New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58A - ADVANCED PRACTICE NURSE SERVICES › Subchapter 4 - CENTERS FOR MEDICARE & MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:58A-4.3 - HCPCS procedure codes and maximum fee allowance schedule for Level II codes and narratives

Current through Register Vol. 56, No. 14, July 15, 2024
IND
HCPCS CODES
MOD
MAXIMUM FEE
ALLOWANCE $
(a) APN Administered Drugs:
J0120
Injection, tetracycline, up to 250 mg
0.73
J0128
Injection, abarelix, 10 mg
70.81
J0129
Injection, abatacept, 10 mg
19.69
J0130
Injection, abciximab, 10 mg
601.69
J0132
Injection, acetylcysteine, 100 mg
2.16
J0133
Injection, acyclovir, 5 mg
0.16
J0135
Injection, adalimumab, 20 mg
335.64
J0150
Injection, adenosine, 6 mg
33.11
J0152
Injection, adenosine, 30 mg
76.50
J0170
Injection, adrenalin, epinephrine, up to 1 ml ampul
2.88
J0180
Injection, agalsidase beta, 1 mg
131.25
J0190
Injection, biperiden lactate, 5 mg
2.91
J0200
Injection, alatrofloxacin mesylate 100 mg
17.15
J0205
Injection, alglucerase, per 10 units
37.52
J0207
Injection, amifostine, 500 mg
536.14
J0210
Injection, methyldopate HCl, (Aldomet), up to 250 mg
1.74
J0215
Injection, alefacept, 0.5 mg
29.02
J0220
Injection, aglucosidase alfa, 10 mg
131.25
J0256
Injection, alpha 1-proteinase inhibitor-human, per 500
0.01
J0278
Injection, amikacin sulfate, 100 mg
2.29
J0280
Injection, aminophylline, up to 250 mg
0.75
J0282
Injection, amiodarone hydrochloride, 30 mg
0.80
J0285
Injection, amphotericin B, 50 mg
17.06
J0287
Injection, amphotericin B lipid complex, 10 mg
21.00
J0288
Injection, amphotericin B cholesteryl sulfate complex, 10 mg
15.17
J0289
Injection, amphotericin B liposome, 10 mg
34.34
J0290
Injection, ampicillin sodium, up to 500 mg
3.86
J0295
Injection, ampicillin sodium/sulbactam sodium, 1.5 mg
7.25
J0300
Injection, amobarbital, up to 125 mg
2.66
J0330
Injection, succinylcholine chloride, (Anectine), up to 20 mg
0.26
J0350
Injection, anistreplase, per 30 units
2,481.13
J0360
Hydralazine HCl, (Apresoline), up to 20 mg
14.77
J0364
Apomorphine hydrochloride, 1 mg
3.39
J0365
Aprotonin, 10,000 KIU
2.85
J0380
Injection, metaraminol bitartrate, per 10 mg
1.21
J0390
Injection, chloroquine HCl, (Araten HCl), up to 250 mg
17.44
J0395
Injection, arbutamine HCl, 1 mg
168.00
J0400
Injection, aripiprazole
0.31
J0456
Injection, azithromycin, 500 mg
27.09
J0461
Injection, atropine sulfate
0.24
J0470
Injection, dimercaprol, per 100 mg
28.84
J0475
Injection, baclofen, 10 mg
223.13
J0476
Injection, baclofen, 50 mcg for intrathecal trial
73.50
J0480
Basiliximab, 20 mg
2,215.72
J0500
Injection, dicyclomine HCl, (Bentyl, Spasmoject), 10 mg
18.52
J0515
Injection, benztropine mesylate, (Cogentin), 1 mg
12.21
J0520
Injection, bethanechol chloride, myotonachol or urecholine,
4.91
up to 5 mg
J0559
Injection, penicillin G benzathine/procaine
0.08
J0560
Injection, penicillin G benzathine, (Bicillin long acting),
25.71
up to 600,000 units
J0570
Injection, penicillin G benzathine, (Bicillin long acting),
19.76
up to 1,200,000 units
J0580
Injection, penicillin G benzathine, (Bicillin long acting),
22.51
up to 2,400,000 units
J0583
Bivalirudin, 1 mg
2.08
J0585
Botulinum toxin type A per unit
5.52
J0586
Botulinum toxin type A
7.16
J0587
Botulinum toxin type B, per 100 units
8.99
J0592
Injection, buprenorphine hydrochloride, 0.1 mg
1.02
J0594
Injection, busulfan, 1 mg
10.09
J0595
Butorphanol; tartrate, 1 mg
3.91
J0598
Injection, C1 Esterase inhibitor
37.71
J0600
Injection, edetate calcium disodium, 200 mg
52.89
J0610
Injection, calcium gluconate, per 10 ml
2.03
J0620
Injection calcium glycerophosphate and calcium lactate, per
12.58
10 ml (Calphosan)
J0630
Injection, calcitonin salmon, up to 400 units
