Payment Allowance Limits for Medicare Part B Drugs
Effective January 1, 2007 through March 31, 2007
Note 1: Payment allowance limits subject to the ASP methodology are based on 3Q06 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	$126.887
90375	Rabies ig, im/sc	150 IU	$65.358
90376	Rabies ig, heat treated	150 IU	$69.574
90385	Rh ig, minidose, im	50 MCG	$8.815
90585	Bcg vaccine, percut	50 MG	$115.641
90586	Bcg vaccine, intravesical	1 EACH	$114.155
90632	Hep a vaccine, adult im	1 ML	$43.586
90633	Hep a vacc, ped/adol, 2 dose	1 ML	$24.274
90634	Hep a vacc, ped/adol, 3 dose	3 EACH	$24.275
90645	Hib vaccine, hboc, im	1 EACH	$22.446
90647	Hib vaccine, prp-omp, im	0.5 ML	$22.446
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	$152.667
90691	Typhoid vaccine, im	0.5 ML	$52.268
90700	Dtap vaccine, < 7 yo, im	0.5 ML	$29.033
90702	Dt vaccine < 7 yo, im	0.5 ML	$18.300
90703	Tetanus vaccine, im	0.5 ML	$19.390
90704	Mumps vaccine, sc	0.5 ML	$20.367
90705	Measles vaccine, sc	0.5 ML	$15.523
90706	Rubella vaccine, sc	0.5 ML	$17.174
90707	Mmr vaccine, sc	0.5 ML	$41.717
90713	Poliovirus, ipv, sc/im	0.5 ML	$25.785
90714	Td vaccine no prsrv >/= 7 yo, im	0.5 ML	$18.868
90715	Tdap => 7 yo, im	0.5 ML	$33.196
90716	Chicken pox vaccine, sc	0.5 ML	$72.753
90717	Yellow fever vaccine, sc	0.5 ML	$54.440
90718	Td vaccine >/= 7 yo, im	0.5 ML	$18.949
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	$96.220
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	$30.077	95%	$30.077
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
J0128	Abarelix injection	10 MG	$68.620
J0129	Abatacept, inj	10 MG	$18.698
J0130	Abciximab injection	10 MG	$414.089
J0132	Acetylcysteine injection	100 MG	$1.951
J0133	Acyclovir injection	5 MG	$0.031
J0135	Adalimumab injection	20 MG	$318.279
J0150	Injection adenosine 6 MG	6 MG	$23.477
J0152	Adenosine injection	30 MG	$69.305
J0170	Adrenalin epinephrin inject	1 ML	$0.801
J0180	Agalsidase beta injection	1 MG	$127.200
J0205	Alglucerase injection	10 UNITS	$39.220
J0207	Amifostine	500 MG	$463.580
J0210	Methyldopate hcl injection	250 MG	$10.075
J0215	Alefacept	0.5 MG	$26.304
J0256	Alpha 1 proteinase inhibitor	10 MG	$3.414
J0270	Alprostadil for injection	1.25 MCG	$1.800
J0275	Alprostadil urethral suppos	125 MCG	$22.641
J0278	Amikacin sulfate injection	100 MG	$1.102
J0280	Aminophyllin 250 MG inj	250 MG	$0.391
J0282	Amiodarone HCl	30 MG	$0.267
J0285	Amphotericin B	50 MG	$8.970			95%	$10.280
J0287	Amphotericin b lipid complex	10 MG	$10.790			95%	$21.850
J0288	Ampho b cholesteryl sulfate	10 MG	$12.000			95%	$15.200
J0289	Amphotericin b liposome inj	10 MG	$16.665			95%	$35.800
J0290	Ampicillin 500 MG inj	500 MG	$2.355
J0295	Ampicillin sodium per 1.5 gm	1.5 GM	$6.085
J0300	Amobarbital 125 MG inj	125 MG	$2.607
J0330	Succinycholine chloride inj	20 MG	$0.176
J0348	Anadulafungin injection	1 MG	$1.908
J0360	Hydralazine hcl injection	20 MG	$6.508
J0364	Apomorphine hcl, inj	1 MG	$3.098
J0365	Aprotonin, 10,000 kiu	10000 KIU	$2.523
J0456	Azithromycin	500 MG	$36.217
J0460	Atropine sulfate injection	0.3 MG	$0.631
J0470	Dimecaprol injection	100 MG	$25.511
J0475	Baclofen 10 MG injection	10 MG	$198.270			95%	$215.180
