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Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective April 1, 2020 through June 30, 2020

Revised: 03.26.21

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.htmlExternal Website

Note 2: Payment allowance limits subject to the ASP methodology are based on 3Q18 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: ** - 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
A9500** Tc99m sestamibi per study dose Invoice Added February 2020
A9502** Tc99m tetrofosmin per study dose Invoice Added February 2020
A9513** lutetium lu 177 dotatate (Lutathera) 1 MCI $ 266.590 Updated dosage and pricing eff 01/01/2019 Updated pricing Eff June 2019/ Updated price July 2019 / Updated April 2020
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 $ 145.199 Eff:1/1/2015 / Pricing change EFF 10/01/17 / price change 7/2018 / Updated August 2019 / Updated April 2020
J0120** Tetracycline   Invoice Added January 2020
J0130** Abciximab injection (Reopro) 10 MG Invoice Added April 2020
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
J0210** Methyldopate hcl injection 250 MG $ 42.400 Added January 2020
J0215** Alefacept (Amevive) 0.5 MG Invoice Added November 2019
J0220** Alglucosidase alfa 10 MG Invoice Added April 2020
J0270** Alprostadil, 1.25 MCG (Caverjet, Edex) 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 January 2020
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.  
J0573** Buprenorphine/naloxone (Suboxone) Considered part of procedure. Added March 2020
J0574** Buprenorphine/Naloxone Considered self-administered. Added November 2019
J0593** Inj., lanadelumab-flyo, 1 mg (Takhzyro) Considered self-administered. Added October 2019 / Updated January 2020
J0599** Injection, C-1 esterase inhibitor (human) (Haegarda) Considered self-administered. Added January 2020
J0620** Calcium glycerophosphate/Calcium lactate (Calphosan) 10 ML Invoice  
J0630** Calcitonin salmon injection (Miacalcin) Considered self-administered. Added November 2019
J0706** Caffeine citrate injection (Cafcit) 5 MG $ 1.855 Added January 2020
J0715** Ceftizoxime sodium / 500 MG (Cefizox) 500 MG Invoice  
J0745** Inj codeine phosphate / 30 MG 30 MG Invoice Added January 2020
J0800** Corticotropin injection (Acthar) Considered self-administered. Added January 2020
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 (Fuzeon) 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
J1559** Hizentra injection Considered self-administered. Added January 2020
J1562** Injection, Immune Globulin (Vivaglobin) Considered self-administered. Added January 2020
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 (Copaxone, Glatopa) Considered self-administered.  
J1600** Gold sodium thiomaleate inj 50 MG Invoice Added November 2019
J1628** Guselkumab (Tremfya) 1 ML $ 12,075.064 Added October 2019 / Updated April 2020
J1675** Histrelin Acetate (Supprelin) 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
J1741** Ibuprofen injection Considered self-administered. Added January 2020
J1744** Injection, Icatibant, 1 mg (Firazyr) Considered self-administered. Added January 2020
J1790** Droperidol injection 5 MG $ 4.887 Added November 2019
J1815** Insulin injection Considered self-administered. Added January 2020
J1817** Insulin for insulin pump use Considered self-administered. Added January 2020
J1823** Nebilizumab-cdon (Uplizna) 10 MG 4628.67 Added January 2021 - Effective 6/11/2020
J1826** Interferon beta-1a / 30 mcg (Avonex) Considered self-administered. Updated August 2019
J1830** Interferon beta-1b / .25 MG (Betaseron, Extavia) Considered self-administered.  
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 (Increlex) Considered self-administered.  
J2180** Meperidine and Promethazine hcl 50 MG Invoice Added November 2019
J2212** Injection, Methylnaltrexone, 0.1 mg (Relistor) Considered self-administered. Added January 2020
J2265** Minocycline Hydrochloride (Minocin) 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 Considered self-administered. Added December 2019 / Updated January 2020
J2502** Pasireotide (Signifor LAR) 1 MG $ 230.698 Updated August 2019 / Updated April 2020
J2504** Pegademase bovine (Adagen) 25 IU $ 367.961 Added April 2020
J2513** Pentastarch 10% solution (Pentaspan) 10% Invoice  
J2547** Peramivir (Rapivab) 1 MG $ 1.678  
J2590** Oxytocin injection (Pitocin) 10 UNITS $ 0.919 Added January 2019 / Updated August 2019
/ Updated April 2020
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
J2810** Inj theophylline per 40 MG 40 MG Invoice Added January 2020
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  
J2993** Reteplase injection (Retavase) 18.1 MG Invoice Added January 2020
J3030** Sumatriptan Succinate (Imitrex) Considered self-administered.  
