Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective October 1, 2019 through December 31, 2019
Revised: 12.09.19
Note 1: The complete ASP Payment Allowance Limits list can be accessed at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html![]()
Note 2: Payment allowance limits subject to the ASP methodology are based on 4Q19 ASP data.
Note 3: 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 4: Skin substitutes/wound care base products are not injectable drugs and therefore, do not fall under the same guidelines for pricing. Invoice information will be required with claim submitted if not CMS priced.
Note 5: ** - Carrier-priced
| HCPCS Code | Short Description | HCPCS Code Dosage | Payment Limit | Notes |
|---|---|---|---|---|
| 90396** | varicella-zoster immune globulin | 125 U / 1.25 ML | Invoice | |
| 90396** | varicella-zoster immune globulin | 625 U / 6.25 ML | Invoice | |
| 90630 | IIV4 Vacc no prsv 3 yrs+id | 0.1 ML | Invoice | No new pricing available for the 2019-2020 flu season. |
| 90654 | Flu vaccine, intradermal, no preserv | Non FDA Approved | No new pricing available for the 2019-2020 flu season. | |
| 90655 | Flu vaccine no preserv 6-35m, im | 0.25 ML | Invoice | No new pricing available for the 2019-2020 flu season. |
| 90657 | Flu vaccine, 6-35 mo, im | 0.25 ML | Invoice | No new pricing available for the 2019-2020 flu season. |
| 90661 | Flu vaccine, derived from cell cultures, subunit | 45 MCG/0.5 ML | Invoice | No new pricing available for the 2019-2020 flu season. |
| 90673 | Flublok, trivalent 18 & > | 0.5 ML | Invoice | No new pricing available for the 2019-2020 flu season. |
| 90689 | Vacc iiv4 no prsrv | Non FDA Approved | ||
| 90736** | Zostavax (live/attenuated form ) | Per Carrier Medical Director not covered by Part B. | Added January 2013 | |
| 90750** | Zostavax (recombinant form) | Per Carrier Medical Director not covered by Part B. | Added February 2018 | |
| A9513** | lutetium lu 177 dotatate (Lutathera) | 1 MCI | $ 259.170 | Updated dosage and pricing eff 01/01/2019 Updated pricing Eff June 2019/ Updated price July 2019 |
| A9583** | Gadofosveset trisodium inj (Ablavar) | 1 ML | Invoice | Added November 2019 |
| A9587** | Gallium ga-68, dotatate, diagnostic, (Netspot) | 0.1 MCI | $ 68.704 | Updated pricing 10/2017 / Updated August 2019 |
| A9588** | Fluciclovine f-18, diagnostic (Axumin) | PER MCI | Invoice | Changed pricing to invoice |
| A9606** | Radium Ra 223 dichloride (Xofigo) | MicroCurie | $ 145.198 | Eff:1/1/2015 / Pricing change EFF 10/01/17 / price change 7/2018 / Updated August 2019 |
| J0121** | Inj., omadacycline, 1 mg (Nuzyra) | 1 MG | $ 3.657 | Added October 2019 |
| J0122** | Inj., eravacycline, 1 mg (Xerava) | 1 MG | $ 1.039 | Added October 2019 |
| J0135** | Adalimumab injection 20 MG (Humira) | Considered self-administered. | Added November 2019 | |
| J0200** | Alatrofloxacin mesylate (Trovan IV) | 100 MG | Invoice | |
| J0205** | Alglucerase injection (Ceredase) | 10 UNITS | Invoice | Added November 2019 |
| J0215** | Alefacept (Amevive) | 0.5 MG | Invoice | Added November 2019 |
| J0222** | Inj., patisiran, 0.1 mg (Onpattro) | 0.1 MG | $ 100.700 | Added October 2019 |