48.09
J0636
Injection, calcitriol, 0.1 mcg
1.34
J0637
Injection, caspofungin acetate, 5 mg
30.89
J0640
Injection, leucovorine calcium, 50 mg
3.28
J0641
Injection, levoleucovorin, 0.5 mg
1.05
J0670
Injection, mepivacaine HCl, (Carbocaine), per 10 ml
2.45
J0690
Injection, cefazolin sodium, (Ancef, Kefzol), up to 500 mg
2.83
J0692
Injection, cefepime HCl, 500 mg (Maxipime)
9.13
J0694
Injection, cefoxitin sodium, (Mefoxin), 1 gm
10.23
J0696
Injection, ceftriaxone sodium, (Rocephin), per 250 mg
12.97
J0697
Injection, sterile cefuroxime sodium, 750 mg
5.92
J0698
Cefotaxime sodium, (Claforan), per gm
7.10
J0702
Injection, betamethasone acetate and betamethasone sodium
2.88
phosphate, per 3 mg
J0704
Injection, betamethasone sodium phosphate, per 4 mg
1.09
J0706
Injection, caffeine citrate, 5 mg (Cafcit)
3.53
J0710
Injection, cephapirin sodium (Cefadyl), up to 1 gram
1.44
J0713
Injection, ceftazidime, per 500 mg
6.48
J0715
Injection, ceftazoxime sodium, per 500 mg
5.89
J0718
Injection, certolizumab pegol
7.37
J0720
Injection, chloramphenicol sodium succinate, (Chloromycetin
14.62
Sodium Succinate), up to 1 gram
J0735
Injection, clonidine hydrochloride, 1 mg
70.58
J0740
Injection, cidofovir, 375 mg
818.27
J0743
Injection, cilastatin sodium/imipenem (Primaxin), 250 mg
18.77
J0744
Injection, ciprofloxacin for IV infusion 200 mg (Cipro)
14.22
J0745
Injection, codeine phosphate, 30 mg
1.07
J0760
Injection, colchicine, per 1 mg
6.78
J0770
Injection, colistimethate sodium, (Coly-Mycin), up to 150mg
49.88
J0780
Injection, prochlorperazine, (Compazine), up to 10 mg
8.37
J0795
Corticorelin ovine triflutal, 1 mcg
4.75
J0800
Injection, corticotropin, up to 40 units
180.49
J0833
Injection, cosyntropin, nos
98.70
J0834
Injection, cosyntropin cortrosyn
107.44
J0850
Injection, cytomegalovirus immune globulin intravenous
925.32
(human), per vial
J0878
Injection, dapromycin
0.35
J0881
Darbepoetin alpha, non-ESRD use, 1 mcg
5.01
J0882
Darbepoetin alpha, ESRD use, 1 mcg
5.01
J0885
Epoetin alfa, non-ESRD, 1,000 units
13.69
J0886
Injection, epoetin alfa, ESRD use, 1,000 units
13.31
J0886
Injection, epoetin alfa, non-ESRD use, 1,000 units
13.31
J0894
Injection, decitabine, 1 mg
26.25
J0895
Injection, deferoxamine mesylate, (Desferal), 100 mg
16.92
J0945
Injection, brompheniramine maleate, per 10 mg
0.62
J0970
Injection, estradiol valerate, up to 40 mg
34.60
J1000
Injection, depo-estradiol cypionate, 5 mg
6.59
J1020
Injection, methylprednisolone acetate, 20 mg
3.13
J1030
Injection, methylprednisolone acetate, 40 mg
6.34
J1040
Injection, methylprednisolone acetate, 80 mg
10.45
J1051
Injection, medroxyprogesterone acetate, 50 mg
15.47
J1055
Injection, medroxprogesterone acetate, for contraceptive use,
53.97
150 mg
J1056
Injection, medroxyprogesterone acetate/estradial cypionate, 5
22.60
mg/25 mg (Lunelle monthly contraceptive)
J1060
Injection, testosterone cypionate and estradiol cypionate, up
3.41
to 1 ml
J1070
Injection, testosterone cypionate, up to 100 mg
6.04
J1080
Injection, testosterone cypionate, 1 cc/200 mg
12.03
J1094
Injection, dexamethasone acetate, 1 mg
0.53
J1100
Injection, dexamethasone sodium phosphate, 1 mg
0.13
J1110
Dihydroergotamine Mesylate, 1 mg
31.94
J1120
Injection, acetazolamide sodium, (Diamox Sodium), up to 500
22.97
mg
J1160
Injection, digoxin, up to 0.5 mg
2.49
J1162
Digoxin immune fab (ovine), per vial
594.23
J1165
Injection, phenytoin sodium, (Dilantin), per 50 mg
0.70
J1170
Injection, hydromorphone, 2 mg
1.01
J1180
Injection, dyphylline, (Dilor, Lufyllin), up to 500 mg
8.30
J1190
Injection, dexrazoxane hydrochloride, per 250 mg
224.47
J1200
Injection, diphenhydramine HCl, (Benadryl), up to 50 mg
1.16
J1205
