Spreadsheet: 1062d37c-84e0-40ca-9ef5-97cbdfec8271
Sheet: Sheet1

Payment Allowance Limits for Medicare Part B Drugs | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11
Effective July 1, 2011 through September 30, 2011
Note 1: Payment allowance limits subject to the ASP methodology are based on 1Q11 ASP data.
Note 2: 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.
HCPCS Code | Short Description | HCPCS Code Dosage | Payment Limit | Vaccine AWP% | [NAME] | Infusion AWP% | DME Infusion Limit | Blood AWP% | Blood limit | Clotting Factor | Notes
90371 | [NAME], im | 1 ML | 116.679
90375 | Rabies ig, im/sc | 150 IU | 186.777
90376 | Rabies ig, heat treated | 150 IU | 179.512
90385 | Rh ig, minidose, im | 50 MCG | 25.09
90585 | Bcg vaccine, percut | 50 MG | 113.95
90586 | Bcg vaccine, intravesical | 1 EACH | 115.319
90632 | [NAME] a vaccine, adult im | 1 ML | 47.299
90655 | Flu vaccine no preserv 6-35m, im | 0.25 ML | 14.858 | 95 | 14.858
90656 | Flu vaccine no preserv 3 yo & >, im | 0.50 ML | 12.375 | 95 | 12.375
90657 | Flu vaccine, 6-35 mo, im | 0.25 ML | 6.296 | 95 | 6.296
90660 | Flu vaccine, nasal | 0.2 ML | 22.316 | 95 | 22.316
90662 | Flu vacc prsv free inc antig | 0.5 ML | 29.213 | 95 | 29.213
90669 | Pneumococcal vacc, 7 val im | 0.5 ML | 95.481 | 95 | 95.481
90670 | Pneumococcal vacc, 13 val im | 0.5 ML | 123.833 | 95 | 123.833
90675 | Rabies vaccine, im | 1 ML | 143.234
90691 | Typhoid vaccine, im | 0.5 ML | 57.829
90703 | Tetanus vaccine, im | 0.5 ML | 30.46
90714 | Td vaccine no prsrv >/= 7 yo, im | 0.5 ML | 18.719
90715 | Tdap => 7 yo, im | 0.5 ML | 39.572
90717 | Yellow fever vaccine, sc | 0.5 ML | 68.082
90718 | Td vaccine >/= 7 yo, im | 0.5 ML | 23.233
90732 | Pneumococcal vaccine | 0.5 ML | 57.194 | 95 | 57.194
90733 | Meningococcal vaccine, sc | 0.5 ML | 106.492
90735 | Encephalitis vaccine, sc | 1 ML | 102.078
90740 | Hepb vacc, [NAME] 3 dose im | 40 MCG | 119.415 | 95 | 119.415
90743 | Hep b vacc, adol, 2 dose, im | 1 DOSE | 24.216 | 95 | 24.216
90744 | Hepb vacc ped/adol 3 dose im | 1 DOSE | 24.216 | 95 | 24.216
90746 | Hep b vaccine, adult, im | 20 MCG | 59.708 | 95 | 59.708
90747 | Hepb vacc, [NAME] 4 dose im | 40 MCG | 119.415 | 95 | 119.415
A9576 | Inj prohance multipack | 1 ML | 1.915
A9577 | Inj multihance | 1 ML | 2.445
A9578 | Inj multihance multipack | 1 ML | 2.313
A9579 | Gad-base MR contrast NOS,1ml | 1 ML | 2.165
A9581 | Gadoxetate disodium inj | 1 ML | 13.504
A9583 | Gadofosveset trisodium inj | 1 ML | 12.707
J0129 | Abatacept injection | 10 MG | 20.916
J0130 | Abciximab injection | 10 MG | 528.813
[NAME] | Acetylcysteine injection | 100 MG | 2.727
J0133 | Acyclovir injection | 5 MG | 0.033
J0135 | Adalimumab injection | 20 MG | 408.091
J0150 | Injection adenosine 6 MG | 6 MG | 8.715
J0152 | Adenosine injection | 30 MG | 95.325
J0171 | Adrenalin epinephrine inject | 0.1 MG | 0.043
J0180 | Agalsidase beta injection | 1 MG | 141.186
J0205 | Alglucerase injection | 10 UNITS | 41.99
J0207 | [NAME] | 500 MG | 314.202
[NAME] | Methyldopate hcl injection | 250 MG | 40.214
J0215 | Alefacept | 0.5 MG | 36.36
J0220 | [NAME] alfa injection | 10 MG | 158.839
[NAME] | Alpha 1 proteinase inhibitor | 10 MG | 3.867
J0270 | Alprostadil for injection | 1.25 MCG | 0.507
J0278 | Amikacin sulfate injection | 100 MG | 0.276
J0280 | [NAME] 250 [NAME] inj | 250 MG | 0.394
J0282 | Amiodarone HCl | 30 MG | 0.229
J0285 | Amphotericin B | 50 MG | 13.102 |  |  | 95 | 10.28
J0287 | Amphotericin b lipid complex | 10 MG | 8.608 |  |  | 95 | 21.85
[NAME] | Ampho b [NAME] | 10 MG | 14 |  |  | 95 | 15.2
J0289 | Amphotericin b liposome inj | 10 MG | 15.419 |  |  | 95 | 35.8
