Payment Allowance Limits for Medicare Part B Drugs
Effective October 1, 2006 through December 31, 2006
Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q06 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	$119.057
90375	Rabies ig, im/sc	150 IU	$64.526
90376	Rabies ig, heat treated	150 IU	$68.236
90385	Rh ig, minidose, im	50 MCG	$7.308
90585	Bcg vaccine, percut	50 MG	$117.391
90586	Bcg vaccine, intravesical	1 EACH	$113.435
90632	Hep a vaccine, adult im	1 ML	$43.383
90633	Hep a vacc, ped/adol, 2 dose	1 ML	$23.646
90634	Hep a vacc, ped/adol, 3 dose	3 EACH	$23.646
90645	Hib vaccine, hboc, im	1 EACH	$21.268
90647	Hib vaccine, prp-omp, im	0.5 ML	$21.268
90648	Hib vaccine, prp-t, im	0.5 ML	$21.782
90655	Flu vaccine no preserv 6-35m	0.25 ML	$15.377	95%	$15.377
90656	Flu vaccine no preserv 3 & >	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 & 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	$157.737
90691	Typhoid vaccine, im	0.5 ML	$52.053
90700	Dtap vaccine, < 7 yrs, im	0.5 ML	$29.401
90702	Dt vaccine < 7, im	0.5 ML	$18.300
90703	Tetanus vaccine, im	0.5 ML	$19.378
90704	Mumps vaccine, sc	0.5 ML	$20.393
90705	Measles vaccine, sc	0.5 ML	$15.578
90706	Rubella vaccine, sc	0.5 ML	$17.331
90707	Mmr vaccine, sc	0.5 ML	$40.999
90713	Poliovirus, ipv, sc/im	0.5 ML	$26.005
90714	Td vaccine no prsrv >/= 7 im	0.5 ML	$18.778
90716	Chicken pox vaccine, sc	0.5 ML	$72.332
90717	Yellow fever vaccine, sc	0.5 ML	$54.440
90718	Td vaccine > 7, im	0.5 ML	$18.828
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	$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
J0128	Abarelix injection	10 MG	$68.620
J0130	Abciximab injection	10 MG	$416.273
J0132	Acetylcysteine injection	100 MG	$1.937
J0133	Acyclovir injection	5 MG	$0.023
J0135	Adalimumab injection	20 MG	$308.330
J0150	Injection adenosine 6 MG	6 MG	$30.491
J0152	Adenosine injection	30 MG	$68.934
J0170	Adrenalin epinephrin inject	1 ML	$0.988
J0180	Agalsidase beta injection	1 MG	$127.200
J0205	Alglucerase injection	10 UNITS	$39.220
J0207	Amifostine	500 MG	$463.266
J0210	Methyldopate hcl injection	250 MG	$10.006
J0215	Alefacept	0.5 MG	$26.308
J0256	Alpha 1 proteinase inhibitor	10 MG	$3.306
J0270	Alprostadil for injection	1.25 MCG	$1.802
J0275	Alprostadil urethral suppos	125 MCG	$22.838
J0278	Amikacin sulfate injection	100 MG	$1.212
J0280	Aminophyllin 250 MG inj	250 MG	$0.371
J0282	Amiodarone HCl	30 MG	$0.279
J0285	Amphotericin B	50 MG	$9.445			95%	$10.280
J0287	Amphotericin b lipid complex	10 MG	$11.111			95%	$21.850
J0288	Ampho b cholesteryl sulfate	10 MG	$12.000			95%	$15.200
J0289	Amphotericin b liposome inj	10 MG	$21.245			95%	$35.800
J0290	Ampicillin 500 MG inj	500 MG	$2.372
J0295	Ampicillin sodium per 1.5 gm	1.5 GM	$4.954
J0300	Amobarbital 125 MG inj	125 MG	$2.274
J0330	Succinycholine chloride inj	20 MG	$0.185
J0360	Hydralazine hcl injection	20 MG	$8.675
J0365	Aprotonin, 10,000 kiu	10000 KIU	$2.522
J0456	Azithromycin	500 MG	$12.257
J0460	Atropine sulfate injection	0.3 MG	$0.185
J0470	Dimecaprol injection	100 MG	$25.315
