Payment Allowance Limits for Medicare Part B Drugs
Effective April 1, 2007 through June 30, 2007
Note 1: Payment allowance limits subject to the ASP methodology are based on 4Q06 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
			Limit
90371	Hep b ig, im	1 ML	$133.685
90375	Rabies ig, im/sc	150 IU	$65.441
90376	Rabies ig, heat treated	150 IU	$70.060
90385	Rh ig, minidose, im	50 MCG	$8.897
90585	Bcg vaccine, percut	50 MG	$113.632
90586	Bcg vaccine, intravesical	1 EACH	$110.674
90632	Hep a vaccine, adult im	1 ML	$43.393
90633	Hep a vacc, ped/adol, 2 dose	1 ML	$24.275
90645	Hib vaccine, hboc, im	1 EACH	$22.492
90647	Hib vaccine, prp-omp, im	0.5 ML	$22.492
90648	Hib vaccine, prp-t, im	0.5 ML	$21.782
90655	Flu vaccine no preserv 6-35m, im	0.25 ML	$15.377	95%	$15.377
90656	Flu vaccine no preserv 3 yo & >, im	0.50 ML	$16.574	95%	$16.574
90657	Flu vaccine, 6-35 mo, im	0.25 ML	$6.312	95%	$6.312
90658	Flu vaccine age 3 yo & over, im	0.5 ML	$12.624	95%	$12.624
90660	Flu vaccine, nasal	0.5 ML	$21.176	95%	$21.176
90675	Rabies vaccine, im	1 ML	$146.911
90691	Typhoid vaccine, im	0.5 ML	$57.547
90700	Dtap vaccine, < 7 yo, im	0.5 ML	$27.742
90702	Dt vaccine < 7 yo, im	0.5 ML	$19.140
90703	Tetanus vaccine, im	0.5 ML	$19.448
90704	Mumps vaccine, sc	0.5 ML	$20.318
90705	Measles vaccine, sc	0.5 ML	$15.535
90706	Rubella vaccine, sc	0.5 ML	$17.202
90707	Mmr vaccine, sc	0.5 ML	$41.761
90713	Poliovirus, ipv, sc/im	0.5 ML	$25.997
90714	Td vaccine no prsrv >/= 7 yo, im	0.5 ML	$18.971
90715	Tdap => 7 yo, im	0.5 ML	$32.812
90716	Chicken pox vaccine, sc	0.5 ML	$72.436
90717	Yellow fever vaccine, sc	0.5 ML	$56.072
90718	Td vaccine >/= 7 yo, im	0.5 ML	$19.050
90721	Dtap/hib vaccine, im	1 EACH	$42.886
90732	Pneumococcal vaccine	0.5 ML	$27.028	95%	$27.028
90733	Meningococcal vaccine, sc	0.5 ML	$89.433
90735	Encephalitis vaccine, sc	1 ML	$99.106
90740	Hepb vacc, ill pat 3 dose im	40 MCG	$114.521	95%	$114.521
90743	Hep b vacc, adol, 2 dose, im	1 DOSE	$24.358	95%	$24.358
90744	Hepb vacc ped/adol 3 dose im	1 DOSE	$24.358	95%	$24.358
90746	Hep b vaccine, adult, im	20 MCG	$57.260	95%	$57.260
90747	Hepb vacc, ill pat 4 dose im	40 MCG	$114.521	95%	$114.521
J0129	Abatacept, inj	10 MG	$18.688
J0130	Abciximab injection	10 MG	$413.156
J0132	Acetylcysteine injection	100 MG	$1.954
J0133	Acyclovir injection	5 MG	$0.024
J0135	Adalimumab injection	20 MG	$319.032
J0150	Injection adenosine 6 MG	6 MG	$22.862
J0152	Adenosine injection	30 MG	$69.157
J0170	Adrenalin epinephrin inject	1 ML	$0.918
J0180	Agalsidase beta injection	1 MG	$127.200
J0205	Alglucerase injection	10 UNITS	$39.220
J0207	Amifostine	500 MG	$480.639
J0210	Methyldopate hcl injection	250 MG	$10.106
J0215	Alefacept	0.5 MG	$26.065
J0256	Alpha 1 proteinase inhibitor	10 MG	$3.275
J0270	Alprostadil for injection	1.25 MCG	$1.836
J0275	Alprostadil urethral suppos	125 MCG	$22.970
J0278	Amikacin sulfate injection	100 MG	$1.149
J0280	Aminophyllin 250 MG inj	250 MG	$0.425
J0282	Amiodarone HCl	30 MG	$0.243
J0285	Amphotericin B	50 MG	$10.228			95%	$10.280
J0287	Amphotericin b lipid complex	10 MG	$10.381			95%	$21.850
J0288	Ampho b cholesteryl sulfate	10 MG	$12.000			95%	$15.200
J0289	Amphotericin b liposome inj	10 MG	$17.236			95%	$35.800
J0290	Ampicillin 500 MG inj	500 MG	$2.481
