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Chicago, IL 60606
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PLA Codes

Laboratory Fee Schedule

2019
2018

Physician Fee Schedule

2019
2018

OPPS Fee Schedule

2019-April
2019-January

ASC Fee Schedule

2019-April
2019-January

APC Codes

2019-April
2019-January

DRG Codes

2019
2018

ASP Drug Pricing Files

April 2019
January 2019


CMS Transmittals



--

October 2018 Payment Allowance Limits for Medicare Part B Drugs


Procedure
Short Descriptor
HCPC Code Dosage
Payment Limit
90371
Hep b ig im 1 ML
$XXX.XX
90375
Rabies ig im/sc 150 IU
$XXX.XX
90376
Rabies ig heat treated 150 IU
$XXX.XX
90585
Bcg vaccine percut 50 MG
$XXX.XX
90586
Bcg vaccine intravesical 1 EACH
$XXX.XX
90632
Hepa vaccine adult im 1 ML
$XXX.XX
90653
Iiv adjuvant vaccine im 0.5 ml
$XXX.XX
90656
Iiv3 vacc no prsv 0.5 ml im 0.5 ML
$XXX.XX
90662
Iiv no prsv increased ag im 0.5 ML
$XXX.XX
90670
Pcv13 vaccine im 0.5 ML
$XXX.XX
90674
Cciiv4 vac no prsv 0.5 ml im 0.5 ML
$XXX.XX
90675
Rabies vaccine im 1 ML
$XXX.XX
90682
Riv4 vacc recombinant dna im 0.5 ML
$XXX.XX
90685
Iiv4 vacc no prsv 0.25 ml im 0.25 mL
$XXX.XX
90686
Iiv4 vacc no prsv 0.5 ml im 0.5 ml
$XXX.XX
90687
Iiv4 vaccine splt 0.25 ml im 0.25 ML
$XXX.XX
90688
Iiv4 vaccine splt 0.5 ml im 0.5 ML
$XXX.XX
90691
Typhoid vaccine im 0.5 ML
$XXX.XX
90714
Td vacc no presv 7 yrs+ im 0.5 ML
$XXX.XX
90715
Tdap vaccine 7 yrs/> im 0.5 ML
$XXX.XX
90732
Ppsv23 vacc 2 yrs+ subq/im 0.5 ML
$XXX.XX
90739
Hepb vacc 2 dose adult im 1 dose
$XXX.XX
90740
Hepb vacc 3 dose immunsup im 40 MCG
$XXX.XX
90744
Hepb vacc 3 dose ped/adol im 1 DOSE
$XXX.XX
90746
Hepb vaccine 3 dose adult im 20 MCG
$XXX.XX
90747
Hepb vacc 4 dose immunsup im 40 MCG
$XXX.XX
90756
Cciiv4 vacc abx free im 0.5 ML
$XXX.XX
A9575
Inj gadoterate meglumi 0.1ml 0.1 ml
$XXX.XX
A9576
Inj prohance multipack 1 ML
$XXX.XX
A9577
Inj multihance 1 ML
$XXX.XX
A9578
Inj multihance multipack 1 ML
$XXX.XX
A9579
Gad-base mr contrast nos,1ml 1 ML
$XXX.XX
A9581
Gadoxetate disodium inj 1 ML
$XXX.XX
A9585
Gadobutrol injection 0.1 ML
$XXX.XX
A9606
Radium ra223 dichloride ther 1 microCurie
$XXX.XX
J0129
Abatacept injection 10 MG
$XXX.XX
J0130
Abciximab injection 10 MG
$XXX.XX
J0132
Acetylcysteine injection 100 MG
$XXX.XX
J0133
Acyclovir injection 5 MG
$XXX.XX
J0153
Adenosine inj 1mg 1 MG
$XXX.XX
J0171
Adrenalin epinephrine inject 0.1 MG
$XXX.XX
J0178
Aflibercept injection 1 MG
$XXX.XX
J0180
Agalsidase beta injection 1 MG
$XXX.XX
J0202
Injection, alemtuzumab 1 MG
$XXX.XX
J0207
Amifostine 500 MG
$XXX.XX
J0221
Lumizyme injection 10 MG
$XXX.XX
J0256
Alpha 1 proteinase inhibitor 10 MG
$XXX.XX
J0257
Glassia injection 10 MG
$XXX.XX
J0278
Amikacin sulfate injection 100 MG
$XXX.XX
J0280
Aminophyllin 250 mg inj 250 MG
$XXX.XX
J0285
Amphotericin b 50 MG
$XXX.XX
J0287
Amphotericin b lipid complex 10 MG
$XXX.XX
J0289
Amphotericin b liposome inj 10 MG
$XXX.XX
J0290
Ampicillin 500 mg inj 500 MG
$XXX.XX
J0295
Ampicillin sodium per 1.5 gm 1.5 GM
$XXX.XX
J0348
Anidulafungin injection 1 MG
$XXX.XX
J0360
Hydralazine hcl injection 20 MG
$XXX.XX
J0401
Inj aripiprazole ext rel 1mg 1 MG
$XXX.XX
J0456
Azithromycin 500 MG
$XXX.XX
J0461
