`
`Effective October 1, 2006 through December 31, 2006
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q06 ASP data.
`Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment
`allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local Medicare contractor
`processing the claim.
`
`HCPCS Code
`90371
`90375
`90376
`90385
`90585
`90586
`90632
`90633
`90634
`90645
`90647
`90648
`90655
`90656
`90657
`90658
`90660
`90675
`90691
`90700
`90702
`90703
`90704
`90705
`90706
`90707
`90713
`90714
`90716
`90717
`90718
`90721
`90732
`90733
`90735
`90740
`90743
`90744
`90746
`90747
`J0128
`J0130
`J0132
`J0133
`J0135
`J0150
`J0152
`J0170
`J0180
`J0205
`J0207
`J0210
`J0215
`J0256
`J0270
`J0275
`J0278
`J0280
`J0282
`J0285
`J0287
`J0288
`J0289
`
`Short Description
`Hep b ig, im
`Rabies ig, im/sc
`Rabies ig, heat treated
`Rh ig, minidose, im
`Bcg vaccine, percut
`Bcg vaccine, intravesical
`Hep a vaccine, adult im
`Hep a vacc, ped/adol, 2 dose
`Hep a vacc, ped/adol, 3 dose
`Hib vaccine, hboc, im
`Hib vaccine, prp‐omp, im
`Hib vaccine, prp‐t, im
`Flu vaccine no preserv 6‐35m
`Flu vaccine no preserv 3 & >
`Flu vaccine, 6‐35 mo, im
`Flu vaccine age 3 & over, im
`Flu vaccine, nasal
`Rabies vaccine, im
`Typhoid vaccine, im
`Dtap vaccine, < 7 yrs, im
`Dt vaccine < 7, im
`Tetanus vaccine, im
`Mumps vaccine, sc
`Measles vaccine, sc
`Rubella vaccine, sc
`Mmr vaccine, sc
`Poliovirus, ipv, sc/im
`Td vaccine no prsrv >/= 7 im
`Chicken pox vaccine, sc
`Yellow fever vaccine, sc
`Td vaccine > 7, im
`Dtap/hib vaccine, im
`Pneumococcal vaccine
`Meningococcal vaccine, sc
`Encephalitis vaccine, sc
`Hepb vacc, ill pat 3 dose im
`Hep b vacc, adol, 2 dose, im
`Hepb vacc ped/adol 3 dose im
`Hep b vaccine, adult, im
`Hepb vacc, ill pat 4 dose im
`Abarelix injection
`Abciximab injection
`Acetylcysteine injection
`Acyclovir injection
`Adalimumab injection
`Injection adenosine 6 MG
`Adenosine injection
`Adrenalin epinephrin inject
`Agalsidase beta injection
`Alglucerase injection
`Amifostine
`Methyldopate hcl injection
`Alefacept
`Alpha 1 proteinase inhibitor
`Alprostadil for injection
`Alprostadil urethral suppos
`Amikacin sulfate injection
`Aminophyllin 250 MG inj
`Amiodarone HCl
`Amphotericin B
`Amphotericin b lipid complex
`Ampho b cholesteryl sulfate
`Amphotericin b liposome inj
`
`Revised 01/01/07
`Revised 01/01/07
`Revised 01/01/07
`
`Revised 01/01/07
`Revised 01/01/07
`Revised 01/01/07
`
`Revised 01/01/07
`
`HCPCS CodPayment Limit Vaccine AWVaccine LimInfusion AWDME Infusi Blood AWPBlood LimitNotes
`1 ML
`$113.27
`Revised 01/01/07
`150 IU
`$64.53
`150 IU
`$68.24
`50 MCG
`$7.31
`50 MG
`$117.39
`1 EACH
`$113.44
`1 ML
`$43.29
`1 ML
`$23.63
`3 EACH
`$23.63
`1 EACH
`$21.27
`0.5 ML
`$21.27
`0.5 ML
`$21.78
`0.25 ML
`$15.38
`0.50 ML
`$16.57
`0.25 ML
`$6.31
`0.5 ML
`$12.62
`0.5 ML
`$21.18
`$157.74
`1 ML
`0.5 ML
`$52.05
`0.5 ML
`$29.40
`0.5 ML
`$18.30
`0.5 ML
`$19.38
`0.5 ML
`$20.38
`0.5 ML
`$15.54
`0.5 ML
`$17.19
`0.5 ML
`$41.00
`0.5 ML
`$26.01
`0.5 ML
`$18.78
`0.5 ML
`$72.28
`0.5 ML
`$54.44
`0.5 ML
`$18.83
`1 EACH
`$41.72
`0.5 ML
`$27.03
`0.5 ML
`$84.46
`1 ML
`$96.22
`40 MCG
`$114.52
`1 DOSE
`$24.36
`1 DOSE
`$24.36
`20 MCG
`$57.26
`40 MCG
`$114.52
`10 MG
`$68.62
`10 MG
`$416.27
`100 MG
`$1.94
`5 MG
`$0.02
`20 MG
`$308.33
`6 MG
`$30.49
`30 MG
`$68.93
`1 ML
`$0.99
`$127.20
`1 MG
`10 UNITS
`$39.22
`500 MG
`$463.27
`250 MG
`$10.01
`0.5 MG
`$26.31
`10 MG
`$3.31
`1.25 MCG
`$1.80
`$22.84
`125 MCG
`100 MG
`$1.21
`250 MG
`$0.37
`30 MG
`$0.28
`50 MG
`$9.45
`10 MG
`$11.11
`$12.00
`10 MG
