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LCDs and LCAs
by Contractor

PLA Codes

Laboratory Fee Schedule

2024
2023

Physician Fee Schedule

OPPS Fee Schedule

ASC Fee Schedule

APC Codes

DRG Codes

ASP Drug Pricing Files

2024-July
2024-April

CMS Transmittals

January 2023 Payment Allowance Limits for Medicare Part B Drugs
Source

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
90377	Rabies ig ht&sol human im/sc	150 IU	$XXX.XX
90586	Bcg vaccine intravesical	1 EACH	$XXX.XX
90632	Hepa vaccine adult im	1 ML	$XXX.XX
90662	Iiv no prsv increased ag im	0.5 ML	$XXX.XX
90670	Pcv13 vaccine im	0.5 ML	$XXX.XX
90671	PCV15 vaccine IM	1 EA	$XXX.XX
90672	Laiv4 vaccine intranasal	0.2 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
90677	Pcv20 vaccine im	0.5 ML	$XXX.XX
90682	Riv4 vacc recombinant dna im	0.5 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
90694	Vacc AIIV4 no prsrv 0.5ML 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
90743	Hep b vacc, adol, 2 dose, im	1 DOSE	$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
90759	Hep b vac 3ag 10mcg 3 dos im	10 MCG	$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
A9589	Insti hexaminolevulinate hcl	100 MG	$XXX.XX
A9606	Radium ra223 dichloride ther	1 microCurie	$XXX.XX
J0121	Inj., omadacycline, 1 mg	1 MG	$XXX.XX
J0122	Inj., eravacycline, 1 mg	1 MG	$XXX.XX
J0129	Abatacept injection	10 MG	$XXX.XX
J0131	Inj, acetaminophen (nos)	10 MG	$XXX.XX
J0132	Acetylcysteine injection	100 MG	$XXX.XX
J0133	Acyclovir injection	5 MG	$XXX.XX
J0134	Inj acetaminophen -fresenius	10 MG	$XXX.XX
J0136	Inj, acetaminophen (b braun)	10 MG	$XXX.XX
J0153	Adenosine inj 1mg	1 MG	$XXX.XX
J0171	Adrenalin epinephrine inject	0.1 MG	$XXX.XX
J0172	Inj, aducanumab-avwa, 2 mg	2 MG	$XXX.XX
J0178	Aflibercept injection	1 MG	$XXX.XX
J0179	Inj, brolucizumab-dbll, 1 mg	1 MG	$XXX.XX
J0180	Agalsidase beta injection	1 MG	$XXX.XX
J0185	Inj., aprepitant, 1 mg	1 MG	$XXX.XX
J0202	Injection, alemtuzumab	1 MG	$XXX.XX
J0219	Inj aval alfa-nqpt 4mg	4 MG	$XXX.XX
J0221	Lumizyme injection	10 MG	$XXX.XX
J0222	Inj., patisiran, 0.1 mg	0.1 MG	$XXX.XX
J0223	Inj givosiran 0.5 mg	0.5 MG	$XXX.XX
J0224	Inj. lumasiran, 0.5 mg	0.5 MG	$XXX.XX
J0248	Inj, remdesivir, 1 mg	1 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
J0291	Inj., plazomicin, 5 mg	5 MG	$XXX.XX
J0295	Ampicillin sulbactam 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
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
J0491	Inj anifrolumab-fnia 1mg	1 MG	$XXX.XX
J0500	Dicyclomine injection	20 MG	$XXX.XX
J0515	Inj benztropine mesylate	1 MG	$XXX.XX
J0517	Inj., benralizumab, 1 mg	1 MG	$XXX.XX
J0558	Peng benzathine/procaine inj	100,000 UNITS	$XXX.XX
J0561	Penicillin g benzathine inj	100,000 UNITS	$XXX.XX
