|
HCPCS Code |
Description |
HCPCS Code Dosage |
Payment Limit |
|
90371 |
Hep b ig, im |
1mL |
$116.800 |
|
90375 |
Rabies ig, im/sc |
150 iu |
$187.923 |
|
90376 |
Rabies ig, heat treated |
150 iu |
$179.692 |
|
90385 |
Rh ig, minidose, im |
50 mcg |
$25.239 |
|
90585 |
Bcg vaccine, percut |
50 mg |
$112.822 |
|
90586 |
Bcg vaccine, intravesical |
1 each |
$15.471 |
|
90632 |
Hep a vaccine, adult im |
1 mL |
$54.180 |
|
90654 |
Flu Vaccine, intradermal, no preserv |
0.1mL |
$18.383 |
|
90655 |
Flu vaccine no preserv 6-35m, im |
0.25 mL |
$15.705 |
|
90656 |
Flu vaccine no preserv 3 yo & >, im |
0.5 mL |
$12.375 |
|
90657 |
Flu vaccine, 6-35 mo, im |
0.25 mL |
$6.653 |
|
90660 |
Flu vaccine, nasal |
0.2 mL |
$22.316 |
|
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 |
$129.276 |
|
90675 |
Rabies vaccine, im |
1 mL |
$200.623 |
|
90691 |
Typhoid vaccine, im |
0.m mL |
$61.083 |
|
90703 |
Tetanus vaccine, im |
0.5 mL |
$31.959 |
|
90714 |
Td vaccine no prsrv >/= 7 yo, im |
0.5 mL |
$19.092 |
|
90715 |
Tdap => 7 yo, im |
0.5 mL |
$41.148 |
|
90717 |
Yellow fever vaccine, sc |
0.5 mL |
$68.082 |
|
90718 |
Td vaccine >/= 7 yo, im |
0.5 mL |
$17.849 |
|
90732 |
Pneumococcal vaccine |
0.5 mL |
$57.194 |
|
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 |
$1.891 |
|
A9577 |
Inj multihance |
1 mL |
$2.373 |
|
A9578 |
Inj multihance multipack |
1 mL |
$2.230 |
|
A9579 |
Gad-base MR contrast NOS, 1mL |
1 mL |
$2.100 |
|
A9581 |
Gadoxetate disodium inj |
1 mL |
$13.504 |
|
A9583 |
Gadofosveset trisodium injection |
1mL |
$12.653 |
|
J0129 |
Abatacept injection |
10 mg |
$21.389 |
|
J0130 |
Abciximab injection |
10 mg |
$555.981 |
|
J0132 |
Acetylcysteine injection |
100 mg |
$2.850 |
|
J0133 |
Acyclovir injection |
5 mg |
$0.33 |
|
J0135 |
Adalimumab injection |
20 mg |
$433.091 |
|
J0150 |
Injection adenosine 6 mg |
6 mg |
$6.713 |
|
J0152 |
Adenosine injection |
30 mg |
$99.816 |
|
J0171 |
Adrenalin epinephrin injection |
0.1 mg |
$0.049 |
|
J0180 |
Agalsidase beta injection |
1 mg |
$141.191 |
|
J0205 |
Alglucerase injection |
10 units |
$42.029 |
|
J0207 |
Amifostine |
500 mg |
$318.576 |
|
J0210 |
Methyldopate hcl injection |
250 mg |
$42.400 |
|
J0215 |
Alefacept |
0.5 mg |
$39.526 |
|
J0220 |
Alglucosidase alfa injection |
10 mg |
$158.849 |
|
J0221 |
Lumizyme injection |
10 mg |
$148.311 |
|
J0256 |
Alpha 1 proteinase inhibitor |
10 mg |
$3.815 |
|
J0257 |
Glassia injection |
10mg |
$3.922 |
|
J0270 |
Alprostadil for injection |
1.25 mcg |
$0.655 |
|
J0278 |
Amikacin sulfate injection |
100 mg |
$0.768 |
|
J0280 |
Aminophyllin 250 mg inj |
250 mg |
$0.381 |
|
J0285 |
Amphotericin B |
50 mg |
$11.905 |
|
J0287 |
Amphotericin b lipid complex |
10 mg |
$8.178 |
|
J0288 |
Ampho b cholesteryl sulfate |
10 mg |
$12.000 |
|
J0289 |
Amphotericin b liposome inj |
10 mg |
$15.183 |
|
J0290 |
Ampicillin 500 mg inj |
500 mg |
$2.312 |
|
J0295 |
Ampicillin sodium per 1.5 gm |
1.5 gm |
$3.079 |
|
J0348 |
Anidulafungin injection |
1 mg |
$1.908 |
|
J0360 |
Hydralazine hcl injection |
30 mg |
$4.807 |
|
J0364 |
Apomorphine hydrochloride |
1 mg |
$5.607 |
|
J0365 |
Aprotonin 10, 000 kiu |
10000 kiu |
$2.646 |
|
J0400 |
Aripiprazole injection |
0.25 mg |
$0.415 |
|
J0456 |
Azithromycin |
500 mcg |
$7.215 |
|
J0461 |
Atropine sulfate injection |
0.3 mg |
$0.020 |
|
J0470 |
Dimecaprol injection |
100 mg |
$28.656 |
|
J0475 |
Baclofen 10 mg injection |
10 mg |
$188.722 |
|
J0476 |
Baclofen intrathecal trial |
50 mcg |
$77.672 |
|
J0480 |
Basiliximab |
20 mg |
$2220.171 |
|
J0490 |
Belimumab injection |
10mg |
$38.417 |
|
J0500 |
Dicyclomine injection |
20 mg |
$26.080 |
|
J0515 |
Inj benztropine mesylate |
