2005 Injection Pricing - Codes Priced by Carrier
HCPCS	Description	Payment Limit
Effective  For Services on or After 1/1/2005
90657	Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use	$10.10
90676	Rabies vaccine, for intradermal use	$121.83
*A4641	Supply radiopharmaceutical diagnostic imaging agent, not otherwise classified	$0.00
A4643	Supply of additional high dose contrast material(s) during magnetic resonance imaging, e.g., gadolinium	$127.36
A4644	Supply of low osmolar contrast material (100-199 mgs of iodine)	$49.45
A4645	Supply of low osmolar contrast material (200-299 mgs of iodine)	$50.89
A4646	Supply of low osmolar contrast material (300-399 mgs of iodine)	$52.89
A9500	Supply of radiopharmaceutical diagnostic imaging agent, technetium tc 99m sestamibi, per unit dose	$121.70
A9502	Supply of radiopharmaceutical diagnostic imaging  agent, technetium tc 99m tetrofosmin, per unit dose	$125.69
A9503	Supply of radiopharmaceutical diagnostic imaging agent, technetium tc 99m, medronate, up to 30 mci	$33.25
A9504	Supply of radiopharmaceutical diagnostic imaging  agent, technetium tc99m apcitide	$475.00
A9505	Supply of radiopharmaceutical diagnostic imaging agent, thallous chloride tl-201, per mci	$33.23
A9507	Supply of radiopharmaceutical diagnostic imaging agent, indium in 111 capromab pendetide, per dose	$2,192.13
A9508	Supply of radiopharmaceutical diagnostic imaging agent, iobenguane sulfate i-131, per 0.5 mci.	$495.65
A9510	Supply of radiopharmaceutical diagnostic imaging  agent, technetium tc99m disofenin, per vial.	$57.00
A9511	Supply of radiopharmaceutical diagnostic imaging  agent, technetium tc99m depreotide, per vial.	$760.00
A9513	Supply Of Radiopharmaceutical Diagnostic Imaging Agent, Technetium Tc-99m  mebrofenin, per mci	$51.44
A9514	Supply Of Radiopharmaceutical Diagnostic Imaging Agent, Technetium Tc-99m pyrophosphate, per mci	$25.54
A9515	Supply Of Radiopharmaceutical Diagnostic Imaging Agent, Technetium Tc-99m pentetate, per mci	$28.12
A9516	Supply Of Radiopharmaceutical Diagnostic Imaging Agent, I-123 Sodium Iodide capsule, per 100 uci	$65.03
A9517	Supply Of Radiopharmaceutical Therapeutic Imaging Agent, I-131 Sodium Iodide capsule, per mci	$164.81
A9519	Supply Of Radiopharmaceutical Diagnostic Imaging Agent, Technetium Tc-99m macroaggregated albumin, per mci	$20.52
A9520	Supply Of Radiopharmaceutical Diagnostic Imaging Agent, Technetium Tc-99m sulfur colloid, per mci	$76.00
A9521	Supply Of Radiopharmaceutical Diagnostic Imaging Agent, Technetium Tc-99m  exametazine, per dose	$890.63
A9522	Supply Of Radiopharmaceutical Diagnostic Imaging Agent, Indium-111 Ibritumomab tiuxetan, per mci	$2,769.63
A9523	Supply Of Radiopharmaceutical Therapeutic Imaging Agent, Yttrium 90 Ibritumomab tiuxetan, per mci	$23,976.91
A9524	Supply Of Radiopharmaceutical Diagnostic Imaging Agent, Iodinated I-131 Serum albumin, 5 microcuries	$53.39
A9528	Supply of radiopharmaceutical diagnostic agent, i-131 sodium iodide capsule, per millicurie	$27.47
A9533	Supply Of Radiopharmaceutical Diagnostic Imaging agent, I-131 tositumomab, per millicurie	$2,565.00
A9534	Supply Of Radiopharmaceutical therapeutic agent, I-131 tositumomab, per millicurie	$22,230.00
A9600	Supply of therapeutic radiopharmaceutical, strontium-89 chloride, per mci	$963.42
A9605	Supply of therapeutic radiopharmaceutical, samarium sm 153 lexidronamm, 50 mci	$1,020.00
A9700	Supply of injectable contrast material for use in echocardiography, per study.	$153.90
G3001	Administration and supp;y of tositumomab, 450 mg	$2,645.86
J0120	Injection, tetracycline, up to 250 mg	$40.14
J0350	Injection, anistreplase, per 30 units	$2,410.24
J0710	Injection, cepharin sodium, up to 1 gm	$1.39
J1330	Injection, ergonovine maleate, up to 0.2 mg	$4.03
J3310	Injection, perphenazine, up to 5 mg	$6.39
J3350	Injection, urea, up to 40 gm	$75.36
J3400	Injection, triflupromazine hcl, up to 20 mg	$10.61
J7636	Atropine, inhalation solution administered through DME, concentrated form, per mg.	$0.32
J7668	Metaproterenol, sulfate, inhalation solution administered through dme, concentrated form, per 10 mg	$1.07
J7680	Terbutaline sulfate, inhalation solution administered through dme, concentrated form, per mg	$26.30
J7681	Terbutaline sulfate, inhalation solution administered through dme, unit dose form, per mg	$29.39
Q2004	irrigation solution for treatment of bladder calculi, example renacidin, per 500 ml	$24.01
Q2005	Injection, corticorelin ovine triflutate, per dose	$418.36
Q2013	Injecton, pentastarch,10% solution,per 100 ml	$13.52
Q2018	Injecton, urofollitropin,75 iu	$60.56
Q2020	Injection, histrelin acetate, 10 mg	$4,000.95
Q3002	Supply of radiopharmaceutical diagnostic imaging agent, gallium ga 67, per mci	$64.08
Q3003	Supply of radiopharmaceutical diagnostic imaging agent,techetium tc99m bicisate,per unit dose	$424.18
Q3004	Supply of radiopharmaceutical diagnostic imaging agent,xenon xe 133, per 10 mci	$38.96
Q3005	Supply of radiopharmaceutical diagnostic imaging agent,techetium tc 99m mertiatide, per mci	$355.68
Q3006	Supply of radiopharmaceutical diagnostic imaging agent,techetium tc 99m glucepate, per 5 mci	$22.61
Q3007	Supply of radiopharmaceutical diagnostic imaging agent,sodium phosphate p32, per mci	$117.52
Q3008	Supply of oral radiopharmaceutical diagnostic imaging agent, indium 111-in pentetreotide, per 3 mci	$1,417.02
Q3009	Supply  of oral radiopharmaceutical diagnostic imaging agent, technetium tc99m oxidronate, per mci	$20.52
Q3010	Supply of oral radiopharmaceutical diagnostic imaging agent, technetium tc99m labeled red blood cells, per mci	$59.96
Q3011	Supply of oral radiopharmaceutical diagnostic imaging agent, chromic phosphate p32 suspension, per mci	$209.46
*	Code A4641 effective 12/1/03 will be priced on a claim to claim basis
	Non-par physicians get 95% of the fee schedule
	1/20/2005