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Nota 1:  El límite de paga sujeto a la metodología de ASP está basado en el informe ASP del 1er trimestre del 2007.

Nota 2:  La ausencia o prexencia de un código HCPCS (healthcare common procedure coding system) y su respectivo límite de pago no indica que l medicamento o producto biológico tiene cobertura de Medicare.  Igualmente, la inclusión de un límite de pago en una columna específica no indica que Medicare cubre dicho medicamento en esa categoría específica.  El contratista que procesa su reclamación hará dichas determinaciones.

Nota: Códigos Medicamentos - 04/01/2008 to 06/30/2008

 

Código Descripción Dosis Pago Limite
90371 Hep b ig, im 1 ML $119.97
90375 Rabies ig, im/sc 150 IU $67.83
90376 Rabies ig, heat treated 150 IU $78.08
90385 Rh ig, minidose, im 50 MCG $26.54
90585 Bcg vaccine, percut 50 MG $116.90
90586 Bcg vaccine, intravesical 1 EACH $113.75
90632 Hep a vaccine, adult im 1 ML $45.81
90633 Hep a vacc, ped/adol, 2 dose 1 ML $24.70
90645 Hib vaccine, hboc, im 1 EACH $20.41
90647 Hib vaccine, prp-omp, im 0.5 ML $20.41
90648 Hib vaccine, prp-t, im 0.5 ML $21.78
90655 Flu vaccine no preserv 6-35m, im 0.25 ML $16.11
90656 Flu vaccine no preserv 3 yo & >, im 0.50 ML $17.37
90657 Flu vaccine, 6-35 mo, im 0.25 ML $6.61
90658 Flu vaccine age 3 yo & over, im 0.5 ML $13.22
90660 Flu vaccine, nasal 0.5 ML $22.03
90669 Pneumococcal vacc, ped <5, IM 0.5 ML $78.80
90675 Rabies vaccine, im 1 ML $152.54
90691 Typhoid vaccine, im 0.5 ML $56.03
90700 Dtap vaccine, < 7 yo, im 0.5 ML $14.87
90702 Dt vaccine < 7 yo, im 0.5 ML $24.96
90703 Tetanus vaccine, im 0.5 ML $21.47
90704 Mumps vaccine, sc 0.5 ML $21.91
90705 Measles vaccine, sc 0.5 ML $16.76
90706 Rubella vaccine, sc 0.5 ML $18.75
90707 Mmr vaccine, sc 0.5 ML $42.55
90713 Poliovirus, ipv, sc/im 0.5 ML $25.71
90714 Td vaccine no prsrv >/= 7 yo, im 0.5 ML $19.97
90715 Tdap => 7 yo, im 0.5 ML $35.13
90716 Chicken pox vaccine, sc 0.5 ML $73.46
90717 Yellow fever vaccine, sc 0.5 ML $57.75
90718 Td vaccine >/= 7 yo, im 0.5 ML $11.69
90721 Dtap/hib vaccine, im 1 EACH $42.89
90732 Pneumococcal vaccine 0.5 ML $32.70
90733 Meningococcal vaccine, sc 0.5 ML $93.87
90735 Encephalitis vaccine, sc 1 ML $102.08
90740 Hepb vacc, ill pat 3 dose im 40 MCG $114.51
90743 Hep b vacc, adol, 2 dose, im 1 DOSE $24.22
90744 Hepb vacc ped/adol 3 dose im 1 DOSE $24.22
90746 Hep b vaccine, adult, im 20 MCG $57.26
90747 Hepb vacc, ill pat 4 dose im 40 MCG $114.51
A9576 Inj Prohance Multipack 1 ML $2.36
A9577 Inj Multihance 1 ML $2.78
A9578 Inj Multihance Multipack 1 ML $2.78
A9579 Gad-base MR contrast NOS 1 ML $2.44
J0129 Abatacept, inj 10 MG $18.69
J0130 Abciximab injection 10 MG $423.05
J0132 Acetylcysteine injection 100 MG $2.17
J0133 Acyclovir injection 5 MG $0.02
J0135 Adalimumab injection 20 MG $330.56
J0150 Injection adenosine 6 MG 6 MG $12.85
J0152 Adenosine injection 30 MG $68.17
J0170 Adrenalin epinephrin inject 1 ML $0.69
J0180 Agalsidase beta injection 1 MG $129.59
J0205 Alglucerase injection 10 UNITS $39.67
J0207 Amifostine 500 MG $511.22
J0210 Methyldopate hcl injection 250 MG $15.19
J0215 Alefacept 0.5 MG $26.66
J0220 Alglucosidase alfa inj 10 MG $127.20
