IND | HCPCS CODES | MOD | MAXIMUM FEE | ||
ALLOWANCE $ | |||||
(a) APN Administered Drugs: | |||||
J0120 | Injection, tetracycline, up to 250 mg | 0.73 | |||
J0128 | Injection, abarelix, 10 mg | 70.81 | |||
J0129 | Injection, abatacept, 10 mg | 19.69 | |||
J0130 | Injection, abciximab, 10 mg | 601.69 | |||
J0132 | Injection, acetylcysteine, 100 mg | 2.16 | |||
J0133 | Injection, acyclovir, 5 mg | 0.16 | |||
J0135 | Injection, adalimumab, 20 mg | 335.64 | |||
J0150 | Injection, adenosine, 6 mg | 33.11 | |||
J0152 | Injection, adenosine, 30 mg | 76.50 | |||
J0170 | Injection, adrenalin, epinephrine, up to 1 ml ampul | 2.88 | |||
J0180 | Injection, agalsidase beta, 1 mg | 131.25 | |||
J0190 | Injection, biperiden lactate, 5 mg | 2.91 | |||
J0200 | Injection, alatrofloxacin mesylate 100 mg | 17.15 | |||
J0205 | Injection, alglucerase, per 10 units | 37.52 | |||
J0207 | Injection, amifostine, 500 mg | 536.14 | |||
J0210 | Injection, methyldopate HCl, (Aldomet), up to 250 mg | 1.74 | |||
J0215 | Injection, alefacept, 0.5 mg | 29.02 | |||
J0220 | Injection, aglucosidase alfa, 10 mg | 131.25 | |||
J0256 | Injection, alpha 1-proteinase inhibitor-human, per 500 | 0.01 | |||
J0278 | Injection, amikacin sulfate, 100 mg | 2.29 | |||
J0280 | Injection, aminophylline, up to 250 mg | 0.75 | |||
J0282 | Injection, amiodarone hydrochloride, 30 mg | 0.80 | |||
J0285 | Injection, amphotericin B, 50 mg | 17.06 | |||
J0287 | Injection, amphotericin B lipid complex, 10 mg | 21.00 | |||
J0288 | Injection, amphotericin B cholesteryl sulfate complex, 10 mg | 15.17 | |||
J0289 | Injection, amphotericin B liposome, 10 mg | 34.34 | |||
J0290 | Injection, ampicillin sodium, up to 500 mg | 3.86 | |||
J0295 | Injection, ampicillin sodium/sulbactam sodium, 1.5 mg | 7.25 | |||
J0300 | Injection, amobarbital, up to 125 mg | 2.66 | |||
J0330 | Injection, succinylcholine chloride, (Anectine), up to 20 mg | 0.26 | |||
J0350 | Injection, anistreplase, per 30 units | 2,481.13 | |||
J0360 | Hydralazine HCl, (Apresoline), up to 20 mg | 14.77 | |||
J0364 | Apomorphine hydrochloride, 1 mg | 3.39 | |||
J0365 | Aprotonin, 10,000 KIU | 2.85 | |||
J0380 | Injection, metaraminol bitartrate, per 10 mg | 1.21 | |||
J0390 | Injection, chloroquine HCl, (Araten HCl), up to 250 mg | 17.44 | |||
J0395 | Injection, arbutamine HCl, 1 mg | 168.00 | |||
J0400 | Injection, aripiprazole | 0.31 | |||
J0456 | Injection, azithromycin, 500 mg | 27.09 | |||
J0461 | Injection, atropine sulfate | 0.24 | |||
J0470 | Injection, dimercaprol, per 100 mg | 28.84 | |||
J0475 | Injection, baclofen, 10 mg | 223.13 | |||
J0476 | Injection, baclofen, 50 mcg for intrathecal trial | 73.50 | |||
J0480 | Basiliximab, 20 mg | 2,215.72 | |||
J0500 | Injection, dicyclomine HCl, (Bentyl, Spasmoject), 10 mg | 18.52 | |||
J0515 | Injection, benztropine mesylate, (Cogentin), 1 mg | 12.21 | |||
J0520 | Injection, bethanechol chloride, myotonachol or urecholine, | 4.91 | |||
up to 5 mg | |||||
J0559 | Injection, penicillin G benzathine/procaine | 0.08 | |||
J0560 | Injection, penicillin G benzathine, (Bicillin long acting), | 25.71 | |||
up to 600,000 units | |||||
J0570 | Injection, penicillin G benzathine, (Bicillin long acting), | 19.76 | |||
up to 1,200,000 units | |||||
J0580 | Injection, penicillin G benzathine, (Bicillin long acting), | 22.51 | |||
up to 2,400,000 units | |||||
J0583 | Bivalirudin, 1 mg | 2.08 | |||
J0585 | Botulinum toxin type A per unit | 5.52 | |||
J0586 | Botulinum toxin type A | 7.16 | |||
J0587 | Botulinum toxin type B, per 100 units | 8.99 | |||
J0592 | Injection, buprenorphine hydrochloride, 0.1 mg | 1.02 | |||
J0594 | Injection, busulfan, 1 mg | 10.09 | |||
J0595 | Butorphanol; tartrate, 1 mg | 3.91 | |||
J0598 | Injection, C1 Esterase inhibitor | 37.71 | |||
J0600 | Injection, edetate calcium disodium, 200 mg | 52.89 | |||
J0610 | Injection, calcium gluconate, per 10 ml | 2.03 | |||
J0620 | Injection calcium glycerophosphate and calcium lactate, per | 12.58 | |||
10 ml (Calphosan) | |||||
J0630 | Injection, calcitonin salmon, up to 400 units | 48.09 | |||
J0636 | Injection, calcitriol, 0.1 mcg | 1.34 | |||
J0637 | Injection, caspofungin acetate, 5 mg | 30.89 | |||
J0640 | Injection, leucovorine calcium, 50 mg | 3.28 | |||
J0641 | Injection, levoleucovorin, 0.5 mg | 1.05 | |||
J0670 | Injection, mepivacaine HCl, (Carbocaine), per 10 ml | 2.45 | |||
J0690 | Injection, cefazolin sodium, (Ancef, Kefzol), up to 500 mg | 2.83 | |||