J0475	Baclofen 10 MG injection	10 MG	$198.544			95%	$215.180
J0476	Baclofen intrathecal trial	50 MCG	$69.631			95%	$79.800
J0480	Basiliximab	20 MG	$1,385.861
J0500	Dicyclomine injection	20 MG	$15.334
J0515	Inj benztropine mesylate	1 MG	$17.078
J0530	Penicillin g benzathine inj	600000 UNITS	$13.278
J0540	Penicillin g benzathine inj	1200000 UNITS	$28.453
J0550	Penicillin g benzathine inj	2400000 UNITS	$30.575
J0560	Penicillin g benzathine inj	600000 UNITS	$21.219
J0570	Penicillin g benzathine inj	1200000 UNITS	$36.297
J0580	Penicillin g benzathine inj	2400000 UNITS	$42.098
J0583	Bivalirudin	1 MG	$1.750
J0585	Botulinum toxin a per unit	1 UNIT	$5.035
J0587	Botulinum toxin type B	100 UNITS	$8.164
J0592	Buprenorphine hydrochloride	0.1 MG	$0.720
J0595	Butorphanol tartrate 1 mg	1 MG	$0.718
J0600	Edetate calcium disodium inj	1000 MG	$40.185
J0610	Calcium gluconate injection	10 ML	$0.418
J0630	Calcitonin salmon injection	400 UNITS	$39.941
J0636	Inj calcitriol per 0.1 mcg	0.1 MCG	$0.525
J0637	Caspofungin acetate	5 MG	$32.249
J0640	Leucovorin calcium injection	50 MG	$0.931
J0670	Inj mepivacaine HCL/10 ml	10 ML	$1.511
J0690	Cefazolin sodium injection	500 MG	$1.191
J0692	Cefepime HCl for injection	500 MG	$7.940
J0694	Cefoxitin sodium injection	1 GM	$6.843
J0696	Ceftriaxone sodium injection	250 MG	$1.608
J0697	Sterile cefuroxime injection	750 MG	$0.799
J0698	Cefotaxime sodium injection	1 GM	$4.163
J0702	Betamethasone acet&sod phosp	3 MG	$5.190
J0704	Betamethasone sod phosp/4 MG	4 MG	$1.133
J0706	Caffeine citrate injection	5 MG	$3.539
J0713	Inj ceftazidime per 500 mg	500 MG	$3.978
J0715	Ceftizoxime sodium / 500 MG	500 MG	$4.444
J0720	Chloramphenicol sodium injec	1 GM	$11.217
J0725	Chorionic gonadotropin/1000u	1000 UNITS	$3.696
J0735	Clonidine hydrochloride	1 MG	$66.038
J0740	Cidofovir injection	375 MG	$763.147
J0743	Cilastatin sodium injection	250 MG	$13.262
J0744	Ciprofloxacin iv	200 MG	$8.487
J0745	Inj codeine phosphate /30 MG	30 MG	$1.049
J0760	Colchicine injection	1 MG	$4.679
J0770	Colistimethate sodium inj	150 MG	$21.508
J0780	Prochlorperazine injection	10 MG	$2.033
J0795	Corticorelin ovine triflutal	1 MCG	$4.174
J0800	Corticotropin injection	40 UNITS	$116.596
J0835	Inj cosyntropin per 0.25 MG	0.25 MG	$62.914
J0850	Cytomegalovirus imm IV /vial	PER VIAL	$853.183
J0878	Daptomycin injection	1 MG	$0.327
J0881	Darbepoetin alfa, non-esrd	1 MCG	$2.991
J0882	Darbepoetin alfa, esrd use	1 MCG	$2.991
J0885	Epoetin alfa, non-esrd	1000 UNITS	$9.362
J0886	Epoetin alfa, esrd	1000 UNITS	$9.446
J0895	Deferoxamine mesylate inj	500 MG	$14.843			95%	$15.630
J0945	Brompheniramine maleate inj	10 MG	$0.798
J0970	Estradiol valerate injection	40 MG	$35.069
J1000	Depo-estradiol cypionate inj	5 MG	$5.565
J1020	Methylprednisolone 20 MG inj	20 MG	$2.327
J1030	Methylprednisolone 40 MG inj	40 MG	$5.079
J1040	Methylprednisolone 80 MG inj	80 MG	$9.267
J1051	Medroxyprogesterone inj	50 MG	$5.484
J1060	Testosterone cypionate 1 ML	1 ML	$4.142
J1070	Testosterone cypionat 100 MG	100 MG	$5.420
J1080	Testosterone cypionat 200 MG	200 MG	$11.635
