|
HCPCS Code |
Description |
HCPCS Code Dosage |
Payment Limit |
|
|
90371 |
Hep b ig, im |
1mL |
$112.108 |
|
90375 |
Rabies ig, im/sc |
150 iu |
$206.529 |
|
90376 |
Rabies ig, heat treated |
150 iu |
$202.716 |
|
90385 |
Rh ig, minidose, im |
50 mcg |
$24.624 |
|
90585 |
Bcg vaccine, percut |
50 mg |
$117.451 |
|
90586 |
Bcg vaccine, intravesical |
1 each |
$117.451 |
|
90632 |
Hep a vaccine, adult im |
1 mL |
$50.450 |
|
90654 |
Flu Vaccine, intradermal, no preserv |
0.1mL |
$18.981 |
|
90655 |
Flu vaccine no preserv 6-35m, im |
0.25 mL |
$16.456 |
|
90656 |
Flu vaccine no preserv 3 yo & >, im |
0.5 mL |
$12.398 |
|
90657 |
Flu vaccine, 6-35 mo, im |
0.25 mL |
$6.023 |
|
90660 |
Flu vaccine, nasal |
0.2 mL |
$23.456 |
|
90662 |
Flu vaccine prsv free inc antig |
0.5mL |
$30.923 |
|
90669 |
Pneumococcal vaccine <5yo |
0.5 mL |
$95.481 |
|
90670 |
Pneumoccocal vacc, 13 val im |
0.5mL |
$145.962 |
|
90675 |
Rabies vaccine, im |
1 mL |
$221.983 |
|
90691 |
Typhoid vaccine, im |
0.m mL |
$60.917 |
|
90703 |
Tetanus vaccine, im |
0.5 mL |
$35.401 |
|
90714 |
Td vaccine no prsrv >/= 7 yo, im |
0.5 mL |
$20.360 |
|
90715 |
Tdap => 7 yo, im |
0.5 mL |
$34.813 |
|
90717 |
Yellow fever vaccine, sc |
0.5 mL |
$75.060 |
|
90732 |
Pneumococcal vaccine |
0.5 mL |
$72.352 |
|
90733 |
Meningococcal vaccine, sc |
0.5 mL |
$106.492 |
|
90735 |
Encephalitis vaccine, sc |
1 mL |
$102.078 |
|
90740 |
Hepb vacc, ill pat 3 dose im |
40 mcg |
$119.415 |
|
90743 |
Hep b vacc, adol, 2 dose, im |
1 dose |
$24.216 |
|
90744 |
Hepb vacc ped/adol 3 dose im |
1 dose |
$24.216 |
|
90746 |
Hep b vaccine, adult, im |
20 mcg |
$59.708 |
|
90747 |
Hepb vacc, ill pat 4 dose im |
40 mcg |
$119.415 |
|
A9576 |
Inj prohance multipack |
1 mL |
$2.038 |
|
A9577 |
Inj multihance |
1 mL |
$2.257 |
|
A9578 |
Inj multihance multipack |
1 mL |
$2.109 |
|
A9579 |
Gad-base MR contrast NOS, 1mL |
1 mL |
$2.036 |
|
A9581 |
Gadoxetate disodium inj |
1 mL |
$13.344 |
|
A9583 |
Gadofosveset trisodium injection |
1mL |
$11.969 |
|
A9585 |
Gadobutrol injection |
0.1mL |
$0.453 |
|
J0129 |
Abatacept injection |
10 mg |
$22.620 |
|
J0130 |
Abciximab injection |
10 mg |
$574.848 |
|
J0132 |
Acetylcysteine injection |
100 mg |
$3.195 |
|
J0133 |
Acyclovir injection |
5 mg |
$0.023 |
|
J0135 |
Adalimumab injection |
20 mg |
$490.563 |
|
J0150 |
Injection adenosine 6 mg |
6 mg |
$6.179 |
|
J0152 |
Adenosine injection |
30 mg |
$109.550 |
|
J0171 |
Adrenalin epinephrin injection |
0.1 mg |
$0.062 |
|
J0178 |
Afilbercept injection (opthalmic) |
1mg |
$980.500 |
|
J0180 |
Agalsidase beta injection |
1 mg |
$140.848 |
|
J0205 |
Alglucerase injection |
10 units |
$42.029 |
|
J0207 |
Amifostine |
500 mg |
$312.762 |
|
J0210 |
Methyldopate hcl injection |
250 mg |
$42.029 |
|
J0215 |
Alefacept |
0.5 mg |
$41.644 |
|
J0220 |
Alglucosidase alfa injection |
10 mg |
$205.872 |
|
J0221 |
Lumizyme injection |
10 mg |
$153.624 |
|
J0256 |
Alpha 1 proteinase inhibitor |
10 mg |
$3.919 |
|
J0257 |
Glassia injection |
10mg |
$3.933 |
|
J0278 |
Amikacin sulfate injection |
100 mg |
$1.002 |
|
J0280 |
Aminophyllin 250 mg inj |
250 mg |
$0.917 |
|
J0285 |
Amphotericin B |
50 mg |
$15.947 |
|
J0287 |
Amphotericin b lipid complex |
10 mg |
$11.278 |
|
J0288 |
Ampho b cholesteryl sulfate |
10 mg |
$14.000 |
|
J0289 |
Amphotericin b liposome inj |
10 mg |
$15.226 |
|
J0290 |
Ampicillin 500 mg inj |
500 mg |
$1.643 |
|
J0295 |
Ampicillin sodium per 1.5 gm |
1.5 gm |
$1.903 |
|
J0348 |
Anidulafungin injection |
1 mg |
$1.038 |
|
J0360 |
Hydralazine hcl injection |
30 mg |
$2.888 |
|
J0364 |
Apomorphine hydrochloride |
1 mg |
$32.864 |
|
J0365 |
Aprotonin 10, 000 kiu |
10000 kiu |
$2.646 |
|
J0400 |
Aripiprazole injection |
0.25 mg |
$0.476 |
|
J0456 |
Azithromycin |
500 mcg |
$2.138 |
|
J0461 |