J0256 Alpha 1 proteinase inhibitor 10 MG $3.66
J0270 Alprostadil for injection 1.25 MCG $0.60
J0275 Alprostadil urethral suppos 125 MCG $22.92
J0278 Amikacin sulfate injection 100 MG $0.73
J0280 Aminophyllin 250 MG inj 250 MG $0.37
J0282 Amiodarone HCl 30 MG $0.20
J0285 Amphotericin B 50 MG $11.98
J0287 Amphotericin b lipid complex 10 MG $10.46
J0288 Ampho b cholesteryl sulfate 10 MG $12.00
J0289 Amphotericin b liposome inj 10 MG $17.16
J0290 Ampicillin 500 MG inj 500 MG $2.25
J0295 Ampicillin sodium per 1.5 gm 1.5 GM $4.40
J0300 Amobarbital 125 MG inj 125 MG $11.96
J0330 Succinycholine chloride inj 20 MG $0.17
J0348 Anadulafungin injection 1 MG $1.53
J0360 Hydralazine hcl injection 20 MG $6.07
J0364 Apomorphine hcl, inj 1 MG $3.35
J0365 Aprotonin, 10,000 kiu 10000 KIU $2.65
J0400 Aripiprazole IM inj 0.25 MG $0.29
J0456 Azithromycin 500 MG $17.98
J0460 Atropine sulfate injection 0.3 MG $0.33
J0470 Dimecaprol injection 100 MG $26.67
J0475 Baclofen 10 MG injection 10 MG $190.85
J0476 Baclofen intrathecal trial 50 MCG $69.76
J0480 Basiliximab 20 MG $1,499.44
J0500 Dicyclomine injection 20 MG $11.92
J0515 Inj benztropine mesylate 1 MG $24.06
J0530 Penicillin g benzathine inj 600000 UNITS $14.75
J0540 Penicillin g benzathine inj 1200000 UNITS $32.90
J0550 Penicillin g benzathine inj 2400000 UNITS $32.90
J0560 Penicillin g benzathine inj 600000 UNITS $23.32
J0570 Penicillin g benzathine inj 1200000 UNITS $40.75
J0580 Penicillin g benzathine inj 2400000 UNITS $46.07
J0583 Bivalirudin 1 MG $2.08
J0585 Botulinum toxin a per unit 1 UNIT $5.22
J0587 Botulinum toxin type B 100 UNITS $8.71
J0592 Buprenorphine hydrochloride 0.1 MG $0.72
J0594 Busulfan, inj 1 MG $9.71
J0595 Butorphanol tartrate 1 mg 1 MG $0.50
J0600 Edetate calcium disodium inj 1000 MG $50.23
J0610 Calcium gluconate injection 10 ML $0.36
J0630 Calcitonin salmon injection 400 UNITS $44.57
J0636 Inj calcitriol per 0.1 mcg 0.1 MCG $0.43
J0637 Caspofungin acetate 5 MG $17.87
J0640 Leucovorin calcium injection 50 MG $0.78
J0670 Inj mepivacaine HCL/10 ml 10 ML $1.15
J0690 Cefazolin sodium injection 500 MG $0.66
J0692 Cefepime HCl for injection 500 MG $6.75
J0694 Cefoxitin sodium injection 1 GM $8.19
J0696 Ceftriaxone sodium injection 250 MG $1.48
J0697 Sterile cefuroxime injection 750 MG $3.44
J0698 Cefotaxime sodium injection 1 GM $4.29
J0702 Betamethasone acet&sod phosp 3 MG $5.75
J0704 Betamethasone sod phosp/4 MG 4 MG $1.13
J0706 Caffeine citrate injection 5 MG $2.28
J0713 Inj ceftazidime per 500 mg 500 MG $3.47
J0715 Ceftizoxime sodium / 500 MG 500 MG $5.24
J0720 Chloramphenicol sodium injec 1 GM $18.38
J0725 Chorionic gonadotropin/1000u 1000 UNITS $3.37
J0735 Clonidine hydrochloride 1 MG $56.00
J0740 Cidofovir injection 375 MG $762.45
J0743 Cilastatin sodium injection 250 MG $14.28
J0744 Ciprofloxacin iv 200 MG $5.34
J0745 Inj codeine phosphate /30 MG 30 MG $1.27
J0760 Colchicine injection 1 MG $5.00
J0770 Colistimethate sodium inj 150 MG $19.88
J0780 Prochlorperazine injection 10 MG $1.16
J0795 Corticorelin ovine triflutal 1 MCG $4.27
J0800 Corticotropin injection 40 UNITS $2,355.52
J0835 Inj cosyntropin per 0.25 MG 0.25 MG $65.60
J0850 Cytomegalovirus imm IV /vial PER VIAL $878.83
J0878 Daptomycin injection 1 MG $0.35
J0881 Darbepoetin alfa, non-esrd 1 MCG $2.77
