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

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

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

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

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

AMA Disclaimer of Warranties and Liabilities.

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

CMS Disclaimer

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

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

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

End User License Agreement

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

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

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

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

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

Print | Bookmark | Font Size: + | –

September 27, 2010 - Revised 03.28.11

4th Quarter Update Part B Not Otherwise Classified Drug Fee Schedule

2010 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

Effective October 1, 2010 through December 31, 2010

Revised: 03/28/2011

Name of Drug and EXACT Dosage Given MUST be in Block 19 (paper), as an Attachement, or Narrative Field (EMC)

NOTE 1: Payment allowance limits subject to the ASP methodology are based on 2Q10 ASP data.

NOTE 2: Providers should contact their local Medicare contractor processing the claim for the most appropriate unlisted/unclassified HCPCS code to use in reporting these drugs to Medicare.

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.

** - Carrier Priced

Changes In Bold

DRUG NAME	DOSAGE	Current PAR	Current NON-PAR	Notes
Actemra (see Tocilizumab)
Alfentanil Hydrochloride (Alfenta)	500 mcg/5 ml	$1.152	$1.094
Alglucosidase Alfa (Myozyme)	10 mg	$148.400	$140.980
Allopurinol Sodium (Aloprim) ICD-9's 274.9 or 790.6 plus the ICD-9 for the neoplasm. Need name of chemotherapy agent causing the elevation of uric acid and a statement as to why patient can not tolerate oral form of the drug.	500 mg/SDV	$363.965	$345.767
Amidate (see Etomidate)
Amino Acid	500 ml	$21.110	$20.055
Amino Acid	1000 ml	$35.190	$33.431
Aminocaproic Acid	250 mg	$0.044	$0.042
Antihemophilic Factor (Recomb) Plasma/Albumin-Free (Xyntha)	1 IU			Code for 2010: J7185
Arformoterol Tartrate (Brovana)	15 mcg			Code for 2010: J7605
Arginine Hydrochloride (R-Gene 10)	300 ml	$11.003	$10.453
Arzerra (see Ofatumumab)
Ascorbic Acid (Vitamin C) Non-covered by Carrier**
** Atenolol (Tenormin) ICD-9's = 401.0 - 429.9	0.5 mg / ml	$0.800	$0.760
Atropine Sulfate / Edrophonium Chloride	10 mg	$1.651	$1.568
Avastin (See Bevacizumab)
Aztreonam (Azactam)	500 mg	$17.148	$16.291
** Bacitracin (Bacim)	50,000 U	$10.170	$9.662
Bendamustine Hydrochloride (Treanda) Covered indications: 204.10 - lymphoid leukemia, chronic, without mention of remission or 204.11 - lymphoid leukemia, chronic, in remission	1 mg			Code for 2010: J9033
Berinert (see C1 Esterase Inhibitor)
Bevacizumab (Avastin) If billed under J3490 or J3590, with CPT code 67028 & 1 of the following ICD-9 combinations: 1) 362.01-362.06 (any) with 362.07; 2) 362.35-362.37 (any); 3) 362.02 with 379.23; or 4) 362.52		Invoice	Invoice
Bretylium Tosylate (Bretylol)	5 mg	$0.175	$0.166
Brevibloc (see Esmolol Hydrochloride)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)	0.25 mg	$0.164	$0.156
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of Procedure)
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure)
Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.25% - 1 ml	$0.660	$0.627	(increased) Updated April 2011
Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.50% - 1 ml	$0.660	$0.627	(increased) Updated April 2011
Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.75% - 1 ml	$0.660	$0.627	(increased) Updated April 2011
C1 Esterase Inhibitor (Berinert) - For the treatment of acute abdominal or facial attacks of hereditary angioedema in adult and adolescent patients (277.6)	10 units	$27.528	$26.152
Cabazitaxel (Jevtana®)	1 mg	$141.333	$134.266
Calciferol (see Ergocalciferol D2)
Calcium Chloride	100 mg / ml	$0.140	$0.133
Canakinumab (Ilaris) - For Cryopyrin-associated periodic syndromes	1 mg	$89.465	$84.992
Capsaicin 8% Patch (Qutenza) - Must be administered under provider supervision.	10 sq cm	$25.554	$24.276
Cardizem IV (see Diltiazem Hydrochloride)
** Cefamanadole Nafate (Mandol)	1 gm	$8.610	$8.180
** Cefoperazone Sodium (Cefobid)	1 gm	$16.380	$15.561
Cefotetan Disodium (Cefotan)	1 gm	$11.376	$10.807
Certolizumab Pegol (Cimzia)	1 mg			Code for 2010: J0718
Chirocaine (see Levobupivacaine Hydrochloride)
Cimetidine Hcl. (Tagamet)	150 mg	$1.064	$1.011
Cimzia (see Certolizumab Pegol)
Clavulanate Potassium / Ticarcillin Disodium	0.1 - 3 gm	$10.495	$9.970
Clevidipine Butyrate	1 mg	$3.001	$2.851
Clindamycin Phosphate (Cleocin)	150 mg	$1.194	$1.134	(decreased) Updated April 2011
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Collagenase Clostridium Histolyticum (Xiaflex) Covered for Contracture of palmar fascia (Dupuytren’s concracture) ICD-9 728.6.	0.1 mg	$375.122	$356.366
Copper Sulfate	0.4 mg	$0.092	$0.087
Cosyntropin IV	0.25 mg			Code for 2010: J0833
Dantrolene Sodium	20 mg	$78.800	$74.860
Degarelix (Firmagon)	1 mg			Code for 2010: J9155
Depacon (see Valproate Sodium)
Denileukin Difitox (Ontak) (For 300 mcg, use code J9160)	150 mcg	$595.430	$565.659
Denosumab (Prolia ™ or Xgeva) If Prolia ™, covered ICD-9 = 733.01; if Xgeva, covered ICD-9 = 198.5.	1 mg	$14.575	$13.846	Xgeva effective 11/18/2010
Dexamethasone Intravitreal Implant (Ozurdex) If billed under J3490 or J3590, with CPT code 67028 & 1 of the following ICD-9 combinations 1) 362.83 plus 362.35 or 362.36; or 2) 362.30	0.1 mg	$196.100	$186.295
Dextrose 2.5%	2.50%	$7.680	$7.296
Dextrose 5%	5%	$7.860	$7.467
Dextrose 10%	500 ml	$10.000	$9.500
Dextrose 50%	50 ml	$0.101	$0.096
** Dextrose / Nitroglycerin 5%-20 mg/ 100 ml/250 ml	20 mg/100 ml/250 ml	$6.320	$6.004
** Dextrose 5% / Sodium Chloride	1000 ml	$11.220	$10.659
Diltiazem Hydrochloride (Cardizem IV)	5 mg	$0.157	$0.149
Diprivan (see Propofol)
Doripenem (Doribax)	10 mg			Code for 2010: J1267
Doxapram Hydrochloride (Dopram)	20 mg	$1.528	$1.452
Doxycycline Hyclate	100 mg	$12.965	$12.317	(increased) Updated April 2011
Ecallantide (Kalbitor) Covered Indications - 277.6 (accute attack of hereditary angioedema)	1 mg	$275.282	$261.518
Eculizumab (Soliris)	10 mg			Code for 2010: J1300
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)	10 mg	$0.608	$0.578
Elaprase (see Idursulfase)
Emend for Injection (see Fosaprepitant Dimeglumine)
Enalaprilat (Vasotec IV)	1.25 mg	$1.843	$1.751
Eovist (see Gadoxetate Disodium)
Ergocalciferol D2 (Calciferol) ICD-9's = 579.8 or 579.9 Allowed when administered in physician's office	500,000 IU/ 1ml	$29.840	$28.348
Eribulin Mesylate (Halaven) - Covered ICD-9's = 174.0 - 174.9	0.5mg / ml SDV	$450.500	$427.975	Effective 12/01/2010
Esmolol Hydrochloride (Brevibloc) Covered ICD-9 = 427.89 (Dosage change from 100 mg to 10 mg.)	10 mg	$0.663	$0.630	(decreased) Updated April 2011
Esomeprazole Sodium (Nexium IV) Covered ICD-9's = 530.10 - 530.19 or 530.81 when administered in the physician's office.	20 MG	$2.264	$2.151
Estradiol	1 gram	$13.300	$12.635
** Estradiol Pellets	Per Pellet	Invoice	Invoice
Ethacrynate Sodium (Edecrin Sodium)	50 mg	$19.040	$18.088
** Ethiodized Oil (Ethiodol)	1 ml	$8.060	$7.657
Etomidate (Amidate)	2 mg	$0.564	$0.536