Injection, chlorothiazide sodium, (Diuril), per 500 mg
149.94
J1212
Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml
52.50
J1230
Injection, methadone HCl, (Dolophine HCl), up to 10 mg
2.14
J1240
Injection, demenhydrinate, (Dramamine), up to 50 mg
2.74
J1245
Injection, dipyridamole, per 10 mg
7.66
J1250
Injection, dobutamine hydrochloride, per 250 mg
43.51
J1260
Injection, dolasetron mesylate, 1 mg
4.27
J1265
Injection, dopamine, 40 mg
0.32
J1267
Injection, doripenem, 10 mg
0.81
J1270
Injection, doxercalciferol, 1 mcg (Hectorol)
6.31
J1300
Injection, eculizumab
182.00
J1320
Injection, amitriptyline HCl, (Elavil HCl), up to 20 mg
2.05
J1324
Injection, enfuvirtide, 1 mg
19.70
J1325
Injection, epoprostenol, 0.5 mg
19.47
J1327
Injection, eptifibatide, 5 mg
21.13
J1330
Injection, ergonovine maleate, up to 0.2 mg
5.08
J1335
Injection, ertapenem, 500 mg
27.27
J1364
Injection, erythromycin lactobionate, 500 mg
9.09
J1380
Injection, estradiol valerate, up to 10 mg
14.81
J1390
Injection, estradiol valerate, up to 20 mg
20.88
J1410
Injection, estrogen conjugated, per 25 mg
70.83
J1430
Ethanolamine oleate, 100 mg
84.99
J1435
Injection, estrone, per 1 mg
0.25
J1436
Injection, etidronate disodium, per 300 mg
70.88
J1438
Injection, etanercept, 25 mg
180.50
J1440
Injection, filgrastim, (G-CSF), 300 mcg
216.68
J1441
Injection, filagrastim, (G-CSF), 480 mcg
345.19
J1450
Injection, fluconazole, 200 mg
20.81
J1451
Fomepizole, 15 mg
12.11
J1452
Injection, fomivirsen sodium, intraocular, 1.65 mg
875.00
J1453
Injection, fosaprepitant, 1 mg
1.62
J1455
Injection, foscarnet sodium, (Foscavir), per 1000 mg
12.00
J1457
Injection, gallium nitrate, 1 mg
1.71
J1458
Injection, galsulfase, 1 mg
327.91
J1459
Injection, ivig privigen, 500 mg
45.94
J1460
Injection, gamma globulin I.M., 1 cc
15.45
J1470
Injection, gamma globulin I.M., 2 cc
30.89
J1480
Injection, gamma globulin I.M., 3 cc
46.34
J1490
Injection, gamma globulin I.M., 4 cc
61.78
J1500
Injection, gamma globulin I.M., 5 cc
77.23
J1510
Injection, gamma globulin I.M., 6 cc
92.67
J1520
Injection, gamma globulin I.M., 7 cc
108.12
J1530
Injection, gamma globulin I.M., 8 cc
123.56
J1540
Injection, gamma globulin I.M., 9 cc
139.01
J1550
Injection, gamma globulin I.M., 10 cc
118.00
J1561
Injection, immune globulin (Gamunex)
47.28
J1562
Injection, globulin sc, 100 mg
13.13
J1566
Immune globulin, powder, 500 mg
43.89
J1568
Injection, octagam
55.61
J1569
Injection, gammagard liquid
59.17
J1570
Injection, ganciclovir sodium, (Cytovene), 500 mg
54.38
J1571
Injection, hepagam B IM, 0.5 ml
75.00
J1572
Injection, flebogamma, 500 mg
44.10
J1573
Injection, hepagam B intravenous, 0.5 ml
75.00
J1580
Injection, garamycin, gentamicin, up to 80 mg
2.12
J1590
Injection, gatifloxacin, 10 mg (Tequin)
0.83
J1600
Injection, gold sodium thiomalate, 50 mg
13.69
J1610
Injection, glucagon hydrochloride, 1 mg
76.56
J1620
Injection, gonadorelin hydrochloride, per 100 mcg
186.03
J1626
Injection, granisetron hydrochloride, 100 mcg
17.08
J1630
Injection, haloperidol, up to 5 mg
6.55
J1631
Injection, haloperidol decanoate, 50 mg
2.97
J1640
Injection, hemin, 1 mg
7.52
J1642
Injection, heparin sodium, (Heparin Lock Flush), 10 units
0.07
J1644
Injection, heparin sodium, 1,000 units
0.14
J1645
Injection, dalteparin sodium, per 2,500 IU
17.47
J1650
Injection, enoxaparin sodium, 10 mg
7.10
J1652
Injection, fondaparinux sodium, 0.5 mg
8.79
J1655
Injection, tinzaparin sodium, 1,000 IU (Innohep)
3.97
J1670
Injection, tetanus immune globulin, human, up to 250 units
124.26
J1675
Injection, histrelin acetate, 10 mcg
8.24
J1680
Injection, human fibrinogen concentrate
91.56
J1700
Injection, hydrocortisone acetate, (Analpram HC, Hydrocortone
0.61
Acetate), up to 25 mg
J1710
