| 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
|
| 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
|
| 90653 |
Iiv adjuvant vaccine im
|
0.5 ML
|
$XXX.XX
|
| 90656 |
IIV3 VACC NO PRSV 0.5 ML IM
|
0.5 ML
|
$XXX.XX
|
| 90657 |
IIV3 VACCINE SPLT 0.25 ML IM
|
0.25 ML
|
$XXX.XX
|
| 90658 |
IIV3 VACCINE SPLT 0.5 ML IM
|
0.5 ML
|
$XXX.XX
|
| 90660 |
LAIV3 Vaccine Intranasal
|
0.2 ML
|
$XXX.XX
|
| 90661 |
CCIIV3 VACCINE NO PRSC 0.5ML 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
|
| 90671 |
PCV15 vaccine IM
|
1 EA
|
$XXX.XX
|
| 90673 |
Riv3 vaccine no preserv im
|
0.5 ML
|
$XXX.XX
|
| 90675 |
Rabies vaccine im
|
1 ML
|
$XXX.XX
|
| 90677 |
Pcv20 vaccine im
|
0.5 ML
|
$XXX.XX
|
| 90684 |
PCV21 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
|
| 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
|
| 90759 |
Hep b vac 3ag 10mcg 3 dos im
|
10 MCG
|
$XXX.XX
|
| 91304 |
SARSCOV2 VAC 5MCG/0.5ML IM
|
0.5 ML
|
$XXX.XX
|
| 91318 |
SARSCOV2 VAC 3MCG TRS-SUC IM
|
0.3 ML
|
$XXX.XX
|
| 91319 |
SARSCV2 VAC 10MCG TRS-SUC IM
|
0.3 ML
|
$XXX.XX
|
| 91320 |
SARSCV2 VAC 30MCG TRS-SUC IM
|
0.3 ML
|
$XXX.XX
|
| 91321 |
SARSCOV2 VAC 25 MCG/.25ML IM
|
0.25 ML
|
$XXX.XX
|
| 91322 |
SARSCOV2 VAC 50 MCG/0.5ML IM
|
0.5 ML
|
$XXX.XX
|
| A9573 |
Inj gadopiclenol
|
1 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
|
| 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
|
| J0137 |
Inj, acetaminophen (hikma)
|
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
|
| J0173 |
Inj, epinephrine (belcher)
|
0.1 MG
|
$XXX.XX
|
| J0174 |
Inj, lecanemab-irmb, 1 mg
|
1 MG
|
$XXX.XX
|
| J0175 |
Inj, donanemab-azbt, 2 mg
|
2 MG
|
$XXX.XX
|
| J0177 |
Inj, aflibercept hd, 1 mg
|
1 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
|
| J0206 |
Inj allopurinol sodium 1 mg
|
1 MG
|
$XXX.XX
|
| J0217 |
Inj velmanase alfa-tycv 1 mg
|
1 MG
|
$XXX.XX
|
| J0218 |
Inj olipudase alfa-rpcp 1mg
|
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
|
| J0225 |
Inj, vutrisiran, 1 mg
|
1 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
|
| J0283 |
Inj, amiodarone (nexterone)
|
30 MG
|
$XXX.XX
|
| J0285 |
Amphotericin b
|
50 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
|
| J0349 |
Inj, rezafungin, 1 mg
|
1 MG
|
$XXX.XX
|
| J0360 |
Hydralazine hcl injection
|
20 MG
|
$XXX.XX
|
| J0401 |
Inj, abilify maintena, 1 mg
|
1 MG
|
$XXX.XX
|
| J0402 |
Inj, abilify asimtufii, 1 mg
|
1 MG
|
$XXX.XX
|
| J0456 |
Azithromycin
|
500 MG
|
$XXX.XX
|
| J0457 |
Injection, aztreonam, 100 mg
|
100 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
|
| J0577 |
Inj, brixadi, 7 days or less
|
Less than or equal to 7 days of therapy
|
$XXX.XX
|
| J0578 |
Inj brixadi, more than 7 day
|
Greater than 7 days and up to 28 days of therapy
|
$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
|
| J0612 |
Inj, calcium gluconate, nos
|
10 MG
|
$XXX.XX
|
| J0613 |
Calcium glucon (wg critical)
|
10 MG
|
$XXX.XX
|
| J0630 |
Calcitonin salmon injection
|
400 UNITS
|
$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
|
| J0665 |
Inj, bupivacaine, nos, 0.5mg
|
0.5 MG
|
$XXX.XX
|
| J0670 |
Inj mepivacaine hcl/10 ml
|
10 ML
|
$XXX.XX
|
| J0687 |
Inj cefazolin (wg crit care)
|
500 MG
|
$XXX.XX
|
| J0688 |
Inj cefazolin sodium, hikma
|
500 MG
|
$XXX.XX
|
| J0689 |
Inj cefazolin sodium, baxter
|
500 MG
|