J0476	Baclofen intrathecal trial	50 MCG	$69.536			95%	$79.800
J0480	Basiliximab	20 MG	$1,377.965
J0500	Dicyclomine injection	20 MG	$15.274
J0515	Inj benztropine mesylate	1 MG	$17.078
J0530	Penicillin g benzathine inj	600000 UNITS	$13.156
J0540	Penicillin g benzathine inj	1200000 UNITS	$28.368
J0550	Penicillin g benzathine inj	2400000 UNITS	$30.490
J0560	Penicillin g benzathine inj	600000 UNITS	$21.335
J0570	Penicillin g benzathine inj	1200000 UNITS	$36.438
J0580	Penicillin g benzathine inj	2400000 UNITS	$43.105
J0583	Bivalirudin	1 MG	$1.755
J0585	Botulinum toxin a per unit	1 UNIT	$5.095
J0587	Botulinum toxin type B	100 UNITS	$8.270
J0592	Buprenorphine hydrochloride	0.1 MG	$0.759
J0594	Busulfan, inj	1 MG	$8.887
J0595	Butorphanol tartrate 1 mg	1 MG	$0.716
J0600	Edetate calcium disodium inj	1000 MG	$40.185
J0610	Calcium gluconate injection	10 ML	$0.593
J0630	Calcitonin salmon injection	400 UNITS	$40.789
J0636	Inj calcitriol per 0.1 mcg	0.1 MCG	$0.560
J0637	Caspofungin acetate	5 MG	$31.206
J0640	Leucovorin calcium injection	50 MG	$0.960
J0670	Inj mepivacaine HCL/10 ml	10 ML	$1.507
J0690	Cefazolin sodium injection	500 MG	$1.458
J0692	Cefepime HCl for injection	500 MG	$6.961
J0694	Cefoxitin sodium injection	1 GM	$7.085
J0696	Ceftriaxone sodium injection	250 MG	$1.763
J0697	Sterile cefuroxime injection	750 MG	$3.946
J0698	Cefotaxime sodium injection	1 GM	$4.433
J0702	Betamethasone acet&sod phosp	3 MG	$5.183
J0704	Betamethasone sod phosp/4 MG	4 MG	$1.133
J0706	Caffeine citrate injection	5 MG	$3.479
J0713	Inj ceftazidime per 500 mg	500 MG	$4.011
J0715	Ceftizoxime sodium / 500 MG	500 MG	$2.983
J0720	Chloramphenicol sodium injec	1 GM	$11.228
J0725	Chorionic gonadotropin/1000u	1000 UNITS	$3.794
J0735	Clonidine hydrochloride	1 MG	$65.839
J0740	Cidofovir injection	375 MG	$761.493
J0743	Cilastatin sodium injection	250 MG	$13.663
J0744	Ciprofloxacin iv	200 MG	$5.066
J0745	Inj codeine phosphate /30 MG	30 MG	$1.047
J0760	Colchicine injection	1 MG	$4.569
J0770	Colistimethate sodium inj	150 MG	$24.445
J0780	Prochlorperazine injection	10 MG	$2.043
J0795	Corticorelin ovine triflutal	1 MCG	$4.482
J0800	Corticotropin injection	40 UNITS	$114.525
J0835	Inj cosyntropin per 0.25 MG	0.25 MG	$63.924
J0850	Cytomegalovirus imm IV /vial	PER VIAL	$866.582
J0878	Daptomycin injection	1 MG	$0.333
J0881	Darbepoetin alfa, non-esrd	1 MCG	$3.093
J0882	Darbepoetin alfa, esrd use	1 MCG	$3.093
J0885	Epoetin alfa, non-esrd	1000 UNITS	$9.332
J0886	Epoetin alfa, esrd on dialysis	1000 UNITS	$9.574
J0894	Decitabine, inj	1 MG	$26.485
J0895	Deferoxamine mesylate inj	500 MG	$14.744			95%	$15.630
J0945	Brompheniramine maleate inj	10 MG	$0.798
J0970	Estradiol valerate injection	40 MG	$34.230
J1000	Depo-estradiol cypionate inj	5 MG	$5.618
J1020	Methylprednisolone 20 MG inj	20 MG	$2.181
J1030	Methylprednisolone 40 MG inj	40 MG	$5.109
J1040	Methylprednisolone 80 MG inj	80 MG	$9.454
J1051	Medroxyprogesterone inj	50 MG	$5.525
J1060	Testosterone cypionate 1 ML	1 ML	$4.142
J1070	Testosterone cypionat 100 MG	100 MG	$5.447
J1080	Testosterone cypionat 200 MG	200 MG	$12.823
J1094	Inj dexamethasone acetate	1 MG	$0.230
J1100	Dexamethasone sodium phos	1 MG	$0.109
J1110	Inj dihydroergotamine mesylt	1 MG	$22.679