`10 MG
`$21.25
`
`95%
`95%
`95%
`95%
`95%
`
`$15.38
`$16.57
`$6.31
`$12.62
`$21.18
`
`95%
`
`$27.03
`
`95% $114.52
`95%
`$24.36
`95%
`$24.36
`95%
`$57.26
`95% $114.52
`
`95%
`95%
`95%
`95%
`
`$10.28
`$21.85
`$15.20
`$35.80
`
`Medac Exhibit 2056
`Frontier Therapeutics v. Medac
`IPR2016-00649
`Page 00001
`
`
`
`J0290
`J0295
`J0300
`J0330
`J0360
`J0365
`J0456
`J0460
`J0470
`J0475
`J0476
`J0480
`J0500
`J0515
`J0530
`J0540
`J0550
`J0560
`J0570
`J0580
`J0583
`J0585
`J0587
`J0592
`J0595
`J0600
`J0610
`J0630
`J0636
`J0637
`J0640
`J0670
`J0690
`J0692
`J0694
`J0696
`J0697
`J0698
`J0702
`J0704
`J0706
`J0713
`J0715
`J0720
`J0725
`J0735
`J0740
`J0743
`J0744
`J0745
`J0760
`J0770
`J0780
`J0795
`J0800
`J0835
`J0850
`J0878
`J0881
`J0882
`J0885
`J0886
`J0895
`J0945
`J0970
`J1000
`J1020
`J1030
`J1040
`J1051
`J1060
`J1070
`J1080
`
`Ampicillin 500 MG inj
`Ampicillin sodium per 1.5 gm
`Amobarbital 125 MG inj
`Succinycholine chloride inj
`Hydralazine hcl injection
`Aprotonin, 10,000 kiu
`Azithromycin
`Atropine sulfate injection
`Dimecaprol injection
`Baclofen 10 MG injection
`Baclofen intrathecal trial
`Basiliximab
`Dicyclomine injection
`Inj benztropine mesylate
`Penicillin g benzathine inj
`Penicillin g benzathine inj
`Penicillin g benzathine inj
`Penicillin g benzathine inj
`Penicillin g benzathine inj
`Penicillin g benzathine inj
`Bivalirudin
`Botulinum toxin a per unit
`Botulinum toxin type B
`Buprenorphine hydrochloride
`Butorphanol tartrate 1 mg
`Edetate calcium disodium inj
`Calcium gluconate injection
`Calcitonin salmon injection
`Inj calcitriol per 0.1 mcg
`Caspofungin acetate
`Leucovorin calcium injection
`Inj mepivacaine HCL/10 ml
`Cefazolin sodium injection
`Cefepime HCl for injection
`Cefoxitin sodium injection
`Ceftriaxone sodium injection
`Sterile cefuroxime injection
`Cefotaxime sodium injection
`Betamethasone acet&sod phosp
`Betamethasone sod phosp/4 MG
`Caffeine citrate injection
`Inj ceftazidime per 500 mg
`Ceftizoxime sodium / 500 MG
`Chloramphenicol sodium injec
`Chorionic gonadotropin/1000u
`Clonidine hydrochloride
`Cidofovir injection
`Cilastatin sodium injection
`Ciprofloxacin iv
`Inj codeine phosphate /30 MG
`Colchicine injection
`Colistimethate sodium inj
`Prochlorperazine injection
`Corticorelin ovine triflutal
`Corticotropin injection
`Inj cosyntropin per 0.25 MG
`Cytomegalovirus imm IV /vial
`Daptomycin injection
`Darbepoetin alfa, non‐esrd
`Darbepoetin alfa, esrd use
`Epoetin alfa, non‐esrd
`Epoetin alfa, esrd
`Deferoxamine mesylate inj
`Brompheniramine maleate inj
`Estradiol valerate injection
`Depo‐estradiol cypionate inj
`Methylprednisolone 20 MG inj
`Methylprednisolone 40 MG inj
`Methylprednisolone 80 MG inj
`Medroxyprogesterone inj
`Testosterone cypionate 1 ML
`Testosterone cypionat 100 MG
`Testosterone cypionat 200 MG
`
`500 MG
`1.5 GM
`125 MG
`20 MG
`20 MG
`10000 KIU
`500 MG
`0.3 MG
`100 MG
`10 MG
`50 MCG
`20 MG
`20 MG
`1 MG
`600000 UN
`1200000 U
`2400000 U
`600000 UN
`1200000 U
`2400000 U
`1 MG
`1 UNIT
`100 UNITS
`0.1 MG
`1 MG
`1000 MG
`10 ML
`400 UNITS
`0.1 MCG
`5 MG
`50 MG
`10 ML
`500 MG
`500 MG
`1 GM
`250 MG
`750 MG
`1 GM
`3 MG
`4 MG
`5 MG
`500 MG
`500 MG
`1 GM
`1000 UNITS
`1 MG
`375 MG
`250 MG
`200 MG
`30 MG
`1 MG
`150 MG
`10 MG
`1 MCG
`40 UNITS
`0.25 MG
`PER VIAL
`1 MG
`1 MCG
`1 MCG
`1000 UNITS
`1000 UNITS
`500 MG
`10 MG
`40 MG
`5 MG
`20 MG
`40 MG
`80 MG
`50 MG
`1 ML
`100 MG
`200 MG
`
`$2.37
`$4.95
`$2.27
`$0.19
`$8.68
`$2.52
`$12.26
`$0.19
`$25.32
`$198.54
`$69.63
`$1,385.86
`$15.33
`$17.08
`$13.28
`$28.45
`$30.58