1 mg |
$24.026 |
|
J0558 |
PenG benzathine/procaine inj |
100,000 units |
$3.466 |
|
J0561 |
Penicillin g benzathine inj |
100,000 units |
$4.373 |
|
J0583 |
Bivalirudin |
1 mg |
$2.771 |
|
J0585 |
injection, onabotulinumtoxinA |
1 unit |
$5.482 |
|
J0586 |
AbobotulinumtoxinA |
5 unit |
$7.328 |
|
J0587 |
Inj, rimabotulinumtoxinB |
100 units |
$10.923 |
|
J0588 |
Incobotulinumtoxin A |
1 unit |
$5.25 |
|
J0592 |
Buprenorphine hydrochloride |
0.1 mg |
$0.747 |
|
J0594 |
Busulfan injection |
1 mg |
$19.079 |
|
J0595 |
Butorphanol tartrate 1 mg |
1 mg |
$1.051 |
|
J5097 |
C-1 esterase, berinert |
10 units |
$30.229 |
|
J5098 |
C1 esterase inhibitor inj |
10 IU |
$44.199 |
|
J0600 |
Edetate calcium disodium inj |
1000 mg |
$190.516 |
|
J0610 |
Calcium gluconate injection |
10 ml |
$0.565 |
|
J0630 |
Calcitonin salmon injection |
400 units |
$57.049 |
|
J0636 |
Inj calcitrol per 0.1 mcg |
0.1 mcg |
$1.033 |
|
J0637 |
Casofungin acetate |
5 mg |
$13.336 |
|
J0368 |
Canakinumab injection |
1 mg |
$89.022 |
|
J0640 |
Leucovorin calcium injection |
50 mg |
$1.529 |
|
J0641 |
Levoleucovorin injection |
0.5 mg |
$1.711 |
|
J0670 |
Inj mepivacaine HCL |
10 mL |
$1.331 |
|
J0690 |
Cefazolin sodium injection |
500 mg |
$0.663 |
|
J0692 |
Cefepime HCI for injection |
500 mg |
$3.276 |
|
J0694 |
Cefoxitin sodium injection |
1 gm |
$5.761 |
|
J0696 |
Ceftriaxone sodium injection |
250 mg |
$0.891 |
|
J0697 |
Sterile cefurxime injection |
750 mg |
$2.397 |
|
J0698 |
Cefotaxime sodium injection |
1 gm |
$1.709 |
|
J0702 |
Betamethasone acet & sod phosp |
3 mg |
$5.527 |
|
J0706 |
Caffeine citrate injection |
5 mg |
$0.394 |
|
J0712 |
Ceftaroline Fosamil inj |
10mg |
$0.739 |
|
J0713 |
Inj ceftazidime per 500 mg |
500 mg |
$2.298 |
|
J0718 |
Certolizumab pegol inj |
1 mg |
$4.205 |
|
J0720 |
Chloramphenicol sodium injection |
1 gm |
$20.349 |
|
J0725 |
Chorionic gonadtropin |
1000 units |
$11.518 |
|
J0735 |
Clonidine hydrochloride |
1 mg |
$28.099 |
|
J0740 |
Cidofovir injection |
375 mg |
$754.508 |
|
J0743 |
Cilastatin sodium injection |
250 mg |
$11.045 |
|
J0744 |
Ciprofloxacin iv |
200 mg |
$1.086 |
|
J0745 |
Inj codeine phosphate / 30 mg |
30 mg |
$1.346 |
|
J0760 |
Colchicine injection |
1 mg |
$6.572 |
|
J0770 |
Colistimethate sodium inj |
150 mg |
$13.610 |
|
J0775 |
Collagenase clost hist inj |
0.01mg |
$37.512 |
|
J0780 |
Prochlorperazine injection |
10 mg |
$2.120 |
|
J0795 |
Corticorelin ovine triflutal |
1 mcg |
$5.605 |
|
J0800 |
Corticotropin injection |
40 units |
$2694.391 |
|
J0834 |
Cosyntropin cortrosyn inj |
0.25 mg |
$67.482 |
|
J0840 |
Crotalide poly immune fab |
UP to 1 gm |
$2111.361 |
|
J0850 |
Cytomegalovirus imm IV/vial |
per vial |
$966.084 |
|
J0878 |
Daptomycin injection |
1 mg |
$0.512 |
|
J0881 |
Darbepoetin alfa, non -esrd |
1 mcg |
$3.212 |
|
J0882 |
Darbepoetin alfa, esrd use |
1 mcg |
$3.212 |
|
J0885 |
Epoetin alfa, non-esrd |
1000 units |
$9.618 |
|
J0886 |
Epoetin alfa 1000 units ESRD |
1000 units |
$9.618 |
|
J0894 |
Decitabine injection |
1 mg |
$33.188 |
|
J0895 |
Deferoxamine mesylate inj |
500 mg |
$9.761 |
|
J1000 |
Depo-estradiol cypionate inj |
5 mg |
$6.829 |
|
J1020 |
Methylprednisolone 20 mg inj |
20 mg |
$3.123 |
|
J1030 |
Methylprednisolone 40 mg inj |
40 mg |
$3.109 |
|
J1040 |
Methylprednisolone 80 MG inj |
80 mg |
$8.036 |
|
J1051 |
Medroxyprogesterone inj |
50 mg |
$87.094 |
|
J1070 |
Testosterone cypionat |
100 mg |
$4.161 |
|
J1080 |
Testosterone cypionat |
200 mg |
$5.438 |
|
J1100 |
Dexamethasone sodium phos |
1 mg |
$0.109 |
|
J1110 |
Inj dihydroergotamine mesylt |
1 mg |
$256.274 |
|
J1120 |
Acetazolamid sodium injection |
500 mg |