J1094	Inj dexamethasone acetate	1 MG	$0.230
J1100	Dexamethasone sodium phos	1 MG	$0.143
J1110	Inj dihydroergotamine mesylt	1 MG	$24.373
J1120	Acetazolamid sodium injectio	500 MG	$15.285
J1160	Digoxin injection	0.5 MG	$1.132
J1162	Digoxin immune fab (ovine)	PER VIAL	$533.715
J1165	Phenytoin sodium injection	50 MG	$0.899
J1170	Hydromorphone injection	4 MG	$1.748			95%	$1.490
J1190	Dexrazoxane HCl injection	250 MG	$180.128
J1200	Diphenhydramine hcl injectio	50 MG	$0.732
J1205	Chlorothiazide sodium inj	500 MG	$123.840
J1212	Dimethyl sulfoxide 50% 50 ML	50 ML	$44.244
J1230	Methadone injection	10 MG	$3.245			95%	$0.750
J1240	Dimenhydrinate injection	50 MG	$4.454
J1245	Dipyridamole injection	10 MG	$1.561
J1250	Inj dobutamine HCL/250 mg	250 MG	$5.228			95%	$4.740
J1260	Dolasetron mesylate	10 MG	$6.890
J1265	Dopamine injection	40 MG	$0.689
J1270	Injection, doxercalciferol	1 MCG	$2.875
J1325	Epoprostenol injection	0.5 MG	$14.389			95%	$12.640
J1327	Eptifibatide injection	5 MG	$15.372
J1335	Ertapenem injection	500 MG	$23.087
J1364	Erythro lactobionate /500 MG	500 MG	$5.901
J1380	Estradiol valerate 10 MG inj	10 MG	$12.603
J1390	Estradiol valerate 20 MG inj	20 MG	$17.534
J1410	Inj estrogen conjugate 25 MG	25 MG	$58.046
J1430	Ethanolamine oleate 100 mg	100 MG	$69.596
J1435	Injection estrone per 1 MG	1 MG	$0.239
J1436	Etidronate disodium inj	300 MG	$71.407
J1438	Etanercept injection	25 MG	$160.392
J1440	Filgrastim 300 mcg injection	300 MCG	$188.074
J1441	Filgrastim 480 mcg injection	480 MCG	$298.698
J1450	Fluconazole	200 MG	$11.053
J1451	Fomepizole, 15 mg	15 MG	$12.328
J1455	Foscarnet sodium injection	1000 MG	$10.490			95%	$13.070
J1457	Gallium nitrate injection	1 MG	$1.247
J1460	Gamma globulin 1 CC inj	1 CC	$10.338
J1470	Gamma globulin 2 CC inj	2 CC	$20.677
J1480	Gamma globulin 3 CC inj	3CC	$31.014
J1490	Gamma globulin 4 CC inj	4 CC	$41.354
J1500	Gamma globulin 5 CC inj	5 CC	$51.692
J1510	Gamma globulin 6 CC inj	6 CC	$62.034
J1520	Gamma globulin 7 CC inj	7 CC	$72.336
J1530	Gamma globulin 8 CC inj	8 CC	$82.707
J1540	Gamma globulin 9 CC inj	9 CC	$93.073
J1550	Gamma globulin 10 CC inj	10 CC	$103.384
J1560	Gamma globulin > 10 CC inj	10 CC	$103.380
J1565	RSV-ivig	50 MG	$16.176
J1566	Immune globulin, powder	500 MG	$25.266
J1567	Immune globulin, liquid	500 MG	$30.327
J1570	Ganciclovir sodium injection	500 MG	$39.167			95%	$35.250
J1580	Garamycin gentamicin inj	80 MG	$0.931
J1590	Gatifloxacin injection	10 MG	$0.502
J1595	Injection glatiramer acetate	20 MG	$46.198
J1600	Gold sodium thiomaleate inj	50 MG	$6.335
J1610	Glucagon hydrochloride/1 MG	1 MG	$70.227
J1620	Gonadorelin hydroch/ 100 mcg	100 MCG	$189.835
J1626	Granisetron HCl injection	100 MCG	$7.206
J1630	Haloperidol injection	5 MG	$2.237
J1631	Haloperidol decanoate inj	50 MG	$5.297
J1640	Hemin, 1 mg	1 MG	$6.799
J1642	Inj heparin sodium per 10 u	10 UNITS	$0.046
J1644	Inj heparin sodium per 1000u	1000 UNITS	$0.114
J1645	Dalteparin sodium	2500 IU	$10.855
J1650	Inj enoxaparin sodium	10 MG	$5.645
J1652	Fondaparinux sodium	0.5 MG	$5.921