J0692 | Injection, cefepime HCl, 500 mg (Maxipime) | 9.13 | |||
J0694 | Injection, cefoxitin sodium, (Mefoxin), 1 gm | 10.23 | |||
J0696 | Injection, ceftriaxone sodium, (Rocephin), per 250 mg | 12.97 | |||
J0697 | Injection, sterile cefuroxime sodium, 750 mg | 5.92 | |||
J0698 | Cefotaxime sodium, (Claforan), per gm | 7.10 | |||
J0702 | Injection, betamethasone acetate and betamethasone sodium | 2.88 | |||
phosphate, per 3 mg | |||||
J0704 | Injection, betamethasone sodium phosphate, per 4 mg | 1.09 | |||
J0706 | Injection, caffeine citrate, 5 mg (Cafcit) | 3.53 | |||
J0710 | Injection, cephapirin sodium (Cefadyl), up to 1 gram | 1.44 | |||
J0713 | Injection, ceftazidime, per 500 mg | 6.48 | |||
J0715 | Injection, ceftazoxime sodium, per 500 mg | 5.89 | |||
J0718 | Injection, certolizumab pegol | 7.37 | |||
J0720 | Injection, chloramphenicol sodium succinate, (Chloromycetin | 14.62 | |||
Sodium Succinate), up to 1 gram | |||||
J0735 | Injection, clonidine hydrochloride, 1 mg | 70.58 | |||
J0740 | Injection, cidofovir, 375 mg | 818.27 | |||
J0743 | Injection, cilastatin sodium/imipenem (Primaxin), 250 mg | 18.77 | |||
J0744 | Injection, ciprofloxacin for IV infusion 200 mg (Cipro) | 14.22 | |||
J0745 | Injection, codeine phosphate, 30 mg | 1.07 | |||
J0760 | Injection, colchicine, per 1 mg | 6.78 | |||
J0770 | Injection, colistimethate sodium, (Coly-Mycin), up to 150mg | 49.88 | |||
J0780 | Injection, prochlorperazine, (Compazine), up to 10 mg | 8.37 | |||
J0795 | Corticorelin ovine triflutal, 1 mcg | 4.75 | |||
J0800 | Injection, corticotropin, up to 40 units | 180.49 | |||
J0833 | Injection, cosyntropin, nos | 98.70 | |||
J0834 | Injection, cosyntropin cortrosyn | 107.44 | |||
J0850 | Injection, cytomegalovirus immune globulin intravenous | 925.32 | |||
(human), per vial | |||||
J0878 | Injection, dapromycin | 0.35 | |||
J0881 | Darbepoetin alpha, non-ESRD use, 1 mcg | 5.01 | |||
J0882 | Darbepoetin alpha, ESRD use, 1 mcg | 5.01 | |||
J0885 | Epoetin alfa, non-ESRD, 1,000 units | 13.69 | |||
J0886 | Injection, epoetin alfa, ESRD use, 1,000 units | 13.31 | |||
J0886 | Injection, epoetin alfa, non-ESRD use, 1,000 units | 13.31 | |||
J0894 | Injection, decitabine, 1 mg | 26.25 | |||
J0895 | Injection, deferoxamine mesylate, (Desferal), 100 mg | 16.92 | |||
J0945 | Injection, brompheniramine maleate, per 10 mg | 0.62 | |||
J0970 | Injection, estradiol valerate, up to 40 mg | 34.60 | |||
J1000 | Injection, depo-estradiol cypionate, 5 mg | 6.59 | |||
J1020 | Injection, methylprednisolone acetate, 20 mg | 3.13 | |||
J1030 | Injection, methylprednisolone acetate, 40 mg | 6.34 | |||
J1040 | Injection, methylprednisolone acetate, 80 mg | 10.45 | |||
J1051 | Injection, medroxyprogesterone acetate, 50 mg | 15.47 | |||
J1055 | Injection, medroxprogesterone acetate, for contraceptive use, | 53.97 | |||
150 mg | |||||
J1056 | Injection, medroxyprogesterone acetate/estradial cypionate, 5 | 22.60 | |||
mg/25 mg (Lunelle monthly contraceptive) | |||||
J1060 | Injection, testosterone cypionate and estradiol cypionate, up | 3.41 | |||
to 1 ml | |||||
J1070 | Injection, testosterone cypionate, up to 100 mg | 6.04 | |||
J1080 | Injection, testosterone cypionate, 1 cc/200 mg | 12.03 | |||
J1094 | Injection, dexamethasone acetate, 1 mg | 0.53 | |||
J1100 | Injection, dexamethasone sodium phosphate, 1 mg | 0.13 | |||
J1110 | Dihydroergotamine Mesylate, 1 mg | 31.94 | |||
J1120 | Injection, acetazolamide sodium, (Diamox Sodium), up to 500 | 22.97 | |||
mg | |||||
J1160 | Injection, digoxin, up to 0.5 mg | 2.49 | |||
J1162 | Digoxin immune fab (ovine), per vial | 594.23 | |||
J1165 | Injection, phenytoin sodium, (Dilantin), per 50 mg | 0.70 | |||
J1170 | Injection, hydromorphone, 2 mg | 1.01 | |||
J1180 | Injection, dyphylline, (Dilor, Lufyllin), up to 500 mg | 8.30 | |||
J1190 | Injection, dexrazoxane hydrochloride, per 250 mg | 224.47 | |||
J1200 | Injection, diphenhydramine HCl, (Benadryl), up to 50 mg | 1.16 | |||
J1205 | Injection, chlorothiazide sodium, (Diuril), per 500 mg | 149.94 | |||
J1212 | Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml | 52.50 | |||
J1230 | Injection, methadone HCl, (Dolophine HCl), up to 10 mg | 2.14 | |||
J1240 | Injection, demenhydrinate, (Dramamine), up to 50 mg | 2.74 | |||
J1245 | Injection, dipyridamole, per 10 mg | 7.66 | |||
J1250 | Injection, dobutamine hydrochloride, per 250 mg | 43.51 | |||
J1260 | Injection, dolasetron mesylate, 1 mg | 4.27 | |||