J0565	Inj, bezlotoxumab, 10 mg	10 MG	$XXX.XX
J0583	Bivalirudin	1 MG	$XXX.XX
J0584	Injection, burosumab-twza 1m	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 glucon (fresenius)	10 ML	$XXX.XX
J0611	Calcium glucon (wg critical)	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	Inj levoleucovorin nos 0.5mg	0.5 MG	$XXX.XX
J0642	Injection, khapzory, 0.5 mg	0.5 MG	$XXX.XX
J0670	Inj mepivacaine hcl/10 ml	10 ML	$XXX.XX
J0689	Inj cefazolin sodium, baxter	500 MG	$XXX.XX
J0690	Cefazolin sodium injection	500 MG	$XXX.XX
J0691	Inj lefamulin 1 mg	1 MG	$XXX.XX
J0692	Cefepime hcl for injection	500 MG	$XXX.XX
J0694	Cefoxitin sodium injection	1 GM	$XXX.XX
J0695	Inj ceftolozane tazobactam	75mg (50mg cft/25mg taz)	$XXX.XX
J0696	Ceftriaxone sodium injection	250 MG	$XXX.XX
J0697	Sterile cefuroxime injection	750 MG	$XXX.XX
J0701	Inj. cefepime hcl (baxter)	500 MG	$XXX.XX
J0702	Betamethasone acet&sod phosp	3 MG & 3 MG	$XXX.XX
J0703	Inj, cefepime hcl (b braun)	500 MG	$XXX.XX
J0712	Ceftaroline fosamil inj	10 MG	$XXX.XX
J0713	Inj ceftazidime per 500 mg	500 MG	$XXX.XX
J0714	Ceftazidime and avibactam	.625 GM	$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
J0741	Inj, cabote rilpivir 2mg 3mg	2MG/3MG	$XXX.XX
J0742	Inj imip 4 cilas 4 releb 2mg	4 MG-4 MG-2 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
J0791	Inj crizanlizumab-tmca 5mg	5 MG	$XXX.XX
J0800	Corticotropin injection	40 UNITS	$XXX.XX
J0834	Inj., cosyntropin, 0.25 mg	0.25 MG	$XXX.XX
J0840	Crotalidae poly immune fab	UP TO 1 GM	$XXX.XX
J0841	Inj crotalidae im f(ab')2 eq	120 MG	$XXX.XX
J0850	Cytomegalovirus imm iv /vial	PER VIAL	$XXX.XX
J0875	Injection, dalbavancin	5 MG	$XXX.XX
J0877	Inj, daptomycin (hospira)	1 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
J0891	Argatroban nonesrd (accord)	1 MG	$XXX.XX
J0892	Argatroban dialysis (accord)	1 MG	$XXX.XX
J0893	Inj, decitabine (sun pharma)	1 MG	$XXX.XX
J0894	Decitabine injection	1 MG	$XXX.XX
J0895	Deferoxamine mesylate inj	500 MG	$XXX.XX
J0896	Inj luspatercept-aamt 0.25mg	0.25 MG	$XXX.XX
J0897	Denosumab injection	1 MG	$XXX.XX
J0898	Argatroban nonesrd (auromed)	1 MG	$XXX.XX
J0899	Argatroban dialysis, auromed	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
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
J1201	Inj. cetirizine hcl 0.5mg	0.5 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
J1270	Injection, doxercalciferol	1 MCG	$XXX.XX
J1290	Ecallantide injection	1 MG	$XXX.XX
J1300	Eculizumab injection	10 MG	$XXX.XX
J1301	Injection, edaravone, 1 mg	1 MG	$XXX.XX
J1303	Inj., ravulizumab-cwvz 10 mg	10 MG	$XXX.XX
J1305	Inj, evinacumab-dgnb, 5mg	5 MG	$XXX.XX
J1306	Injection, inclisiran, 1 mg	1 MG	$XXX.XX
J1322	Elosulfase alfa, injection	1 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