Atropine sulfate injection 0.01 MG
$XXX.XX
J0470
Dimecaprol injection 100 MG
$XXX.XX
J0475
Baclofen 10 mg injection 10 MG
$XXX.XX
J0476
Baclofen intrathecal trial 50 MCG
$XXX.XX
J0480
Basiliximab 20 MG
$XXX.XX
J0485
Belatacept injection 1 MG
$XXX.XX
J0490
Belimumab injection 10 MG
$XXX.XX
J0500
Dicyclomine injection 20 MG
$XXX.XX
J0515
Inj benztropine mesylate 1 MG
$XXX.XX
J0558
Peng benzathine/procaine inj 100,000 UNITS
$XXX.XX
J0561
Penicillin g benzathine inj 100,000 UNITS
$XXX.XX
J0570
Buprenorphine implant 74.2mg 74.2 MG
$XXX.XX
J0583
Bivalirudin 1 MG
$XXX.XX
J0585
Injection,onabotulinumtoxina 1 UNIT
$XXX.XX
J0586
Abobotulinumtoxina 5 Unit
$XXX.XX
J0587
Inj, rimabotulinumtoxinb 100 UNITS
$XXX.XX
J0588
Incobotulinumtoxin a 1 UNIT
$XXX.XX
J0592
Buprenorphine hydrochloride 0.1 MG
$XXX.XX
J0594
Busulfan injection 1 MG
$XXX.XX
J0595
Butorphanol tartrate 1 mg 1 MG
$XXX.XX
J0596
Injection, ruconest 10 UNITS
$XXX.XX
J0597
C-1 esterase, berinert 10 UNITS
$XXX.XX
J0598
C-1 esterase, cinryze 10 UNITS
$XXX.XX
J0600
Edetate calcium disodium inj 1000 MG
$XXX.XX
J0610
Calcium gluconate injection 10 ML
$XXX.XX
J0630
Calcitonin salmon injection 400 UNITS
$XXX.XX
J0636
Inj calcitriol per 0.1 mcg 0.1 MCG
$XXX.XX
J0637
Caspofungin acetate 5 MG
$XXX.XX
J0638
Canakinumab injection 1 MG
$XXX.XX
J0640
Leucovorin calcium injection 50 MG
$XXX.XX
J0641
Levoleucovorin injection 0.5 MG
$XXX.XX
J0670
Inj mepivacaine hcl/10 ml 10 ML
$XXX.XX
J0690
Cefazolin sodium injection 500 MG
$XXX.XX
J0692
Cefepime hcl for injection 500 MG
$XXX.XX
J0694
Cefoxitin sodium injection 1 GM
$XXX.XX
J0696
Ceftriaxone sodium injection 250 MG
$XXX.XX
J0697
Sterile cefuroxime injection 750 MG
$XXX.XX
J0702
Betamethasone acet&sod phosp 3 MG & 3 MG
$XXX.XX
J0712
Ceftaroline fosamil inj 10 MG
$XXX.XX
J0713
Inj ceftazidime per 500 mg 500 MG
$XXX.XX
J0717
Certolizumab pegol inj 1mg 1 MG
$XXX.XX
J0720
Chloramphenicol sodium injec 1 GM
$XXX.XX
J0725
Chorionic gonadotropin/1000u 1000 UNITS
$XXX.XX
J0735
Clonidine hydrochloride 1 MG
$XXX.XX
J0740
Cidofovir injection 375 MG
$XXX.XX
J0743
Cilastatin sodium injection 250 MG
$XXX.XX
J0744
Ciprofloxacin iv 200 MG
$XXX.XX
J0770
Colistimethate sodium inj 150 MG
$XXX.XX
J0775
Collagenase, clost hist inj 0.01 MG
$XXX.XX
J0780
Prochlorperazine injection 10 MG
$XXX.XX
J0795
Corticorelin ovine triflutal 1 MCG
$XXX.XX
J0800
Corticotropin injection 40 UNITS
$XXX.XX
J0834
Cosyntropin cortrosyn inj 0.25 MG
$XXX.XX
J0840
Crotalidae poly immune fab UP TO 1 GM
$XXX.XX
J0850
Cytomegalovirus imm iv /vial PER VIAL
$XXX.XX
J0875
Injection, dalbavancin 5 MG
$XXX.XX
J0878
Daptomycin injection 1 MG
$XXX.XX
J0881
Darbepoetin alfa, non-esrd 1 MCG
$XXX.XX
J0882
Darbepoetin alfa, esrd use 1 MCG
$XXX.XX
J0885
Epoetin alfa, non-esrd 1000 UNITS
$XXX.XX
J0887
Epoetin beta esrd use 1 MCG
$XXX.XX
J0888
Epoetin beta non esrd 1 MCG
$XXX.XX
J0894
Decitabine injection 1 MG
$XXX.XX
J0895
Deferoxamine mesylate inj 500 MG
$XXX.XX
J0897
Denosumab injection 1 MG
$XXX.XX
J1000
Depo-estradiol cypionate inj 5 MG
$XXX.XX
J1020
Methylprednisolone 20 mg inj 20 MG
$XXX.XX
J1030
Methylprednisolone 40 mg inj 40 MG
$XXX.XX
J1040
Methylprednisolone 80 mg inj 80 MG
$XXX.XX
J1050
Medroxyprogesterone acetate 1 MG