Injection, hydrocortisone sodium phosphate, (Hydrocortone
5.13
Phosphate), up to 50 mg
J1720
Injection, hydrocortisone sodium succinate, (Solu-Cortef), up
1.74
to 100 mg
J1730
Injection, diazoxide, (Hyperstat), up to 300 mg
117.96
J1740
Injection, ibandronate sodium, 1 mg
147.20
J1742
Injection, ibutilide fumarate, 1 mg
309.71
J1743
Injection, idursulfase
479.10
J1745
Injection, infliximab, 10 mg
61.15
J1750
Injection, iron dextran, 50 mg
13.41
J1756
Injection, iron sucrose, 1 mg
0.60
J1785
Injection, imiglucerase, per unit
4.05
J1790
Injection, droperidol, (Inapsine), up to 5 mg
3.72
J1800
Injection, propranolol HCl, (Inderal), up to 1 mg
8.62
J1810
Injection, droperidol and fentanyl citrate, (Innovar), up to
14.67
2 ml ampule
J1815
Injection, insulin, per 5 units
0.34
J1817
Insulin for insulin pump use, per 50 units
4.50
J1825
Injection, interferon beta-1a, 33 mcg administered under
400.18
direct supervision of a physician, excludes self administration
J1830
Injection, interferon beta-1B, 0.25 mg
96.08
J1835
Injection, itraconazole, 50 mg (Sporanox)
43.63
J1840
Injection, kanamycin sulfate, (Kantrex), up to 500 mg
7.70
J1850
Injection, kanamycin sulfate, (Kantrex), up to 75 mg
2.66
J1885
Injection, ketorolac tromethamine, (Toradol I.M.), per 15 mg
3.05
J1890
Injection, cephalothin sodium, (Keflin), up to 1 gram
9.45
J1930
Injection, lanreotide, 1 mg
27.81
J1931
Injection, laronidase (aldurazyme), 0.1 mg
24.63
J1940
Injection, furosemide, (Lasix), up to 20 mg
0.63
J1945
Lepirudin, 50 mg
174.13
J1950
Injection, leuprolide acetate, (Depot Suspension), 3.75 mg
544.60
J1953
Injection, levetiracetam, 10 mg
0.69
J1955
Injection, levocarnitine, per 1 gram
34.30
J1956
Injection, levofloxacin, 250 mg
18.82
J1960
Injection, levorphanal tartrate, up to 2 mg
3.72
J1980
Injection, hyoscyamine sulfate, (Levsin), up to 0.25 mg
10.35
J1990
Injection, chlordiazepoxide HCl, (Librium), up to 100mg
23.02
J2001
Injection, lidocaine, per 10 mg
0.31
J2010
Injection, lincomycin HCl, up to 300 mg
2.76
J2020
Injection, linezolid, 200 mg (Zyvox)
36.13
J2060
Injection, lorazepam (Atvian), 2 mg
2.82
J2150
Injection, mannitol, 25% in 50 ml
2.49
J2170
Injection, mecasermin, 1 mg
14.15
J2175
Injection, meperidine HCl, 100 mg
1.19
J2180
Injection, meperidine/ promethazine HCl, (Mepergan), up to 50
8.00
mg
J2185
Meropenem, 100 mg
6.21
J2210
Injection, methylergonovine maleate, (Metherqine Maleate), up
5.37
to 0.2 mg
J2248
Injection, micafungin sodium, 1 mg
2.05
J2250
Injection, midazolam hydrochloride, per 1 mg
0.56
J2260
Injection, milrinone lactate, per 5 ml
6.56
J2270
Injection, morphine sulfate, up to 10 mg
1.62
J2271
Injection, morphine sulfate, 100 mg
4.22
J2275
Injection, morphine sulfate, 10 mg (Preservative Free)
6.25
J2278
Injection, ziconotide, 1 mcg
6.99
J2280
Injection, moxifloxacin, 100 mg
9.57
J2300
Injection, nalbuphine HCl, per 10 mg
1.76
J2310
Injection, naloxone hydrochloride, per 1 mg
5.12
J2315
Naltrexone, depot form, 1 mg
2.00
J2320
Injection, nandrolone deconate, up to 50 mg
6.15
J2321
Injection, nandrolone deconoate, up to 100 mg
8.17
J2322
Injection, nandrolone deconoate, up to 200 mg
20.66
J2323
Injection, natalizumab
8.12
J2325
Injection, nesiritide, 0.1 mg
34.99
J2353
Injection, octreotide depot, 1 mg
104.36
J2354
Injection, octreotide, non-depot, 25 mcg
4.89
J2355
Injection, oprelvekin, 5 mg
267.75
J2357
Injection, omalizumab, 5 mg
18.11
J2360
Injection, orphenadrine citrate, (Norflex, Norgesic), up to
17.94
60 mg
J2370
Injection, phenylephrine HCl, (Neo-Synephrine), up to 1 ml
2.73
J2400
Injection, chloroprocaine HCl, (Nesacaine and Nesacaine MPF),
17.17
per 30 ml
J2405
Injection, ondansetron HCl, 1 mg
1.23
J2410
Injection, oxymorphone HCl, (Numorphan), up to 1 mg
