Payment Allowance Limits for Medicare Part B Drugs
Effective April 1, 2006 through June 30, 2006

Note 1: Payment allowance limits subject to the ASP methodology are based on 4Q05 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% Vaccine Limit Infusion AWP% DME Infusion Limit Blood AWP% Blood Limit Notes
90371 Hep b ig, im 1 ML $119.736            
90375 Rabies ig, im/sc 150 IU $64.591            
90376 Rabies ig, heat treated 150 IU $69.231            
90385 Rh ig, minidose, im 50 MCG $4.928            
90585 Bcg vaccine, percut 50 MG $116.558            
90586 Bcg vaccine, intravesical 1 EACH $111.537            
90632 Hep a vaccine, adult im 1 ML $46.827            
90633 Hep a vacc, ped/adol, 2 dose 1 ML $23.829            
90634 Hep a vacc, ped/adol, 3 dose 3 EACH $23.855            
90645 Hib vaccine, hboc, im 1 EACH $21.524            
90647 Hib vaccine, prp-omp, im 0.5 ML $21.524            
90648 Hib vaccine, prp-t, im 0.5 ML $21.782            
90655 Flu vaccine no preserv 6-35m 0.25 ML $14.678 95% $14.678        
90656 Flu vaccine no preserv 3 & > 0.50 ML $15.818 95% $15.818        
90657 Flu vaccine, 6-35 mo, im 0.25 ML $6.028 95% $6.028        
90658 Flu vaccine age 3 & over, im 0.5 ML $12.056 95% $12.056        
90660 Flu vaccine, nasal 0.5 ML $21.176 95% $21.176        
90675 Rabies vaccine, im 1 ML $156.732            
90691 Typhoid vaccine, im 0.5 ML $50.679            
90700 Dtap vaccine, < 7 yrs, im 0.5 ML $23.466            
90702 Dt vaccine < 7, im 0.5 ML $18.300            
90703 Tetanus vaccine, im 0.5 ML $18.337            
90704 Mumps vaccine, sc 0.5 ML $19.144            
90705 Measles vaccine, sc 0.5 ML $14.518            
90706 Rubella vaccine, sc 0.5 ML $16.161            
90707 Mmr vaccine, sc 0.5 ML $38.586            
90713 Poliovirus, ipv, sc/im 0.5 ML $24.888            
90714 Td vaccine no prsrv >/= 7 im 0.5 ML $18.266            
90716 Chicken pox vaccine, sc 0.5 ML $67.475            
90717 Yellow fever vaccine, sc 0.5 ML $54.440            
90718 Td vaccine > 7, im 0.5 ML $18.266            
90721 Dtap/hib vaccine, im 1 EACH $41.724            
90732 Pneumococcal vaccine 0.5 ML $27.028 95% $27.028        
90733 Meningococcal vaccine, sc 0.5 ML $84.460            
90735 Encephalitis vaccine, sc 1 ML $100.099            
90740 Hepb vacc, ill pat 3 dose im 40 MCG $113.914 95% $113.914        
90743 Hep b vacc, adol, 2 dose, im 10 MCG $57.551 95% $57.551        
90744 Hepb vacc ped/adol 3 dose im 1 DOSE $68.381 95% $68.381        
90746 Hep b vaccine, adult, im 1 EACH $56.957 95% $56.957        
90747 Hepb vacc, ill pat 4 dose im 40 MCG $113.914 95% $113.914        
J0128 Abarelix injection 10 MG $66.833            
J0130 Abciximab injection 10 MG $457.273            
J0132 Acetylcysteine injection 100 MG $1.874            
J0133 Acyclovir injection 5 MG $0.026            
J0135 Adalimumab injection 20 MG $307.302            
J0150 Injection adenosine 6 MG 6 MG $30.189            
J0152 Adenosine injection 30 MG $70.071            
J0170 Adrenalin epinephrin inject 1 ML $0.570            
J0180 Agalsidase beta injection 1 MG $127.200            
J0205 Alglucerase injection 10 UNITS $39.220            
J0207 Amifostine 500 MG $452.684            
J0210 Methyldopate hcl injection 250 MG $9.950            
J0215 Alefacept 0.5 MG $26.153            
J0256 Alpha 1 proteinase inhibitor 10 MG $3.242            
J0270 Alprostadil for injection 1.25 MCG $1.815            
J0275 Alprostadil urethral suppos 125 MCG $21.995            
J0278 Amikacin sulfate injection 100 MG $1.309            