$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
|
| 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
|
| J0699 |
Inj, cefiderocol, 10 mg
|
10 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
|
| J0725 |
Chorionic gonadotropin/1000u
|
1000 UNITS
|
$XXX.XX
|
| J0735 |
Clonidine hydrochloride
|
1 MG
|
$XXX.XX
|
| J0736 |
Inj, clindamycin phosp 300mg
|
300 MG
|
$XXX.XX
|
| J0737 |
Inj, clindamycin (baxter)
|
300 MG
|
$XXX.XX
|
| J0739 |
Hiv prep, inj, cabotegravir
|
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
|
| J0750 |
Hiv prep, ftc/tdf 200/300mg
|
200 mg/300 mg
|
$XXX.XX
|
| J0751 |
Hiv prep, ftc/taf 200/25mg
|
200 mg/25 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
|
| J0801 |
Inj. acthar gel to 40 units
|
40 UNITS
|
$XXX.XX
|
| J0802 |
Inj. (ani), up to 40 units
|
up to 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
|
| J0872 |
Daptomycin (xellia) unrefrig
|
1 MG
|
$XXX.XX
|
| J0873 |
Inj daptomycin (xellia)
|
1 MG
|
$XXX.XX
|
| J0874 |
Inj, daptomycin (baxter)
|
1 MG
|
$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
|
| 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
|
| J1000 |
Depo-estradiol cypionate inj
|
5 MG
|
$XXX.XX
|
| J1010 |
Inj, methylpred acetate 1 mg
|
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
|
| J1171 |
Inj, hydromorphone, 0.1 mg
|
0.1 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
|
| J1203 |
Inj, cipaglucosidase, 5 mg
|
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
|
| J1302 |
Inj, sutimlimab-jome, 10 mg
|
10 MG
|
$XXX.XX
|
| J1303 |
Inj., ravulizumab-cwvz 10 mg
|
10 MG
|
$XXX.XX
|
| J1304 |
Inj tofersen intrathec 1 mg
|
1 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
|
| J1323 |
Inj, elranatamab-bcmm, 1 mg
|
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
|
| J1440 |
Fecal microbiota jslm 1 ml
|
1 ML
|
$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
|
| J1449 |
Inj eflapegrastim-xnst 0.1mg
|
0.1 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
|
| J1456 |
Inj, fosaprepitant (teva)
|
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
|
| 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
|
| J1575 |
Hyqvia 100mg immuneglobulin
|
100 MG
|
$XXX.XX
|
| J1576 |
Inj, panzyga, 500 mg
|
500 MG
|
$XXX.XX
|
| J1580 |
Garamycin gentamicin inj
|
80 MG
|
$XXX.XX
|
| J1596 |
Inj, glycopyrrolate, 0.1 mg
|
0.1 MG
|
$XXX.XX
|
| J1598 |
Inj glycopyrrolate fres kabi
|
0.1 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
|
| J1643 |
Inj heparin, pfizer, 1000u
|
1000 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
|
| 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
|
| J1747 |
Inj, spesolimab-sbzo, 1 mg
|
1 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
|
| J1805 |
Inj, esmolol hcl, 10mg
|
10 MG
|
$XXX.XX
|
| J1806 |
Inj esmolol hcl wg crit care
|
10 MG
|
$XXX.XX
|
| J1811 |
Fiasp for insulin pump use
|
50 UNITS
|
$XXX.XX
|
| J1813 |
Lyumjev for insulin pump use
|
50 UNITS
|
$XXX.XX
|
| J1817 |
Insulin for insulin pump use
|
50 UNITS
|
$XXX.XX
|
| J1823 |
Inj. inebilizumab-cdon, 1 mg
|
1 MG
|
$XXX.XX
|
| J1836 |
Inj, metronidazole, 10 mg
|
10 MG
|
$XXX.XX
|
| J1885 |
Ketorolac tromethamine inj
|
15 MG
|
$XXX.XX
|
| J1920 |
Inj, labetalol hcl, 5mg
|
5 MG
|
$XXX.XX
|
| J1921 |
Inj labetalol hcl hikma, 5mg
|
5 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