$30.500 |
|
J1160 |
Digoxin injection |
0.5 mg |
$0.732 |
|
J1162 |
Digoxin immune fab (ovine) |
per vial |
$680.605 |
|
J1165 |
Phenytoin sodium injection |
50 mg |
$0.348 |
|
J1170 |
Hydromorphone injection |
4 mg |
$1.706 |
|
J1190 |
Dexrazoxane HCI injection |
250 mg |
184.093 |
|
J1200 |
Diphenhydramine hcl injection |
50 mg |
$0.670 |
|
J1205 |
Chlorothiazide sodium inj |
500 mg |
$279.792 |
|
J1212 |
Dimethyl sulfoxide 50% |
50 mL |
$86.273 |
|
J1230 |
Methadone injection |
10 mg |
$6.948 |
|
J1240 |
Dimenhydrinate injection |
50 mg |
4.234 |
|
J1245 |
Dipridamole injection |
10 mg |
$0.812 |
|
J1250 |
Inj dobutamine hcl |
250 mg |
$5.343 |
|
J1260 |
Dolasetron mesylate |
10 mg |
$5.072 |
|
J1265 |
Dopamine injection |
40 mg |
$0.546 |
|
J1267 |
Doripenem injection |
10 mg |
$0.528 |
|
J1270 |
Injection, doxercalciferol |
1 mcg |
$1.429 |
|
J1290 |
Ecallantide injection |
1mg |
$288.905 |
|
J1300 |
Eculizumab injection |
10 mg |
$194.105 |
|
J1325 |
Epoprostenol injection |
0.5 mg |
$14.133 |
|
J1327 |
Eptifibatide injection |
5 mg |
$22.829 |
|
J1335 |
Ertapenem injection |
500 mg |
038 |
|
J1364 |
Erythro lactobionate |
500 mg |
$10.120 |
|
J1380 |
Estradiol valerate |
10 mg |
$7.438 |
|
J1410 |
Inj estrogen conjugate |
25 mg |
$114.628 |
|
J1430 |
Ethanolamine oleate |
100 mg |
$299.937 |
|
J1438 |
Etanercept injection |
25 mg |
$219.585 |
|
J1440 |
Filgrastim |
300 mcg |
$257.491 |
|
J1441 |
Filgrastim |
480 mcg |
$408.131 |
|
J1450 |
Fluconazole |
200 mg |
$4.334 |
|
J1451 |
Fomepizole |
15 mg |
$7.757 |
|
J1453 |
Fosaprepitant injection |
1mg |
$1.718 |
|
J1455 |
Foscarnet sodium injection |
1000 mg |
$13.316 |
|
J1457 |
Gallium nitrate injection |
1 mg |
$2.071 |
|
J1458 |
Galsulfase injection |
1 mg |
$347.708 |
|
J1459 |
inj IVIG privigen |
500 mg |
$35.065 |
|
J1460 |
Gamma globulin |
1 CC |
$21.470 |
|
j1577 |
Gammaplex injection |
500mg |
$37.293 |
|
J1559 |
Hizentra injection |
100 mg |
$7.285 |
|
J1560 |
Gamma globulin |
>10 CC |
$214.703 |
|
J1561 |
Gamunex, Gamunex-C, Gammaked |
500 mg |
$37.618 |
|
J1566 |
Immune globulin, powder |
500 mg |
$30.819 |
|
J1568 |
Octagam injection |
500 mg |
$56.874 |
|
J1569 |
Gammagard liquid injection |
500 mg |
$37.928 |
|
J1570 |
Ganciclovir sodium injection |
500 mg |
$67.308 |
|
J1571 |
Hepagam b im injection |
0.5mL |
$549.801 |
|
J1572 |
Flebogamma injection |
500 mg |
$35.076 |
|
J1573 |
Hepagam b intravenous , inj |
0.5 mL |
$49.801 |
|
J1580 |
Garamycin gentamicin inj |
80 mg |
$1.171 |
|
J1600 |
Gold sodium thiomaleate inj |
50 mg |
$7.171 |
|
J1610 |
Glucagon hydrochloride |
1 mg |
$106.464 |
|
J1626 |
Granisetron hcl injecction |
100 mcg |
$0.735 |
|
J1630 |
Haloperidol injection |
5 mg |
$3.172 |
|
J1631 |
Haloperidol decanote inj |
50 mg |
$136.963 |
|
J1640 |
Hemin |
1 mg |
$10.629 |
|
J1642 |
inj heparin sodium per 10 u |
10 units |
$0.161 |
|
J1644 |
inj heparin sodium per 1000u |
1000 units |
$0.267 |
|
J1645 |
Dalteparin sodium |
2500 iu |
$10.969 |
|
J1650 |
inj enoxaparin sodium |
10 mg |
$5.509 |
|
J1652 |
Fondaparinux sodium |
0.5 mg |
$6.158 |
|
J1670 |
Tetanus immune globulin |
250 units |
$239.412 |
|
J1720 |
Hydrocortisone sodium succ inj |
100 mg |
$4.075 |
|
J1740 |
Ibandronate sodium injection |
1 mg |
$151.256 |
|
J1742 |
Ibutilide furmarate injection |
1 mg |
$182.772 |
|
J1743 |
Idursulfase injection |
1 mg |
$455.030 |
|
J1745 |
Infliximab injection |
10 mg |
$62.680 |
|
J1750 |
Inj iron dextran |
50 mg |
$12.053 |
|
J1756 |
Iron sucrose injection |
1 mg |
$0.321 |
|
J1786 |
Injection imiglucerase / unit |
10 units |
$41.990 |
|
J1790 |
Droperidol injection |
5 mg |
$3.230 |
|
J1800 |
Propanolol injection |