Atropine sulfate injection |
0.3 mg |
$0.029 |
|
J0470 |
Dimecaprol injection |
100 mg |
$29.752 |
|
J0475 |
Baclofen 10 mg injection |
10 mg |
$175.158 |
|
J0476 |
Baclofen intrathecal trial |
50 mcg |
$75.909 |
|
J0480 |
Basiliximab |
20 mg |
$2321.248 |
|
Jo485 |
Beltacept injection |
1 mg |
$3.806 |
|
J0490 |
Belimumab injection |
10mg |
$38.286 |
|
J0500 |
Dicyclomine injection |
20 mg |
$30.464 |
|
J0515 |
Inj benztropine mesylate |
1 mg |
$23.359 |
|
J0558 |
PenG benzathine/procaine inj |
100,000 units |
$3.774 |
|
J0561 |
Penicillin g benzathine inj |
100,000 units |
$4.763 |
|
J0583 |
Bivalirudin |
1 mg |
$2.990 |
|
J0585 |
injection, onabotulinumtoxinA |
1 unit |
$5.464 |
|
J0586 |
AbobotulinumtoxinA |
5 unit |
$6.890 |
|
J0587 |
Inj, rimabotulinumtoxinB |
100 units |
$10.817 |
|
J0588 |
Incobotulinumtoxin A |
1 unit |
$4.453 |
|
J0592 |
Buprenorphine hydrochloride |
0.1 mg |
$0.989 |
|
J0594 |
Busulfan injection |
1 mg |
$21.919 |
|
J0595 |
Butorphanol tartrate 1 mg |
1 mg |
$0.929 |
|
J5097 |
C-1 esterase, berinert |
10 units |
$31.136 |
|
J5098 |
C1 esterase inhibitor inj |
10 IU |
$47.256 |
|
J0600 |
Edetate calcium disodium inj |
1000 mg |
$201.400 |
|
J0610 |
Calcium gluconate injection |
10 ml |
$0.723 |
|
J0630 |
Calcitonin salmon injection |
400 units |
$62.788 |
|
J0636 |
Inj calcitrol per 0.1 mcg |
0.1 mcg |
$0.381 |
|
J0637 |
Casofungin acetate |
5 mg |
$13.078 |
|
J0368 |
Canakinumab injection |
1 mg |
$90.241 |
|
J0640 |
Leucovorin calcium injection |
50 mg |
$5.111 |
|
J0641 |
Levoleucovorin injection |
0.5 mg |
$1.820 |
|
J0670 |
Inj mepivacaine HCL |
10 mL |
$1.208 |
|
J0690 |
Cefazolin sodium injection |
500 mg |
$0.782 |
|
J0692 |
Cefepime HCI for injection |
500 mg |
$2.558 |
|
J0694 |
Cefoxitin sodium injection |
1 gm |
$5.351 |
|
J0696 |
Ceftriaxone sodium injection |
250 mg |
$0.739 |
|
J0697 |
Sterile cefurxime injection |
750 mg |
$3.283 |
|
J0698 |
Cefotaxime sodium injection |
1 gm |
$1.756 |
|
J0702 |
Betamethasone acet & sod phosp |
3 mg |
$5.700 |
|
J0706 |
Caffeine citrate injection |
5 mg |
$0.308 |
|
J0712 |
Ceftaroline Fosamil inj |
10mg |
$0.823 |
|
J0713 |
Inj ceftazidime per 500 mg |
500 mg |
$2.317 |
|
J0718 |
Certolizumab pegol inj |
1 mg |
$5.150 |
|
J0720 |
Chloramphenicol sodium injection |
1 gm |
$26.161 |
|
J0725 |
Chorionic gonadtropin |
1000 units |
$13.089 |
|
J0735 |
Clonidine hydrochloride |
1 mg |
$22.533 |
|
J0740 |
Cidofovir injection |
375 mg |
$757.156 |
|
J0743 |
Cilastatin sodium injection |
250 mg |
$6.910 |
|
J0744 |
Ciprofloxacin iv |
200 mg |
$0.975 |
|
J0745 |
Inj codeine phosphate / 30 mg |
30 mg |
$1.346 |
|
J0760 |
Colchicine injection |
1 mg |
$6.572 |
|
J0770 |
Colistimethate sodium inj |
150 mg |
$12.353 |
|
J0775 |
Collagenase clost hist inj |
0.01mg |
$37.509 |
|
J0780 |
Prochlorperazine injection |
10 mg |
$4.548 |
|
J0795 |
Corticorelin ovine triflutal |
1 mcg |
$5.821 |
|
J0800 |
Corticotropin injection |
40 units |
$3012.764 |
|
J0834 |
Cosyntropin cortrosyn inj |
0.25 mg |
$68.592 |
|
J0840 |
Crotalide poly immune fab |
UP to 1 gm |
$2220.920 |
|
J0850 |
Cytomegalovirus imm IV/vial |
per vial |
$1013.869 |
|
J0878 |
Daptomycin injection |
1 mg |
$0.569 |
|
J0881 |
Darbepoetin alfa, non -esrd |
1 mcg |
$3.334 |
|
J0882 |
Darbepoetin alfa, esrd use |
1 mcg |
$3.334 |
|
J0885 |
Epoetin alfa, non-esrd |
1000 units |
$10.385 |
|
J0886 |
Epoetin alfa 1000 units ESRD |
1000 units |
$10.385 |
|
J0894 |
Decitabine injection |
1 mg |
$34.088 |
|
J0895 |
Deferoxamine mesylate inj |
500 mg |
$8.250 |
|
J0897 |
Denosumab injection |
1mg |
$14.219 |
|
J1000 |
Depo-estradiol cypionate inj |
5 mg |
$7.439 |
|
J1020 |
Methylprednisolone 20 mg inj |
20 mg |
$3.157 |
|
J1030 |
Methylprednisolone 40 mg inj |
40 mg |
$2.957 |
|
J1040 |
Methylprednisolone 80 MG inj |