[NAME] | Ampicillin 500 MG inj | 500 MG | 3.451
J0295 | Ampicillin sodium per 1.5 gm | 1.5 GM | 2.476
J0348 | Anidulafungin injection | 1 MG | 1.406
J0360 | Hydralazine hcl injection | 20 MG | 4.2
J0364 | Apomorphine hydrochloride | 1 MG | 4.929
J0365 | Aprotonin, 10,000 kiu | 10000 KIU | 2.646
J0400 | Aripiprazole injection | 0.25 MG | 0.393
J0456 | [NAME] | 500 MG | 4.787
J0461 | Atropine sulfate injection | 0.01 MG | 0.019
J0470 | Dimecaprol injection | 100 MG | 29.167
[NAME] | Baclofen 10 MG injection | 10 MG | 197.235 |  |  | 95 | 215.18
[NAME] | Baclofen intrathecal trial | 50 MCG | 75.006 |  |  | 95 | 79.8
[NAME] | [NAME] | 20 MG | 2209.471
J0500 | Dicyclomine injection | 20 MG | 21.251
[NAME] | Inj benztropine mesylate | 1 MG | 28.239
[NAME] | PenG benzathine/procaine inj | 100,000 UNITS | 3.403
[NAME] | Penicillin g benzathine inj | 100,000 UNITS | 4.331
J0583 | Bivalirudin | 1 MG | 2.768
J0585 | Injection,onabotulinumtoxinA | 1 UNIT | 5.485
[NAME] | AbobotulinumtoxinA | 5 Unit | 7.478
J0587 | Inj, rimabotulinumtoxinB | 100 UNITS | 10.75
J0592 | Buprenorphine hydrochloride | 0.1 MG | 1.059
J0594 | Busulfan injection | 1 MG | 18.985
J0595 | Butorphanol tartrate 1 mg | 1 MG | 0.851
J0597 | C-1 esterase, berinert | 10 UNITS | 30.226
[NAME] | C-1 esterase, cinryze | 10 IU | 44.199
J0600 | Edetate calcium disodium inj | 1000 MG | 194.169
J0610 | Calcium gluconate injection | 10 ML | 0.493
[NAME] | Calcitonin salmon injection | 400 UNITS | 56.763
[NAME] | Inj calcitriol per 0.1 mcg | 0.1 MCG | 0.364
J0637 | Caspofungin acetate | 5 MG | 12.383
[NAME] | [NAME] injection | 1 MG | 88.99
J0640 | Leucovorin calcium injection | 50 MG | 1.259
[NAME] | Levoleucovorin injection | 0.5 MG | 1.839
[NAME] | Inj mepivacaine HCL/10 ml | 10 ML | 1.421
[NAME] | Cefazolin sodium injection | 500 MG | 0.622
J0692 | Cefepime HCl for injection | 500 MG | 3.443
J0694 | Cefoxitin sodium injection | 1 GM | 5.269
[NAME] | Ceftriaxone sodium injection | 250 MG | 0.935
J0697 | Sterile cefuroxime injection | 750 MG | 2.034
J0698 | Cefotaxime sodium injection | 1 GM | 1.571
J0702 | Betamethasone acet&sod phosp | 3 MG & 3 MG | 5.525
[NAME] | Caffeine citrate injection | 5 MG | 0.39
[NAME] | Inj ceftazidime per 500 mg | 500 MG | 1.984
J0718 | [NAME] pegol inj | 1 MG | 3.964
J0720 | Chloramphenicol sodium injec | 1 GM | 19.871
J0725 | Chorionic gonadotropin/1000u | 1000 UNITS | 11.046
J0735 | Clonidine hydrochloride | 1 MG | 23.869
J0740 | Cidofovir injection | 375 MG | 756.003
[NAME] | Cilastatin sodium injection | 250 MG | 12.216
J0744 | Ciprofloxacin iv | 200 MG | 1.152
J0745 | Inj codeine phosphate /30 MG | 30 MG | 1.346
[NAME] | Colchicine injection | 1 MG | 6.572
J0770 | Colistimethate sodium inj | 150 MG | 13.949
J0775 | Collagenase, clost hist inj | 0.01 MG | 37.512
J0780 | Prochlorperazine injection | 10 MG | 1.942
J0795 | Corticorelin ovine triflutal | 1 MCG | 5.055
J0800 | Corticotropin injection | 40 UNITS | 2564.493
[NAME] | Cosyntropin cortrosyn inj | 0.25 MG | 69.759
J0850 | [NAME] | PER VIAL | 965.543
J0878 | [NAME] injection | 1 MG | 0.487
J0881 | Darbepoetin alfa, non-esrd | 1 MCG | 3.12
J0882 | Darbepoetin alfa, esrd use | 1 MCG | 3.12
J0885 | Epoetin alfa, non-esrd | 1000 UNITS | 9.824
J0886 | Epoetin alfa 1000 units ESRD | 1000 UNITS | 9.824
[NAME] | Decitabine injection | 1 MG | 32.484
[NAME] | Deferoxamine mesylate inj | 500 MG | 9.786 |  |  | 95 | 15.63
J1000 | Depo-estradiol cypionate inj | 5 MG | 6.829
J1020 | Methylprednisolone 20 MG inj | 20 MG | 1.358
J1030 | Methylprednisolone 40 MG inj | 40 MG | 2.435
J1040 | Methylprednisolone 80 MG inj | 80 MG | 6.905
