New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 58A - ADVANCED PRACTICE NURSE SERVICES
Subchapter 4 - CENTERS FOR MEDICARE & MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS
Section 10:58A-4.3 - HCPCS procedure codes and maximum fee allowance schedule for Level II codes and narratives

Universal Citation: NJ Admin Code 10:58A-4.3
Current through Register Vol. 56, No. 18, September 16, 2024

INDHCPCS CODESMODMAXIMUM FEE
ALLOWANCE $
(a) APN Administered Drugs:
J0120Injection, tetracycline, up to 250 mg0.73
J0128Injection, abarelix, 10 mg70.81
J0129Injection, abatacept, 10 mg19.69
J0130Injection, abciximab, 10 mg601.69
J0132Injection, acetylcysteine, 100 mg2.16
J0133Injection, acyclovir, 5 mg0.16
J0135Injection, adalimumab, 20 mg335.64
J0150Injection, adenosine, 6 mg33.11
J0152Injection, adenosine, 30 mg76.50
J0170Injection, adrenalin, epinephrine, up to 1 ml ampul2.88
J0180Injection, agalsidase beta, 1 mg131.25
J0190Injection, biperiden lactate, 5 mg2.91
J0200Injection, alatrofloxacin mesylate 100 mg17.15
J0205Injection, alglucerase, per 10 units37.52
J0207Injection, amifostine, 500 mg536.14
J0210Injection, methyldopate HCl, (Aldomet), up to 250 mg1.74
J0215Injection, alefacept, 0.5 mg29.02
J0220Injection, aglucosidase alfa, 10 mg131.25
J0256Injection, alpha 1-proteinase inhibitor-human, per 5000.01
J0278Injection, amikacin sulfate, 100 mg2.29
J0280Injection, aminophylline, up to 250 mg0.75
J0282Injection, amiodarone hydrochloride, 30 mg0.80
J0285Injection, amphotericin B, 50 mg17.06
J0287Injection, amphotericin B lipid complex, 10 mg21.00
J0288Injection, amphotericin B cholesteryl sulfate complex, 10 mg15.17
J0289Injection, amphotericin B liposome, 10 mg34.34
J0290Injection, ampicillin sodium, up to 500 mg3.86
J0295Injection, ampicillin sodium/sulbactam sodium, 1.5 mg7.25
J0300Injection, amobarbital, up to 125 mg2.66
J0330Injection, succinylcholine chloride, (Anectine), up to 20 mg0.26
J0350Injection, anistreplase, per 30 units2,481.13
J0360Hydralazine HCl, (Apresoline), up to 20 mg14.77
J0364Apomorphine hydrochloride, 1 mg3.39
J0365Aprotonin, 10,000 KIU2.85
J0380Injection, metaraminol bitartrate, per 10 mg1.21
J0390Injection, chloroquine HCl, (Araten HCl), up to 250 mg17.44
J0395Injection, arbutamine HCl, 1 mg168.00
J0400Injection, aripiprazole0.31
J0456Injection, azithromycin, 500 mg27.09
J0461Injection, atropine sulfate0.24
J0470Injection, dimercaprol, per 100 mg28.84
J0475Injection, baclofen, 10 mg223.13
J0476Injection, baclofen, 50 mcg for intrathecal trial73.50
J0480Basiliximab, 20 mg2,215.72
J0500Injection, dicyclomine HCl, (Bentyl, Spasmoject), 10 mg18.52
J0515Injection, benztropine mesylate, (Cogentin), 1 mg12.21
J0520Injection, bethanechol chloride, myotonachol or urecholine,4.91
up to 5 mg
J0559Injection, penicillin G benzathine/procaine0.08
J0560Injection, penicillin G benzathine, (Bicillin long acting),25.71
up to 600,000 units
J0570Injection, penicillin G benzathine, (Bicillin long acting),19.76
up to 1,200,000 units
J0580Injection, penicillin G benzathine, (Bicillin long acting),22.51
up to 2,400,000 units
J0583Bivalirudin, 1 mg2.08
J0585Botulinum toxin type A per unit5.52
J0586Botulinum toxin type A7.16
J0587Botulinum toxin type B, per 100 units8.99
J0592Injection, buprenorphine hydrochloride, 0.1 mg1.02
J0594Injection, busulfan, 1 mg10.09
J0595Butorphanol; tartrate, 1 mg3.91
J0598Injection, C1 Esterase inhibitor37.71
J0600Injection, edetate calcium disodium, 200 mg52.89
J0610Injection, calcium gluconate, per 10 ml2.03
J0620Injection calcium glycerophosphate and calcium lactate, per12.58