1 mg |
$3.108 |
|
J1815 |
Insulin injection |
5 units |
$0.468 |
|
J1817 |
Insulin for insulin pump use |
50 units |
$2.700 |
|
J1840 |
Kanamycin sulfate |
500 mg |
$7.685 |
|
J1850 |
Kanamycin sulfate |
75 mg |
$1.153 |
|
J1885 |
Ketorolac tromethamine inj |
15 mg |
$0.260 |
|
J1930 |
Lanreotide injection |
1 mg |
$33.082 |
|
J1931 |
Laronidase injection |
0.1 mg |
$26.837 |
|
J1940 |
Furosemide injection |
20 mg |
$0.704 |
|
J1945 |
Lepirudin |
50 mg |
$396.811 |
|
J1950 |
Leuprprolide acetate |
3.75 mg |
$637.301 |
|
J1953 |
Levetiracetam injection |
10 mg |
$0.280 |
|
J1955 |
Inj levocarnitine |
1 gm |
$8.017 |
|
J1956 |
Levofloxacin injection |
250 mg |
$3.937 |
|
J1980 |
Hyoscyamine sulfate inj |
0.25 mg |
$14.031 |
|
J2001 |
Lidocaine injection |
10 mg |
$0.017 |
|
J2010 |
Lincomycin injection |
300 mg |
$6.414 |
|
J2020 |
Linezolid injection |
200 mg |
$36.035 |
|
J2060 |
Lorazepam injection |
2 mg |
$0.667 |
|
J2150 |
Mannitol injection |
50 ml |
$0.983 |
|
J2175 |
Meperedine hydrochl |
100 mg |
$1.993 |
|
J2185 |
Meropenem |
100 mg |
$2.022 |
|
J2210 |
Methylergonovin maleate injection |
0.2 mg |
$5.552 |
|
J2248 |
Micafungin sodium injection |
1 mg |
$0.985 |
|
J2250 |
Inj midazolam hydrochloride |
1 mg |
$0.141 |
|
J2260 |
Inj milrinone lactate |
5 mg |
$5.534 |
|
J2270 |
Morphine sulphate injection |
10 mg |
$1.950 |
|
J2271 |
Morphine so4 injection |
100 mg |
$0.726 |
|
J2275 |
Morphine sulfate injection |
10 mg |
$2.413 |
|
J2278 |
Ziconotide injection |
1 mcg |
$6.606 |
|
J2280 |
Moxifloxacin injection |
100 mg |
$3.406 |
|
J2300 |
Nalbuphine hydrochloride injection |
10 mg |
$0.873 |
|
J2310 |
Naloxone hydrochloride |
1 mg |
$10.435 |
|
J2315 |
Naltrexone, depot form |
1 mg |
$2.815 |
|
J2323 |
Natulizumab injection |
1 mg |
$11.056 |
|
J2325 |
Nesirritide injection |
0.1 mg |
$49.638 |
|
J2353 |
Octreotide injection, depot |
1 mg |
$121.585 |
|
J2354 |
Octreotide inj, non-depot |
25 mcg |
$1.395 |
|
J2355 |
Oprelvekin injection |
5 mg |
$244.319 |
|
J2357 |
Omalizumab injection |
5 mg |
$21.932 |
|
J2358 |
Olanzapine long-acting inj |
1 mg |
$2.753 |
|
J2360 |
Orphenadrine injection |
60 mg |
$6.119 |
|
J2370 |
Phenylphrine hcl injection |
1 mL |
$0.811 |
|
J2400 |
Chloroprocaine hcl injection |
30 mL |
$15.875 |
|
J2405 |
Ondansetron hcl injection |
1 mg |
$0.094 |
|
J2410 |
Oxymorphone hcl injection |
1 mg |
$2.310 |
|
J2425 |
Palifermin injection |
50 mcg |
$11.692 |
|
J2426 |
Paliperidone palmitate inj |
1 mg |
$6.610 |
|
J2430 |
Pamidronate disodium |
30 mg |
$12.654 |
|
J2440 |
Papaverin hcl injection |
60 mg |
$1.541 |
|
J2469 |
Palonosetron hcl |
25 mcg |
$18.467 |
|
J2501 |
Paricalcitol |
1 mcg |
$2.204 |
|
J2503 |
Pegaptanib sodium injection |
0.3 mg |
$1029.069 |
|
J2504 |
Pegademase bovine |
25 iu |
$259.700 |
|
J2505 |
Pegfilgrastim injection |
6 mg |
$2754.071 |
|
J2510 |
Penecillin g procaine injection |
600000 units |
$12.289 |
|
J2515 |
Pentobarbital sodium injection |
50 mg |
$21.745 |
|
J2540 |
Penecillin g potassium injection |
600000 units |
$0.701 |
|
J2543 |
Piperacillin / tazobactam |
1.125 gm |
$3.490 |
|
J2545 |
Pentamidine non-comp unit |
300 mg |
$55.109 |
|
J2550 |
Promethazine hcl injection |
50 mg |
$1.738 |
|
J2560 |
Phenobarbital sodium injection |
120 mg |
$2.706 |
|
J2562 |
Plerixaforinjection |
1 mg |
$286.029 |
|
J2590 |
Oxytocin injection |
10 units |
$0.622 |
|
J2597 |
desmopressin acetate injection |
1 mcg |
$3.975 |
|
J2675 |
Inj progesterone per 50mg |
50 mg |
$1.593 |
|
J2680 |
Fluphenazine decanoate |
25 mg |
$11.338 |
|
J2690 |
Procainimide hcl injection |
1 gm |
$7.775 |
|
J2700 |
Oxacillin sodium injection |
250 mg |