J0295	Ampicillin sodium per 1.5 gm	1.5 GM	$5.491
J0300	Amobarbital 125 MG inj	125 MG	$2.595
J0330	Succinycholine chloride inj	20 MG	$0.085
J0348	Anidulafungin injection	1 MG	$1.908
J0360	Hydralazine hcl injection	20 MG	$7.607
J0364	Apomorphine hcl, inj	1 MG	$2.988
J0365	Aprotonin, 10,000 kiu	10000 KIU	$2.523
J0456	Azithromycin	500 MG	$19.564
J0460	Atropine sulfate injection	0.3 MG	$0.594
J0470	Dimecaprol injection	100 MG	$24.518
J0475	Baclofen 10 MG injection	10 MG	$197.041			95%	$215.180
J0476	Baclofen intrathecal trial	50 MCG	$71.592			95%	$79.800
J0480	Basiliximab	20 MG	$1,359.970
J0500	Dicyclomine injection	20 MG	$14.392
J0515	Inj benztropine mesylate	1 MG	$17.078
J0530	Penicillin g benzathine inj	600000 UNITS	$13.410
J0540	Penicillin g benzathine inj	1200000 UNITS	$28.912
J0550	Penicillin g benzathine inj	2400000 UNITS	$30.698
J0560	Penicillin g benzathine inj	600000 UNITS	$22.841
J0570	Penicillin g benzathine inj	1200000 UNITS	$38.820
J0580	Penicillin g benzathine inj	2400000 UNITS	$43.284
J0583	Bivalirudin	1 MG	$1.735
J0585	Botulinum toxin a per unit	1 UNIT	$5.102
J0587	Botulinum toxin type B	100 UNITS	$8.374
J0592	Buprenorphine hydrochloride	0.1 MG	$0.716
J0594	Busulfan, inj	1 MG	$8.887
J0595	Butorphanol tartrate 1 mg	1 MG	$0.723
J0600	Edetate calcium disodium inj	1000 MG	$40.185
J0610	Calcium gluconate injection	10 ML	$0.581
J0630	Calcitonin salmon injection	400 UNITS	$40.746
J0636	Inj calcitriol per 0.1 mcg	0.1 MCG	$0.619
J0637	Caspofungin acetate	5 MG	$30.354
J0640	Leucovorin calcium injection	50 MG	$1.026
J0670	Inj mepivacaine HCL/10 ml	10 ML	$1.695
J0690	Cefazolin sodium injection	500 MG	$1.422
J0692	Cefepime HCl for injection	500 MG	$8.248
J0694	Cefoxitin sodium injection	1 GM	$8.188
J0696	Ceftriaxone sodium injection	250 MG	$1.847
J0697	Sterile cefuroxime injection	750 MG	$3.897
J0698	Cefotaxime sodium injection	1 GM	$4.883
J0702	Betamethasone acet&sod phosp	3 MG	$5.257
J0704	Betamethasone sod phosp/4 MG	4 MG	$1.133
J0706	Caffeine citrate injection	5 MG	$3.359
J0713	Inj ceftazidime per 500 mg	500 MG	$4.002
J0715	Ceftizoxime sodium / 500 MG	500 MG	$4.378
J0720	Chloramphenicol sodium injec	1 GM	$10.295
J0725	Chorionic gonadotropin/1000u	1000 UNITS	$3.708
J0735	Clonidine hydrochloride	1 MG	$63.460
J0740	Cidofovir injection	375 MG	$761.811
J0743	Cilastatin sodium injection	250 MG	$13.633
J0744	Ciprofloxacin iv	200 MG	$3.619
J0745	Inj codeine phosphate /30 MG	30 MG	$1.176
J0760	Colchicine injection	1 MG	$4.588
J0770	Colistimethate sodium inj	150 MG	$21.853
J0780	Prochlorperazine injection	10 MG	$1.877
J0795	Corticorelin ovine triflutal	1 MCG	$4.305
J0800	Corticotropin injection	40 UNITS	$127.728
J0835	Inj cosyntropin per 0.25 MG	0.25 MG	$63.851
J0850	Cytomegalovirus imm IV /vial	PER VIAL	$868.045
J0878	Daptomycin injection	1 MG	$0.333
J0881	Darbepoetin alfa, non-esrd	1 MCG	$3.143
J0882	Darbepoetin alfa, esrd use	1 MCG	$3.143
J0885	Epoetin alfa, non-esrd	1000 UNITS	$9.452
J0886	Epoetin alfa, esrd on dialysis	1000 UNITS	$9.577
J0894	Decitabine, inj	1 MG	$26.478
J0895	Deferoxamine mesylate inj	500 MG	$14.515			95%	$15.630
J0945	Brompheniramine maleate inj	10 MG	$0.798
J0970	Estradiol valerate injection	40 MG	$34.907
J1000	Depo-estradiol cypionate inj	5 MG	$5.618