|
| J1939 |
Inj, bumetanide, 0.5 mg
|
0.5 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
|
| J1954 |
Leuprolide depot cipla 7.5mg
|
7.5 MG
|
$XXX.XX
|
| J1955 |
Inj levocarnitine per 1 gm
|
1 GM
|
$XXX.XX
|
| J1956 |
Levofloxacin injection
|
250 MG
|
$XXX.XX
|
| J1961 |
Inj, lenacapavir, 1 mg
|
1 MG
|
$XXX.XX
|
| J2002 |
Inj, lidocaine in d5w, 1 mg
|
1 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
|
| J2183 |
Inj meropenem (wg crit care)
|
100 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 in 0.9% nacl
|
1 MG
|
$XXX.XX
|
| J2260 |
Inj milrinone lactate / 5 mg
|
5 MG
|
$XXX.XX
|
| J2267 |
Inj, mirikizumab-mrkz, 1 mg
|
1 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
|
| J2277 |
Inj, motixafortide, 0.25 mg
|
0.25 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
|
| J2305 |
Inj, nitroglycerin, 5 mg
|
5 MG
|
$XXX.XX
|
| J2310 |
Inj naloxone hydrochloride
|
1 MG
|
$XXX.XX
|
| J2311 |
Inj, naloxone hcl (zimhi)
|
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
|
| J2329 |
Inj ublituximab-xiiy, 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
|
| J2359 |
Inj. olanzapine, 0.5mg
|
0.5 MG
|
$XXX.XX
|
| J2360 |
Orphenadrine injection
|
60 MG
|
$XXX.XX
|
| J2372 |
Inj, biorphen, 20 micrograms
|
20 MCG
|
$XXX.XX
|
| J2373 |
Inj, immphentiv, 20 mcg
|
20 MCG
|
$XXX.XX
|
| J2401 |
Chloroprocaine hcl injection
|
1 MG
|
$XXX.XX
|
| J2403 |
Chloroprocaine opht gel, 1mg
|
1 MG
|
$XXX.XX
|
| J2404 |
Inj, nicardipine 0.1 mg
|
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
|
| J2426 |
Inj, invega sustenna, 1 mg
|
1 MG
|
$XXX.XX
|
| J2427 |
Inj, invega hafyera/trinza
|
1MG
|
$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
|
| J2508 |
Pegunigalsidase alfa-iwxj
|
1 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
|
| J2598 |
Inj, vasopressin, 1 unit
|
1 UNIT
|
$XXX.XX
|
| J2599 |
Inj vasopressin (am reg) 1 u
|
1 UNIT
|
$XXX.XX
|
| J2675 |
Inj progesterone per 50 mg
|
50 MG
|
$XXX.XX
|
| J2679 |
Inj fluphenazine hcl 1.25 mg
|
1.25 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
|
| 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
|
| J2781 |
Inj, pegcetacoplan, 1mg
|
1 MG
|
$XXX.XX
|
| J2782 |
Inj avacincaptad pegol 0.1mg
|
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
|
| J2799 |
Inj, uzedy, 1 mg
|
1 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
|
| J2919 |
Inj, methylpred sod succ 5mg
|
5 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
|
| J3055 |
Inj talquetamab-tgvs 0.25 mg
|
0.25 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
|
| J3246 |
Tirofiban hcl
|
0.25 MG
|
$XXX.XX
|
| J3247 |
Inj secukinumab intrav 1mg
|
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
|
| J3263 |
Inj, toripalimab-tpzi, 1 mg
|
1 MG
|
$XXX.XX
|
| J3285 |
Treprostinil injection
|
1 MG
|
$XXX.XX
|
| J3299 |
Inj xipere 1 mg
|
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 |
Inj vedolizumab iv 1 mg
|
1 MG
|
$XXX.XX
|
| J3385 |
Velaglucerase alfa
|
100 UNITS
|
$XXX.XX
|
| J3396 |
Verteporfin injection
|
0.1 MG
|
$XXX.XX
|
| J3401 |
Vyjuvek 5x10^9pfu/ml, 0.1 ml
|
0.1 ML
|
$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
|
| J3425 |
Hydroxocobalamin im 10mcg
|
10 MCG
|
$XXX.XX
|
| J3430 |
Vitamin k phytonadione inj
|
1 MG
|
$XXX.XX
|
| J3465 |
Injection, voriconazole
|
10 MG
|