J1265 | Injection, dopamine, 40 mg | 0.32 | |||
J1267 | Injection, doripenem, 10 mg | 0.81 | |||
J1270 | Injection, doxercalciferol, 1 mcg (Hectorol) | 6.31 | |||
J1300 | Injection, eculizumab | 182.00 | |||
J1320 | Injection, amitriptyline HCl, (Elavil HCl), up to 20 mg | 2.05 | |||
J1324 | Injection, enfuvirtide, 1 mg | 19.70 | |||
J1325 | Injection, epoprostenol, 0.5 mg | 19.47 | |||
J1327 | Injection, eptifibatide, 5 mg | 21.13 | |||
J1330 | Injection, ergonovine maleate, up to 0.2 mg | 5.08 | |||
J1335 | Injection, ertapenem, 500 mg | 27.27 | |||
J1364 | Injection, erythromycin lactobionate, 500 mg | 9.09 | |||
J1380 | Injection, estradiol valerate, up to 10 mg | 14.81 | |||
J1390 | Injection, estradiol valerate, up to 20 mg | 20.88 | |||
J1410 | Injection, estrogen conjugated, per 25 mg | 70.83 | |||
J1430 | Ethanolamine oleate, 100 mg | 84.99 | |||
J1435 | Injection, estrone, per 1 mg | 0.25 | |||
J1436 | Injection, etidronate disodium, per 300 mg | 70.88 | |||
J1438 | Injection, etanercept, 25 mg | 180.50 | |||
J1440 | Injection, filgrastim, (G-CSF), 300 mcg | 216.68 | |||
J1441 | Injection, filagrastim, (G-CSF), 480 mcg | 345.19 | |||
J1450 | Injection, fluconazole, 200 mg | 20.81 | |||
J1451 | Fomepizole, 15 mg | 12.11 | |||
J1452 | Injection, fomivirsen sodium, intraocular, 1.65 mg | 875.00 | |||
J1453 | Injection, fosaprepitant, 1 mg | 1.62 | |||
J1455 | Injection, foscarnet sodium, (Foscavir), per 1000 mg | 12.00 | |||
J1457 | Injection, gallium nitrate, 1 mg | 1.71 | |||
J1458 | Injection, galsulfase, 1 mg | 327.91 | |||
J1459 | Injection, ivig privigen, 500 mg | 45.94 | |||
J1460 | Injection, gamma globulin I.M., 1 cc | 15.45 | |||
J1470 | Injection, gamma globulin I.M., 2 cc | 30.89 | |||
J1480 | Injection, gamma globulin I.M., 3 cc | 46.34 | |||
J1490 | Injection, gamma globulin I.M., 4 cc | 61.78 | |||
J1500 | Injection, gamma globulin I.M., 5 cc | 77.23 | |||
J1510 | Injection, gamma globulin I.M., 6 cc | 92.67 | |||
J1520 | Injection, gamma globulin I.M., 7 cc | 108.12 | |||
J1530 | Injection, gamma globulin I.M., 8 cc | 123.56 | |||
J1540 | Injection, gamma globulin I.M., 9 cc | 139.01 | |||
J1550 | Injection, gamma globulin I.M., 10 cc | 118.00 | |||
J1561 | Injection, immune globulin (Gamunex) | 47.28 | |||
J1562 | Injection, globulin sc, 100 mg | 13.13 | |||
J1566 | Immune globulin, powder, 500 mg | 43.89 | |||
J1568 | Injection, octagam | 55.61 | |||
J1569 | Injection, gammagard liquid | 59.17 | |||
J1570 | Injection, ganciclovir sodium, (Cytovene), 500 mg | 54.38 | |||
J1571 | Injection, hepagam B IM, 0.5 ml | 75.00 | |||
J1572 | Injection, flebogamma, 500 mg | 44.10 | |||
J1573 | Injection, hepagam B intravenous, 0.5 ml | 75.00 | |||
J1580 | Injection, garamycin, gentamicin, up to 80 mg | 2.12 | |||
J1590 | Injection, gatifloxacin, 10 mg (Tequin) | 0.83 | |||
J1600 | Injection, gold sodium thiomalate, 50 mg | 13.69 | |||
J1610 | Injection, glucagon hydrochloride, 1 mg | 76.56 | |||
J1620 | Injection, gonadorelin hydrochloride, per 100 mcg | 186.03 | |||
J1626 | Injection, granisetron hydrochloride, 100 mcg | 17.08 | |||
J1630 | Injection, haloperidol, up to 5 mg | 6.55 | |||
J1631 | Injection, haloperidol decanoate, 50 mg | 2.97 | |||
J1640 | Injection, hemin, 1 mg | 7.52 | |||
J1642 | Injection, heparin sodium, (Heparin Lock Flush), 10 units | 0.07 | |||
J1644 | Injection, heparin sodium, 1,000 units | 0.14 | |||
J1645 | Injection, dalteparin sodium, per 2,500 IU | 17.47 | |||
J1650 | Injection, enoxaparin sodium, 10 mg | 7.10 | |||
J1652 | Injection, fondaparinux sodium, 0.5 mg | 8.79 | |||
J1655 | Injection, tinzaparin sodium, 1,000 IU (Innohep) | 3.97 | |||
J1670 | Injection, tetanus immune globulin, human, up to 250 units | 124.26 | |||
J1675 | Injection, histrelin acetate, 10 mcg | 8.24 | |||
J1680 | Injection, human fibrinogen concentrate | 91.56 | |||
J1700 | Injection, hydrocortisone acetate, (Analpram HC, Hydrocortone | 0.61 | |||
Acetate), up to 25 mg | |||||
J1710 | Injection, hydrocortisone sodium phosphate, (Hydrocortone | 5.13 | |||
Phosphate), up to 50 mg | |||||
J1720 | Injection, hydrocortisone sodium succinate, (Solu-Cortef), up | 1.74 | |||
to 100 mg | |||||
J1730 | Injection, diazoxide, (Hyperstat), up to 300 mg | 117.96 | |||
J1740 | Injection, ibandronate sodium, 1 mg | 147.20 | |||
J1742 | Injection, ibutilide fumarate, 1 mg | 309.71 | |||
J1743 | Injection, idursulfase | 479.10 | |||
J1745 | Injection, infliximab, 10 mg | 61.15 | |||