J0882 Darbepoetin alfa, esrd use 1 MCG $2.77
J0885 Epoetin alfa, non-esrd 1000 UNITS $9.07
J0886 Epoetin alfa, esrd on dialysis 1000 UNITS $9.07
J0894 Decitabine, inj 1 MG $27.11
J0895 Deferoxamine mesylate inj 500 MG $12.31
J0970 Estradiol valerate injection 40 MG $34.43
J1000 Depo-estradiol cypionate inj 5 MG $6.18
J1020 Methylprednisolone 20 MG inj 20 MG $2.41
J1030 Methylprednisolone 40 MG inj 40 MG $4.47
J1040 Methylprednisolone 80 MG inj 80 MG $9.41
J1051 Medroxyprogesterone inj 50 MG $6.67
J1060 Testosterone cypionate 1 ML 1 ML $4.14
J1070 Testosterone cypionat 100 MG 100 MG $4.82
J1080 Testosterone cypionat 200 MG 200 MG $6.96
J1094 Inj dexamethasone acetate 1 MG $0.23
J1100 Dexamethasone sodium phos 1 MG $0.08
J1110 Inj dihydroergotamine mesylt 1 MG $24.50
J1120 Acetazolamid sodium injectio 500 MG $16.68
J1160 Digoxin injection 0.5 MG $1.18
J1162 Digoxin immune fab (ovine) PER VIAL $488.35
J1165 Phenytoin sodium injection 50 MG $0.45
J1170 Hydromorphone injection 4 MG $1.28
J1190 Dexrazoxane HCl injection 250 MG $180.94
J1200 Diphenhydramine hcl injectio 50 MG $0.75
J1205 Chlorothiazide sodium inj 500 MG $165.12
J1212 Dimethyl sulfoxide 50% 50 ML 50 ML $50.49
J1230 Methadone injection 10 MG $2.95
J1240 Dimenhydrinate injection 50 MG $3.12
J1245 Dipyridamole injection 10 MG $0.73
J1250 Inj dobutamine HCL/250 mg 250 MG $5.14
J1260 Dolasetron mesylate 10 MG $4.19
J1265 Dopamine injection 40 MG $0.51
J1270 Injection, doxercalciferol 1 MCG $2.80
J1300 Eculizumab inj 10 MG $176.38
J1325 Epoprostenol injection 0.5 MG $14.36
J1327 Eptifibatide injection 5 MG $17.03
J1335 Ertapenem injection 500 MG $25.51
J1364 Erythro lactobionate /500 MG 500 MG $6.76
J1380 Estradiol valerate 10 MG inj 10 MG $8.61
J1390 Estradiol valerate 20 MG inj 20 MG $17.22
J1410 Inj estrogen conjugate 25 MG 25 MG $71.25
J1430 Ethanolamine oleate 100 mg 100 MG $120.49
J1438 Etanercept injection 25 MG $167.04
J1440 Filgrastim 300 mcg injection 300 MCG $199.24
J1441 Filgrastim 480 mcg injection 480 MCG $306.63
J1450 Fluconazole 200 MG $9.57
J1451 Fomepizole, 15 mg 15 MG $14.12
J1455 Foscarnet sodium injection 1000 MG $10.38
J1457 Gallium nitrate injection 1 MG $1.62
J1458 Galsulfase, inj 1 MG $320.04
J1460 Gamma globulin 1 CC inj 1 CC $11.55
J1470 Gamma globulin 2 CC inj 2 CC $23.11
J1480 Gamma globulin 3 CC inj 3CC $34.66
J1490 Gamma globulin 4 CC inj 4 CC $46.21
J1500 Gamma globulin 5 CC inj 5 CC $57.77
J1510 Gamma globulin 6 CC inj 6 CC $69.33
J1520 Gamma globulin 7 CC inj 7 CC $80.83
J1530 Gamma globulin 8 CC inj 8 CC $92.42
J1540 Gamma globulin 9 CC inj 9 CC $104.01
J1550 Gamma globulin 10 CC inj 10 CC $115.53
J1560 Gamma globulin > 10 CC inj 10 CC $115.53
J1561 Gamunex injection 500 MG $33.45
J1562 Vivaglobulin, injection 100 MG $7.08
J1566 Immune globulin, powder 500 MG $28.07
J1568 Octagam Injection 500 MG $34.07
J1569 Gammagard Liquid injection 500 MG $31.79
J1570 Ganciclovir sodium injection 500 MG $43.85
J1571 HepaGam B IM Injection 0.5 ML $48.35
J1572 Flebogamma injection 500 MG $32.53
J1573 HepaGam B IV 0.5 ML $48.35
J1580 Garamycin gentamicin inj 80 MG $1.04
J1590 Gatifloxacin injection 10 MG $0.80
J1595 Injection glatiramer acetate 20 MG $55.28