$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 CC
|
$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 CC
|
$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
|
| J7171 |
Inj, adzynma, 10 iu
|
10 UNITS
|
$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 MG
|
$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 IU
|
$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
|
| J7213 |
Inj, ixinity, 1 i.u.
|
1 IU
|
$XXX.XX
|
| J7214 |
Altuviiio per factor viii iu
|
1 IU
|
$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
|
| J7331 |
Synojoynt, inj., 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
|
| J7345 |
Aminolevulinic acid, 10% gel
|
10 MG
|
$XXX.XX
|
| J7351 |
Inj bimatoprost itc imp1mcg
|
1 MCG
|
$XXX.XX
|
| J7354 |
Cantharidin top, applicator
|
Per 3.2 mg single-use applicator
|
$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
|
| J7517 |
Mycophenolate mofetil oral
|
250 MG
|
$XXX.XX
|
| J7518 |
Mycophenolic acid
|
180 MG
|
$XXX.XX
|
| J7519 |
Inj. mycophenolate mofetil
|
10 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
|
| J8522 |
Capecitabine, oral, 50 mg
|
50 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
|
| J9029 |
Instill adstiladrin, tx dose
|
PER THERAPEUTIC DOSE
|
$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
|
| 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
|
| J9047 |
Injection, carfilzomib, 1 mg
|
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
|
| J9056 |
Inj, bendamustine, 1 mg
|
1 MG
|
$XXX.XX
|
| J9058 |
Inj apotex/bendamustine 1 mg
|
1 MG
|
$XXX.XX
|
| J9059 |
Inj bendamustine, baxter 1mg
|
1 MG
|
$XXX.XX
|
| J9060 |
Cisplatin 10 mg injection
|
10 MG
|
$XXX.XX
|
| J9061 |
Inj, amivantamab-vmjw
|
2 MG
|
$XXX.XX
|
| J9063 |
Inj, elahere, 1 mg
|
1 MG
|
$XXX.XX
|
| J9065 |
Inj cladribine per 1 mg
|
1 MG
|
$XXX.XX
|
| J9071 |
Inj cyclophosphamd auromedic
|
5 MG
|
$XXX.XX
|
| J9073 |
Inj cyclophosphamd (ingenus)
|
5 MG
|
$XXX.XX
|
| J9075 |
Inj, cyclophosphamide, nos
|
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
|
| J9196 |
Inj gemcitabine hcl (accord)
|
200 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
|
| 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
|
| J9260 |
Inj methotrexate sodium 50mg
|
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
|
| 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
|
| J9286 |
Inj glofitamab gxbm, 2.5 mg
|
2.5 MG
|
$XXX.XX
|
| J9293 |
Mitoxantrone hydrochl / 5 mg
|
5 MG
|
$XXX.XX
|
| J9294 |
Inj pemetrexed, hospira 10mg
|
10 MG
|
$XXX.XX
|
| J9295 |
Injection, necitumumab, 1 mg
|
1 MG
|
$XXX.XX
|
| J9297 |
Inj pemetrexed (sandoz) 10mg
|
10 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
|
| 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
|
| J9314 |
Inj pemetrexed (teva) 10mg
|
10 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
|
| J9321 |
Inj epcoritamab-bysp 0.16 mg
|
0.16 MG
|
$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
|
| J9333 |
Inj ronzanolixizum-noli 1 mg
|
1 MG
|
$XXX.XX
|
| J9334 |
Inj efgart-alfa 2mg hya-qvfc
|
2 MG
|
$XXX.XX
|
| J9340 |
Thiotepa injection
|
15 MG
|
$XXX.XX
|
| J9345 |
Inj, retifanlimab-dlwr, 1 mg
|
1 MG
|
$XXX.XX
|
| J9347 |
Inj, tremelimumab-actl, 1 mg
|
1 MG
|
$XXX.XX
|
| J9348 |
Inj. naxitamab-gqgk, 1 mg
|
1 MG
|
$XXX.XX
|
| J9349 |
Inj., tafasitamab-cxix
|