J1051 | Medroxyprogesterone inj | 50 MG | 8.237
J1070 | Testosterone cypionat 100 MG | 100 MG | 3.557
[NAME] | Testosterone cypionat 200 MG | 200 MG | 6.085
[NAME] | Dexamethasone sodium phos | 1 MG | 0.09
[NAME] | Inj dihydroergotamine mesylt | 1 MG | 26.246
J1120 | Acetazolamid sodium injectio | 500 MG | 32.298
J1160 | Digoxin injection | 0.5 MG | 1.212
[NAME] | Digoxin immune fab (ovine) | PER VIAL | 619.631
J1165 | Phenytoin sodium injection | 50 MG | 0.297
J1170 | Hydromorphone injection | 4 MG | 1.564 |  |  | 95 | 1.49
J1190 | [NAME] HCl injection | 250 MG | 248.668
J1200 | Diphenhydramine hcl injectio | 50 MG | 0.775
J1205 | Chlorothiazide sodium inj | 500 MG | 278.347
[NAME] | Dimethyl sulfoxide 50% 50 ML | 50 ML | 96.195
[NAME] | Methadone injection | 10 MG | 6.603 |  |  | 95 | 0.75
J1240 | Dimenhydrinate injection | 50 MG | 3.504
J1245 | Dipyridamole injection | 10 MG | 0.797
J1250 | Inj dobutamine HCL/250 mg | 250 MG | 4.986 |  |  | 95 | 4.74
[NAME] | Dolasetron mesylate | 10 MG | 5.261
J1265 | Dopamine injection | 40 MG | 0.412
J1267 | [NAME] injection | 10 MG | 0.552
J1270 | Injection, doxercalciferol | 1 MCG | 3.184
J1290 | Ecallantide injection | 1 MG | 275.282
J1300 | Eculizumab injection | 10 MG | 189.952
J1325 | Epoprostenol injection | 0.5 MG | 14.462 |  |  | 95 | 12.64
J1327 | Eptifibatide injection | 5 MG | 22.402
J1335 | Ertapenem injection | 500 MG | 28.768
[NAME] | Erythro lactobionate /500 MG | 500 MG | 7.074
J1380 | [NAME] valerate 10 MG inj | 10 MG | 7.539
[NAME] | Inj estrogen conjugate 25 MG | 25 MG | 105.194
J1430 | Ethanolamine oleate 100 mg | 100 MG | 291.495
J1438 | Etanercept injection | 25 MG | 208.152
J1440 | Filgrastim 300 mcg injection | 300 MCG | 249.381
J1441 | Filgrastim 480 mcg injection | 480 MCG | 393.266
J1450 | Fluconazole | 200 MG | 4.811
J1451 | Fomepizole, 15 mg | 15 MG | 7.718
J1453 | Fosaprepitant injection | 1 MG | 1.772
J1455 | Foscarnet sodium injection | 1000 MG | 14.647 |  |  | 95 | 13.07
J1457 | Gallium nitrate injection | 1 MG | 2.05
[NAME] | Galsulfase injection | 1 MG | 348.662
J1459 | Inj IVIG privigen 500 mg | 500 MG | 35.053
J1460 | Gamma globulin 1 CC inj | 1 CC | 19.774
J1559 | Hizentra injection | 100 MG | 7.284
[NAME] | Gamma globulin > 10 CC inj | 10 CC | 197.736
J1561 | [NAME] injection | 500 MG | 37.675
J1562 | [NAME], inj | 100 MG | 7.25
J1566 | Immune globulin, powder | 500 MG | 31.088
J1568 | Octagam injection | 500 MG | 56.874
J1569 | Gammagard liquid injection | 500 MG | 38.048
[NAME] | Ganciclovir sodium injection | 500 MG | 67.872 |  |  | 95 | 35.25
[NAME] | Hepagam b im injection | 0.5 ML | 55.183
J1572 | Flebogamma injection | 500 MG | 35.297
J1573 | Hepagam b intravenous, inj | 0.5 ML | 55.183
J1580 | Garamycin gentamicin inj | 80 MG | 0.947
J1600 | Gold sodium thiomaleate inj | 50 MG | 13.496
J1610 | Glucagon hydrochloride/1 MG | 1 MG | 94.15
J1626 | Granisetron hcl injection | 100 MCG | 1.595
[NAME] | [NAME] injection | 5 MG | 1.721
J1631 | [NAME] decanoate inj | 50 MG | 15.444
J1640 | Hemin, 1 mg | 1 MG | 10.363
J1642 | Inj heparin sodium per 10 u | 10 UNITS | 0.187
J1644 | Inj heparin sodium per 1000u | 1000 UNITS | 0.287
J1645 | Dalteparin sodium | 2500 IU | 11.62
J1650 | Inj enoxaparin sodium | 10 MG | 6.332
J1652 | Fondaparinux sodium | 0.5 MG | 6.072
[NAME] | Tinzaparin sodium injection | 1000 IU | 3.494
[NAME] | Tetanus immune globulin inj | 250 UNITS | 257.591
J1720 | Hydrocortisone sodium succ i | 100 MG | 3.876
J1740 | Ibandronate sodium injection | 1 MG | 151.209
[NAME] | Ibutilide fumarate injection | 1 MG | 125.182
[NAME] | Idursulfase injection | 1 MG | 455.03
