100 MG $1.999              
J9080 Cyclophosphamide 200 MG inj 200 MG $3.998              
J9090 Cyclophosphamide 500 MG inj 500 MG $16.732              
J9091 Cyclophosphamide 1.0 grm inj 1 GM $19.989              
J9092 Cyclophosphamide 2.0 grm inj 2 GM $39.978              
J9093** Cyclophosphamide, lyophilized 100 MG $5.194              
J9094** Cyclophosphamide, lyophilized 200 MG $10.388              
J9095** Cyclophosphamide, lyophilized 500 MG $25.970              
J9096** Cyclophosphamide, lyophilized 1 GM $51.940              
J9097** Cyclophosphamide, lyophilized 2 GM $103.880              
J9098 Cytarabine liposome 10 MG $378.316              
J9100 Cytarabine hcl 100 MG inj 100 MG $1.501     95% $8.190      
J9110 Cytarabine hcl 500 MG inj 500 MG $7.506     95% $8.550      
J9120 Dactinomycin actinomycin d 0.5 MG $13.928              
J9130 Dacarbazine 100 mg inj 100 MG $4.263              
J9140 Dacarbazine 200 MG inj 200 MG $8.525              
J9150 Daunorubicin 10 MG $23.585              
J9151 Daunorubicin citrate liposom 10 MG $56.252              
J9160 Denileukin diftitox, 300 mcg 300 MCG $1,404.299              
J9165** Diethylstilbestrol injection 250 MG $12.135              
J9170 Docetaxel 20 MG $297.286              
J9175 Elliotts b solution per ml 1 ML $3.356              
J9178 Inj, epirubicin hcl, 2 mg 2 MG $24.702              
J9181 Etoposide 10 MG inj 10 MG $0.485              
J9182 Etoposide 100 MG inj 100 MG $4.848              
J9185 Fludarabine phosphate inj 50 MG $232.306              
J9190 Fluorouracil injection 500 MG $1.776     95% $2.070      
J9200 Floxuridine injection 500 MG $63.202     95% $136.800      
J9201 Gemcitabine HCl 200 MG $117.697              
J9202 Goserelin acetate implant 3.6 MG $199.474              
J9206 Irinotecan injection 20 MG $126.471              
J9208 Ifosfomide injection 1 GM $54.710     95% $150.380      
J9209 Mesna injection 200 MG $7.949              
J9211 Idarubicin hcl injection 5 MG $268.059              
J9212 Interferon alfacon-1 1 MCG $3.923              
J9213 Interferon alfa-2a inj 3 MIL UNITS $33.848              
J9214 Interferon alfa-2b inj 1 MIL UNITS $13.670              
J9215** Interferon, alfa-n3 250,000 IU $9.118              
J9216 Interferon gamma 1-b inj 3 MIL UNITS $289.865              
J9217 Leuprolide acetate suspnsion 7.5 MG $245.306              
J9218 Leuprolide acetate injeciton 1 MG $7.937              
J9219 Leuprolide acetate implant 65 MG $2,178.364              
J9225 Histrelin implant 50 MG $2,039.058              
J9230 Mechlorethamine hcl inj 10 MG $13.104              
J9245 Inj melphalan hydrochl 50 MG 50 MG $1,202.146              
J9250 Methotrexate sodium inj 5 MG $0.196              
J9260 Methotrexate sodium inj 50 MG $1.993              
J9263 Oxaliplatin 0.5 MG $8.546              
J9264 Paclitaxel injection 1 MG $8.271              
J9265 Paclitaxel injection 30 MG $15.582              
J9266 Pegaspargase/singl dose vial 1 EA $1,611.200              
J9268 Pentostatin injection 10 MG $2,020.021              
J9270** Plicamycin (mithramycin) inj 2.5 MG $78.989              
J9280 Mitomycin 5 MG inj 5 MG $18.996     95% $127.400      
J9290 Mitomycin 20 MG inj 20 MG $75.982              
J9291 Mitomycin 40 MG inj 40 MG $151.964              
J9293 Mitoxantrone hydrochl / 5 MG 5 MG $339.968              
J9300 Gemtuzumab ozogamicin 5 MG $2,287.151              
J9305 Pemetrexed injection 10 MG $41.287              
J9310 Rituximab cancer treatment 100 MG $469.658              