J1020	Methylprednisolone 20 MG inj	20 MG	$2.429
J1030	Methylprednisolone 40 MG inj	40 MG	$4.927
J1040	Methylprednisolone 80 MG inj	80 MG	$9.006
J1051	Medroxyprogesterone inj	50 MG	$5.556
J1060	Testosterone cypionate 1 ML	1 ML	$4.142
J1070	Testosterone cypionat 100 MG	100 MG	$5.406
J1080	Testosterone cypionat 200 MG	200 MG	$12.800
J1094	Inj dexamethasone acetate	1 MG	$0.230
J1100	Dexamethasone sodium phos	1 MG	$0.124
J1110	Inj dihydroergotamine mesylt	1 MG	$24.515
J1120	Acetazolamid sodium injectio	500 MG	$16.536
J1160	Digoxin injection	0.5 MG	$2.457
J1162	Digoxin immune fab (ovine)	PER VIAL	$516.348
J1165	Phenytoin sodium injection	50 MG	$0.548
J1170	Hydromorphone injection	4 MG	$1.976			95%	$1.490
J1190	Dexrazoxane HCl injection	250 MG	$174.073
J1200	Diphenhydramine hcl injectio	50 MG	$0.776
J1205	Chlorothiazide sodium inj	500 MG	$123.840
J1212	Dimethyl sulfoxide 50% 50 ML	50 ML	$41.170
J1230	Methadone injection	10 MG	$3.257			95%	$0.750
J1240	Dimenhydrinate injection	50 MG	$2.595
J1245	Dipyridamole injection	10 MG	$1.335
J1250	Inj dobutamine HCL/250 mg	250 MG	$4.965			95%	$4.740
J1260	Dolasetron mesylate	10 MG	$6.112
J1265	Dopamine injection	40 MG	$0.781
J1270	Injection, doxercalciferol	1 MCG	$2.784
J1325	Epoprostenol injection	0.5 MG	$14.457			95%	$12.640
J1327	Eptifibatide injection	5 MG	$16.050
J1335	Ertapenem injection	500 MG	$24.124
J1364	Erythro lactobionate /500 MG	500 MG	$6.395
J1380	Estradiol valerate 10 MG inj	10 MG	$12.589
J1390	Estradiol valerate 20 MG inj	20 MG	$17.454
J1410	Inj estrogen conjugate 25 MG	25 MG	$60.897
J1430	Ethanolamine oleate 100 mg	100 MG	$79.006
J1435	Injection estrone per 1 MG	1 MG	$0.239
J1438	Etanercept injection	25 MG	$161.554
J1440	Filgrastim 300 mcg injection	300 MCG	$189.467
J1441	Filgrastim 480 mcg injection	480 MCG	$300.582
J1450	Fluconazole	200 MG	$10.977
J1451	Fomepizole, 15 mg	15 MG	$12.393
J1455	Foscarnet sodium injection	1000 MG	$10.198			95%	$13.070
J1457	Gallium nitrate injection	1 MG	$1.485
J1458	Galsulfase, inj	1 MG	$299.923
J1460	Gamma globulin 1 CC inj	1 CC	$11.421
J1470	Gamma globulin 2 CC inj	2 CC	$22.841
J1480	Gamma globulin 3 CC inj	3CC	$34.254
J1490	Gamma globulin 4 CC inj	4 CC	$45.683
J1500	Gamma globulin 5 CC inj	5 CC	$57.103
J1510	Gamma globulin 6 CC inj	6 CC	$68.555
J1520	Gamma globulin 7 CC inj	7 CC	$79.890
J1530	Gamma globulin 8 CC inj	8 CC	$91.365
J1540	Gamma globulin 9 CC inj	9 CC	$102.846
J1550	Gamma globulin 10 CC inj	10 CC	$114.206
J1560	Gamma globulin > 10 CC inj	10 CC	$114.206
J1566	Immune globulin, powder	500 MG	$25.720
J1567	Immune globulin, liquid	500 MG	$30.571
J1570	Ganciclovir sodium injection	500 MG	$39.636			95%	$35.250
J1580	Garamycin gentamicin inj	80 MG	$1.080
J1590	Gatifloxacin injection	10 MG	$0.795
J1595	Injection glatiramer acetate	20 MG	$48.384
J1600	Gold sodium thiomaleate inj	50 MG	$7.458
J1610	Glucagon hydrochloride/1 MG	1 MG	$66.268
J1626	Granisetron HCl injection	100 MCG	$7.500
J1630	Haloperidol injection	5 MG	$1.956
J1631	Haloperidol decanoate inj	50 MG	$5.658
J1640	Hemin, 1 mg	1 MG	$6.802
J1642	Inj heparin sodium per 10 u	10 UNITS	$0.054
J1644	Inj heparin sodium per 1000u	1000 UNITS	$0.212
J1645	Dalteparin sodium	2500 IU	$11.732
J1650	Inj enoxaparin sodium	10 MG	$5.613
J1652	Fondaparinux sodium	0.5 MG	$5.873