J0280 Aminophyllin 250 MG inj 250 MG $0.414            
J0282 Amiodarone HCl 30 MG $0.193            
J0285 Amphotericin B 50 MG $8.879     95% $10.280    
J0287 Amphotericin b lipid complex 10 MG $11.205     95% $21.850    
J0288 Ampho b cholesteryl sulfate 10 MG $12.000     95% $15.200    
J0289 Amphotericin b liposome inj 10 MG $17.566     95% $35.800    
J0290 Ampicillin 500 MG inj 500 MG $1.888            
J0295 Ampicillin sodium per 1.5 gm 1.5 GM $4.518            
J0300 Amobarbital 125 MG inj 125 MG $2.145            
J0330 Succinycholine chloride inj 20 MG $0.140            
J0350 Injection anistreplase 30 u 30 UNITS $2,265.460            
J0360 Hydralazine hcl injection 20 MG $5.106            
J0365 Aprotonin, 10,000 kiu 10000 KIU $2.347            
J0456 Azithromycin 500 MG $25.324            
J0460 Atropine sulfate injection 0.3 MG $0.227            
J0470 Dimecaprol injection 100 MG $21.834            
J0475 Baclofen 10 MG injection 10 MG $193.322     95% $215.180    
J0476 Baclofen intrathecal trial 50 MCG $70.872     95% $79.800    
J0480 Basiliximab 20 MG $1,402.038            
J0500 Dicyclomine injection 20 MG $15.112            
J0515 Inj benztropine mesylate 1 MG $4.774            
J0530 Penicillin g benzathine inj 600000 UNITS $13.069            
J0540 Penicillin g benzathine inj 1200000 UNITS $25.889            
J0550 Penicillin g benzathine inj 2400000 UNITS $32.597            
J0560 Penicillin g benzathine inj 600000 UNITS $19.463            
J0570 Penicillin g benzathine inj 1200000 UNITS $33.827            
J0580 Penicillin g benzathine inj 2400000 UNITS $68.507            
J0583 Bivalirudin 1 MG $1.635            
J0585 Botulinum toxin a per unit 1 UNIT $4.901            
J0587 Botulinum toxin type B 100 UNITS $7.929            
J0592 Buprenorphine hydrochloride 0.1 MG $0.747            
J0595 Butorphanol tartrate 1 mg 1 MG $0.839            
J0600 Edetate calcium disodium inj 1000 MG $40.179            
J0610 Calcium gluconate injection 10 ML $0.545            
J0630 Calcitonin salmon injection 400 UNITS $37.810            
J0636 Inj calcitriol per 0.1 mcg 0.1 MCG $0.462            
J0637 Caspofungin acetate 5 MG $32.496            
J0640 Leucovorin calcium injection 50 MG $0.913            
J0670 Inj mepivacaine HCL/10 ml 10 ML $1.363            
J0690 Cefazolin sodium injection 500 MG $1.287            
J0692 Cefepime HCl for injection 500 MG $7.818            
J0694 Cefoxitin sodium injection 1 GM $7.516            
J0696 Ceftriaxone sodium injection 250 MG $4.187            
J0697 Sterile cefuroxime injection 750 MG $1.770            
J0698 Cefotaxime sodium injection 1 GM $4.317            
J0702 Betamethasone acet&sod phosp 3 MG $5.068            
J0704 Betamethasone sod phosp/4 MG 4 MG $0.907            
J0706 Caffeine citrate injection 5 MG $3.369            
J0713 Inj ceftazidime per 500 mg 500 MG $4.073            
J0715 Ceftizoxime sodium / 500 MG 500 MG $3.559            
J0720 Chloramphenicol sodium injec 1 GM $12.039            
J0725 Chorionic gonadotropin/1000u 1000 UNITS $3.132            
J0735 Clonidine hydrochloride 1 MG $63.311            
J0740 Cidofovir injection 375 MG $764.239            
J0743 Cilastatin sodium injection 250 MG $13.205            
J0744 Ciprofloxacin iv 200 MG $8.320            
J0745 Inj codeine phosphate /30 MG 30 MG $0.950            
J0760 Colchicine injection 1 MG $4.543            
J0770 Colistimethate sodium inj 150 MG $25.080            
J0780 Prochlorperazine injection 10 MG $2.284            