J1655	Tinzaparin sodium injection	1000 IU	$2.483
J1670	Tetanus immune globulin inj	250 UNITS	$87.768
J1720	Hydrocortisone sodium succ i	100 MG	$1.982
J1730	Diazoxide injection	300 MG	$111.894
J1742	Ibutilide fumarate injection	1 MG	$265.753
J1745	Infliximab injection	10 MG	$53.743
J1751	Iron dextran 165 injection	50 MG	$11.778
J1752	Iron dextran 267 injection	50 MG	$10.378
J1756	Iron sucrose injection	1 MG	$0.363
J1785	Injection imiglucerase /unit	1 UNIT	$3.908
J1790	Droperidol injection	5 MG	$1.402
J1800	Propranolol injection	1 MG	$4.225
J1815	Insulin injection	5 UNITS	$0.242
J1817	Insulin for insulin pump use	50 UNITS	$2.466			95%	$2.800
J1830	Interferon beta-1b / .25 MG	0.25 MG	$90.002
J1835	Itraconazole injection	50 MG	$36.451
J1840	Kanamycin sulfate 500 MG inj	500 MG	$4.285
J1850	Kanamycin sulfate 75 MG inj	75 MG	$0.643
J1885	Ketorolac tromethamine inj	15 MG	$0.498
J1931	Laronidase injection	0.1 MG	$23.868
J1940	Furosemide injection	20 MG	$0.292
J1945	Lepirudin	50 MG	$153.544
J1950	Leuprolide acetate /3.75 MG	3.75 MG	$437.582
J1955	Inj levocarnitine per 1 gm	1 GM	$10.458
J1956	Levofloxacin injection	250 MG	$7.471
J1980	Hyoscyamine sulfate inj	0.25 MG	$8.693
J1990	Chlordiazepoxide injection	100 MG	$21.050
J2001	Lidocaine injection	10 MG	$0.019
J2010	Lincomycin injection	300 MG	$3.765
J2020	Linezolid injection	200 MG	$24.160
J2060	Lorazepam injection	2 MG	$0.997
J2150	Mannitol injection	50 ML	$0.723
J2175	Meperidine hydrochl /100 MG	100 MG	$1.690			95%	$0.560
J2180	Meperidine/promethazine inj	50 MG	$3.788
J2185	Meropenem	100 MG	$3.682
J2210	Methylergonovin maleate inj	0.2 MG	$4.600
J2250	Inj midazolam hydrochloride	1 MG	$0.217
J2260	Inj milrinone lactate / 5 MG	5 MG	$2.791			95%	$51.580
J2270	Morphine sulfate injection	10 MG	$1.404			95%	$0.710
J2271	Morphine so4 injection 100mg	100 MG	$3.810			95%	$11.070
J2275	Morphine sulfate injection	10 MG	$4.769			95%	$4.390
J2278	Ziconotide injection	1 MCG	$6.339
J2280	Inj, moxifloxacin 100 mg	100 MG	$3.913
J2300	Inj nalbuphine hydrochloride	10 MG	$0.588
J2310	Inj naloxone hydrochloride	1 MG	$1.919
J2320	Nandrolone decanoate 50 MG	50 MG	$3.235
J2321	Nandrolone decanoate 100 MG	100 MG	$6.397
J2322	Nandrolone decanoate 200 MG	200 MG	$13.035
J2325	Nesiritide injection	0.1 MG	$30.127
J2353	Octreotide injection, depot	1 MG	$93.348
J2354	Octreotide inj, non-depot	25 MCG	$3.537
J2355	Oprelvekin injection	5 MG	$245.981
J2357	Omalizumab injection	5 MG	$16.605
J2360	Orphenadrine injection	60 MG	$11.806
J2370	Phenylephrine hcl injection	1 ML	$0.502
J2400	Chloroprocaine hcl injection	30 ML	$15.503
J2405	Ondansetron hcl injection	1 MG	$3.715
J2410	Oxymorphone hcl injection	1 MG	$2.306
J2425	Palifermin injection	50 MCG	$11.432
J2430	Pamidronate disodium /30 MG	30 MG	$34.801
J2440	Papaverin hcl injection	60 MG	$0.704
J2460	Oxytetracycline injection	50 MG	$0.936
J2469	Palonosetron HCl	25 MCG	$18.078
J2501	Paricalcitol	1 MCG	$3.812
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	$2,163.608
J2510	Penicillin g procaine inj	600000 UNITS	$9.038