`$21.22
`$36.30
`$42.10
`$1.75
`$5.04
`$8.16
`$0.72
`$0.72
`$40.19
`$0.42
`$39.94
`$0.53
`$32.22
`$0.93
`$1.51
`$1.19
`$7.94
`$6.84
`$1.62
`$0.80
`$4.16
`$5.19
`$1.13
`$3.54
`$3.98
`$4.44
`$11.22
`$3.70
`$66.04
`$763.15
`$13.12
`$8.15
`$1.05
`$4.68
`$21.51
`$2.03
`$4.17
`$116.60
`$62.91
`$853.18
`$0.33
`$2.98
`$2.98
`$9.36
`$9.20
`$14.84
`$0.80
`$35.07
`$5.57
`$2.33
`$5.08
`$9.27
`$5.48
`$4.14
`$5.42
`$11.64
`
`95% $215.18
`95%
`$79.80
`
`95%
`
`$15.63
`
`Revised 01/01/07
`
`Revised 01/01/07
`
`Revised 01/01/2008
`
`Revised 01/01/07
`Revised 01/01/2008
`
`Revised 01/01/2008
`Revised 01/01/2008
`
`Revised 01/01/2008
`
`Page 00002
`
`
`
`J1094
`J1100
`J1110
`J1120
`J1160
`J1162
`J1165
`J1170
`J1190
`J1200
`J1205
`J1212
`J1230
`J1240
`J1245
`J1250
`J1260
`J1265
`J1270
`J1325
`J1327
`J1335
`J1364
`J1380
`J1390
`J1410
`J1430
`J1435
`J1436
`J1438
`J1440
`J1441
`J1450
`J1451
`J1455
`J1457
`J1460
`J1470
`J1480
`J1490
`J1500
`J1510
`J1520
`J1530
`J1540
`J1550
`J1560
`J1565
`J1566
`J1567
`J1570
`J1580
`J1590
`J1595
`J1600
`J1610
`J1620
`J1626
`J1630
`J1631
`J1640
`J1642
`J1644
`J1645
`J1650
`J1652
`J1655
`J1670
`J1720
`J1730
`J1742
`J1745
`J1751
`
`Inj dexamethasone acetate
`Dexamethasone sodium phos
`Inj dihydroergotamine mesylt
`Acetazolamid sodium injectio
`Digoxin injection
`Digoxin immune fab (ovine)
`Phenytoin sodium injection
`Hydromorphone injection
`Dexrazoxane HCl injection
`Diphenhydramine hcl injectio
`Chlorothiazide sodium inj
`Dimethyl sulfoxide 50% 50 ML
`Methadone injection
`Dimenhydrinate injection
`Dipyridamole injection
`Inj dobutamine HCL/250 mg
`Dolasetron mesylate
`Dopamine injection
`Injection, doxercalciferol
`Epoprostenol injection
`Eptifibatide injection
`Ertapenem injection
`Erythro lactobionate /500 MG
`Estradiol valerate 10 MG inj
`Estradiol valerate 20 MG inj
`Inj estrogen conjugate 25 MG
`Ethanolamine oleate 100 mg
`Injection estrone per 1 MG
`Etidronate disodium inj
`Etanercept injection
`Filgrastim 300 mcg injection
`Filgrastim 480 mcg injection
`Fluconazole
`Fomepizole, 15 mg
`Foscarnet sodium injection
`Gallium nitrate injection
`Gamma globulin 1 CC inj
`Gamma globulin 2 CC inj
`Gamma globulin 3 CC inj
`Gamma globulin 4 CC inj
`Gamma globulin 5 CC inj
`Gamma globulin 6 CC inj
`Gamma globulin 7 CC inj
`Gamma globulin 8 CC inj
`Gamma globulin 9 CC inj
`Gamma globulin 10 CC inj
`Gamma globulin > 10 CC inj
`RSV‐ivig
`Immune globulin, powder
`Immune globulin, liquid
`Ganciclovir sodium injection
`Garamycin gentamicin inj
`Gatifloxacin injection
`Injection glatiramer acetate
`Gold sodium thiomaleate inj
`Glucagon hydrochloride/1 MG
`Gonadorelin hydroch/ 100 mcg
`Granisetron HCl injection
`Haloperidol injection
`Haloperidol decanoate inj
`Hemin, 1 mg
`Inj heparin sodium per 10 u
`Inj heparin sodium per 1000u
`Dalteparin sodium
`Inj enoxaparin sodium
`Fondaparinux sodium
`Tinzaparin sodium injection
`Tetanus immune globulin inj
`Hydrocortisone sodium succ i
`Diazoxide injection
`Ibutilide fumarate injection
`Infliximab injection
`Iron dextran 165 injection
`
`1 MG
`1 MG
`1 MG
`500 MG
`0.5 MG
`PER VIAL
`50 MG
`4 MG
`250 MG
`50 MG
`500 MG
`50 ML
`10 MG
`50 MG
`10 MG
`250 MG
`10 MG
`40 MG
`1 MCG
`0.5 MG
`5 MG
`500 MG
`500 MG
`10 MG
`20 MG
`25 MG
`100 MG
`1 MG
`300 MG
`25 MG
`300 MCG
`480 MCG
`200 MG
`15 MG
`1000 MG
`1 MG
`1 CC
`2 CC
`3CC
`4 CC
`5 CC
`6 CC
`7 CC
`8 CC
`9 CC
`10 CC
`10 CC
`50 MG
`500 MG
`500 MG
`500 MG
`80 MG
`10 MG
`20 MG
`50 MG
`1 MG
`100 MCG
`100 MCG
`5 MG
`50 MG
`1 MG
`10 UNITS
`1000 UNITS
`2500 IU
`10 MG