$2.843 |
|
J2720 |
Protamine sulfate |
10 mg |
$0.491 |
|
J2724 |
Protein c concentrate |
10 units |
$13.144 |
|
J2730 |
Pralidoxime chloride injection |
1 gm |
$90.195 |
|
J2760 |
Phentolaine mesylate injection |
5 mg |
$54.579 |
|
J2765 |
Metoclopramide hcl injection |
10 mg |
$0.318 |
|
J2770 |
Quinupristin / dalfopristin |
500 mg |
$174.779 |
|
J2778 |
Ranibizumab injection |
0.1 mg |
$401.835 |
|
J2780 |
Ranitidine hydrochloride injection |
25 mg |
$0.762 |
|
J2783 |
Rasburicase |
0.5 mg |
$197.489 |
|
J2785 |
Regadenoson injection |
0.1 mg |
$52.732 |
|
J2788 |
Rho d immune globulin |
50 mcg |
$24.993 |
|
J2790 |
Rho d immune globulin injection |
300 mcg |
&82.191 |
|
J2791 |
Rhophylac injection |
100 iu |
$5.188 |
|
J2792 |
Rho(D) immune globulin h, sd |
100 iu |
$15.706 |
|
J2794 |
Risperidone, long acting |
0,5 mg |
$5.279 |
|
J2795 |
Ropivacaine hcl injection |
1 mg |
$0.074 |
|
J2796 |
Romiplostim injection |
10 mcg |
$46.805 |
|
J2800 |
Methocarbamol injection |
10 mL |
$28.217 |
|
J2805 |
Sincalide injection |
5 mcg |
$76.109 |
|
J2810 |
Theophylline injection |
40 mg |
$0.231 |
|
J2820 |
Sargramostin injection |
50 mcg |
$24.763 |
|
J2850 |
Secretin synthetic human injection |
1 mcg |
$27.494 |
|
J2916 |
Na ferric gluconate complex |
12.5 mg |
$4.740 |
|
J2920 |
Methylprednisolone injection |
40 mg |
$1.865 |
|
J2930 |
Methyprednisolone injection |
125 mg |
$2.575 |
|
J2993 |
Reteplase injection |
18.1 mg |
$2301.907 |
|
J2997 |
Alteplase recombinant |
1 mg |
$45.680 |
|
J3000 |
Streptomycin injection |
1 gm |
$9.957 |
|
J3010 |
Fentanyl citrate injection |
0.1 mg |
$0.354 |
|
J3030 |
Sumatriptan succinate |
6 mg |
$75.197 |
|
J3070 |
Pentazocine injection |
30 mg |
$14.334 |
|
J3095 |
Telavancin injection |
10 mg |
$2.039 |
|
J3101 |
Tenecteplase injection |
1 mg |
$64.176 |
|
J3105 |
Terbutaline sulfate injection |
1 mg |
$3.661 |
|
J3120 |
Testosterone enethate injection |
100 mg |
$4.734 |
|
J3130 |
Testosterone enethate injection |
200 mg |
$9.468 |
|
J3230 |
Chlorpromazine hcl injection |
50 mg |
$9.069 |
|
J3240 |
Thyrotropin injection |
0.9 mg |
$1052.395 |
|
J3243 |
Tigecycline injection |
1 mg |
$1.325 |
|
J3246 |
Tirofiban hcl |
0.25 mg |
$10.314 |
|
J3250 |
Trimethobenzamide hcl inj |
200 mg |
$5.783 |
|
J3260 |
Tobramycin sulfate injection |
80 mg |
$1.950 |
|
J3262 |
Tocilizumab injection |
1 mg |
$3.474 |
|
J3285 |
Treprostinil injection |
1 mg |
$61.237 |
|
J3300 |
triamcinalone A inj PRS free |
1 mg |
$3.492 |
|
J3301 |
Triamcinalone acet injection NOS |
10 mg |
$1.693 |
|
J3302 |
Triamcinalocne diacetate injection |
5 mg |
$0.280 |
|
J3303 |
Triamcinalone hexacetonl injection |
5 mg |
$1.681 |
|
J3315 |
Triptorelin pamoate |
3.75 mg |
$178.085 |
|
j3355 |
Urofollitropin |
75 iu |
$58.692 |
|
J3357 |
Ustekinumab injection |
1 mg |
$124.632 |
|
J3360 |
Diazepam injection |
5 mg |
$0.911 |
|
J3365 |
Urokinase 250,000 iu inj |
250000iu |
$457.729 |
|
J3370 |
Vancomycin hcl injection |
0.1 mg |
$2.555 |
|
J3385 |
Velaglucerase alfa |
100 units |
$349.228 |
|
J3396 |
Verteporfin injection |
0.1mg |
$10.048 |
|
J3410 |
Hydroxyzine hcl injection |
25 mg |
$1.288 |
|
J3411 |
Thiamine hcl |
100 mg |
$3.254 |
|
J3415 |
Pyridoxine hcl |
100 mg |
$6.826 |
|
J3420 |
Vitamin b 12 injection |
1000 mcg |
$0.658 |
|
J3430 |
Vitamin k phytonadione injection |
1 mg |
$1.430 |
|
J3465 |
Voriconazole injection |
10 mg |
$6.510 |
|
J3470 |
Hyaluronidase ijection |
150 units |
$21.200 |
|
J3471 |
Ovine, up to 999 USP units |
1 usp init |
$0.208 |
|
J3473 |
Hyaluronidase recombinant |
1 usp unit |
$0.636 |
|
J3475 |
Magnesium sulfate injection |
500 mg |
$0.081 |
|
J3480 |