J1750 | Injection, iron dextran, 50 mg | 13.41 | |||
J1756 | Injection, iron sucrose, 1 mg | 0.60 | |||
J1785 | Injection, imiglucerase, per unit | 4.05 | |||
J1790 | Injection, droperidol, (Inapsine), up to 5 mg | 3.72 | |||
J1800 | Injection, propranolol HCl, (Inderal), up to 1 mg | 8.62 | |||
J1810 | Injection, droperidol and fentanyl citrate, (Innovar), up to | 14.67 | |||
2 ml ampule | |||||
J1815 | Injection, insulin, per 5 units | 0.34 | |||
J1817 | Insulin for insulin pump use, per 50 units | 4.50 | |||
J1825 | Injection, interferon beta-1a, 33 mcg administered under | 400.18 | |||
direct supervision of a physician, excludes self administration | |||||
J1830 | Injection, interferon beta-1B, 0.25 mg | 96.08 | |||
J1835 | Injection, itraconazole, 50 mg (Sporanox) | 43.63 | |||
J1840 | Injection, kanamycin sulfate, (Kantrex), up to 500 mg | 7.70 | |||
J1850 | Injection, kanamycin sulfate, (Kantrex), up to 75 mg | 2.66 | |||
J1885 | Injection, ketorolac tromethamine, (Toradol I.M.), per 15 mg | 3.05 | |||
J1890 | Injection, cephalothin sodium, (Keflin), up to 1 gram | 9.45 | |||
J1930 | Injection, lanreotide, 1 mg | 27.81 | |||
J1931 | Injection, laronidase (aldurazyme), 0.1 mg | 24.63 | |||
J1940 | Injection, furosemide, (Lasix), up to 20 mg | 0.63 | |||
J1945 | Lepirudin, 50 mg | 174.13 | |||
J1950 | Injection, leuprolide acetate, (Depot Suspension), 3.75 mg | 544.60 | |||
J1953 | Injection, levetiracetam, 10 mg | 0.69 | |||
J1955 | Injection, levocarnitine, per 1 gram | 34.30 | |||
J1956 | Injection, levofloxacin, 250 mg | 18.82 | |||
J1960 | Injection, levorphanal tartrate, up to 2 mg | 3.72 | |||
J1980 | Injection, hyoscyamine sulfate, (Levsin), up to 0.25 mg | 10.35 | |||
J1990 | Injection, chlordiazepoxide HCl, (Librium), up to 100mg | 23.02 | |||
J2001 | Injection, lidocaine, per 10 mg | 0.31 | |||
J2010 | Injection, lincomycin HCl, up to 300 mg | 2.76 | |||
J2020 | Injection, linezolid, 200 mg (Zyvox) | 36.13 | |||
J2060 | Injection, lorazepam (Atvian), 2 mg | 2.82 | |||
J2150 | Injection, mannitol, 25% in 50 ml | 2.49 | |||
J2170 | Injection, mecasermin, 1 mg | 14.15 | |||
J2175 | Injection, meperidine HCl, 100 mg | 1.19 | |||
J2180 | Injection, meperidine/ promethazine HCl, (Mepergan), up to 50 | 8.00 | |||
mg | |||||
J2185 | Meropenem, 100 mg | 6.21 | |||
J2210 | Injection, methylergonovine maleate, (Metherqine Maleate), up | 5.37 | |||
to 0.2 mg | |||||
J2248 | Injection, micafungin sodium, 1 mg | 2.05 | |||
J2250 | Injection, midazolam hydrochloride, per 1 mg | 0.56 | |||
J2260 | Injection, milrinone lactate, per 5 ml | 6.56 | |||
J2270 | Injection, morphine sulfate, up to 10 mg | 1.62 | |||
J2271 | Injection, morphine sulfate, 100 mg | 4.22 | |||
J2275 | Injection, morphine sulfate, 10 mg (Preservative Free) | 6.25 | |||
J2278 | Injection, ziconotide, 1 mcg | 6.99 | |||
J2280 | Injection, moxifloxacin, 100 mg | 9.57 | |||
J2300 | Injection, nalbuphine HCl, per 10 mg | 1.76 | |||
J2310 | Injection, naloxone hydrochloride, per 1 mg | 5.12 | |||
J2315 | Naltrexone, depot form, 1 mg | 2.00 | |||
J2320 | Injection, nandrolone deconate, up to 50 mg | 6.15 | |||
J2321 | Injection, nandrolone deconoate, up to 100 mg | 8.17 | |||
J2322 | Injection, nandrolone deconoate, up to 200 mg | 20.66 | |||
J2323 | Injection, natalizumab | 8.12 | |||
J2325 | Injection, nesiritide, 0.1 mg | 34.99 | |||
J2353 | Injection, octreotide depot, 1 mg | 104.36 | |||
J2354 | Injection, octreotide, non-depot, 25 mcg | 4.89 | |||
J2355 | Injection, oprelvekin, 5 mg | 267.75 | |||
J2357 | Injection, omalizumab, 5 mg | 18.11 | |||
J2360 | Injection, orphenadrine citrate, (Norflex, Norgesic), up to | 17.94 | |||
60 mg | |||||
J2370 | Injection, phenylephrine HCl, (Neo-Synephrine), up to 1 ml | 2.73 | |||
J2400 | Injection, chloroprocaine HCl, (Nesacaine and Nesacaine MPF), | 17.17 | |||
per 30 ml | |||||
J2405 | Injection, ondansetron HCl, 1 mg | 1.23 | |||
J2410 | Injection, oxymorphone HCl, (Numorphan), up to 1 mg | 2.85 | |||
J2425 | Injection, paliferim, 50 mcg | 12.03 | |||
J2430 | Injection, pamidronate disodium, per 30 mg | 92.70 | |||
J2440 | Injection, papaverine HCl, up to 60 mg | 4.77 | |||
J2460 | Injection, oxytetracycline HCl, up to 50 mg | 0.97 | |||
J2469 | Palonosetron HCL, 25 mcg | 34.86 | |||
J2501 | Injection, paricalcitol, 1 mcg | 5.11 | |||
J2503 | Injection, pegaptanib sodium, .03 mg | 1,088.28 | |||
J2504 | Pedademase bovine, 25 IU | 204.17 | |||