| J0270** | Alprostadil, 1.25 MCG | Considered self-administered. | ||
| J0275** | Alprostadil Urethral Suppository | Considered self-administered. | ||
| J0282** | Amiodarone Hcl | 30 MG | $ 0.424 | Updated August 2019 |
| J0288** | Ampho b cholesteryl sulfate (Amphotec) | 10 MG | Invoice | Added November 2019 |
| J0291** | Inj., plazomicin, 5 mg (Zemdri) | 5 MG | $ 3.339 | Added October 2019 |
| J0364** | Apomorphine Hydrochloride (Apokyn) | Considered self-administered. | Added November 2019 | |
| J0365** | Aprotinin (Trasylol) | 10000 KIU | Invoice | Added November 2019 |
| J0380** | metaraminol bitartrate, inj (Aramine) | 10 MG | Invoice | |
| J0390** | Chloroquine injection (Aralen Hcl) | 250 MG | Invoice | |
| J0395** | Arbutamine HCl injection (Genesa) | 1 MG | Invoice | |
| J0400** | Aripiprazole injection (Abilify) | 0.25 MG | Invoice | Added November 2019 |
| J0520** | Bethanechol chloride inject | Oral drug considered part of procedure in physician's office. | ||
| J0574** | Buprenorphine/Naloxone | Considered self-administered. | Added November 2019 | |
| J0593** | Inj., lanadelumab-flyo, 1 mg (Takhzyro) | 1 MG | $ 77.981 | Added October 2019 |
| J0620** | Calcium glycerophosphate/Calcium lactate (Calphosan) | 10 ML | Invoice | |
| J0630** | Calcitonin salmon injection (Miacalcin) | Considered self-administered. | Added November 2019 | |
| J0715** | Ceftizoxime sodium / 500 MG (Cefizox) | 500 MG | Invoice | |
| J0890** | Peginesatide injection (Omontys) | 0.1 MG | Invoice | Added November 2019 |
| J0945** | Brompheniramine Maleate | 10 MG | Invoice | Added November 2019 |
| J1094** | Dexamethasone Acetate | 1 MG | Invoice | Added November 2019 |
| J1096** | Dexametha opth insert 0.1 mg (Dextenza) | 0.1 MG | $ 142.790 | Added October 2019 |
| J1097** | Phenylep ketorolac opth soln (Omidria) | 1 ML | $ 123.225 | Added October 2019 |
| J1130** | Diclofenac sodium | 0.5 MG | Invoice | Added 05/2017 / Updated August 2019 |
| J1260** | Dolasetron mesylate (Anzemat) | 10 MG | $ 6.214 | Added November 2019 |
| J1267** | Doripenem injection | 10 MG | $ 0.764 | Added November 2019 |
| J1324** | Enfuvirtide | Considered self-administered. | ||
| J1327** | Eptifibatide injection (Integrilin) | 5 MG | $ 24.907 | Added November 2019 |
| J1330** | Ergonovine maleate, injection | 1 GM | Invoice | Added August 2019 |
| J1438** | Etanercept injection (Enbrel) | Considered self-administered. | Added November 2019 | |
| J1443** | Ferric Pyrophosphate Citrate Sol (Triferic) | 0.1 MG | Invoice | |
| J1444** | Inj, ferric pyrophosphate citrate powder, 0.1 mg of iron | 0.1 MG | Invoice | Added July 2019 |
| J1451** | Fomepizole, 15 mg | 15 MG | $ 11.357 | Added November 2019 |
| J1455** | Foscarnet sodium injection (Foscavir) | 1000 MG | $ 82.268 | Added November 2019 |
| J1457** | Gallium nitrate injection (Ganite) | 1 MG | Invoice | Added November 2019 |
| J1573** | Hepagam b intravenous, inj | 0.5 ML | $ 60.057 | Added November 2019 |
| J1590** | Gatifloxacin injection | Considered self-administered. | End Date 12/31/2016 | |
| J1595** | Injection glatiramer acetate | Considered self-administered. | ||
| J1600** | Gold sodium thiomaleate inj | 50 MG | Invoice | Added November 2019 |
