TAX ID1|582149128|TAX ID2|823914925
NPI 1|1043270564||NPI 2|1316938459|
Payment Allowance Limits for Medicare Part B Drugs|Fee Allowance is amount in column Reimbursement Rate.|
HCPCS Code|Short Description|HCPCS Code Dosage|Payment Limit|Reimbursement Rate|Vaccine AWP%|Vaccine Limit|Blood AWP%|Blood limit|Clotting Factor|Notes||Rates effective 10.1.2022 to 9.30.2023
90371|Hep b ig im|1 ML|138.873|$138.87 |
90375|Rabies ig im/sc|150 IU|286.016|$286.02 |
90376|Rabies ig heat treated|150 IU|353.489|$353.49|
90377|Rabies ig ht&sol human im/sc|150 IU|241.202|$241.20|
90586|Bcg vaccine intravesical|1 EACH|141.652|$141.65 ||||||||
90632|Hepa vaccine adult im|1 ML|68.745|$68.75 ||||||||
90662|Iiv no prsv increased ag im|0.5 ML|65.261|$65.26 |95|65.261||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates||
90670|Pcv13 vaccine im|0.5 ML|257.989|$257.99 |95|257.989||||||
90671|PCV15 vaccine IM|1 EA|246.195|$246.20 |95|246.195||||||
90672|Laiv4 vaccine intranasal|0.2 ML|26.876|$26.88 |95|26.876||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates||
90674|Cciiv4 vac no prsv 0.5 ml im|0.5 ML|29.940|$29.94 |95|29.940||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates||
90675|Rabies vaccine im|1 ML|291.791|$291.79 ||||||||
90677|Pcv20 vaccine im|0.5 ML|283.717|$283.72 |95|283.717||||||
90682|Riv4 vacc recombinant dna im|0.5 ML|65.261|$65.26 |95|65.261||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates||
90685|Iiv4 vacc no prsv 0.25 ml im|0.25 mL|21.639|$21.64 |95|21.639||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates||
90686|Iiv4 vacc no prsv 0.5 ml im|0.5 ml|20.526|$20.53 |95|20.526||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates||
90687|Iiv4 vaccine splt 0.25 ml im|0.25 ML|9.953|$9.95 |95|9.953||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates ||
90688|Iiv4 vaccine splt 0.5 ml im|0.5 ML|19.906|$19.91 |95|19.906||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates ||
90694|Vacc AIIV4 no prsrv 0.5ML IM|0.5 ML|66.426|$66.43 |95|66.426||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates ||
90714|Td vacc no presv 7 yrs+ im|0.5 ML|28.986|$28.99 ||||||||
90715|Tdap vaccine 7 yrs/> im|0.5 ML|36.760|$36.76 ||||||||
90732|Ppsv23 vacc 2 yrs+ subq/im|0.5 ML|133.472|$133.47 |95|133.472||||||
90739|Hepb vacc 2 dose adult im|1 dose|152.076|$152.08 |95|152.076||||||
90740|Hepb vacc 3 dose immunsup im|40 MCG|146.329|$146.33 |95|146.329||||||
90744|Hepb vacc 3 dose ped/adol im|1 DOSE|29.043|$29.04 |95|29.043||||||
90746|Hepb vaccine 3 dose adult im|20 MCG|70.376|$70.38 |95|70.376||||||
90747|Hepb vacc 4 dose immunsup im|40 MCG|140.752|$140.75 |95|140.752||||||
90756|Cciiv4 vacc abx free im|0.5 ML|28.370|$28.37 |95|28.370||||see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates||
90759|Hep b vac 3ag 10mcg 3 dos im|10 MCG|73.815|$73.82 |95|73.815||||||
A9575|Inj gadoterate meglumi 0.1ml|0.1 ML|0.132|$0.13 ||||||||
A9576|Inj prohance multipack|1 ML|1.441|$1.44 ||||||||
A9577|Inj multihance|1 ML|1.850|$1.85 ||||||||
A9578|Inj multihance multipack|1 ML|1.821|$1.82 ||||||||
A9579|Gad-base mr contrast nos|1ml|1 ML|1.559|$1.56 ||||||||
A9581|Gadoxetate disodium inj|1 ML|14.739|$14.74 ||||||||
A9585|Gadobutrol injection|0.1 ML|0.331|$0.33 ||||||||
A9589|Insti hexaminolevulinate hcl|100 MG|1225.445|$1|225.45 ||||||||
A9606|Radium ra223 dichloride ther|1 microCurie|N/A|N/A||||||microCurie 100% AWP = $176.640
microCurie 100% WAC = $147.200||
J0121|Inj.| omadacycline| 1 mg|1 MG|3.467|$3.47 ||||||||
J0122|Inj.| eravacycline| 1 mg|1 MG|1.068|$1.07 ||||||||
J0129|Abatacept injection|10 MG|44.220|$44.22 ||||||lesser of methodology applied||
J0132|Acetylcysteine injection|100 MG|0.553|$0.55 ||||||||
J0133|Acyclovir injection|5 MG|0.021|$0.02 ||||||||
J0153|Adenosine inj 1mg|1 MG|0.467|$0.47 ||||||||
J0171|Adrenalin epinephrine inject|0.1 MG|0.745|$0.75 ||||||||
J0172|Inj| aducanumab-avwa| 2 mg|2 MG|5.978|$5.98 ||||||||
J0178|Aflibercept injection|1 MG|912.889|$912.89 ||||||||
J0179|Inj| brolucizumab-dbll| 1 mg|1 MG|311.960|$311.96 ||||||||
J0180|Agalsidase beta injection|1 MG|205.921|$205.92 ||||||||
J0185|Inj.| aprepitant| 1 mg|1 MG|1.720|$1.72 ||||||||
J0202|Injection| alemtuzumab|1 MG|2194.489|$2|194.49 ||||||||
J0219|Inj aval alfa-nqpt 4mg|4 MG|72.681|$72.68 ||||||Added July 2022||
J0221|Lumizyme injection|10 MG|186.414|$186.41 ||||||||
J0222|Inj.| patisiran| 0.1 mg|0.1 MG|98.970|$98.97 ||||||||
J0223|Inj givosiran 0.5 mg|0.5 MG|107.959|$107.96 ||||||||
J0248|Inj| remdesivir| 1 mg|1 MG|5.512|$5.51 ||||||||
J0256|Alpha 1 proteinase inhibitor|10 MG|4.613|$4.61 ||||||||
J0257|Glassia injection|10 MG|5.152|$5.15 ||||||||
J0278|Amikacin sulfate injection|100 MG|0.803|$0.80 ||||||||
J0280|Aminophyllin 250 mg inj|250 MG|11.714|$11.71 ||||||||
J0285|Amphotericin b|50 MG|46.322|$46.32 ||||||||
J0287|Amphotericin b lipid complex|10 MG|10.198|$10.20 ||||||||
J0289|Amphotericin b liposome inj|10 MG|26.363|$26.36 ||||||||
J0290|Ampicillin 500 mg inj|500 MG|0.746|$0.75 ||||||||
J0291|Inj.| plazomicin| 5 mg|5 MG|3.128|$3.13 ||||||||
J0295|Ampicillin sulbactam 1.5 gm|1.5 GM|2.238|$2.24 ||||||||