`0.5 MG
`1000 IU
`250 UNITS
`100 MG
`300 MG
`1 MG
`10 MG
`50 MG
`
`$0.23
`$0.14
`$24.37
`$15.29
`$1.13
`$533.72
`$0.90
`$1.75
`$180.13
`$0.73
`$123.84
`$44.24
`$3.25
`$4.45
`$1.56
`$5.23
`$6.89
`$0.69
`$2.88
`$14.39
`$15.37
`$23.07
`$5.90
`$12.60
`$17.53
`$58.05
`$69.60
`$0.24
`$71.41
`$159.93
`$189.66
`$293.93
`$11.05
`$12.33
`$10.49
`$1.25
`$10.34
`$20.68
`$31.01
`$41.35
`$51.69
`$62.03
`$72.34
`$82.71
`$93.07
`$103.38
`$103.38
`$16.18
`$25.27
`$30.33
`$39.17
`$0.93
`$0.50
`$46.20
`$6.34
`$70.23
`$189.84
`$7.21
`$2.24
`$5.30
`$6.80
`$0.05
`$0.11
`$10.86
`$5.65
`$5.92
`$2.48
`$87.77
`$1.98
`$111.88
`$265.75
`$53.74
`$11.78
`
`95%
`
`$1.49
`
`95%
`
`$0.75
`
`95%
`
`$4.74
`
`95%
`
`$12.64
`
`95%
`
`$13.07
`
`95%
`
`$35.25
`
`Revised 01/01/2008
`Revised 01/01/07
`
`Revised 01/01/2008
`Revised 01/01/2008
`Revised 01/01/2008
`
`Revised 01/01/2008
`
`Page 00003
`
`
`
`J1752
`J1756
`J1785
`J1790
`J1800
`J1815
`J1817
`J1830
`J1835
`J1840
`J1850
`J1885
`J1931
`J1940
`J1945
`J1950
`J1955
`J1956
`J1980
`J1990
`J2001
`J2010
`J2020
`J2060
`J2150
`J2175
`J2180
`J2185
`J2210
`J2250
`J2260
`J2270
`J2271
`J2275
`J2278
`J2280
`J2300
`J2310
`J2320
`J2321
`J2322
`J2325
`J2353
`J2354
`J2355
`J2357
`J2360
`J2370
`J2400
`J2405
`J2410
`J2425
`J2430
`J2440
`J2460
`J2469
`J2501
`J2503
`J2504
`J2505
`J2510
`J2513
`J2515
`J2540
`J2543
`J2545
`J2550
`J2560
`J2590
`J2597
`J2650
`J2675
`J2680
`
`Iron dextran 267 injection
`Iron sucrose injection
`Injection imiglucerase /unit
`Droperidol injection
`Propranolol injection
`Insulin injection
`Insulin for insulin pump use
`Interferon beta‐1b / .25 MG
`Itraconazole injection
`Kanamycin sulfate 500 MG inj
`Kanamycin sulfate 75 MG inj
`Ketorolac tromethamine inj
`Laronidase injection
`Furosemide injection
`Lepirudin
`Leuprolide acetate /3.75 MG
`Inj levocarnitine per 1 gm
`Levofloxacin injection
`Hyoscyamine sulfate inj
`Chlordiazepoxide injection
`Lidocaine injection
`Lincomycin injection
`Linezolid injection
`Lorazepam injection
`Mannitol injection
`Meperidine hydrochl /100 MG
`Meperidine/promethazine inj
`Meropenem
`Methylergonovin maleate inj
`Inj midazolam hydrochloride
`Inj milrinone lactate / 5 MG
`Morphine sulfate injection
`Morphine so4 injection 100mg
`Morphine sulfate injection
`Ziconotide injection
`Inj, moxifloxacin 100 mg
`Inj nalbuphine hydrochloride
`Inj naloxone hydrochloride
`Nandrolone decanoate 50 MG
`Nandrolone decanoate 100 MG
`Nandrolone decanoate 200 MG
`Nesiritide injection
`Octreotide injection, depot
`Octreotide inj, non‐depot
`Oprelvekin injection
`Omalizumab injection
`Orphenadrine injection
`Phenylephrine hcl injection
`Chloroprocaine hcl injection
`Ondansetron hcl injection
`Oxymorphone hcl injection
`Palifermin injection
`Pamidronate disodium /30 MG
`Papaverin hcl injection
`Oxytetracycline injection
`Palonosetron HCl
`Paricalcitol
`Pegaptanib sodium injection
`Pegademase bovine, 25 iu
`Injection, pegfilgrastim 6mg
`Penicillin g procaine inj
`Pentastarch 10% solution
`Pentobarbital sodium inj
`Penicillin g potassium inj
`Piperacillin/tazobactam
`Pentamidine isethionte/300mg
`Promethazine hcl injection
`Phenobarbital sodium inj
`Oxytocin injection
`Inj desmopressin acetate
`Prednisolone acetate inj
`Inj progesterone per 50 MG
`Fluphenazine decanoate 25 MG
`
`50 MG
`1 MG
`1 UNIT
`5 MG
`1 MG
`5 UNITS
`50 UNITS
`0.25 MG
`50 MG
`500 MG
`75 MG
`15 MG
`0.1 MG
`20 MG
`50 MG
`3.75 MG
`1 GM
`250 MG
`0.25 MG
`100 MG
`10 MG
`300 MG
`200 MG
`2 MG
`50 ML
`100 MG
`50 MG
`100 MG
`0.2 MG
`1 MG
`5 MG
`10 MG