80 mg |
$5.730 |
|
J1070 |
Testosterone cypionat |
100 mg |
$4.772 |
|
J1080 |
Testosterone cypionat |
200 mg |
$5.766 |
|
J1100 |
Dexamethasone sodium phos |
1 mg |
$0.095 |
|
J1110 |
Inj dihydroergotamine mesylt |
1 mg |
$39.317 |
|
J1120 |
Acetazolamid sodium injection |
500 mg |
$28.821 |
|
J1160 |
Digoxin injection |
0.5 mg |
$1.601 |
|
J1162 |
Digoxin immune fab (ovine) |
per vial |
$1045.830 |
|
J1165 |
Phenytoin sodium injection |
50 mg |
$0.512 |
|
J1170 |
Hydromorphone injection |
4 mg |
$1.797 |
|
J1190 |
Dexrazoxane HCI injection |
250 mg |
$153.069 |
|
J1200 |
Diphenhydramine hcl injection |
50 mg |
$0.785 |
|
J1205 |
Chlorothiazide sodium inj |
500 mg |
$205.851 |
|
J1212 |
Dimethyl sulfoxide 50% |
50 mL |
$84.196 |
|
J1230 |
Methadone injection |
10 mg |
$7.136 |
|
J1240 |
Dimenhydrinate injection |
50 mg |
$5.032 |
|
J1245 |
Dipridamole injection |
10 mg |
$0.840 |
|
J1250 |
Inj dobutamine hcl |
250 mg |
$7.986 |
|
J1260 |
Dolasetron mesylate |
10 mg |
$4.680 |
|
J1265 |
Dopamine injection |
40 mg |
$0.474 |
|
J1267 |
Doripenem injection |
10 mg |
$0.492 |
|
J1270 |
Injection, doxercalciferol |
1 mcg |
$0.975 |
|
J1290 |
Ecallantide injection |
1mg |
$319.612 |
|
J1300 |
Eculizumab injection |
10 mg |
$199.356 |
|
J1325 |
Epoprostenol injection |
0.5 mg |
$14.169 |
|
J1327 |
Eptifibatide injection |
5 mg |
$25.952 |
|
J1335 |
Ertapenem injection |
500 mg |
$31.580 |
|
J1364 |
Erythro lactobionate |
500 mg |
$14.849 |
|
J1380 |
Estradiol valerate |
10 mg |
$9.097 |
|
J1410 |
Inj estrogen conjugate |
25 mg |
$136.719 |
|
J1430 |
Ethanolamine oleate |
100 mg |
$299.937 |
|
J1438 |
Etanercept injection |
25 mg |
$241.207 |
|
J1440 |
Filgrastim |
300 mcg |
$277.248 |
|
J1441 |
Filgrastim |
480 mcg |
$439.903 |
|
J1450 |
Fluconazole |
200 mg |
$4.036 |
|
J1451 |
Fomepizole |
15 mg |
$6.230 |
|
J1453 |
Fosaprepitant injection |
1mg |
$1.718 |
|
J1458 |
Galsulfase injection |
1 mg |
$355.386 |
|
J1459 |
inj IVIG privigen |
500 mg |
$37.215 |
|
J1460 |
Gamma globulin |
1 CC |
$23.862 |
|
j1577 |
Gammaplex injection |
500mg |
$37.215 |
|
J1559 |
Hizentra injection |
100 mg |
$7.286 |
|
J1560 |
Gamma globulin |
>10 CC |
$238.619 |
|
J1561 |
Gamunex, Gamunex-C, Gammaked |
500 mg |
$38.231 |
|
J1566 |
Immune globulin, powder |
500 mg |
$33.119 |
|
J1568 |
Octagam injection |
500 mg |
$31.496 |
|
J1569 |
Gammagard liquid injection |
500 mg |
$37.826 |
|
J1570 |
Ganciclovir sodium injection |
500 mg |
$64.485 |
|
J1571 |
Hepagam b im injection |
0.5mL |
$52.012 |
|
J1572 |
Flebogamma injection |
500 mg |
$35.515 |
|
J1573 |
Hepagam b intravenous , inj |
0.5 mL |
$52.012 |
|
J1580 |
Garamycin gentamicin inj |
80 mg |
$1.187 |
|
J1600 |
Gold sodium thiomaleate inj |
50 mg |
$25.037 |
|
J1610 |
Glucagon hydrochloride |
1 mg |
$115.044 |
|
J1626 |
Granisetron hcl injecction |
100 mcg |
$0.437 |
|
J1630 |
Haloperidol injection |
5 mg |
$1.524 |
|
J1631 |
Haloperidol decanote inj |
50 mg |
$19.391 |
|
J1640 |
Hemin |
1 mg |
$13.268 |
|
J1642 |
inj heparin sodium per 10 u |
10 units |
$0.177 |
|
J1644 |
inj heparin sodium per 1000u |
1000 units |
$0.212 |
|
J1645 |
Dalteparin sodium |
2500 iu |
$11.048 |
|
J1650 |
inj enoxaparin sodium |
10 mg |
$2.907 |
|
J1652 |
Fondaparinux sodium |
0.5 mg |
$4.095 |
|
J1670 |
Tetanus immune globulin |
250 units |
$276.724 |
|
J1720 |
Hydrocortisone sodium succ inj |
100 mg |
$4.806 |
|
J1740 |
Ibandronate sodium injection |
1 mg |
$151.499 |
|
J1742 |
Ibutilide furmarate injection |
1 mg |
$164.730 |
|
J1743 |
Idursulfase injection |
1 mg |
$470.352 |
|
J1745 |
Infliximab injection |
10 mg |
$67.675 |
|
J1750 |
Inj iron dextran |
50 mg |
$12.145 |
|
J1756 |
Iron sucrose injection |
1 mg |
$0.287 |
|
J1786 |
Injection imiglucerase / unit |
10 units |
$41.868 |
|
J1790 |