Potassium chloride injection |
2 meq |
$0.013 |
|
J3485 |
Zidovudine |
10 mg |
$1.408 |
|
J3486 |
Ziprasidone mesylate |
10 mg |
$7.562 |
|
J3487 |
Zoledronic acid |
1 mg |
$226.828 |
|
J3488 |
Reclast injection |
1 mg |
$222.640 |
|
J7030 |
Normal saline solution infusion |
1000 cc |
$1.147 |
|
J7040 |
Normal saline solution infusion |
500 mL |
$0.573 |
|
J7042 |
5% dextrose / normal saline |
500 mL |
$0.357 |
|
J7050 |
Normal saline solution infusion |
250 cc |
$0.287 |
|
J7060 |
5% dextrose / water |
500 mL |
$1.065 |
|
J7070 |
D5W infusion |
1000 cc |
$2.102 |
|
J7100 |
Dextran 40 infusion |
500 mL |
$20.459 |
|
J7110 |
Dextran 75 infusion |
500 mL |
$14.522 |
|
J7120 |
Ringers lactate infusion |
1000 cc |
$1.055 |
|
J7183 |
Wilate injection |
1i.u.vwf:rco |
$0.879 |
|
J7185 |
Xyntha injection |
1 iu |
$1.054 |
|
J7186 |
Antihemophilic VIII / vWF |
per factor VII iu |
$0.923 |
|
J7187 |
Humate-P, injection |
1 iu |
$0.886 |
|
J7189 |
Factor VIIa |
1 mcg |
$1.555 |
|
J7190 |
Factor VIII |
1 iu |
$0.894 |
|
J7192 |
Factor VIII recombinant NOS |
1 iu |
$1.113 |
|
J7193 |
FactorIX non-recombinant |
1 iu |
$0.910 |
|
J7194 |
Factor IX complex |
1 iu |
$0.887 |
|
J7195 |
Factor IX recombinant |
1 iu |
$1.184 |
|
J7197 |
Antithrombin III injection |
1 iu |
$2.756 |
|
J7198 |
Anti-inhibitor |
1 iu |
$1.637 |
|
J7308 |
Aminolevulinic acid hcl top |
354 mg |
$151.400 |
|
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 |
$195.947 |
|
J7321 |
Hyalagan/supartz injection |
per dose |
$90.550 |
|
J7323 |
Euflexxa injection |
per dose |
$154.078 |
|
J7324 |
Orthovisc injection |
per dose |
$165.381 |
|
J7325 |
Synvisc or Synvisc-One |
1 mg |
$12.272 |
|
J7330 |
Cultured chondrocytes implant |
1 ea |
$27533.659 |
|
J7335 |
Capsaicin 8% patch |
10SQ cm |
$25.554 |
|
J7500 |
Azathioprine oral |
50 mg |
$0.095 |
|
J7501 |
Azathioprine parenteral |
100 mg |
$119.282 |
|
J7502 |
Cyclosporine oral |
100 mg |
$3.189 |
|
J7504 |
Lymphocyte immune globulin |
250 mg |
$616.218 |
|
J7505 |
Monoclonal antibodies |
5 mg |
$1132.960 |
|
J7506 |
Prednisone oral |
5 mg |
$0.023 |
|
J7507 |
tacrolimus oral |
1 mg |
$2.560 |
|
J7509 |
Methylprednisolone oral |
4 mg |
$0.884 |
|
J7510 |
Prednisolone oral |
5 mg |
$0.020 |
|
J7511 |
Antithymocyte globulin rabbit |
25 mg |
$441.660 |
|
J7513 |
Daclizumab, parenteral |
25 mg |
$526.343 |
|
J7515 |
Cyclosporine oral |
25 mg |
$0.838 |
|
J7516 |
Cyclosporin parenteral |
250 mg |
$25.937 |
|
J7517 |
Mycophenolate mofetil oral |
250 mg |
$1.311 |
|
J7518 |
Mycophenolic acid |
180 mg |
$3.330 |
|
J7520 |
Sirolimus, oral |
1 mg |
$11.000 |
|
J7525 |
Tacrolimus injection |
5 mg |
$139.591 |
|
J7605 |
Arformoterol non-comp unit |
15 mcg |
$5.353 |
|
J7606 |
Formoterol fumarate, inh |
20 mcg |
$4.845 |
|
J7608 |
Acetylcysteine non-comp unit |
1 gm |
2.152 |
|
J7611 |
Albuterol non-comp con |
1 mg |
$0.106 |
|
J7612 |
Levalbuterol non-comp con |
0.5 mg |
$0.210 |
|
J7613 |
ALbuterol non-comp unit |
1 mg |
$.061 |
|
J7614 |
Levalbuterol non-comp unit |
0.5 mg |
$0.256 |
|
J7620 |
Albuterol ipratrop non-comp |
2.5 mg / 0.5 mg |
$0.281 |
|
J7626 |
Budesonide non-comp unit |
0.5 mg |
$4.633 |
|
J7631 |
Cromolyn sodium noncomp unit |
10 mg |
$0.394 |
|
J7639 |
Dornase alfa non-comp unit |
1 mg |
$28.110 |
|
J7644 |
Ipratropium bromide non-comp |
1 mg |
$0.269 |
|
J7669 |
Metaproterenol non-comp unit |
10 mg |
$0.252 |
|
J7674 |
Methacholine chloride, neb |
1 mg |
$0.494 |
|
J7682 |
Tobramycin non-comp unit |
300 mg |
$84.130 |
|
J7686 |
Treprostinil, non-comp unit |
1.74 mg |
$418.153 |
|
J8501 |
Oral aprepitant |
5 mg |
$6.166 |
|
J8510 |
Oral busulfan |
2 mg |
$3.898 |
|
J8520 |