J1120	Acetazolamid sodium injectio	500 MG	$16.101
J1160	Digoxin injection	0.5 MG	$3.364
J1162	Digoxin immune fab (ovine)	PER VIAL	$527.781
J1165	Phenytoin sodium injection	50 MG	$0.727
J1170	Hydromorphone injection	4 MG	$1.920			95%	$1.490
J1190	Dexrazoxane HCl injection	250 MG	$175.189
J1200	Diphenhydramine hcl injectio	50 MG	$0.795
J1205	Chlorothiazide sodium inj	500 MG	$123.840
J1212	Dimethyl sulfoxide 50% 50 ML	50 ML	$41.552
J1230	Methadone injection	10 MG	$3.332			95%	$0.750
J1240	Dimenhydrinate injection	50 MG	$2.929
J1245	Dipyridamole injection	10 MG	$1.465
J1250	Inj dobutamine HCL/250 mg	250 MG	$4.173			95%	$4.740
J1260	Dolasetron mesylate	10 MG	$6.329
J1265	Dopamine injection	40 MG	$0.817
J1270	Injection, doxercalciferol	1 MCG	$2.893
J1325	Epoprostenol injection	0.5 MG	$14.429			95%	$12.640
J1327	Eptifibatide injection	5 MG	$15.867
J1335	Ertapenem injection	500 MG	$24.297
J1364	Erythro lactobionate /500 MG	500 MG	$5.994
J1380	Estradiol valerate 10 MG inj	10 MG	$12.523
J1390	Estradiol valerate 20 MG inj	20 MG	$17.115
J1410	Inj estrogen conjugate 25 MG	25 MG	$60.780
J1430	Ethanolamine oleate 100 mg	100 MG	$69.724
J1435	Injection estrone per 1 MG	1 MG	$0.138
J1436	Etidronate disodium inj	300 MG	$71.407
J1438	Etanercept injection	25 MG	$162.388
J1440	Filgrastim 300 mcg injection	300 MCG	$188.289
J1441	Filgrastim 480 mcg injection	480 MCG	$299.090
J1450	Fluconazole	200 MG	$10.618
J1451	Fomepizole, 15 mg	15 MG	$12.259
J1455	Foscarnet sodium injection	1000 MG	$10.169			95%	$13.070
J1457	Gallium nitrate injection	1 MG	$1.243
J1458	Galsulfase, inj	1 MG	$302.800
J1460	Gamma globulin 1 CC inj	1 CC	$11.827
J1470	Gamma globulin 2 CC inj	2 CC	$23.655
J1480	Gamma globulin 3 CC inj	3CC	$35.467
J1490	Gamma globulin 4 CC inj	4 CC	$47.309
J1500	Gamma globulin 5 CC inj	5 CC	$59.136
J1510	Gamma globulin 6 CC inj	6 CC	$71.021
J1520	Gamma globulin 7 CC inj	7 CC	$82.717
J1530	Gamma globulin 8 CC inj	8 CC	$94.618
J1540	Gamma globulin 9 CC inj	9 CC	$106.537
J1550	Gamma globulin 10 CC inj	10 CC	$118.272
J1560	Gamma globulin > 10 CC inj	10 CC	$118.241
J1565	RSV-ivig	50 MG	$16.176
J1566	Immune globulin, powder	500 MG	$25.605
J1567	Immune globulin, liquid	500 MG	$30.443
J1570	Ganciclovir sodium injection	500 MG	$39.547			95%	$35.250
J1580	Garamycin gentamicin inj	80 MG	$1.072
J1590	Gatifloxacin injection	10 MG	$0.840
J1595	Injection glatiramer acetate	20 MG	$46.818
J1600	Gold sodium thiomaleate inj	50 MG	$5.409
J1610	Glucagon hydrochloride/1 MG	1 MG	$68.038
J1620	Gonadorelin hydroch/ 100 mcg	100 MCG	$180.295
J1626	Granisetron HCl injection	100 MCG	$7.637
J1630	Haloperidol injection	5 MG	$2.116
J1631	Haloperidol decanoate inj	50 MG	$5.250
J1640	Hemin, 1 mg	1 MG	$6.799
J1642	Inj heparin sodium per 10 u	10 UNITS	$0.051
J1644	Inj heparin sodium per 1000u	1000 UNITS	$0.225
J1645	Dalteparin sodium	2500 IU	$11.115
J1650	Inj enoxaparin sodium	10 MG	$5.635
J1652	Fondaparinux sodium	0.5 MG	$5.845
J1655	Tinzaparin sodium injection	1000 IU	$2.449
J1670	Tetanus immune globulin inj	250 UNITS	$95.906
J1720	Hydrocortisone sodium succ i	100 MG	$1.988
J1730	Diazoxide injection	300 MG	$111.851
J1740	Ibandronate sodium, inj	1 MG	$138.853