Droperidol injection |
5 mg |
$3.306 |
|
J1800 |
Propanolol injection |
1 mg |
$2.951 |
|
J1815 |
Insulin injection |
5 units |
$0.542 |
|
J1817 |
Insulin for insulin pump use |
50 units |
$5.373 |
|
J1840 |
Kanamycin sulfate |
500 mg |
$7.685 |
|
J1850 |
Kanamycin sulfate |
75 mg |
$1.153 |
|
J1885 |
Ketorolac tromethamine inj |
15 mg |
$0.274 |
|
J1930 |
Lanreotide injection |
1 mg |
$35.648 |
|
J1931 |
Laronidase injection |
0.1 mg |
$28.212 |
|
J1940 |
Furosemide injection |
20 mg |
$2.315 |
|
J1945 |
Lepirudin |
50 mg |
$570.540 |
|
J1950 |
Leuprprolide acetate |
3.75 mg |
$680.666 |
|
J1953 |
Levetiracetam injection |
10 mg |
$0.189 |
|
J1955 |
Inj levocarnitine |
1 gm |
$7.657 |
|
J1956 |
Levofloxacin injection |
250 mg |
$2.923 |
|
J1980 |
Hyoscyamine sulfate inj |
0.25 mg |
$16.194 |
|
J2001 |
Lidocaine injection |
10 mg |
$0.020 |
|
J2010 |
Lincomycin injection |
300 mg |
$7.394 |
|
J2020 |
Linezolid injection |
200 mg |
$39.098 |
|
J2060 |
Lorazepam injection |
2 mg |
$0.756 |
|
J2150 |
Mannitol injection |
50 ml |
$1.660 |
|
J2175 |
Meperedine hydrochl |
100 mg |
$2.060 |
|
J2185 |
Meropenem |
100 mg |
$1.232 |
|
J2210 |
Methylergonovin maleate injection |
0.2 mg |
$4.020 |
|
J2248 |
Micafungin sodium injection |
1 mg |
$0.953 |
|
J2250 |
Inj midazolam hydrochloride |
1 mg |
$0.159 |
|
J2260 |
Inj milrinone lactate |
5 mg |
$4.824 |
|
J2270 |
Morphine sulphate injection |
10 mg |
$4.704 |
|
J2271 |
Morphine so4 injection |
100 mg |
$0.541 |
|
J2275 |
Morphine sulfate injection |
10 mg |
$2.033 |
|
J2278 |
Ziconotide injection |
1 mcg |
$6.606 |
|
J2280 |
Moxifloxacin injection |
100 mg |
$3.508 |
|
J2300 |
Nalbuphine hydrochloride injection |
10 mg |
$1.294 |
|
J2310 |
Naloxone hydrochloride |
1 mg |
$15.301 |
|
J2315 |
Naltrexone, depot form |
1 mg |
$2.830 |
|
J2323 |
Natulizumab injection |
1 mg |
$12.289 |
|
J2325 |
Nesirritide injection |
0.1 mg |
$54.681 |
|
J2353 |
Octreotide injection, depot |
1 mg |
$131.134 |
|
J2354 |
Octreotide inj, non-depot |
25 mcg |
$1.270 |
|
J2355 |
Oprelvekin injection |
5 mg |
$256.796 |
|
J2357 |
Omalizumab injection |
5 mg |
$24.473 |
|
J2358 |
Olanzapine long-acting inj |
1 mg |
$2.754 |
|
J2360 |
Orphenadrine injection |
60 mg |
$6.477 |
|
J2370 |
Phenylphrine hcl injection |
1 mL |
$1.443 |
|
J2400 |
Chloroprocaine hcl injection |
30 mL |
$22.666 |
|
J2405 |
Ondansetron hcl injection |
1 mg |
$0.152 |
|
J2410 |
Oxymorphone hcl injection |
1 mg |
$2.335 |
|
J2425 |
Palifermin injection |
50 mcg |
$13.255 |
|
J2426 |
Paliperidone palmitate inj |
1 mg |
$7.233 |
|
J2430 |
Pamidronate disodium |
30 mg |
$10.754 |
|
J2469 |
Palonosetron hcl |
25 mcg |
$19.445 |
|
J2501 |
Paricalcitol |
1 mcg |
$1.817 |
|
J2503 |
Pegaptanib sodium injection |
0.3 mg |
$1030.426 |
|
J2504 |
Pegademase bovine |
25 iu |
$267.827 |
|
J2505 |
Pegfilgrastim injection |
6 mg |
$2940.196 |
|
J2507 |
Peglocticase injection |
1mg |
$365.788 |
|
J2510 |
Penecillin g procaine injection |
600000 units |
$13.722 |
|
J2515 |
Pentobarbital sodium injection |
50 mg |
$32.562 |
|
J2540 |
Penecillin g potassium injection |
600000 units |
$0.601 |
|
J2543 |
Piperacillin / tazobactam |
1.125 gm |
$2.349 |
|
J2545 |
Pentamidine non-comp unit |
300 mg |
$73.776 |
|
J2550 |
Promethazine hcl injection |
50 mg |
$1.593 |
|
J2560 |
Phenobarbital sodium injection |
120 mg |
$10.855 |
|
J2562 |
Plerixaforinjection |
1 mg |
$291.3925 |
|
J2590 |
Oxytocin injection |
10 units |
$0.638 |
|
J2597 |
desmopressin acetate injection |
1 mcg |
$5.597 |
|
J2675 |
Inj progesterone per 50mg |
50 mg |
$1.391 |
|
J2680 |
Fluphenazine decanoate |
25 mg |
$15.875 |
|
J2690 |
Procainimide hcl injection |
1 gm |
$16.298 |
|
J2700 |
Oxacillin sodium injection |
250 mg |
$2.251 |
|
J2720 |
Protamine sulfate |
10 mg |
$0.773 |
|