J2505 | Injection, pegfilgrastim, 6 mg | 3,080.01 | |||
J2510 | Injection, penicillin G procaine, aqueous, up to 600,000 | 10.50 | |||
units | |||||
J2513 | Pentastarch 10% solution, 100 ml | 13.16 | |||
J2515 | Injection, pentobarbital sodium, per 50 mg | 5.61 | |||
J2540 | Injection, penicillen G potassium, up to 600,000 units | 0.43 | |||
(Pfizerpen) | |||||
J2543 | Injection, piperacillin sodium/tazobactam sodium, 1 gram | 5.81 | |||
0.125 grams (1.125 g) | |||||
J2545 | Pentamadine isethionate, 300 mg, solution for inhalation | 86.41 | |||
J2550 | Injection, promethazine HCl, (Phenergan), up to 50 mg | 3.79 | |||
J2560 | Phenobarbital Sodium, up to 120 mg | 2.96 | |||
J2562 | Injection, plerixafor | 262.50 | |||
J2590 | Injection, oxytocin, (Pitocin), up to 10 units | 2.56 | |||
J2597 | Injection, desmopressin acetate, per 1 mcg | 5.01 | |||
J2650 | Injection, prednisolone acetate, up to 1 ml | 0.68 | |||
J2670 | Injection, tolazoline HCl, (Priscoline HCl), up to 25 mg | 3.61 | |||
J2680 | Injection, fluphenazine deconoate, (Prolixin DeConoate), up | 4.38 | |||
to 25 mg | |||||
J2690 | Injection, procainamide HCl, (Proenstyl), up to 1 gram | 3.45 | |||
J2700 | Injection, oxacillin sodium, (Prostaphlin), up to 250 mg | 1.02 | |||
J2710 | Injection, neostigmine methylsulfate, (Prostigmin | 0.44 | |||
Methylsulfate), up to 0.5 mg | |||||
J2720 | Injection, protamine sulfate, 10 mg | 0.93 | |||
J2724 | Protein C concentrate, 10 I.U. | 1.26 | |||
J2725 | Injection, protirelin, per 250 mcg | 22.47 | |||
J2730 | Injection, pralidoxime chloride, (Protopam Chloride), up to 1 | 94.83 | |||
gm | |||||
J2760 | Injection, phentolamine mesylate, (Regitine), up to 5 mg | 33.91 | |||
J2765 | Injection, metoclopramide HCl, (Reglan), up to 10 mg | 0.77 | |||
J2770 | Injection, quinupristin/dalfopri stin, 500 mg (150/350) | 137.00 | |||
J2778 | Injection, ranibizumab | 426.56 | |||
J2780 | Injection, ranitidine hydrochloride, 25 mg | 1.38 | |||
J2783 | Rasburicase, 0.5 mg | 152.18 | |||
J2785 | Injection, regadenoson, 0.1 mg | 107.50 | |||
J2788 UD | Injection, Rho D immune globulin, human, minidose, 50 mcg | 49.55 | |||
J2788 | Injection, Rho D immune globulin, human, minidose, 50 mcg | 49.55 | |||
J2790 | Injection, Rho (D) Immune Globulin, (Human), (Rhogam), Human, | 115.94 | |||
Full dose, 300 mcg | |||||
J2790 UD | Injection, RHO (D) Immune Globulin Human, Full dose, 300 mcg | 115.94 | |||
J2791 | Injection, rhophylac | 1.12 | |||
J2792 | Injection, Rho(D) immune globulin, intravenous, human, | 20.71 | |||
solvent detergent, 100 IU | |||||
J2793 | Injection, rilonacept | 22.91 | |||
J2794 | Risperidone, long acting, 0.5 mg | 5.10 | |||
J2795 | Injection, ropivacaine hydrochloride, 1 mg | 0.08 | |||
J2796 | Injection, romiplostim | 43.70 | |||
J2800 | Injection, methocarbamol, (Robaxin), up to 10 ml | 17.27 | |||
J2805 | Injection, sincalide, 5 mcg | 60.03 | |||
J2820 | Injection, sarqramostim, (GM-CSF), 50 mcg | 33.30 | |||
J2850 | Injection, secretin synthetic, human, 1 mcg | 22.22 | |||
J2910 | Injection, aurothioglucose, (Solqanal), up to 50 mg | 25.73 | |||
J2916 | Injection, sodium ferric gluconate complex in sucrose | 7.53 | |||
Injection, 12.5 mg | |||||
J2920 | Injection, methylprednisolone sodium succinate, (Solu | 2.25 | |||
Medrol), up to 40 mg | |||||
J2930 | Injection, methylprednisolone sodium succinate, (Solu | 3.79 | |||
Medrol), up to 125 mg | |||||
J2941 | Injection, somatropin, 1 mg | 48.21 | |||
J2950 | Injection, promazine HCl, (Prozine, Sparine), up to 25 mg | 0.22 | |||
J2993 | Injection, reteplase, 18.8 mg | 1,319.55 | |||
J2995 | Injection, streptokinase, per 250,000 IU | 82.03 | |||
J2997 | Injection, alteplase recombinant, 1 mg | 33.47 | |||
J3000 | Injection, streptomycin, up to 1 gram | 7.96 | |||
J3010 | Injection, fentanyl citrate, (Sublimaze), up to 2 ml | 0.63 | |||
J3030 | Injection, sumatriptan succinate, 6 mg | 137.25 | |||
J3070 | Injection, pentazocine HCl, (Talwin), up to 30 mg | 4.43 | |||
J3101 | Injection, tenecteplase, 1 mg | 51.09 | |||
J3105 | Terbutaline sulfate, up to 1 mg | 15.86 | |||
J3120 | Injection, testosterone enanthate, up to 100 mg | 0.39 | |||
J3130 | Injection, testosterone enanthate, up to 200 mg | 17.88 | |||
J3150 | Injection, testosterone propionate, up to 100 mg | 0.87 | |||
J3230 | Injection, chlorpromazine HCl, (Thorazine), up to 50 mg | 5.70 | |||
J3240 | Injection, thyrotropin, alpha 1.1 mg | 869.53 | |||
J3243 | Injection, tigecycline, 1 mg | 1.04 | |||