2.85
J2425
Injection, paliferim, 50 mcg
12.03
J2430
Injection, pamidronate disodium, per 30 mg
92.70
J2440
Injection, papaverine HCl, up to 60 mg
4.77
J2460
Injection, oxytetracycline HCl, up to 50 mg
0.97
J2469
Palonosetron HCL, 25 mcg
34.86
J2501
Injection, paricalcitol, 1 mcg
5.11
J2503
Injection, pegaptanib sodium, .03 mg
1,088.28
J2504
Pedademase bovine, 25 IU
204.17
J2505
Injection, pegfilgrastim, 6 mg
3,080.01
J2510
Injection, penicillin G procaine, aqueous, up to 600,000
10.50
units
J2513
Pentastarch 10% solution, 100 ml
13.16
J2515
Injection, pentobarbital sodium, per 50 mg
5.61
J2540
Injection, penicillen G potassium, up to 600,000 units
0.43
(Pfizerpen)
J2543
Injection, piperacillin sodium/tazobactam sodium, 1 gram
5.81
0.125 grams (1.125 g)
J2545
Pentamadine isethionate, 300 mg, solution for inhalation
86.41
J2550
Injection, promethazine HCl, (Phenergan), up to 50 mg
3.79
J2560
Phenobarbital Sodium, up to 120 mg
2.96
J2562
Injection, plerixafor
262.50
J2590
Injection, oxytocin, (Pitocin), up to 10 units
2.56
J2597
Injection, desmopressin acetate, per 1 mcg
5.01
J2650
Injection, prednisolone acetate, up to 1 ml
0.68
J2670
Injection, tolazoline HCl, (Priscoline HCl), up to 25 mg
3.61
J2680
Injection, fluphenazine deconoate, (Prolixin DeConoate), up
4.38
to 25 mg
J2690
Injection, procainamide HCl, (Proenstyl), up to 1 gram
3.45
J2700
Injection, oxacillin sodium, (Prostaphlin), up to 250 mg
1.02
J2710
Injection, neostigmine methylsulfate, (Prostigmin
0.44
Methylsulfate), up to 0.5 mg
J2720
Injection, protamine sulfate, 10 mg
0.93
J2724
Protein C concentrate, 10 I.U.
1.26
J2725
Injection, protirelin, per 250 mcg
22.47
J2730
Injection, pralidoxime chloride, (Protopam Chloride), up to 1
94.83
gm
J2760
Injection, phentolamine mesylate, (Regitine), up to 5 mg
33.91
J2765
Injection, metoclopramide HCl, (Reglan), up to 10 mg
0.77
J2770
Injection, quinupristin/dalfopri stin, 500 mg (150/350)
137.00
J2778
Injection, ranibizumab
426.56
J2780
Injection, ranitidine hydrochloride, 25 mg
1.38
J2783
Rasburicase, 0.5 mg
152.18
J2785
Injection, regadenoson, 0.1 mg
107.50
J2788 UD
Injection, Rho D immune globulin, human, minidose, 50 mcg
49.55
J2788
Injection, Rho D immune globulin, human, minidose, 50 mcg
49.55
J2790
Injection, Rho (D) Immune Globulin, (Human), (Rhogam), Human,
115.94
Full dose, 300 mcg
J2790 UD
Injection, RHO (D) Immune Globulin Human, Full dose, 300 mcg
115.94
J2791
Injection, rhophylac
1.12
J2792
Injection, Rho(D) immune globulin, intravenous, human,
20.71
solvent detergent, 100 IU
J2793
Injection, rilonacept
22.91
J2794
Risperidone, long acting, 0.5 mg
5.10
J2795
Injection, ropivacaine hydrochloride, 1 mg
0.08
J2796
Injection, romiplostim
43.70
J2800
Injection, methocarbamol, (Robaxin), up to 10 ml
17.27
J2805
Injection, sincalide, 5 mcg
60.03
J2820
Injection, sarqramostim, (GM-CSF), 50 mcg
33.30
J2850
Injection, secretin synthetic, human, 1 mcg
22.22
J2910
Injection, aurothioglucose, (Solqanal), up to 50 mg
25.73
J2916
Injection, sodium ferric gluconate complex in sucrose
7.53
Injection, 12.5 mg
J2920
Injection, methylprednisolone sodium succinate, (Solu
2.25
Medrol), up to 40 mg
J2930
Injection, methylprednisolone sodium succinate, (Solu
3.79
Medrol), up to 125 mg
J2941
Injection, somatropin, 1 mg
48.21
J2950
Injection, promazine HCl, (Prozine, Sparine), up to 25 mg
0.22
J2993
Injection, reteplase, 18.8 mg
1,319.55
J2995
Injection, streptokinase, per 250,000 IU
82.03
J2997
Injection, alteplase recombinant, 1 mg
33.47
J3000
Injection, streptomycin, up to 1 gram
7.96
J3010
Injection, fentanyl citrate, (Sublimaze), up to 2 ml
0.63
J3030
Injection, sumatriptan succinate, 6 mg
137.25
J3070
Injection, pentazocine HCl, (Talwin), up to 30 mg