`100 MG
`10 MG
`1 MCG
`100 MG
`10 MG
`1 MG
`50 MG
`100 MG
`200 MG
`0.1 MG
`1 MG
`25 MCG
`5 MG
`5 MG
`60 MG
`1 ML
`30 ML
`1 MG
`1 MG
`50 MCG
`30 MG
`60 MG
`50 MG
`25 MCG
`1 MCG
`0.3 MG
`25 IU
`6 MG
`600000 UN
`100 ML
`50 MG
`600000 UN
`1.125 GM
`300 MG
`50 MG
`120 MG
`10 UNITS
`1 MCG
`1 ML
`50 MG
`25 MG
`
`$10.38
`$0.36
`$3.91
`$1.40
`$4.23
`$0.24
`$2.47
`$90.00
`$36.45
`$4.29
`$0.64
`$0.50
`$23.87
`$0.29
`$153.54
`$437.58
`$10.46
`$7.47
`$8.69
`$21.05
`$0.02
`$3.77
`$24.16
`$1.00
`$0.72
`$1.69
`$3.79
`$3.68
`$4.60
`$0.22
`$2.79
`$1.40
`$3.81
`$4.77
`$6.34
`$3.77
`$0.59
`$1.92
`$3.24
`$6.40
`$13.04
`$30.13
`$93.35
`$3.54
`$245.98
`$16.61
`$11.81
`$0.50
`$15.50
`$3.72
`$2.31
`$11.41
`$35.46
`$0.70
`$0.94
`$18.08
`$3.81
`$1,054.70
`$177.83
`$2,149.93
`$9.04
`$12.72
`$5.43
`$0.83
`$5.06
`$43.42
`$1.84
`$2.16
`$2.31
`$2.50
`$0.44
`$1.79
`$1.21
`
`95%
`
`$2.80
`
`95%
`
`$0.56
`
`95%
`95%
`95%
`95%
`
`$51.58
`$0.71
`$11.07
`$4.39
`
`Revised 01/01/2008
`
`Revised 01/01/2008
`Revised 01/01/07
`
`Revised 01/01/2008
`
`Page 00004
`
`
`
`95%
`
`$0.70
`
`J2690
`J2700
`J2710
`J2720
`J2725
`J2730
`J2760
`J2765
`J2770
`J2780
`J2783
`J2788
`J2790
`J2792
`J2794
`J2795
`J2800
`J2805
`J2810
`J2820
`J2850
`J2912
`J2916
`J2920
`J2930
`J2941
`J2950
`J2993
`J2997
`J3000
`J3010
`J3030
`J3070
`J3100
`J3105
`J3120
`J3130
`J3230
`J3240
`J3246
`J3250
`J3260
`J3265
`J3285
`J3301
`J3302
`J3303
`J3305
`J3315
`J3320
`J3355
`J3360
`J3364
`J3365
`J3370
`J3396
`J3410
`J3411
`J3415
`J3420
`J3430
`J3465
`J3470
`J3471
`J3472
`J3475
`J3480
`J3485
`J3486
`J3487
`J7030
`J7040
`J7042
`
`Procainamide hcl injection
`Oxacillin sodium injeciton
`Neostigmine methylslfte inj
`Inj protamine sulfate/10 MG
`Inj protirelin per 250 mcg
`Pralidoxime chloride inj
`Phentolaine mesylate inj
`Metoclopramide hcl injection
`Quinupristin/dalfopristin
`Ranitidine hydrochloride inj
`Rasburicase
`Rho d immune globulin 50 mcg
`Rho d immune globulin inj
`Rho(D) immune globulin h, sd
`Risperidone, long acting
`Ropivacaine HCl injection
`Methocarbamol injection
`Sincalide injection
`Inj theophylline per 40 MG
`Sargramostim injection
`Inj secretin synthetic human
`Sodium chloride injection
`Na ferric gluconate complex
`Methylprednisolone injection
`Methylprednisolone injection
`Somatropin injection
`Promazine hcl injection
`Reteplase injection
`Alteplase recombinant
`Streptomycin injection
`Fentanyl citrate injeciton
`Sumatriptan succinate / 6 MG
`Pentazocine injection
`Tenecteplase injection
`Terbutaline sulfate inj
`Testosterone enanthate inj
`Testosterone enanthate inj
`Chlorpromazine hcl injection
`Thyrotropin injection
`Tirofiban HCl
`Trimethobenzamide hcl inj
`Tobramycin sulfate injection
`Injection torsemide 10 mg/ml
`Treprostinil injection
`Triamcinolone acetonide inj
`Triamcinolone diacetate inj
`Triamcinolone hexacetonl inj
`Inj trimetrexate glucoronate
`Triptorelin pamoate
`Spectinomycn di‐hcl inj
`Urofollitropin, 75 iu
`Diazepam injection
`Urokinase 5000 IU injection
`Urokinase 250,000 IU inj
`Vancomycin hcl injection
`Verteporfin injection
`Hydroxyzine hcl injection
`Thiamine hcl 100 mg
`Pyridoxine hcl 100 mg
`Vitamin b12 injection
`Vitamin k phytonadione inj
`Injection, voriconazole
`Hyaluronidase injection
`Ovine, up to 999 USP units
`Ovine, 1000 USP units
`Inj magnesium sulfate
`Inj potassium chloride
`Zidovudine
`Ziprasidone mesylate
`Zoledronic acid
`Normal saline solution infus
`Normal saline solution infus
`5% dextrose/normal saline
`
`1 GM
`250 MG
`0.5 MG
`10 MG
`250 MCG
`1 GM
`5 MG