$XXX.XX
J1071
Inj testosterone cypionate 1 MG
$XXX.XX
J1100
Dexamethasone sodium phos 1 MG
$XXX.XX
J1110
Inj dihydroergotamine mesylt 1 MG
$XXX.XX
J1120
Acetazolamid sodium injectio 500 MG
$XXX.XX
J1160
Digoxin injection 0.5 MG
$XXX.XX
J1162
Digoxin immune fab (ovine) PER VIAL
$XXX.XX
J1165
Phenytoin sodium injection 50 MG
$XXX.XX
J1170
Hydromorphone injection 4 MG
$XXX.XX
J1190
Dexrazoxane hcl injection 250 MG
$XXX.XX
J1200
Diphenhydramine hcl injectio 50 MG
$XXX.XX
J1205
Chlorothiazide sodium inj 500 MG
$XXX.XX
J1212
Dimethyl sulfoxide 50% 50 ml 50 ML
$XXX.XX
J1230
Methadone injection 10 MG
$XXX.XX
J1240
Dimenhydrinate injection 50 MG
$XXX.XX
J1245
Dipyridamole injection 10 MG
$XXX.XX
J1250
Inj dobutamine hcl/250 mg 250 MG
$XXX.XX
J1265
Dopamine injection 40 MG
$XXX.XX
J1267
Doripenem injection 10 MG
$XXX.XX
J1270
Injection, doxercalciferol 1 MCG
$XXX.XX
J1290
Ecallantide injection 1 MG
$XXX.XX
J1300
Eculizumab injection 10 MG
$XXX.XX
J1325
Epoprostenol injection 0.5 MG
$XXX.XX
J1335
Ertapenem injection 500 MG
$XXX.XX
J1364
Erythro lactobionate /500 mg 500 MG
$XXX.XX
J1380
Estradiol valerate 10 mg inj 10 MG
$XXX.XX
J1410
Inj estrogen conjugate 25 mg 25 MG
$XXX.XX
J1430
Ethanolamine oleate 100 mg 100 MG
$XXX.XX
J1439
Inj ferric carboxymaltos 1mg 1 MG
$XXX.XX
J1442
Inj filgrastim excl biosimil 1 MCG
$XXX.XX
J1447
Inj tbo filgrastim 1 microg 1 MCG
$XXX.XX
J1450
Fluconazole 200 MG
$XXX.XX
J1453
Fosaprepitant injection 1 MG
$XXX.XX
J1458
Galsulfase injection 1 MG
$XXX.XX
J1459
Inj ivig privigen 500 mg 500 MG
$XXX.XX
J1460
Gamma globulin 1 cc inj 1 CC
$XXX.XX
J1555
Inj cuvitru, 100 mg 100 MG
$XXX.XX
J1556
Inj, imm glob bivigam, 500mg 500 MG
$XXX.XX
J1557
Gammaplex injection 500 MG
$XXX.XX
J1559
Hizentra injection 100 MG
$XXX.XX
J1560
Gamma globulin > 10 cc inj 10 CC
$XXX.XX
J1561
Gamunex-c/gammaked 500 MG
$XXX.XX
J1566
Immune globulin, powder 500 MG
$XXX.XX
J1568
Octagam injection 500 MG
$XXX.XX
J1569
Gammagard liquid injection 500 MG
$XXX.XX
J1570
Ganciclovir sodium injection 500 MG
$XXX.XX
J1571
Hepagam b im injection 0.5 ML
$XXX.XX
J1572
Flebogamma injection 500 MG
$XXX.XX
J1575
Hyqvia 100mg immuneglobulin 100 MG
$XXX.XX
J1580
Garamycin gentamicin inj 80 MG
$XXX.XX
J1602
Golimumab for iv use 1mg 1 MG
$XXX.XX
J1610
Glucagon hydrochloride/1 mg 1 MG
$XXX.XX
J1626
Granisetron hcl injection 100 MCG
$XXX.XX
J1627
Inj, granisetron, xr, 0.1 mg 0.1 MG
$XXX.XX
J1630
Haloperidol injection 5 MG
$XXX.XX
J1631
Haloperidol decanoate inj 50 MG
$XXX.XX
J1640
Hemin, 1 mg 1 MG
$XXX.XX
J1642
Inj heparin sodium per 10 u 10 UNITS
$XXX.XX
J1644
Inj heparin sodium per 1000u 1000 UNITS
$XXX.XX
J1645
Dalteparin sodium 2500 IU
$XXX.XX
J1650
Inj enoxaparin sodium 10 MG
$XXX.XX
J1652
Fondaparinux sodium 0.5 MG
$XXX.XX
J1670
Tetanus immune globulin inj 250 UNITS
$XXX.XX
J1720
Hydrocortisone sodium succ i 100 MG
$XXX.XX
J1740
Ibandronate sodium injection 1 MG
$XXX.XX
J1742
Ibutilide fumarate injection 1 MG
$XXX.XX
J1743
Idursulfase injection 1 MG
$XXX.XX
J1745
Infliximab not biosimil 10mg 10 MG
$XXX.XX
J1750
Inj iron dextran 50 MG
$XXX.XX
J1756
Iron sucrose injection 1 MG
$XXX.XX
J1786
Imuglucerase injection 10 UNITS
$XXX.XX
J1800
Propranolol injection 1 MG