| J1628** | Guselkumab (Tremfya) | 1 ML | $ 11,511.028 | Added October 2019 |
| J1675** | Histrelin Acetate | Considered self-administered. | ||
| J1680** | fibrinogen concentrate human | 100 MG | $ 103.550 | End Date 12/31/2012 |
| J1700** | Hydrocortisone acetate inj | 25 MG | Invoice | Updated August 2019 |
| J1710** | Hydrocortisone sodium ph inj | 50 MG | Invoice | |
| J1726** | Hydroxyprogesterone Caproate (Makena) | 10 MG | $ 28.940 | Added January 2018 / Updated August 2019 |
| J1790** | Droperidol injection | 5 MG | $ 4.887 | Added November 2019 |
| J1826** | Interferon beta-1a / 30 mcg (Avonex) | Considered self-administered. | Updated August 2019 | |
| J1830** | Interferon beta-1b / .25 MG | Not covered by carrier. | ||
| J1833** | Isavuconazonium Sulfate (Cresemba) | 1 MG | $ 0.899 | Updated August 2019 |
| J1840** | Kanamycin sulfate 500 MG inj (Kantrex) | 500 MG | Invoice | Added November 2019 |
| J1850** | Kanamycin sulfate 75 MG inj (Kantrex) | 75 MG | Invoice | Added November 2019 |
| J1890** | Cephalothin sodium injection | 1 G | Invoice | |
| J1945** | Lepirudin (Refludan) | 50 MG | Invoice | Added November 2019 |
| J1960** | Levorphanol tartrate | 2 MG | Invoice | Updated August 2019 |
| J1990** | Chlordiazepoxide injection | 100 MG | Invoice | |
| J2170** | Mecasermin | Considered self-administered. | ||
| J2180** | Meperidine and Promethazine hcl | 50 MG | Invoice | Added November 2019 |
| J2265** | Minocycline Hydrochloride | Considered self-administered. | ||
| J2278KD** | Ziconotide injection | 1 MCG | Invoice | |
| J2320** | Nandrolone decanoate 50 MG | 50 MG | Invoice | Updated August 2019 |
| J2325** | Nesiritide injection (Natrecor) | 0.1 MG | Invoice | Added December 2019 |
| J2354** | Octreotide Acetate inj, non-depot (Sandostatin) | Considered self-administered. | Added December 2019 | |
| J2355** | Oprelvekin injection (Neumega) | 5 MG | Invoice | Added December 2019 |
| J2370** | Phenylephrine hcl injection (Biorphen/Vazculep) | 1 ML | $2.120 | Eff. Date 11/1/2019 - Added December 2019 |
| J2410** | Oxymorphone hcl injection (Numorphan hcl/Opana) | 1 MG | Invoice | Added December 2019 |
| J2440** | Papaverin hcl injection | 60 MG | $36.400 | Added December 2019 |
| J2502** | Pasireotide (Signifor LAR) | 1 MG | $223.979 | Updated August 2019 |
| J2513** | Pentastarch 10% solution | 10% | Invoice | |
| J2547** | Peramivir (Rapivab) | 1 MG | $1.678 | |
| J2590** | Oxytocin injection (Pitocin) | 10 UNITS | $0.859 | Added December 2019 |
| J2650** | Prednisolone acetate (Cotolone/Key-Pred) | 1 ML | Invoice | Updated August 2019 |
| J2670** | Tolazoline hcl injection | 25 MG | Invoice | |
| J2730** | Pralidoxime chloride inj (Protopam Chloride) | 1 GM | $91.902 | Added December 2019 |
| J2797** | Rolapitant (Varubi) | 0.5 MG | $0.939 | Added January 2019 / Updated August 2019 |
| J2840** | Seblipase alfa (Kanuma) | 1 MG | $541.130 | Added January 2017 / Updated August 2019 |
| J2850** | Inj secretin synthetic human (Chirhostim) | 1 MCG | $27.494 | Added December 2019 |
| J2940** | Somatrem injection | Considered self-administered. | ||
| J2941** | Somatropin injection | Considered self-administered. | ||
| J2950** | Promazine HCL (Sparine) | 25MG | Invoice | |