J1437	Inj. fe derisomaltose 10 mg	10 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
J1448	Injection, trilaciclib, 1mg	1 MG	$XXX.XX
J1450	Fluconazole	200 MG	$XXX.XX
J1453	Fosaprepitant injection	1 MG	$XXX.XX
J1454	Inj fosnetupitant, palonoset	0.25 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
J1551	Inj cutaquig 100 mg	100 MG	$XXX.XX
J1554	Inj. asceniv	500 MG	$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
J1558	Inj. xembify, 100 mg	100 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
J1611	Inj glucagon hcl, fresenius	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
J1738	Inj. meloxicam 1 mg	1 MG	$XXX.XX
J1740	Ibandronate sodium injection	1 MG	$XXX.XX
J1743	Idursulfase injection	1 MG	$XXX.XX
J1745	Infliximab not biosimil 10mg	10 MG	$XXX.XX
J1746	Inj., ibalizumab-uiyk, 10 mg	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
J1817	Insulin for insulin pump use	50 UNITS	$XXX.XX
J1823	Inj. inebilizumab-cdon, 1 mg	1 MG	$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
J1932	Inj, lanreotide, (cipla) 1mg	1 MG	$XXX.XX
J1940	Furosemide injection	20 MG	$XXX.XX
J1943	Inj., aristada initio, 1 mg	1 MG	$XXX.XX
J1944	Aripiprazole lauroxil 1 mg	1 MG	$XXX.XX
J1950	Leuprolide acetate /3.75 mg	3.75 MG	$XXX.XX
J1951	Inj fensolvi 0.25 mg	0.25 MG	$XXX.XX
J1952	Leuprolide inj, camcevi, 1mg	1 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
J2021	Inj, linezolid (hospira)	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
J2184	Inj, meropenem (b. braun)	100 MG	$XXX.XX
J2185	Meropenem	100 MG	$XXX.XX
J2210	Methylergonovin maleate inj	0.2 MG	$XXX.XX
J2247	Inj, micafungin (par pharm)	1 MG	$XXX.XX
J2248	Micafungin sodium injection	1 MG	$XXX.XX
J2250	Inj midazolam hydrochloride	1 MG	$XXX.XX
J2251	Inj midazolam (wg crit care)	1 MG	$XXX.XX
J2260	Inj milrinone lactate / 5 mg	5 MG	$XXX.XX
J2270	Morphine sulfate injection	10 MG	$XXX.XX
J2272	Inj, morphine (fresenius)	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
J2281	Inj moxifloxacin (fres kabi)	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
J2327	Inj risankizumab-rzaa 1 mg	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
J2356	Inj tezepelumab-ekko, 1mg	1 MG	$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
J2401	Chloroprocaine hcl injection	1 MG	$XXX.XX
J2405	Ondansetron hcl injection	1 MG	$XXX.XX
J2406	Injection, oritavancin 10 mg	10 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
J2506	Inj pegfilgrast ex bio 0.5mg	0.5 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
J2760	Phentolaine mesylate inj	5 MG	$XXX.XX
J2765	Metoclopramide hcl injection	10 MG	$XXX.XX
J2770	Quinupristin/dalfopristin	500 MG	$XXX.XX
J2777	Inj, faricimab-svoa, 0.1mg	0.1 MG	$XXX.XX
J2778	Ranibizumab injection	0.1 mg	$XXX.XX