10 ml (Calphosan)
J0630Injection, calcitonin salmon, up to 400 units48.09
J0636Injection, calcitriol, 0.1 mcg1.34
J0637Injection, caspofungin acetate, 5 mg30.89
J0640Injection, leucovorine calcium, 50 mg3.28
J0641Injection, levoleucovorin, 0.5 mg1.05
J0670Injection, mepivacaine HCl, (Carbocaine), per 10 ml2.45
J0690Injection, cefazolin sodium, (Ancef, Kefzol), up to 500 mg2.83
J0692Injection, cefepime HCl, 500 mg (Maxipime)9.13
J0694Injection, cefoxitin sodium, (Mefoxin), 1 gm10.23
J0696Injection, ceftriaxone sodium, (Rocephin), per 250 mg12.97
J0697Injection, sterile cefuroxime sodium, 750 mg5.92
J0698Cefotaxime sodium, (Claforan), per gm7.10
J0702Injection, betamethasone acetate and betamethasone sodium2.88
phosphate, per 3 mg
J0704Injection, betamethasone sodium phosphate, per 4 mg1.09
J0706Injection, caffeine citrate, 5 mg (Cafcit)3.53
J0710Injection, cephapirin sodium (Cefadyl), up to 1 gram1.44
J0713Injection, ceftazidime, per 500 mg6.48
J0715Injection, ceftazoxime sodium, per 500 mg5.89
J0718Injection, certolizumab pegol7.37
J0720Injection, chloramphenicol sodium succinate, (Chloromycetin14.62
Sodium Succinate), up to 1 gram
J0735Injection, clonidine hydrochloride, 1 mg70.58
J0740Injection, cidofovir, 375 mg818.27
J0743Injection, cilastatin sodium/imipenem (Primaxin), 250 mg18.77
J0744Injection, ciprofloxacin for IV infusion 200 mg (Cipro)14.22
J0745Injection, codeine phosphate, 30 mg1.07
J0760Injection, colchicine, per 1 mg6.78
J0770Injection, colistimethate sodium, (Coly-Mycin), up to 150mg49.88
J0780Injection, prochlorperazine, (Compazine), up to 10 mg8.37
J0795Corticorelin ovine triflutal, 1 mcg4.75
J0800Injection, corticotropin, up to 40 units180.49
J0833Injection, cosyntropin, nos98.70
J0834Injection, cosyntropin cortrosyn107.44
J0850Injection, cytomegalovirus immune globulin intravenous925.32
(human), per vial
J0878Injection, dapromycin0.35
J0881Darbepoetin alpha, non-ESRD use, 1 mcg5.01
J0882Darbepoetin alpha, ESRD use, 1 mcg5.01
J0885Epoetin alfa, non-ESRD, 1,000 units13.69
J0886Injection, epoetin alfa, ESRD use, 1,000 units13.31
J0886Injection, epoetin alfa, non-ESRD use, 1,000 units13.31
J0894Injection, decitabine, 1 mg26.25
J0895Injection, deferoxamine mesylate, (Desferal), 100 mg16.92
J0945Injection, brompheniramine maleate, per 10 mg0.62
J0970Injection, estradiol valerate, up to 40 mg34.60
J1000Injection, depo-estradiol cypionate, 5 mg6.59
J1020Injection, methylprednisolone acetate, 20 mg3.13
J1030Injection, methylprednisolone acetate, 40 mg6.34
J1040Injection, methylprednisolone acetate, 80 mg10.45
J1051Injection, medroxyprogesterone acetate, 50 mg15.47
J1055Injection, medroxprogesterone acetate, for contraceptive use,53.97
150 mg
J1056Injection, medroxyprogesterone acetate/estradial cypionate, 522.60
mg/25 mg (Lunelle monthly contraceptive)
J1060Injection, testosterone cypionate and estradiol cypionate, up3.41
to 1 ml
J1070Injection, testosterone cypionate, up to 100 mg6.04
J1080Injection, testosterone cypionate, 1 cc/200 mg12.03
J1094Injection, dexamethasone acetate, 1 mg0.53
J1100Injection, dexamethasone sodium phosphate, 1 mg0.13
J1110Dihydroergotamine Mesylate, 1 mg31.94
J1120Injection, acetazolamide sodium, (Diamox Sodium), up to 50022.97
mg
J1160Injection, digoxin, up to 0.5 mg2.49
J1162Digoxin immune fab (ovine), per vial594.23
J1165Injection, phenytoin sodium, (Dilantin), per 50 mg0.70
J1170Injection, hydromorphone, 2 mg1.01
J1180Injection, dyphylline, (Dilor, Lufyllin), up to 500 mg8.30
J1190Injection, dexrazoxane hydrochloride, per 250 mg224.47
J1200Injection, diphenhydramine HCl, (Benadryl), up to 50 mg1.16