| J3030** | Sumatriptan Succinate | Considered self-administered. | ||
| J3031** | Inj. Fremanezumab-vfrm (Ajovy) | 1 MG | $ 2.709 | Added October 2019 |
| J3110** | Teriparatide injection | Considered self-administered. | ||
| J3265** | Injection torsemide 10 mg/ml | 10 MG | Invoice | Updated August 2019 |
| J3280** | Thiethylperazine maleate, inj | 10 MG | Invoice | |
| J3310** | Perphenazine | 5 MG | $ 1.476 | |
| J7121** | 5% Dextrose in lactated ringers | 1000 CC | Invoice | |
| J7130** | Hypertonic saline solution | 20 CC | Invoice | |
| J7191** | Factor viii (porcine) | 1 IU | Invoice | |
| J7296** | Levonorgestrel releasing intrauterine contraceptive system, (Kyleena) | 19.5 MG | $ 1,010.721 | Added January 2018 / Updated August 2019 |
| J7314** | Inj, yutiq | 0.01 MG | $ 491.333 | Added October 2019 |
| J7315** | Mitomycin - ophthalmic 0.2 mg topical solution | Considered part of procedure | Added September 2018 | |
| J7318** | Hyaluronic acid (Durolane) | 1 MG | $ 17.225 | Added January 2019/updated June 2019 |
| J7320** | Hyaluronate sodium or derivative (Genvisc 850) | 1 MG | $ 16.918 | Added October 2018/Updated pricing 04/15/2019 |
| J7322** | Hyaluronic acid (Hymovis) | 1 MG | $ 31.668 | Added January 2017/ Updated July 2017 / Updated August 2019 |
| J7326** | Hyaluronate sodium (Gel-One) | per dose-30 MG/3 ML | $ 1,166.000 | Added January 2019/updated June 2019 |
| J7328** | Hyaluronan or derivative, gel-syn (Gelsyn-3) | 0.1 MG | $ 2.177 | |
| J7331** | Synojoynt, inj. | 1 MG | Invoice | Added October 2019 |
| J7332** | Inj., triluron, 1 mg | 1 MG | $ 25.917 | Added October 2019 |
| J7342** | Ciprofloxacin (otic suspension) (OTIPRIO) | 6 MG/1ML | $ 30.019 | Added 05/10/2018 |
| J7401** | Mometasone furoate sinus imp (Sinuva Sinus Implant) | 10 MCG | $ 10.011 | Added October 2019 |
| J7604 - J7699** | Inhalation Solutions | Considered part of procedure in physician's office. | Updated March 2019 | |
| J8561** | Everolimus, 0.25 MG | Should be billed to DMAC. | End Date 12/31/2012 | |
| J9057** | Copanlisib (Aliqopa) | 1 MG | $ 82.420 | Added January 2019 / Updated August 2019 |
| J9118** | Inj. Calaspargase pegol-mknl | 10 UNITS | Invoice | Added October 2019 |
| J9165** | Diethylstilbestrol diphosphate injection | 250 MG | Invoice | |
| J9210** | Inj., emapalumab-lzsg, 1 mg (Gamifant) | 1 MG | $ 786.732 | Added October 2019 |
| J9213** | Interferon alfa-2a inj | 3 MIL UNITS | Invoice | |
| J9215** | Interferon, alfa-n3 (Alferon-N) | 250,000 IU | $ 31.800 | Updated August 2019 |
| J9269** | Inj. Tagraxofusp-erzs 10 mcg (Elzonris) | 10 MCG | $ 270.611 | Added October 2019 |
| J9270** | Plicamycin (mithramycin) inj | 2.5 MG | Invoice | |
| J9313** | Inj., lumoxiti, 0.01 mg | 0.01 MG | $ 22.083 | Added October 2019 |
| J9600** | Porfimer Sodium injection (Photofrin) | 75 MG | $ 22,302.400 | Updated August 2019 |
| Q0174** | Thiethylperazine maleate, 10mg | Should be billed to DMAC. | ||
| Q0179** | Ondansetron hcl 9 mg oral | Should be billed to DMAC. | End Date 12/31/2011 | |
| Q0181** | Unspecified oral dosage form, FDA approved presription anti-emetic | Should be billed to DMAC. | ||
| Q2026** | Radiesse injection | 0.1 ML | Invoice | |