J1655	Tinzaparin sodium injection	1000 IU	$2.445
J1670	Tetanus immune globulin inj	250 UNITS	$97.263
J1720	Hydrocortisone sodium succ i	100 MG	$2.019
J1740	Ibandronate sodium, inj	1 MG	$138.705
J1742	Ibutilide fumarate injection	1 MG	$266.919
J1745	Infliximab injection	10 MG	$53.756
J1751	Iron dextran 165 injection	50 MG	$11.719
J1752	Iron dextran 267 injection	50 MG	$10.422
J1756	Iron sucrose injection	1 MG	$0.371
J1785	Injection imiglucerase /unit	1 UNIT	$3.922
J1790	Droperidol injection	5 MG	$1.121
J1800	Propranolol injection	1 MG	$3.714
J1815	Insulin injection	5 UNITS	$0.252
J1817	Insulin for insulin pump use	50 UNITS	$2.518			95%	$2.800
J1830	Interferon beta-1b / .25 MG	0.25 MG	$84.923
J1835	Itraconazole injection	50 MG	$38.412
J1840	Kanamycin sulfate 500 MG inj	500 MG	$3.880
J1850	Kanamycin sulfate 75 MG inj	75 MG	$0.582
J1885	Ketorolac tromethamine inj	15 MG	$0.475
J1931	Laronidase injection	0.1 MG	$23.868
J1940	Furosemide injection	20 MG	$0.292
J1945	Lepirudin	50 MG	$154.885
J1950	Leuprolide acetate /3.75 MG	3.75 MG	$433.924
J1955	Inj levocarnitine per 1 gm	1 GM	$8.963
J1956	Levofloxacin injection	250 MG	$7.142
J1980	Hyoscyamine sulfate inj	0.25 MG	$8.961
J1990	Chlordiazepoxide injection	100 MG	$21.050
J2001	Lidocaine injection	10 MG	$0.017
J2010	Lincomycin injection	300 MG	$3.820
J2020	Linezolid injection	200 MG	$25.172
J2060	Lorazepam injection	2 MG	$1.150
J2150	Mannitol injection	50 ML	$0.832
J2175	Meperidine hydrochl /100 MG	100 MG	$1.874			95%	$0.560
J2185	Meropenem	100 MG	$3.709
J2210	Methylergonovin maleate inj	0.2 MG	$4.595
J2248	Micafungin sodium, inj	1 MG	$1.712
J2250	Inj midazolam hydrochloride	1 MG	$0.220
J2260	Inj milrinone lactate / 5 MG	5 MG	$2.023			95%	$51.580
J2270	Morphine sulfate injection	10 MG	$2.632			95%	$0.710
J2271	Morphine so4 injection 100mg	100 MG	$4.376			95%	$11.070
J2275	Morphine sulfate injection	10 MG	$6.937			95%	$4.390
J2278	Ziconotide injection	1 MCG	$6.518
J2280	Inj, moxifloxacin 100 mg	100 MG	$3.214
J2300	Inj nalbuphine hydrochloride	10 MG	$0.977
J2310	Inj naloxone hydrochloride	1 MG	$2.028
J2315	Naltrexone, depot form inj	1 MG	$1.900
J2320	Nandrolone decanoate 50 MG	50 MG	$3.173
J2321	Nandrolone decanoate 100 MG	100 MG	$6.470
J2322	Nandrolone decanoate 200 MG	200 MG	$12.612
J2325	Nesiritide injection	0.1 MG	$31.661
J2353	Octreotide injection, depot	1 MG	$96.773
J2354	Octreotide inj, non-depot	25 MCG	$2.619
J2355	Oprelvekin injection	5 MG	$247.311
J2357	Omalizumab injection	5 MG	$16.947
J2360	Orphenadrine injection	60 MG	$10.486
J2370	Phenylephrine hcl injection	1 ML	$0.713
J2400	Chloroprocaine hcl injection	30 ML	$16.523
J2405	Ondansetron hcl injection	1 MG	$3.399
J2410	Oxymorphone hcl injection	1 MG	$2.369
J2425	Palifermin injection	50 MCG	$11.426
J2430	Pamidronate disodium /30 MG	30 MG	$30.777
J2440	Papaverin hcl injection	60 MG	$0.671
J2460	Oxytetracycline injection	50 MG	$0.936
J2469	Palonosetron HCl	25 MCG	$16.003
J2501	Paricalcitol	1 MCG	$3.777
J2503	Pegaptanib sodium injection	0.3 MG	$1,054.700
J2504	Pegademase bovine, 25 iu	25 IU	$177.833
J2505	Injection, pegfilgrastim 6mg	6 MG	$2,163.333
J2510	Penicillin g procaine inj	600000 UNITS	$9.067
J2515	Pentobarbital sodium inj	50 MG	$5.480
J2540	Penicillin g potassium inj	600000 UNITS	$0.888