J2779	Inj, susvimo 0.1 mg	0.1 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	Inj risperdal consta, 0.5 mg	0.5 MG	$XXX.XX
J2795	Ropivacaine hcl injection	1 MG	$XXX.XX
J2796	Romiplostim injection	10 MCG	$XXX.XX
J2798	Inj., perseris, 0.5 mg	0.5 mg	$XXX.XX
J2800	Methocarbamol injection	10 ML	$XXX.XX
J2805	Sincalide injection	5 MCG	$XXX.XX
J2820	Sargramostim injection	50 MCG	$XXX.XX
J2860	Injection, siltuximab	10 MG	$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
J3032	Inj. eptinezumab-jjmr 1 mg	1 MG	$XXX.XX
J3060	Inj, taliglucerase alfa 10 u	10 UNITS	$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
J3111	Inj. romosozumab-aqqg 1 mg	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
J3241	Inj. teprotumumab-trbw 10 mg	10 MG	$XXX.XX
J3243	Tigecycline injection	1 MG	$XXX.XX
J3245	Inj., tildrakizumab, 1 mg	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
J3299	Inj xipere 1 mg	0.1 MG	$XXX.XX
J3300	Triamcinolone a inj prs-free	1 MG	$XXX.XX
J3301	Triamcinolone acet inj nos	10 MG	$XXX.XX
J3304	Inj triamcinolone ace xr 1mg	1 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
J3371	Inj, vancomycin hcl (mylan)	500 MG	$XXX.XX
J3372	Inj, vancomycin hcl (xellia)	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
J7170	Inj., emicizumab-kxwh 0.5 mg	0.5 MG	$XXX.XX
J7175	Inj, factor x, (human), 1iu	1 IU	$XXX.XX
J7177	Inj., fibryga, 1 mg	1 MG	$XXX.XX
J7178	Inj human fibrinogen con nos	1 IU	$XXX.XX
J7179	Vonvendi inj 1 iu vwf:rco	1 IU	$XXX.XX
J7180	Factor xiii anti-hem factor	1 IU	$XXX.XX
J7181	Factor xiii recomb a-subunit	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
J7188	Factor viii recomb obizur	1 IU	$XXX.XX
J7189	Factor viia recomb novoseven	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
J7203	Factor ix recomb gly rebinyn	1 MG	$XXX.XX
J7204	Inj recombin esperoct per iu	1 IU	$XXX.XX
J7205	Factor viii fc fusion recomb	1 IU	$XXX.XX
J7207	Factor viii pegylated recomb	1 IU	$XXX.XX
J7208	Inj. jivi 1 iu	1 IU	$XXX.XX
J7209	Factor viii nuwiq recomb 1iu	1 IU	$XXX.XX
J7210	Inj, afstyla, 1 i.u.	1 IU	$XXX.XX
J7211	Inj, kovaltry, 1 i.u.	1 IU	$XXX.XX
J7212	Factor viia recomb sevenfact	1 MCG	$XXX.XX
J7308	Aminolevulinic acid hcl top	354 MG	$XXX.XX
J7311	Inj., retisert, 0.01 mg	0.01 MG	$XXX.XX
J7312	Dexamethasone intra implant	0.1 MG	$XXX.XX
J7313	Inj., iluvien, 0.01 mg	0.01 MG	$XXX.XX
J7314	Inj., yutiq, 0.01 mg	0.01 MG	$XXX.XX
J7318	Inj, durolane 1 mg	1 MG	$XXX.XX
J7320	Genvisc 850, inj, 1mg	1 MG	$XXX.XX
J7321	Hyalgan supartz visco-3 dose	per dose	$XXX.XX
J7322	Hymovis injection 1 mg	1 MG	$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
J7328	Gelsyn-3 injection 0.1 mg	0.1 MG	$XXX.XX
J7329	Inj, trivisc 1 mg	1 MG	$XXX.XX
J7332	Inj., triluron, 1 mg	1 MG	$XXX.XX
J7336	Capsaicin 8% patch	1 SQ CM	$XXX.XX