J0348|Anidulafungin injection|1 MG|0.553|$0.55 ||||||||
J0360|Hydralazine hcl injection|20 MG|4.415|$4.42 ||||||||
J0401|Inj aripiprazole ext rel 1mg|1 MG|6.312|$6.31 ||||||||
J0456|Azithromycin|500 MG|2.527|$2.53 ||||||||
J0461|Atropine sulfate injection|0.01 MG|0.077|$0.08 ||||||||
J0475|Baclofen 10 mg injection|10 MG|182.024|$182.02 ||||||||
J0476|Baclofen intrathecal trial|50 MCG|57.224|$57.22 ||||||||
J0480|Basiliximab|20 MG|4087.668|$4|087.67 ||||||||
J0485|Belatacept injection|1 MG|3.782|$3.78 ||||||||
J0490|Belimumab injection|10 MG|49.439|$49.44 ||||||||
J0491|Inj anifrolumab-fnia 1mg|1 MG|16.177|$16.18 ||||||||
J0500|Dicyclomine injection|20 MG|27.215|$27.22 ||||||||
J0515|Inj benztropine mesylate|1 MG|18.034|$18.03 ||||||||
J0517|Inj.| benralizumab| 1 mg|1 MG|168.863|$168.86 ||||||||
J0558|Peng benzathine/procaine inj|100|000 UNITS|12.861|$12.86 ||||||||
J0561|Penicillin g benzathine inj|100|000 UNITS|16.483|$16.48 ||||||||
J0565|Inj| bezlotoxumab| 10 mg|10 MG|39.874|$39.87 ||||||||
J0583|Bivalirudin|1 MG|0.287|$0.29 ||||||||
J0584|Injection| burosumab-twza 1m|1 MG|401.498|$401.50 ||||||||
J0585|Injection|onabotulinumtoxina|1 UNIT|6.207|$6.21 ||||||||
J0586|Abobotulinumtoxina|5 Unit|8.520|$8.52 ||||||||
J0587|Inj| rimabotulinumtoxinb|100 UNITS|12.172|$12.17 ||||||||
J0588|Incobotulinumtoxin a|1 UNIT|5.058|$5.06 ||||||||
J0592|Buprenorphine hydrochloride|0.1 MG|4.079|$4.08 ||||||||
J0594|Busulfan injection|1 MG|2.040|$2.04 ||||||||
J0595|Butorphanol tartrate 1 mg|1 MG|2.969|$2.97 ||||||||
J0596|Injection| ruconest|10 UNITS|31.597|$31.60 ||||||||
J0597|C-1 esterase| berinert|10 UNITS|60.773|$60.77 ||||||||
J0598|C-1 esterase| cinryze|10 UNITS|60.674|$60.67 ||||||||
J0600|Edetate calcium disodium inj|1000 MG|5708.594|$5|708.59 ||||||||
J0610|Calcium gluconate injection|10 ML|3.956|$3.96 ||||||||
J0630|Calcitonin salmon injection|400 UNITS|2231.387|$2|231.39 ||||||||
J0636|Inj calcitriol per 0.1 mcg|0.1 MCG|0.682|$0.68 ||||||||
J0637|Caspofungin acetate|5 MG|5.481|$5.48 ||||||||
J0638|Canakinumab injection|1 MG|118.609|$118.61 ||||||||
J0640|Leucovorin calcium injection|50 MG|4.373|$4.37 ||||||||
J0641|Inj levoleucovorin nos 0.5mg|0.5 MG|0.093|$0.09 ||||||||
J0642|Injection| khapzory| 0.5 mg|0.5 MG|1.458|$1.46 ||||||AMP-based payment limit||
J0670|Inj mepivacaine hcl/10 ml|10 ML|3.143|$3.14 ||||||||
J0690|Cefazolin sodium injection|500 MG|0.755|$0.76 ||||||||
J0691|Inj lefamulin 1 mg|1 MG|0.724|$0.72 ||||||||
J0692|Cefepime hcl for injection|500 MG|1.776|$1.78 ||||||||
J0694|Cefoxitin sodium injection|1 GM|4.633|$4.63 ||||||||
J0695|Inj ceftolozane tazobactam|75mg (50mg cft/25mg taz)|6.395|$6.40 ||||||||
J0696|Ceftriaxone sodium injection|250 MG|0.510|$0.51 ||||||||
J0697|Sterile cefuroxime injection|750 MG|2.038|$2.04 ||||||||
J0702|Betamethasone acet&sod phosp|3 MG & 3 MG|6.554|$6.55 ||||||||
J0712|Ceftaroline fosamil inj|10 MG|3.725|$3.73 ||||||||
J0713|Inj ceftazidime per 500 mg|500 MG|2.092|$2.09 ||||||||
J0714|Ceftazidime and avibactam|.625 GM|91.786|$91.79 ||||||||
J0717|Certolizumab pegol inj 1mg|1 MG|5.581|$5.58 ||||||lesser of methodology applied||
J0720|Chloramphenicol sodium injec|1 GM|35.086|$35.09 ||||||AMP-based payment limit||
J0725|Chorionic gonadotropin/1000u|1000 UNITS|24.529|$24.53 ||||||||
J0735|Clonidine hydrochloride|1 MG|26.304|$26.30 ||||||||
J0740|Cidofovir injection|375 MG|583.011|$583.01 ||||||||
J0741|Inj| cabote rilpivir 2mg 3mg|2MG/3MG|21.053|$21.05 ||||||||
J0742|Inj imip 4 cilas 4 releb 2mg|4 MG-4 MG-2 MG|2.380|$2.38 ||||||||
J0743|Cilastatin sodium injection|250 MG|8.281|$8.28 ||||||||
J0744|Ciprofloxacin iv|200 MG|1.103|$1.10 ||||||||
J0770|Colistimethate sodium inj|150 MG|15.167|$15.17 ||||||||
J0775|Collagenase| clost hist inj|0.01 MG|58.871|$58.87 ||||||||
J0780|Prochlorperazine injection|10 MG|3.995|$4.00 ||||||||
J0791|Inj crizanlizumab-tmca 5mg|5 MG|125.057|$125.06 ||||||||
J0800|Corticotropin injection|40 UNITS|3879.745|$3|879.75 ||||||||
J0834|Inj.| cosyntropin| 0.25 mg|0.25 MG|26.953|$26.95 ||||||||
J0840|Crotalidae poly immune fab|UP TO 1 GM|2605.388|$2|605.39 ||||||||
J0841|Inj crotalidae im f(ab')2 eq|120 MG|1072.212|$1|072.21 ||||||||
J0850|Cytomegalovirus imm iv /vial|PER VIAL|1654.657|$1|654.66 ||||||||
J0875|Injection| dalbavancin|5 MG|14.912|$14.91 ||||||||
J0878|Daptomycin injection|1 MG|0.047|$0.05 ||||||||
J0881|Darbepoetin alfa| non-esrd|1 MCG|3.315|$3.32 ||||||||
J0882|Darbepoetin alfa| esrd use|1 MCG|3.315|$3.32 ||||||||
J0885|Epoetin alfa| non-esrd|1000 UNITS|8.216|$8.22 ||||||||
J0887|Epoetin beta esrd use|1 MCG|1.621|$1.62 ||||||||
J0888|Epoetin beta non esrd|1 MCG|1.621|$1.62 ||||||||
J0894|Decitabine injection|1 MG|1.585|$1.59 ||||||||
J0895|Deferoxamine mesylate inj|500 MG|10.416|$10.42 ||||||||
J0896|Inj luspatercept-aamt 0.25mg|0.25 MG|37.941|$37.94 ||||||||
J0897|Denosumab injection|1 MG|22.255|$22.26 ||||||||
J1000|Depo-estradiol cypionate inj|5 MG|26.093|$26.09 ||||||||
J1020|Methylprednisolone 20 mg inj|20 MG|4.611|$4.61 ||||||||
J1030|Methylprednisolone 40 mg inj|40 MG|6.926|$6.93 ||||||||
J1040|Methylprednisolone 80 mg inj|80 MG|10.443|$10.44 ||||||||