J1745 | Infliximab injection | 10 MG | 60.672
[NAME] | Inj iron dextran | 50 MG | 11.771
J1756 | Iron sucrose injection | 1 MG | 0.382
J1786 | Imuglucerase injection | 10 UNITS | 41.99
J1790 | Droperidol injection | 5 MG | 2.26
[NAME] | Propranolol injection | 1 MG | 2.871
J1815 | Insulin injection | 5 UNITS | 0.453
J1817 | Insulin for insulin pump use | 50 UNITS | 2.506 |  |  | 95 | 2.8
J1840 | Kanamycin sulfate 500 [NAME] inj | 500 MG | 7.685
J1850 | Kanamycin sulfate 75 MG inj | 75 MG | 1.153
[NAME] | Ketorolac tromethamine inj | 15 MG | 0.28
[NAME] | Lanreotide injection | 1 MG | 31.259
[NAME] | Laronidase injection | 0.1 MG | 26.837
[NAME] | Furosemide injection | 20 MG | 1.446
J1945 | [NAME] | 50 MG | 305.17
[NAME] | Leuprolide acetate /3.75 MG | 3.75 MG | 599.035
[NAME] | [NAME] injection | 10 MG | 0.34
J1955 | Inj levocarnitine per 1 gm | 1 GM | 6.808
J1956 | Levofloxacin injection | 250 MG | 5.343
J1980 | [NAME] sulfate inj | 0.25 MG | 13.304
J2001 | Lidocaine injection | 10 MG | 0.019
[NAME] | Lincomycin injection | 300 MG | 6.092
J2020 | Linezolid injection | 200 MG | 34.976
J2060 | Lorazepam injection | 2 MG | 0.723
J2150 | [NAME] injection | 50 ML | 0.936
J2175 | Meperidine hydrochl /100 [NAME] | 100 MG | 1.884 |  |  | 95 | 0.56
J2185 | Meropenem | 100 MG | 3.287
J2210 | Methylergonovin maleate inj | 0.2 MG | 5.931
J2248 | Micafungin sodium injection | 1 MG | 1.031
[NAME] | Inj midazolam hydrochloride | 1 MG | 0.07
J2260 | Inj milrinone lactate / 5 MG | 5 MG | 3.693 |  |  | 95 | 51.58
J2270 | Morphine sulfate injection | 10 MG | 2.788 |  |  | 95 | 0.71
J2271 | [NAME] so4 injection 100mg | 100 MG | 1.063 |  |  | 95 | 11.07
[NAME] | Morphine sulfate injection | 10 MG | 2.804 |  |  | 95 | 4.39
J2278 | Ziconotide injection | 1 MCG | 6.604
J2280 | Inj, moxifloxacin 100 mg | 100 MG | 3.288
J2300 | Inj nalbuphine hydrochloride | 10 MG | 1.058
[NAME] | Inj naloxone hydrochloride | 1 MG | 7.694
[NAME] | Naltrexone, depot form | 1 MG | 2.831
[NAME] | [NAME] injection | 1 MG | 10.614
J2325 | Nesiritide injection | 0.1 MG | 46.921
J2353 | Octreotide injection, depot | 1 MG | 118.136
J2354 | Octreotide inj, non-depot | 25 MCG | 1.372
J2355 | Oprelvekin injection | 5 MG | 244.553
J2357 | Omalizumab injection | 5 MG | 21.065
[NAME] | Olanzapine long-acting inj | 1 MG | 2.753
J2360 | Orphenadrine injection | 60 MG | 5.656
[NAME] | Phenylephrine hcl injection | 1 ML | 1.385
[NAME] | Chloroprocaine hcl injection | 30 ML | 13.792
J2405 | Ondansetron hcl injection | 1 MG | 0.138
J2410 | Oxymorphone hcl injection | 1 MG | 2.31
[NAME] | Palifermin injection | 50 MCG | 11.713
J2426 | Paliperidone palmitate inj | 1 MG | 6.691
J2430 | Pamidronate disodium /30 MG | 30 MG | 14.616
J2440 | Papaverin hcl injection | 60 MG | 0.844
J2469 | Palonosetron hcl | 25 MCG | 17.859
J2501 | [NAME] | 1 MCG | 2.655
[NAME] | Pegaptanib sodium injection | 0.3 MG | 1031.995
[NAME] | Pegademase bovine, 25 iu | 25 IU | 247.333
[NAME] | Injection, pegfilgrastim 6mg | 6 MG | 2653.307
[NAME] | Penicillin g procaine inj | 600000 UNITS | 12.274
[NAME] | Pentobarbital sodium inj | 50 MG | 21.442
J2540 | Penicillin g potassium inj | 600000 UNITS | 0.66
J2543 | Piperacillin/tazobactam | 1.125 GM | 4.253
J2545 | Pentamidine non-comp unit | 300 MG | 52.269
[NAME] | Promethazine hcl injection | 50 MG | 1.673
[NAME] | Phenobarbital sodium inj | 120 MG | 3.08
J2562 | Plerixafor injection | 1 MG | 276.955
[NAME] | Oxytocin injection | 10 UNITS | 0.82
J2597 | Inj desmopressin acetate | 1 MCG | 2.642
J2675 | Inj progesterone per 50 MG | 50 MG | 1.581
J2680 | Fluphenazine decanoate 25 MG | 25 MG | 10.882