`10 MG
`500 MG
`25 MG
`0.5 MG
`50 MCG
`300 MCG
`100 IU
`0.5 MG
`1 MG
`10 ML
`5 MCG
`40 MG
`50 MCG
`1 MCG
`2 ML
`12.5 MG
`40 MG
`125 MG
`1 MG
`UP TO 25 M
`18.1 MG
`1 MG
`1 GM
`0.1 MG
`6 MG
`30 MG
`50 MG
`1 MG
`100 MG
`200 MG
`50 MG
`0.9 MG
`0.25 MG
`200 MG
`80 MG
`10 MG
`1 MG
`10 MG
`5 MG
`5 MG
`25 MG
`3.75 MG
`2 GM
`75 IU
`5 MG
`5000 IU
`250000 IU
`500 MG
`0.1 MG
`25 MG
`100 MG
`100 MG
`1000 MCG
`1 MG
`10 MG
`150 UNITS
`1 USP UNIT
`1000 USP U
`500 MG
`2 MEQ
`10 MG
`10 MG
`1 MG
`1000 CC
`500 ML
`500 ML
`
`$2.08
`$1.51
`$0.14
`$0.44
`$21.78
`$74.00
`$23.78
`$0.46
`$114.49
`$0.70
`$121.26
`$27.70
`$80.52
`$14.30
`$4.80
`$0.07
`$11.81
`$52.08
`$0.04
`$25.55
`$20.31
`$0.12
`$4.81
`$1.94
`$2.38
`$46.80
`$0.38
`$902.72
`$32.07
`$6.20
`$0.32
`$57.40
`$5.26
`$2,036.66
`$4.03
`$4.38
`$11.26
`$3.67
`$765.76
`$8.74
`$4.41
`$2.06
`$2.34
`$54.02
`$1.40
`$0.28
`$1.30
`$145.17
`$218.53
`$30.08
`$49.35
`$0.71
`$9.16
`$457.73
`$3.35
`$8.91
`$0.19
`$2.08
`$3.25
`$0.28
`$2.89
`$4.66
`$17.13
`$0.11
`$137.43
`$0.11
`$0.02
`$1.06
`$5.05
`$204.03
`$1.04
`$0.52
`$0.39
`
`Page 00005
`
`
`
`J7050
`J7060
`J7070
`J7100
`J7110
`J7120
`J7188
`J7189
`J7190
`J7192
`J7193
`J7194
`J7195
`J7197
`J7198
`J7308
`J7310
`J7317
`J7320
`J7330
`J7340
`J7341
`J7342
`J7343
`J7344
`J7350
`J7500
`J7501
`J7502
`J7504
`J7505
`J7506
`J7507
`J7509
`J7510
`J7511
`J7513
`J7515
`J7516
`J7517
`J7518
`J7520
`J7525
`J7608
`J7611
`J7613
`J7614
`J7620
`J7626
`J7631
`J7639
`J7644
`J7669
`J7674
`J7682
`J8501
`J8510
`J8515
`J8520
`J8521
`J8530
`J8540
`J8560
`J8610
`J8700
`J9000
`J9001
`J9010
`J9015
`J9017
`J9020
`J9025
`J9027
`
`Normal saline solution infus
`5% dextrose/water
`D5w infusion
`Dextran 40 infusion
`Dextran 75 infusion
`Ringers lactate infusion
`Inj Vonwillebrand factor iu
`Factor viia
`Factor viii
`Factor viii recombinant
`Factor IX non‐recombinant
`Factor ix complex
`Factor IX recombinant
`Antithrombin iii injection
`Anti‐inhibitor
`Aminolevulinic acid hcl top
`Ganciclovir long act implant
`Sodium hyaluronate injection
`Hylan G‐F 20 injection
`Cultured chondrocytes implnt
`Metabolic active D/E tissue
`Non‐human, metabolic tissue
`Metabolically active tissue
`Nonmetabolic act d/e tissue
`Nonmetabolic active tissue
`Injectable human tissue
`Azathioprine oral 50mg
`Azathioprine parenteral
`Cyclosporine oral 100 mg
`Lymphocyte immune globulin
`Monoclonal antibodies
`Prednisone oral
`Tacrolimus oral per 1 MG
`Methylprednisolone oral
`Prednisolone oral per 5 mg
`Antithymocyte globuln rabbit
`Daclizumab, parenteral
`Cyclosporine oral 25 mg
`Cyclosporin parenteral 250mg
`Mycophenolate mofetil oral
`Mycophenolic acid
`Sirolimus, oral
`Tacrolimus injection
`Acetylcysteine inh sol u d
`Albuterol concentrated form
`Albuterol unit dose
`Levalbuterol unit dose
`Duoneb
`Pulmicort
`Cromolyn sodium inh sol u d
`Dornase alpha inhal sol u d
`Ipratropium brom inh sol u d
`Metaproterenol inh sol u d
`Methacholine chloride, neb
`Tobramycin inhalation sol
`Oral aprepitant
`Oral busulfan
`Cabergoline, oral 0.25mg
`Capecitabine, oral, 150 mg
`Capecitabine, oral, 500 mg
`Cyclophosphamide oral 25 MG
`Oral dexamethasone
`Etoposide oral 50 MG
`Methotrexate oral 2.5 MG
`Temozolomide
`Doxorubic hcl 10 MG vl chemo
`Doxorubicin hcl liposome inj
`Alemtuzumab injection
`Aldesleukin/single use vial
`Arsenic trioxide
`Asparaginase injection
`Azacitidine injection
`Clofarabine injection
`
`250 CC
`500 ML
`1000 CC
`500 ML
`500 ML
`1000 CC
`1 IU
`1 MCG
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`354 MG
`4.5 MG