J2543	Piperacillin/tazobactam	1.125 GM	$4.887
J2545	Pentamidine isethionte/300mg	300 MG	$45.156
J2550	Promethazine hcl injection	50 MG	$1.787
J2560	Phenobarbital sodium inj	120 MG	$3.162
J2590	Oxytocin injection	10 UNITS	$2.010
J2597	Inj desmopressin acetate	1 MCG	$2.640
J2650	Prednisolone acetate inj	1 ML	$0.173
J2675	Inj progesterone per 50 MG	50 MG	$1.668
J2680	Fluphenazine decanoate 25 MG	25 MG	$2.130
J2690	Procainamide hcl injection	1 GM	$2.336
J2700	Oxacillin sodium injeciton	250 MG	$1.310
J2710	Neostigmine methylslfte inj	0.5 MG	$0.089
J2720	Inj protamine sulfate/10 MG	10 MG	$0.470
J2730	Pralidoxime chloride inj	1 GM	$52.117
J2760	Phentolaine mesylate inj	5 MG	$23.914
J2765	Metoclopramide hcl injection	10 MG	$0.449
J2770	Quinupristin/dalfopristin	500 MG	$117.809
J2780	Ranitidine hydrochloride inj	25 MG	$0.650
J2783	Rasburicase	0.5 MG	$132.529
J2788	Rho d immune globulin 50 mcg	50 MCG	$26.657
J2790	Rho d immune globulin inj	300 MCG	$81.481
J2792	Rho(D) immune globulin h, sd	100 IU	$15.911
J2794	Risperidone, long acting	0.5 MG	$4.845
J2795	Ropivacaine HCl injection	1 MG	$0.072
J2800	Methocarbamol injection	10 ML	$10.773
J2805	Sincalide injection	5 MCG	$52.077
J2810	Inj theophylline per 40 MG	40 MG	$0.037
J2820	Sargramostim injection	50 MCG	$25.314
J2850	Inj secretin synthetic human	1 MCG	$20.313
J2916	Na ferric gluconate complex	12.5 MG	$4.719
J2920	Methylprednisolone injection	40 MG	$2.013
J2930	Methylprednisolone injection	125 MG	$2.514
J2941	Somatropin injection	1 MG	$47.193
J2993	Reteplase injection	18.1 MG	$899.513
J2997	Alteplase recombinant	1 MG	$32.791
J3000	Streptomycin injection	1 GM	$7.043
J3010	Fentanyl citrate injeciton	0.1 MG	$0.338			95%	$0.700
J3030	Sumatriptan succinate / 6 MG	6 MG	$59.377
J3070	Pentazocine injection	30 MG	$4.661
J3100	Tenecteplase injection	50 MG	$2,043.404
J3105	Terbutaline sulfate inj	1 MG	$2.277
J3120	Testosterone enanthate inj	100 MG	$5.110
J3130	Testosterone enanthate inj	200 MG	$10.220
J3230	Chlorpromazine hcl injection	50 MG	$3.372
J3240	Thyrotropin injection	0.9 MG	$765.378
J3243	Tigecycline, inj	1 MG	$0.906
J3246	Tirofiban HCl	0.25 MG	$7.730
J3250	Trimethobenzamide hcl inj	200 MG	$4.132
J3260	Tobramycin sulfate injection	80 MG	$1.875
J3265	Injection torsemide 10 mg/ml	10 MG	$2.356
J3285	Treprostinil injection	1 MG	$55.887
J3301	Triamcinolone acetonide inj	10 MG	$1.397
J3302	Triamcinolone diacetate inj	5 MG	$0.280
J3303	Triamcinolone hexacetonl inj	5 MG	$3.450
J3305	Inj trimetrexate glucoronate	25 MG	$145.263
J3315	Triptorelin pamoate	3.75 MG	$155.439
J3320	Spectinomycn di-hcl inj	2 GM	$30.083
J3355	Urofollitropin, 75 iu	75 IU	$51.317
J3360	Diazepam injection	5 MG	$0.739
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	$3.457
J3396	Verteporfin injection	0.1 MG	$8.922
J3410	Hydroxyzine hcl injection	25 MG	$0.194
J3411	Thiamine hcl 100 mg	100 MG	$2.027
J3415	Pyridoxine hcl 100 mg	100 MG	$3.238
J3420	Vitamin b12 injection	1000 MCG	$0.357
J3430	Vitamin k phytonadione inj	1 MG	$2.888
J3465	Injection, voriconazole	10 MG	$4.985
J3470	Hyaluronidase injection	150 UNITS	$16.632
J3471	Ovine, up to 999 USP units	1 USP UNIT	$0.113
J3472	Ovine, 1000 USP units	1000 USP UNITS	$135.044
J3473	Hyaluronidase, recombinant, inj	1 USP UNIT	$0.403