J2690 | Procainamide hcl injection | 1 GM | 7.943
J2700 | Oxacillin sodium injeciton | 250 MG | 2.603
J2720 | Inj protamine sulfate/10 MG | 10 MG | 0.504
J2724 | Protein c concentrate | 10 UNITS | 13.062
J2730 | Pralidoxime chloride inj | 1 GM | 90.227
J2760 | [NAME] mesylate inj | 5 MG | 57.028
J2765 | Metoclopramide hcl injection | 10 MG | 0.386
J2770 | Quinupristin/dalfopristin | 500 MG | 172.91
J2778 | [NAME] injection | 0.1 mg | 404.297
J2780 | Ranitidine hydrochloride inj | 25 MG | 0.805
J2783 | Rasburicase | 0.5 MG | 188.776
J2785 | Regadenoson injection | 0.1 MG | 52.213
J2788 | Rho d immune globulin 50 mcg | 50 MCG (250 IU) | 30.284
J2790 | Rho d immune globulin inj | 300 MCG (1500 IU) | 86.187
J2791 | [NAME] injection | 100 IU | 5.182
[NAME] | Rho(D) immune globulin h, sd | 100 IU | 18.33
J2794 | Risperidone, long acting | 0.5 MG | 5.163
J2795 | [NAME] HCl injection | 1 MG | 0.074
[NAME] | Romiplostim injection | 10 MCG | 46.124
[NAME] | Methocarbamol injection | 10 ML | 28.62
J2805 | Sincalide injection | 5 MCG | 75.98
J2810 | Inj theophylline per 40 MG | 40 MG | 0.206
J2820 | Sargramostim injection | 50 MCG | 24.639
J2850 | Inj secretin synthetic human | 1 MCG | 27.494
J2916 | Na ferric gluconate complex | 12.5 MG | 4.639
J2920 | Methylprednisolone injection | 40 MG | 1.914
J2930 | Methylprednisolone injection | 125 MG | 2.775
J2993 | Reteplase injection | 18.1 MG | 1382.95
J2997 | Alteplase recombinant | 1 MG | 42.034
[NAME] | Streptomycin injection | 1 GM | 9.958
[NAME] | [NAME] citrate injeciton | 0.1 MG | 0.328 |  |  | 95 | 0.7
J3030 | Sumatriptan succinate / 6 MG | 6 MG | 77.452
J3070 | Pentazocine injection | 30 MG | 10.602
J3095 | Telavancin injection | 10 MG | 1.988
J3101 | Tenecteplase injection | 1 MG | 56.486
[NAME] | Terbutaline sulfate inj | 1 MG | 1.821
J3120 | Testosterone enanthate inj | 100 MG | 4.364
J3130 | Testosterone enanthate inj | 200 MG | 10.073
J3230 | Chlorpromazine hcl injection | 50 MG | 9.046
J3240 | Thyrotropin injection | 0.9 MG | 1053.741
[NAME] | Tigecycline injection | 1 MG | 1.325
J3246 | Tirofiban HCl | 0.25 MG | 9.816
[NAME] | Trimethobenzamide hcl inj | 200 MG | 5.8
[NAME] | Tobramycin sulfate injection | 80 MG | 2.434
J3262 | Tocilizumab injection | 1 MG | 3.474
J3285 | Treprostinil injection | 1 MG | 61.237
J3300 | Triamcinolone A inj PRS-free | 1 MG | 3.48
J3301 | Triamcinolone acet inj NOS | 10 MG | 1.641
[NAME] | Triamcinolone diacetate inj | 5 MG | 0.28
[NAME] | Triamcinolone hexacetonl inj | 5 MG | 1.605
[NAME] | Triptorelin pamoate | 3.75 MG | 211.086
J3355 | Urofollitropin, 75 iu | 75 IU | 66.017
J3357 | Ustekinumab injection | 1 MG | 117.209
J3360 | Diazepam injection | 5 MG | 0.742
J3365 | Urokinase 250,000 IU inj | 250000 IU | 457.729
J3370 | Vancomycin hcl injection | 500 MG | 2.935
[NAME] | Velaglucerase alfa | 100 UNITS | 349.906
J3396 | [NAME] injection | 0.1 MG | 9.846
J3410 | Hydroxyzine hcl injection | 25 MG | 1.367
J3411 | Thiamine hcl 100 mg | 100 MG | 3.137
J3415 | Pyridoxine hcl 100 mg | 100 MG | 6.377
J3420 | Vitamin b12 injection | 1000 MCG | 0.362
J3430 | Vitamin k phytonadione inj | 1 MG | 1.43
J3465 | Injection, voriconazole | 10 MG | 6.205
J3470 | Hyaluronidase injection | 150 UNITS | 21.2
J3471 | Ovine, up to 999 USP units | 1 USP UNIT | 0.191
[NAME] | Ovine, 1000 USP units | 1000 USP UNITS | 137.8
J3473 | Hyaluronidase recombinant | 1 USP UNIT | 0.636
[NAME] | Inj magnesium sulfate | 500 MG | 0.086
[NAME] | Inj potassium chloride | 2 MEQ | 0.015
[NAME] | [NAME] | 10 MG | 1.399
J3486 | Ziprasidone mesylate | 10 MG | 7.056
J3487 | Zoledronic acid | 1 MG | 224.797