J0795 Corticorelin ovine triflutal 1 MCG $4.260            
J0800 Corticotropin injection 40 UNITS $109.884            
J0835 Inj cosyntropin per 0.25 MG 0.25 MG $64.155            
J0850 Cytomegalovirus imm IV /vial PER VIAL $762.988            
J0878 Daptomycin injection 1 MG $0.313            
J0881 Darbepoetin alfa, non-esrd 1 MCG $3.033            
J0882 Darbepoetin alfa, esrd use 1 MCG $3.033            
J0885 Epoetin alfa, non-esrd 1000 UNITS $9.339            
J0886 Epoetin alfa, esrd 1000 UNITS $9.334            
J0895 Deferoxamine mesylate inj 500 MG $14.912     95% $15.630    
J0900 Testosterone enanthate inj 1 CC $1.379            
J0945 Brompheniramine maleate inj 10 MG $0.732            
J0970 Estradiol valerate injection 40 MG $32.524            
J1000 Depo-estradiol cypionate inj 5 MG $5.303            
J1020 Methylprednisolone 20 MG inj 20 MG $2.803            
J1030 Methylprednisolone 40 MG inj 40 MG $5.231            
J1040 Methylprednisolone 80 MG inj 80 MG $9.421            
J1051 Medroxyprogesterone inj 50 MG $5.234            
J1056 MA/EC contraceptiveinjection 5 MG $22.885            
J1060 Testosterone cypionate 1 ML 1 ML $4.142            
J1070 Testosterone cypionat 100 MG 100 MG $5.156            
J1080 Testosterone cypionat 200 MG 200 MG $12.517            
J1094 Inj dexamethasone acetate 1 MG $0.230            
J1100 Dexamethasone sodium phos 1 MG $0.127            
J1110 Inj dihydroergotamine mesylt 1 MG $25.271            
J1120 Acetazolamid sodium injectio 500 MG $14.946            
J1160 Digoxin injection 0.5 MG $1.034            
J1162 Digoxin immune fab (ovine) PER VIAL $532.483            
J1165 Phenytoin sodium injection 50 MG $0.844            
J1170 Hydromorphone injection 4 MG $1.765     95% $1.490    
J1180 Dyphylline injection 500 MG $8.045            
J1190 Dexrazoxane HCl injection 250 MG $181.330            
J1200 Diphenhydramine hcl injectio 50 MG $0.791            
J1205 Chlorothiazide sodium inj 500 MG $12.815            
J1212 Dimethyl sulfoxide 50% 50 ML 50 ML $42.103            
J1230 Methadone injection 10 MG $3.485     95% $0.750    
J1240 Dimenhydrinate injection 50 MG $3.779            
J1245 Dipyridamole injection 10 MG $1.706            
J1250 Inj dobutamine HCL/250 mg 250 MG $4.779     95% $4.740    
J1260 Dolasetron mesylate 10 MG $6.824            
J1265 Dopamine injection 40 MG $0.729            
J1270 Injection, doxercalciferol 1 MCG $3.167            
J1320 Amitriptyline injection 20 MG $2.237            
J1325 Epoprostenol injection 0.5 MG $13.200     95% $12.640    
J1327 Eptifibatide injection 5 MG $13.440            
J1335 Ertapenem injection 500 MG $23.172            
J1364 Erythro lactobionate /500 MG 500 MG $5.602            
J1380 Estradiol valerate 10 MG inj 10 MG $11.974            
J1390 Estradiol valerate 20 MG inj 20 MG $16.262            
J1410 Inj estrogen conjugate 25 MG 25 MG $58.332            
J1430 Ethanolamine oleate 100 mg 100 MG $72.252            
J1435 Injection estrone per 1 MG 1 MG $0.138            
J1436 Etidronate disodium inj 300 MG $71.407            
J1438 Etanercept injection 25 MG $155.584            
J1440 Filgrastim 300 mcg injection 300 MCG $184.266            
J1441 Filgrastim 480 mcg injection 480 MCG $292.346            
J1450 Fluconazole 200 MG $11.853            
J1451 Fomepizole, 15 mg 15 MG $11.933            
J1452 Intraocular Fomivirsen na 1.65 MG $212.000            
J1455 Foscarnet sodium injection 1000 MG $10.794     95% $13.070    
J1457 Gallium nitrate injection 1 MG $1.247            