J1742	Ibutilide fumarate injection	1 MG	$267.820
J1745	Infliximab injection	10 MG	$53.730
J1751	Iron dextran 165 injection	50 MG	$11.688
J1752	Iron dextran 267 injection	50 MG	$10.402
J1756	Iron sucrose injection	1 MG	$0.364
J1785	Injection imiglucerase /unit	1 UNIT	$3.922
J1790	Droperidol injection	5 MG	$1.127
J1800	Propranolol injection	1 MG	$3.795
J1815	Insulin injection	5 UNITS	$0.239
J1817	Insulin for insulin pump use	50 UNITS	$2.407			95%	$2.800
J1830	Interferon beta-1b / .25 MG	0.25 MG	$90.275
J1835	Itraconazole injection	50 MG	$37.893
J1840	Kanamycin sulfate 500 MG inj	500 MG	$4.067
J1850	Kanamycin sulfate 75 MG inj	75 MG	$0.610
J1885	Ketorolac tromethamine inj	15 MG	$0.494
J1931	Laronidase injection	0.1 MG	$23.868
J1940	Furosemide injection	20 MG	$0.291
J1945	Lepirudin	50 MG	$154.660
J1950	Leuprolide acetate /3.75 MG	3.75 MG	$431.950
J1955	Inj levocarnitine per 1 gm	1 GM	$9.357
J1956	Levofloxacin injection	250 MG	$7.553
J1980	Hyoscyamine sulfate inj	0.25 MG	$8.696
J1990	Chlordiazepoxide injection	100 MG	$21.050
J2001	Lidocaine injection	10 MG	$0.018
J2010	Lincomycin injection	300 MG	$3.835
J2020	Linezolid injection	200 MG	$24.699
J2060	Lorazepam injection	2 MG	$1.220
J2150	Mannitol injection	50 ML	$0.862
J2175	Meperidine hydrochl /100 MG	100 MG	$1.794			95%	$0.560
J2180	Meperidine/promethazine inj	50 MG	$3.788
J2185	Meropenem	100 MG	$3.758
J2210	Methylergonovin maleate inj	0.2 MG	$4.596
J2248	Micafungin sodium, inj	1 MG	$1.782
J2250	Inj midazolam hydrochloride	1 MG	$0.243
J2260	Inj milrinone lactate / 5 MG	5 MG	$3.226			95%	$51.580
J2270	Morphine sulfate injection	10 MG	$2.559			95%	$0.710
J2271	Morphine so4 injection 100mg	100 MG	$3.883			95%	$11.070
J2275	Morphine sulfate injection	10 MG	$6.504			95%	$4.390
J2278	Ziconotide injection	1 MCG	$6.480
J2280	Inj, moxifloxacin 100 mg	100 MG	$3.998
J2300	Inj nalbuphine hydrochloride	10 MG	$0.578
J2310	Inj naloxone hydrochloride	1 MG	$1.836
J2315	Naltrexone, depot form inj	1 MG	$1.900
J2320	Nandrolone decanoate 50 MG	50 MG	$3.202
J2321	Nandrolone decanoate 100 MG	100 MG	$6.424
J2322	Nandrolone decanoate 200 MG	200 MG	$12.786
J2325	Nesiritide injection	0.1 MG	$31.679
J2353	Octreotide injection, depot	1 MG	$95.390
J2354	Octreotide inj, non-depot	25 MCG	$3.062
J2355	Oprelvekin injection	5 MG	$246.069
J2357	Omalizumab injection	5 MG	$16.675
J2360	Orphenadrine injection	60 MG	$11.125
J2370	Phenylephrine hcl injection	1 ML	$0.726
J2400	Chloroprocaine hcl injection	30 ML	$15.198
J2405	Ondansetron hcl injection	1 MG	$3.714
J2410	Oxymorphone hcl injection	1 MG	$2.364
J2425	Palifermin injection	50 MCG	$11.294
J2430	Pamidronate disodium /30 MG	30 MG	$33.947
J2440	Papaverin hcl injection	60 MG	$0.601
J2460	Oxytetracycline injection	50 MG	$0.936
J2469	Palonosetron HCl	25 MCG	$17.459
J2501	Paricalcitol	1 MCG	$3.772
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	$2,152.341
J2510	Penicillin g procaine inj	600000 UNITS	$8.889
J2515	Pentobarbital sodium inj	50 MG	$5.497
J2540	Penicillin g potassium inj	600000 UNITS	$0.962
J2543	Piperacillin/tazobactam	1.125 GM	$4.871
J2545	Pentamidine isethionte/300mg	300 MG	$44.732
J2550	Promethazine hcl injection	50 MG	$1.849