J9320 Streptozocin injection 1 GM $148.856              
J9340 Thiotepa injection 15 MG $45.813              
J9350 Topotecan 4 MG $787.974              
J9355 Trastuzumab 10 MG $55.112     95% $58.130      
J9357** Valrubicin 200 MG $391.776              
J9360 Vinblastine sulfate inj 1 MG $0.995     95% $4.100      
J9370 Vincristine sulfate 1 MG inj 1 MG $5.363     95% $33.980      
J9375 Vincristine sulfate 2 MG inj 2 MG $10.726     95% $67.960      
J9380 Vincristine sulfate 5 MG inj 5 MG $26.816     95% $169.910      
J9390 Vinorelbine tartrate/10 mg 10 MG $22.254              
J9395 Injection, Fulvestrant 25 MG $81.076              
J9600 Porfimer sodium 75 MG $2,505.395              
P9041 Albumin (human),5%, 50ml 50 ML $11.020         95% $11.020  
P9043 Plasma protein fract,5%,50ml 50 ML $14.545         95% $14.545  
P9045 Albumin (human), 5%, 250 ml 250 ML $190.000         95% $190.000  
P9046 Albumin (human), 25%, 20 ml 20 ML $22.040         95% $22.040  
P9047 Albumin (human), 25%, 50ml 50 ML $55.100         95% $55.100  
P9048 Plasmaprotein fract,5%,250ml 250 ML $29.099         95% $29.099  
Q0163 Diphenhydramine HCl 50mg 50 MG $0.036              
Q0164 Prochlorperazine maleate 5mg 5 MG $0.030              
Q0165 Prochlorperazine maleate10mg 10 MG $0.025              
Q0166 Granisetron HCl 1 mg oral 1 MG $37.434              
Q0167 Dronabinol 2.5mg oral 2.5 MG $4.551              
Q0168 Dronabinol 5mg oral 5 MG $9.363              
Q0169 Promethazine HCl 12.5mg oral 12.5 MG $0.310              
Q0170 Promethazine HCl 25 mg oral 25 MG $0.559              
Q0171 Chlorpromazine HCl 10mg oral 10 MG $0.014              
Q0172 Chlorpromazine HCl 25mg oral 25 MG $0.037              
Q0173 Trimethobenzamide HCl 250mg 250 MG $0.706              
Q0174** Thiethylperazine maleate10mg Oral anti-emetic should be billed to DME Carrier                
Q0175 Perphenazine 4mg oral 4 MG $0.191              
Q0176 Perphenazine 8mg oral 8 MG $0.207              
Q0177 Hydroxyzine pamoate 25mg 25 MG $0.074              
Q0178 Hydroxyzine pamoate 50mg 50 MG $0.084              
Q0179 Ondansetron HCl 8mg oral 8 MG $34.534              
Q0180 Dolasetron mesylate oral 100 MG $47.974              
Q0181** Unspecified oral dosage form, FDA approved presription anti-emetic Oral anti-emetic should be billed to DME Carrier                
Q0515 Sermorelin acetate injection 1 MCG $1.751              
Q2009 Fosphenytoin, 50 mg 50 MG $5.232              
Q2017 Teniposide, 50 mg 50 MG $266.781              
Q3025 IM inj interferon beta 1-a 11 MCG $98.926              
Q4079 Natalizumab injection 1 MG $6.387              
Q4080 Iloprost inhalation solution 20 MCG $31.111              
Q9945 LOCM <=149 mg/ml iodine, 1ml 1 ML $0.299              
Q9946 LOCM 150-199mg/ml iodine,1ml 1 ML $1.859              
Q9947 LOCM 200-249mg/ml iodine,1ml 1 ML $1.263              
Q9948 LOCM 250-299mg/ml iodine,1ml 1 ML $0.321              
Q9949 LOCM 300-349mg/ml iodine,1ml 1 ML $0.346              
Q9950 LOCM 350-399mg/ml iodine,1ml 1 ML $0.209              
Q9952 Inj Gad-base MR contrast,1ml 1 ML $2.907              
Q9953 Inj Fe-based MR contrast,1ml 1 ML $30.406              
Q9954 Oral MR contrast, 100 ml 100 ML $8.958              
Q9955** Inj perflexane lip micros, ml 1 ML Invoice              
Q9956 Inj octafluoropropane mic,ml 1 ML $41.143              
Q9957 Inj perflutren lip micros,ml 1 ML $61.835              

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