2 MG
|
$XXX.XX
|
| J9350 |
Inj mosunetuzumab-axgb, 1 mg
|
1 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
|
| J9380 |
Inj teclistamab cqyv 0.5 mg
|
0.5 MG
|
$XXX.XX
|
| J9381 |
Inj teplizumab mzwv 5 mcg
|
5 MCG
|
$XXX.XX
|
| J9390 |
Vinorelbine tartrate inj
|
10 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
|
| Q0224 |
Inj, pemivibart, 4500 mg
|
4500 MG
|
$XXX.XX
|
| Q0249 |
Tocilizumab for COVID-19
|
1 MG
|
$XXX.XX
|
| Q2041 |
Axicabtagene ciloleucel car+
|
UP TO 200 MILLION CAR T CELLS
|
$XXX.XX
|
| Q2042 |
Tisagenlecleucel car-pos t
|
up to 600 million CAR-positive viable T cells
|
$XXX.XX
|
| Q2043 |
Sipuleucel-t auto cd54+
|
Per infusion (minimum 50 million cells)
|
$XXX.XX
|
| Q2050 |
Doxorubicin inj 10mg
|
10 MG
|
$XXX.XX
|
| Q2053 |
Brexucabtagene car pos t
|
UP TO 200 MILLION AUTOLOGOUS ANTI-CD19 CAR POSITIVE VIABLE T CELLS
|
$XXX.XX
|
| Q2054 |
Lisocabtagene mara car pos t
|
Up to 110 million CAR-positive viable T cells, per therapeutic dose
|
$XXX.XX
|
| Q2055 |
Idecabtagene vicleucel car
|
UP TO 510 MILLION AUTOLOGOUS ANTI-BCMA CAR-POSITIVE VIABLE T CELLS
|
$XXX.XX
|
| Q2056 |
Ciltacabtagene car-pos t
|
up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells
|
$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
|
| 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
|
| Q4118 |
Matristem micromatrix
|
1 MG
|
$XXX.XX
|
| Q4121 |
Theraskin
|
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
|
| Q4147 |
Architect ecm px fx 1 sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4148 |
Neox neox rt or clarix cord
|
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
|
| Q4155 |
Neoxflo or clarixflo 1 mg
|
1 MG
|
$XXX.XX
|
| Q4156 |
Neox 100 or clarix 100
|
1 SQ CM
|
$XXX.XX
|
| Q4158 |
Kerecis omega3, per sq 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
|
| Q4164 |
Helicoll, per square cm
|
1 SQ CM
|
$XXX.XX
|
| Q4166 |
Cytal, per square centimeter
|
1 SQ CM
|
$XXX.XX
|
| Q4170 |
Cygnus, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4171 |
Interfyl, 1 mg
|
1 MG
|
$XXX.XX
|
| Q4173 |
Palingen or palingen xplus
|
1 SQ CM
|
$XXX.XX
|
| Q4175 |
Miroderm
|
1 SQ CM
|
$XXX.XX
|
| Q4178 |
Floweramniopatch, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4180 |
Revita, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4184 |
Cellesta or duo 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
|
| Q4188 |
Amnioarmor 1 sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4190 |
Artacent ac 1 sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4191 |
Restorigin 1 sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4193 |
Coll-e-derm 1 sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4194 |
Novachor 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
|
| Q4204 |
Xwrap 1 sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4205 |
Membrane graft or wrap sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4217 |
Woundfix biowound plus xplus
|
1 SQ CM
|
$XXX.XX
|
| Q4221 |
Amniowrap2 per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4222 |
Progenamatrix, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4225 |
Amnio or derma tl, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4227 |
Amniocore per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4229 |
Cogenex amnio memb per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4232 |