J1050|Medroxyprogesterone acetate|1 MG|0.571|$0.57 ||||||||
J1071|Inj testosterone cypionate|1 MG|0.029|$0.03 ||||||||
J1100|Dexamethasone sodium phos|1 MG|0.131|$0.13 ||||||||
J1110|Inj dihydroergotamine mesylt|1 MG|58.236|$58.24 ||||||||
J1120|Acetazolamid sodium injectio|500 MG|21.568|$21.57 ||||||||
J1160|Digoxin injection|0.5 MG|10.301|$10.30 ||||||||
J1162|Digoxin immune fab (ovine)|PER VIAL|4293.360|$4|293.36 ||||||||
J1165|Phenytoin sodium injection|50 MG|0.441|$0.44 ||||||||
J1170|Hydromorphone injection|4 MG|3.289|$3.29 ||||||||
J1190|Dexrazoxane hcl injection|250 MG|168.783|$168.78 ||||||||
J1200|Diphenhydramine hcl injectio|50 MG|1.510|$1.51 ||||||||
J1201|Inj. cetirizine hcl 0.5mg|0.5 MG|15.088|$15.09 ||||||||
J1205|Chlorothiazide sodium inj|500 MG|30.550|$30.55 ||||||||
J1212|Dimethyl sulfoxide 50% 50 ml|50 ML|636.414|$636.41 ||||||||
J1230|Methadone injection|10 MG|16.787|$16.79 ||||||||
J1240|Dimenhydrinate injection|50 MG|6.973|$6.97 ||||||||
J1245|Dipyridamole injection|10 MG|3.510|$3.51 ||||||||
J1250|Inj dobutamine hcl/250 mg|250 MG|6.350|$6.35 ||||||||
J1265|Dopamine injection|40 MG|0.490|$0.49 ||||||||
J1270|Injection| doxercalciferol|1 MCG|0.323|$0.32 ||||||||
J1290|Ecallantide injection|1 MG|513.735|$513.74 ||||||||
J1300|Eculizumab injection|10 MG|228.015|$228.02 ||||||||
J1301|Injection| edaravone| 1 mg|1 MG|20.994|$20.99 ||||||||
J1303|Inj.| ravulizumab-cwvz 10 mg|10 MG|224.087|$224.09 ||||||||
J1322|Elosulfase alfa| injection|1 MG|262.308|$262.31 ||||||||
J1325|Epoprostenol injection|0.5 MG|15.768|$15.77 ||||||||
J1335|Ertapenem injection|500 MG|17.240|$17.24 ||||||||
J1364|Erythro lactobionate /500 mg|500 MG|73.653|$73.65 ||||||||
J1380|Estradiol valerate 10 mg inj|10 MG|9.803|$9.80 ||||||||
J1410|Inj estrogen conjugate 25 mg|25 MG|353.670|$353.67 ||||||||
J1430|Ethanolamine oleate 100 mg|100 MG|454.170|$454.17 ||||||||
J1437|Inj. fe derisomaltose 10 mg|10 MG|23.030|$23.03 ||||||||
J1439|Inj ferric carboxymaltos 1mg|1 MG|1.108|$1.11 ||||||||
J1442|Inj filgrastim excl biosimil|1 MCG|0.996|$1.00 ||||||||
J1447|Inj tbo filgrastim 1 microg|1 MCG|0.419|$0.42 ||||||||
J1448|Injection| trilaciclib| 1mg|1 MG|4.940|$4.94 ||||||||
J1450|Fluconazole|200 MG|2.879|$2.88 ||||||||
J1453|Fosaprepitant injection|1 MG|0.183|$0.18 ||||||||
J1454|Inj fosnetupitant| palonoset|0.25 MG|466.074|$466.07 ||||||||
J1458|Galsulfase injection|1 MG|432.431|$432.43 ||||||||
J1459|Inj ivig privigen 500 mg|500 MG|46.933|$46.93 ||||||||
J1460|Gamma globulin 1 cc inj|1 CC|46.164|$46.16 ||||||||
J1551|Inj cutaquig 100 mg|100 MG|12.028|$12.03 ||||||Added July 2022||
J1554|Inj. asceniv|500 MG|481.770|$481.77 ||||||||
J1555|Inj cuvitru| 100 mg|100 MG|14.971|$14.97 ||||||||
J1556|Inj| imm glob bivigam| 500mg|500 MG|70.490|$70.49 ||||||||
J1557|Gammaplex injection|500 MG|48.338|$48.34 ||||||||
J1558|Inj. xembify| 100 mg|100 MG|13.569|$13.57 ||||||||
J1559|Hizentra injection|100 MG|12.347|$12.35 ||||||||
J1560|Gamma globulin > 10 cc inj|10 CC|461.639|$461.64 ||||||||
J1561|Gamunex-c/gammaked|500 MG|43.390|$43.39 ||||||||
J1566|Immune globulin| powder|500 MG|73.175|$73.18 ||||||||
J1568|Octagam injection|500 MG|42.019|$42.02 ||||||||
J1569|Gammagard liquid injection|500 MG|44.997|$45.00 ||||||||
J1570|Ganciclovir sodium injection|500 MG|47.154|$47.15 ||||||||
J1571|Hepagam b im injection|0.5 ML|75.141|$75.14 ||||||||
J1572|Flebogamma injection|500 MG|40.522|$40.52 ||||||||
J1575|Hyqvia 100mg immuneglobulin|100 MG|15.894|$15.89 ||||||||
J1580|Garamycin gentamicin inj|80 MG|2.365|$2.37 ||||||||
J1602|Golimumab for iv use 1mg|1 MG|14.689|$14.69 ||||||||
J1610|Glucagon hydrochloride/1 mg|1 MG|171.601|$171.60 ||||||||
J1626|Granisetron hcl injection|100 MCG|0.311|$0.31 ||||||||
J1627|Inj| granisetron| xr| 0.1 mg|0.1 MG|6.446|$6.45 ||||||||
J1630|Haloperidol injection|5 MG|0.734|$0.73 ||||||||
J1631|Haloperidol decanoate inj|50 MG|8.750|$8.75 ||||||||
J1640|Hemin| 1 mg|1 MG|28.924|$28.92 ||||||||
J1642|Inj heparin sodium per 10 u|10 UNITS|0.015|$0.02 ||||||||
J1644|Inj heparin sodium per 1000u|1000 UNITS|0.242|$0.24 ||||||||
J1645|Dalteparin sodium|2500 IU|11.725|$11.73 ||||||||
J1650|Inj enoxaparin sodium|10 MG|0.757|$0.76 ||||||||
J1652|Fondaparinux sodium|0.5 MG|1.156|$1.16 ||||||||
J1670|Tetanus immune globulin inj|250 UNITS|516.486|$516.49 ||||||||
J1720|Hydrocortisone sodium succ i|100 MG|17.574|$17.57 ||||||||
J1740|Ibandronate sodium injection|1 MG|33.792|$33.79 ||||||||
J1743|Idursulfase injection|1 MG|542.824|$542.82 ||||||||
J1745|Infliximab not biosimil 10mg|10 MG|35.713|$35.71 ||||||||
J1746|Inj.| ibalizumab-uiyk| 10 mg|10 MG|69.759|$69.76 ||||||||
J1750|Inj iron dextran|50 MG|16.373|$16.37 ||||||||
J1756|Iron sucrose injection|1 MG|0.203|$0.20 ||||||AMP-based payment limit||
J1786|Imuglucerase injection|10 UNITS|44.151|$44.15 ||||||||
J1817|Insulin for insulin pump use|50 UNITS|8.311|$8.31 ||||||||
J1823|Inj. inebilizumab-cdon| 1 mg|1 MG|462.867|$462.87 ||||||||
J1885|Ketorolac tromethamine inj|15 MG|0.654|$0.65 ||||||||
J1930|Lanreotide injection|1 MG|65.972|$65.97 ||||||||
J1931|Laronidase injection|0.1 MG|35.884|$35.88 ||||||||