$XXX.XX
J1815
Insulin injection 5 UNITS
$XXX.XX
J1817
Insulin for insulin pump use 50 UNITS
$XXX.XX
J1885
Ketorolac tromethamine inj 15 MG
$XXX.XX
J1930
Lanreotide injection 1 MG
$XXX.XX
J1931
Laronidase injection 0.1 MG
$XXX.XX
J1940
Furosemide injection 20 MG
$XXX.XX
J1942
Aripiprazole lauroxil 1mg 1 MG
$XXX.XX
J1950
Leuprolide acetate /3.75 mg 3.75 MG
$XXX.XX
J1953
Levetiracetam injection 10 MG
$XXX.XX
J1955
Inj levocarnitine per 1 gm 1 GM
$XXX.XX
J1956
Levofloxacin injection 250 MG
$XXX.XX
J1980
Hyoscyamine sulfate inj 0.25 MG
$XXX.XX
J2001
Lidocaine injection 10 MG
$XXX.XX
J2010
Lincomycin injection 300 MG
$XXX.XX
J2020
Linezolid injection 200 MG
$XXX.XX
J2060
Lorazepam injection 2 MG
$XXX.XX
J2150
Mannitol injection 50 ML
$XXX.XX
J2175
Meperidine hydrochl /100 mg 100 MG
$XXX.XX
J2182
Injection, mepolizumab, 1mg 1 MG
$XXX.XX
J2185
Meropenem 100 MG
$XXX.XX
J2210
Methylergonovin maleate inj 0.2 MG
$XXX.XX
J2248
Micafungin sodium injection 1 MG
$XXX.XX
J2250
Inj midazolam hydrochloride 1 MG
$XXX.XX
J2260
Inj milrinone lactate / 5 mg 5 MG
$XXX.XX
J2270
Morphine sulfate injection 10 MG
$XXX.XX
J2274
Inj morphine pf epid ithc 10 MG
$XXX.XX
J2278
Ziconotide injection 1 MCG
$XXX.XX
J2280
Inj, moxifloxacin 100 mg 100 MG
$XXX.XX
J2300
Inj nalbuphine hydrochloride 10 MG
$XXX.XX
J2310
Inj naloxone hydrochloride 1 MG
$XXX.XX
J2315
Naltrexone, depot form 1 MG
$XXX.XX
J2323
Natalizumab injection 1 MG
$XXX.XX
J2350
Injection, ocrelizumab, 1 mg 1 MG
$XXX.XX
J2353
Octreotide injection, depot 1 MG
$XXX.XX
J2354
Octreotide inj, non-depot 25 MCG
$XXX.XX
J2357
Omalizumab injection 5 MG
$XXX.XX
J2358
Olanzapine long-acting inj 1 MG
$XXX.XX
J2360
Orphenadrine injection 60 MG
$XXX.XX
J2400
Chloroprocaine hcl injection 30 ML
$XXX.XX
J2405
Ondansetron hcl injection 1 MG
$XXX.XX
J2407
Injection, oritavancin 10 MG
$XXX.XX
J2425
Palifermin injection 50 MCG
$XXX.XX
J2426
Paliperidone palmitate inj 1 MG
$XXX.XX
J2430
Pamidronate disodium /30 mg 30 MG
$XXX.XX
J2469
Palonosetron hcl 25 MCG
$XXX.XX
J2501
Paricalcitol 1 MCG
$XXX.XX
J2503
Pegaptanib sodium injection 0.3 MG
$XXX.XX
J2504
Pegademase bovine, 25 iu 25 IU
$XXX.XX
J2505
Injection, pegfilgrastim 6mg 6 MG
$XXX.XX
J2507
Pegloticase injection 1 MG
$XXX.XX
J2510
Penicillin g procaine inj 600000 UNITS
$XXX.XX
J2515
Pentobarbital sodium inj 50 MG
$XXX.XX
J2540
Penicillin g potassium inj 600000 UNITS
$XXX.XX
J2543
Piperacillin/tazobactam 1.125 GM
$XXX.XX
J2545
Pentamidine non-comp unit 300 MG
$XXX.XX
J2550
Promethazine hcl injection 50 MG
$XXX.XX
J2560
Phenobarbital sodium inj 120 MG
$XXX.XX
J2562
Plerixafor injection 1 MG
$XXX.XX
J2597
Inj desmopressin acetate 1 MCG
$XXX.XX
J2675
Inj progesterone per 50 mg 50 MG
$XXX.XX
J2680
Fluphenazine decanoate 25 mg 25 MG
$XXX.XX
J2690
Procainamide hcl injection 1 GM
$XXX.XX
J2700
Oxacillin sodium injeciton 250 MG
$XXX.XX
J2704
Inj, propofol, 10 mg 10 MG
$XXX.XX
J2720
Inj protamine sulfate/10 mg 10 MG
$XXX.XX
J2724
Protein c concentrate 10 UNITS
$XXX.XX
J2765
Metoclopramide hcl injection 10 MG
$XXX.XX
J2770
Quinupristin/dalfopristin 500 MG
$XXX.XX
J2778
Ranibizumab injection 0.1 mg
$XXX.XX
J2780
Ranitidine hydrochloride inj 25 MG
$XXX.XX
J2783
Rasburicase 0.5 MG