J2560	Phenobarbital sodium inj	120 MG	$3.186
J2590	Oxytocin injection	10 UNITS	$2.183
J2597	Inj desmopressin acetate	1 MCG	$2.657
J2650	Prednisolone acetate inj	1 ML	$0.440
J2675	Inj progesterone per 50 MG	50 MG	$1.690
J2680	Fluphenazine decanoate 25 MG	25 MG	$1.493
J2690	Procainamide hcl injection	1 GM	$2.237
J2700	Oxacillin sodium injeciton	250 MG	$1.538
J2710	Neostigmine methylslfte inj	0.5 MG	$0.084
J2720	Inj protamine sulfate/10 MG	10 MG	$0.431
J2730	Pralidoxime chloride inj	1 GM	$66.492
J2760	Phentolaine mesylate inj	5 MG	$23.967
J2765	Metoclopramide hcl injection	10 MG	$0.441
J2770	Quinupristin/dalfopristin	500 MG	$115.479
J2780	Ranitidine hydrochloride inj	25 MG	$0.670
J2783	Rasburicase	0.5 MG	$132.576
J2788	Rho d immune globulin 50 mcg	50 MCG	$26.167
J2790	Rho d immune globulin inj	300 MCG	$81.594
J2792	Rho(D) immune globulin h, sd	100 IU	$16.515
J2794	Risperidone, long acting	0.5 MG	$4.798
J2795	Ropivacaine HCl injection	1 MG	$0.069
J2800	Methocarbamol injection	10 ML	$12.279
J2805	Sincalide injection	5 MCG	$51.974
J2810	Inj theophylline per 40 MG	40 MG	$0.026
J2820	Sargramostim injection	50 MCG	$24.887
J2850	Inj secretin synthetic human	1 MCG	$20.313
J2916	Na ferric gluconate complex	12.5 MG	$4.771
J2920	Methylprednisolone injection	40 MG	$1.948
J2930	Methylprednisolone injection	125 MG	$2.476
J2941	Somatropin injection	1 MG	$46.563
J2950	Promazine hcl injection	UP TO 25 MG	$0.384
J2993	Reteplase injection	18.1 MG	$901.355
J2997	Alteplase recombinant	1 MG	$32.763
J3000	Streptomycin injection	1 GM	$6.788
J3010	Fentanyl citrate injeciton	0.1 MG	$0.335			95%	$0.700
J3030	Sumatriptan succinate / 6 MG	6 MG	$58.492
J3070	Pentazocine injection	30 MG	$5.803
J3100	Tenecteplase injection	50 MG	$2,050.231
J3105	Terbutaline sulfate inj	1 MG	$3.861
J3120	Testosterone enanthate inj	100 MG	$5.175
J3130	Testosterone enanthate inj	200 MG	$10.350
J3230	Chlorpromazine hcl injection	50 MG	$3.946
J3240	Thyrotropin injection	0.9 MG	$765.198
J3243	Tigecycline, inj	1 MG	$0.904
J3246	Tirofiban HCl	0.25 MG	$8.656
J3250	Trimethobenzamide hcl inj	200 MG	$4.027
J3260	Tobramycin sulfate injection	80 MG	$1.972
J3265	Injection torsemide 10 mg/ml	10 MG	$2.345
J3285	Treprostinil injection	1 MG	$55.886
J3301	Triamcinolone acetonide inj	10 MG	$1.437
J3302	Triamcinolone diacetate inj	5 MG	$0.280
J3303	Triamcinolone hexacetonl inj	5 MG	$3.424
J3305	Inj trimetrexate glucoronate	25 MG	$145.062
J3315	Triptorelin pamoate	3.75 MG	$178.139
J3320	Spectinomycn di-hcl inj	2 GM	$18.296
J3355	Urofollitropin, 75 iu	75 IU	$50.698
J3360	Diazepam injection	5 MG	$0.781
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	$3.435
J3396	Verteporfin injection	0.1 MG	$8.889
J3410	Hydroxyzine hcl injection	25 MG	$0.213
J3411	Thiamine hcl 100 mg	100 MG	$2.010
J3415	Pyridoxine hcl 100 mg	100 MG	$3.468
J3420	Vitamin b12 injection	1000 MCG	$0.343
J3430	Vitamin k phytonadione inj	1 MG	$2.888
J3465	Injection, voriconazole	10 MG	$4.803
J3470	Hyaluronidase injection	150 UNITS	$16.712
J3471	Ovine, up to 999 USP units	1 USP UNIT	$0.113
J3472	Ovine, 1000 USP units	1000 USP UNITS	$135.364
J3473	Hyaluronidase, recombinant, inj	1 USP UNIT	$0.403
J3475	Inj magnesium sulfate	500 MG	$0.147