J1940|Furosemide injection|20 MG|0.600|$0.60 ||||||||
J1943|Inj.| aristada initio| 1 mg|1 MG|2.941|$2.94 ||||||||
J1944|Aripirazole lauroxil 1 mg|1 MG|2.924|$2.92 ||||||||
J1950|Leuprolide acetate /3.75 mg|3.75 MG|1495.367|$1|495.37 ||||||||
J1951|Inj fensolvi 0.25 mg|0.25 MG|133.464|$133.46 ||||||||
J1953|Levetiracetam injection|10 MG|0.092|$0.09 ||||||||
J1955|Inj levocarnitine per 1 gm|1 GM|25.375|$25.38 ||||||||
J1956|Levofloxacin injection|250 MG|0.878|$0.88 ||||||||
J1980|Hyoscyamine sulfate inj|0.25 MG|29.753|$29.75 ||||||||
J2001|Lidocaine injection|10 MG|0.023|$0.02 ||||||||
J2010|Lincomycin injection|300 MG|9.588|$9.59 ||||||||
J2020|Linezolid injection|200 MG|4.855|$4.86 ||||||||
J2060|Lorazepam injection|2 MG|0.741|$0.74 ||||||||
J2150|Mannitol injection|50 ML|2.604|$2.60 ||||||||
J2175|Meperidine hydrochl /100 mg|100 MG|6.110|$6.11 ||||||||
J2182|Injection| mepolizumab| 1mg|1 MG|29.110|$29.11 ||||||||
J2185|Meropenem|100 MG|0.699|$0.70 ||||||||
J2210|Methylergonovin maleate inj|0.2 MG|20.197|$20.20 ||||||||
J2248|Micafungin sodium injection|1 MG|0.476|$0.48 ||||||||
J2250|Inj midazolam hydrochloride|1 MG|0.168|$0.17 ||||||||
J2260|Inj milrinone lactate / 5 mg|5 MG|1.705|$1.71 ||||||||
J2270|Morphine sulfate injection|10 MG|5.125|$5.13 ||||||||
J2274|Inj morphine pf epid ithc|10 MG|11.529|$11.53 ||||||||
J2278|Ziconotide injection|1 MCG|9.078|$9.08 ||||||||
J2280|Inj| moxifloxacin 100 mg|100 MG|9.667|$9.67 ||||||||
J2300|Inj nalbuphine hydrochloride|10 MG|2.775|$2.78 ||||||||
J2310|Inj naloxone hydrochloride|1 MG|9.585|$9.59 ||||||||
J2315|Naltrexone| depot form|1 MG|3.537|$3.54 ||||||||
J2323|Natalizumab injection|1 MG|24.171|$24.17 ||||||||
J2350|Injection| ocrelizumab| 1 mg|1 MG|60.492|$60.49 ||||||||
J2353|Octreotide injection| depot|1 MG|207.507|$207.51 ||||||||
J2354|Octreotide inj| non-depot|25 MCG|0.816|$0.82 ||||||||
J2357|Omalizumab injection|5 MG|38.117|$38.12 ||||||||
J2358|Olanzapine long-acting inj|1 MG|2.914|$2.91 ||||||||
J2360|Orphenadrine injection|60 MG|4.115|$4.12 ||||||||
J2400|Chloroprocaine hcl injection|30 ML|30.447|$30.45 ||||||||
J2405|Ondansetron hcl injection|1 MG|0.086|$0.09 ||||||||
J2406|Injection| oritavancin 10 mg|10 MG|42.269|$42.27 ||||||||
J2407|Injection| oritavancin|10 MG|25.588|$25.59 ||||||||
J2425|Palifermin injection|50 MCG|25.127|$25.13 ||||||||
J2426|Paliperidone palmitate inj|1 MG|13.132|$13.13 ||||||||
J2430|Pamidronate disodium /30 mg|30 MG|10.576|$10.58 ||||||||
J2469|Palonosetron hcl|25 MCG|0.905|$0.91 ||||||||
J2501|Paricalcitol|1 MCG|0.697|$0.70 ||||||AMP-based payment limit||
J2506|Inj pegfilgrast ex bio 0.5mg|0.5 MG|155.827|$155.83 ||||||||
J2507|Pegloticase injection|1 MG|3110.558|$3|110.56 ||||||||
J2510|Penicillin g procaine inj|600000 UNITS|35.227|$35.23 ||||||||
J2515|Pentobarbital sodium inj|50 MG|26.170|$26.17 ||||||||
J2540|Penicillin g potassium inj|600000 UNITS|0.687|$0.69 ||||||||
J2543|Piperacillin/tazobactam|1.125 GM|1.284|$1.28 ||||||||
J2545|Pentamidine non-comp unit|300 MG|121.211|$121.21 ||||||||
J2550|Promethazine hcl injection|50 MG|2.781|$2.78 ||||||||
J2560|Phenobarbital sodium inj|120 MG|40.295|$40.30 ||||||||
J2562|Plerixafor injection|1 MG|402.538|$402.54 ||||||||
J2597|Inj desmopressin acetate|1 MCG|7.706|$7.71 ||||||||
J2675|Inj progesterone per 50 mg|50 MG|1.086|$1.09 ||||||||
J2680|Fluphenazine decanoate 25 mg|25 MG|9.844|$9.84 ||||||||
J2690|Procainamide hcl injection|1 GM|113.925|$113.93 ||||||||
J2700|Oxacillin sodium injeciton|250 MG|1.040|$1.04 ||||||||
J2704|Inj| propofol| 10 mg|10 MG|0.116|$0.12 ||||||||
J2720|Inj protamine sulfate/10 mg|10 MG|1.807|$1.81 ||||||||
J2724|Protein c concentrate|10 UNITS|15.058|$15.06 ||||||||
J2760|Phentolaine mesylate inj|5 MG|392.679|$392.68 ||||||||
J2765|Metoclopramide hcl injection|10 MG|1.050|$1.05 ||||||||
J2770|Quinupristin/dalfopristin|500 MG|337.465|$337.47 ||||||||
J2778|Ranibizumab injection|0.1 mg|275.140|$275.14 ||||||||
J2779|Inj| susvimo 0.1 mg|0.1 MG|83.229|$83.23 ||||||Added July 2022||
J2783|Rasburicase|0.5 MG|330.896|$330.90 ||||||||
J2785|Regadenoson injection|0.1 MG|61.475|$61.48 ||||||||
J2786|Injection| reslizumab| 1mg|1 MG|9.945|$9.95 ||||||||
J2788|Rho d immune globulin 50 mcg|50 MCG (250 IU)|24.195|$24.20 ||||||||
J2790|Rho d immune globulin inj|300 MCG (1500 IU)|79.468|$79.47 ||||||||
J2791|Rhophylac injection|100 IU|4.814|$4.81 ||||||||
J2792|Rho(d) immune globulin h| sd|100 IU|31.909|$31.91 ||||||||
J2794|Inj risperdal consta| 0.5 mg|0.5 MG|11.467|$11.47 ||||||||
J2795|Ropivacaine hcl injection|1 MG|0.071|$0.07 ||||||||
J2796|Romiplostim injection|10 MCG|87.737|$87.74 ||||||||
J2798|Inj.| perseris| 0.5 mg|0.5 mg|10.921|$10.92 ||||||||
J2800|Methocarbamol injection|10 ML|6.513|$6.51 ||||||||
J2805|Sincalide injection|5 MCG|119.267|$119.27 ||||||||
J2820|Sargramostim injection|50 MCG|55.320|$55.32 ||||||||
J2860|Injection| siltuximab|10 MG|128.492|$128.49 ||||||||
J2916|Na ferric gluconate complex|12.5 MG|1.862|$1.86 ||||||||
J2920|Methylprednisolone injection|40 MG|4.188|$4.19 ||||||||
J2930|Methylprednisolone injection|125 MG|5.524|$5.52 ||||||||