4.43
J3101
Injection, tenecteplase, 1 mg
51.09
J3105
Terbutaline sulfate, up to 1 mg
15.86
J3120
Injection, testosterone enanthate, up to 100 mg
0.39
J3130
Injection, testosterone enanthate, up to 200 mg
17.88
J3150
Injection, testosterone propionate, up to 100 mg
0.87
J3230
Injection, chlorpromazine HCl, (Thorazine), up to 50 mg
5.70
J3240
Injection, thyrotropin, alpha 1.1 mg
869.53
J3243
Injection, tigecycline, 1 mg
1.04
J3246
Tirofiban HCL (Aggrastat), 0.25 mg
9.29
J3250
Injection, trimethobenzamide HCl, up to 200 mg
2.88
J3260
Injection, tobramycin sulfate, (Nebcin), up to 80 mg
3.71
J3265
Injection, torsemide, 10 mg/ml
2.74
J3280
Injection, thiethylperazine maleate, up to 10 mg
4.24
J3285
Injection, treprostinil, 1 mg
58.84
J3300
Injection, triamcinolone A, prs-free, 1 mg
0.06
J3301
Injection, triamcinolone acetonide, (Kenalog), 10 mg
1.45
J3302
Injection, triamcinolole diacetate, (Aristocort), per 5 mg
0.57
J3303
Injection, triamcinolone hexacetonide, (Aristospan), per 5 mg
2.97
J3305
Injection, trimetrexate glucoronate, per 25 mg
154.48
J3310
Injection, perphenazine, (Trilafon), up to 5 mg
6.38
J3315
Injection, triptorelin pamoate, 3.75 mg
530.47
J3320
Injection, spectinomycin hydrochloride, (Trobicin), up to 2
31.05
mg
J3350
Injection, urea, (Ureaphil), up to 40 mg
77.77
J3360
Injection, diazepam, (Valium), up to 5 mg
1.25
J3364
Injection, urokinase, 5,000 IU vial
49.53
J3365
Injection, IV, urokinase, 250,000 IU vial
472.31
J3370
Injection, vancomycin HCl, up to 500 mg
4.01
J3396
Injection, verteporfin, .01 mg
10.14
J3400
Injection, triflupromazine HCl, (Vesprin), up to 20 mg
11.38
J3410
Injection, hydroxyzine HCl, (Vistaril), 25 mg
0.39
J3411
Thiamine HCL, 100 mg
1.89
J3415
Pyridoxine HCL, 100 mg
2.49
J3420
Injection, vitamin B-12 cyanocobalamin, up to 1,000 mg
0.42
J3430
Injection, phytonadione, (Vitamin K), 1 mg
2.26
J3465
Injection, voriconazole, 10 mg
5.54
J3470
Injection, hyaluronidase, (Wydase), up to 150 units
21.88
J3471
Ovine, up to 999 USP units
0.12
J3472
Ovine, 1000 USP units
142.19
J3475
Injection, magnesium sulfate, per 500 mg
3.13
J3480
Injection, potassium chloride, per 2 mEq
0.09
J3485
Injection, zidovudine, 10 mg
1.19
J3486
Ziprasidone mesylate, 10 mg
5.36
J3487
Injection, zoledronic acid, 1 mg
223.00
J3488
Injection, reclast
227.84
J7030
Infusion, normal saline solution, 1,000 ml = 1 unit
7.14
J7040
Infusion, normal saline solution, sterile, 500 ml = 1 unit
6.98
J7042
5% dextrose/normal saline solution, 500 ml = 1 unit
5.65
J7050
Infusion, normal saline solution. 250 ml = 1 unit
6.03
J7060
5% dextrose/water solution, 500 ml = 1 unit
8.09
J7070
Infusion, D5W, 1,000 cc
7.10
J7100
Infusion, dextran 40, 500 ml
54.49
J7110
Infusion, dextran 75, 500 ml
64.28
J7120
Ringer's Lactate Infusion, up to 1,000 ml = 1 unit
10.39
J7185
Injection, xyntha
1.39
J7186
Antihemophilic VIII/VWF composition
1.06
J7189
Factor VIIA (antihemophilic factor, recombinant), per IU
1.44
J7190
Factor VIII (antihemophilic factor, human) per IU
0.90
J7191
Factor VIII (antihemophilic factor, porcine) per IU
1.93
J7192
Factor VIII (antihemophilic factor, recombinant), per IU
1.48
J7193
Factor IX (antihemophilic factor, purified non-recombinant)
1.09
per IU (Alphanine SD)
J7194
Factor IX complex, per IU
0.59
J7195
Factor IX (antihemophilic factor, recombinant) per IU
0.91
(Benefix)
J7198
Anti-inhibitor, per IU
1.31
J7300
Intrauterine copper contraceptive (Paragard)
396.64
J7302
Levonorgestrel-releasing intrauterine contraceptive system,
450.88
52 mg (Mirena)
J7303
Contraceptive vaginal ring
40.02
J7304
Contraceptive hormone patch
15.72
J7307
Estrogestrel implant system
620.08
J7310
Ganciclovir, 4.5 mg, long-acting implant
4,725.00
J7311