J1600 Gold sodium thiomaleate inj 50 MG $7.84
J1610 Glucagon hydrochloride/1 MG 1 MG $68.66
J1626 Granisetron HCl injection 100 MCG $4.96
J1630 Haloperidol injection 5 MG $1.73
J1631 Haloperidol decanoate inj 50 MG $2.41
J1640 Hemin, 1 mg 1 MG $7.37
J1642 Inj heparin sodium per 10 u 10 UNITS $0.04
J1644 Inj heparin sodium per 1000u 1000 UNITS $0.07
J1645 Dalteparin sodium 2500 IU $10.79
J1650 Inj enoxaparin sodium 10 MG $5.90
J1652 Fondaparinux sodium 0.5 MG $5.72
J1655 Tinzaparin sodium injection 1000 IU $1.95
J1670 Tetanus immune globulin inj 250 UNITS $99.75
J1720 Hydrocortisone sodium succ i 100 MG $2.23
J1740 Ibandronate sodium, inj 1 MG $138.97
J1742 Ibutilide fumarate injection 1 MG $323.30
J1743 Idursulfase inj 1 MG $455.03
J1745 Infliximab injection 10 MG $55.04
J1756 Iron sucrose injection 1 MG $0.35
J1785 Injection imiglucerase /unit 1 UNIT $4.00
J1790 Droperidol injection 5 MG $1.32
J1800 Propranolol injection 1 MG $3.18
J1815 Insulin injection 5 UNITS $0.28
J1817 Insulin for insulin pump use 50 UNITS $2.84
J1830 Interferon beta-1b / .25 MG 0.25 MG $116.62
J1835 Itraconazole injection 50 MG $39.90
J1840 Kanamycin sulfate 500 MG inj 500 MG $5.09
J1850 Kanamycin sulfate 75 MG inj 75 MG $0.76
J1885 Ketorolac tromethamine inj 15 MG $0.34
J1931 Laronidase injection 0.1 MG $24.35
J1940 Furosemide injection 20 MG $0.19
J1945 Lepirudin 50 MG $161.01
J1950 Leuprolide acetate /3.75 MG 3.75 MG $441.65
J1955 Inj levocarnitine per 1 gm 1 GM $5.88
J1956 Levofloxacin injection 250 MG $5.87
J1980 Hyoscyamine sulfate inj 0.25 MG $9.29
J1990 Chlordiazepoxide injection 100 MG $21.05
J2001 Lidocaine injection 10 MG $0.02
J2010 Lincomycin injection 300 MG $4.26
J2020 Linezolid injection 200 MG $28.09
J2060 Lorazepam injection 2 MG $0.64
J2150 Mannitol injection 50 ML $0.86
J2175 Meperidine hydrochl /100 MG 100 MG $1.52
J2185 Meropenem 100 MG $3.76
J2210 Methylergonovin maleate inj 0.2 MG $5.04
J2248 Micafungin sodium, inj 1 MG $1.35
J2250 Inj midazolam hydrochloride 1 MG $0.15
J2260 Inj milrinone lactate / 5 MG 5 MG $4.55
J2270 Morphine sulfate injection 10 MG $1.79
J2271 Morphine so4 injection 100mg 100 MG $3.72
J2275 Morphine sulfate injection 10 MG $2.39
J2278 Ziconotide injection 1 MCG $6.51
J2280 Inj, moxifloxacin 100 mg 100 MG $2.85
J2300 Inj nalbuphine hydrochloride 10 MG $0.96
J2310 Inj naloxone hydrochloride 1 MG $3.16
J2315 Naltrexone, depot form inj 1 MG $1.88
J2320 Nandrolone decanoate 50 MG 50 MG $4.76
J2321 Nandrolone decanoate 100 MG 100 MG $7.13
J2322 Nandrolone decanoate 200 MG 200 MG $19.03
J2323 Natalizumab injection 1 MG $7.53
J2325 Nesiritide injection 0.1 MG $33.50
J2353 Octreotide injection, depot 1 MG $101.76
J2354 Octreotide inj, non-depot 25 MCG $2.21
J2355 Oprelvekin injection 5 MG $246.98
J2357 Omalizumab injection 5 MG $17.82
J2360 Orphenadrine injection 60 MG $9.02
J2370 Phenylephrine hcl injection 1 ML $0.70
J2400 Chloroprocaine hcl injection 30 ML $12.72
J2405 Ondansetron hcl injection 1 MG $0.22
J2410 Oxymorphone hcl injection 1 MG $2.51
J2425 Palifermin injection 50 MCG $11.36
J2430 Pamidronate disodium /30 MG 30 MG $28.33
J2440 Papaverin hcl injection 60 MG $0.57
J2469 Palonosetron HCl 25 MCG $17.22
J2501 Paricalcitol 1 MCG $3.92
J2503 Pegaptanib sodium injection 0.3 MG $1,031.02