J3475	Inj magnesium sulfate	500 MG	$0.145
J3480	Inj potassium chloride	2 MEQ	$0.018
J3485	Zidovudine	10 MG	$1.069
J3486	Ziprasidone mesylate	10 MG	$5.087
J3487	Zoledronic acid	1 MG	$206.035
J7030	Normal saline solution infus	1000 CC	$1.083
J7040	Normal saline solution infus	500 ML	$0.542
J7042	5% dextrose/normal saline	500 ML	$0.400
J7050	Normal saline solution infus	250 CC	$0.271
J7060	5% dextrose/water	500 ML	$1.330
J7070	D5w infusion	1000 CC	$2.659
J7100	Dextran 40 infusion	500 ML	$14.797
J7110	Dextran 75 infusion	500 ML	$9.331
J7120	Ringers lactate infusion	1000 CC	$0.903
J7187	Inj Vonwillebrand factor IU	1 IU	$0.883
J7189	Factor viia	1 MCG	$1.115
J7190	Factor viii	1 IU	$0.699
J7192	Factor viii recombinant	1 IU	$1.071
J7193	Factor IX non-recombinant	1 IU	$0.889
J7194	Factor ix complex	1 IU	$0.750
J7195	Factor IX recombinant	1 IU	$0.992
J7197	Antithrombin iii injection	1 IU	$1.636
J7198	Anti-inhibitor	1 IU	$1.361
J7308	Aminolevulinic acid hcl top	354 MG	$105.428
J7310	Ganciclovir long act implant	4.5 MG	$4,752.256
J7311	Fluocinolone acetonide implt	0.59 MG	$19,345.000
J7330	Cultured chondrocytes implnt	1 EA	$18,207.917
J7340	Metabolic active D/E tissue	1 SQ CM	$28.781
J7341	Non-human, metabolic tissue	1 SQ CM	$1.819
J7342	Metabolically active tissue	1 SQ CM	$31.659
J7343	Nonmetabolic act d/e tissue	1 SQ CM	$18.303
J7344	Nonmetabolic active tissue	1 SQ CM	$89.212
J7345	Non-human, non-metab tissue	1 SQ CM	$36.098
J7346	Injectable human tissue	1 CC	$735.377
J7500	Azathioprine oral 50mg	50 MG	$0.182
J7501	Azathioprine parenteral	100 MG	$48.442
J7502	Cyclosporine oral 100 mg	100 MG	$3.599
J7504	Lymphocyte immune globulin	250 MG	$317.184
J7505	Monoclonal antibodies	5 MG	$895.149
J7506	Prednisone oral	5 MG	$0.192
J7507	Tacrolimus oral per 1 MG	1 MG	$3.662
J7509	Methylprednisolone oral	4 MG	$0.078
J7510	Prednisolone oral per 5 mg	5 MG	$0.040
J7511	Antithymocyte globuln rabbit	25 MG	$327.752
J7513	Daclizumab, parenteral	25 MG	$299.863
J7515	Cyclosporine oral 25 mg	25 MG	$0.949
J7516	Cyclosporin parenteral 250mg	250 MG	$19.680
J7517	Mycophenolate mofetil oral	250 MG	$2.624
J7518	Mycophenolic acid	180 MG	$2.267
J7520	Sirolimus, oral	1 MG	$7.222
J7525	Tacrolimus injection	5 MG	$140.439
J7608	Acetylcysteine inh sol u d	1 GM	$2.630
J7611	Albuterol non-comp con1	1 MG	$0.071
J7612	Levalbuterol non-comp con1	0.5 MG	$0.922
J7613	Albuterol non-comp unit dose1	1 MG	$0.081
J7614	Levalbuterol non-comp unit dose1	0.5 MG	$1.535
J7620	Albuterol ipratrop non-comp1	2.5 MG/0.5 MG	$1.148
J7626	Budesonide non-comp unit dose1	0.5 MG	$4.564
J7631	Cromolyn sodium inh sol u d	10 MG	$0.070
J7639	Dornase alpha inhal sol u d	1 MG	$19.873
J7644	Ipratropium bromide non-comp1	1 MG	$0.170
J7669	Metaproterenol non-comp unit dose1	10 MG	$0.254
J7674	Methacholine chloride, neb	1 MG	$0.427
J7682	Tobramycin non-comp unit dose1	300 MG	$57.280
J8501	Oral aprepitant	5 MG	$5.067
J8510	Oral busulfan	2 MG	$2.136
J8515	Cabergoline, oral 0.25mg	0.25 MG	$17.270
J8520	Capecitabine, oral, 150 mg	150 MG	$3.974
J8521	Capecitabine, oral, 500 mg	500 MG	$13.242
J8530	Cyclophosphamide oral 25 MG	25 MG	$0.975
J8540	Oral dexamethasone	0.25 MG	$0.249
J8560	Etoposide oral 50 MG	50 MG	$29.604
J8610	Methotrexate oral 2.5 MG	2.5 MG	$0.260