J3246 | Tirofiban HCL (Aggrastat), 0.25 mg | 9.29 | |||
J3250 | Injection, trimethobenzamide HCl, up to 200 mg | 2.88 | |||
J3260 | Injection, tobramycin sulfate, (Nebcin), up to 80 mg | 3.71 | |||
J3265 | Injection, torsemide, 10 mg/ml | 2.74 | |||
J3280 | Injection, thiethylperazine maleate, up to 10 mg | 4.24 | |||
J3285 | Injection, treprostinil, 1 mg | 58.84 | |||
J3300 | Injection, triamcinolone A, prs-free, 1 mg | 0.06 | |||
J3301 | Injection, triamcinolone acetonide, (Kenalog), 10 mg | 1.45 | |||
J3302 | Injection, triamcinolole diacetate, (Aristocort), per 5 mg | 0.57 | |||
J3303 | Injection, triamcinolone hexacetonide, (Aristospan), per 5 mg | 2.97 | |||
J3305 | Injection, trimetrexate glucoronate, per 25 mg | 154.48 | |||
J3310 | Injection, perphenazine, (Trilafon), up to 5 mg | 6.38 | |||
J3315 | Injection, triptorelin pamoate, 3.75 mg | 530.47 | |||
J3320 | Injection, spectinomycin hydrochloride, (Trobicin), up to 2 | 31.05 | |||
mg | |||||
J3350 | Injection, urea, (Ureaphil), up to 40 mg | 77.77 | |||
J3360 | Injection, diazepam, (Valium), up to 5 mg | 1.25 | |||
J3364 | Injection, urokinase, 5,000 IU vial | 49.53 | |||
J3365 | Injection, IV, urokinase, 250,000 IU vial | 472.31 | |||
J3370 | Injection, vancomycin HCl, up to 500 mg | 4.01 | |||
J3396 | Injection, verteporfin, .01 mg | 10.14 | |||
J3400 | Injection, triflupromazine HCl, (Vesprin), up to 20 mg | 11.38 | |||
J3410 | Injection, hydroxyzine HCl, (Vistaril), 25 mg | 0.39 | |||
J3411 | Thiamine HCL, 100 mg | 1.89 | |||
J3415 | Pyridoxine HCL, 100 mg | 2.49 | |||
J3420 | Injection, vitamin B-12 cyanocobalamin, up to 1,000 mg | 0.42 | |||
J3430 | Injection, phytonadione, (Vitamin K), 1 mg | 2.26 | |||
J3465 | Injection, voriconazole, 10 mg | 5.54 | |||
J3470 | Injection, hyaluronidase, (Wydase), up to 150 units | 21.88 | |||
J3471 | Ovine, up to 999 USP units | 0.12 | |||
J3472 | Ovine, 1000 USP units | 142.19 | |||
J3475 | Injection, magnesium sulfate, per 500 mg | 3.13 | |||
J3480 | Injection, potassium chloride, per 2 mEq | 0.09 | |||
J3485 | Injection, zidovudine, 10 mg | 1.19 | |||
J3486 | Ziprasidone mesylate, 10 mg | 5.36 | |||
J3487 | Injection, zoledronic acid, 1 mg | 223.00 | |||
J3488 | Injection, reclast | 227.84 | |||
J7030 | Infusion, normal saline solution, 1,000 ml = 1 unit | 7.14 | |||
J7040 | Infusion, normal saline solution, sterile, 500 ml = 1 unit | 6.98 | |||
J7042 | 5% dextrose/normal saline solution, 500 ml = 1 unit | 5.65 | |||
J7050 | Infusion, normal saline solution. 250 ml = 1 unit | 6.03 | |||
J7060 | 5% dextrose/water solution, 500 ml = 1 unit | 8.09 | |||
J7070 | Infusion, D5W, 1,000 cc | 7.10 | |||
J7100 | Infusion, dextran 40, 500 ml | 54.49 | |||
J7110 | Infusion, dextran 75, 500 ml | 64.28 | |||
J7120 | Ringer's Lactate Infusion, up to 1,000 ml = 1 unit | 10.39 | |||
J7185 | Injection, xyntha | 1.39 | |||
J7186 | Antihemophilic VIII/VWF composition | 1.06 | |||
J7189 | Factor VIIA (antihemophilic factor, recombinant), per IU | 1.44 | |||
J7190 | Factor VIII (antihemophilic factor, human) per IU | 0.90 | |||
J7191 | Factor VIII (antihemophilic factor, porcine) per IU | 1.93 | |||
J7192 | Factor VIII (antihemophilic factor, recombinant), per IU | 1.48 | |||
J7193 | Factor IX (antihemophilic factor, purified non-recombinant) | 1.09 | |||
per IU (Alphanine SD) | |||||
J7194 | Factor IX complex, per IU | 0.59 | |||
J7195 | Factor IX (antihemophilic factor, recombinant) per IU | 0.91 | |||
(Benefix) | |||||
J7198 | Anti-inhibitor, per IU | 1.31 | |||
J7300 | Intrauterine copper contraceptive (Paragard) | 396.64 | |||
J7302 | Levonorgestrel-releasing intrauterine contraceptive system, | 450.88 | |||
52 mg (Mirena) | |||||
J7303 | Contraceptive vaginal ring | 40.02 | |||
J7304 | Contraceptive hormone patch | 15.72 | |||
J7307 | Estrogestrel implant system | 620.08 | |||
J7310 | Ganciclovir, 4.5 mg, long-acting implant | 4,725.00 | |||
J7311 | Fluocinolone acetonide implant | 1,662.50 | |||
J7321 | Injection, hyalgan/supartz, per dose | 126.88 | |||
J7323 | Injection, euflexxa, per dose | 133.96 | |||
J7324 | Injection, orthovisc, per dose | 228.69 | |||
J7325 | Injection, synvisc or synvisc-one | 405.72 | |||
J7500 | Azathioprine, oral, 50 mg | 1.15 | |||
J7501 | Azathioprine; parenteral, vial, 100 mg, 20 ml each | 74.38 | |||
J7502 | Cyclosporin, oral, 100 mg | 5.34 | |||
J7503 | Cyclosporin, parenteral, 50 mg | 5.50 | |||