J2504 Pegademase bovine, 25 iu 25 IU $199.39
J2505 Injection, pegfilgrastim 6mg 6 MG $2,200.10
J2510 Penicillin g procaine inj 600000 UNITS $10.29
J2515 Pentobarbital sodium inj 50 MG $7.61
J2540 Penicillin g potassium inj 600000 UNITS $0.94
J2543 Piperacillin/tazobactam 1.125 GM $5.15
J2545 Pentamidine isethionte/300mg 300 MG $54.31
J2550 Promethazine hcl injection 50 MG $1.37
J2560 Phenobarbital sodium inj 120 MG $3.00
J2590 Oxytocin injection 10 UNITS $2.05
J2597 Inj desmopressin acetate 1 MCG $1.87
J2650 Prednisolone acetate inj 1 ML $0.17
J2675 Inj progesterone per 50 MG 50 MG $1.51
J2680 Fluphenazine decanoate 25 MG 25 MG $2.37
J2690 Procainamide hcl injection 1 GM $2.65
J2700 Oxacillin sodium injeciton 250 MG $1.58
J2710 Neostigmine methylslfte inj 0.5 MG $0.10
J2720 Inj protamine sulfate/10 MG 10 MG $0.59
J2724 Ceprotin inj 10 UNITS $12.19
J2730 Pralidoxime chloride inj 1 GM $88.08
J2760 Phentolaine mesylate inj 5 MG $21.08
J2765 Metoclopramide hcl injection 10 MG $0.34
J2770 Quinupristin/dalfopristin 500 MG $127.97
J2778 Ranibizumab inj 0.1 mg $405.18
J2780 Ranitidine hydrochloride inj 25 MG $0.74
J2783 Rasburicase 0.5 MG $150.29
J2788 Rho d immune globulin 50 mcg 50 MCG $28.43
J2790 Rho d immune globulin inj 300 MCG $89.71
J2791 Rhophylac injection 100 IU $5.33
J2792 Rho(D) immune globulin h, sd 100 IU $15.62
J2794 Risperidone, long acting 0.5 MG $4.93
J2795 Ropivacaine HCl injection 1 MG $0.07
J2800 Methocarbamol injection 10 ML $10.22
J2805 Sincalide injection 5 MCG $55.37
J2810 Inj theophylline per 40 MG 40 MG $0.03
J2820 Sargramostim injection 50 MCG $25.10
J2850 Inj secretin synthetic human 1 MCG $20.31
J2916 Na ferric gluconate complex 12.5 MG $4.78
J2920 Methylprednisolone injection 40 MG $2.07
J2930 Methylprednisolone injection 125 MG $3.02
J2941 Somatropin injection 1 MG $48.08
J2993 Reteplase injection 18.1 MG $833.74
J2997 Alteplase recombinant 1 MG $32.18
J3000 Streptomycin injection 1 GM $6.98
J3010 Fentanyl citrate injeciton 0.1 MG $0.28
J3030 Sumatriptan succinate / 6 MG 6 MG $66.61
J3070 Pentazocine injection 30 MG $6.11
J3100 Tenecteplase injection 50 MG $2,046.33
J3105 Terbutaline sulfate inj 1 MG $2.42
J3120 Testosterone enanthate inj 100 MG $5.29
J3130 Testosterone enanthate inj 200 MG $10.12
J3230 Chlorpromazine hcl injection 50 MG $3.22
J3240 Thyrotropin injection 0.9 MG $838.96
J3243 Tigecycline, inj 1 MG $1.02
J3246 Tirofiban HCl 0.25 MG $7.42
J3250 Trimethobenzamide hcl inj 200 MG $4.46
J3260 Tobramycin sulfate injection 80 MG $2.32
J3265 Injection torsemide 10 mg/ml 10 MG $2.18
J3285 Treprostinil injection 1 MG $55.89
J3301 Triamcinolone acetonide inj 10 MG $1.38
J3302 Triamcinolone diacetate inj 5 MG $0.28
J3303 Triamcinolone hexacetonl inj 5 MG $1.34
J3315 Triptorelin pamoate 3.75 MG $149.17
J3355 Urofollitropin, 75 iu 75 IU $49.18
J3360 Diazepam injection 5 MG $0.79
J3364 Urokinase 5000 IU injection 5000 IU $9.16
J3365 Urokinase 250,000 IU inj 250000 IU $457.73
J3370 Vancomycin hcl injection 500 MG $3.14
J3396 Verteporfin injection 0.1 MG $9.15
J3410 Hydroxyzine hcl injection 25 MG $0.14
J3411 Thiamine hcl 100 mg 100 MG $3.51
J3415 Pyridoxine hcl 100 mg 100 MG $6.54
J3420 Vitamin b12 injection 1000 MCG $0.25
