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Local Carrier Payment Allowance Limits for Medicare Part B Drugs – Effective April 1, 2021 through June 30, 2021

Revised: 01.14.22

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 1Q21 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 2020-2021 flu season.
90654 Flu vaccine, intradermal, no preserv Non FDA Approved No new pricing available for the 2020-2021 flu season.
90655 Flu vaccine no preserv 6-35m, im 0.25 ML Invoice No new pricing available for the 2020-2021 flu season.
90657 Flu vaccine, 6-35 mo, im 0.25 ML Invoice No new pricing available for the 2020-2021 flu season.
90661 Flu vaccine, derived from cell cultures, subunit 45 MCG/0.5 ML Invoice No new pricing available for the 2020-2021 flu season.
90666 Influenza virus vaccine Per Carrier Medical Director not covered by Part B.  
90673 Flublok, trivalent 18 & > 0.5 ML Invoice No new pricing available for the 2020-2021 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
91303** Janssen COVID-19 Vaccine 0.5 ML 0.01 Added September 2021
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
C9076** Lisocabtagene maraleucel (Breyanzi) Should be billed to Part A   Added August 2021
A9606** Radium Ra 223 dichloride (Xofigo) MicroCurie $ 149.364 Eff:1/1/2015 /  Pricing change EFF 10/01/17 / price change 7/2018 / Updated August 2019 / Updated April 2020 / Updated October 2020 / Updated January 2021
G2216** Naloxone - injectable 1 MG $ 11.226 Added January 2021
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
J0364** Apomorphine Hydrochloride (Apokyn) Considered self-administered. Added November 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 Added October 2020
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 Invoice Added November 2019 / Updated October 2020
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
J1437** Ferric derisomaltose (Monoferric) 10 MG 26.121 Added January 2021 / Eff. 9/25/2020
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 $ 82.679 Added November 2019 / Updated January 2021
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 $ 65.605 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 / Updated October 2020
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 $ 7.918 Added November 2019 / Updated October 2020
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.  
J2278** Ziconotide injection 1 MCG $ 8.395 Updated April 2021
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 $ 0.742 Eff. Date 11/1/2019 - Added December 2019 / Updated October 2020
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 / Updated October 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 / Updated October 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
J2787 Riboflavin 5'-phosphate (Photrexa, Viscous/Photrexa )     If billed with 0402T, considered part of the procedure. If billed without 0402T, considered not reasonable & necessary. Updated  June 2021.
J2797** Rolapitant (Varubi) 0.5 MG Invoice Added January 2019 / Updated August 2019
/ Updated April 2020 / Updated October 2020
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 $ 28.262 Added January 2020 / Updated January 2021
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
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 $ 1,219.000 Added January 2019 / Updated June 2019 / Updated October 2020
J7328** Hyaluronan or derivative, gel-syn (Gelsyn-3) 0.1 MG $ 2.177  
J7329** Hyaluronate sodium (Trivisc) 1 MG $ 19.120 Added January 2021 - Effective 12/1/2020 / Updated April 2021
J7330** Cultured chondrocytes implnt (Maci) 1 EA Invoice Added January 2020
J7332** Inj., triluron, 1 mg 1 MG $ 25.917 Added October 2019
J7333** Hyaluronate Sodium (Visco-3) 25 MG $ 352.980 Added July 2020
J7401** Mometasone furoate sinus imp (Sinuva Sinus Implant) 10 MCG $ 10.775 END DATE 03/31/2021
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 / Updated December 2021
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) 100MG $ 40.280 Added March 2021 / CMS priced April 2021
J9199** Gemcitabine Hydrochloride (Infugem) 200 MG $ 80.560 Added March 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
J9270** Plicamycin inj (Mithracin) 2.5 MG Invoice  
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 2020-2021 flu season.
Q2036** Flulaval Quadrivalent 3 yrs & >, im 0.05 ML Invoice No new pricing available for the 2020-2021 flu season.
Q2037** Fluvirin vacc, 3 yrs & >, im 0.5 ML Invoice No new pricing available for the 2020-2021 flu season.
Q2038** Fluzone vacc, 3 yrs & >, im 0.5 ML Invoice No new pricing available for the 2020-2021 flu season.
Q2039** Not Otherwise Classified flu vacc, 3 yrs & >, im 0.5 ML Invoice Updated November 2021
Q2040** tisagenlecleucel (Kymriah) Per infusion $503,500.000 Added January 2018 / End Date 12/31/2018
Q2041** Axicabtagene ciloleucel (Yescarta) Should be billed to Part A   Added August 2021
Q2042** Tisagenlecleucel (Kymriah) Should be billed to Part A   Added August 2021
Q2047** Peginesatide injection (Omontys) 0.1 MG Invoice End Date 12/31/2012
Q2049** Imported Lipodox injection 10 MG $ 508.429 Added January 2020
Q2053** Brexucabtagene autoleucel (Tecartus) Should be billed to Part A   Added April 2021 / Updated August 2021
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
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
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
Q4197** Puraply XT 1 SQ CM Invoice Added June 2020 / See Note: 4
Q4203** Geistlich Derma-Gide 1 sq cm 1 SQ CM Invoice Added October 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 $ 65.720 Updated December 2019 /
Eff. 5/28/2020 - Updated June 2020 / Updated October 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
Q4234** Xcellerate amniotic membrane human   Invoice Added July 2021 / See Note: 4
Q4237** Cyro-Cord 1 SQ CM Invoice Added July 2020 / See Note: 4
Q4238** Derm-Maxx 1 SQ CM Invoice Added July 2020 / See Note: 4
Q4239** Amnio-Maxx or Amnio-Maxx Lite 1 SQ CM Invoice Added July 2020 / See Note: 4
Q4254** Novafix per sq cm Considered investigational   Added September 2021
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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