$XXX.XX
J2785
Regadenoson injection 0.1 MG
$XXX.XX
J2786
Injection, reslizumab, 1mg 1 MG
$XXX.XX
J2788
Rho d immune globulin 50 mcg 50 MCG (250 IU)
$XXX.XX
J2790
Rho d immune globulin inj 300 MCG (1500 IU)
$XXX.XX
J2791
Rhophylac injection 100 IU
$XXX.XX
J2792
Rho(d) immune globulin h, sd 100 IU
$XXX.XX
J2794
Risperidone, long acting 0.5 MG
$XXX.XX
J2795
Ropivacaine hcl injection 1 MG
$XXX.XX
J2796
Romiplostim injection 10 MCG
$XXX.XX
J2800
Methocarbamol injection 10 ML
$XXX.XX
J2805
Sincalide injection 5 MCG
$XXX.XX
J2810
Inj theophylline per 40 mg 40 MG
$XXX.XX
J2820
Sargramostim injection 50 MCG
$XXX.XX
J2916
Na ferric gluconate complex 12.5 MG
$XXX.XX
J2920
Methylprednisolone injection 40 MG
$XXX.XX
J2930
Methylprednisolone injection 125 MG
$XXX.XX
J2997
Alteplase recombinant 1 MG
$XXX.XX
J3000
Streptomycin injection 1 GM
$XXX.XX
J3010
Fentanyl citrate injection 0.1 MG
$XXX.XX
J3060
Inj, taliglucerase alfa 10 u 10 UNITS
$XXX.XX
J3070
Pentazocine injection 30 MG
$XXX.XX
J3090
Inj tedizolid phosphate 1 MG
$XXX.XX
J3095
Telavancin injection 10 MG
$XXX.XX
J3101
Tenecteplase injection 1 MG
$XXX.XX
J3105
Terbutaline sulfate inj 1 MG
$XXX.XX
J3121
Inj testostero enanthate 1mg 1 MG
$XXX.XX
J3145
Testosterone undecanoate 1mg 1 MG
$XXX.XX
J3230
Chlorpromazine hcl injection 50 MG
$XXX.XX
J3240
Thyrotropin injection 0.9 MG
$XXX.XX
J3243
Tigecycline injection 1 MG
$XXX.XX
J3250
Trimethobenzamide hcl inj 200 MG
$XXX.XX
J3260
Tobramycin sulfate injection 80 MG
$XXX.XX
J3262
Tocilizumab injection 1 MG
$XXX.XX
J3285
Treprostinil injection 1 MG
$XXX.XX
J3300
Triamcinolone a inj prs-free 1 MG
$XXX.XX
J3301
Triamcinolone acet inj nos 10 MG
$XXX.XX
J3315
Triptorelin pamoate 3.75 MG
$XXX.XX
J3357
Ustekinumab sub cu inj, 1 mg 1 MG
$XXX.XX
J3358
Ustekinumab, iv inject,1 mg 1 MG
$XXX.XX
J3360
Diazepam injection 5 MG
$XXX.XX
J3370
Vancomycin hcl injection 500 MG
$XXX.XX
J3380
Injection, vedolizumab 1 MG
$XXX.XX
J3385
Velaglucerase alfa 100 UNITS
$XXX.XX
J3396
Verteporfin injection 0.1 MG
$XXX.XX
J3410
Hydroxyzine hcl injection 25 MG
$XXX.XX
J3411
Thiamine hcl 100 mg 100 MG
$XXX.XX
J3415
Pyridoxine hcl 100 mg 100 MG
$XXX.XX
J3420
Vitamin b12 injection 1000 MCG
$XXX.XX
J3430
Vitamin k phytonadione inj 1 MG
$XXX.XX
J3465
Injection, voriconazole 10 MG
$XXX.XX
J3471
Ovine, up to 999 usp units 1 UNIT
$XXX.XX
J3473
Hyaluronidase recombinant 1 USP UNIT
$XXX.XX
J3475
Inj magnesium sulfate 500 MG
$XXX.XX
J3480
Inj potassium chloride 2 MEQ
$XXX.XX
J3485
Zidovudine 10 MG
$XXX.XX
J3486
Ziprasidone mesylate 10 MG
$XXX.XX
J3489
Zoledronic acid 1mg 1 MG
$XXX.XX
J7030
Normal saline solution infus 1000 ML
$XXX.XX
J7040
Normal saline solution infus 500 ML
$XXX.XX
J7042
5% dextrose/normal saline 500 ML
$XXX.XX
J7050
Normal saline solution infus 250 ML
$XXX.XX
J7060
5% dextrose/water 500 ML
$XXX.XX
J7070
D5w infusion 1000 CC
$XXX.XX
J7120
Ringers lactate infusion 1000 CC
$XXX.XX
J7180
Factor xiii anti-hem factor 1 IU
$XXX.XX
J7182
Factor viii recomb novoeight 1 IU
$XXX.XX
J7183
Wilate injection 1 I.U. VWF:RCO
$XXX.XX
J7185
Xyntha inj 1 IU
$XXX.XX
J7186
Antihemophilic viii/vwf comp PER FACTOR VIII IU
$XXX.XX
J7187
Humate-p, inj 1 IU
$XXX.XX
J7189
Factor viia 1 MCG
$XXX.XX