J7504 | Lymphocyte immune globulin, antithymocyte globulin, | 367.36 | |||
parenteral, amp, 50 mg/ml, 5 ml each | |||||
J7506 | Prednisone, oral, 5 mg tablet | 0.14 | |||
J7507 | Tacrolimus, oral, per 1 mg | 3.97 | |||
J5709 | Methylprednisolone, oral, 4 mg | 0.58 | |||
J5710 | Prednisolone, oral, 5 mg | 0.12 | |||
J7511 | Lymphocyte immune globulin, antithymocyte globulin, rabbit, | 426.56 | |||
parenteral, 25 mg (Thymoglobulin) | |||||
J7513 | Daclizumab, parenteral, 25 mg | 449.66 | |||
J7515 | Cyclosporine, oral, 25 mg | 1.20 | |||
J7516 | Cyclosporine, parenteral, 250 mg | 24.06 | |||
J7517 | Mycophenolate mofetil, 250 mg | 3.27 | |||
J7518 | Mycophenolic acid, 180 mg | 4.02 | |||
J7520 | Sirolimus, oral, 1 mg | 7.97 | |||
J7525 | Tacrolimus, parenteral, 5 mg | 149.43 | |||
J7604 | Acetylcysteine, comp unit, per gram | 3.57 | |||
J7605 | Arformoterol, non-comp unit, 15 mcg | 5.04 | |||
J7606 | Formoterol fumarate, inhale | 5.60 | |||
J7607 | Levabuterol, comp concentrate, 0.5 mg | 1.33 | |||
J7608 | Acetylcysteine, inhale solution, unit dose, per gram | 1.80 | |||
J7611 | Albuterol, concentrate form, 1 mg | 0.15 | |||
J7612 | Levabuterol, concentrate, 0.5 mg | 1.19 | |||
J7613 | Albuterol, unit dose, 1 mg | 0.54 | |||
J7614 | Levalbuterol, unit dose, 0.5 mg | 2.61 | |||
J7615 | Levalbuterol, inhalation solution, 0.5 mg | 1.89 | |||
J7620 | Albuterol, 2.5 mg/Ipratrop, 0.5 mg | 2.18 | |||
J7626 | Budesonide, inhalation solution, up to 0.5 mg | 9.35 | |||
J7627 | Budesonide, powder, inhalation, up to 0.5 mg | 161.35 | |||
J7628 | Bitolterol mesylate, concentrate form, per mg | 0.48 | |||
J7631 | Cromolyn sodium, unit dose form | 0.34 | |||
J7632 | Cromolyn sodium, comp unit | 0.31 | |||
J7634 | Budesonide, comp concentrate, per 0.25 mg | 4.81 | |||
J7635 | Atropine, inhalation solution, concentrated, per mg | 1.23 | |||
J7636 | Atropine, inhalation solution, unit dose, per mg | 1.09 | |||
J7637 | Dexamethasone, inhalation solution, concentrated, per mg | 0.43 | |||
J7638 | Dexamethasone, inhalation solution, unit dose, per mg | 0.20 | |||
J7639 | Dornase alpha inhalation solution | 21.00 | |||
J7642 | Glycopyrrolate, inhalation solution, per mg | 2.32 | |||
J7644 | Ipratroprium bromide, inhalation solution, per mg | 1.54 | |||
J7645 | Ipratroprium bromide, inhalation solution, comp, per mg | 1.26 | |||
J7669 | Metaproterenol, inhalation solution, unit dose, per 10 mg | 0.49 | |||
J7674 | Methacholine chloride, nebulizers, per mg | 0.42 | |||
J7676 | Pentamidine comp, unit dose | 93.44 | |||
J7682 | Tobramycin, inhalation solution, 300 mg | 66.11 | |||
J7684 | Triamcinolone, inhalation solution, per mg | 0.61 | |||
J8501 | Oral aprepitant, 5 mg | 4.71 | |||
J8510 | Bulsulfan, oral, 2 mg | 2.59 | |||
J8520 | Capecitabine, oral, 150 mg | 6.51 | |||
J8521 | Capecitabine, oral, 500 mg | 21.71 | |||
J8530 | Cyclophosphamide, oral, 25 mg | 3.15 | |||
J8560 | Etoposide, oral, 50 mg | 41.68 | |||
J8600 | Melphalan, oral, 2 mg | 5.29 | |||
J8610 | Methotrexate, oral, 2.5 mg | 3.19 | |||
J8700 | Temozolomide, 5 mg | 7.93 | |||
J9000 | Doxorubicin HCl, (Adriamycin), 10 mg | 12.03 | |||
J9001 | Doxorubicin HCI, all lipid formulations, 10 mg | 435.26 | |||
J9010 | Alemtuzumab, 10 mg | 585.40 | |||
J9015 | Aldesleukin, per single use vial | 826.40 | |||
J9017 | Arsenic trioxide, 1 mg (Trisenox) | 36.79 | |||
J9020 | Asparaginase, 10,000 units | 55.02 | |||
J9025 | Injection, azacitidine, 1 mg | 4.42 | |||
J9027 | Injection, clofarabine, 1 mg | 123.05 | |||
J9031 | BCG (intravesical) per installation | 172.59 | |||
J9033 | Injection, bendamustine, 1 mg | 19.13 | |||
J9035 | Injection, bevacizumab (Avastin), 10 mg | 60.16 | |||
J9040 | Bleomycin sulfate, (Blenoxane) 15 units | 77.11 | |||
J9041 | Injection, bortezomib (Velcade), 0.1 mg | 35.31 | |||
J9045 | Carboplatin (Paraplatin), 50 mg | 76.42 | |||
J9050 | Carmustine, (BiCNU), 100 mg | 163.91 | |||
J9055 | Injection, cetuximab (Erbitux), 10 mg | 52.50 | |||
J9060 | Cisplatin, (Platinol), powder or solution, 10 mg | 4.05 | |||
J9062 | Cisplatin, 50 mg | 20.13 | |||
J9065 | Injection, cladribine, (Leustatin), per 1 mg | 53.05 | |||
J9070 | Cyclophosphamide, (Cytoxan), 100 mg | 2.52 | |||
J9080 | Cyclophosphamide, (Cytoxan), 200 mg | 5.04 | |||
J9090 | Cyclophosphamide, (Cytoxan), 500 mg | 13.86 | |||
J9091 | Cyclophosphamide, (Cytoxan), 1 gram | 25.08 | |||
J9092 | Cyclophosphamide, (Cytoxan), 2 grams | 45.37 | |||
J9093 | Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 100 mg | 5.42 | |||