J3430 Vitamin k phytonadione inj 1 MG $3.62
J3465 Injection, voriconazole 10 MG $5.24
J3470 Hyaluronidase injection 150 UNITS $17.28
J3471 Ovine, up to 999 USP units 1 USP UNIT $0.13
J3472 Ovine, 1000 USP units 1000 USP UNITS $135.04
J3473 Hyaluronidase, recombinant, inj 1 USP UNIT $0.41
J3475 Inj magnesium sulfate 500 MG $0.05
J3480 Inj potassium chloride 2 MEQ $0.01
J3485 Zidovudine 10 MG $1.17
J3486 Ziprasidone mesylate 10 MG $5.09
J3487 Zoledronic acid 1 MG $210.66
J3488 Reclast injection 1 MG $216.59
J7030 Normal saline solution infus 1000 CC $1.03
J7040 Normal saline solution infus 500 ML $0.52
J7042 5% dextrose/normal saline 500 ML $0.28
J7050 Normal saline solution infus 250 CC $0.26
J7060 5% dextrose/water 500 ML $1.09
J7070 D5W infusion 1000 CC $2.18
J7100 Dextran 40 infusion 500 ML $13.60
J7110 Dextran 75 infusion 500 ML $10.46
J7120 Ringers lactate infusion 1000 CC $0.91
J7187 Inj Vonwillebrand factor IU 1 IU $0.89
J7189 Factor viia 1 MCG $1.19
J7190 Factor viii 1 IU $0.76
J7192 Factor viii recombinant 1 IU $1.08
J7193 Factor IX non-recombinant 1 IU $0.89
J7194 Factor ix complex 1 IU $0.80
J7195 Factor IX recombinant 1 IU $1.07
J7197 Antithrombin iii injection 1 IU $1.91
J7198 Anti-inhibitor 1 IU $1.43
J7308 Aminolevulinic acid hcl top 354 MG $109.74
J7310 Ganciclovir long act implant 4.5 MG $4,770.00
J7311 Fluocinolone acetonide implt 0.59 MG $19,345.00
J7321 Hyalgan or Supartz, inj PER DOSE $101.24
J7322 Synvisc, inj PER DOSE $180.06
J7323 Euflexxa, inj PER DOSE $110.04
J7324 Orthovisc, inj PER DOSE $177.68
J7330 Cultured chondrocytes implnt 1 EA $21,847.78
J7340 Metabolic active D/E tissue 1 SQ CM $30.17
J7341 Non-human, metabolic tissue 1 SQ CM $2.33
J7342 Metabolically active tissue 1 SQ CM $36.71
J7343 Nonmetabolic act d/e tissue 1 SQ CM $10.81
J7344 Nonmetabolic active tissue 1 SQ CM $86.30
J7346 Injectable human tissue 1 CC $779.64
J7347 Non-human, non-metab tissue 1 SQ CM $19.31
J7348 Tissuemend tissue PER SQ CM $79.89
J7349 Primatrix tissue PER SQ CM $38.47
J7500 Azathioprine oral 50mg 50 MG $0.15
J7501 Azathioprine parenteral 100 MG $50.04
J7502 Cyclosporine oral 100 mg 100 MG $3.66
J7504 Lymphocyte immune globulin 250 MG $383.79
J7505 Monoclonal antibodies 5 MG $986.88
J7506 Prednisone oral 5 MG $0.04
J7507 Tacrolimus oral per 1 MG 1 MG $3.91
J7509 Methylprednisolone oral 4 MG $0.08
J7510 Prednisolone oral per 5 mg 5 MG $0.03
J7511 Antithymocyte globuln rabbit 25 MG $344.72
J7513 Daclizumab, parenteral 25 MG $315.68
J7515 Cyclosporine oral 25 mg 25 MG $0.90
J7516 Cyclosporin parenteral 250mg 250 MG $19.81
J7517 Mycophenolate mofetil oral 250 MG $2.91
J7518 Mycophenolic acid 180 MG $2.46
J7520 Sirolimus, oral 1 MG $7.93
J7525 Tacrolimus injection 5 MG $140.03
J7605 Arformoterol non-comp unit 15 mcg $4.74
J7608 Acetylcysteine inh sol u d 1 GM $1.73
J7611 Albuterol non-comp con1 1 MG $0.07
J7612 Levalbuterol non-comp con1 0.5 MG $0.12
J7613 Albuterol non-comp unit dose1 1 MG $0.04
J7614 Levalbuterol non-comp unit dose1 0.5 MG $0.28
J7620 Albuterol ipratrop non-comp 2.5 MG/0.5 MG $0.83
J7626 Budesonide non-comp unit dose 0.5 MG $5.02
J7631 Cromolyn sodium inh sol u d 10 MG $0.06
J7639 Dornase alpha inhal sol u d 1 MG $20.87
J7644 Ipratropium bromide non-comp 1 MG $0.20