J7340	Carbidopa levodopa ent 100ml	100 ML	$XXX.XX
J7342	Ciprofloxacin otic susp 6 mg	6 MG	$XXX.XX
J7345	Aminolevulinic acid, 10% gel	10 MG	$XXX.XX
J7351	Inj bimatoprost itc imp1mcg	1 MCG	$XXX.XX
J7402	Mometasone sinus sinuva	10 MCG	$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
J7677	Revefenacin inh non-com 1mcg	1 MCG	$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
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
J8610	Methotrexate oral 2.5 mg	2.5 MG	$XXX.XX
J8655	Oral netupitant, palonosetro	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
J9021	Inj, aspara, rylaze, 0.1 mg	0.1 MG	$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
J9030	Bcg live intravesical 1mg	1 MG	$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
J9036	Inj. belrapzo/bendamustine	1 MG	$XXX.XX
J9037	Inj belantamab mafodot blmf	0.5 MG	$XXX.XX
J9039	Injection, blinatumomab	1 MCG	$XXX.XX
J9040	Bleomycin sulfate injection	15 UNITS	$XXX.XX
J9041	Injection, bortezomib, 0.1mg	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
J9046	Inj, bortezomib, dr. reddy's	0.1 MG	$XXX.XX
J9047	Injection, carfilzomib, 1 mg	1 MG	$XXX.XX
J9048	Inj, bortezomib freseniuskab	0.1 MG	$XXX.XX
J9049	Inj, bortezomib, hospira	0.1 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
J9061	Inj, amivantamab-vmjw	2 MG	$XXX.XX
J9065	Inj cladribine per 1 mg	1 MG	$XXX.XX
J9070	Cyclophosphamide 100 mg inj	100 MG	$XXX.XX
J9071	Inj cyclophosphamd auromedic	5 MG	$XXX.XX
J9100	Cytarabine hcl 100 mg inj	100 MG	$XXX.XX
J9118	Inj. calaspargase pegol-mknl	10 UNIT	$XXX.XX
J9119	Inj., cemiplimab-rwlc, 1 mg	1 MG	$XXX.XX
J9120	Dactinomycin injection	0.5 MG	$XXX.XX
J9130	Dacarbazine 100 mg inj	100 MG	$XXX.XX
J9144	Daratumumab, hyaluronidase	10 MG	$XXX.XX
J9145	Injection, daratumumab 10 mg	10 MG	$XXX.XX
J9150	Daunorubicin injection	10 MG	$XXX.XX
J9153	Inj daunorubicin, cytarabine	1 MG/2.27 MG	$XXX.XX
J9155	Degarelix injection	1 MG	$XXX.XX
J9171	Docetaxel injection	1 MG	$XXX.XX
J9173	Inj., durvalumab, 10 mg	10 MG	$XXX.XX
J9176	Injection, elotuzumab, 1mg	1 MG	$XXX.XX
J9177	Inj enfort vedo-ejfv 0.25mg	0.25 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
J9198	Inj. infugem, 100 mg	100 MG	$XXX.XX
J9200	Floxuridine injection	500 MG	$XXX.XX
J9201	In gemcitabine hcl nos 200mg	200 MG	$XXX.XX
J9202	Goserelin acetate implant	3.6 MG	$XXX.XX
J9203	Gemtuzumab ozogamicin 0.1 mg	0.1 MG	$XXX.XX
J9204	Inj mogamulizumab-kpkc, 1 mg	1 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
J9210	Inj., emapalumab-lzsg, 1 mg	1 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
J9223	Inj. lurbinectedin, 0.1 mg	0.1 MG	$XXX.XX
J9226	Supprelin la implant	50 MG	$XXX.XX
J9227	Inj. isatuximab-irfc 10 mg	10 MG	$XXX.XX
J9228	Ipilimumab injection	1 MG	$XXX.XX