J1460 Gamma globulin 1 CC inj 1 CC $10.686            
J1470 Gamma globulin 2 CC inj 2 CC $21.372            
J1480 Gamma globulin 3 CC inj 3CC $32.053            
J1490 Gamma globulin 4 CC inj 4 CC $42.744            
J1500 Gamma globulin 5 CC inj 5 CC $53.430            
J1510 Gamma globulin 6 CC inj 6 CC $64.134            
J1520 Gamma globulin 7 CC inj 7 CC $74.758            
J1530 Gamma globulin 8 CC inj 8 CC $85.487            
J1540 Gamma globulin 9 CC inj 9 CC $96.218            
J1550 Gamma globulin 10 CC inj 10 CC $106.859            
J1560 Gamma globulin > 10 CC inj 10 CC $106.859            
J1565 RSV-ivig 50 MG $16.176            
J1566 Immune globulin, powder 500 MG $22.261            
J1567 Immune globulin, liquid 500 MG $29.090            
J1570 Ganciclovir sodium injection 500 MG $37.166     95% $35.250     Revised 10/1/2006
J1580 Garamycin gentamicin inj 80 MG $1.680            
J1590 Gatifloxacin injection 10 MG $0.445            
J1595 Injection glatiramer acetate 20 MG $41.647            
J1600 Gold sodium thiomaleate inj 50 MG $3.974            
J1610 Glucagon hydrochloride/1 MG 1 MG $63.019            
J1620 Gonadorelin hydroch/ 100 mcg 100 MCG $180.295            
J1626 Granisetron HCl injection 100 MCG $6.860             Revised 10/1/2006
J1630 Haloperidol injection 5 MG $1.287            
J1631 Haloperidol decanoate inj 50 MG $5.869            
J1640 Hemin, 1 mg 1 MG $6.651            
J1642 Inj heparin sodium per 10 u 10 UNITS $0.059            
J1644 Inj heparin sodium per 1000u 1000 UNITS $0.121            
J1645 Dalteparin sodium 2500 IU $10.535            
J1650 Inj enoxaparin sodium 10 MG $5.442            
J1652 Fondaparinux sodium 0.5 MG $5.344            
J1655 Tinzaparin sodium injection 1000 IU $2.196            
J1670 Tetanus immune globulin inj 250 UNITS $91.573            
J1720 Hydrocortisone sodium succ i 100 MG $1.904            
J1730 Diazoxide injection 300 MG $111.936            
J1742 Ibutilide fumarate injection 1 MG $251.379            
J1745 Infliximab injection 10 MG $54.242            
J1751 Iron dextran 165 injection 50 MG $12.420            
J1752 Iron dextran 267 injection 50 MG $10.270            
J1756 Iron sucrose injection 1 MG $0.361            
J1785 Injection imiglucerase /unit 1 UNIT $3.908            
J1790 Droperidol injection 5 MG $1.080            
J1800 Propranolol injection 1 MG $4.741            
J1810 Droperidol/fentanyl inj 2 ML $5.944            
J1815 Insulin injection 5 UNITS $0.239            
J1817 Insulin for insulin pump use 50 UNITS $2.440     95% $2.800    
J1830 Interferon beta-1b / .25 MG 0.25 MG $92.214            
J1835 Itraconazole injection 50 MG $36.572            
J1840 Kanamycin sulfate 500 MG inj 500 MG $4.362            
J1850 Kanamycin sulfate 75 MG inj 75 MG $0.654            
J1885 Ketorolac tromethamine inj 15 MG $0.501            
J1931 Laronidase injection 0.1 MG $23.868            
J1940 Furosemide injection 20 MG $0.434            
J1945 Lepirudin 50 MG $147.772            
J1950 Leuprolide acetate /3.75 MG 3.75 MG $444.553            
J1955 Inj levocarnitine per 1 gm 1 GM $8.038            
J1956 Levofloxacin injection 250 MG $7.593            
J1980 Hyoscyamine sulfate inj 0.25 MG $7.528            
J1990 Chlordiazepoxide injection 100 MG $21.050            
J2001 Lidocaine injection 10 MG $0.015            
J2010 Lincomycin injection 300 MG $3.574            
J2020 Linezolid injection 200 MG $23.726            
J2060 Lorazepam injection 2 MG $1.063            
J2150 Mannitol injection 50 ML $0.999            