| Q2028** | Sculptra | 0.5 MG | Invoice | |
| Q2034** | Agriflu | 0.05 ML | Invoice | |
| Q2036** | Flulaval Quadrivalent 3 yrs & >, im | 0.05 ML | Invoice | No new pricing available for the 2019-2020 flu season. |
| Q2037 | Fluvirin vacc, 3 yrs & >, im | 0.5 ML | Invoice | No new pricing available for the 2019-2020 flu season. |
| Q2038 | Fluzone vacc, 3 yrs & >, im | 0.5 ML | Invoice | No new pricing available for the 2019-2020 flu season. |
| Q2039** | Not Otherwise Classified flu vacc, 3 yrs & >, im | 0.5 ML | Invoice | Effective 01/01/2018 forward use CPT code 90756 for Flucelvax and 90674 for Flucelvax-no preservatives |
| Q2040** | tisagenlecleucel (Kymriah) | Per infusion | $503,500.000 | Added January 2018 / End Date 12/31/2018 |
| Q4103** | Oasis Burn Matrix | 1 SQ CM | Invoice | Added May 2019 |
| Q4105** | Integra Omnigraft | 1 SQ CM | Invoice | See Note: 4 |
| Q4114** | Integra flowable wound matri | 1 CC | Invoice | Added May 2019 / See Note: 4 |
| Q4116** | Alloderm skin sub | 1 SQ CM | Invoice | Added May 2019 / See Note: 4 |
| Q4117** | Hyalomatrix | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4118** | Matristem Micromatrix | 1 MG | Invoice | See Note: 4 |
| Q4119** | Matristem Micromatrix | 1 SQ CM | Invoice | See Note: 4 |
| Q4122** | Dermacell, awm porous sq cm | 1 SQ CM | Invoice | See Note: 4 |
| Q4123** | Alloskin RT | 1 SQ CM | Invoice | Added May 2019 |
| Q4124** | Oasis Ultra Tri-Layer Wound Matrix | 1 SQ CM | Invoice | See Note: 4 |
| Q4125** | Arthroflex | 1 SQ CM | Invoice | See Note: 4 |
| Q4126** | Memoderm | 1 SQ CM | Invoice | See Note: 4 |
| Q4127** | Talymed | 1 SQ CM | Invoice | See Note: 4 |
| Q4128** | Flex HD or Allopatch HD | 1 SQ CM | Invoice | See Note: 4 |
| Q4129** | Unite Biomatrix | 1 SQ CM | Invoice | End Date 12/31/2016 |
| Q4130** | Strattice TM | 1 SQ CM | Invoice | See Note: 4 |
| Q4136** | E-Z Derm | 1 SQ CM | Invoice | Added 04/05/2018 |
| Q4138** | Biodfence dryflex | 1 SQ CM | Invoice | See Note: 4 |
| Q4139* | Amniomatrix or Biodmatrix | 1 CC | Invoice | See Note: 4 |
| Q4140** | Biodfence | 1 SQ CM | Invoice | See Note: 4 |
| Q4141** | Alloskin ac | 1 SQ CM | Invoice | See Note: 4 |
| Q4142** | Xcm Biologic Tissue Matrix | 1 SQ CM | Invoice | See Note: 4 |
| Q4143** | Repriza | 1 SQ CM | Invoice | See Note: 4 |
| Q4146** | Tensix | 1 SQ CM | Invoice | See Note: 4 |
| Q4147** | Architect Extracellular Matrix | 1 SQ CM | Invoice | See Note: 4 |
| Q4148** | Neox 1k | 1 SQ CM | Invoice | See Note: 4 |
| Q4149** | Excellagen | 0.1 CC | Invoice | See Note: 4 |
| Q4152** | Dermapure | 1 SQ CM | Invoice | See Note: 4 |
| Q4158** | Kerecis Omega3 Wound (Marigen) | 1 SQ CM | Invoice | See Note: 4 |
| Q4161** | Bio-connekt | 1 SQ CM | Invoice | See Note: 4 |
| Q4162** | Amnio bio, woundex flow | 1 SQ CM | Invoice | See Note: 4 |
| Q4163** | Amnio bio, woundex | 1 SQ CM | Invoice | See Note: 4 |
| Q4164** | Helicoll | 1 SQ CM | Invoice | See Note: 4 |
| Q4165** | Keramatrix | 1 SQ CM | Invoice | See Note: 4 |
| Q4169** | Artacent Wound | 1 SQ CM | Invoice | Added 07/2018 |
| Q4172** | PuraPly | 1 SQ CM | Invoice | Added May 2019 / End Date 12/31/2018 |
| Q4173** | Palingen or Palingen Xplus | 1 SQ CM | Invoice | Added 11/02/17 |