J3488 | Reclast injection | 1 MG | 222.655
J7030 | Normal saline solution infus | 1000 CC | 0.472
J7040 | Normal saline solution infus | 500 ML | 0.567
J7042 | 5% dextrose/normal saline | 500 ML | 0.352
J7050 | Normal saline solution infus | 250 CC | 0.283
J7060 | 5% dextrose/water | 500 ML | 1.112
J7070 | D5w infusion | 1000 CC | 2.188
J7100 | [NAME] 40 infusion | 500 ML | 21.076
J7110 | [NAME] 75 infusion | 500 ML | 12.72
J7120 | Ringers lactate infusion | 1000 CC | 1.051
J7185 | [NAME] inj | 1 IU | 1.054 |  |  |  |  |  |  | 1
[NAME] | Antihemophilic viii/[NAME] comp | PER FACTOR VIII IU | 0.918 |  |  |  |  |  |  | 1
[NAME] | Humate-P, inj | 1 IU | 0.879 |  |  |  |  |  |  | 1
J7189 | Factor viia | 1 MCG | 1.542 |  |  |  |  |  |  | 1
J7190 | Factor viii | 1 IU | 0.886 |  |  |  |  |  |  | 1
J7192 | Factor viii recombinant NOS | 1 IU | 1.102 |  |  |  |  |  |  | 1
J7193 | Factor IX non-recombinant | 1 IU | 0.897 |  |  |  |  |  |  | 1
J7194 | Factor ix complex | 1 IU | 0.928 |  |  |  |  |  |  | 1
[NAME] | Factor IX recombinant | 1 IU | 1.156 |  |  |  |  |  |  | 1
J7197 | [NAME] injection | 1 IU | 2.682
[NAME] | Anti-inhibitor | 1 IU | 1.632 |  |  |  |  |  |  | 1
J7308 | Aminolevulinic acid hcl top | 354 MG | 151.304
J7310 | Ganciclovir long act implant | 4.5 MG | 16960
J7311 | Fluocinolone acetonide implt | 0.59 MG | 19345
J7312 | Dexamethasone intra implant | 0.1 MG | 195.985
[NAME] | Hyalgan/supartz inj per dose | per dose | 89.332
[NAME] | Euflexxa inj per dose | per dose | 137.157
[NAME] | Orthovisc inj per dose | per dose | 168.996
[NAME] | Synvisc or Synvisc-One | 1 MG | 12.093
[NAME] | Cultured chondrocytes implnt | 1 EA | 27540.581
J7335 | Capsaicin 8% patch | 10 SQ CM | 25.554
J7500 | Azathioprine oral 50mg | 50 MG | 0.127
J7501 | Azathioprine parenteral | 100 MG | 108.417
[NAME] | Cyclosporine oral 100 mg | 100 MG | 3.278
J7504 | [NAME] immune globulin | 250 MG | 571.23
J7505 | Monoclonal antibodies | 5 MG | 1133.659
J7506 | Prednisone oral | 5 MG | 0.024
J7507 | Tacrolimus oral per 1 MG | 1 MG | 2.813
[NAME] | Methylprednisolone oral | 4 MG | 0.12
J7510 | Prednisolone oral per 5 mg | 5 MG | 0.036
[NAME] | Antithymocyte globuln rabbit | 25 MG | 442.402
J7513 | [NAME], parenteral | 25 MG | 526.343
J7515 | Cyclosporine oral 25 mg | 25 MG | 0.858
[NAME] | Cyclosporin parenteral 250mg | 250 MG | 22.917
J7517 | Mycophenolate mofetil oral | 250 MG | 1.414
J7518 | Mycophenolic acid | 180 MG | 3.336
[NAME] | Sirolimus, oral | 1 MG | 10.97
J7525 | Tacrolimus injection | 5 MG | 139.528
J7605 | Arformoterol non-comp unit | 15 mcg | 5.458
J7606 | Formoterol fumarate, inh | 20 MCG | 4.763
J7608 | Acetylcysteine non-comp unit | 1 GM | 2.107
J7611 | Albuterol non-comp con | 1 MG | 0.091
J7612 | [NAME] con | 0.5 MG | 0.203
[NAME] | Albuterol non-comp unit | 1 MG | 0.067
[NAME] | [NAME] unit | 0.5 MG | 0.297
J7620 | Albuterol ipratrop non-comp | 2.5 MG/0.5 MG | 0.275
J7626 | Budesonide non-comp unit | 0.5 MG | 4.509
J7631 | Cromolyn sodium noncomp unit | 10 MG | 0.474
J7639 | Dornase alfa non-comp unit | 1 MG | 27.997
J7644 | Ipratropium bromide non-comp | 1 MG | 0.263
J7669 | Metaproterenol non-comp unit | 10 MG | 0.252
J7674 | Methacholine chloride, neb | 1 MG | 0.458
J7682 | Tobramycin non-comp unit | 300 MG | 79.257
J7686 | Treprostinil, non-comp unit | 1.74 MG | 418.154
J8501 | Oral aprepitant | 5 MG | 6.037
J8510 | Oral busulfan | 2 MG | 3.661
J8520 | Capecitabine, oral, 150 mg | 150 MG | 7.371
J8521 | Capecitabine, oral, 500 mg | 500 MG | 24.372
J8530 | Cyclophosphamide oral 25 MG | 25 MG | 0.827
J8540 | Oral dexamethasone | 0.25 MG | 0.367
J8560 | Etoposide oral 50 MG | 50 MG | 36.046