J7190
Factor viii 1 IU
$XXX.XX
J7192
Factor viii recombinant nos 1 IU
$XXX.XX
J7193
Factor ix non-recombinant 1 IU
$XXX.XX
J7194
Factor ix complex 1 IU
$XXX.XX
J7195
Factor ix recombinant nos 1 IU
$XXX.XX
J7197
Antithrombin iii injection 1 IU
$XXX.XX
J7198
Anti-inhibitor 1 IU
$XXX.XX
J7200
Factor ix recombinan rixubis 1 IU
$XXX.XX
J7201
Factor ix alprolix recomb 1 IU
$XXX.XX
J7202
Factor ix idelvion inj 1 IU
$XXX.XX
J7205
Factor viii fc fusion recomb 1 IU
$XXX.XX
J7207
Factor viii pegylated recomb 1 IU
$XXX.XX
J7308
Aminolevulinic acid hcl top 354 MG
$XXX.XX
J7311
Fluocinolone acetonide implt 0.59 MG
$XXX.XX
J7312
Dexamethasone intra implant 0.1 MG
$XXX.XX
J7313
Fluocinol acet intravit imp 0.01 MG
$XXX.XX
J7316
Inj, ocriplasmin, 0.125 mg 0.125 MG
$XXX.XX
J7321
Hyalgan supartz visco-3 dose per dose
$XXX.XX
J7323
Euflexxa inj per dose per dose
$XXX.XX
J7324
Orthovisc inj per dose per dose
$XXX.XX
J7325
Synvisc or synvisc-one 1 MG
$XXX.XX
J7326
Gel-one per dose
$XXX.XX
J7327
Monovisc inj per dose Per Dose
$XXX.XX
J7336
Capsaicin 8% patch 1 SQ CM
$XXX.XX
J7500
Azathioprine oral 50mg 50 MG
$XXX.XX
J7502
Cyclosporine oral 100 mg 100 MG
$XXX.XX
J7503
Tacrol envarsus ex rel oral 0.25 MG
$XXX.XX
J7504
Lymphocyte immune globulin 250 MG
$XXX.XX
J7507
Tacrolimus imme rel oral 1mg 1 MG
$XXX.XX
J7508
Tacrol astagraf ex rel oral 0.1 MG
$XXX.XX
J7509
Methylprednisolone oral 4 MG
$XXX.XX
J7510
Prednisolone oral per 5 mg 5 MG
$XXX.XX
J7511
Antithymocyte globuln rabbit 25 MG
$XXX.XX
J7512
Prednisone ir or dr oral 1mg 1 MG
$XXX.XX
J7515
Cyclosporine oral 25 mg 25 MG
$XXX.XX
J7516
Cyclosporin parenteral 250mg 250 MG
$XXX.XX
J7517
Mycophenolate mofetil oral 250 MG
$XXX.XX
J7518
Mycophenolic acid 180 MG
$XXX.XX
J7520
Sirolimus, oral 1 MG
$XXX.XX
J7525
Tacrolimus injection 5 MG
$XXX.XX
J7527
Oral everolimus 0.25 MG
$XXX.XX
J7605
Arformoterol non-comp unit 15 mcg
$XXX.XX
J7606
Formoterol fumarate, inh 20 MCG
$XXX.XX
J7608
Acetylcysteine non-comp unit 1 GM
$XXX.XX
J7611
Albuterol non-comp con 1 MG
$XXX.XX
J7612
Levalbuterol non-comp con 0.5 MG
$XXX.XX
J7613
Albuterol non-comp unit 1 MG
$XXX.XX
J7614
Levalbuterol non-comp unit 0.5 MG
$XXX.XX
J7620
Albuterol ipratrop non-comp 2.5 MG/0.5 MG
$XXX.XX
J7626
Budesonide non-comp unit 0.5 MG
$XXX.XX
J7631
Cromolyn sodium noncomp unit 10 MG
$XXX.XX
J7639
Dornase alfa non-comp unit 1 MG
$XXX.XX
J7644
Ipratropium bromide non-comp 1 MG
$XXX.XX
J7674
Methacholine chloride, neb 1 MG
$XXX.XX
J7682
Tobramycin non-comp unit 300 MG
$XXX.XX
J7686
Treprostinil, non-comp unit 1.74 MG
$XXX.XX
J8501
Oral aprepitant 5 MG
$XXX.XX
J8510
Oral busulfan 2 MG
$XXX.XX
J8520
Capecitabine, oral, 150 mg 150 MG
$XXX.XX
J8521
Capecitabine, oral, 500 mg 500 MG
$XXX.XX
J8530
Cyclophosphamide oral 25 mg 25 MG
$XXX.XX
J8540
Oral dexamethasone 0.25 MG
$XXX.XX
J8560
Etoposide oral 50 mg 50 MG
$XXX.XX
J8600
Melphalan oral 2 mg 2 MG
$XXX.XX
J8610
Methotrexate oral 2.5 mg 2.5 MG
$XXX.XX
J8655
Netupitant palonosetron oral 0.5 MG
$XXX.XX
J8670
Rolapitant, oral, 1mg 1 MG
$XXX.XX
J8700
Temozolomide 5 MG
$XXX.XX
J8705
Topotecan oral 0.25 mg
$XXX.XX
J9000
Doxorubicin hcl injection 10 MG
$XXX.XX
J9017
Arsenic trioxide injection 1 MG
$XXX.XX
J9019