Fluocinolone acetonide implant
1,662.50
J7321
Injection, hyalgan/supartz, per dose
126.88
J7323
Injection, euflexxa, per dose
133.96
J7324
Injection, orthovisc, per dose
228.69
J7325
Injection, synvisc or synvisc-one
405.72
J7500
Azathioprine, oral, 50 mg
1.15
J7501
Azathioprine; parenteral, vial, 100 mg, 20 ml each
74.38
J7502
Cyclosporin, oral, 100 mg
5.34
J7503
Cyclosporin, parenteral, 50 mg
5.50
J7504
Lymphocyte immune globulin, antithymocyte globulin,
367.36
parenteral, amp, 50 mg/ml, 5 ml each
J7506
Prednisone, oral, 5 mg tablet
0.14
J7507
Tacrolimus, oral, per 1 mg
3.97
J5709
Methylprednisolone, oral, 4 mg
0.58
J5710
Prednisolone, oral, 5 mg
0.12
J7511
Lymphocyte immune globulin, antithymocyte globulin, rabbit,
426.56
parenteral, 25 mg (Thymoglobulin)
J7513
Daclizumab, parenteral, 25 mg
449.66
J7515
Cyclosporine, oral, 25 mg
1.20
J7516
Cyclosporine, parenteral, 250 mg
24.06
J7517
Mycophenolate mofetil, 250 mg
3.27
J7518
Mycophenolic acid, 180 mg
4.02
J7520
Sirolimus, oral, 1 mg
7.97
J7525
Tacrolimus, parenteral, 5 mg
149.43
J7604
Acetylcysteine, comp unit, per gram
3.57
J7605
Arformoterol, non-comp unit, 15 mcg
5.04
J7606
Formoterol fumarate, inhale
5.60
J7607
Levabuterol, comp concentrate, 0.5 mg
1.33
J7608
Acetylcysteine, inhale solution, unit dose, per gram
1.80
J7611
Albuterol, concentrate form, 1 mg
0.15
J7612
Levabuterol, concentrate, 0.5 mg
1.19
J7613
Albuterol, unit dose, 1 mg
0.54
J7614
Levalbuterol, unit dose, 0.5 mg
2.61
J7615
Levalbuterol, inhalation solution, 0.5 mg
1.89
J7620
Albuterol, 2.5 mg/Ipratrop, 0.5 mg
2.18
J7626
Budesonide, inhalation solution, up to 0.5 mg
9.35
J7627
Budesonide, powder, inhalation, up to 0.5 mg
161.35
J7628
Bitolterol mesylate, concentrate form, per mg
0.48
J7631
Cromolyn sodium, unit dose form
0.34
J7632
Cromolyn sodium, comp unit
0.31
J7634
Budesonide, comp concentrate, per 0.25 mg
4.81
J7635
Atropine, inhalation solution, concentrated, per mg
1.23
J7636
Atropine, inhalation solution, unit dose, per mg
1.09
J7637
Dexamethasone, inhalation solution, concentrated, per mg
0.43
J7638
Dexamethasone, inhalation solution, unit dose, per mg
0.20
J7639
Dornase alpha inhalation solution
21.00
J7642
Glycopyrrolate, inhalation solution, per mg
2.32
J7644
Ipratroprium bromide, inhalation solution, per mg
1.54
J7645
Ipratroprium bromide, inhalation solution, comp, per mg
1.26
J7669
Metaproterenol, inhalation solution, unit dose, per 10 mg
0.49
J7674
Methacholine chloride, nebulizers, per mg
0.42
J7676
Pentamidine comp, unit dose
93.44
J7682
Tobramycin, inhalation solution, 300 mg
66.11
J7684
Triamcinolone, inhalation solution, per mg
0.61
J8501
Oral aprepitant, 5 mg
4.71
J8510
Bulsulfan, oral, 2 mg
2.59
J8520
Capecitabine, oral, 150 mg
6.51
J8521
Capecitabine, oral, 500 mg
21.71
J8530
Cyclophosphamide, oral, 25 mg
3.15
J8560
Etoposide, oral, 50 mg
41.68
J8600
Melphalan, oral, 2 mg
5.29
J8610
Methotrexate, oral, 2.5 mg
3.19
J8700
Temozolomide, 5 mg
7.93
J9000
Doxorubicin HCl, (Adriamycin), 10 mg
12.03
J9001
Doxorubicin HCI, all lipid formulations, 10 mg
435.26
J9010
Alemtuzumab, 10 mg
585.40
J9015
Aldesleukin, per single use vial
826.40
J9017
Arsenic trioxide, 1 mg (Trisenox)
36.79
J9020
Asparaginase, 10,000 units
55.02
J9025
Injection, azacitidine, 1 mg
4.42
J9027
Injection, clofarabine, 1 mg
123.05
J9031
BCG (intravesical) per installation
172.59
J9033
Injection, bendamustine, 1 mg
19.13
J9035
Injection, bevacizumab (Avastin), 10 mg
60.16
J9040
Bleomycin sulfate, (Blenoxane) 15 units
77.11
J9041
Injection, bortezomib (Velcade), 0.1 mg
35.31
J9045
Carboplatin (Paraplatin), 50 mg
76.42
J9050
Carmustine, (BiCNU), 100 mg
163.91
J9055
Injection, cetuximab (Erbitux), 10 mg
52.50
J9060