J3031** Inj. Fremanezumab-vfrm (Ajovy) Considered self-administered. Added October 2019 / Updated January 2020
J3070** Pentazocine injection 30 MG Invoice Added January 2020
J3110** Teriparatide injection (Forteo) Considered self-administered.  
J3246** Tirofiban Hcl (Aggrastat) 0.25 MG $ 10.978 Added January 2020
J3265** Injection torsemide 10 mg/ml (Demadex) 10 MG Invoice Updated August 2019
J3280** Thiethylperazine maleate, inj (Norzine, Torecan) 10 MG Invoice  
J3303** Triamcinolone hexacetonl inj (Aristospan) 5 MG Invoice Added January 2020
J3310** Perphenazine (Trilafon) 5 MG Invoice Updated January 2020
J3355** Urofollitropin, 75 iu (Bravelle) Considered self-administered. Added January 2020
J3365** Urokinase 250,000 IU inj (Abbokinase) 250000 IU Invoice Added January 2020
J3470** Hyaluronidase injection (Amphadase) 150 UNITS $ 59.148 Added January 2020
J7100** Dextran 40 infusion (LMD in dextrose) 500 ML $ 28.122 Added January 2020
J7110** Dextran 75 infusion 500 ML Invoice Added January 2020
J7121** 5% Dextrose in lactated ringers 1000 CC Invoice  
J7130** Hypertonic saline solution 20 CC Invoice  
J7131** Hypertonic saline solution 1 ML Invoice Added January 2020
J7191** Factor viii (porcine) (Hyate:C) 1 IU Invoice  
J7296** Levonorgestrel releasing intrauterine contraceptive system, (Kyleena) 19.5 MG $ 1,010.721 Added January 2018 / Updated August 2019
J7309** Methyl Aminolevulinate, top (Metvixia) 1 GM Invoice Added January 2020
J7310** Ganciclovir long act implant (Vitrasert) 4.5 MG Invoice Added January 2020
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  
J7330** Cultured chondrocytes implnt (Maci) 1 EA Invoice Added January 2020
J7331** Synojoynt, inj. 1 MG Invoice Added October 2019
J7332** Inj., triluron, 1 mg 1 MG $ 25.917 Added October 2019
J7401** Mometasone furoate sinus imp (Sinuva Sinus Implant) 10 MCG $ 10.461 Added October 2019 / Updated January 2020
J7500** Azathioprine oral 50 mg (Azasan) Should be billed to DMAC. Added January 2020
J7501** Azathioprine parenteral 100 MG $ 265.000 Added January 2020
J7502** Cyclosporine oral 100 mg Should be billed to DMAC. Added January 2020
J7503** Tacrol envarsus (Envarsus XR) Considered self-administered. Added January 2020
J7505** Monoclonal anitibodies 5 MG Invoice Added January 2020
J7507** Tacrolimus oral per 1 mg (Prograf) Should be billed to DMAC. Added January 2020
J7508** Tacrolimus Ex Rel oral 0.1 mg (Astagraf XL) Should be billed to DMAC. Added January 2020
J7509** Methylprednisolone oral Should be billed to DMAC. Added January 2020
J7510** Prednisolone oral per 5 mg Should be billed to DMAC. Added January 2020
J7512** Prednisone ir or dr oral 1 mg Considered self-administered. Added January 2020
J7513** Daclizumab, parenteral (Zenapax, Zinbryta) 25 MG Invoice Added January 2020
J7515** Cyclosporine oral 25 mg Should be billed to DMAC. Added January 2020
J7517** Mycophenolate mofetil oral (Cellcept) Should be billed to DMAC. Added January 2020
J7518** Mycophenolic acid (Myfortic) Should be billed to DMAC. Added January 2020
J7520** Sirolimus, oral (Rapamune) Should be billed to DMAC. Added January 2020
J7527** Oral Everolimus (Afinitor, Zortress) Should be billed to DMAC. Added January 2020
J7604 - J7699** Inhalation Solutions Considered part of procedure in physician's office. Updated March 2019
J8499** Estramustine Phosphate Sodium (Emcyt) Should be billed to DMAC. Added January 2020
J8501** Oral aprepitant (Emend) Should be billed to DMAC. Added January 2020
J8510** Oral busulfan (Myleran) Should be billed to DMAC. Added January 2020