J2997|Alteplase recombinant|1 MG|85.823|$85.82 ||||||||
J3000|Streptomycin injection|1 GM|38.199|$38.20 ||||||||
J3010|Fentanyl citrate injection|0.1 MG|0.841|$0.84 ||||||||
J3032|Inj. eptinezumab-jjmr 1 mg|1 MG|16.421|$16.42 ||||||||
J3060|Inj| taliglucerase alfa 10 u|10 UNITS|41.685|$41.69 ||||||||
J3090|Inj tedizolid phosphate|1 MG|1.744|$1.74 ||||||||
J3095|Telavancin injection|10 MG|6.999|$7.00 ||||||||
J3101|Tenecteplase injection|1 MG|139.480|$139.48 ||||||||
J3105|Terbutaline sulfate inj|1 MG|3.197|$3.20 ||||||||
J3111|Inj. romosozumab-aqqg 1 mg|1 MG|9.700|$9.70 ||||||||
J3121|Inj testostero enanthate 1mg|1 MG|0.046|$0.05 ||||||||
J3145|Testosterone undecanoate 1mg|1 MG|1.649|$1.65 ||||||||
J3230|Chlorpromazine hcl injection|50 MG|31.276|$31.28 ||||||||
J3240|Thyrotropin injection|0.9 MG|1906.933|$1|906.93 ||||||||
J3241|Inj. teprotumumab-trbw 10 mg|10 MG|321.370|$321.37 ||||||||
J3243|Tigecycline injection|1 MG|1.001|$1.00 ||||||||
J3245|Inj.| tildrakizumab| 1 mg|1 MG|138.635|$138.64 ||||||||
J3250|Trimethobenzamide hcl inj|200 MG|42.826|$42.83 ||||||||
J3260|Tobramycin sulfate injection|80 MG|2.237|$2.24 ||||||||
J3262|Tocilizumab injection|1 MG|5.798|$5.80 ||||||||
J3285|Treprostinil injection|1 MG|55.706|$55.71 ||||||||
J3300|Triamcinolone a inj prs-free|1 MG|3.902|$3.90 ||||||||
J3301|Triamcinolone acet inj nos|10 MG|1.291|$1.29 ||||||||
J3304|Inj triamcinolone ace xr 1mg|1 MG|16.989|$16.99 ||||||||
J3315|Triptorelin pamoate|3.75 MG|363.571|$363.57 ||||||||
J3357|Ustekinumab sub cu inj| 1 mg|1 MG|174.691|$174.69 ||||||||
J3358|Ustekinumab| iv inject| 1 mg|1 MG|12.292|$12.29 ||||||||
J3360|Diazepam injection|5 MG|5.163|$5.16 ||||||||
J3370|Vancomycin hcl injection|500 MG|2.958|$2.96 ||||||||
J3380|Injection| vedolizumab|1 MG|22.757|$22.76 ||||||||
J3385|Velaglucerase alfa|100 UNITS|359.732|$359.73 ||||||||
J3396|Verteporfin injection|0.1 MG|11.383|$11.38 ||||||||
J3410|Hydroxyzine hcl injection|25 MG|10.775|$10.78 ||||||||
J3411|Thiamine hcl 100 mg|100 MG|2.561|$2.56 ||||||||
J3415|Pyridoxine hcl 100 mg|100 MG|10.320|$10.32 ||||||||
J3420|Vitamin b12 injection|1000 MCG|1.572|$1.57 ||||||||
J3430|Vitamin k phytonadione inj|1 MG|3.215|$3.22 ||||||||
J3465|Injection| voriconazole|10 MG|1.059|$1.06 ||||||||
J3471|Ovine| up to 999 usp units|1 UNIT|0.494|$0.49 ||||||||
J3473|Hyaluronidase recombinant|1 USP UNIT|0.360|$0.36 ||||||||
J3475|Inj magnesium sulfate|500 MG|0.754|$0.75 ||||||||
J3480|Inj potassium chloride|2 MEQ|0.172|$0.17 ||||||||
J3485|Zidovudine|10 MG|1.511|$1.51 ||||||||
J3486|Ziprasidone mesylate|10 MG|11.584|$11.58 ||||||||
J3489|Zoledronic acid 1mg|1 MG|8.343|$8.34 ||||||||
J7030|Normal saline solution infus|1000 ML|2.712|$2.71 ||||||||
J7040|Normal saline solution infus|500 ML|1.356|$1.36 ||||||||
J7042|5% dextrose/normal saline|500 ML|0.893|$0.89 ||||||AMP-based payment limit||
J7050|Normal saline solution infus|250 ML|0.678|$0.68 ||||||||
J7060|5% dextrose/water|500 ML|1.866|$1.87 ||||||||
J7070|D5w infusion|1000 CC|3.731|$3.73 ||||||||
J7120|Ringers lactate infusion|1000 CC|2.489|$2.49 ||||||||
J7170|Inj.| emicizumab-kxwh 0.5 mg|0.5 MG|49.904|$49.90 |||||1|||
J7175|Inj| factor x| (human)| 1iu|1 IU|8.545|$8.55 |||||1|||
J7177|Inj.| fibryga| 1 mg|1 MG|1.091|$1.09 |||||1|||
J7178|Inj human fibrinogen con nos|1 IU|1.341|$1.34 |||||1|||
J7179|Vonvendi inj 1 iu vwf:rco|1 IU|1.858|$1.86 |||||1|||
J7180|Factor xiii anti-hem factor|1 IU|9.370|$9.37 |||||1|||
J7181|Factor xiii recomb a-subunit|1 IU|16.345|$16.35 |||||1|||
J7182|Factor viii recomb novoeight|1 IU|1.261|$1.26 |||||1|||
J7183|Wilate injection|1 I.U. VWF:RCO|1.147|$1.15 |||||1|||
J7185|Xyntha inj|1 IU|1.253|$1.25 |||||1|||
J7186|Antihemophilic viii/vwf comp|PER FACTOR VIII IU|1.140|$1.14 |||||1|||
J7187|Humate-p| inj|1 IU|1.292|$1.29 |||||1|||
J7188|Factor viii recomb obizur|1 IU|3.199|$3.20 |||||1|||
J7189|Factor viia recomb novoseven|1 MCG|2.345|$2.35 |||||1|||
J7190|Factor viii|1 IU|1.144|$1.14 |||||1|||
J7192|Factor viii recombinant nos|1 IU|1.446|$1.45 |||||1|||
J7193|Factor ix non-recombinant|1 IU|1.164|$1.16 |||||1|||
J7194|Factor ix complex|1 IU|1.536|$1.54 |||||1|||
J7195|Factor ix recombinant nos|1 IU|1.631|$1.63 |||||1|||
J7197|Antithrombin iii injection|1 IU|3.586|$3.59 ||||||||
J7198|Anti-inhibitor|1 IU|2.281|$2.28 |||||1|||
J7200|Factor ix recombinan rixubis|1 IU|1.491|$1.49 |||||1|||
J7201|Factor ix alprolix recomb|1 IU|3.365|$3.37 |||||1|||
J7202|Factor ix idelvion inj|1 IU|4.713|$4.71 |||||1|||
J7203|Factor ix recomb gly rebinyn|1 MG|4.203|$4.20 |||||1|||
J7204|Inj recombin esperoct per iu|1 IU|2.102|$2.10 |||||1|||
J7205|Factor viii fc fusion recomb|1 IU|2.168|$2.17 |||||1|||
J7207|Factor viii pegylated recomb|1 IU|1.987|$1.99 |||||1|||
J7208|Inj. jivi 1 iu|1 IU|2.163|$2.16 |||||1|||
J7209|Factor viii nuwiq recomb 1iu|1 IU|1.269|$1.27 |||||1|||
J7210|Inj| afstyla| 1 i.u.|1 IU|1.389|$1.39 |||||1|||
J7211|Inj| kovaltry| 1 i.u.|1 IU|1.272|$1.27 |||||1|||
J7212|Factor viia recomb sevenfact|1 MCG|1.969|$1.97 |||||1|||
J7308|Aminolevulinic acid hcl top|354 MG|392.086|$392.09 ||||||||
J7311|Inj.| retisert| 0.01 mg|0.01 MG|332.609|$332.61 ||||||||