J8700	Temozolomide	5 MG	$7.409
J9000	Doxorubic hcl 10 MG vl chemo	10 MG	$6.306
J9001	Doxorubicin hcl liposome inj	10 MG	$389.481			95%	$393.480
J9010	Alemtuzumab injection	10 MG	$541.201
J9015	Aldesleukin/single use vial	1 EA	$762.977
J9017	Arsenic trioxide	1 MG	$34.167
J9020	Asparaginase injection	10000 UNITS	$54.721
J9025	Azacitidine injection	1 MG	$4.300
J9027	Clofarabine injection	1 MG	$116.745
J9031	Bcg live intravesical vac	1 EA	$110.674
J9035	Bevacizumab injection	10 MG	$57.527
J9040	Bleomycin sulfate injection	15 UNITS	$35.854			95%	$289.370
J9041	Bortezomib injection	0.1 MG	$32.679
J9045	Carboplatin injection	50 MG	$8.461
J9050	Carmus bischl nitro inj	100 MG	$139.835
J9055	Cetuximab injection	10 MG	$49.809
J9060	Cisplatin 10 MG injection	10 MG	$2.699
J9062	Cisplatin 50 MG injection	50 MG	$13.496
J9065	Inj cladribine per 1 MG	1 MG	$36.117			95%	$61.720
J9070	Cyclophosphamide 100 MG inj	100 MG	$1.907
J9080	Cyclophosphamide 200 MG inj	200 MG	$3.815
J9090	Cyclophosphamide 500 MG inj	500 MG	$16.503
J9091	Cyclophosphamide 1.0 grm inj	1 GM	$19.074
J9092	Cyclophosphamide 2.0 grm inj	2 GM	$38.148
J9093	Cyclophosphamide lyophilized	100 MG	$1.987
J9094	Cyclophosphamide lyophilized	200 MG	$3.974
J9095	Cyclophosphamide lyophilized	500 MG	$9.934
J9096	Cyclophosphamide lyophilized	1 GM	$19.868
J9097	Cyclophosphamide lyophilized	2 GM	$39.736
J9098	Cytarabine liposome	10 MG	$395.041
J9100	Cytarabine hcl 100 MG inj	100 MG	$1.760			95%	$8.190
J9110	Cytarabine hcl 500 MG inj	500 MG	$8.802			95%	$8.550
J9120	Dactinomycin actinomycin d	0.5 MG	$493.430
J9130	Dacarbazine 100 mg inj	100 MG	$5.247
J9140	Dacarbazine 200 MG inj	200 MG	$10.493
J9150	Daunorubicin	10 MG	$20.469
J9151	Daunorubicin citrate liposom	10 MG	$55.923
J9160	Denileukin diftitox, 300 mcg	300 MCG	$1,406.588
J9170	Docetaxel	20 MG	$306.812
J9175	Elliotts b solution per ml	1 ML	$4.074
J9178	Inj, epirubicin hcl, 2 mg	2 MG	$21.210
J9181	Etoposide 10 MG inj	10 MG	$0.483
J9182	Etoposide 100 MG inj	100 MG	$4.832
J9185	Fludarabine phosphate inj	50 MG	$236.440
J9190	Fluorouracil injection	500 MG	$1.664			95%	$2.070
J9200	Floxuridine injection	500 MG	$51.305			95%	$136.800
J9201	Gemcitabine HCl	200 MG	$125.163
J9202	Goserelin acetate implant	3.6 MG	$198.682
J9206	Irinotecan injection	20 MG	$125.998
J9208	Ifosfomide injection	1 GM	$46.591			95%	$150.380
J9209	Mesna injection	200 MG	$8.972
J9211	Idarubicin hcl injection	5 MG	$304.609
J9212	Interferon alfacon-1	1 MCG	$4.645
J9213	Interferon alfa-2a inj	3 MIL UNITS	$37.887
J9214	Interferon alfa-2b inj	1 MIL UNITS	$13.876
J9216	Interferon gamma 1-b inj	3 MIL UNITS	$289.865
J9217	Leuprolide acetate suspnsion	7.5 MG	$229.501
J9218	Leuprolide acetate injeciton	1 MG	$8.878
J9219	Leuprolide acetate implant	65 MG	$1,713.119
J9225	Histrelin implant	50 MG	$1,460.765
J9230	Mechlorethamine hcl inj	10 MG	$141.608
J9245	Inj melphalan hydrochl 50 MG	50 MG	$1,284.116
J9250	Methotrexate sodium inj	5 MG	$0.249
J9260	Methotrexate sodium inj	50 MG	$2.638
J9261	Nelarabine injection	50 MG	$83.330
J9263	Oxaliplatin	0.5 MG	$8.973
J9264	Paclitaxel protein bound	1 MG	$8.660
J9265	Paclitaxel injection	30 MG	$12.588
J9266	Pegaspargase/singl dose vial	1 EA	$1,683.492
J9268	Pentostatin injection	10 MG	$1,934.913