Erwinaze injection 1,000 IU
$XXX.XX
J9022
Inj, atezolizumab,10 mg 10 MG
$XXX.XX
J9023
Injection, avelumab, 10 mg 10 MG
$XXX.XX
J9025
Azacitidine injection 1 MG
$XXX.XX
J9027
Clofarabine injection 1 MG
$XXX.XX
J9031
Bcg live intravesical vac 1 EA
$XXX.XX
J9032
Injection, belinostat, 10mg 10 MG
$XXX.XX
J9033
Inj., treanda 1 mg 1 MG
$XXX.XX
J9034
Inj., bendeka 1 mg 1 MG
$XXX.XX
J9035
Bevacizumab injection 10 MG
$XXX.XX
J9039
Injection, blinatumomab 1 MCG
$XXX.XX
J9040
Bleomycin sulfate injection 15 UNITS
$XXX.XX
J9041
Bortezomib injection 0.1 MG
$XXX.XX
J9042
Brentuximab vedotin inj 1 MG
$XXX.XX
J9043
Cabazitaxel injection 1 MG
$XXX.XX
J9045
Carboplatin injection 50 MG
$XXX.XX
J9047
Injection, carfilzomib, 1 mg 1 MG
$XXX.XX
J9050
Carmustine injection 100 MG
$XXX.XX
J9055
Cetuximab injection 10 MG
$XXX.XX
J9060
Cisplatin 10 mg injection 10 MG
$XXX.XX
J9065
Inj cladribine per 1 mg 1 MG
$XXX.XX
J9070
Cyclophosphamide 100 mg inj 100 MG
$XXX.XX
J9098
Cytarabine liposome inj 10 MG
$XXX.XX
J9100
Cytarabine hcl 100 mg inj 100 MG
$XXX.XX
J9120
Dactinomycin injection 0.5 MG
$XXX.XX
J9130
Dacarbazine 100 mg inj 100 MG
$XXX.XX
J9145
Injection, daratumumab 10 mg 10 MG
$XXX.XX
J9150
Daunorubicin injection 10 MG
$XXX.XX
J9155
Degarelix injection 1 MG
$XXX.XX
J9171
Docetaxel injection 1 MG
$XXX.XX
J9176
Injection, elotuzumab, 1mg 1 MG
$XXX.XX
J9178
Inj, epirubicin hcl, 2 mg 2 MG
$XXX.XX
J9179
Eribulin mesylate injection 0.1 MG
$XXX.XX
J9181
Etoposide injection 10 MG
$XXX.XX
J9185
Fludarabine phosphate inj 50 MG
$XXX.XX
J9190
Fluorouracil injection 500 MG
$XXX.XX
J9200
Floxuridine injection 500 MG
$XXX.XX
J9201
Gemcitabine hcl injection 200 MG
$XXX.XX
J9202
Goserelin acetate implant 3.6 MG
$XXX.XX
J9205
Inj irinotecan liposome 1 mg 1 MG
$XXX.XX
J9206
Irinotecan injection 20 MG
$XXX.XX
J9207
Ixabepilone injection 1 MG
$XXX.XX
J9208
Ifosfamide injection 1 GM
$XXX.XX
J9209
Mesna injection 200 MG
$XXX.XX
J9211
Idarubicin hcl injection 5 MG
$XXX.XX
J9214
Interferon alfa-2b inj 1 MIL UNITS
$XXX.XX
J9217
Leuprolide acetate suspnsion 7.5 MG
$XXX.XX
J9218
Leuprolide acetate injeciton 1 MG
$XXX.XX
J9225
Vantas implant 50 MG
$XXX.XX
J9226
Supprelin la implant 50 MG
$XXX.XX
J9228
Ipilimumab injection 1 MG
$XXX.XX
J9230
Mechlorethamine hcl inj 10 MG
$XXX.XX
J9245
Inj melphalan hydrochl 50 mg 50 MG
$XXX.XX
J9250
Methotrexate sodium inj 5 MG
$XXX.XX
J9260
Methotrexate sodium inj 50 MG
$XXX.XX
J9261
Nelarabine injection 50 MG
$XXX.XX
J9263
Oxaliplatin 0.5 MG
$XXX.XX
J9264
Paclitaxel protein bound 1 MG
$XXX.XX
J9266
Pegaspargase injection 1 EA
$XXX.XX
J9267
Paclitaxel injection 1 MG
$XXX.XX
J9268
Pentostatin injection 10 MG
$XXX.XX
J9271
Inj pembrolizumab 1 MG
$XXX.XX
J9280
Mitomycin injection 5 MG
$XXX.XX
J9285
Inj, olaratumab, 10 mg 10 MG
$XXX.XX
J9293
Mitoxantrone hydrochl / 5 mg 5 MG
$XXX.XX
J9295
Injection, necitumumab, 1 mg 1 MG
$XXX.XX
J9299
Injection, nivolumab 1 MG
$XXX.XX
J9301
Obinutuzumab inj 10 MG
$XXX.XX
J9302
Ofatumumab injection 10 MG
$XXX.XX
J9303
Panitumumab injection 10 MG
$XXX.XX
J9305
Pemetrexed injection 10 MG
$XXX.XX
J9306
Injection, pertuzumab, 1 mg 1 MG
$XXX.XX
J9307
Pralatrexate injection 1 MG
$XXX.XX
J9308
Injection, ramucirumab 5 MG
$XXX.XX
J9310