J2513	Pentastarch 10% solution	100 ML	$12.722
J2515	Pentobarbital sodium inj	50 MG	$5.432
J2540	Penicillin g potassium inj	600000 UNITS	$0.830
J2543	Piperacillin/tazobactam	1.125 GM	$5.056
J2545	Pentamidine isethionte/300mg	300 MG	$43.418
J2550	Promethazine hcl injection	50 MG	$1.843
J2560	Phenobarbital sodium inj	120 MG	$2.157
J2590	Oxytocin injection	10 UNITS	$2.307
J2597	Inj desmopressin acetate	1 MCG	$2.499
J2650	Prednisolone acetate inj	1 ML	$0.440
J2675	Inj progesterone per 50 MG	50 MG	$1.788
J2680	Fluphenazine decanoate 25 MG	25 MG	$1.208
J2690	Procainamide hcl injection	1 GM	$2.084
J2700	Oxacillin sodium injeciton	250 MG	$1.506
J2710	Neostigmine methylslfte inj	0.5 MG	$0.137
J2720	Inj protamine sulfate/10 MG	10 MG	$0.440
J2725	Inj protirelin per 250 mcg	250 MCG	$21.778
J2730	Pralidoxime chloride inj	1 GM	$73.997
J2760	Phentolaine mesylate inj	5 MG	$23.776
J2765	Metoclopramide hcl injection	10 MG	$0.461
J2770	Quinupristin/dalfopristin	500 MG	$114.492
J2780	Ranitidine hydrochloride inj	25 MG	$0.700
J2783	Rasburicase	0.5 MG	$121.258
J2788	Rho d immune globulin 50 mcg	50 MCG	$27.695
J2790	Rho d immune globulin inj	300 MCG	$80.518
J2792	Rho(D) immune globulin h, sd	100 IU	$14.297
J2794	Risperidone, long acting	0.5 MG	$4.798
J2795	Ropivacaine HCl injection	1 MG	$0.070
J2800	Methocarbamol injection	10 ML	$11.814
J2805	Sincalide injection	5 MCG	$52.079
J2810	Inj theophylline per 40 MG	40 MG	$0.042
J2820	Sargramostim injection	50 MCG	$25.548
J2850	Inj secretin synthetic human	1 MCG	$20.313
J2912	Sodium chloride injection	2 ML	$0.115
J2916	Na ferric gluconate complex	12.5 MG	$4.813
J2920	Methylprednisolone injection	40 MG	$1.939
J2930	Methylprednisolone injection	125 MG	$2.378
J2941	Somatropin injection	1 MG	$46.798
J2950	Promazine hcl injection	UP TO 25 MG	$0.384
J2993	Reteplase injection	18.1 MG	$902.723
J2997	Alteplase recombinant	1 MG	$32.072
J3000	Streptomycin injection	1 GM	$6.197
J3010	Fentanyl citrate injeciton	0.1 MG	$0.320			95%	$0.700
J3030	Sumatriptan succinate / 6 MG	6 MG	$57.401
J3070	Pentazocine injection	30 MG	$5.260
J3100	Tenecteplase injection	50 MG	$2,036.663
J3105	Terbutaline sulfate inj	1 MG	$4.026
J3120	Testosterone enanthate inj	100 MG	$4.383
J3130	Testosterone enanthate inj	200 MG	$11.256
J3230	Chlorpromazine hcl injection	50 MG	$3.669
J3240	Thyrotropin injection	0.9 MG	$765.760
J3246	Tirofiban HCl	0.25 MG	$8.739
J3250	Trimethobenzamide hcl inj	200 MG	$4.411
J3260	Tobramycin sulfate injection	80 MG	$2.059
J3265	Injection torsemide 10 mg/ml	10 MG	$2.344
J3285	Treprostinil injection	1 MG	$54.018
J3301	Triamcinolone acetonide inj	10 MG	$1.400
J3302	Triamcinolone diacetate inj	5 MG	$0.280
J3303	Triamcinolone hexacetonl inj	5 MG	$1.300
J3305	Inj trimetrexate glucoronate	25 MG	$145.171
J3315	Triptorelin pamoate	3.75 MG	$218.530
J3320	Spectinomycn di-hcl inj	2 GM	$30.083
J3355	Urofollitropin, 75 iu	75 IU	$49.345
J3360	Diazepam injection	5 MG	$0.708
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	$3.346
J3396	Verteporfin injection	0.1 MG	$8.905