J2724 |
Protein c concentrate |
10 units |
$13.748 |
|
J2730 |
Pralidoxime chloride injection |
1 gm |
$89.517 |
|
J2760 |
Phentolaine mesylate injection |
5 mg |
$132.522 |
|
J2765 |
Metoclopramide hcl injection |
10 mg |
$0.618 |
|
J2770 |
Quinupristin / dalfopristin |
500 mg |
$188.542 |
|
J2778 |
Ranibizumab injection |
0.1 mg |
$397.722 |
|
J2780 |
Ranitidine hydrochloride injection |
25 mg |
$1.636 |
|
J2783 |
Rasburicase |
0.5 mg |
$208.167 |
|
J2785 |
Regadenoson injection |
0.1 mg |
$53.631 |
|
J2788 |
Rho d immune globulin |
50 mcg |
$24.970 |
|
J2790 |
Rho d immune globulin injection |
300 mcg |
$58.455 |
|
J2791 |
Rhophylac injection |
100 iu |
$4.784 |
|
J2792 |
Rho(D) immune globulin h, sd |
100 iu |
$18.592 |
|
J2794 |
Risperidone, long acting |
0,5 mg |
$5.622 |
|
J2795 |
Ropivacaine hcl injection |
1 mg |
$0.095 |
|
J2796 |
Romiplostim injection |
10 mcg |
$49.842 |
|
J2800 |
Methocarbamol injection |
10 mL |
$34.989 |
|
J2805 |
Sincalide injection |
5 mcg |
$60.935 |
|
J2810 |
Theophylline injection |
40 mg |
$0.190 |
|
J2820 |
Sargramostin injection |
50 mcg |
$26.895 |
|
J2850 |
Secretin synthetic human injection |
1 mcg |
$27.494 |
|
J2916 |
Na ferric gluconate complex |
12.5 mg |
$2.950 |
|
J2920 |
Methylprednisolone injection |
40 mg |
$1.898 |
|
J2930 |
Methyprednisolone injection |
125 mg |
$2.667 |
|
J2993 |
Reteplase injection |
18.1 mg |
$2301.896 |
|
J2997 |
Alteplase recombinant |
1 mg |
$52.194 |
|
J3000 |
Streptomycin injection |
1 gm |
$13.485 |
|
J3010 |
Fentanyl citrate injection |
0.1mg |
$0.585 |
|
J3070 |
Pentazocine injection |
30 mg |
$27.446 |
|
J3095 |
Telavancin injection |
10 mg |
$2.663 |
|
J3101 |
Tenecteplase injection |
1 mg |
$72.440 |
|
J3105 |
Terbutaline sulfate injection |
1 mg |
$2.363 |
|
J3120 |
Testosterone enethate injection |
100 mg |
$4.492 |
|
J3130 |
Testosterone enethate injection |
200 mg |
$8.985 |
|
J3230 |
Chlorpromazine hcl injection |
50 mg |
$17.767 |
|
J3240 |
Thyrotropin injection |
0.9 mg |
$1053.982 |
|
J3243 |
Tigecycline injection |
1 mg |
$1.608 |
|
J3246 |
Tirofiban hcl |
0.25 mg |
$8.202 |
|
J3250 |
Trimethobenzamide hcl inj |
200 mg |
$10.173 |
|
J3260 |
Tobramycin sulfate injection |
80 mg |
$2.618 |
|
J3262 |
Tocilizumab injection |
1 mg |
$3.693 |
|
J3285 |
Treprostinil injection |
1 mg |
$61.237 |
|
J3300 |
triamcinalone A inj PRS free |
1 mg |
$3.668 |
|
J3301 |
Triamcinalone acet injection NOS |
10 mg |
$1.775 |
|
J3302 |
Triamcinalocne diacetate injection |
5 mg |
$0.280 |
|
J3303 |
Triamcinalone hexacetonl injection |
5 mg |
$1.607 |
|
J3315 |
Triptorelin pamoate |
3.75 mg |
$172.295 |
|
j3355 |
Urofollitropin |
75 iu |
$65.063 |
|
J3357 |
Ustekinumab injection |
1 mg |
$134.187 |
|
J3360 |
Diazepam injection |
5 mg |
$3.082 |
|
J3365 |
Urokinase 250,000 iu inj |
250000iu |
$457.729 |
|
J3370 |
Vancomycin hcl injection |
0.1 mg |
$2.375 |
|
J3385 |
Velaglucerase alfa |
100 units |
$348.628 |
|
J3396 |
Verteporfin injection |
0.1mg |
$10.298 |
|
J3410 |
Hydroxyzine hcl injection |
25 mg |
$0.948 |
|
J3411 |
Thiamine hcl |
100 mg |
$3.603 |
|
J3415 |
Pyridoxine hcl |
100 mg |
$7.409 |
|
J3420 |
Vitamin b 12 injection |
1000 mcg |
$1.427 |
|
J3430 |
Vitamin k phytonadione injection |
1 mg |
$1.539 |
|
J3465 |
Voriconazole injection |
10 mg |
$4.870 |
|
J3470 |
Hyaluronidase ijection |
150 units |
$21.200 |
|
J3473 |
Hyaluronidase recombinant |
1 usp unit |
$0.320 |
|
J3475 |
Magnesium sulfate injection |
500 mg |
$0.193 |
|
J3480 |
Potassium chloride injection |
2 meq |
$0.013 |
|
J3485 |
Zidovudine |
10 mg |
$1.504 |
|
J3486 |
Ziprasidone mesylate |
10 mg |
$8.760 |
|
J3487 |
Zoledronic acid |
1 mg |
$220.950 |
|
J3488 |
Reclast injection |
1 mg |
$224.679 |
|
J7030 |
Normal saline solution infusion |
1000 cc |
$1.077 |
|
J7040 |