Famotidine (Pepcid)	10 mg	$0.366	$0.348	(decreased) Upated April 2011
Ferumoxytol (Feraheme)	1 mg			Codes for 2010: Q0138 (non-esrd) & Q0139 (esrd)
Firmagon (see Degarelix)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Fludarabine phosphate, oral - Not Covered by Part B	10 mg
Flumazenil (Mazicon, Romazicon)	0.1 mg	$1.062	$1.009	(decreased) Updated April 2011
Flumazenil (Mazicon, Romazicon)	0.5 mg	$42.830	$40.689
Folic Acid	5 mg	$1.532	$1.455	(decreased) Updated April 2011
Folotyn (see Pralatrexate)
Fosaprepitant Dimeglumine (Emend) Allowed when billed on the same day as chemotherapy.	1 mg			Code for 2010: J1453
Fospropofol Disodium injection (Lusedra)	35 mg	$1.065	$1.012
Gadoxetate Disodium (Eovist)	1 ml			Code for 2010: A9581
Gammaplex (see Human Immune Globulin Intravenous)
Glycopyrrolate (Robinul)	0.2 mg	$0.213	$0.202
Graftjacket Gel	1 cc			Code for 2010: Q4113
Halaven (see Eribulin Mesylate)
** Heparin Sodium	100 units	$0.032	$0.030
Hetastarch Sodium Cl., 6 gm/500 ml	6 gm	$23.040	$21.888
Hizentra (see Immune Globulin Subcutaneous)
Human Immune Globulin Intravenous (Gammaplex)	500 mg	$60.420	$57.399
Hylan G-F 20 (Synvisc-One)	48 mg			Code for 2010: J7325
Idursulfase (Elaprase)	1 mg			Code for 2010: J1743
Ilaris (see Canakinumab)
Immune Globulin Subcutaneous (Hizentra)	100 mg	$13.356	$12.688
** Inamrinone Lactate	5 mg	$4.050	$3.848
Incobotullinumtoxin A (Xeomin) - Covered Indications = 333.6 (treatment of Genetic torsion dystonia) or 333.81 (Blepharospasm).	50 units	$278.250	$264.338	Effective 12/01/2010
INTEGRA™ Bilayer Matrix Wound Dressing - Covered Indications = 757.39, 941.20-941.21, 941.24-941.31, 941.34-941.41, 941.44-941.51, 941.54-941.59, 942.20-942.59, 943.20-943.59, 944.20-944.58, 945.20-945.59, 946.2-946.5, 948.00-948.99	1 sq cm	$19.562	$18.584
Invega® Sustenna® (see Paliperidone Palmitate injection)
Isoproterenol Hydrochloride (Isuprel)	0.2 mg	$2.250	$2.138
Isoptin IV (see Verapamil Hydrochloride)
Istodax (see Romidepsin)
Isuprel (see Isoproterenol Hydrochloride)
Ixabepilone (Ixempra) Covered for metastatic or locally advanced breast cancer (ICD-9 codes 174.0 - 175.9)	1 mg			Code for 2010: J9207
Jevtana® (see Cabazitaxel)
Kalbitor (see Ecallantide)
Kenalog (see Triamcinolone Acetonide)
Keppra intraveneous (see Levetiracetam)
Ketamine Hydrochloride (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530.	10 mg	$0.116	$0.110
Krystexxa (see Pegloticase)
Labetalol Hydrochloride (Trandate, Normodyne) Covered if given IV in the office for control of BP in severe hypertension. Patient is normally switched to oral for maintainance doses.	5 mg	$0.081	$0.077
Lanreotide (Somatuline Depot)	1 mg			Code for 2010: J1930
Levetiracetam (Keppra intraveneous)	10 mg			Code for 2010: J1953
** Levobupivacaine Hydrochloride (Chirocaine) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76003, 95990, or 96530. Not payable separately when billed with any other procedures	2.5 mg/ml	$0.310	$0.295
** Levophed Bitartrate (see Norepinephrine Bitartrate)
** Levothyroxine Sodium (Synthroid) Need statemnt on claim as to why patient can't take oral form of drug.	0.5 mg	$62.010	$58.910
Lexiscan (see Regadenoson)
Lidocaine - Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505 - 64530, 77033, 95990, or 96530. Not payable when billed with any other procedure.	1 ml	$0.116	$0.110	(increased) Updated April 2011
Lopressor (see Metoprolol Tartrate)
Lucentis (see Ranibizumab)
Lusedra (see Fospropofol Disodium injection)
Mandol (see Cefamanadole Nafate)
Mazicon (see Flumazenil)
Methylnaltrexone Bromide (Relistor) Non-covered by carrier.
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	$0.157	$0.149