J3410	Hydroxyzine hcl injection	25 MG	$0.186
J3411	Thiamine hcl 100 mg	100 MG	$2.082
J3415	Pyridoxine hcl 100 mg	100 MG	$3.250
J3420	Vitamin b12 injection	1000 MCG	$0.281
J3430	Vitamin k phytonadione inj	1 MG	$2.888
J3465	Injection, voriconazole	10 MG	$4.657
J3470	Hyaluronidase injection	150 UNITS	$17.126
J3471	Ovine, up to 999 USP units	1 USP UNIT	$0.112
J3472	Ovine, 1000 USP units	1000 USP UNITS	$137.426
J3475	Inj magnesium sulfate	500 MG	$0.111
J3480	Inj potassium chloride	2 MEQ	$0.019
J3485	Zidovudine	10 MG	$1.058
J3486	Ziprasidone mesylate	10 MG	$5.045
J3487	Zoledronic acid	1 MG	$204.031
J7030	Normal saline solution infus	1000 CC	$1.037
J7040	Normal saline solution infus	500 ML	$0.518
J7042	5% dextrose/normal saline	500 ML	$0.391
J7050	Normal saline solution infus	250 CC	$0.259
J7060	5% dextrose/water	500 ML	$1.268
J7070	D5w infusion	1000 CC	$2.534
J7100	Dextran 40 infusion	500 ML	$14.807
J7110	Dextran 75 infusion	500 ML	$8.310
J7120	Ringers lactate infusion	1000 CC	$0.890
J7188	Inj Vonwillebrand factor iu	1 IU	$0.877
J7189	Factor viia	1 MCG	$1.097
J7190	Factor viii	1 IU	$0.685
J7192	Factor viii recombinant	1 IU	$1.057
J7193	Factor IX non-recombinant	1 IU	$0.901
J7194	Factor ix complex	1 IU	$0.718
J7195	Factor IX recombinant	1 IU	$0.985
J7197	Antithrombin iii injection	1 IU	$1.619
J7198	Anti-inhibitor	1 IU	$1.360
J7308	Aminolevulinic acid hcl top	354 MG	$107.721
J7310	Ganciclovir long act implant	4.5 MG	$4,766.142
J7317	Sodium hyaluronate injection	20 - 25 MG	$106.709
J7320	Hylan G-F 20 injection	16 MG	$198.739
J7330	Cultured chondrocytes implnt	1 EA	$18,262.316
J7340	Metabolic active D/E tissue	1 SQ CM	$27.890
J7341	Non-human, metabolic tissue	1 SQ CM	$1.784
J7342	Metabolically active tissue	1 SQ CM	$13.868
J7343	Nonmetabolic act d/e tissue	1 SQ CM	$18.493
J7344	Nonmetabolic active tissue	1 SQ CM	$45.017
J7350	Injectable human tissue	10 MG	$22.544
J7500	Azathioprine oral 50mg	50 MG	$0.186
J7501	Azathioprine parenteral	100 MG	$49.173
J7502	Cyclosporine oral 100 mg	100 MG	$3.664
J7504	Lymphocyte immune globulin	250 MG	$315.761
J7505	Monoclonal antibodies	5 MG	$856.045
J7506	Prednisone oral	5 MG	$0.185
J7507	Tacrolimus oral per 1 MG	1 MG	$3.549
J7509	Methylprednisolone oral	4 MG	$0.078
J7510	Prednisolone oral per 5 mg	5 MG	$0.095
J7511	Antithymocyte globuln rabbit	25 MG	$329.618
J7513	Daclizumab, parenteral	25 MG	$328.833
J7515	Cyclosporine oral 25 mg	25 MG	$0.962
J7516	Cyclosporin parenteral 250mg	250 MG	$19.670
J7517	Mycophenolate mofetil oral	250 MG	$2.504
J7518	Mycophenolic acid	180 MG	$2.148
J7520	Sirolimus, oral	1 MG	$7.247
J7525	Tacrolimus injection	5 MG	$140.715
J7608	Acetylcysteine inh sol u d	1 GM	$3.338
J7611	Albuterol concentrated form	1 MG	$0.101
J7613	Albuterol unit dose	1 MG	$0.061
J7614	Levalbuterol unit dose	0.5 MG	$1.359
J7620	Duoneb	2.5 MG/0.5 MG	$1.089
J7626	Pulmicort	0.5 MG	$4.562
J7631	Cromolyn sodium inh sol u d	10 MG	$0.057
J7639	Dornase alpha inhal sol u d	1 MG	$18.754
J7644	Ipratropium brom inh sol u d	1 MG	$0.211