J1205Injection, chlorothiazide sodium, (Diuril), per 500 mg149.94
J1212Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml52.50
J1230Injection, methadone HCl, (Dolophine HCl), up to 10 mg2.14
J1240Injection, demenhydrinate, (Dramamine), up to 50 mg2.74
J1245Injection, dipyridamole, per 10 mg7.66
J1250Injection, dobutamine hydrochloride, per 250 mg43.51
J1260Injection, dolasetron mesylate, 1 mg4.27
J1265Injection, dopamine, 40 mg0.32
J1267Injection, doripenem, 10 mg0.81
J1270Injection, doxercalciferol, 1 mcg (Hectorol)6.31
J1300Injection, eculizumab182.00
J1320Injection, amitriptyline HCl, (Elavil HCl), up to 20 mg2.05
J1324Injection, enfuvirtide, 1 mg19.70
J1325Injection, epoprostenol, 0.5 mg19.47
J1327Injection, eptifibatide, 5 mg21.13
J1330Injection, ergonovine maleate, up to 0.2 mg5.08
J1335Injection, ertapenem, 500 mg27.27
J1364Injection, erythromycin lactobionate, 500 mg9.09
J1380Injection, estradiol valerate, up to 10 mg14.81
J1390Injection, estradiol valerate, up to 20 mg20.88
J1410Injection, estrogen conjugated, per 25 mg70.83
J1430Ethanolamine oleate, 100 mg84.99
J1435Injection, estrone, per 1 mg0.25
J1436Injection, etidronate disodium, per 300 mg70.88
J1438Injection, etanercept, 25 mg180.50
J1440Injection, filgrastim, (G-CSF), 300 mcg216.68
J1441Injection, filagrastim, (G-CSF), 480 mcg345.19
J1450Injection, fluconazole, 200 mg20.81
J1451Fomepizole, 15 mg12.11
J1452Injection, fomivirsen sodium, intraocular, 1.65 mg875.00
J1453Injection, fosaprepitant, 1 mg1.62
J1455Injection, foscarnet sodium, (Foscavir), per 1000 mg12.00
J1457Injection, gallium nitrate, 1 mg1.71
J1458Injection, galsulfase, 1 mg327.91
J1459Injection, ivig privigen, 500 mg45.94
J1460Injection, gamma globulin I.M., 1 cc15.45
J1470Injection, gamma globulin I.M., 2 cc30.89
J1480Injection, gamma globulin I.M., 3 cc46.34
J1490Injection, gamma globulin I.M., 4 cc61.78
J1500Injection, gamma globulin I.M., 5 cc77.23
J1510Injection, gamma globulin I.M., 6 cc92.67
J1520Injection, gamma globulin I.M., 7 cc108.12
J1530Injection, gamma globulin I.M., 8 cc123.56
J1540Injection, gamma globulin I.M., 9 cc139.01
J1550Injection, gamma globulin I.M., 10 cc118.00
J1561Injection, immune globulin (Gamunex)47.28
J1562Injection, globulin sc, 100 mg13.13
J1566Immune globulin, powder, 500 mg43.89
J1568Injection, octagam55.61
J1569Injection, gammagard liquid59.17
J1570Injection, ganciclovir sodium, (Cytovene), 500 mg54.38
J1571Injection, hepagam B IM, 0.5 ml75.00
J1572Injection, flebogamma, 500 mg44.10
J1573Injection, hepagam B intravenous, 0.5 ml75.00
J1580Injection, garamycin, gentamicin, up to 80 mg2.12
J1590Injection, gatifloxacin, 10 mg (Tequin)0.83
J1600Injection, gold sodium thiomalate, 50 mg13.69
J1610Injection, glucagon hydrochloride, 1 mg76.56
J1620Injection, gonadorelin hydrochloride, per 100 mcg186.03
J1626Injection, granisetron hydrochloride, 100 mcg17.08
J1630Injection, haloperidol, up to 5 mg6.55
J1631Injection, haloperidol decanoate, 50 mg2.97
J1640Injection, hemin, 1 mg7.52
J1642Injection, heparin sodium, (Heparin Lock Flush), 10 units0.07
J1644Injection, heparin sodium, 1,000 units0.14
J1645Injection, dalteparin sodium, per 2,500 IU17.47
J1650Injection, enoxaparin sodium, 10 mg7.10
J1652Injection, fondaparinux sodium, 0.5 mg8.79
J1655Injection, tinzaparin sodium, 1,000 IU (Innohep)3.97
J1670Injection, tetanus immune globulin, human, up to 250 units124.26
J1675Injection, histrelin acetate, 10 mcg8.24
J1680Injection, human fibrinogen concentrate91.56
J1700Injection, hydrocortisone acetate, (Analpram HC, Hydrocortone0.61