J3480	Inj potassium chloride	2 MEQ	$0.018
J3485	Zidovudine	10 MG	$1.060
J3486	Ziprasidone mesylate	10 MG	$5.091
J3487	Zoledronic acid	1 MG	$204.996
J7030	Normal saline solution infus	1000 CC	$1.059
J7040	Normal saline solution infus	500 ML	$0.529
J7042	5% dextrose/normal saline	500 ML	$0.392
J7050	Normal saline solution infus	250 CC	$0.265
J7060	5% dextrose/water	500 ML	$1.301
J7070	D5w infusion	1000 CC	$2.601
J7100	Dextran 40 infusion	500 ML	$13.983
J7110	Dextran 75 infusion	500 ML	$8.658
J7120	Ringers lactate infusion	1000 CC	$0.882
J7187	Inj Vonwillebrand factor IU	1 IU	$0.887
J7189	Factor viia	1 MCG	$1.121
J7190	Factor viii	1 IU	$0.700
J7192	Factor viii recombinant	1 IU	$1.067
J7193	Factor IX non-recombinant	1 IU	$0.896
J7194	Factor ix complex	1 IU	$0.743
J7195	Factor IX recombinant	1 IU	$0.988
J7197	Antithrombin iii injection	1 IU	$1.636
J7198	Anti-inhibitor	1 IU	$1.360
J7308	Aminolevulinic acid hcl top	354 MG	$106.954
J7310	Ganciclovir long act implant	4.5 MG	$4,739.811
J7311	Fluocinolone acetonide implt	0.59 MG	$19,345.000
J7330	Cultured chondrocytes implnt	1 EA	$18,285.572
J7340	Metabolic active D/E tissue	1 SQ CM	$28.754
J7341	Non-human, metabolic tissue	1 SQ CM	$1.822
J7342	Metabolically active tissue	1 SQ CM	$14.416
J7343	Nonmetabolic act d/e tissue	1 SQ CM	$18.303
J7344	Nonmetabolic active tissue	1 SQ CM	$87.234
J7345	Non-human, non-metab tissue	1 SQ CM	$37.480
J7346	Injectable human tissue	1 CC	$713.283
J7500	Azathioprine oral 50mg	50 MG	$0.274
J7501	Azathioprine parenteral	100 MG	$49.587
J7502	Cyclosporine oral 100 mg	100 MG	$3.541
J7504	Lymphocyte immune globulin	250 MG	$317.148
J7505	Monoclonal antibodies	5 MG	$876.832
J7506	Prednisone oral	5 MG	$0.191
J7507	Tacrolimus oral per 1 MG	1 MG	$3.540
J7509	Methylprednisolone oral	4 MG	$0.072
J7510	Prednisolone oral per 5 mg	5 MG	$0.089
J7511	Antithymocyte globuln rabbit	25 MG	$331.070
J7513	Daclizumab, parenteral	25 MG	$314.587
J7515	Cyclosporine oral 25 mg	25 MG	$0.952
J7516	Cyclosporin parenteral 250mg	250 MG	$20.635
J7517	Mycophenolate mofetil oral	250 MG	$2.547
J7518	Mycophenolic acid	180 MG	$2.140
J7520	Sirolimus, oral	1 MG	$7.224
J7525	Tacrolimus injection	5 MG	$140.386
J7608	Acetylcysteine inh sol u d	1 GM	$2.395
J7611	Albuterol non-comp con1	1 MG	$0.097
J7612	Levalbuterol non-comp con1	0.5 MG	$0.989
J7613	Albuterol non-comp unit dose1	1 MG	$0.065
J7614	Levalbuterol non-comp unit dose1	0.5 MG	$1.391
J7620	Albuterol ipratrop non-comp1	2.5 MG/0.5 MG	$1.052
J7626	Budesonide non-comp unit dose1	0.5 MG	$4.590
J7631	Cromolyn sodium inh sol u d	10 MG	$0.069
J7639	Dornase alpha inhal sol u d	1 MG	$19.864
J7644	Ipratropium bromide non-comp1	1 MG	$0.213
J7669	Metaproterenol non-comp unit dose1	10 MG	$0.238
J7674	Methacholine chloride, neb	1 MG	$0.419
J7682	Tobramycin non-comp unit dose1	300 MG	$57.313
J8501	Oral aprepitant	5 MG	$5.035
J8510	Oral busulfan	2 MG	$2.123
J8515	Cabergoline, oral 0.25mg	0.25 MG	$17.270
J8520	Capecitabine, oral, 150 mg	150 MG	$3.959
J8521	Capecitabine, oral, 500 mg	500 MG	$13.181
J8530	Cyclophosphamide oral 25 MG	25 MG	$0.978
J8540	Oral dexamethasone	0.25 MG	$0.257
J8560	Etoposide oral 50 MG	50 MG	$30.536