Corplex, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4234 |
Xcellerate, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4235 |
Amniorepair or altiply sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4236 |
Carepatch per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4238 |
Derm-maxx, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4239 |
Amnio-maxx or lite 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
|
| Q4253 |
Zenith amniotic membrane psc
|
1 SQ CM
|
$XXX.XX
|
| Q4256 |
Mlg complet, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4257 |
Relese, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4258 |
Enverse, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4259 |
Celera per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4262 |
Dual layer impax, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4263 |
Surgraft tl, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4265 |
Neostim tl per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4266 |
Neostim per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4267 |
Neostim dl per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4268 |
Surgraft ft per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4271 |
Complete ft per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4276 |
Orion, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4278 |
Epieffect, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4279 |
Vendaje ac, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4280 |
Xcell amnio matrix per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4281 |
Barrera slor dl per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4282 |
Cygnus dual per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4283 |
Biovance tri or 3l, sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4290 |
Membrane wrap hydr per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4293 |
Acesso dl, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4294 |
Amnio quad-core, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4295 |
Amnio tri-core, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4296 |
Rebound matrix, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4297 |
Emerge matrix, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4299 |
Amnicore pro+, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4300 |
Acesso tl, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4301 |
Activate matrix, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4302 |
Complete aca, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4303 |
Complete aa, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4304 |
Grafix plus, per sq cm
|
1 SQ CM
|
$XXX.XX
|
| Q4310 |
Procenta, per 100 mg
|
100 MG
|
$XXX.XX
|
| Q4332 |
Axolotl dualgraft, 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
|
| 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
|
| Q5125 |
Inj, releuko 1 mcg
|
1 MCG
|
$XXX.XX
|
| Q5126 |
Inj alymsys 10 mg
|
10 MG
|
$XXX.XX
|
| Q5127 |
Inj, stimufend, 0.5 mg
|
0.5 MG
|
$XXX.XX
|
| Q5128 |
Inj, cimerli, 0.1 mg
|
0.1 MG
|
$XXX.XX
|
| Q5129 |
Inj, vegzelma, 10 mg
|
10 MG
|
$XXX.XX
|
| Q5130 |
Inj, fylnetra, 0.5 mg
|
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
|
| 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
|