Acetate), up to 25 mg
J1710Injection, hydrocortisone sodium phosphate, (Hydrocortone5.13
Phosphate), up to 50 mg
J1720Injection, hydrocortisone sodium succinate, (Solu-Cortef), up1.74
to 100 mg
J1730Injection, diazoxide, (Hyperstat), up to 300 mg117.96
J1740Injection, ibandronate sodium, 1 mg147.20
J1742Injection, ibutilide fumarate, 1 mg309.71
J1743Injection, idursulfase479.10
J1745Injection, infliximab, 10 mg61.15
J1750Injection, iron dextran, 50 mg13.41
J1756Injection, iron sucrose, 1 mg0.60
J1785Injection, imiglucerase, per unit4.05
J1790Injection, droperidol, (Inapsine), up to 5 mg3.72
J1800Injection, propranolol HCl, (Inderal), up to 1 mg8.62
J1810Injection, droperidol and fentanyl citrate, (Innovar), up to14.67
2 ml ampule
J1815Injection, insulin, per 5 units0.34
J1817Insulin for insulin pump use, per 50 units4.50
J1825Injection, interferon beta-1a, 33 mcg administered under400.18
direct supervision of a physician, excludes self administration
J1830Injection, interferon beta-1B, 0.25 mg96.08
J1835Injection, itraconazole, 50 mg (Sporanox)43.63
J1840Injection, kanamycin sulfate, (Kantrex), up to 500 mg7.70
J1850Injection, kanamycin sulfate, (Kantrex), up to 75 mg2.66
J1885Injection, ketorolac tromethamine, (Toradol I.M.), per 15 mg3.05
J1890Injection, cephalothin sodium, (Keflin), up to 1 gram9.45
J1930Injection, lanreotide, 1 mg27.81
J1931Injection, laronidase (aldurazyme), 0.1 mg24.63
J1940Injection, furosemide, (Lasix), up to 20 mg0.63
J1945Lepirudin, 50 mg174.13
J1950Injection, leuprolide acetate, (Depot Suspension), 3.75 mg544.60
J1953Injection, levetiracetam, 10 mg0.69
J1955Injection, levocarnitine, per 1 gram34.30
J1956Injection, levofloxacin, 250 mg18.82
J1960Injection, levorphanal tartrate, up to 2 mg3.72
J1980Injection, hyoscyamine sulfate, (Levsin), up to 0.25 mg10.35
J1990Injection, chlordiazepoxide HCl, (Librium), up to 100mg23.02
J2001Injection, lidocaine, per 10 mg0.31
J2010Injection, lincomycin HCl, up to 300 mg2.76
J2020Injection, linezolid, 200 mg (Zyvox)36.13
J2060Injection, lorazepam (Atvian), 2 mg2.82
J2150Injection, mannitol, 25% in 50 ml2.49
J2170Injection, mecasermin, 1 mg14.15
J2175Injection, meperidine HCl, 100 mg1.19
J2180Injection, meperidine/ promethazine HCl, (Mepergan), up to 508.00
mg
J2185Meropenem, 100 mg6.21
J2210Injection, methylergonovine maleate, (Metherqine Maleate), up5.37
to 0.2 mg
J2248Injection, micafungin sodium, 1 mg2.05
J2250Injection, midazolam hydrochloride, per 1 mg0.56
J2260Injection, milrinone lactate, per 5 ml6.56
J2270Injection, morphine sulfate, up to 10 mg1.62
J2271Injection, morphine sulfate, 100 mg4.22
J2275Injection, morphine sulfate, 10 mg (Preservative Free)6.25
J2278Injection, ziconotide, 1 mcg6.99
J2280Injection, moxifloxacin, 100 mg9.57
J2300Injection, nalbuphine HCl, per 10 mg1.76
J2310Injection, naloxone hydrochloride, per 1 mg5.12
J2315Naltrexone, depot form, 1 mg2.00
J2320Injection, nandrolone deconate, up to 50 mg6.15
J2321Injection, nandrolone deconoate, up to 100 mg8.17
J2322Injection, nandrolone deconoate, up to 200 mg20.66
J2323Injection, natalizumab8.12
J2325Injection, nesiritide, 0.1 mg34.99
J2353Injection, octreotide depot, 1 mg104.36
J2354Injection, octreotide, non-depot, 25 mcg4.89
J2355Injection, oprelvekin, 5 mg267.75
J2357Injection, omalizumab, 5 mg18.11
J2360Injection, orphenadrine citrate, (Norflex, Norgesic), up to17.94
60 mg
J2370Injection, phenylephrine HCl, (Neo-Synephrine), up to 1 ml2.73
J2400Injection, chloroprocaine HCl, (Nesacaine and Nesacaine MPF),17.17
per 30 ml
J2405Injection, ondansetron HCl, 1 mg1.23