J2175 Meperidine hydrochl /100 MG 100 MG $1.621     95% $0.560    
J2180 Meperidine/promethazine inj 50 MG $3.788            
J2185 Meropenem 100 MG $3.793            
J2210 Methylergonovin maleate inj 0.2 MG $4.305            
J2250 Inj midazolam hydrochloride 1 MG $0.283            
J2260 Inj milrinone lactate / 5 MG 5 MG $3.226     95% $51.580    
J2270 Morphine sulfate injection 10 MG $1.409     95% $0.710    
J2271 Morphine so4 injection 100mg 100 MG $3.853     95% $11.070    
J2275 Morphine sulfate injection 10 MG $5.125     95% $4.390    
J2278 Ziconotide injection 1 MCG $6.197            
J2280 Inj, moxifloxacin 100 mg 100 MG $3.909            
J2300 Inj nalbuphine hydrochloride 10 MG $1.081            
J2310 Inj naloxone hydrochloride 1 MG $2.505            
J2320 Nandrolone decanoate 50 MG 50 MG $3.272            
J2321 Nandrolone decanoate 100 MG 100 MG $6.677            
J2322 Nandrolone decanoate 200 MG 200 MG $12.950            
J2325 Nesiritide injection 0.1 MG $30.000            
J2353 Octreotide injection, depot 1 MG $90.354            
J2354 Octreotide inj, non-depot 25 MCG $4.310            
J2355 Oprelvekin injection 5 MG $245.703            
J2357 Omalizumab injection 5 MG $16.491            
J2360 Orphenadrine injection 60 MG $11.916            
J2370 Phenylephrine hcl injection 1 ML $0.500            
J2400 Chloroprocaine hcl injection 30 ML $13.685            
J2405 Ondansetron hcl injection 1 MG $3.724            
J2410 Oxymorphone hcl injection 1 MG $2.243            
J2425 Palifermin injection 50 MCG $11.475            
J2430 Pamidronate disodium /30 MG 30 MG $29.591            
J2440 Papaverin hcl injection 60 MG $0.542            
J2460 Oxytetracycline injection 50 MG $0.936            
J2469 Palonosetron HCl 25 MCG $17.677            
J2501 Paricalcitol 1 MCG $3.796            
J2503 Pegaptanib sodium injection 0.3 MG $1,054.700            
J2504 Pegademase bovine, 25 iu 25 IU $166.067            
J2505 Injection, pegfilgrastim 6mg 6 MG $2,163.195            
J2510 Penicillin g procaine inj 600000 UNITS $8.266            
J2513 Pentastarch 10% solution 100 ML $12.722            
J2515 Pentobarbital sodium inj 50 MG $5.233            
J2540 Penicillin g potassium inj 600000 UNITS $1.066            
J2543 Piperacillin/tazobactam 1.125 GM $4.846            
J2545 Pentamidine isethionte/300mg 300 MG $44.626            
J2550 Promethazine hcl injection 50 MG $2.076            
J2560 Phenobarbital sodium inj 120 MG $2.259            
J2590 Oxytocin injection 10 UNITS $2.223            
J2597 Inj desmopressin acetate 1 MCG $2.252            
J2650 Prednisolone acetate inj 1 ML $0.333            
J2675 Inj progesterone per 50 MG 50 MG $1.813            
J2680 Fluphenazine decanoate 25 MG 25 MG $1.498            
J2690 Procainamide hcl injection 1 GM $1.863            
J2700 Oxacillin sodium injeciton 250 MG $1.493            
J2710 Neostigmine methylslfte inj 0.5 MG $0.085            
J2720 Inj protamine sulfate/10 MG 10 MG $0.534            
J2725 Inj protirelin per 250 mcg 250 MCG $21.778            
J2730 Pralidoxime chloride inj 1 GM $30.673            
J2760 Phentolaine mesylate inj 5 MG $23.596            
J2765 Metoclopramide hcl injection 10 MG $0.515            
J2770 Quinupristin/dalfopristin 500 MG $109.056            
J2780 Ranitidine hydrochloride inj 25 MG $0.670            
J2783 Rasburicase 0.5 MG $111.406            
J2788 Rho d immune globulin 50 mcg 50 MCG $24.404            
J2790 Rho d immune globulin inj 300 MCG $80.639            
J2792 Rho(D) immune globulin h, sd 100 IU $13.700            