J8520** Capecitabine, oral, 150 mg (Xeloda) Should be billed to DMAC. Added January 2020
J8521** Capecitabine, oral, 500 mg (Xeloda) Should be billed to DMAC. Added January 2020
J8530** Cyclophosphamide oral 25 mg Should be billed to DMAC. Added January 2020
J8540** Oral dexamethasone (Hidex, Taperdex) Should be billed to DMAC. Added January 2020
J8560** Etoposide oral 50 mg Should be billed to DMAC. Added January 2020
J8561** Everolimus, 0.25 MG Should be billed to DMAC. End Date 12/31/2012
J8562** Oral fludarabine phosphate (Oforta) Should be billed to DMAC. Added January 2020
J8600** Melphalan oral 2 mg (Alkeran) Should be billed to DMAC. Added January 2020
J8610** Methotrexate oral 2.5 mg (Xatmep, Trexall) Should be billed to DMAC. Added January 2020
J8655** Netupitant Palonosetron oral (Akynzeo) Should be billed to DMAC. Added January 2020
J8700** Temozolomide (Temodar) Should be billed to DMAC. Added January 2020
J8705** Topotecan oral (Hycamtin) Should be billed to DMAC. Added January 2020
J9015** Aldesleukin injection (Proleukin) 1 EA $ 4,964.616 Added January 2020
J9020** Asparaginase injection (Elspar) 10000 UNITS Invoice Added January 2020
J9057** Copanlisib (Aliqopa) 1 MG $ 82.420 Added January 2019 / Updated August 2019
J9098** Cytarabine liposome inj (Depocyt) 10 MG Invoice Added January 2020
J9118** Inj. Calaspargase pegol-mknl (Asparlas) 10 UNITS $ 67.840 Added October 2019 / Updated January 2020
J9151** Daunorubicin citrate inj (Daunoxome) 10 MG Invoice Added January 2020
J9160** Denileukin diftitox inj (Ontak) 300 MCG Invoice Added January 2020
J9165** Diethylstilbestrol diphosphate injection (Stilphostrol) 250 MG Invoice  
J9175** Elliotts b solution per ml 1 ML $ 8.373 Added January 2020
J9198** gemcitabine hydrochloride (Infugem) 100 MG $40.280 Added March 2021
J9199** Gemcitabine Hydrochloride (Infugem) 200 MG $ 80.560 Added March 2020
J9210** Inj., emapalumab-lzsg, 1 mg (Gamifant) 1 MG $ 357.963 Added October 2019 / Updated January 2020
J9212** Inj., interferon alfacon-1, recomb, 1 mcg (Pegasys) Considered self-administered. Added January 2020
J9213** Interferon alfa-2a inj (Roferon-A) Considered self-administered. Updated January 2020
J9215** Interferon, alfa-n3 (Alferon-N) 250,000 IU $ 31.800 Updated August 2019
J9216** Injection, interferon, gamma 1-B, 3 million units (Actimmune) Considered self-administered. Added January 2020
J9218** Leuprolide acetate injection (Lupron) Considered self-administered. Added January 2020
J9219** Leuprolide acetate implant 65 MG Invoice Added January 2020
J9230** Mechlorethamine hcl inj (Mustargen) 10 MG Invoice Added January 2020
J9269** Inj. Tagraxofusp-erzs 10 mcg (Elzonris) 10 MCG $ 270.611 Added October 2019
J9270** Plicamycin inj (Mithracin) 2.5 MG Invoice  
J9313** Inj., lumoxiti, 0.01 mg 0.01 MG $ 22.415 Added October 2019 / Updated January 2020
J9600** Porfimer Sodium injection (Photofrin) 75 MG $ 22,302.400 Updated August 2019
P9043** Plasma protein fract, 5%, 50 ml (Plasmanate 50 ml) 50 ML $ 23.871 Added January 2020
P9048** Plasma protein fract, 5%, 250 ml (Plasmanate 250 ml) 250 ML $ 56.063 Added January 2020
Q0163** Diphenhydramine HCl 50mg (Alercap, Banophen, Benadryl) Should be billed to DMAC. Added January 2020
Q0164** Prochlorperazine maleate 5mg Should be billed to DMAC. Added January 2020
Q0166** Granisetron hcl 1 mg oral Should be billed to DMAC. Added January 2020
Q0167** Dronabinol 2.5mg oral (Marinol) Should be billed to DMAC. Added January 2020
Q0169** Promethazine HCl 12.5mg oral Should be billed to DMAC. Added January 2020
Q0174** Thiethylperazine maleate, 10mg Should be billed to DMAC.  