J9229	Inj inotuzumab ozogam 0.1 mg	0.1 MG	$XXX.XX
J9245	Inj melpha hydroch nos 50 mg	50 MG	$XXX.XX
J9246	Inj., evomela, 1 mg	1 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
J9262	Inj, omacetaxine mep, 0.01mg	0.01 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
J9269	Inj. tagraxofusp-erzs 10 mcg	10 MCG	$XXX.XX
J9271	Inj pembrolizumab	1 MG	$XXX.XX
J9272	Inj, dostarlimab-gxly, 10 mg	10 MG	$XXX.XX
J9273	Inj tisotu vedotin-tftv, 1mg	1 MG	$XXX.XX
J9274	Inj, tebentafusp-tebn, 1 mcg	1 MCG	$XXX.XX
J9280	Mitomycin injection	5 MG	$XXX.XX
J9281	Mitomycin instillation	1 MG	$XXX.XX
J9293	Mitoxantrone hydrochl / 5 mg	5 MG	$XXX.XX
J9295	Injection, necitumumab, 1 mg	1 MG	$XXX.XX
J9298	Inj nivol relatlimab 3mg/1mg	3 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
J9304	Inj. pemetrexed, 10 mg	10 MG	$XXX.XX
J9305	Inj. pemetrexed nos 10mg	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
J9309	Inj, polatuzumab vedotin 1mg	1 MG	$XXX.XX
J9311	Inj rituximab, hyaluronidase	10 mg	$XXX.XX
J9312	Inj., rituximab, 10 mg	10 MG	$XXX.XX
J9313	Inj., lumoxiti, 0.01 mg	0.01 MG	$XXX.XX
J9316	Pertuzu, trastuzu, 10 mg	10 MG	$XXX.XX
J9317	Sacituzumab govitecan-hziy	2.5 MG	$XXX.XX
J9319	Inj romidepsin lyophil 0.1mg	0.1 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
J9331	Inj sirolimus prot part 1 mg	1 MG	$XXX.XX
J9332	Inj efgartigimod 2mg	2 MG	$XXX.XX
J9340	Thiotepa injection	15 MG	$XXX.XX
J9349	Inj., tafasitamab-cxix	2 MG	$XXX.XX
J9351	Topotecan injection	0.1 MG	$XXX.XX
J9352	Injection trabectedin 0.1mg	0.1 MG	$XXX.XX
J9353	Inj. margetuximab-cmkb, 5 mg	5 MG	$XXX.XX
J9354	Inj, ado-trastuzumab emt 1mg	1 MG	$XXX.XX
J9355	Inj trastuzumab excl biosimi	10 MG	$XXX.XX
J9356	Inj. herceptin hylecta, 10mg	10 MG	$XXX.XX
J9357	Valrubicin injection	200 MG	$XXX.XX
J9358	Inj fam-trastu deru-nxki 1mg	1 MG	$XXX.XX
J9359	Inj lon tesirin-lpyl 0.075mg	0.075 MG	$XXX.XX
J9360	Vinblastine sulfate inj	1 MG	$XXX.XX
J9370	Vincristine sulfate 1 mg inj	1 MG	$XXX.XX
J9390	Vinorelbine tartrate inj	10 MG	$XXX.XX
J9393	Inj, fulvestrant (teva)	25 MG	$XXX.XX
J9394	Inj, fulvestrant (fresenius)	25 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
Q0167	Dronabinol 2.5mg oral	2.5 MG	$XXX.XX
Q0222	Bebtelovimab 175 mg	175 MG	$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
Q4103	Oasis burn matrix	1 SQ CM	$XXX.XX
Q4104	Integra bmwd	1 SQ CM	$XXX.XX
Q4105	Integra drt or omnigraft	1 SQ CM	$XXX.XX
Q4106	Dermagraft	1 SQ CM	$XXX.XX
Q4108	Integra matrix	1 SQ CM	$XXX.XX
Q4110	Primatrix	1 SQ CM	$XXX.XX
Q4111	Gammagraft	1 SQ CM	$XXX.XX
Q4114	Integra flowable wound matri	1 CC	$XXX.XX
Q4115	Alloskin	1 SQ CM	$XXX.XX
Q4117	Hyalomatrix	1 SQ CM	$XXX.XX
Q4118	Matristem micromatrix	1 MG	$XXX.XX
Q4121	Theraskin	1 SQ CM	$XXX.XX
Q4123	Alloskin	1 SQ CM	$XXX.XX