J7669	Metaproterenol inh sol u d	10 MG	$0.205
J7674	Methacholine chloride, neb	1 MG	$0.409
J7682	Tobramycin inhalation sol	300 MG	$55.633
J8501	Oral aprepitant	5 MG	$4.847
J8510	Oral busulfan	2 MG	$2.139
J8515	Cabergoline, oral 0.25mg	0.25 MG	$16.387
J8520	Capecitabine, oral, 150 mg	150 MG	$3.829
J8521	Capecitabine, oral, 500 mg	500 MG	$12.753
J8530	Cyclophosphamide oral 25 MG	25 MG	$0.995
J8540	Oral dexamethasone	0.25 MG	$0.253
J8560	Etoposide oral 50 MG	50 MG	$32.014
J8610	Methotrexate oral 2.5 MG	2.5 MG	$0.253
J8700	Temozolomide	5 MG	$7.296
J9000	Doxorubic hcl 10 MG vl chemo	10 MG	$5.997
J9001	Doxorubicin hcl liposome inj	10 MG	$379.213			95%	$393.480
J9010	Alemtuzumab injection	10 MG	$531.238
J9015	Aldesleukin/single use vial	1 EA	$726.694
J9017	Arsenic trioxide	1 MG	$33.364
J9020	Asparaginase injection	10000 UNITS	$54.463
J9025	Azacitidine injection	1 MG	$4.221
J9027	Clofarabine injection	1 MG	$116.622
J9031	Bcg live intravesical vac	1 EA	$113.435
J9035	Bevacizumab injection	10 MG	$56.877
J9040	Bleomycin sulfate injection	15 UNITS	$37.623			95%	$289.370
J9041	Bortezomib injection	0.1 MG	$31.865
J9045	Carboplatin injection	50 MG	$10.120
J9050	Carmus bischl nitro inj	100 MG	$139.835
J9055	Cetuximab injection	10 MG	$49.862
J9060	Cisplatin 10 MG injection	10 MG	$2.262
J9062	Cisplatin 50 MG injection	50 MG	$11.312
J9065	Inj cladribine per 1 MG	1 MG	$37.869			95%	$61.720
J9070	Cyclophosphamide 100 MG inj	100 MG	$1.916
J9080	Cyclophosphamide 200 MG inj	200 MG	$3.832
J9090	Cyclophosphamide 500 MG inj	500 MG	$15.534
J9091	Cyclophosphamide 1.0 grm inj	1 GM	$19.159
J9092	Cyclophosphamide 2.0 grm inj	2 GM	$38.317
J9098	Cytarabine liposome	10 MG	$396.660
J9100	Cytarabine hcl 100 MG inj	100 MG	$1.694			95%	$8.190
J9110	Cytarabine hcl 500 MG inj	500 MG	$8.468			95%	$8.550
J9120	Dactinomycin actinomycin d	0.5 MG	$493.430
J9130	Dacarbazine 100 mg inj	100 MG	$4.898
J9140	Dacarbazine 200 MG inj	200 MG	$9.796
J9150	Daunorubicin	10 MG	$24.562
J9151	Daunorubicin citrate liposom	10 MG	$56.205
J9160	Denileukin diftitox, 300 mcg	300 MCG	$1,403.228
J9170	Docetaxel	20 MG	$302.681
J9175	Elliotts b solution per ml	1 ML	$3.395
J9178	Inj, epirubicin hcl, 2 mg	2 MG	$24.674
J9181	Etoposide 10 MG inj	10 MG	$0.497
J9182	Etoposide 100 MG inj	100 MG	$4.974
J9185	Fludarabine phosphate inj	50 MG	$243.818
J9190	Fluorouracil injection	500 MG	$1.882			95%	$2.070
J9200	Floxuridine injection	500 MG	$64.168			95%	$136.800
J9201	Gemcitabine HCl	200 MG	$121.304
J9202	Goserelin acetate implant	3.6 MG	$199.118
J9206	Irinotecan injection	20 MG	$126.877
J9208	Ifosfomide injection	1 GM	$52.390			95%	$150.380
J9209	Mesna injection	200 MG	$10.097
J9211	Idarubicin hcl injection	5 MG	$308.967
J9212	Interferon alfacon-1	1 MCG	$4.645
J9213	Interferon alfa-2a inj	3 MIL UNITS	$37.557
J9214	Interferon alfa-2b inj	1 MIL UNITS	$13.753
J9216	Interferon gamma 1-b inj	3 MIL UNITS	$289.865
J9217	Leuprolide acetate suspnsion	7.5 MG	$227.634
J9218	Leuprolide acetate injeciton	1 MG	$11.095
J9219	Leuprolide acetate implant	65 MG	$2,208.902