J8610	Methotrexate oral 2.5 MG	2.5 MG	$0.218
J8700	Temozolomide	5 MG	$7.415
J9000	Doxorubic hcl 10 MG vl chemo	10 MG	$6.237
J9001	Doxorubicin hcl liposome inj	10 MG	$386.083			95%	$393.480
J9010	Alemtuzumab injection	10 MG	$541.295
J9015	Aldesleukin/single use vial	1 EA	$739.520
J9017	Arsenic trioxide	1 MG	$33.493
J9020	Asparaginase injection	10000 UNITS	$54.770
J9025	Azacitidine injection	1 MG	$4.223
J9027	Clofarabine injection	1 MG	$116.581
J9031	Bcg live intravesical vac	1 EA	$114.155
J9035	Bevacizumab injection	10 MG	$57.476
J9040	Bleomycin sulfate injection	15 UNITS	$33.299			95%	$289.370
J9041	Bortezomib injection	0.1 MG	$32.682
J9045	Carboplatin injection	50 MG	$8.938
J9050	Carmus bischl nitro inj	100 MG	$139.782
J9055	Cetuximab injection	10 MG	$49.834
J9060	Cisplatin 10 MG injection	10 MG	$2.451
J9062	Cisplatin 50 MG injection	50 MG	$12.257
J9065	Inj cladribine per 1 MG	1 MG	$37.576			95%	$61.720
J9070	Cyclophosphamide 100 MG inj	100 MG	$1.917
J9080	Cyclophosphamide 200 MG inj	200 MG	$3.834
J9090	Cyclophosphamide 500 MG inj	500 MG	$15.745
J9091	Cyclophosphamide 1.0 grm inj	1 GM	$19.168
J9092	Cyclophosphamide 2.0 grm inj	2 GM	$38.335
J9093	Cyclophosphamide lyophilized	100 MG	$1.985
J9094	Cyclophosphamide lyophilized	200 MG	$3.971
J9095	Cyclophosphamide lyophilized	500 MG	$9.931
J9096	Cyclophosphamide lyophilized	1 GM	$17.086
J9097	Cyclophosphamide lyophilized	2 GM	$39.709
J9098	Cytarabine liposome	10 MG	$394.203
J9100	Cytarabine hcl 100 MG inj	100 MG	$1.645			95%	$8.190
J9110	Cytarabine hcl 500 MG inj	500 MG	$8.223			95%	$8.550
J9120	Dactinomycin actinomycin d	0.5 MG	$493.430
J9130	Dacarbazine 100 mg inj	100 MG	$4.669
J9140	Dacarbazine 200 MG inj	200 MG	$9.339
J9150	Daunorubicin	10 MG	$22.780
J9151	Daunorubicin citrate liposom	10 MG	$55.917
J9160	Denileukin diftitox, 300 mcg	300 MCG	$1,390.508
J9170	Docetaxel	20 MG	$306.133
J9175	Elliotts b solution per ml	1 ML	$3.734
J9178	Inj, epirubicin hcl, 2 mg	2 MG	$24.604
J9181	Etoposide 10 MG inj	10 MG	$0.513
J9182	Etoposide 100 MG inj	100 MG	$5.129
J9185	Fludarabine phosphate inj	50 MG	$244.053
J9190	Fluorouracil injection	500 MG	$1.504			95%	$2.070
J9200	Floxuridine injection	500 MG	$58.272			95%	$136.800
J9201	Gemcitabine HCl	200 MG	$124.547
J9202	Goserelin acetate implant	3.6 MG	$200.429
J9206	Irinotecan injection	20 MG	$126.669
J9208	Ifosfomide injection	1 GM	$49.614			95%	$150.380
J9209	Mesna injection	200 MG	$8.893
J9211	Idarubicin hcl injection	5 MG	$285.376
J9212	Interferon alfacon-1	1 MCG	$4.645
J9213	Interferon alfa-2a inj	3 MIL UNITS	$37.293
J9214	Interferon alfa-2b inj	1 MIL UNITS	$13.816
J9216	Interferon gamma 1-b inj	3 MIL UNITS	$289.865
J9217	Leuprolide acetate suspnsion	7.5 MG	$230.380
J9218	Leuprolide acetate injeciton	1 MG	$7.226
J9219	Leuprolide acetate implant	65 MG	$1,717.041
J9225	Histrelin implant	50 MG	$1,597.462
J9230	Mechlorethamine hcl inj	10 MG	$141.608
J9245	Inj melphalan hydrochl 50 MG	50 MG	$1,197.779
J9250	Methotrexate sodium inj	5 MG	$0.247
J9260	Methotrexate sodium inj	50 MG	$2.587
J9261	Nelarabine injection	50 MG	$82.943
J9263	Oxaliplatin	0.5 MG	$8.917
J9264	Paclitaxel protein bound	1 MG	$8.666
J9265	Paclitaxel injection	30 MG	$12.362