J7312|Dexamethasone intra implant|0.1 MG|200.097|$200.10 ||||||||
J7313|Inj.| iluvien| 0.01 mg|0.01 MG|490.947|$490.95 ||||||||
J7314|Inj.| yutiq| 0.01 mg|0.01 MG|518.136|$518.14 ||||||||
J7318|Inj| durolane 1 mg|1 MG|10.355|$10.36 ||||||Added July 2022||
J7320|Genvisc 850| inj| 1mg|1 MG|6.678|$6.68 ||||||Updated October 2022||
J7321|Hyalgan supartz visco-3 dose|per dose|76.089|$76.09 ||||||||
J7322|Hymovis injection 1 mg|1 MG|15.708|$15.71 ||||||Added July 2022||
J7323|Euflexxa inj per dose|per dose|131.033|$131.03 ||||||||
J7324|Orthovisc inj per dose|PER DOSE|131.882|$131.88 ||||||||
J7325|Synvisc or synvisc-one|1 MG|9.771|$9.77 ||||||||
J7326|Gel-one|per dose|488.088|$488.09 ||||||Added July 2022||
J7327|Monovisc inj per dose|PER DOSE|754.903|$754.90 ||||||||
J7328|Gelsyn-3 injection 0.1 mg|0.1 MG|1.284|$1.28 ||||||Added July 2022||
J7329|Inj| trivisc 1 mg|1 MG|9.633|$9.63 ||||||Updated October 2022||
J7332|Inj.| triluron| 1 mg|1 MG|9.809|$9.81 ||||||Added July 2022||
J7336|Capsaicin 8% patch|1 SQ CM|3.242|$3.24 ||||||||
J7340|Carbidopa levodopa ent 100ml|100 ML|211.501|$211.50 ||||||||
J7342|Ciprofloxacin otic susp 6 mg|6 MG|29.980|$29.98 ||||||||
J7345|Aminolevulinic acid| 10% gel|10 MG|1.579|$1.58 ||||||||
J7351|Inj bimatoprost itc imp1mcg|1 MCG|206.402|$206.40 ||||||||
J7402|Mometasone sinus sinuva|10 MCG|10.930|$10.93 ||||||||
J7500|Azathioprine oral 50mg|50 MG|9.145|$9.15 ||||||||
J7502|Cyclosporine oral 100 mg|100 MG|2.131|$2.13 ||||||||
J7503|Tacrol envarsus ex rel oral|0.25 MG|1.561|$1.56 ||||||||
J7504|Lymphocyte immune globulin|250 MG|2898.297|$2|898.30 ||||||||
J7507|Tacrolimus imme rel oral 1mg|1 MG|0.375|$0.38 ||||||||
J7508|Tacrol astagraf ex rel oral|0.1 MG|0.520|$0.52 ||||||||
J7509|Methylprednisolone oral|4 MG|0.275|$0.28 ||||||||
J7510|Prednisolone oral per 5 mg|5 MG|0.234|$0.23 ||||||||
J7511|Antithymocyte globuln rabbit|25 MG|896.708|$896.71 ||||||||
J7512|Prednisone ir or dr oral 1mg|1 MG|0.014|$0.01 ||||||||
J7515|Cyclosporine oral 25 mg|25 MG|0.778|$0.78 ||||||||
J7516|Cyclosporin parenteral 250mg|250 MG|62.428|$62.43 ||||||||
J7517|Mycophenolate mofetil oral|250 MG|0.231|$0.23 ||||||||
J7518|Mycophenolic acid|180 MG|1.183|$1.18 ||||||||
J7520|Sirolimus| oral|1 MG|2.215|$2.22 ||||||||
J7525|Tacrolimus injection|5 MG|231.223|$231.22 ||||||||
J7527|Oral everolimus|0.25 MG|4.712|$4.71 ||||||||
J7605|Arformoterol non-comp unit|15 mcg|5.091|$5.09 ||||||||
J7606|Formoterol fumarate| inh|20 MCG|7.791|$7.79 ||||||||
J7608|Acetylcysteine non-comp unit|1 GM|6.030|$6.03 ||||||||
J7611|Albuterol non-comp con|1 MG|0.219|$0.22 ||||||||
J7612|Levalbuterol non-comp con|0.5 MG|0.267|$0.27 ||||||||
J7613|Albuterol non-comp unit|1 MG|0.049|$0.05 ||||||||
J7614|Levalbuterol non-comp unit|0.5 MG|0.064|$0.06 ||||||||
J7620|Albuterol ipratrop non-comp|2.5 MG/0.5 MG|0.130|$0.13 ||||||||
J7626|Budesonide non-comp unit|0.5 MG|1.044|$1.04 ||||||||
J7631|Cromolyn sodium noncomp unit|10 MG|1.257|$1.26 ||||||||
J7639|Dornase alfa non-comp unit|1 MG|47.809|$47.81 ||||||||
J7644|Ipratropium bromide non-comp|1 MG|0.200|$0.20 ||||||||
J7674|Methacholine chloride| neb|1 MG|0.810|$0.81 ||||||||
J7677|Revefenacin inh non-com 1mcg|1 MCG|0.188|$0.19 ||||||||
J7682|Tobramycin non-comp unit|300 MG|27.774|$27.77 ||||||||
J7686|Treprostinil| non-comp unit| 1.74 MG|704.634|$704.63 ||||||||
J8501|Oral aprepitant|5 MG|3.701|$3.70 ||||||||
J8520|Capecitabine| oral| 150 mg|150 MG|0.450|$0.45 ||||||||
J8521|Capecitabine| oral| 500 mg|500 MG|0.805|$0.81 ||||||||
J8530|Cyclophosphamide oral 25 mg|25 MG|0.755|$0.76 ||||||||
J8540|Oral dexamethasone|0.25 MG|0.100|$0.10 ||||||||
J8560|Etoposide oral 50 mg|50 MG|76.094|$76.09 ||||||||
J8610|Methotrexate oral 2.5 mg|2.5 MG|0.187|$0.19 ||||||||
J8655|Oral netupitant| palonosetro|0.5 MG|379.060|$379.06 ||||||||
J8670|Rolapitant| oral| 1mg|1 MG|1.757|$1.76 ||||||||
J8700|Temozolomide|5 MG|0.255|$0.26 ||||||||
J8705|Topotecan oral|0.25 mg|104.358|$104.36 ||||||||
J9000|Doxorubicin hcl injection|10 MG|2.511|$2.51 ||||||AMP-based payment limit||
J9017|Arsenic trioxide injection|1 MG|12.334|$12.33 ||||||||
J9019|Erwinaze injection|1|000 IU|427.269|$427.27 ||||||||
J9021|Inj| aspara| rylaze| 0.1 mg|0.1 MG|46.534|$46.53 ||||||||
J9022|Inj| atezolizumab|10 mg|10 MG|82.269|$82.27 ||||||||
J9023|Injection| avelumab| 10 mg|10 MG|88.376|$88.38 ||||||||
J9025|Azacitidine injection|1 MG|0.670|$0.67 ||||||||
J9027|Clofarabine injection|1 MG|48.395|$48.40 ||||||||
J9030|Bcg live intravesical 1mg|1 MG|2.833|$2.83 ||||||||
J9032|Injection| belinostat| 10mg|10 MG|44.359|$44.36 ||||||||
J9033|Inj.| treanda 1 mg|1 MG|17.700|$17.70 ||||||||
J9034|Inj.| bendeka 1 mg|1 MG|17.843|$17.84 ||||||||
J9035|Bevacizumab injection|10 MG|69.225|$69.23 ||||||||
J9036|Inj. belrapzo/bendamustine|1 MG|19.374|$19.37 ||||||||
J9037|Inj belantamab mafodot blmf|0.5 MG|44.134|$44.13 ||||||||
J9039|Injection| blinatumomab|1 MCG|129.822|$129.82 ||||||||
J9040|Bleomycin sulfate injection|15 UNITS|24.117|$24.12 ||||||||
J9041|Inj.| velcade 0.1 mg|0.1 MG|44.009|$44.01 ||||||||
J9042|Brentuximab vedotin inj|1 MG|205.564|$205.56 ||||||||