Rituximab injection 100 MG
$XXX.XX
J9315
Romidepsin injection 1 MG
$XXX.XX
J9320
Streptozocin injection 1 GM
$XXX.XX
J9325
Inj talimogene laherparepvec 1 million PFU
$XXX.XX
J9328
Temozolomide injection 1 MG
$XXX.XX
J9330
Temsirolimus injection 1 MG
$XXX.XX
J9351
Topotecan injection 0.1 MG
$XXX.XX
J9352
Injection trabectedin 0.1mg 0.1 MG
$XXX.XX
J9354
Inj, ado-trastuzumab emt 1mg 1 MG
$XXX.XX
J9355
Trastuzumab injection 10 MG
$XXX.XX
J9357
Valrubicin injection 200 MG
$XXX.XX
J9360
Vinblastine sulfate inj 1 MG
$XXX.XX
J9370
Vincristine sulfate 1 mg inj 1 MG
$XXX.XX
J9371
Inj, vincristine sul lip 1mg 1 MG
$XXX.XX
J9390
Vinorelbine tartrate inj 10 MG
$XXX.XX
J9395
Injection, fulvestrant 25 MG
$XXX.XX
J9400
Inj, ziv-aflibercept, 1mg 1 MG
$XXX.XX
P9041
Albumin (human),5%, 50ml 50 ML
$XXX.XX
P9045
Albumin (human), 5%, 250 ml 250 ML
$XXX.XX
P9046
Albumin (human), 25%, 20 ml 20 ML
$XXX.XX
P9047
Albumin (human), 25%, 50ml 50 ML
$XXX.XX
Q0138
Ferumoxytol, non-esrd 1 MG
$XXX.XX
Q0139
Ferumoxytol, esrd use 1 MG
$XXX.XX
Q0162
Ondansetron oral 1 MG
$XXX.XX
Q0163
Diphenhydramine hcl 50mg 50 MG
$XXX.XX
Q0164
Prochlorperazine maleate 5mg 5 MG
$XXX.XX
Q0166
Granisetron hcl 1 mg oral 1 MG
$XXX.XX
Q0167
Dronabinol 2.5mg oral 2.5 MG
$XXX.XX
Q0169
Promethazine hcl 12.5mg oral 12.5 MG
$XXX.XX
Q2035
Afluria vacc, 3 yrs & >, im 0.5 ml
$XXX.XX
Q2043
Sipuleucel-t auto cd54+ Per infusion (minimum 50 million cells)
$XXX.XX
Q2050
Doxorubicin inj 10mg 10 MG
$XXX.XX
Q3027
Inj beta interferon im 1 mcg 1 MCG
$XXX.XX
Q4074
Iloprost non-comp unit dose UP TO 20 MCG
$XXX.XX
Q4081
Epoetin alfa, 100 units esrd 100 UNITS
$XXX.XX
Q4101
Apligraf 1 SQ CM
$XXX.XX
Q4102
Oasis wound matrix 1 SQ CM
$XXX.XX
Q4106
Dermagraft 1 SQ CM
$XXX.XX
Q4107
Graftjacket 1 SQ CM
$XXX.XX
Q4111
Gammagraft 1 SQ CM
$XXX.XX
Q4112
Cymetra injectable 1 CC
$XXX.XX
Q4113
Graftjacket xpress 1 CC
$XXX.XX
Q4115
Alloskin 1 SQ CM
$XXX.XX
Q4121
Theraskin 1 SQ CM
$XXX.XX
Q4123
Alloskin 1 SQ CM
$XXX.XX
Q4131
Epifix or epicord 1 SQ CM
$XXX.XX
Q4132
Grafix core, grafixpl core 1 SQ CM
$XXX.XX
Q4133
Grafix prime grafix pl prime 1 SQ CM
$XXX.XX
Q4172
Puraply or puraply am 1 SQ CM
$XXX.XX
Q5101
Inj filgrastim gcsf biosimil 1 MCG
$XXX.XX
Q5103
Injection, inflectra 10 MG
$XXX.XX
Q5104
Injection, renflexis 10 MG
$XXX.XX
Q5105
Inj Retacrit esrd on dialysi 100 UNITS
$XXX.XX
Q5106
Inj Retacrit non-esrd use 1000 UNITS
$XXX.XX
Q5108
Injection, fulphila 0.5 MG
$XXX.XX
Q9950
Inj sulf hexa lipid microsph 1 ML
$XXX.XX
Q9956
Inj octafluoropropane mic,ml 1 ML
$XXX.XX
Q9957
Inj perflutren lip micros,ml 1 ML
$XXX.XX
Q9958
Hocm <=149 mg/ml iodine, 1ml 1 ML
$XXX.XX
Q9960
Hocm 200-249mg/ml iodine,1ml 1 ML
$XXX.XX
Q9961
Hocm 250-299mg/ml iodine,1ml 1 ML
$XXX.XX
Q9963
Hocm 350-399mg/ml iodine,1ml 1 ML
$XXX.XX
Q9965
Locm 100-199mg/ml iodine,1ml 1 ML
$XXX.XX
Q9966
Locm 200-299mg/ml iodine,1ml 1 ML
$XXX.XX
Q9967
Locm 300-399mg/ml iodine,1ml 1 ML
$XXX.XX
Q9991
Buprenorph xr 100 mg or less Less than or equal to 100 MG
$XXX.XX
Q9992
Buprenorphine xr over 100 mg Greater than 100 MG
$XXX.XX
Q9993
Inj., triamcinolone ext rel 1 MG
$XXX.XX
Q9995
Inj. emicizumab-kxwh, 0.5 mg 0.5 MG
$XXX.XX



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