J9094 | Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 200 mg | 10.29 | |||
J9095 | Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 500 mg | 21.60 | |||
J9096 | Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 1 gram | 43.21 | |||
J9097 | Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 2 grams | 86.44 | |||
J9098 | Cytarabine liposome, 10 mg | 437.50 | |||
J9100 | Cytarabine, (Cytarabine Hydrochloride), 100 mg | 3.17 | |||
J9110 | Cytarabine, (Cytarabine Hydrochloride), 500 mg | 8.75 | |||
J9120 | Dactinomycin, 0.5 mg | 519.53 | |||
J9130 | Dacarbazine, 100 mg | 10.34 | |||
J9140 | Dacarbazine, 200 mg | 20.67 | |||
J9150 | Daunorubicin, 10 mg | 70.57 | |||
J9151 | Daunorubicin citrate, liposomal formulation, 10 mg | 59.50 | |||
J9155 | Injection, degarelix | 3.92 | |||
J9160 | Denileukin diftitox, 300 mcg | 1,487.50 | |||
J9165 | Injection, diethlstilbestrol diphosphate, (Stilphostrol), 250 | 13.27 | |||
mg | |||||
J9171 | Injection, docetaxel | 19.51 | |||
J9175 | Elliotts B solution, per ml | 4.29 | |||
J9178 | Injection, epirubicin, 2 mg | 26.22 | |||
J9181 | Etoposide, (VePesid), 10 mg | 1.64 | |||
J9185 | Fludarabine Phosphate, 50 mg | 317.80 | |||
J9190 | Fluorouracil, 500 mg | 3.28 | |||
J9200 | Floxuridine, 500 mg | 130.70 | |||
J9201 | Gemcitabine HCl, (Gemzar), 200 mg | 135.98 | |||
J9202 | Goserelin acetate implant, (Zoladex), 3.6 mg | 411.24 | |||
J9206 | Irinotecan, 20 mg | 134.24 | |||
J9207 | Injection, ixabepilione, 1 mg | 65.31 | |||
J9208 | Ifosfomide, 1 gram | 63.49 | |||
J9209 | Mesna, (Mesnex), 200 mg | 30.76 | |||
J9211 | Idarubicin hydrochloride, 5 mg | 386.79 | |||
J9212 | Injection, interferon alfacon-1, recombinant, 1 mcg | 8.50 | |||
J9213 | Interferon alfa-2A, Recombinant, 3 million units | 40.53 | |||
J9214 | Interferon alfa-2B, recombinant, 1 million units (Intron A) | 14.84 | |||
J9215 | Interferon alfa-N3 (human leukocyte derived) 250,000 IU | 15.68 | |||
(Alferon N) | |||||
J9216 | Interferon gamma-1B, 3 million units | 344.41 | |||
J9217 | Leuprolide acetate, (Lupron Depot), 7.5 mg | 678.73 | |||
J9218 | Leuprolide acetate, (Lupron), 1 mg | 271.53 | |||
J9219 | Leuprolide acetate implant, 65 mg | 4,973.50 | |||
J9225 | Histrelin implant, 50 mg | 5,250.00 | |||
J9226 | Supprelin LA implant | 15,312.50 | |||
J9230 | Mechlorethamide HCl, (nitrogen mustard), Mustargen OE, 10 mg | 152.08 | |||
J9245 | Injection, melphalan HCl, 50 mg | 1,267.39 | |||
J9250 | Methotrexate sodium, 5 mg (Folex) | 0.48 | |||
J9260 | Methotrexate sodium, 50 mg | 4.16 | |||
J9261 | Injection, nelarabine, 50 mg | 90.13 | |||
J9263 | Oxaliplatin, 0.5 mg | 9.32 | |||
J9264 | Injection, paclitaxel, 1 mg | 9.40 | |||
J9265 | Paclitaxel, 30 mg | 151.13 | |||
J9266 | Pegaspargase, per single dose vial | 2,187.50 | |||
J9268 | Pentostatin, per 10 mg | 2,324.00 | |||
J9270 | Plicamycin, (Mithracin), 2.5 mg | 86.39 | |||
J9280 | Mitomycin, 5 mg | 61.25 | |||
J9290 | Injection, mitoxantrone HCl, per 5 mg | 199.06 | |||
J9291 | Mitomycin, 40 mg | 273.44 | |||
J9293 | Injection, mitoxantrone HCl, per 5 mg | 325.23 | |||
J9300 | Gemtuzumab ozogamicin, 5 mg (Gemzar) | 2,563.75 | |||
J9303 | Injection, panitumumab | 87.50 | |||
J9305 | Injection, pemetrexed (Alimta), 10 mg | 47.63 | |||
J9310 | Rituximab, 100 mg | 571.97 | |||
J9320 | Streptozocin, 1 gram | 113.78 | |||
J9328 | Injection, temozolomide | 4.75 | |||
J9330 | Injection, temsirolimus, 1 mg | 48.99 | |||
J9340 | Thiotepa, 15 mg | 85.59 | |||
J9350 | Topotecan, 4 mg | 932.71 | |||
J9355 | Trastuzumab, 10 mg | 61.81 | |||
J9357 | Valrubicin, intravesical, 200 mg | 485.10 | |||
J9360 | Vinblastine sulfate, (Velban), 1 mg | 2.90 | |||
J9370 | Vincristine sulfate, (Oncovin), 1 mg | 12.60 | |||
J9375 | Vincristine sulfate, (Oncovin), 2 mg | 25.21 | |||
J9380 | Vincristine sulfate, (Oncovin), 5 mg | 142.37 | |||
J9390 | Vinorelbine tartrate, per 10 mg | 82.25 | |||
J9395 | Injection, fulvestrant, 25 mg | 86.93 | |||
J9600 | Porfimer sodium, (Photofrin), 75 mg | 2,637.93 | |||
N.J. Admin. Code § 10:58A-4.3
See: 31 N.J.R. 3968(a), 32 N.J.R. 1208(a).
Rewrote the section.
Amended by R.2004 d.409, effective 11/1/2004.
See: 35 N.J.R. 4977(a), 36 N.J.R. 4968(a).
Rewrote the section.
Amended by R.2005 d.406, effective 11/21/2005.
See: 37 N.J.R. 2329(a), 37 N.J.R. 4445(a).
Rewrote the section.
Amended by R.2011 d.119, effective 4/18/2011.
See: 42 N.J.R. 2890(a), 43 N.J.R. 1015(a).
Rewrote the section.