J9043|Cabazitaxel injection|1 MG|196.606|$196.61 ||||||||
J9044|Inj| bortezomib| nos| 0.1 mg|0.1 MG|14.866|$14.87 ||||||||
J9045|Carboplatin injection|50 MG|2.922|$2.92 ||||||||
J9047|Injection| carfilzomib| 1 mg|1 MG|43.242|$43.24 ||||||||
J9050|Carmustine injection|100 MG|760.826|$760.83 ||||||||
J9055|Cetuximab injection|10 MG|69.408|$69.41 ||||||||
J9060|Cisplatin 10 mg injection|10 MG|2.075|$2.08 ||||||||
J9061|Inj| amivantamab-vmjw|2 MG|18.663|$18.66 ||||||||
J9065|Inj cladribine per 1 mg|1 MG|21.658|$21.66 ||||||||
J9070|Cyclophosphamide 100 mg inj|100 MG|26.870|$26.87 ||||||||
J9100|Cytarabine hcl 100 mg inj|100 MG|0.923|$0.92 ||||||||
J9119|Inj.| cemiplimab-rwlc| 1 mg|1 MG|27.252|$27.25 ||||||||
J9120|Dactinomycin injection|0.5 MG|633.765|$633.77 ||||||||
J9130|Dacarbazine 100 mg inj|100 MG|4.012|$4.01 ||||||||
J9144|Daratumumab| hyaluronidase|10 MG|46.580|$46.58 ||||||||
J9145|Injection| daratumumab 10 mg|10 MG|58.749|$58.75 ||||||||
J9150|Daunorubicin injection|10 MG|44.045|$44.05 ||||||||
J9153|Inj daunorubicin| cytarabine|1 MG/2.27 MG|215.407|$215.41 ||||||||
J9155|Degarelix injection|1 MG|4.032|$4.03 ||||||||
J9171|Docetaxel injection|1 MG|0.498|$0.50 ||||||||
J9173|Inj.| durvalumab| 10 mg|10 MG|78.200|$78.20 ||||||||
J9176|Injection| elotuzumab| 1mg|1 MG|6.954|$6.95 ||||||||
J9177|Inj enfort vedo-ejfv 0.25mg|0.25 MG|31.356|$31.36 ||||||||
J9178|Inj| epirubicin hcl| 2 mg|2 MG|1.583|$1.58 ||||||||
J9179|Eribulin mesylate injection|0.1 MG|128.994|$128.99 ||||||Updated October 2022||
J9181|Etoposide injection|10 MG|0.803|$0.80 ||||||||
J9185|Fludarabine phosphate inj|50 MG|48.062|$48.06 ||||||||
J9190|Fluorouracil injection|500 MG|2.126|$2.13 ||||||||
J9198|Inj. infugem| 100 mg|100 MG|25.779|$25.78 ||||||||
J9200|Floxuridine injection|500 MG|97.309|$97.31 ||||||||
J9201|In gemcitabine hcl nos 200mg|200 MG|3.764|$3.76 ||||||||
J9202|Goserelin acetate implant|3.6 MG|576.100|$576.10 ||||||||
J9203|Gemtuzumab ozogamicin 0.1 mg|0.1 MG|214.279|$214.28 ||||||||
J9204|Inj mogamulizumab-kpkc| 1 mg|1 MG|216.249|$216.25 ||||||||
J9205|Inj irinotecan liposome 1 mg|1 MG|60.140|$60.14 ||||||||
J9206|Irinotecan injection|20 MG|2.373|$2.37 ||||||||
J9207|Ixabepilone injection|1 MG|117.057|$117.06 ||||||||
J9208|Ifosfamide injection|1 GM|26.012|$26.01 ||||||||
J9209|Mesna injection|200 MG|1.769|$1.77 ||||||||
J9210|Inj.| emapalumab-lzsg| 1 mg|1 MG|380.389|$380.39 ||||||||
J9211|Idarubicin hcl injection|5 MG|41.269|$41.27 ||||||||
J9214|Interferon alfa-2b inj|1 MIL UNITS|31.846|$31.85 ||||||||
J9217|Leuprolide acetate suspnsion|7.5 MG|179.267|$179.27 ||||||||
J9218|Leuprolide acetate injeciton|1 MG|13.321|$13.32 ||||||||
J9223|Inj. lurbinectedin| 0.1 mg|0.1 MG|183.979|$183.98 ||||||||
J9225|Vantas implant|50 MG|5166.292|$5|166.29 ||||||||
J9226|Supprelin la implant|50 MG|42302.581|$42|302.58 ||||||||
J9227|Inj. isatuximab-irfc 10 mg|10 MG|70.496|$70.50 ||||||||
J9228|Ipilimumab injection|1 MG|163.659|$163.66 ||||||||
J9229|Inj inotuzumab ozogam 0.1 mg|0.1 MG|2443.305|$2|443.31 ||||||||
J9245|Inj melpha hydroch nos 50 mg|50 MG|181.506|$181.51 ||||||||
J9247|Inj| melphalan flufenami 1mg|1 MG|503.500|$503.50 ||||||||
J9250|Methotrexate sodium inj|5 MG|0.197|$0.20 ||||||||
J9260|Methotrexate sodium inj|50 MG|1.974|$1.97 ||||||||
J9261|Nelarabine injection|50 MG|130.140|$130.14 ||||||||
J9262|Inj| omacetaxine mep| 0.01mg|0.01 MG|3.610|$3.61 ||||||||
J9263|Oxaliplatin|0.5 MG|0.059|$0.06 ||||||||
J9264|Paclitaxel protein bound|1 MG|14.693|$14.69 ||||||||
J9266|Pegaspargase injection|1 EA|23554.475|$23|554.48 ||||||||
J9267|Paclitaxel injection|1 MG|0.124|$0.12 ||||||||
J9268|Pentostatin injection|10 MG|2076.079|$2|076.08 ||||||||
J9269|Inj. tagraxofusp-erzs 10 mcg|10 MCG|309.406|$309.41 ||||||||
J9271|Inj pembrolizumab|1 MG|53.139|$53.14 ||||||||
J9272|Inj| dostarlimab-gxly| 10 mg|10 MG|220.428|$220.43 ||||||||
J9273|Inj tisotu vedotin-tftv| 1mg|1 MG|155.908|$155.91 ||||||Added July 2022||
J9280|Mitomycin injection|5 MG|47.160|$47.16 ||||||||
J9281|Mitomycin instillation|1 MG|285.361|$285.36 ||||||||
J9293|Mitoxantrone hydrochl / 5 mg|5 MG|35.786|$35.79 ||||||||
J9295|Injection| necitumumab| 1 mg|1 MG|5.737|$5.74 ||||||||
J9299|Injection| nivolumab|1 MG|29.685|$29.69 ||||||||
J9301|Obinutuzumab inj|10 MG|66.005|$66.01 ||||||||
J9302|Ofatumumab injection|10 MG|63.957|$63.96 ||||||||
J9303|Panitumumab injection|10 MG|136.965|$136.97 ||||||||
J9305|Inj. pemetrexed nos 10mg|10 MG|78.393|$78.39 ||||||||
J9306|Injection| pertuzumab| 1 mg|1 MG|14.152|$14.15 ||||||||
J9307|Pralatrexate injection|1 MG|321.088|$321.09 ||||||||
J9308|Injection| ramucirumab|5 MG|65.674|$65.67 ||||||||
J9309|Inj| polatuzumab vedotin 1mg|1 MG|117.809|$117.81 ||||||||
J9311|Inj rituximab| hyaluronidase|10 mg|37.901|$37.90 ||||||||
J9312|Inj.| rituximab| 10 mg|10 MG|84.166|$84.17 ||||||||
J9313|Inj.| lumoxiti| 0.01 mg|0.01 MG|23.394|$23.39 ||||||||
J9316|Pertuzu| trastuzu| 10 mg|10 MG|70.371|$70.37 ||||||||
J9317|Sacituzumab govitecan-hziy|2.5 MG|32.033|$32.03 ||||||||
J9319|Inj romidepsin lyophil 0.1mg|0.1 MG|33.228|$33.23 ||||||||