Q0179** Ondansetron hcl 8 mg oral Should be billed to DMAC. End Date 12/31/2011
Q0180** Dolasetron mesylate oral (Anzemet) Should be billed to DMAC. Added January 2020
Q0181** Unspecified oral dosage form, FDA approved presription anti-emetic Should be billed to DMAC.  
Q0515** Sermorelin acetate injection 1 MCG Invoice Added January 2020
Q2009** Fosphenytoin inj PE (Cerebyx) 50 MG $ 5.062 Added January 2020
Q2017** Teniposide, 50 mg 50 MG $ 2,645.707 Added January 2020
Q2026** Radiesse injection 0.1 ML Invoice  
Q2028** Sculptra 0.5 MG Invoice  
Q2033** Flublok (quadravalent form) 0.5 ML Invoice Added January 2020
Q2034** Agriflu 0.05 ML Invoice  
Q2035** Afluria vacc, 3 yrs & >, im 0.5 ML Invoice No new pricing available for the 2019-2020 flu season.
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
Q2047** Peginesatide injection (Omontys) 0.1 MG Invoice End Date 12/31/2012
Q2049** Imported Lipodox injection 10 MG $ 508.429 Added January 2020
Q4074** Iloprost non-comp unit dose (Ventavis) Considered part of procedure in physician's office. Added January 2020
Q4100** Skin substitutes; not otherwise specified 1 SQ CM Invoice Added June 2020 / See Note: 4
Q4103** Oasis Burn Matrix 1 SQ CM Invoice Added May 2019
Q4104** Integra BMWD skin sub 1 SQ CM Invoice Added January 2020 / See Note: 4
Q4105** Integra Omnigraft 1 SQ CM Invoice See Note: 4
Q4107** Graftjacket skin sub 1 SQ CM Invoice Added January 2020 / See Note: 4
Q4108** Integra matrix skin sub 1 SQ CM Invoice Added January 2020 / See Note: 4
Q4112** Cymetra allograft 1 CC Invoice Added January 2020 / See Note: 4
Q4113** Graftjacket express allograf 1 CC Invoice Added January 2020 / 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 End Date 12/31/2016
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
Q4131** Epifix 1 SQ CM Invoice End Date 12/31/2018
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
Q4153** Dermavest and Plurivest 1 SQ CM Invoice Added April 2020 / See Note: 4
Q4158** Kerecis Omega3 Wound (Marigen) 1 SQ CM Invoice See Note: 4
Q4159** Affinity 1 SQ CM Invoice Added April 2020 / 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
Q4166** Cytal Wound/Burn Matrix 1 SQ CM Invoice Added January 2020 / See Note: 4
Q4169** Artacent Wound 1 SQ CM Invoice Added 07/2018
Q4170** Cygnus 1 SQ CM Invoice Added April 2020 / See Note: 4
Q4172** PuraPly 1 SQ CM Invoice 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
Q4197** Puraply XT 1 SQ CM Invoice Added June 2020 / See Note: 4
Q4205** Membrane graft or wrap sq cm 1 SQ CM Invoice Added October 2019 / See Note: 4
Q4206** Fluid flow or fluid gf 1 ML $ 2,120.000 Added October 2019 / Updated June 2020 / Updated September 2020
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 $ 55.208 Updated December 2019 /
Eff. 5/28/2020 - Updated June 2020
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
Q4231** Corplex P 1 SQ CM Invoice Added June 2020 / See Note: 4
Q4232** Corplex 1 SQ CM Invoice Added June 2020 / See Note: 4
Q5112** Inj, ontruzant 10mg 10 MG Invoice Added July 2019
Q5113** Inj, herzuma 10mg 10 MG Invoice Added July 2019
Q9953** Iron Based Magnetic Resonance Contrast Agent 1 ML Invoice  
Q9954** Oral MR contrast, 100 ml 100 ML Invoice Added January 2020
Q9955** Inj perflexane lip micros, ml (Imagent) 1 ML Invoice  
Q9962** HOCM 300-349 mg/ml iodine, 1 ml 1 ML Invoice Added January 2020
Q9968** Inj Non-Radioactive, Non contrast   Invoice Added January 2020
Q9969** Tc-99m from non-highly uranium source   Invoice Added January 2020
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
Q9988** Platelets, Pathogen Reduced   Invoice End Date 12/31/2017

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