Normal saline solution infusion |
500 mL |
$0.538 |
|
J7042 |
5% dextrose / normal saline |
500 mL |
$0.471 |
|
J7050 |
Normal saline solution infusion |
250 cc |
$0.269 |
|
J7060 |
5% dextrose / water |
500 mL |
$1.048 |
|
J7070 |
D5W infusion |
1000 cc |
$2.095 |
|
J7100 |
Dextran 40 infusion |
500 mL |
$22.465 |
|
J7110 |
Dextran 75 infusion |
500 mL |
$14.522 |
|
J7120 |
Ringers lactate infusion |
1000 cc |
$0.979 |
|
J7183 |
Wilate injection |
1i.u.vwf:rco |
$0.927 |
|
J7185 |
Xyntha injection |
1 iu |
$1.061 |
|
J7186 |
Antihemophilic VIII / vWF |
per factor VII iu |
$0.932 |
|
J7187 |
Humate-P, injection |
1 iu |
$0.904 |
|
J7189 |
Factor VIIa |
1 mcg |
$1.620 |
|
J7190 |
Factor VIII |
1 iu |
$0.909 |
|
J7192 |
Factor VIII recombinant NOS |
1 iu |
$1.131 |
|
J7193 |
FactorIX non-recombinant |
1 iu |
$0.953 |
|
J7194 |
Factor IX complex |
1 iu |
$1.094 |
|
J7195 |
Factor IX recombinant |
1 iu |
$1.261 |
|
J7197 |
Antithrombin III injection |
1 iu |
$3.042 |
|
J7198 |
Anti-inhibitor |
1 iu |
$1.640 |
|
J7308 |
Aminolevulinic acid hcl top |
354 mg |
$160.028 |
|
J7310 |
Ganciclovir long act implant |
4.5 mg |
$16960.000 |
|
J7311 |
Fluocinolone acetonide implant |
0.59 mg |
$19345.000 |
|
J7312 |
Dexamethasone intra implant |
0.1 mg |
$195.924 |
|
J7321 |
Hyalagan/supartz injection |
per dose |
$88.836 |
|
J7323 |
Euflexxa injection |
per dose |
$163.959 |
|
J7324 |
Orthovisc injection |
per dose |
$167.459 |
|
J7325 |
Synvisc or Synvisc-One |
1 mg |
$12.196 |
|
J7330 |
Cultured chondrocytes implant |
1 ea |
$29193.230 |
|
J7335 |
Capsaicin 8% patch |
10SQ cm |
$25.554 |
|
J7500 |
Azathioprine oral |
50 mg |
$0.111 |
|
J7501 |
Azathioprine parenteral |
100 mg |
$162.954 |
|
J7502 |
Cyclosporine oral |
100 mg |
$3.354 |
|
J7504 |
Lymphocyte immune globulin |
250 mg |
$705.820 |
|
J7505 |
Monoclonal antibodies |
5 mg |
$1156.078 |
|
J7506 |
Prednisone oral |
5 mg |
$0.049 |
|
J7507 |
tacrolimus oral |
1 mg |
$1.698 |
|
J7509 |
Methylprednisolone oral |
4 mg |
$0.772 |
|
J7510 |
Prednisolone oral |
5 mg |
$0.032 |
|
J7511 |
Antithymocyte globulin rabbit |
25 mg |
$538.680 |
|
J7513 |
Daclizumab, parenteral |
25 mg |
$526.343 |
|
J7515 |
Cyclosporine oral |
25 mg |
$0.883 |
|
J7516 |
Cyclosporin parenteral |
250 mg |
$33.800 |
|
J7517 |
Mycophenolate mofetil oral |
250 mg |
$1.269 |
|
J7518 |
Mycophenolic acid |
180 mg |
$3.615 |
|
J7520 |
Sirolimus, oral |
1 mg |
$12.129 |
|
J7525 |
Tacrolimus injection |
5 mg |
$138.001 |
|
J7605 |
Arformoterol non-comp unit |
15 mcg |
$5.372 |
|
J7606 |
Formoterol fumarate, inh |
20 mcg |
$5.792 |
|
J7608 |
Acetylcysteine non-comp unit |
1 gm |
$2.045 |
|
J7611 |
Albuterol non-comp con |
1 mg |
$0.101 |
|
J7612 |
Levalbuterol non-comp con |
0.5 mg |
$0.098 |
|
J7613 |
ALbuterol non-comp unit |
1 mg |
$.052 |
|
J7614 |
Levalbuterol non-comp unit |
0.5 mg |
$0.119 |
|
J7620 |
Albuterol ipratrop non-comp |
2.5 mg / 0.5 mg |
$0.219 |
|
J7626 |
Budesonide non-comp unit |
0.5 mg |
$4.762 |
|
J7631 |
Cromolyn sodium noncomp unit |
10 mg |
$0.551 |
|
J7639 |
Dornase alfa non-comp unit |
1 mg |
$30.641 |
|
J7644 |
Ipratropium bromide non-comp |
1 mg |
$0.241 |
|
J7665 |
Mannitol for inhaler |
5mg |
$0.669 |
|
J7669 |
Metaproterenol non-comp unit |
10 mg |
$0.252 |
|
J7674 |
Methacholine chloride, neb |
1mg |
$0.500 |
|
J7682 |
Tobramycin non-comp unit |
300 mg |
$101.277 |
|
J7686 |
Treprostinil, non-comp unit |
1.74 mg |
$438.919 |
|
J8501 |
Oral aprepitant |
5 mg |
$6.481 |
|
J8510 |
Oral busulfan |
2 mg |
$6.567 |
|
J8520 |
Cepecitabine, oral |
150 mg |
$8.917 |
|
J8521 |
Capacitabine, oral |
500 mg |
$29.669 |
|
J8530 |
Cyclophosphamide oral |
25 mg |
$0.917 |
|
J8540 |
Oral dexamethasone |
0.25 mg |
$0.321 |
|
J8560 |
Etoposide oral |
50 mg |
$52.294 |
|
J8562 |
Oral fludarabine phosphate |