J2794 Risperidone, long acting 0.5 MG $4.775            
J2795 Ropivacaine HCl injection 1 MG $0.071            
J2800 Methocarbamol injection 10 ML $8.467            
J2805 Sincalide injection 5 MCG $44.565            
J2810 Inj theophylline per 40 MG 40 MG $0.035            
J2820 Sargramostim injection 50 MCG $23.339            
J2850 Inj secretin synthetic human 1 MCG $20.313            
J2910 Aurothioglucose injeciton 50 MG $24.500            
J2912 Sodium chloride injection 2 ML $0.113            
J2916 Na ferric gluconate complex 12.5 MG $5.056            
J2920 Methylprednisolone injection 40 MG $1.418            
J2930 Methylprednisolone injection 125 MG $2.357            
J2941 Somatropin injection 1 MG $44.151            
J2993 Reteplase injection 18.1 MG $761.899            
J2995 Inj streptokinase /250000 IU 250000 IU $79.500            
J2997 Alteplase recombinant 1 MG $31.355            
J3000 Streptomycin injection 1 GM $6.648            
J3010 Fentanyl citrate injeciton 0.1 MG $0.289     95% $0.700    
J3030 Sumatriptan succinate / 6 MG 6 MG $52.246            
J3070 Pentazocine injection 30 MG $4.841            
J3100 Tenecteplase injection 50 MG $2,078.618            
J3105 Terbutaline sulfate inj 1 MG $7.296            
J3120 Testosterone enanthate inj 100 MG $7.187            
J3130 Testosterone enanthate inj 200 MG $14.375            
J3230 Chlorpromazine hcl injection 50 MG $3.121            
J3240 Thyrotropin injection 0.9 MG $773.911            
J3246 Tirofiban HCl 0.25 MG $7.679            
J3250 Trimethobenzamide hcl inj 200 MG $4.618            
J3260 Tobramycin sulfate injection 80 MG $1.748            
J3265 Injection torsemide 10 mg/ml 10 MG $2.354             Revised 10/1/2006
J3285 Treprostinil injection 1 MG $54.018            
J3301 Triamcinolone acetonide inj 10 MG $1.362            
J3302 Triamcinolone diacetate inj 5 MG $0.280            
J3303 Triamcinolone hexacetonl inj 5 MG $1.300            
J3305 Inj trimetrexate glucoronate 25 MG $145.763            
J3315 Triptorelin pamoate 3.75 MG $303.767            
J3320 Spectinomycn di-hcl inj 2 GM $30.083            
J3355 Urofollitropin, 75 iu 75 IU $49.309            
J3360 Diazepam injection 5 MG $0.754            
J3364 Urokinase 5000 IU injection 5000 IU $9.155            
J3365 Urokinase 250,000 IU inj 250000 IU $457.729            
J3370 Vancomycin hcl injection 500 MG $3.239            
J3396 Verteporfin injection 0.1 MG $8.977            
J3410 Hydroxyzine hcl injection 25 MG $0.398            
J3411 Thiamine hcl 100 mg 100 MG $1.918            
J3415 Pyridoxine hcl 100 mg 100 MG $3.108            
J3420 Vitamin b12 injection 1000 MCG $0.872            
J3430 Vitamin k phytonadione inj 1 MG $3.356            
J3465 Injection, voriconazole 10 MG $4.592            
J3470 Hyaluronidase injection 150 UNITS $17.178            
J3471 Ovine, up to 999 USP units 1 USP UNIT $0.112            
J3472 Ovine, 1000 USP units 1000 USP UNITS $135.044            
J3475 Inj magnesium sulfate 500 MG $0.149            
J3480 Inj potassium chloride 2 MEQ $0.023            
J3485 Zidovudine 10 MG $1.007            
J3486 Ziprasidone mesylate 10 MG $19.875            
J3487 Zoledronic acid 1 MG $202.736            
J7030 Normal saline solution infus 1000 CC $0.938            
J7040 Normal saline solution infus 500 ML $0.459            
J7042 5% dextrose/normal saline 500 ML $0.387            
J7050 Normal saline solution infus 250 CC $0.228            
J7060 5% dextrose/water 500 ML $1.264            