`20 ‐ 25 MG
`16 MG
`1 EA
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`10 MG
`50 MG
`100 MG
`100 MG
`250 MG
`5 MG
`5 MG
`1 MG
`4 MG
`5 MG
`25 MG
`25 MG
`25 MG
`250 MG
`250 MG
`180 MG
`1 MG
`5 MG
`1 GM
`1 MG
`1 MG
`0.5 MG
`2.5 MG/0.5
`0.5 MG
`10 MG
`1 MG
`1 MG
`10 MG
`1 MG
`300 MG
`5 MG
`2 MG
`0.25 MG
`150 MG
`500 MG
`25 MG
`0.25 MG
`50 MG
`2.5 MG
`5 MG
`10 MG
`10 MG
`10 MG
`1 EA
`1 MG
`10000 UNIT
`1 MG
`1 MG
`
`$0.26
`$1.27
`$2.53
`$14.81
`$8.31
`$0.89
`$0.88
`$1.10
`$0.69
`$1.06
`$0.90
`$0.72
`$0.99
`$1.62
`$1.36
`$107.72
`$4,766.14
`$106.71
`$198.74
`$18,262.32
`$21.37
`$1.78
`$13.87
`$18.49
`$89.31
`$22.54
`$0.19
`$49.17
`$3.66
`$315.76
`$856.05
`$0.18
`$3.55
`$0.08
`$0.10
`$329.62
`$328.83
`$0.96
`$19.67
`$2.50
`$2.15
`$7.25
`$140.72
`$3.34
`$0.10
`$0.06
`$1.36
`$1.09
`$4.56
`$0.05
`$18.75
`$0.22
`$0.21
`$0.41
`$55.63
`$4.85
`$2.14
`$16.39
`$3.83
`$12.75
`$1.00
`$0.25
`$32.01
`$0.25
`$7.30
`$6.00
`$379.21
`$531.24
`$726.69
`$33.36
`$54.46
`$4.22
`$116.62
`
`Revised 01/01/07
`
`Revised 01/01/07
`
`Revised 01/01/07
`
`Revised 01/01/07
`Revised 01/01/07
`
`Revised 01/01/07
`
`Revised 01/01/07
`
`Revised 01/01/07
`
`95% $393.48
`
`Revised 01/01/2008
`
`Page 00006
`
`
`
`J9031
`J9035
`J9040
`J9041
`J9045
`J9050
`J9055
`J9060
`J9062
`J9065
`J9070
`J9080
`J9090
`J9091
`J9092
`J9098
`J9100
`J9110
`J9120
`J9130
`J9140
`J9150
`J9151
`J9160
`J9170
`J9175
`J9178
`J9181
`J9182
`J9185
`J9190
`J9200
`J9201
`J9202
`J9206
`J9208
`J9209
`J9211
`J9212
`J9213
`J9214
`J9216
`J9217
`J9218
`J9219
`J9225
`J9230
`J9245
`J9250
`J9260
`J9263
`J9264
`J9265
`J9266
`J9268
`J9280
`J9290
`J9291
`J9293
`J9300
`J9305
`J9310
`J9320
`J9340
`J9350
`J9355
`J9360
`J9370
`J9375
`J9380
`J9390
`J9395
`J9600
`
`Bcg live intravesical vac
`Bevacizumab injection
`Bleomycin sulfate injection
`Bortezomib injection
`Carboplatin injection
`Carmus bischl nitro inj
`Cetuximab injection
`Cisplatin 10 MG injection
`Cisplatin 50 MG injection
`Inj cladribine per 1 MG
`Cyclophosphamide 100 MG inj
`Cyclophosphamide 200 MG inj
`Cyclophosphamide 500 MG inj
`Cyclophosphamide 1.0 grm inj
`Cyclophosphamide 2.0 grm inj
`Cytarabine liposome
`Cytarabine hcl 100 MG inj
`Cytarabine hcl 500 MG inj
`Dactinomycin actinomycin d
`Dacarbazine 100 mg inj
`Dacarbazine 200 MG inj
`Daunorubicin
`Daunorubicin citrate liposom
`Denileukin diftitox, 300 mcg
`Docetaxel
`Elliotts b solution per ml
`Inj, epirubicin hcl, 2 mg
`Etoposide 10 MG inj
`Etoposide 100 MG inj
`Fludarabine phosphate inj
`Fluorouracil injection
`Floxuridine injection
`Gemcitabine HCl
`Goserelin acetate implant
`Irinotecan injection
`Ifosfomide injection
`Mesna injection
`Idarubicin hcl injection
`Interferon alfacon‐1
`Interferon alfa‐2a inj
`Interferon alfa‐2b inj
`Interferon gamma 1‐b inj
`Leuprolide acetate suspnsion
`Leuprolide acetate injeciton
`Leuprolide acetate implant
`Histrelin implant
`Mechlorethamine hcl inj
`Inj melphalan hydrochl 50 MG
`Methotrexate sodium inj
`Methotrexate sodium inj
`Oxaliplatin
`Paclitaxel injection
`Paclitaxel injection
`Pegaspargase/singl dose vial
`Pentostatin injection
`Mitomycin 5 MG inj
`Mitomycin 20 MG inj
`Mitomycin 40 MG inj
`Mitoxantrone hydrochl / 5 MG
`Gemtuzumab ozogamicin
`Pemetrexed injection
`Rituximab cancer treatment
`Streptozocin injection
`Thiotepa injection
`Topotecan
`Trastuzumab
`Vinblastine sulfate inj
`Vincristine sulfate 1 MG inj
`Vincristine sulfate 2 MG inj
`Vincristine sulfate 5 MG inj
`Vinorelbine tartrate/10 mg
`Injection, Fulvestrant
`Porfimer sodium
`
`1 EA
`10 MG
`15 UNITS