J7669 Metaproterenol non-comp unit dose 10 MG $0.26
J7674 Methacholine chloride, neb 1 MG $0.41
J7682 Tobramycin non-comp unit dose 300 MG $59.75
J8501 Oral aprepitant 5 MG $5.27
J8510 Oral busulfan 2 MG $2.50
J8515 Cabergoline, oral 0.25mg 0.25 MG $17.27
J8520 Capecitabine, oral, 150 mg 150 MG $4.61
J8521 Capecitabine, oral, 500 mg 500 MG $15.29
J8530 Cyclophosphamide oral 25 MG 25 MG $0.82
J8540 Oral dexamethasone 0.25 MG $0.25
J8560 Etoposide oral 50 MG 50 MG $29.55
J8610 Methotrexate oral 2.5 MG 2.5 MG $0.16
J8700 Temozolomide 5 MG $7.67
J9000 Doxorubic hcl 10 MG vl chemo 10 MG $4.75
J9001 Doxorubicin hcl liposome inj 10 MG $413.49
J9010 Alemtuzumab injection 10 MG $551.07
J9015 Aldesleukin/single use vial 1 EA $767.40
J9017 Arsenic trioxide 1 MG $34.48
J9020 Asparaginase injection 10000 UNITS $57.02
J9025 Azacitidine injection 1 MG $4.48
J9027 Clofarabine injection 1 MG $115.17
J9031 Bcg live intravesical vac 1 EA $113.75
J9035 Bevacizumab injection 10 MG $57.44
J9040 Bleomycin sulfate injection 15 UNITS $29.02
J9041 Bortezomib injection 0.1 MG $34.43
J9045 Carboplatin injection 50 MG $6.31
J9050 Carmus bischl nitro inj 100 MG $156.83
J9055 Cetuximab injection 10 MG $49.81
J9060 Cisplatin 10 MG injection 10 MG $2.27
J9062 Cisplatin 50 MG injection 50 MG $11.32
J9065 Inj cladribine per 1 MG 1 MG $30.63
J9070 Cyclophosphamide 100 MG inj 100 MG $1.87
J9080 Cyclophosphamide 200 MG inj 200 MG $3.74
J9090 Cyclophosphamide 500 MG inj 500 MG $9.36
J9091 Cyclophosphamide 1.0 grm inj 1 GM $18.71
J9092 Cyclophosphamide 2.0 grm inj 2 GM $37.43
J9093 Cyclophosphamide lyophilized 100 MG $1.86
J9094 Cyclophosphamide lyophilized 200 MG $3.72
J9095 Cyclophosphamide lyophilized 500 MG $9.29
J9096 Cyclophosphamide lyophilized 1 GM $18.59
J9097 Cyclophosphamide lyophilized 2 GM $37.17
J9098 Cytarabine liposome 10 MG $414.95
J9100 Cytarabine hcl 100 MG inj 100 MG $1.20
J9110 Cytarabine hcl 500 MG inj 500 MG $6.02
J9120 Dactinomycin actinomycin d 0.5 MG $493.43
J9130 Dacarbazine 100 mg inj 100 MG $4.60
J9140 Dacarbazine 200 MG inj 200 MG $9.21
J9150 Daunorubicin 10 MG $17.14
J9151 Daunorubicin citrate liposom 10 MG $56.06
J9160 Denileukin diftitox, 300 mcg 300 MCG $1,410.03
J9170 Docetaxel 20 MG $325.85
J9175 Elliotts b solution per ml 1 ML $4.07
J9178 Inj, epirubicin hcl, 2 mg 2 MG $6.24
J9181 Etoposide 10 MG inj 10 MG $0.40
J9182 Etoposide 100 MG inj 100 MG $4.03
J9185 Fludarabine phosphate inj 50 MG $200.75
J9190 Fluorouracil injection 500 MG $1.87
J9200 Floxuridine injection 500 MG $51.12
J9201 Gemcitabine HCl 200 MG $131.78
J9202 Goserelin acetate implant 3.6 MG $189.73
J9206 Irinotecan injection 20 MG $126.24
J9208 Ifosfamide injection 1 GM $37.92
J9209 Mesna injection 200 MG $7.87
J9211 Idarubicin hcl injection 5 MG $276.07
J9212 Interferon alfacon-1 1 MCG $4.80
J9213 Interferon alfa-2a inj 3 MIL UNITS $40.92
J9214 Interferon alfa-2b inj 1 MIL UNITS $14.16
J9216 Interferon gamma 1-b inj 3 MIL UNITS $309.58
J9217 Leuprolide acetate suspnsion 7.5 MG $220.86
J9218 Leuprolide acetate injeciton 1 MG $7.47
J9219 Leuprolide acetate implant 65 MG $1,608.17
J9225 Histrelin implant 50 MG $1,508.09
J9226 Supprelin LA implant 50 MG $14,655.78
J9230 Mechlorethamine hcl inj 10 MG $144.44