J8562 | Oral fludarabine phosphate | 10 MG | 79.561
J8600 | Melphalan oral 2 MG | 2 MG | 6.684
J8610 | Methotrexate oral 2.5 MG | 2.5 MG | 0.006
J8700 | Temozolomide | 5 MG | 9.539
J8705 | Topotecan oral | 0.25 mg | 77.202
J9000 | [NAME] injection | 10 MG | 3.03
J9001 | [NAME] liposome inj | 10 MG | 540.92 |  |  | 95 | 393.48
[NAME] | Alemtuzumab injection | 10 MG | 589.856
[NAME] | Aldesleukin injection | 1 EA | 990.877
J9017 | Arsenic trioxide injection | 1 MG | 40.752
J9020 | Asparaginase injection | 10000 UNITS | 63.271
J9025 | Azacitidine injection | 1 MG | 5.24
J9027 | Clofarabine injection | 1 MG | 122.312
[NAME] | Bcg live intravesical vac | 1 EA | 115.319
J9033 | Bendamustine injection | 1 MG | 18.605
J9035 | Bevacizumab injection | 10 MG | 61.196
J9040 | Bleomycin sulfate injection | 15 UNITS | 24.546 |  |  | 95 | 289.37
J9041 | Bortezomib injection | 0.1 MG | 41.453
J9045 | Carboplatin injection | 50 MG | 5.003
J9050 | Carmustine injection | 100 MG | 176.108
J9055 | [NAME] injection | 10 MG | 50.484
[NAME] | Cisplatin 10 MG injection | 10 MG | 2.235
J9065 | Inj cladribine per 1 MG | 1 MG | 24.324 |  |  | 95 | 61.72
J9070 | Cyclophosphamide 100 MG inj | 100 MG | 11.043
[NAME] | Cytarabine liposome inj | 10 MG | 490.398
J9100 | Cytarabine hcl 100 [NAME] inj | 100 MG | 0.89 |  |  | 95 | 8.19
[NAME] | Dactinomycin injection | 0.5 MG | 572.418
J9130 | Dacarbazine 100 mg inj | 100 MG | 3.822
J9150 | Daunorubicin injection | 10 MG | 13.863
J9151 | Daunorubicin citrate inj | 10 MG | 57.664
J9155 | Degarelix injection | 1 MG | 2.65
J9160 | Denileukin diftitox inj | 300 MCG | 1616.373
J9171 | Docetaxel injection | 1 MG | 19.615
J9175 | Elliotts b solution per ml | 1 ML | 4.074
J9178 | Inj, [NAME], 2 mg | 2 MG | 2.039
J9181 | Etoposide injection | 10 MG | 0.876
J9185 | Fludarabine phosphate inj | 50 MG | 105.934
J9190 | Fluorouracil injection | 500 MG | 1.456 |  |  | 95 | 2.07
J9200 | Floxuridine injection | 500 MG | 60.863 |  |  | 95 | 136.8
J9201 | Gemcitabine hcl injection | 200 MG | 95.926
J9202 | Goserelin acetate implant | 3.6 MG | 211.324
[NAME] | Irinotecan injection | 20 MG | 8.73
[NAME] | Ixabepilone injection | 1 MG | 64.213
J9208 | Ifosfamide injection | 1 GM | 33.224 |  |  | 95 | 150.38 |  |  |  | Updated short description
J9209 | Mesna injection | 200 MG | 2.356
J9211 | Idarubicin hcl injection | 5 MG | 52.123
[NAME] | Interferon alfa-2b inj | 1 MIL UNITS | 17.14
J9217 | Leuprolide acetate suspnsion | 7.5 MG | 201.854
[NAME] | Leuprolide acetate injeciton | 1 MG | 3.796
J9219 | Leuprolide acetate implant | 65 MG | 4819.82
[NAME] | Vantas implant | 50 MG | 3839.733
J9226 | Supprelin LA implant | 50 MG | 15485.551
J9230 | Mechlorethamine hcl inj | 10 MG | 157.855
J9245 | Inj melphalan hydrochl 50 MG | 50 MG | 1403.769
J9250 | Methotrexate sodium inj | 5 MG | 0.187
J9260 | Methotrexate sodium inj | 50 MG | 1.869
[NAME] | Nelarabine injection | 50 MG | 112.849
J9263 | [NAME] | 0.5 MG | 9.804
J9264 | Paclitaxel protein bound | 1 MG | 9.47
J9265 | Paclitaxel injection | 30 MG | 5.551
[NAME] | Pegaspargase injection | 1 EA | 2726.85
[NAME] | Pentostatin injection | 10 MG | 1116.008
[NAME] | Mitomycin 5 MG inj | 5 MG | 19.929 |  |  | 95 | 127.4
J9293 | Mitoxantrone hydrochl / 5 MG | 5 MG | 41.703
J9300 | [NAME] ozogamicin inj | 5 MG | 2742.591
J9302 | Ofatumumab injection | 10 MG | 45.397
J9303 | Panitumumab injection | 10 MG | 87.318
[NAME] | Pemetrexed injection | 10 MG | 53.433
[NAME] | Pralatrexate injection | 1 MG | 165.625
[NAME] | [NAME] injection | 100 MG | 611.031
[NAME] | Romidepsin injection | 1 MG | 224.759
J9320 | Streptozocin injection | 1 GM | 269.028