10 mg |
$81.772 |
|
J8600 |
Melphalan oral |
2 mg |
$8.553 |
|
J8610 |
Methotrexate oral |
2.5 mg |
$0.30 |
|
J8700 |
Temozolomide |
5 mg |
$11.185 |
|
J8705 |
Topotecan oral |
0.25 mg |
$86.575 |
|
J9000 |
Doxorubicin hcl injection |
10 mg |
$4.225 |
|
J9010 |
ALemtuzumab injection |
10 mg |
$543.061 |
|
J9015 |
Aldesleukin injection |
1 ea |
$1246.984 |
|
J9017 |
Arsenic trioxide injection |
1 mg |
$45.072 |
|
J9020 |
Asparaginase injection |
10000 units |
$63.206 |
|
J9025 |
Azacitidine injection |
1 mg |
$5.716 |
|
J9027 |
Clofarabine injection |
1 mg |
$126.317 |
|
J9031 |
Bcg live intavesical vac |
1 ea |
$117.451 |
|
J9033 |
Bendamustine injection |
1 mg |
$20.616 |
|
J9035 |
Bevacizumab injection |
10 mg |
$63.561 |
|
J9040 |
Bleomycin sulfate injection |
15 units |
$21.828 |
|
J9041 |
Bortezomib injection |
0.1 mg |
$44.311 |
|
J9043 |
Cabazitaxel injection |
1 mg |
$140.584 |
|
J9045 |
Carboplatin injection |
50 mg |
$3.442 |
|
J9050 |
Carmustine injection |
100 mg |
$175813 |
|
J9055 |
Cetuximab injection |
10 mg |
$51.808 |
|
J9060 |
Cisplatin 10 mg injection |
10 mg |
$2.040 |
|
J9065 |
Cladribine |
1 mg |
$26.665 |
|
J9070 |
Cyclophosphamine |
100 mg |
$35.418 |
|
J9098 |
CYtarabine liposome injection |
10 mg |
$528.749 |
|
J9100 |
Cytarabine hcl |
100 mg |
$0.951 |
|
J9120 |
Dactinomycin injection |
0.5 mg |
$592.428 |
|
J9130 |
Dacarbazine |
100 mg |
$3.725 |
|
J9150 |
Daunorubicin injection |
10 mg |
$26.075 |
|
J9155 |
Degarelix injection |
1 mg |
$2.871 |
|
J9160 |
Denileukin diftitox injection |
300 mcg |
$1646.180 |
|
J9171 |
Docetaxel injection |
1 mg |
$6.151 |
|
J9175 |
Elliots b solution |
1 mL |
$4.074 |
|
J9178 |
Epirubicin hcl injection |
2 mg |
$1.412 |
|
J9179 |
Eribulin mesylate injection |
0.1mg |
$95.562 |
|
J9181 |
Etoposide injection |
10 mg |
$0.758 |
|
J9185 |
Fludarabine phosphate injection |
50 mg |
$83.740 |
|
J9190 |
Fluoroucil injection |
500 mg |
$2.096 |
|
J9200 |
Floxuridine injection |
500 mg |
$57.675 |
|
J9201 |
Gemcitabine hcl injection |
200 mg |
$8.036 |
|
J9202 |
Goserelin acetate implant |
3.6 mg |
$193.194 |
|
J9206 |
Irinotecan injection |
20 mg |
$3.395 |
|
J9207 |
ixabepilone injection |
1 mg |
$67.593 |
|
J9208 |
ifosfomide injection |
1 gm |
$29.829 |
|
J9209 |
Mesna injection |
200 mg |
$2.966 |
|
J9211 |
Idarubicin hcl injection |
5 mg |
$62.712 |
|
J9214 |
Interferon alfa-2b injection |
1 mil units |
$17.385 |
|
J9217 |
Leuprolide acetate suspension |
7.5 mg |
$207.810 |
|
J9218 |
Leuprolide acetate injection |
1 mg |
$8.867 |
|
J9219 |
Leuprolide acetate implant |
65 mg |
$4819.820 |
|
J9225 |
Vantas implant |
50 mg |
$2981.867 |
|
J9226 |
Supprelin LA implant |
50 mg |
$16417.132 |
|
J9228 |
Ipilimumab injection |
1 mg |
$126.959 |
|
J9230 |
Mechlorethamine hcl injection |
10 mg |
$154.698 |
|
J9245 |
Melphalan hydrochl |
50 mg |
$1301.513 |
|
J9250 |
Methotrexate sodium injection |
5 mg |
$0.197 |
|
J9260 |
Methotrexate sodium injection |
50 mg |
$1.945 |
|
J9261 |
Nelarabine injection |
50 mg |
$127.022 |
|
J9263 |
Oxaliplatin |
0.5 mg |
$1.060 |
|
J9264 |
Paclitaxel protein bound |
1 mg |
$9.540 |
|
J9265 |
Paclitaxel injection |
30 mg |
$4.975 |
|
J9266 |
Pegaspargase injection |
1 ea |
$5889.996 |
|
J9268 |
Pentostatin injection |
10 mg |
$1390.646 |
|
J9280 |
Mitomycin injection |
5 mg |
$22.246 |
|
J9293 |
Mitoxantrone hydrochl |
5 mg |
$37.318 |
|
J9300 |
Gemtuzumabozogamicin inj |
5 mg |
$2742.591 |
|
J9302 |
Ofatumumab injection |
10 mg |
$45.329 |
|
J9303 |
Panitumumab injection |
10 mg |
$89.252 |
|
J9305 |
Pemetrexed |
10 mg |
$57.960 |
|
J9307 |
Pralatrexate injection |
1 mg |
$182.601 |
|
J9310 |
Rituximab injection |
100 mg |
$677.936 |
|
J9315 |
Romidepsin injection |
1 mg |
$242.172 |
|
J9320 |
Stretozocin injection |