Metronidazole Hcl. (Flagyl IV) IV in the office. Covered for ICD-9's= 001.0-009.3, 040.0-041.9, 481-482.9, 567.0-567.9, 599.0-599.9, 615.0-615.9.	500 mg	$1.217	$1.156
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride (Non-covered oral drug)
Monistat IV (see Miconazole)
Morrhuate Sodium	50 mg	$2.140	$2.033
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	$7.443	$7.071	(decreased) Updated January 2011
Nalmefene Hydrochloride (Revex)	10 mcg	$0.276	$0.262
Netilmicin Sulfate (Netromycin), 150 mg		Invoice	Invoice
Nexium IV (see Esomeprazole Sodium)
Nitroglycerin IV – Allowed in emergency situations.	5 mg	$0.384	$0.365
Nodolo & Tusal (see Sodium Thiosalicylate)
** Norepinephrine Bitartrate (Levophed Bitartrate) Allow in emergency situations.	1 mg	$2.161	$2.053
Norcuron (see Vecuronium Bromide)
Normal Saline (Sterile Water)	50 ml	$1.430	$1.359
Normodyne (see Labetalol Hydrochloride)
Nplate™ (see Romiplostim)
Ofatumumab (Arzerra) Covered indications - 204.10 or 204.12	10 mg	$45.468	$43.195
Ofloxacin (Floxin IV), 20 mg		Invoice	Invoice
Olanzapine long -acting intramuscular injection - Covered indications = 295.00 - 295.95 or 296.40 - 296.66 when administered in the physicians office.	1 mg	$2.753	$2.615
Olanzapine short -acting intramuscular injection (Zyprexa IM) Covered indications = 295.01 - 295.84 when administered in the physicians office.	0.5 mg	$1.468	$1.395
Ontak (see Denileukin Difitox)
Optison		Invoice	Invoice
** Oxychlorosene Sodium (Clorpactin WCS-90)	1 gm	$1.850	$1.758
Ozurdex (see Dexamethasone Intravitreal Implant)
Paliperidone Palmitate injection (Invega® Sustenna®) Covered indications: 295.00-295.95, 296.40-296.46, 296.50-296.56, or 296.60-296.66	1 mg	$6.523	$6.197
Panitumumab (Vectibix) Covered indications-153.0-154.8	10 mg			Code for 2010: J9303
Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	$4.174	$3.965
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®) Covered indication 070.54 when administered in the office.	180mcg/ml	$480.273	$456.259
Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered indication 070.54 when administered in the office.	50 mcg	$320.610	$304.580
** Peginterferon Alfa-2B, 80mcg	80 mcg	$336.600	$319.770
** Peginterferon Alfa-2B, 120mcg	120 mcg	$353.460	$335.787
** Peginterferon Alfa-2B, 150mcg	150 mcg	$371.120	$352.564
Pegloticase (Krystexxa) When billed with J3490 or J3590, covered for chronic gout, ICD-9's 274.00 through 274.03	8 mg SDV	Invoice	Invoice
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered
Pepcid (see Famotidine)
Potassium Acetate	2 meq	$0.022	$0.021
Potassium Phosphate	3 mmol	$0.041	$0.039
Pralatrexate (Folotyn) - Covered indications: 202.70 - 202.78	1 mg	$165.625	$157.344
Procaine Hydrochloride	1%	$2.360	$2.242
Procaine Hydrochloride	2%	$3.400	$3.230
Prolia ™ (see Denosumab)
Propofol (Diprivan)	10 mg	$0.086	$0.082	(increased) Updated April 2011
Protonix IV (see Pantoprazole Sodium)
Provenge (see Sipuleucel-T)
Qutenza (see Capsaicin 8% Patch)
R-Gene 10 (see Arginine Hcl.)
Ranibizumab Injection (Lucentis)	1 mcg			Code for 2010: J2778
Regadenoson (Lexiscan)	0.1 mg			Code for 2010: J2785
Relistor (see Methylnaltrexone Bromide)
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
Rifampin	600 mg	$37.291	$35.426
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
Romidepsin (Istodax) Covered indications: 202.70 - 202.78	1 mg	$219.302	$208.337
Romiplostim (Nplate™)	10 mcg			Code for 2010: J2796
Sarracenia Purpura Non-covered by Carrier
Secretin (SecreFlo) Used in secretin stimulation testing	1 mcg			Code for 2010: J2850
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Sipuleucel-T (Provenge) ICD-9 = 185	Per infusion (minimum 50 million cells)	$32,860.000	$31,217.000
Sodium Acetate	2 meq	$0.022	$0.021