`0.1 MG
`50 MG
`100 MG
`10 MG
`10 MG
`50 MG
`1 MG
`100 MG
`200 MG
`500 MG
`1 GM
`2 GM
`10 MG
`100 MG
`500 MG
`0.5 MG
`100 MG
`200 MG
`10 MG
`10 MG
`300 MCG
`20 MG
`1 ML
`2 MG
`10 MG
`100 MG
`50 MG
`500 MG
`500 MG
`200 MG
`3.6 MG
`20 MG
`1 GM
`200 MG
`5 MG
`1 MCG
`3 MIL UNIT
`1 MIL UNIT
`3 MIL UNIT
`7.5 MG
`1 MG
`65 MG
`50 MG
`10 MG
`50 MG
`5 MG
`50 MG
`0.5 MG
`1 MG
`30 MG
`1 EA
`10 MG
`5 MG
`20 MG
`40 MG
`5 MG
`5 MG
`10 MG
`100 MG
`1 GM
`15 MG
`4 MG
`10 MG
`1 MG
`1 MG
`2 MG
`5 MG
`10 MG
`25 MG
`75 MG
`
`$113.44
`$56.88
`$37.62
`$31.87
`$10.12
`$139.84
`$49.86
`$2.26
`$11.31
`$37.87
`$1.92
`$3.83
`$15.53
`$19.16
`$38.32
`$396.66
`$1.69
`$8.47
`$493.43
`$4.90
`$9.80
`$24.56
`$56.21
`$1,403.23
`$302.68
`$3.40
`$24.67
`$0.50
`$4.97
`$243.82
`$1.88
`$64.17
`$121.30
`$199.12
`$126.88
`$52.39
`$10.10
`$308.97
`$4.65
`$37.56
`$13.75
`$289.87
`$227.63
`$11.10
`$2,208.90
`$1,741.71
`$141.61
`$1,194.15
`$0.24
`$2.45
`$8.77
`$8.46
`$15.11
`$1,687.04
`$2,034.63
`$18.31
`$73.26
`$146.52
`$223.27
`$2,317.16
`$42.49
`$481.69
`$152.92
`$44.58
`$813.08
`$56.17
`$0.97
`$6.69
`$13.37
`$33.43
`$22.82
`$80.66
`$2,505.40
`
`95% $289.37
`
`95%
`
`$61.72
`
`95%
`95%
`
`$8.19
`$8.55
`
`$2.07
`95%
`95% $136.80
`
`95% $150.38
`
`95% $127.40
`
`$58.13
`95%
`$4.10
`95%
`$33.98
`95%
`$67.96
`95%
`95% $169.91
`
`Revised 01/01/2008
`
`Revised 01/01/07
`
`Page 00007
`
`
`
`95%
`95%
`95%
`95%
`95%
`95%
`
`$12.99
`$14.55
`$55.10
`$14.55
`$29.10
`$29.10
`
`Revised 01/01/07
`Revised 01/01/07
`
`P9041
`P9043
`P9045
`P9046
`P9047
`P9048
`Q0163
`Q0164
`Q0165
`Q0166
`Q0167
`Q0168
`Q0169
`Q0170
`Q0171
`Q0172
`Q0173
`Q0175
`Q0176
`Q0177
`Q0178
`Q0179
`Q0180
`Q0515
`Q2009
`Q2017
`Q3025
`Q4079
`Q4080
`Q9945
`Q9946
`Q9947
`Q9948
`Q9949
`Q9950
`Q9952
`Q9953
`Q9954
`Q9956
`Q9957
`
`Albumin (human),5%, 50ml
`Plasma protein fract,5%,50ml
`Albumin (human), 5%, 250 ml
`Albumin (human), 25%, 20 ml
`Albumin (human), 25%, 50ml
`Plasmaprotein fract,5%,250ml
`Diphenhydramine HCl 50mg
`Prochlorperazine maleate 5mg
`Prochlorperazine maleate10mg
`Granisetron HCl 1 mg oral
`Dronabinol 2.5mg oral
`Dronabinol 5mg oral
`Promethazine HCl 12.5mg oral
`Promethazine HCl 25 mg oral
`Chlorpromazine HCl 10mg oral
`Chlorpromazine HCl 25mg oral
`Trimethobenzamide HCl 250mg
`Perphenazine 4mg oral
`Perphenazine 8mg oral
`Hydroxyzine pamoate 25mg
`Hydroxyzine pamoate 50mg
`Ondansetron HCl 8mg oral
`Dolasetron mesylate oral
`Sermorelin acetate injection
`Fosphenytoin, 50 mg
`Teniposide, 50 mg
`IM inj interferon beta 1‐a
`Natalizumab injection
`Iloprost inhalation solution
`LOCM <=149 mg/ml iodine, 1ml
`LOCM 150‐199mg/ml iodine,1ml
`LOCM 200‐249mg/ml iodine,1ml
`LOCM 250‐299mg/ml iodine,1ml
`LOCM 300‐349mg/ml iodine,1ml
`LOCM 350‐399mg/ml iodine,1ml
`Inj Gad‐base MR contrast,1ml
`Inj Fe‐based MR contrast,1ml
`Oral MR contrast, 100 ml
`Inj octafluoropropane mic,ml
`Inj perflutren lip micros,ml
`
`50 ML
`50 ML
`250 ML
`20 ML
`50 ML
`250 ML
`50 MG
`5 MG
`10 MG
`1 MG
`2.5 MG
`5 MG
`12.5 MG
`25 MG
`10 MG
`25 MG
`250 MG
`4 MG
`8 MG
`25 MG
`50 MG
`8 MG
`100 MG
`1 MCG
`50 MG
`50 MG
`11 MCG
`1 MG
`20 MCG
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`100 ML
`1 ML
`1 ML
`
`$12.99
`$14.55
`$55.10
`$14.55
`$29.10
`$29.10
`$0.03
`$0.05
`$0.03
`$41.18
`$4.92
`$10.13
`$0.39
`$0.41
`$0.02
`$0.05
`$0.24
`$0.22
`$0.23
`$0.06
`$0.07
`$36.06
`$48.91
`$1.75
`$5.59
`$264.88
`$108.04
`$7.72
`$33.18
`$0.29
`$1.96
`$1.42
`$0.27
`$0.35
`$0.21
`$2.87
`$30.41
`$8.90
`$49.61
`$61.64
`
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