| Q4174** | Palingen or promatrx | 1 SQ CM | Invoice | Added 05/2018 |
| Q4175** | MicroDerm | 1 SQ CM | Invoice | Added 10/17 |
| Q4176** | Neopatch | 1 SQ CM | Invoice | Added January 2018 |
| Q4177** | Floweramnioflo | 0.1 CC | Invoice | Added January 2018 |
| Q4178** | Floweraminopatch | 1 SQ CM | Invoice | Added January 2018 |
| Q4179** | Flowerderm | 1 SQ CM | Invoice | Added January 2018 |
| Q4180** | Revita | 1 SQ CM | Invoice | See Note: 4 |
| Q4181** | Amino wound | 1 SQ CM | Invoice | Added January 2018 |
| Q4182** | Transcyte | 1 SQ CM | Invoice | Added January 2018 |
| Q4184** | Cellesta or duo per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4187** | Epicord | 1 SQ CM | Invoice | Added April 2019 |
| Q4205** | Membrane graft or wrap sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4206** | Fluid flow or fluid gf 1 cc | 1 CC | Invoice | Added October 2019 / See Note: 4 |
| Q4208** | Novafix per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4209** | Surgraft per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4210** | Axolotl graf dualgraf sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4211** | Amnion bio or axobio sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4212** | Allogen, per cc | 1 CC | Invoice | Added October 2019 / See Note: 4 |
| Q4213** | Ascent, 0.5 mg | 0.5 MG | $44.167 | Updated December 2019 |
| Q4214** | Cellesta cord per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4215** | Axolotl ambient, cryo 0.1 mg | 0.1 MG | Invoice | Added October 2019 / See Note: 4 |
| Q4216** | Artacent cord per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4217** | Woundfix biowound plus xplus | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4218** | Surgicord per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4219** | Surgigraft dual per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4220** | Bellacell HD, Surederm sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4221** | Amniowrap2 per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4222** | Progenamatrix, per sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q4226** | Myown harv prep proc sq cm | 1 SQ CM | Invoice | Added October 2019 / See Note: 4 |
| Q5112** | Inj, ontruzant 10mg | 10 MG | Invoice | Added July 2019 |
| Q5113** | Inj, herzuma 10mg | 10 MG | Invoice | Added July 2019 |
| Q5114** | Inj, ogivri 10mg | 10 MG | Invoice | Added July 2019 |
| Q5115** | Inj, rituximab-abbs, bio 10mg (Truxima) | 10 MG | $ 89.628 | Added July 2019 - Invoice Price Eff. 11/09/2019 |
| Q5116** | Inj., trazimera, 10 mg | 10 MG | Invoice | Added October 2019 |
| Q5118** | Inj., zirabev, 10 mg | 10 MG | Invoice | Added October 2019 |
| Q9953** | Iron Based Magnetic Resonance Contrast Agent | 1 ML | Invoice | |
| Q9955** | Inj perflexane lip micros, ml | 1 ML | Invoice | |
| Q9980** | Genvisc | 1 MG | $ 9.765 | End Date 12/31/2016 |
| Q9985** | Hydroxyprogesterone Caporate (other forms) | Invoice | End Date 12/31/2017 | |
| Q9986** | Hydroxyprogesterone Caporate (Makena) | 10 MG | $ 32.408 | End date 12/31/2017/ see new code J1726 |
| Q9988** | Platelets, Pathogen Reduced | Invoice | Added 10/17 / End Date 12/31/2017 | |