J2410Injection, oxymorphone HCl, (Numorphan), up to 1 mg2.85
J2425Injection, paliferim, 50 mcg12.03
J2430Injection, pamidronate disodium, per 30 mg92.70
J2440Injection, papaverine HCl, up to 60 mg4.77
J2460Injection, oxytetracycline HCl, up to 50 mg0.97
J2469Palonosetron HCL, 25 mcg34.86
J2501Injection, paricalcitol, 1 mcg5.11
J2503Injection, pegaptanib sodium, .03 mg1,088.28
J2504Pedademase bovine, 25 IU204.17
J2505Injection, pegfilgrastim, 6 mg3,080.01
J2510Injection, penicillin G procaine, aqueous, up to 600,00010.50
units
J2513Pentastarch 10% solution, 100 ml13.16
J2515Injection, pentobarbital sodium, per 50 mg5.61
J2540Injection, penicillen G potassium, up to 600,000 units0.43
(Pfizerpen)
J2543Injection, piperacillin sodium/tazobactam sodium, 1 gram5.81
0.125 grams (1.125 g)
J2545Pentamadine isethionate, 300 mg, solution for inhalation86.41
J2550Injection, promethazine HCl, (Phenergan), up to 50 mg3.79
J2560Phenobarbital Sodium, up to 120 mg2.96
J2562Injection, plerixafor262.50
J2590Injection, oxytocin, (Pitocin), up to 10 units2.56
J2597Injection, desmopressin acetate, per 1 mcg5.01
J2650Injection, prednisolone acetate, up to 1 ml0.68
J2670Injection, tolazoline HCl, (Priscoline HCl), up to 25 mg3.61
J2680Injection, fluphenazine deconoate, (Prolixin DeConoate), up4.38
to 25 mg
J2690Injection, procainamide HCl, (Proenstyl), up to 1 gram3.45
J2700Injection, oxacillin sodium, (Prostaphlin), up to 250 mg1.02
J2710Injection, neostigmine methylsulfate, (Prostigmin0.44
Methylsulfate), up to 0.5 mg
J2720Injection, protamine sulfate, 10 mg0.93
J2724Protein C concentrate, 10 I.U.1.26
J2725Injection, protirelin, per 250 mcg22.47
J2730Injection, pralidoxime chloride, (Protopam Chloride), up to 194.83
gm
J2760Injection, phentolamine mesylate, (Regitine), up to 5 mg33.91
J2765Injection, metoclopramide HCl, (Reglan), up to 10 mg0.77
J2770Injection, quinupristin/dalfopri stin, 500 mg (150/350)137.00
J2778Injection, ranibizumab426.56
J2780Injection, ranitidine hydrochloride, 25 mg1.38
J2783Rasburicase, 0.5 mg152.18
J2785Injection, regadenoson, 0.1 mg107.50
J2788 UDInjection, Rho D immune globulin, human, minidose, 50 mcg49.55
J2788Injection, Rho D immune globulin, human, minidose, 50 mcg49.55
J2790Injection, Rho (D) Immune Globulin, (Human), (Rhogam), Human,115.94
Full dose, 300 mcg
J2790 UDInjection, RHO (D) Immune Globulin Human, Full dose, 300 mcg115.94
J2791Injection, rhophylac1.12
J2792Injection, Rho(D) immune globulin, intravenous, human,20.71
solvent detergent, 100 IU
J2793Injection, rilonacept22.91
J2794Risperidone, long acting, 0.5 mg5.10
J2795Injection, ropivacaine hydrochloride, 1 mg0.08
J2796Injection, romiplostim43.70
J2800Injection, methocarbamol, (Robaxin), up to 10 ml17.27
J2805Injection, sincalide, 5 mcg60.03
J2820Injection, sarqramostim, (GM-CSF), 50 mcg33.30
J2850Injection, secretin synthetic, human, 1 mcg22.22
J2910Injection, aurothioglucose, (Solqanal), up to 50 mg25.73
J2916Injection, sodium ferric gluconate complex in sucrose7.53
Injection, 12.5 mg
J2920Injection, methylprednisolone sodium succinate, (Solu2.25
Medrol), up to 40 mg
J2930Injection, methylprednisolone sodium succinate, (Solu3.79
Medrol), up to 125 mg
J2941Injection, somatropin, 1 mg48.21
J2950Injection, promazine HCl, (Prozine, Sparine), up to 25 mg0.22
J2993Injection, reteplase, 18.8 mg1,319.55
J2995Injection, streptokinase, per 250,000 IU82.03
J2997Injection, alteplase recombinant, 1 mg33.47
J3000Injection, streptomycin, up to 1 gram7.96
J3010Injection, fentanyl citrate, (Sublimaze), up to 2 ml0.63
J3030Injection, sumatriptan succinate, 6 mg137.25