Cepecitabine, oral |
150 mg |
$7.833 |
|
J8521 |
Capacitabine, oral |
500 mg |
$25.852 |
|
J8530 |
Cyclophosphamide oral |
25 mg |
$0.817 |
|
J8540 |
Oral dexamethasone |
0.25 mg |
$0.348 |
|
J8560 |
Etoposide oral |
50 mg |
$40.703 |
|
J8562 |
Oral fludarabine phosphate |
10 mg |
$79.269 |
|
J8600 |
Melphalan oral |
2 mg |
$7.374 |
|
J8610 |
Methotrexate oral |
2.5 mg |
$0.127 |
|
J8700 |
Temozolomide |
5 mg |
$9.748 |
|
J8705 |
Topotecan oral |
0.25 mg |
$79.455 |
|
J9000 |
Doxorubicin hcl injection |
10 mg |
$3.877 |
|
J9001 |
Doxorubicin hcl liposome |
10 mg |
$543.031 |
|
J9010 |
ALemtuzumab injection |
10 mg |
$589.083 |
|
J9015 |
Aldesleukin injection |
1 ea |
$1054.340 |
|
J9017 |
Arsenic trioxide injection |
1 mg |
$40.838 |
|
J9020 |
Asparaginase injection |
10000 units |
$63.271 |
|
J9025 |
Azacitidine injection |
1 mg |
$5.255 |
|
J9027 |
Clofarabine injection |
1 mg |
$122.187 |
|
J9031 |
Bcg live intavesical vac |
1 ea |
$115.471 |
|
J9033 |
Bendamustine injection |
1 mg |
$18.811 |
|
J9035 |
Bevacizumab injection |
10 mg |
$61.086 |
|
J9040 |
Bleomycin sulfate injection |
15 units |
$25.581 |
|
J9041 |
Bortezomib injection |
0.1 mg |
$42.451 |
|
J9045 |
Carboplatin injection |
50 mg |
$4.214 |
|
J9050 |
Carmustine injection |
100 mg |
$175.801 |
|
J9055 |
Cetuximab injection |
10 mg |
$50.464 |
|
J9060 |
Cisplatin 10 mg injection |
10 mg |
$1.779 |
|
J9065 |
Cladribine |
1 mg |
$23.398 |
|
J9070 |
Cyclophosphamine |
100 mg |
$14.910 |
|
J9098 |
CYtarabine liposome injection |
10 mg |
$513.167 |
|
J9100 |
Cytarabine hcl |
100 mg |
$0.946 |
|
J9120 |
Dactinomycin injection |
0.5 mg |
$577.379 |
|
J9130 |
Dacarbazine |
100 mg |
$3.612 |
|
J9150 |
Daunorubicin injection |
10 mg |
$14.338 |
|
J9151 |
Daunorubicin citrate injection |
10 mg |
$57.664 |
|
J9155 |
Degarelix injection |
1 mg |
$2.800 |
|
J9160 |
Denileukin diftitox injection |
300 mcg |
$1646.180 |
|
J9171 |
Docetaxel injection |
1 mg |
$13.957 |
|
J9175 |
Elliots b solution |
1 mL |
$4.074 |
|
J9178 |
Epirubicin hcl injection |
2 mg |
$1.733 |
|
J9181 |
Etoposide injection |
10 mg |
$0.764 |
|
J9185 |
Fludarabine phosphate injection |
50 mg |
95.240 |
|
J9190 |
Fluoroucil injection |
500 mg |
$1.26 |
|
J9200 |
Floxuridine injection |
500 mg |
$62.011 |
|
J9201 |
Gemcitabine hcl injection |
200 mg |
$51.185 |
|
J9202 |
Goserelin acetate implant |
3.6 mg |
$176.681 |
|
J9206 |
Irinotecan injection |
20 mg |
$4.668 |
|
J9207 |
ixabepilone injection |
1 mg |
$64.694 |
|
J9208 |
ifosfomide injection |
1 gm |
$32.035 |
|
J9209 |
Mesna injection |
200 mg |
$4.194 |
|
J9211 |
Idarubicin hcl injection |
5 mg |
$116.509 |
|
J9214 |
Interferon alfa-2b injection |
1 mil units |
$17.759 |
|
J9217 |
Leuprolide acetate suspension |
7.5 mg |
$215.040 |
|
J9218 |
Leuprolide acetate injection |
1 mg |
$4.864 |
|
J9219 |
Leuprolide acetate implant |
65 mg |
$4819.820 |
|
J9225 |
Vantas implant |
50 mg |
$3188.766 |
|
J9226 |
Supprelin LA implant |
50 mg |
$15698.314 |
|
J9230 |
Mechlorethamine hcl injection |
10 mg |
$125.050 |
|
J9245 |
Melphalan hydrochl |
50 mg |
$1315.210 |
|
J9250 |
Methotrexate sodium injection |
5 mg |
$0.158 |
|
J9260 |
Methotrexate sodium injection |
50 mg |
$1.6548 |
|
J9261 |
Nelarabine injection |
50 mg |
$116.151 |
|
J9263 |
Oxaliplatin |
0.5 mg |
$10.264 |
|
J9264 |
Paclitaxel protein bound |
1 mg |
$9.5630 |
|
J9265 |
Paclitaxel injection |
30 mg |
$7.548 |
|
J9266 |
Pegaspargase injection |
1 ea |
$2726.850 |
|
J9268 |
Pentostatin injection |
10 mg |
$1188.957 |
|
J9280 |
Mitomycin injection |
5 mg |
$17.836 |
|
J9293 |
Mitoxantrone hydrochl |
5 mg |
$39.567 |
|
J9300 |
Gemtuzumabozogamicin inj |
5 mg |