Q4124	Oasis tri-layer wound matrix	1 SQ CM	$XXX.XX
Q4126	Memoderm/derma/tranz/integup	1 SQ CM	$XXX.XX
Q4127	Talymed	1 SQ CM	$XXX.XX
Q4128	Flexhd/allopatchhd/sq cm	1 SQ CM	$XXX.XX
Q4132	Grafix core, grafixpl core	1 SQ CM	$XXX.XX
Q4133	Grafix stravix prime pl sqcm	1 SQ CM	$XXX.XX
Q4137	Amnioexcel biodexcel 1sq cm	1 SQ CM	$XXX.XX
Q4143	Repriza, 1cm	1 SQ CM	$XXX.XX
Q4150	Allowrap ds or dry 1 sq cm	1 SQ CM	$XXX.XX
Q4151	Amnioband, guardian 1 sq cm	1 SQ CM	$XXX.XX
Q4152	Dermapure 1 square cm	1 SQ CM	$XXX.XX
Q4153	Dermavest, plurivest sq cm	1 SQ CM	$XXX.XX
Q4154	Biovance 1 square cm	1 SQ CM	$XXX.XX
Q4159	Affinity1 square cm	1 SQ CM	$XXX.XX
Q4160	Nushield 1 square cm	1 SQ CM	$XXX.XX
Q4161	Bio-connekt per square cm	1 SQ CM	$XXX.XX
Q4163	Woundex, bioskin, per sq cm	1 SQ CM	$XXX.XX
Q4170	Cygnus, per sq cm	1 SQ CM	$XXX.XX
Q4171	Interfyl, 1 mg	1 MG	$XXX.XX
Q4175	Miroderm	1 SQ CM	$XXX.XX
Q4176	Neopatch or therion, 1 sq cm	1 SQ CM	$XXX.XX
Q4180	Revita, per sq cm	1 SQ CM	$XXX.XX
Q4186	Epifix 1 sq cm	1 SQ CM	$XXX.XX
Q4187	Epicord 1 sq cm	1 SQ CM	$XXX.XX
Q4195	Puraply 1 sq cm	1 SQ CM	$XXX.XX
Q4196	Puraply am 1 sq cm	1 SQ CM	$XXX.XX
Q4197	Puraply xt 1 sq cm	1 SQ CM	$XXX.XX
Q4199	Cygnus matrix, per sq cm	1 SQ CM	$XXX.XX
Q4201	Matrion 1 sq cm	1 SQ CM	$XXX.XX
Q4203	Derma-gide, 1 sq cm	1 SQ CM	$XXX.XX
Q4210	Axolotl graf dualgraf sq cm	1 SQ CM	$XXX.XX
Q4227	Amniocore per sq cm	1 SQ CM	$XXX.XX
Q4231	Corplex p, per cc	1 CC	$XXX.XX
Q4232	Corplex, per sq cm	1 SQ CM	$XXX.XX
Q4235	Amniorepair or altiply sq cm	1 SQ CM	$XXX.XX
Q4244	Procenta, per 200 mg	200 MG	$XXX.XX
Q4246	Coretext or protext, per cc	1 CC	$XXX.XX
Q4247	Amniotext patch, per sq cm	1 SQ CM	$XXX.XX
Q4248	Dermacyte amn mem allo sq cm	1 SQ CM	$XXX.XX
Q4252	Vendaje, per square centimet	1 SQ CM	$XXX.XX
Q4254	Novafix dl per sq cm	1 SQ CM	$XXX.XX
Q4258	Enverse, per sq cm	1 SQ CM	$XXX.XX
Q5101	Injection, zarxio	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
Q5107	Inj mvasi 10 mg	10 MG	$XXX.XX
Q5108	Injection, fulphila	0.5 MG	$XXX.XX
Q5110	Nivestym	1 MCG	$XXX.XX
Q5111	Injection, udenyca 0.5 mg	0.5 MG	$XXX.XX
Q5112	Inj ontruzant 10 mg	10 MG	$XXX.XX
Q5113	Inj herzuma 10 mg	10 MG	$XXX.XX
Q5114	Inj ogivri 10 mg	10 MG	$XXX.XX
Q5115	Inj truxima 10 mg	10 MG	$XXX.XX
Q5116	Inj., trazimera, 10 mg	10 MG	$XXX.XX
Q5117	Inj., kanjinti, 10 mg	10 MG	$XXX.XX
Q5118	Inj., zirabev, 10 mg	10 MG	$XXX.XX
Q5119	Inj ruxience, 10 mg	10 MG	$XXX.XX
Q5120	Inj pegfilgrastim-bmez 0.5mg	0.5 MG	$XXX.XX
Q5121	Inj. avsola, 10 mg	10 MG	$XXX.XX
Q5122	Inj, nyvepria	0.5 MG	$XXX.XX
Q5123	Inj. riabni, 10 mg	10 MG	$XXX.XX
Q5124	Inj. byooviz, 0.1 mg	0.1 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
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

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