[NAME] | Temozolomide injection | 1 MG | 4.876
J9330 | Temsirolimus injection | 1 MG | 51.766
[NAME] | Thiotepa injection | 15 MG | 116.579
J9351 | Topotecan injection | 0.1 MG | 9.377
J9355 | [NAME] injection | 10 MG | 70.412 |  |  | 95 | 58.13
J9357 | Valrubicin injection | 200 MG | 972.473
[NAME] | Vinblastine sulfate inj | 1 MG | 1.049 |  |  | 95 | 4.1
[NAME] | Vincristine sulfate 1 [NAME] inj | 1 MG | 3.931 |  |  | 95 | 33.98
[NAME] | Vinorelbine tartrate inj | 10 MG | 20.381
[NAME] | Injection, Fulvestrant | 25 MG | 85.445
J9600 | Porfimer sodium injection | 75 MG | 3004.74
P9041 | [NAME] (human),5%, 50ml | 50 ML | 9.546 |  |  |  |  | 95 | 9.546
P9043 | Plasma protein fract,5%,50ml | 50 ML | 8.333 |  |  |  |  | 95 | 8.333
P9045 | Albumin (human), 5%, 250 ml | 250 ML | 47.728 |  |  |  |  | 95 | 47.728
P9046 | Albumin (human), 25%, 20 ml | 20 ML | 19.68 |  |  |  |  | 95 | 19.68
P9047 | Albumin (human), 25%, 50ml | 50 ML | 49.201 |  |  |  |  | 95 | 49.201
P9048 | Plasmaprotein fract,5%,250ml | 250 ML | 41.667 |  |  |  |  | 95 | 41.667
[NAME] | Ferumoxytol, non-esrd | 1 MG | 0.682
Q0139 | Ferumoxytol, esrd use | 1 MG | 0.682
[NAME] | Diphenhydramine HCl 50mg | 50 MG | 0.019
Q0164 | Prochlorperazine maleate 5mg | 5 MG | 0.039
Q0165 | Prochlorperazine maleate10mg | 10 MG | 0.037
Q0166 | Granisetron hcl 1 mg oral | 1 MG | 0.822
Q0167 | [NAME] 2.5mg oral | 2.5 MG | 5.352
Q0168 | Dronabinol 5mg oral | 5 MG | 14.329
Q0169 | Promethazine HCl 12.5mg oral | 12.5 MG | 0.395
Q0170 | Promethazine HCl 25 mg oral | 25 MG | 0.096
Q0179 | Ondansetron hcl 8 mg oral | 8 MG | 0.74
Q0180 | Dolasetron mesylate oral | 100 MG | 66.588
[NAME] | Sermorelin acetate injection | 1 MCG | 1.8
Q2009 | Fosphenytoin inj PE | 50 MG | 0.681
Q2017 | Teniposide, 50 mg | 50 MG | 323.109
Q2036 | Flulaval vacc, 3 yrs & >, im | 0.5 ML | 8.784 | 95 | 8.784
Q2037 | [NAME] vacc, 3 yrs & >, im | 0.5 ML | 13.253 | 95 | 13.253
Q2038 | Fluzone vacc, 3 yrs & >, im | 0.5 ML | 12.593 | 95 | 12.593
Q2040 | Incobotulinumtoxin A | 1 UNIT | 5.535
Q2041 | Wilate injection | 1 I.U. VWF:RCO | 0.877 |  |  |  |  |  |  | 1 | Added July 2011
Q2043 | Sipuleucel-T auto CD54+ | Per infusion (minimum 50 million cells) | 32860 |  |  |  |  |  |  |  | Added July 2011
Q3025 | IM inj interferon beta 1-a | 11 MCG | 237.737
Q4074 | Iloprost non-comp unit dose | UP TO 20 MCG | 68.176
Q4081 | Epoetin alfa, 100 units ESRD | 100 UNITS | 0.982
[NAME] | Apligraf skin sub | 1 SQ CM | 36.537
Q4102 | Oasis wound matrix skin sub | 1 SQ CM | 4.673
Q4103 | Oasis burn matrix skin sub | 1 SQ CM | 4.673
Q4104 | Integra BMWD skin sub | 1 SQ CM | 17.455
Q4105 | Integra DRT skin sub | 1 SQ CM | 10.556
Q4106 | Dermagraft skin sub | 1 SQ CM | 41.27
Q4107 | Graftjacket skin sub | 1 SQ CM | 96.149
[NAME] | Integra matrix skin sub | 1 SQ CM | 20.111
Q4110 | Primatrix skin sub | 1 SQ CM | 31.224
Q4111 | Gammagraft skin sub | 1 SQ CM | 7.025
Q4112 | Cymetra allograft | 1 CC | 354.715
Q4113 | Graftjacket express allograf | 1 CC | 354.715
Q4114 | Integra flowable wound matri | 1 CC | 1034.207
Q4116 | Alloderm skin sub | 1 SQ CM | 32.741
Q9954 | Oral MR contrast, 100 ml | 100 ML | 10.515
Q9956 | Inj octafluoropropane mic,ml | 1 ML | 41.193
Q9957 | Inj perflutren lip micros,ml | 1 ML | 61.79
Q9958 | HOCM <=149 mg/ml iodine, 1ml | 1 ML | 0.072
Q9960 | HOCM 200-249mg/ml iodine,1ml | 1 ML | 0.141
Q9961 | HOCM 250-299mg/ml iodine,1ml | 1 ML | 0.181
Q9963 | HOCM 350-399mg/ml iodine,1ml | 1 ML | 0.173
Q9965 | LOCM 100-199mg/ml iodine,1ml | 1 ML | 1.059
Q9966 | LOCM 200-299mg/ml iodine,1ml | 1 ML | 0.29
Q9967 | LOCM 300-399mg/ml iodine,1ml | 1 ML | 0.166