$2742.591 |
|
J9302 |
Ofatumumab injection |
10 mg |
$45.424 |
|
J9303 |
Panitumumab injection |
10 mg |
$87.173 |
|
J9305 |
Pemetrexed |
10 mg |
$55.055 |
|
J9307 |
Pralatrexate injection |
1 mg |
$165.625 |
|
J9310 |
Rituximab injection |
100 mg |
$626.919 |
|
J9315 |
Romidepsin injection |
1 mg |
$225.976 |
|
J9320 |
Stretozocin injection |
1 gm |
$269.198 |
|
J9328 |
Temozolomide injection |
1 mg |
$4.822 |
|
J9330 |
Temsirolimus injection |
1 mg |
$52.327 |
|
J9340 |
Thiotepa injection |
15 mg |
$130.380 |
|
J9351 |
Topotecan injection |
0.1 mg |
$7.865 |
|
J9355 |
Trastuzumab injection |
10 mg |
$72.446 |
|
J9357 |
Valrubicin injection |
200 mg |
$991.362 |
|
J9360 |
Vinblastine sulfate injection |
1 mg |
$1.008 |
|
J9370 |
Vincristine sulfate injection |
1 mg |
$4.550 |
|
J9390 |
Vinorelbine tartrate injection |
10 mg |
$11.591 |
|
J9395 |
Fulvestrant injection |
25 mg |
$86.252 |
|
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 |
$0.651 |
|
Q0139 |
Ferumoxytol, esrd use |
1 mg |
$0.651 |
|
Q0163 |
Diphenhydramine HCI |
50 mg |
$0.025 |
|
Q0164 |
Prochloreperazine maleate |
5 mg |
$0.065 |
|
Q0165 |
Prochlorperazine maleate |
10 mg |
$0.043 |
|
Q0166 |
Granisetron hcl |
1 mg |
$2.506 |
|
Q0167 |
Dronabinol |
2.5 mg |
$5.003 |
|
Q0168 |
Dronabinol |
5 mg |
$13.986 |
|
Q0169 |
Promethazine HCI |
12.5 mg |
$0.124 |
|
Q0170 |
Promethazine HCI |
25 mg |
$0.062 |
|
Q0180 |
Dolesetron mesylate oral |
100mg |
$66.789 |
|
Q0515 |
Sermorelin acetate injection |
1 mcg |
$1.800 |
|
Q2009 |
Fosphenytoin injection PE |
50 mg |
$0.526 |
|
Q2017 |
Teniposide |
50 mg |
$322.388 |
|
Q2035 |
Afluris vacc, 3yrs &>, im |
0.5 mg |
$11.543 |
|
Q2036 |
Flulaval vacc, 3 yrs & >, im |
0.5 ml |
$8.784 |
|
Q2037 |
Fluvirin vacc, 3 yrs & >. IM |
0.5 mL |
$13.652 |
|
Q2038 |
Fluzone vacc, 3 yrs & >, im |
0.5mL |
$13.306 |
|
Q2040 |
Incobotulinumtoxin A |
1 unit |
$5.526 |
|
Q2041 |
Wilate injection |
1 i.u vwf:RCO |
0.865 |
|
Q2043 |
Sipuleucel-T auto CD54+ |
minimum 50 million |
$32860.00 |
|
Q2044 |
Belimumab injection |
10mg |
$38.614 |
|
Q3025 |
Interferon IM injection beta 1-a |
11 mcg |
$249.996 |
|
Q4074 |
lloprost non-comp |
up to 20 mcg |
$68.900 |
|
Q4081 |
Epoetin alfa ESRD |
100 unites |
$0.962 |
|
Q4101 |
Apilgraf skin sub |
1 sq cm |
$36.567 |
|
Q4102 |
Oasis wound matrix skin sub |
1 sq cm |
$7.376 |
|
Q4103 |
Oasis burn matrix skin sub |
1 sq cm |
$7.376 |
|
Q4104 |
Integra BMWD skin sub |
1 sq cm |
$16.917 |
|
Q4105 |
Integra DRT skin sub |
1 sq cm |
$11.934 |
|
Q4106 |
Dermagraft skin sub |
1 sq cm |
$41.278 |
|
Q4107 |
Graftjacket skin sub |
1 sq cm |
$99.525 |
|
Q4108 |
Integra matrix skin sub |
1 sq cm |
$23.013 |
|
Q4110 |
Primatrix skin sub |
1 sq cm |
$30.808 |
|
Q4111 |
Gammagraft skin sub |
1 sq cm |
$7.061 |
|
Q4112 |
Cymetra allograft |
1cc |
$177.607 |
|
Q1143 |
Graftjacket express allograft |
1cc |
$177.607 |
|
Q4114 |
Integra flowable wound matrix |
1cc |
$1111.587 |
|
Q4116 |
Alloderm skin sub |
1 sq cm |
$32.176 |
|
Q9954 |
MR contrast |
100 mL |
$10.522 |
|
Q9956 |
Octafluropropane mic |
1 mL |
$40.773 |
|
Q9957 |
Perlutren lip micros |
1 mL |
$61.159 |
|
Q9958 |
HOCM<=149 mg/mL iodine |
1mL |
$0.074 |
|
Q9960 |
HOCM 200 -249 mg/mL iodine |
1 mL |
$0.140 |
|
Q9961 |
HOCM 250-299mg/mL iodine |
1 mL |
$0.172 |
|
Q9963 |
HOCM 350-399mg/mL iodine |
1 mL |
$0.230 |
|
Q9965 |
LOCM 100 - 199 MG/Ml IODINE |
1 mL |
$1.004 |
|
Q9966 |
LOCM 200-299mg.mL iodine |
1 mL |
$0.275 |
|
Q9967 |
LOCM 300-399mg/mL iodine |
1 mL |
$0.154 |
|
|
|
Note 1: Payment allowance limits subject to the ASP
methodology are based on 2Q11 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
2011
Click Here |