J3070Injection, pentazocine HCl, (Talwin), up to 30 mg4.43
J3101Injection, tenecteplase, 1 mg51.09
J3105Terbutaline sulfate, up to 1 mg15.86
J3120Injection, testosterone enanthate, up to 100 mg0.39
J3130Injection, testosterone enanthate, up to 200 mg17.88
J3150Injection, testosterone propionate, up to 100 mg0.87
J3230Injection, chlorpromazine HCl, (Thorazine), up to 50 mg5.70
J3240Injection, thyrotropin, alpha 1.1 mg869.53
J3243Injection, tigecycline, 1 mg1.04
J3246Tirofiban HCL (Aggrastat), 0.25 mg9.29
J3250Injection, trimethobenzamide HCl, up to 200 mg2.88
J3260Injection, tobramycin sulfate, (Nebcin), up to 80 mg3.71
J3265Injection, torsemide, 10 mg/ml2.74
J3280Injection, thiethylperazine maleate, up to 10 mg4.24
J3285Injection, treprostinil, 1 mg58.84
J3300Injection, triamcinolone A, prs-free, 1 mg0.06
J3301Injection, triamcinolone acetonide, (Kenalog), 10 mg1.45
J3302Injection, triamcinolole diacetate, (Aristocort), per 5 mg0.57
J3303Injection, triamcinolone hexacetonide, (Aristospan), per 5 mg2.97
J3305Injection, trimetrexate glucoronate, per 25 mg154.48
J3310Injection, perphenazine, (Trilafon), up to 5 mg6.38
J3315Injection, triptorelin pamoate, 3.75 mg530.47
J3320Injection, spectinomycin hydrochloride, (Trobicin), up to 231.05
mg
J3350Injection, urea, (Ureaphil), up to 40 mg77.77
J3360Injection, diazepam, (Valium), up to 5 mg1.25
J3364Injection, urokinase, 5,000 IU vial49.53
J3365Injection, IV, urokinase, 250,000 IU vial472.31
J3370Injection, vancomycin HCl, up to 500 mg4.01
J3396Injection, verteporfin, .01 mg10.14
J3400Injection, triflupromazine HCl, (Vesprin), up to 20 mg11.38
J3410Injection, hydroxyzine HCl, (Vistaril), 25 mg0.39
J3411Thiamine HCL, 100 mg1.89
J3415Pyridoxine HCL, 100 mg2.49
J3420Injection, vitamin B-12 cyanocobalamin, up to 1,000 mg0.42
J3430Injection, phytonadione, (Vitamin K), 1 mg2.26
J3465Injection, voriconazole, 10 mg5.54
J3470Injection, hyaluronidase, (Wydase), up to 150 units21.88
J3471Ovine, up to 999 USP units0.12
J3472Ovine, 1000 USP units142.19
J3475Injection, magnesium sulfate, per 500 mg3.13
J3480Injection, potassium chloride, per 2 mEq0.09
J3485Injection, zidovudine, 10 mg1.19
J3486Ziprasidone mesylate, 10 mg5.36
J3487Injection, zoledronic acid, 1 mg223.00
J3488Injection, reclast227.84
J7030Infusion, normal saline solution, 1,000 ml = 1 unit7.14
J7040Infusion, normal saline solution, sterile, 500 ml = 1 unit6.98
J70425% dextrose/normal saline solution, 500 ml = 1 unit5.65
J7050Infusion, normal saline solution. 250 ml = 1 unit6.03
J70605% dextrose/water solution, 500 ml = 1 unit8.09
J7070Infusion, D5W, 1,000 cc7.10
J7100Infusion, dextran 40, 500 ml54.49
J7110Infusion, dextran 75, 500 ml64.28
J7120Ringer's Lactate Infusion, up to 1,000 ml = 1 unit10.39
J7185Injection, xyntha1.39
J7186Antihemophilic VIII/VWF composition1.06
J7189Factor VIIA (antihemophilic factor, recombinant), per IU1.44
J7190Factor VIII (antihemophilic factor, human) per IU0.90
J7191Factor VIII (antihemophilic factor, porcine) per IU1.93
J7192Factor VIII (antihemophilic factor, recombinant), per IU1.48
J7193Factor IX (antihemophilic factor, purified non-recombinant)1.09
per IU (Alphanine SD)
J7194Factor IX complex, per IU0.59
J7195Factor IX (antihemophilic factor, recombinant) per IU0.91
(Benefix)
J7198Anti-inhibitor, per IU1.31
J7300Intrauterine copper contraceptive (Paragard)396.64
J7302Levonorgestrel-releasing intrauterine contraceptive system,450.88
52 mg (Mirena)
J7303Contraceptive vaginal ring40.02
J7304Contraceptive hormone patch15.72
J7307Estrogestrel implant system620.08
J7310Ganciclovir, 4.5 mg, long-acting implant4,725.00