J7070 D5w infusion 1000 CC $2.282            
J7100 Dextran 40 infusion 500 ML $14.008            
J7110 Dextran 75 infusion 500 ML $8.609            
J7120 Ringers lactate infusion 1000 CC $0.901            
J7188 Inj Vonwillebrand factor iu 1 IU $0.877            
J7189 Factor viia 1 MCG $1.091            
J7190 Factor viii 1 IU $0.681            
J7192 Factor viii recombinant 1 IU $1.058            
J7193 Factor IX non-recombinant 1 IU $0.888            
J7194 Factor ix complex 1 IU $0.639            
J7195 Factor IX recombinant 1 IU $0.985            
J7197 Antithrombin iii injection 1 IU $1.630            
J7198 Anti-inhibitor 1 IU $1.301            
J7308 Aminolevulinic acid hcl top 354 MG $100.870            
J7310 Ganciclovir long act implant 4.5 MG $4,240.000            
J7317 Sodium hyaluronate injection 20 - 25 MG $113.105            
J7320 Hylan G-F 20 injection 16 MG $198.867            
J7330 Cultured chondrocytes implnt 1 EA $17,414.973            
J7340 Metabolic active D/E tissue 1 SQ CM $27.827            
J7341 Non-human, metabolic tissue 1 SQ CM $1.794            
J7342 Metabolically active tissue 1 SQ CM $15.149            
J7343 Nonmetabolic act d/e tissue 1 SQ CM $15.345            
J7344 Nonmetabolic active tissue 1 SQ CM $67.022            
J7350 Injectable human tissue 10 MG $21.469            
J7500 Azathioprine oral 50mg 50 MG $0.169            
J7501 Azathioprine parenteral 100 MG $49.195            
J7502 Cyclosporine oral 100 mg 100 MG $3.920            
J7504 Lymphocyte immune globulin 250 MG $298.193            
J7505 Monoclonal antibodies 5 MG $869.136            
J7506 Prednisone oral 5 MG $0.230            
J7507 Tacrolimus oral per 1 MG 1 MG $3.434            
J7509 Methylprednisolone oral 4 MG $0.083            
J7510 Prednisolone oral per 5 mg 5 MG $0.073            
J7511 Antithymocyte globuln rabbit 25 MG $304.347            
J7513 Daclizumab, parenteral 25 MG $348.178             Revised 10/1/2006
J7515 Cyclosporine oral 25 mg 25 MG $0.995            
J7516 Cyclosporin parenteral 250mg 250 MG $19.370            
J7517 Mycophenolate mofetil oral 250 MG $2.519             Revised 10/1/2006
J7518 Mycophenolic acid 180 MG $2.166            
J7520 Sirolimus, oral 1 MG $6.904            
J7525 Tacrolimus injection 5 MG $136.454            
J7608 Acetylcysteine inh sol u d 1 GM $2.261            
J7611 Albuterol concentrated form 1 MG $0.090            
J7612 Levalbuterol concentrated 0.5 MG $0.987            
J7613 Albuterol unit dose 1 MG $0.073            
J7614 Levalbuterol unit dose 0.5 MG $1.413            
J7620 Duoneb 2.5 MG/0.5 MG $1.092            
J7626 Pulmicort 0.5 MG $4.373            
J7631 Cromolyn sodium inh sol u d 10 MG $0.059            
J7635 Atropine inhal sol con 1 MG $0.116            
J7636 Atropine inhal sol unit dose 1 MG $0.116            
J7637 Dexamethasone inhal sol con 1 MG $0.127            
J7638 Dexamethasone inhal sol u d 1 MG $0.127            
J7639 Dornase alpha inhal sol u d 1 MG $18.757            
J7642 Glycopyrrolate inhal sol con 1 MG $1.040            
J7643 Glycopyrrolate inhal sol u d 1 MG $1.040            
J7644 Ipratropium brom inh sol u d 1 MG $0.216            
J7669 Metaproterenol inh sol u d 10 MG $0.232            
J7674 Methacholine chloride, neb 1 MG $0.389            
J7682 Tobramycin inhalation sol 300 MG $53.658            
J8501 Oral aprepitant 5 MG $4.634            
J8510 Oral busulfan 2 MG $1.973            
J8515 Cabergoline, oral 0.25mg 0.25 MG $15.929            
J8520 Capecitabine, oral, 150 mg 150 MG $3.630