J9245 Inj melphalan hydrochl 50 MG 50 MG $1,563.63
J9250 Methotrexate sodium inj 5 MG $0.21
J9260 Methotrexate sodium inj 50 MG $2.26
J9261 Nelarabine injection 50 MG $91.68
J9263 Oxaliplatin 0.5 MG $9.49
J9264 Paclitaxel protein bound 1 MG $8.85
J9265 Paclitaxel injection 30 MG $11.95
J9266 Pegaspargase/singl dose vial 1 EA $2,093.62
J9268 Pentostatin injection 10 MG $1,828.92
J9280 Mitomycin 5 MG inj 5 MG $13.05
J9290 Mitomycin 20 MG inj 20 MG $52.19
J9291 Mitomycin 40 MG inj 40 MG $104.38
J9293 Mitoxantrone hydrochl / 5 MG 5 MG $88.70
J9300 Gemtuzumab ozogamicin 5 MG $2,428.97
J9303 Panitumumab inj 10 MG $82.26
J9305 Pemetrexed injection 10 MG $46.20
J9310 Rituximab cancer treatment 100 MG $520.57
J9320 Streptozocin injection 1 GM $190.64
J9340 Thiotepa injection 15 MG $40.40
J9350 Topotecan 4 MG $898.54
J9355 Trastuzumab 10 MG $60.08
J9360 Vinblastine sulfate inj 1 MG $1.07
J9370 Vincristine sulfate 1 MG inj 1 MG $7.02
J9375 Vincristine sulfate 2 MG inj 2 MG $14.04
J9380 Vincristine sulfate 5 MG inj 5 MG $35.09
J9390 Vinorelbine tartrate/10 mg 10 MG $16.22
J9395 Injection, Fulvestrant 25 MG $81.36
J9600 Porfimer sodium 75 MG $2,503.55
P9041 Albumin (human),5%, 50ml 50 ML $20.06
P9043 Plasma protein fract,5%,50ml 50 ML $20.06
P9045 Albumin (human), 5%, 250 ml 250 ML $40.13
P9046 Albumin (human), 25%, 20 ml 20 ML $20.06
P9047 Albumin (human), 25%, 50ml 50 ML $40.13
P9048 Plasmaprotein fract,5%,250ml 250 ML $40.13
Q0163 Diphenhydramine HCl 50mg 50 MG $0.02
Q0164 Prochlorperazine maleate 5mg 5 MG $0.06
Q0165 Prochlorperazine maleate10mg 10 MG $0.08
Q0166 Granisetron HCl 1 mg oral 1 MG $46.96
Q0167 Dronabinol 2.5mg oral 2.5 MG $5.42
Q0168 Dronabinol 5mg oral 5 MG $10.84
Q0169 Promethazine HCl oral 12.5 MG $0.45
Q0170 Promethazine HCl 25 mg oral 25 MG $0.19
Q0171 Chlorpromazine HCl 10mg oral 10 MG $0.01
Q0172 Chlorpromazine HCl 25mg oral 25 MG $0.04
Q0173 Trimethobenzamide HCl 250mg 250 MG $0.29
Q0175 Perphenazine 4mg oral 4 MG $0.19
Q0176 Perphenazine 8mg oral 8 MG $0.20
Q0177 Hydroxyzine pamoate 25mg 25 MG $0.05
Q0178 Hydroxyzine pamoate 50mg 50 MG $0.05
Q0179 Ondansetron HCl 8mg oral 8 MG $4.60
Q0180 Dolasetron mesylate oral 100 MG $49.17
Q0515 Sermorelin acetate injection 1 MCG $1.75
Q2009 Fosphenytoin, 50 mg 50 MG $0.82
Q2017 Teniposide, 50 mg 50 MG $287.40
Q3025 IM inj interferon beta 1-a 11 MCG $132.30
Q4080 Iloprost inhalation solution 20 MCG $40.86
Q4081 Epoetin alfa, for ESRD on dialysis 100 UNITS $0.91
Q4096 VWF complex, NOS 1 IU VWF:RCO 0.656
Q4097 Privigen Injection 500 MG $34.19
Q4098 Iron dextran injection 50 MG $11.60
Q4099 Formoterol fumarate, inh 20 MCG $4.93
Q9953 Inj Fe-based MR contrast,1ml 1 ML $30.41
Q9954 Oral MR contrast, 100 ml 100 ML $9.53
Q9956 Inj octafluoropropane mic,ml 1 ML $42.32
Q9957 Inj perflutren lip micros,ml 1 ML $62.61
Q9958 HOCM <=149 mg/ml iodine 1 ML $0.06
Q9960 HOCM 200-249mg/ml iodine 1 ML $0.11
Q9961 HOCM 250-299mg/ml iodine 1 ML $0.15
Q9962 HOCM 300-349mg/ml iodine 1 ML $0.18
Q9963 HOCM 350-399mg/ml iodine 1 ML $0.16
Q9964 HOCM>= 400mg/ml iodine 1 ML $0.29
Q9965 LOCM 100-199mg/ml iodine 1 ML $1.39
Q9966 LOCM 200-299mg/ml iodine 1 ML $0.41
Q9967 LOCM 300-399mg/ml iodine 1 ML $0.21
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