J9225	Histrelin implant	50 MG	$1,741.707
J9230	Mechlorethamine hcl inj	10 MG	$141.608
J9245	Inj melphalan hydrochl 50 MG	50 MG	$1,194.154
J9250	Methotrexate sodium inj	5 MG	$0.236
J9260	Methotrexate sodium inj	50 MG	$2.448
J9263	Oxaliplatin	0.5 MG	$8.769
J9264	Paclitaxel injection	1 MG	$8.461
J9265	Paclitaxel injection	30 MG	$14.347
J9266	Pegaspargase/singl dose vial	1 EA	$1,687.043
J9268	Pentostatin injection	10 MG	$2,034.628
J9280	Mitomycin 5 MG inj	5 MG	$18.314			95%	$127.400
J9290	Mitomycin 20 MG inj	20 MG	$73.258
J9291	Mitomycin 40 MG inj	40 MG	$146.515
J9293	Mitoxantrone hydrochl / 5 MG	5 MG	$223.265
J9300	Gemtuzumab ozogamicin	5 MG	$2,317.160
J9305	Pemetrexed injection	10 MG	$42.486
J9310	Rituximab cancer treatment	100 MG	$481.689
J9320	Streptozocin injection	1 GM	$152.916
J9340	Thiotepa injection	15 MG	$44.584
J9350	Topotecan	4 MG	$813.082
J9355	Trastuzumab	10 MG	$56.170			95%	$58.130
J9360	Vinblastine sulfate inj	1 MG	$0.970			95%	$4.100
J9370	Vincristine sulfate 1 MG inj	1 MG	$6.685			95%	$33.980
J9375	Vincristine sulfate 2 MG inj	2 MG	$13.371			95%	$67.960
J9380	Vincristine sulfate 5 MG inj	5 MG	$33.427			95%	$169.910
J9390	Vinorelbine tartrate/10 mg	10 MG	$22.823
J9395	Injection, Fulvestrant	25 MG	$80.664
J9600	Porfimer sodium	75 MG	$2,505.395
P9041	Albumin (human),5%, 50ml	50 ML	$12.985					95%	$12.985
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	$29.099					95%	$29.099
P9048	Plasmaprotein fract,5%,250ml	250 ML	$29.099					95%	$29.099
Q0163	Diphenhydramine HCl 50mg	50 MG	$0.033
Q0164	Prochlorperazine maleate 5mg	5 MG	$0.053
Q0165	Prochlorperazine maleate10mg	10 MG	$0.034
Q0166	Granisetron HCl 1 mg oral	1 MG	$41.183
Q0167	Dronabinol 2.5mg oral	2.5 MG	$4.921
Q0168	Dronabinol 5mg oral	5 MG	$10.125
Q0169	Promethazine HCl 12.5mg oral	12.5 MG	$0.390
Q0170	Promethazine HCl 25 mg oral	25 MG	$0.406
Q0171	Chlorpromazine HCl 10mg oral	10 MG	$0.022
Q0172	Chlorpromazine HCl 25mg oral	25 MG	$0.051
Q0173	Trimethobenzamide HCl 250mg	250 MG	$0.244
Q0175	Perphenazine 4mg oral	4 MG	$0.230
Q0176	Perphenazine 8mg oral	8 MG	$0.226
Q0177	Hydroxyzine pamoate 25mg	25 MG	$0.059
Q0178	Hydroxyzine pamoate 50mg	50 MG	$0.067
Q0179	Ondansetron HCl 8mg oral	8 MG	$36.064
Q0180	Dolasetron mesylate oral	100 MG	$48.912
Q0515	Sermorelin acetate injection	1 MCG	$1.752
Q2009	Fosphenytoin, 50 mg	50 MG	$5.585
Q2017	Teniposide, 50 mg	50 MG	$264.883
Q3025	IM inj interferon beta 1-a	11 MCG	$108.037
Q4079	Natalizumab injection	1 MG	$7.719
Q4080	Iloprost inhalation solution	20 MCG	$33.175
Q9945	LOCM <=149 mg/ml iodine, 1ml	1 ML	$0.291
Q9946	LOCM 150-199mg/ml iodine,1ml	1 ML	$1.963
Q9947	LOCM 200-249mg/ml iodine,1ml	1 ML	$1.424
Q9948	LOCM 250-299mg/ml iodine,1ml	1 ML	$0.265
Q9949	LOCM 300-349mg/ml iodine,1ml	1 ML	$0.351
Q9950	LOCM 350-399mg/ml iodine,1ml	1 ML	$0.214
Q9952	Inj Gad-base MR contrast,1ml	1 ML	$2.874
Q9953	Inj Fe-based MR contrast,1ml	1 ML	$30.406
Q9954	Oral MR contrast, 100 ml	100 ML	$8.902
Q9956	Inj octafluoropropane mic,ml	1 ML	$49.608
Q9957	Inj perflutren lip micros,ml	1 ML	$61.635
	10/5/2006