J7311Fluocinolone acetonide implant1,662.50
J7321Injection, hyalgan/supartz, per dose126.88
J7323Injection, euflexxa, per dose133.96
J7324Injection, orthovisc, per dose228.69
J7325Injection, synvisc or synvisc-one405.72
J7500Azathioprine, oral, 50 mg1.15
J7501Azathioprine; parenteral, vial, 100 mg, 20 ml each74.38
J7502Cyclosporin, oral, 100 mg5.34
J7503Cyclosporin, parenteral, 50 mg5.50
J7504Lymphocyte immune globulin, antithymocyte globulin,367.36
parenteral, amp, 50 mg/ml, 5 ml each
J7506Prednisone, oral, 5 mg tablet0.14
J7507Tacrolimus, oral, per 1 mg3.97
J5709Methylprednisolone, oral, 4 mg0.58
J5710Prednisolone, oral, 5 mg0.12
J7511Lymphocyte immune globulin, antithymocyte globulin, rabbit,426.56
parenteral, 25 mg (Thymoglobulin)
J7513Daclizumab, parenteral, 25 mg449.66
J7515Cyclosporine, oral, 25 mg1.20
J7516Cyclosporine, parenteral, 250 mg24.06
J7517Mycophenolate mofetil, 250 mg3.27
J7518Mycophenolic acid, 180 mg4.02
J7520Sirolimus, oral, 1 mg7.97
J7525Tacrolimus, parenteral, 5 mg149.43
J7604Acetylcysteine, comp unit, per gram3.57
J7605Arformoterol, non-comp unit, 15 mcg5.04
J7606Formoterol fumarate, inhale5.60
J7607Levabuterol, comp concentrate, 0.5 mg1.33
J7608Acetylcysteine, inhale solution, unit dose, per gram1.80
J7611Albuterol, concentrate form, 1 mg0.15
J7612Levabuterol, concentrate, 0.5 mg1.19
J7613Albuterol, unit dose, 1 mg0.54
J7614Levalbuterol, unit dose, 0.5 mg2.61
J7615Levalbuterol, inhalation solution, 0.5 mg1.89
J7620Albuterol, 2.5 mg/Ipratrop, 0.5 mg2.18
J7626Budesonide, inhalation solution, up to 0.5 mg9.35
J7627Budesonide, powder, inhalation, up to 0.5 mg161.35
J7628Bitolterol mesylate, concentrate form, per mg0.48
J7631Cromolyn sodium, unit dose form0.34
J7632Cromolyn sodium, comp unit0.31
J7634Budesonide, comp concentrate, per 0.25 mg4.81
J7635Atropine, inhalation solution, concentrated, per mg1.23
J7636Atropine, inhalation solution, unit dose, per mg1.09
J7637Dexamethasone, inhalation solution, concentrated, per mg0.43
J7638Dexamethasone, inhalation solution, unit dose, per mg0.20
J7639Dornase alpha inhalation solution21.00
J7642Glycopyrrolate, inhalation solution, per mg2.32
J7644Ipratroprium bromide, inhalation solution, per mg1.54
J7645Ipratroprium bromide, inhalation solution, comp, per mg1.26
J7669Metaproterenol, inhalation solution, unit dose, per 10 mg0.49
J7674Methacholine chloride, nebulizers, per mg0.42
J7676Pentamidine comp, unit dose93.44
J7682Tobramycin, inhalation solution, 300 mg66.11
J7684Triamcinolone, inhalation solution, per mg0.61
J8501Oral aprepitant, 5 mg4.71
J8510Bulsulfan, oral, 2 mg2.59
J8520Capecitabine, oral, 150 mg6.51
J8521Capecitabine, oral, 500 mg21.71
J8530Cyclophosphamide, oral, 25 mg3.15
J8560Etoposide, oral, 50 mg41.68
J8600Melphalan, oral, 2 mg5.29
J8610Methotrexate, oral, 2.5 mg3.19
J8700Temozolomide, 5 mg7.93
J9000Doxorubicin HCl, (Adriamycin), 10 mg12.03
J9001Doxorubicin HCI, all lipid formulations, 10 mg435.26
J9010Alemtuzumab, 10 mg585.40
J9015Aldesleukin, per single use vial826.40
J9017Arsenic trioxide, 1 mg (Trisenox)36.79
J9020Asparaginase, 10,000 units55.02
J9025Injection, azacitidine, 1 mg4.42
J9027Injection, clofarabine, 1 mg123.05
J9031BCG (intravesical) per installation172.59
J9033Injection, bendamustine, 1 mg19.13
J9035Injection, bevacizumab (Avastin), 10 mg60.16
J9040Bleomycin sulfate, (Blenoxane) 15 units77.11
J9041Injection, bortezomib (Velcade), 0.1 mg35.31
J9045Carboplatin (Paraplatin), 50 mg76.42
J9050Carmustine, (BiCNU), 100 mg163.91
J9055Injection, cetuximab (Erbitux), 10 mg52.50
J9060Cisplatin, (Platinol), powder or solution, 10 mg4.05