J9280	Mitomycin 5 MG inj	5 MG	$16.133			95%	$127.400
J9290	Mitomycin 20 MG inj	20 MG	$64.534
J9291	Mitomycin 40 MG inj	40 MG	$129.067
J9293	Mitoxantrone hydrochl / 5 MG	5 MG	$168.228
J9300	Gemtuzumab ozogamicin	5 MG	$2,356.984
J9305	Pemetrexed injection	10 MG	$43.793
J9310	Rituximab cancer treatment	100 MG	$496.222
J9320	Streptozocin injection	1 GM	$153.732
J9340	Thiotepa injection	15 MG	$40.704
J9350	Topotecan	4 MG	$830.735
J9355	Trastuzumab	10 MG	$57.874			95%	$58.130
J9360	Vinblastine sulfate inj	1 MG	$1.036			95%	$4.100
J9370	Vincristine sulfate 1 MG inj	1 MG	$6.656			95%	$33.980
J9375	Vincristine sulfate 2 MG inj	2 MG	$13.312			95%	$67.960
J9380	Vincristine sulfate 5 MG inj	5 MG	$33.281			95%	$169.910
J9390	Vinorelbine tartrate/10 mg	10 MG	$20.068
J9395	Injection, Fulvestrant	25 MG	$80.560
J9600	Porfimer sodium	75 MG	$2,563.313
P9041	Albumin (human),5%, 50ml	50 ML	$20.900					95%	$20.900
P9043	Plasma protein fract,5%,50ml	50 ML	$14.545					95%	$14.545
P9045	Albumin (human), 5%, 250 ml	250 ML	$55.100					95%	$55.100
P9046	Albumin (human), 25%, 20 ml	20 ML	$14.545					95%	$14.545
P9047	Albumin (human), 25%, 50ml	50 ML	$55.100					95%	$55.100
P9048	Plasmaprotein fract,5%,250ml	250 ML	$29.099					95%	$29.099
Q0163	Diphenhydramine HCl 50mg	50 MG	$0.031
Q0164	Prochlorperazine maleate 5mg	5 MG	$0.040
Q0165	Prochlorperazine maleate10mg	10 MG	$0.099
Q0166	Granisetron HCl 1 mg oral	1 MG	$44.867
Q0167	Dronabinol 2.5mg oral	2.5 MG	$4.951
Q0168	Dronabinol 5mg oral	5 MG	$10.115
Q0170	Promethazine HCl 25 mg oral	25 MG	$0.365
Q0171	Chlorpromazine HCl 10mg oral	10 MG	$0.026
Q0172	Chlorpromazine HCl 25mg oral	25 MG	$0.058
Q0173	Trimethobenzamide HCl 250mg	250 MG	$0.324
Q0175	Perphenazine 4mg oral	4 MG	$0.191
Q0176	Perphenazine 8mg oral	8 MG	$0.201
Q0177	Hydroxyzine pamoate 25mg	25 MG	$0.059
Q0178	Hydroxyzine pamoate 50mg	50 MG	$0.060
Q0179	Ondansetron HCl 8mg oral	8 MG	$36.550
Q0180	Dolasetron mesylate oral	100 MG	$47.519
Q0515	Sermorelin acetate injection	1 MCG	$1.753
Q2009	Fosphenytoin, 50 mg	50 MG	$5.555
Q2017	Teniposide, 50 mg	50 MG	$264.428
Q3025	IM inj interferon beta 1-a	11 MCG	$114.571
Q4079	Natalizumab injection	1 MG	$7.517
Q4080	Iloprost inhalation solution	20 MCG	$34.238
Q4081	Epoetin alfa, for ESRD on dialysis	100 UNITS	$0.958
Q4083	Hyalgan or Supartz, inj	PER DOSE	$104.852
Q4084	Synvisc, inj	PER DOSE	$186.655
Q4085	Euflexxa, inj	PER DOSE	$116.286
Q4086	Orthovisc, inj	PER DOSE	$198.337
Q9945	LOCM <=149 mg/ml iodine, 1ml	1 ML	$0.421
Q9946	LOCM 150-199mg/ml iodine,1ml	1 ML	$1.946
Q9947	LOCM 200-249mg/ml iodine,1ml	1 ML	$1.329
Q9948	LOCM 250-299mg/ml iodine,1ml	1 ML	$0.356
Q9949	LOCM 300-349mg/ml iodine,1ml	1 ML	$0.372
Q9950	LOCM 350-399mg/ml iodine,1ml	1 ML	$0.218
Q9952	Inj Gad-base MR contrast,1ml	1 ML	$2.818
Q9953	Inj Fe-based MR contrast,1ml	1 ML	$30.406
Q9954	Oral MR contrast, 100 ml	100 ML	$8.817
Q9956	Inj octafluoropropane mic,ml	1 ML	$49.608
Q9957	Inj perflutren lip micros,ml	1 ML	$61.545
Q9958	HOCM <=149 mg/ml iodine	1 ML	$0.073
Q9960	HOCM 200-249mg/ml iodine	1 ML	$0.099
Q9961	HOCM 250-299mg/ml iodine	1 ML	$0.214
Q9962	HOCM 300-349mg/ml iodine	1 ML	$0.183
Q9963	HOCM 350-399mg/ml iodine	1 ML	$0.403
Q9964	HOCM>= 400mg/ml iodine	1 ML	$0.198
	1 FDA-approved final product
	3/22/2007