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	$2.730	$2.594
Sodium Bicarbonate, 8.4% (NACH03)	50 ml	$0.201	$0.191	(increased) Updated April 2011
Sodium Chloride, Hypertonic	250 cc	$0.849	$0.807
** Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	$0.970	$0.922
Sodium Thiosulfate	100 mg	$0.149	$0.142
Soliris (see Eculizumab)
Somatuline Depot (see Lanreotide)
** Somavert (see Pegvisomant for Injection)	5 cc	$0.052	$0.049
Stelara (see Ustekinumab)
Sterile Saline / Water	1000 ml	$5.640	$5.358
** Sterile Saline / Water, 1000 ml	50mcg/ml	$9.810	$9.320
** Sufentanil Citrate (Sufenta) Separate payment allowed when billed with 62310, 62311, 62318, 62319, 76005, 95990, or 96530. If billed with any other procedures, it will be considered part of the procedure and separate payment will not be allowed.
Sulfamethoxazole/Trimethoprim (SMZ-TMP) Documentation as to why the patient needs to be on IV infusion instead of oral medication, must be in block 19 or as an attachment for paper claims or in the notepad for EMC claims.	400 - 80 mg	$0.183	$0.174
SurgiMend	0.5 sq cm	$10.703	$10.168
Synthroid (see Levothyroxine Sodium)
Synvisc-One (see Hylan G-F 20)
Tagamet (see Cimetidine Hydrochloride)
Telavancin Injection (VIBATIV™)	10 mg	$1.865	$1.772
Temsirolimus (Torisel) Covered indication is for the treatment of advanced renal cell carcinoma (189.0 Malignant neoplasm of kidney, except pelvis).	1 mg			Code for 2010: J9330
Tenormin (see Atenolol)
Tensilon (see Edrophonium Chloride)
Testosterone	37.5 mg	$0.110	$0.105
** Testosterone Pellets (Testopel)	Per Pellet	Invoice	Invoice
Tetanus Toxoid (use codes 90702, 90703, or 90718)
Tetracycline		Invoice	Invoice
Tocilizumab (Actemra) Covered Indications: 714.0, 714.1 or 714.2.	1 mg	$3.477	$3.303
Torisel (see Temsirolimus)
Trandate (see Labetalol Hydrochloride)
Treanda (see Bendamustine Hydrochloride)
Treprostinil inhalation (Tyvaso) - If administered in-office, considered part of service performed. If administered at-home, not covered by Part B.	1.74 MG
Triamcinolone Acetonide, Preservative Free	1 mg			Code for 2010: J3300
Triamcinolone Acetonide (Kenalog)	10 mg			Code for 2010: J3301
Tyvaso (see Treprostinil inhalation)
Ustekinumab (Stelara) - For the treatment of adults (18+) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy (696.1)	1 MG	$107.114	$101.758
Vaccinia IVIG (see Human Immune Globulin Intravenous)
Valproate Sodium (Depacon) IV, Covered ICD9's = 345.00 - 345.91, Allowed when administered IV, in the physician's office. (Dosage change from 500 mg to 100 mg)	100 mg	$0.613	$0.582	(increased) Updated April 2011
Vasopressin	20 units	$1.477	$1.403	(decreased) Updated April 2011
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)	1 mg	$0.417	$0.396
Velaglucerase alfa for injection (VPRIV™)	100 units	$350.595	$333.065
Verapamil Hydrochloride (Isoptin IV)	2.5 mg	$1.821	$1.730
VIBATIV™ (see Telavancin Injection)
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3ml	$0.930	$0.884
Vitamin C (see Ascorbic Acid) Non-covered by Carrier**
Vivaglobin (see Immune Globulin Subcutaneous)
VPRIV™ (see Velaglucerase alfa for injection)
Wilate (Human coagulation factor VIII (FVIII) and von Willebrand factor (VWF) powder and solvent for solution for injection) Covered ICD-9: 286.4	100 IU VWF:RCO	$71.190	$67.631
Xeomin (see IncobotulinumtoxinA)
Xgeva (see Denosumab)
Xiaflex (see Collagenase Clostridum Histolyticum)
Xyntha (see Antihemophilic Factor (Recomb) Plasma/Albumin-Free)
Zyprexa IM (see Olanzapine)
HOCM <= 149 MG/ML	1 ml	$0.041	$0.039
HOCM 200 - 249 MG/ML	1 ml	$0.093	$0.088
HOCM 250 - 299 MG/ML	1 ml	$0.100	$0.095
HOCM 300 - 349 MG/ML	1 ml	$0.104	$0.099
HOCM 350 - 399 MG/ML	1 ml	$0.107	$0.102
HOCM >= 400 MG/ML	1 ml	$0.191	$0.181