J9062Cisplatin, 50 mg20.13
J9065Injection, cladribine, (Leustatin), per 1 mg53.05
J9070Cyclophosphamide, (Cytoxan), 100 mg2.52
J9080Cyclophosphamide, (Cytoxan), 200 mg5.04
J9090Cyclophosphamide, (Cytoxan), 500 mg13.86
J9091Cyclophosphamide, (Cytoxan), 1 gram25.08
J9092Cyclophosphamide, (Cytoxan), 2 grams45.37
J9093Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 100 mg5.42
J9094Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 200 mg10.29
J9095Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 500 mg21.60
J9096Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 1 gram43.21
J9097Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 2 grams86.44
J9098Cytarabine liposome, 10 mg437.50
J9100Cytarabine, (Cytarabine Hydrochloride), 100 mg3.17
J9110Cytarabine, (Cytarabine Hydrochloride), 500 mg8.75
J9120Dactinomycin, 0.5 mg519.53
J9130Dacarbazine, 100 mg10.34
J9140Dacarbazine, 200 mg20.67
J9150Daunorubicin, 10 mg70.57
J9151Daunorubicin citrate, liposomal formulation, 10 mg59.50
J9155Injection, degarelix3.92
J9160Denileukin diftitox, 300 mcg1,487.50
J9165Injection, diethlstilbestrol diphosphate, (Stilphostrol), 25013.27
mg
J9171Injection, docetaxel19.51
J9175Elliotts B solution, per ml4.29
J9178Injection, epirubicin, 2 mg26.22
J9181Etoposide, (VePesid), 10 mg1.64
J9185Fludarabine Phosphate, 50 mg317.80
J9190Fluorouracil, 500 mg3.28
J9200Floxuridine, 500 mg130.70
J9201Gemcitabine HCl, (Gemzar), 200 mg135.98
J9202Goserelin acetate implant, (Zoladex), 3.6 mg411.24
J9206Irinotecan, 20 mg134.24
J9207Injection, ixabepilione, 1 mg65.31
J9208Ifosfomide, 1 gram63.49
J9209Mesna, (Mesnex), 200 mg30.76
J9211Idarubicin hydrochloride, 5 mg386.79
J9212Injection, interferon alfacon-1, recombinant, 1 mcg8.50
J9213Interferon alfa-2A, Recombinant, 3 million units40.53
J9214Interferon alfa-2B, recombinant, 1 million units (Intron A)14.84
J9215Interferon alfa-N3 (human leukocyte derived) 250,000 IU15.68
(Alferon N)
J9216Interferon gamma-1B, 3 million units344.41
J9217Leuprolide acetate, (Lupron Depot), 7.5 mg678.73
J9218Leuprolide acetate, (Lupron), 1 mg271.53
J9219Leuprolide acetate implant, 65 mg4,973.50
J9225Histrelin implant, 50 mg5,250.00
J9226Supprelin LA implant15,312.50
J9230Mechlorethamide HCl, (nitrogen mustard), Mustargen OE, 10 mg152.08
J9245Injection, melphalan HCl, 50 mg1,267.39
J9250Methotrexate sodium, 5 mg (Folex)0.48
J9260Methotrexate sodium, 50 mg4.16
J9261Injection, nelarabine, 50 mg90.13
J9263Oxaliplatin, 0.5 mg9.32
J9264Injection, paclitaxel, 1 mg9.40
J9265Paclitaxel, 30 mg151.13
J9266Pegaspargase, per single dose vial2,187.50
J9268Pentostatin, per 10 mg2,324.00
J9270Plicamycin, (Mithracin), 2.5 mg86.39
J9280Mitomycin, 5 mg61.25
J9290Injection, mitoxantrone HCl, per 5 mg199.06
J9291Mitomycin, 40 mg273.44
J9293Injection, mitoxantrone HCl, per 5 mg325.23
J9300Gemtuzumab ozogamicin, 5 mg (Gemzar)2,563.75
J9303Injection, panitumumab87.50
J9305Injection, pemetrexed (Alimta), 10 mg47.63
J9310Rituximab, 100 mg571.97
J9320Streptozocin, 1 gram113.78
J9328Injection, temozolomide4.75
J9330Injection, temsirolimus, 1 mg48.99
J9340Thiotepa, 15 mg85.59
J9350Topotecan, 4 mg932.71
J9355Trastuzumab, 10 mg61.81
J9357Valrubicin, intravesical, 200 mg485.10
J9360Vinblastine sulfate, (Velban), 1 mg2.90
J9370Vincristine sulfate, (Oncovin), 1 mg12.60
J9375Vincristine sulfate, (Oncovin), 2 mg25.21
J9380Vincristine sulfate, (Oncovin), 5 mg142.37
J9390Vinorelbine tartrate, per 10 mg82.25
J9395Injection, fulvestrant, 25 mg86.93
J9600Porfimer sodium, (Photofrin), 75 mg2,637.93

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