J9266	Pegaspargase/singl dose vial	1 EA	$1,687.849
J9268	Pentostatin injection	10 MG	$1,490.127
J9280	Mitomycin 5 MG inj	5 MG	$17.129			95%	$127.400
J9290	Mitomycin 20 MG inj	20 MG	$68.515
J9291	Mitomycin 40 MG inj	40 MG	$137.031
J9293	Mitoxantrone hydrochl / 5 MG	5 MG	$162.368
J9300	Gemtuzumab ozogamicin	5 MG	$2,357.419
J9305	Pemetrexed injection	10 MG	$43.675
J9310	Rituximab cancer treatment	100 MG	$486.553
J9320	Streptozocin injection	1 GM	$151.739
J9340	Thiotepa injection	15 MG	$40.609
J9350	Topotecan	4 MG	$820.562
J9355	Trastuzumab	10 MG	$56.763			95%	$58.130
J9360	Vinblastine sulfate inj	1 MG	$1.215			95%	$4.100
J9370	Vincristine sulfate 1 MG inj	1 MG	$7.704			95%	$33.980
J9375	Vincristine sulfate 2 MG inj	2 MG	$15.408			95%	$67.960
J9380	Vincristine sulfate 5 MG inj	5 MG	$38.521			95%	$169.910
J9390	Vinorelbine tartrate/10 mg	10 MG	$18.366
J9395	Injection, Fulvestrant	25 MG	$80.465
J9600	Porfimer sodium	75 MG	$2,505.395
P9041	Albumin (human),5%, 50ml	50 ML	$19.000					95%	$19.000
P9043	Plasma protein fract,5%,50ml	50 ML	$14.545					95%	$14.545
P9045	Albumin (human), 5%, 250 ml	250 ML	$95.000					95%	$95.000
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	$0.034
Q0164	Prochlorperazine maleate 5mg	5 MG	$0.029
Q0165	Prochlorperazine maleate10mg	10 MG	$0.045
Q0166	Granisetron HCl 1 mg oral	1 MG	$44.174
Q0167	Dronabinol 2.5mg oral	2.5 MG	$4.646
Q0168	Dronabinol 5mg oral	5 MG	$10.051
Q0170	Promethazine HCl 25 mg oral	25 MG	$0.394
Q0171	Chlorpromazine HCl 10mg oral	10 MG	$0.021
Q0172	Chlorpromazine HCl 25mg oral	25 MG	$0.047
Q0173	Trimethobenzamide HCl 250mg	250 MG	$0.326
Q0175	Perphenazine 4mg oral	4 MG	$0.191
Q0176	Perphenazine 8mg oral	8 MG	$0.213
Q0177	Hydroxyzine pamoate 25mg	25 MG	$0.062
Q0178	Hydroxyzine pamoate 50mg	50 MG	$0.064
Q0179	Ondansetron HCl 8mg oral	8 MG	$36.829
Q0180	Dolasetron mesylate oral	100 MG	$48.707
Q0515	Sermorelin acetate injection	1 MCG	$1.752
Q2009	Fosphenytoin, 50 mg	50 MG	$5.660
Q2017	Teniposide, 50 mg	50 MG	$264.088
Q3025	IM inj interferon beta 1-a	11 MCG	$115.155
Q4079	Natalizumab injection	1 MG	$7.719
Q4080	Iloprost inhalation solution	20 MCG	$34.238
Q4081	Epoetin alfa, for ESRD on dialysis	100 UNITS	$0.957
Q4083	Hyalgan or Supartz, inj	PER DOSE	$105.558
Q4084	Synvisc, inj	PER DOSE	$198.089
Q4085	Euflexxa, inj	PER DOSE	$115.155
Q4086	Orthovisc, inj	PER DOSE	$200.541
Q9945	LOCM <=149 mg/ml iodine, 1ml	1 ML	$0.280
Q9946	LOCM 150-199mg/ml iodine,1ml	1 ML	$1.897
Q9947	LOCM 200-249mg/ml iodine,1ml	1 ML	$1.335
Q9948	LOCM 250-299mg/ml iodine,1ml	1 ML	$0.321
Q9949	LOCM 300-349mg/ml iodine,1ml	1 ML	$0.359
Q9950	LOCM 350-399mg/ml iodine,1ml	1 ML	$0.219
Q9952	Inj Gad-base MR contrast,1ml	1 ML	$2.808
Q9953	Inj Fe-based MR contrast,1ml	1 ML	$30.406
Q9954	Oral MR contrast, 100 ml	100 ML	$8.937
Q9956	Inj octafluoropropane mic,ml	1 ML	$49.608
Q9957	Inj perflutren lip micros,ml	1 ML	$61.590
Q9958	HOCM <=149 mg/ml iodine	1 ML	$0.074
Q9960	HOCM 200-249mg/ml iodine	1 ML	$0.098
Q9961	HOCM 250-299mg/ml iodine	1 ML	$0.190
Q9962	HOCM 300-349mg/ml iodine	1 ML	$0.125
Q9963	HOCM 350-399mg/ml iodine	1 ML	$0.395
Q9964	HOCM>= 400mg/ml iodine	1 ML	$0.189
	1 FDA-approved final product
	12/28/2006