N.J. Admin. Code § 10:58-3.4
Current through Register Vol. 56, No. 21, November 4, 2024
| HCPCS | Maximum Fee | |
|---|---|---|
| Codes | Descriptions | Allowance |
| J2790 | RhoGAM, Rho (D) Immune | $ 26.00 |
| Globulin (Human) | ||
| Single dose (Micro-Dose) | ||
| J2790 22 | RhoGAM, Rho (D) Immune | $ 45.00 |
| Globulin (Human) | ||
| Single dose (Full dose) | ||
| (22--Services greater than usual) | ||
| J1050 | Medroxyprogesterone acetate, 100 mg | 9.05 |
| J1055 | Medroxyprogesterone acetate for | 44.54 |
| contraceptive use, 150 mg | ||
| J1056 | Lunelle (25mg medroxyprogesterone and 5 mg | Lower of AWP |
| estradiol cypionate)/0.5 ml | minus 12.5 | |
| percent or the | ||
| acquisition | ||
| cost + | ||
| + Effective September 18, 2006, the Maximum Fee Allowance based on the AWP | ||
| minus 12.5 percent is $ 24.95 per 0.5 ml. Enter the lower of the AWP minus | ||
| 12.5 percent or the acquisition cost in Block 24G on the CMS 1500 claim | ||
| form. | ||
N.J. Admin. Code § 10:58-3.4
See: 33 N.J.R. 1160(a), 33 N.J.R. 2188(a).
Rewrote the table.
Amended by R.2006 d.338, effective 9/18/2006.
See: 38 N.J.R. 2003(a), 38 N.J.R. 3900(a).
In the table, inserted reference to HCPCS code "J1056".