J9320|Streptozocin injection|1 GM|349.384|$349.38 ||||||||
J9325|Inj talimogene laherparepvec|1 million PFU|59.678|$59.68 ||||||||
J9328|Temozolomide injection|1 MG|10.398|$10.40 ||||||||
J9330|Temsirolimus injection|1 MG|32.910|$32.91 ||||||||
J9332|Inj efgartigimod 2mg|2 MG|31.530|$31.53 ||||||Added July 2022||
J9340|Thiotepa injection|15 MG|298.191|$298.19 ||||||||
J9349|Inj.| tafasitamab-cxix|2 MG|12.965|$12.97 ||||||||
J9351|Topotecan injection|0.1 MG|0.831|$0.83 ||||||||
J9352|Injection trabectedin 0.1mg|0.1 MG|330.175|$330.18 ||||||||
J9353|Inj. margetuximab-cmkb| 5 mg|5 MG|44.032|$44.03 ||||||||
J9354|Inj| ado-trastuzumab emt 1mg|1 MG|35.616|$35.62 ||||||||
J9355|Inj trastuzumab excl biosimi|10 MG|86.607|$86.61 ||||||||
J9356|Inj. herceptin hylecta| 10mg|10 MG|68.734|$68.73 ||||||||
J9357|Valrubicin injection|200 MG|1437.847|$1|437.85 ||||||||
J9358|Inj fam-trastu deru-nxki 1mg|1 MG|25.167|$25.17 ||||||||
J9359|Inj lon tesirin-lpyl 0.075mg|0.075 MG|188.295|$188.30 ||||||||
J9360|Vinblastine sulfate inj|1 MG|4.007|$4.01 ||||||AMP-based payment limit||
J9370|Vincristine sulfate 1 mg inj|1 MG|4.906|$4.91 ||||||||
J9371|Inj| vincristine sul lip 1mg|1 MG|3420.781|$3|420.78 ||||||||
J9390|Vinorelbine tartrate inj|10 MG|11.397|$11.40 ||||||||
J9395|Injection| fulvestrant|25 MG|14.017|$14.02 ||||||||
J9400|Inj| ziv-aflibercept| 1mg|1 MG|8.091|$8.09 ||||||||
P9041|Albumin (human)|5%| 50ml|50 ML|10.490|$10.49 |||95|10.490||||
P9045|Albumin (human)| 5%| 250 ml|250 ML|52.450|$52.45 |||95|52.450||||
P9046|Albumin (human)| 25%| 20 ml|20 ML|20.980|$20.98 |||95|20.980||||
P9047|Albumin (human)| 25%| 50ml|50 ML|52.450|$52.45 |||95|52.450||||
Q0138|Ferumoxytol| non-esrd|1 MG|0.702|$0.70 ||||||||
Q0139|Ferumoxytol| esrd use|1 MG|0.702|$0.70 ||||||||
Q0162|Ondansetron oral|1 MG|0.011|$0.01 ||||||||
Q0164|Prochlorperazine maleate 5mg|5 MG|0.442|$0.44 ||||||||
Q0167|Dronabinol 2.5mg oral|2.5 MG|0.877|$0.88 ||||||||
Q2043|Sipuleucel-t auto cd54+|Per infusion (minimum 50 million cells)|55114.745|$55|114.75 ||||||||
Q2050|Doxorubicin inj 10mg|10 MG|129.993|$129.99 ||||||||
Q3027|Inj beta interferon im 1 mcg|1 MCG|56.067|$56.07 ||||||||
Q4074|Iloprost non-comp unit dose|UP TO 20 MCG|139.476|$139.48 ||||||||
Q4081|Epoetin alfa| 100 units esrd|100 UNITS|0.822|$0.82 ||||||||
Q4101|Apligraf|1 SQ CM|30.365|$30.37 ||||||||
Q4102|Oasis wound matrix|1 SQ CM|11.624|$11.62 ||||||||
Q4106|Dermagraft|1 SQ CM|26.763|$26.76 ||||||||
Q4110|Primatrix|1 SQ CM|41.798|$41.80 ||||||||
Q4111|Gammagraft|1 SQ CM|7.194|$7.19 ||||||||
Q4121|Theraskin|1 SQ CM|43.218|$43.22 ||||||||
Q4133|Grafix stravix prime pl sqcm|1 SQ CM|135.467|$135.47 ||||||||
Q4137|Amnioexcel biodexcel 1sq cm|1 SQ CM|98.483|$98.48 ||||||||
Q4151|Amnioband| guardian 1 sq cm|1 SQ CM|134.793|$134.79 ||||||||
Q4159|Affinity1 square cm|1 SQ CM|535.093|$535.09 ||||||||
Q4160|Nushield 1 square cm|1 SQ CM|92.336|$92.34 ||||||||
Q4163|Woundex| bioskin| per sq cm|1 SQ CM|90.420|$90.42 ||||||||
Q4186|Epifix 1 sq cm|1 SQ CM|156.222|$156.22 ||||||||
Q4187|Epicord 1 sq cm|1 SQ CM|237.064|$237.06 ||||||||
Q4195|Puraply 1 sq cm|1 SQ CM|71.232|$71.23 ||||||||
Q4196|Puraply am 1 sq cm|1 SQ CM|109.450|$109.45 ||||||||
Q5101|Injection| zarxio|1 MCG|0.231|$0.23 ||||||||
Q5103|Injection| inflectra|10 MG|33.257|$33.26 ||||||||
Q5104|Injection| renflexis|10 MG|51.253|$51.25 ||||||||
Q5105|Inj retacrit esrd on dialysi|100 UNITS|0.839|$0.84 ||||||||
Q5106|Inj retacrit non-esrd use|1000 UNITS|8.395|$8.40 ||||||||
Q5107|Inj mvasi 10 mg|10 MG|32.239|$32.24 ||||||||
Q5108|Injection| fulphila|0.5 MG|165.659|$165.66 ||||||Updated October 2022||
Q5110|Nivestym|1 MCG|0.340|$0.34 ||||||||
Q5111|Injection| udenyca 0.5 mg|0.5 MG|171.869|$171.87 ||||||||
Q5112|Inj ontruzant 10 mg|10 MG|68.497|$68.50 ||||||||
Q5113|Inj herzuma 10 mg|10 MG|42.955|$42.96 ||||||||
Q5114|Inj ogivri 10 mg|10 MG|47.886|$47.89 ||||||Updated October 2022||
Q5115|Inj truxima 10 mg|10 MG|48.340|$48.34 ||||||||
Q5116|Inj.| trazimera| 10 mg|10 MG|45.480|$45.48 ||||||||
Q5117|Inj.| kanjinti| 10 mg|10 MG|38.491|$38.49 ||||||||
Q5118|Inj.| zirabev| 10 mg|10 MG|41.862|$41.86 ||||||||
Q5119|Inj ruxience| 10 mg|10 MG|44.029|$44.03 ||||||||
Q5120|Inj pegfilgrastim-bmez 0.5mg|0.5 MG|153.333|$153.33 ||||||||
Q5121|Inj. avsola| 10 mg|10 MG|38.649|$38.65 ||||||||
Q5122|Inj| nyvepria|0.5 MG|217.685|$217.69 ||||||||
Q5123|Inj. riabni| 10 mg|10 MG|49.837|$49.84 ||||||||
Q9950|Inj sulf hexa lipid microsph|1 ML|18.492|$18.49 ||||||||
Q9956|Inj octafluoropropane mic|ml|1 ML|30.437|$30.44 ||||||||
Q9957|Inj perflutren lip micros|ml|1 ML|45.656|$45.66 ||||||||
Q9958|Hocm <=149 mg/ml iodine| 1ml|1 ML|0.073|$0.07 ||||||||
Q9961|Hocm 250-299mg/ml iodine|1ml|1 ML|0.247|$0.25 ||||||||
Q9963|Hocm 350-399mg/ml iodine|1ml|1 ML|0.185|$0.19 ||||||||
Q9965|Locm 100-199mg/ml iodine|1ml|1 ML|0.892|$0.89 ||||||||
Q9966|Locm 200-299mg/ml iodine|1ml|1 ML|0.340|$0.34 ||||||||
Q9967|Locm 300-399mg/ml iodine|1ml|1 ML|0.116|$0.12 ||||||||
Q9991|Buprenorph xr 100 mg or less|Less than or equal to 100 MG|1858.610|$1|858.61 ||||||||
Q9992|Buprenorphine xr over 100 mg|Greater than 100 MG|1858.610|$1|858.61 ||||||||