Cisplatin, (Platinol), powder or solution, 10 mg
4.05
J9062
Cisplatin, 50 mg
20.13
J9065
Injection, cladribine, (Leustatin), per 1 mg
53.05
J9070
Cyclophosphamide, (Cytoxan), 100 mg
2.52
J9080
Cyclophosphamide, (Cytoxan), 200 mg
5.04
J9090
Cyclophosphamide, (Cytoxan), 500 mg
13.86
J9091
Cyclophosphamide, (Cytoxan), 1 gram
25.08
J9092
Cyclophosphamide, (Cytoxan), 2 grams
45.37
J9093
Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 100 mg
5.42
J9094
Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 200 mg
10.29
J9095
Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 500 mg
21.60
J9096
Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 1 gram
43.21
J9097
Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 2 grams
86.44
J9098
Cytarabine liposome, 10 mg
437.50
J9100
Cytarabine, (Cytarabine Hydrochloride), 100 mg
3.17
J9110
Cytarabine, (Cytarabine Hydrochloride), 500 mg
8.75
J9120
Dactinomycin, 0.5 mg
519.53
J9130
Dacarbazine, 100 mg
10.34
J9140
Dacarbazine, 200 mg
20.67
J9150
Daunorubicin, 10 mg
70.57
J9151
Daunorubicin citrate, liposomal formulation, 10 mg
59.50
J9155
Injection, degarelix
3.92
J9160
Denileukin diftitox, 300 mcg
1,487.50
J9165
Injection, diethlstilbestrol diphosphate, (Stilphostrol), 250
13.27
mg
J9171
Injection, docetaxel
19.51
J9175
Elliotts B solution, per ml
4.29
J9178
Injection, epirubicin, 2 mg
26.22
J9181
Etoposide, (VePesid), 10 mg
1.64
J9185
Fludarabine Phosphate, 50 mg
317.80
J9190
Fluorouracil, 500 mg
3.28
J9200
Floxuridine, 500 mg
130.70
J9201
Gemcitabine HCl, (Gemzar), 200 mg
135.98
J9202
Goserelin acetate implant, (Zoladex), 3.6 mg
411.24
J9206
Irinotecan, 20 mg
134.24
J9207
Injection, ixabepilione, 1 mg
65.31
J9208
Ifosfomide, 1 gram
63.49
J9209
Mesna, (Mesnex), 200 mg
30.76
J9211
Idarubicin hydrochloride, 5 mg
386.79
J9212
Injection, interferon alfacon-1, recombinant, 1 mcg
8.50
J9213
Interferon alfa-2A, Recombinant, 3 million units
40.53
J9214
Interferon alfa-2B, recombinant, 1 million units (Intron A)
14.84
J9215
Interferon alfa-N3 (human leukocyte derived) 250,000 IU
15.68
(Alferon N)
J9216
Interferon gamma-1B, 3 million units
344.41
J9217
Leuprolide acetate, (Lupron Depot), 7.5 mg
678.73
J9218
Leuprolide acetate, (Lupron), 1 mg
271.53
J9219
Leuprolide acetate implant, 65 mg
4,973.50
J9225
Histrelin implant, 50 mg
5,250.00
J9226
Supprelin LA implant
15,312.50
J9230
Mechlorethamide HCl, (nitrogen mustard), Mustargen OE, 10 mg
152.08
J9245
Injection, melphalan HCl, 50 mg
1,267.39
J9250
Methotrexate sodium, 5 mg (Folex)
0.48
J9260
Methotrexate sodium, 50 mg
4.16
J9261
Injection, nelarabine, 50 mg
90.13
J9263
Oxaliplatin, 0.5 mg
9.32
J9264
Injection, paclitaxel, 1 mg
9.40
J9265
Paclitaxel, 30 mg
151.13
J9266
Pegaspargase, per single dose vial
2,187.50
J9268
Pentostatin, per 10 mg
2,324.00
J9270
Plicamycin, (Mithracin), 2.5 mg
86.39
J9280
Mitomycin, 5 mg
61.25
J9290
Injection, mitoxantrone HCl, per 5 mg
199.06
J9291
Mitomycin, 40 mg
273.44
J9293
Injection, mitoxantrone HCl, per 5 mg
325.23
J9300
Gemtuzumab ozogamicin, 5 mg (Gemzar)
2,563.75
J9303
Injection, panitumumab
87.50
J9305
Injection, pemetrexed (Alimta), 10 mg
47.63
J9310
Rituximab, 100 mg
571.97
J9320
Streptozocin, 1 gram
113.78
J9328
Injection, temozolomide
4.75
J9330
Injection, temsirolimus, 1 mg
48.99
J9340
Thiotepa, 15 mg
85.59
J9350
Topotecan, 4 mg
932.71
J9355
Trastuzumab, 10 mg
61.81
J9357
Valrubicin, intravesical, 200 mg
485.10
J9360
Vinblastine sulfate, (Velban), 1 mg
2.90
J9370
Vincristine sulfate, (Oncovin), 1 mg
12.60
J9375
Vincristine sulfate, (Oncovin), 2 mg
25.21
J9380
Vincristine sulfate, (Oncovin), 5 mg
142.37
J9390
Vinorelbine tartrate, per 10 mg
82.25
J9395
Injection, fulvestrant, 25 mg
86.93
J9600
Porfimer sodium, (Photofrin), 75 mg
2,637.93