1 gm |
$273.307 |
|
J9328 |
Temozolomide injection |
1 mg |
$4.828 |
|
J9330 |
Temsirolimus injection |
1 mg |
$54.844 |
|
J9340 |
Thiotepa injection |
15 mg |
$265.00 |
|
J9351 |
Topotecan injection |
0.1 mg |
$2.351 |
|
J9355 |
Trastuzumab injection |
10 mg |
$78.546 |
|
J9357 |
Valrubicin injection |
200 mg |
$1038.416 |
|
J9360 |
Vinblastine sulfate injection |
1 mg |
$1.343 |
|
J9370 |
Vincristine sulfate injection |
1 mg |
$4.026 |
|
J9390 |
Vinorelbine tartrate injection |
10 mg |
$9.832 |
|
J9395 |
Fulvestrant injection |
25 mg |
$88.333 |
|
P9041 |
Albumin (human) 5%, 50mL |
50 mL |
$9.546 |
|
P9043 |
Plasma protein fraction 5%, 50 ml |
50 mL |
$8.333 |
|
P9045 |
ALbumin (human), 5%, 250 mL |
250 mL |
$47.728 |
|
P9046 |
Albumin (human) 25%, 20 mL |
20 mL |
$19.680 |
|
P9047 |
Albumin (human) 25%, 50 mL |
50 mL |
$49.201 |
|
P9048 |
Plasmaprotein fraction 5%, 250 mL |
250 mL |
$41.667 |
|
Q0138 |
Ferumoxytol, non-esrd |
1 mg |
$0.640 |
|
Q0139 |
Ferumoxytol, esrd use |
1 mg |
$0.640 |
|
Q0162 |
Ondansetron oral |
1mg |
$0.052 |
|
Q0163 |
Diphenhydramine HCI |
50 mg |
$0.030 |
|
Q0164 |
Prochloreperazine maleate |
5 mg |
$0.041 |
|
Q0165 |
Prochlorperazine maleate |
10 mg |
$0.036 |
|
Q0166 |
Granisetron hcl |
1 mg |
$4.140 |
|
Q0167 |
Dronabinol |
2.5 mg |
$3.096 |
|
Q0168 |
Dronabinol |
5 mg |
$14.236 |
|
Q0169 |
Promethazine HCI |
12.5 mg |
$0.065 |
|
Q0170 |
Promethazine HCI |
25 mg |
$0.050 |
|
Q0180 |
Dolesetron mesylate oral |
100mg |
$65.213 |
|
Q0515 |
Sermorelin acetate injection |
1 mcg |
$1.800 |
|
Q2009 |
Fosphenytoin injection PE |
50 mg |
$0.941 |
|
Q2017 |
Teniposide |
50 mg |
$321.863 |
|
Q2035 |
Afluris vacc, 3yrs &>, im |
0.5 mg |
$11.543 |
|
Q2036 |
Flulaval vacc, 3 yrs & >, im |
0.5 ml |
$9.833 |
|
Q2037 |
Fluvirin vacc, 3 yrs & >. IM |
0.5 mL |
$14.051 |
|
Q2038 |
Fluzone vacc, 3 yrs & >, im |
0.5mL |
$12.046 |
|
Q2043 |
Sipuleucel-T auto CD54+ |
minimum 50 million |
$32769.417 |
|
Q2049 |
Imported Lipodox Inj |
10mg |
498.263 |
|
Q3025 |
Interferon IM injection beta 1-a |
11 mcg |
$305.423 |
|
Q4074 |
lloprost non-comp |
up to 20 mcg |
$73.670 |
|
Q4081 |
Epoetin alfa ESRD |
100 unites |
$1.039 |
|
Q4101 |
Apilgraf skin sub |
1 sq cm |
$39.576 |
|
Q4102 |
Oasis wound matrix skin sub |
1 sq cm |
$8.209 |
|
Q4103 |
Oasis burn matrix skin sub |
1 sq cm |
$8.209 |
|
Q4104 |
Integra BMWD skin sub |
1 sq cm |
$19.099 |
|
Q4105 |
Integra DRT skin sub |
1 sq cm |
$13.413 |
|
Q4106 |
Dermagraft skin sub |
1 sq cm |
$42.547 |
|
Q4107 |
Graftjacket skin sub |
1 sq cm |
$97.680 |
|
Q4108 |
Integra matrix skin sub |
1 sq cm |
$24.127 |
|
Q4110 |
Primatrix skin sub |
1 sq cm |
$33.803 |
|
Q4111 |
Gammagraft skin sub |
1 sq cm |
$7.009 |
|
Q4112 |
Cymetra allograft |
1cc |
$355.511 |
|
Q1143 |
Graftjacket express allograft |
1cc |
$355.511 |
|
Q4114 |
Integra flowable wound matrix |
1cc |
$1175.893 |
|
Q4115 |
Alloskin |
1 sg cm |
$7.606 |
|
Q4116 |
Alloderm skin sub |
1 sq cm |
$31.686 |
|
Q4121 |
Theraskin |
1 sq cm |
$21.934 |
|
Q4123 |
Alloskin RT |
1 sq cm |
$16.156 |
|
Q9954 |
MR contrast |
100 mL |
$11.660 |
|
Q9956 |
Octafluropropane mic |
1 mL |
$37.229 |
|
Q9957 |
Perlutren lip micros |
1 mL |
$55.949 |
|
Q9958 |
HOCM<=149 mg/mL iodine |
1mL |
$0.083 |
|
Q9960 |
HOCM 200 -249 mg/mL iodine |
1 mL |
$0.169 |
|
Q9961 |
HOCM 250-299mg/mL iodine |
1 mL |
$0.192 |
|
Q9963 |
HOCM 350-399mg/mL iodine |
1 mL |
$0.181 |
|
Q9965 |
LOCM 100 - 199 MG/Ml IODINE |
1 mL |
$0.949 |
|
Q9966 |
LOCM 200-299mg.mL iodine |
1 mL |
$0.279 |
|
Q9967 |
LOCM 300-399mg/mL iodine |
1 mL |
$0.164 |
|
|
|
Note 1: Payment allowance limits subject to the ASP
methodology are based on 2Q13 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. |
|
For a more complete listing of Payment Allowance limits for
2013
Click Here |