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|
CY 2008 |
CY 2008 |
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|
|
Effective Jan. 1 - Through Mar. 31 |
Effective April 1 - Through June 30 |
| Code |
Description |
Code Dosage |
ASP plus 6% |
ASP plus 6% |
| J0129 |
Abatacept |
10mg |
$18.69 |
$18.69 |
| J0130 |
Abciximab injection |
10mg |
$420.77 |
$423.05 |
| J0133 |
Acyclovir, 5 mg |
5mg |
$0.02 |
$0.02 |
| J0150 |
Injection adenosine 6 MG |
6mg |
$22.74 |
$12.85 |
| J0152 |
Adenosine injection |
30mg |
$68.54 |
$68.17 |
| J0170 |
Adrenalin epinephrin inject |
1ml |
$1.04 |
$0.69 |
| J0205 |
Alglucerase injection |
10units |
$39.22 |
$39.67 |
| J0207 |
Amifostine |
500mg |
$496.28 |
$511.22 |
| J0210 |
Methyldopate hcl injection |
250mg |
$16.77 |
$15.19 |
| J0215 |
Alefacept |
0.5mg |
$26.56 |
$26.66 |
| J0256 |
Alpha 1 proteinase inhibitor |
10mg |
$3.38 |
$3.66 |
| J0270 |
Alprostadil for injection |
1.25mcg |
$1.98 |
$0.60 |
| J0275 |
Alprostadil urethral suppos |
1dose |
$23.24 |
$22.92 |
| J0280 |
Aminophyllin 250 MG inj |
250mg |
$0.42 |
$0.37 |
| J0282 |
Amiodarone HCl |
30mg |
$0.17 |
$0.20 |
| J0289 |
Amphotericin b liposome inj |
10mg |
$16.51 |
$17.16 |
| J0295 |
Ampicillin sodium per 1.5 gm |
1.5gm |
$4.66 |
$4.40 |
| J0300 |
Amobarbital 125 MG inj |
125mg |
$7.66 |
$11.96 |
| J0330 |
Succinycholine chloride inj |
20mg |
$0.16 |
$0.17 |
| J0360 |
Hydralazine hcl injection |
20mg |
$6.86 |
$6.07 |
| J0456 |
Azithromycin |
500mg |
$17.61 |
$17.98 |
| J0460 |
Atropine sulfate injection |
0.3mg |
$0.60 |
$0.33 |
| J0475 |
Baclofen 10 MG injection |
10mg |
$196.92 |
$190.85 |
| J0476 |
Baclofen intrathecal trial |
50mcg |
$70.96 |
$69.76 |
| J0480 |
Basiliximab |
20mg |
$1,502.90 |
$1,499.44 |
| J0500 |
Dicyclomine injection |
20mg |
$13.81 |
$11.92 |
| J0515 |
Inj benztropine mesylate |
1mg |
$22.33 |
$24.06 |
| J0530 |
Penicillin g benzathine inj |
600,00units |
$14.75 |
$14.75 |
| J0540 |
Penicillin g benzathine inj |
1,200,000units |
$33.00 |
$32.90 |
| J0550 |
Penicillin g benzathine inj |
2,400,000units |
$33.00 |
$32.90 |
| J0570 |
Penicillin g benzathine inj |
1,200,000units |
$40.89 |
$40.75 |
| J0580 |
Penicillin g benzathine inj |
2,4000,000units |
$46.53 |
$46.07 |
| J0583 |
Bivalirudin |
1mg |
$1.98 |
$2.08 |
| J0585 |
Botulinum toxin a per unit |
1unit |
$5.26 |
$5.22 |
| J0587 |
Botulinum toxin type B |
100units |
$8.71 |
$8.71 |
| J0592 |
Buprenorphine hydrochloride |
0.1mg |
$0.71 |
$0.72 |
| J0595 |
Butorphanol tartrate 1 mg |
1mg |
$0.59 |
$0.50 |
| J0600 |
Edetate calcium disodium inj |
1000mg |
$50.19 |
$50.23 |
| J0610 |
Calcium gluconate injection |
10ml |
$0.63 |
$0.36 |
| J0630 |
Calcitonin salmon injection |
400units |
$44.53 |
$44.57 |
| J0636 |
Inj calcitriol per 0.1 mcg |
0.1mcg |
$0.33 |
$0.43 |
| J0637 |
Caspofungin acetate |
5mg |
$21.18 |
$17.87 |
| J0640 |
Leucovorin calcium injection |
50mg |
$0.86 |
$0.78 |
| J0690 |
Cefazolin sodium injection |
500mg |
$1.42 |
$0.66 |
| J0692 |
Cefepime HCl for injection |
500mg |
$5.72 |
$6.75 |
| J0694 |
Cefoxitin sodium injection |
1gm |
$8.28 |
$8.19 |
| J0696 |
Ceftriaxone sodium injection |
250mg |
$1.25 |
$1.48 |
| J0697 |
Sterile cefuroxime injection |
750mg |
$3.97 |
$3.44 |
| J0698 |
Cefotaxime sodium injection |
1gm |
$5.60 |
$4.29 |
| J0702 |
Betamethasone acet&sod phosp |
3mg |
$5.60 |
$5.75 |
| J0706 |
Caffeine citrate injection |
5mg |
$2.51 |
$2.28 |
| J0713 |
Inj ceftazidime per 500 mg |
500mg |
$3.61 |
$3.47 |
| J0715 |
Ceftizoxime sodium / 500 MG |
500mg |
$4.75 |
$5.24 |
| J0720 |
Chloramphenicol sodium injec |
1gm |
$14.93 |
$18.38 |
| J0725 |
Chorionic gonadotropin/1000u |
1,000units |
$3.71 |
$3.37 |
| J0740 |
Cidofovir injection |
375mg |
$760.92 |
$762.45 |
| J0743 |
Cilastatin sodium injection |
250mg |
$14.23 |
$14.28 |
| J0745 |
Inj codeine phosphate /30 MG |
30mg |
$1.53 |
$1.27 |
| J0760 |
Colchicine injection |
1mg |
$5.09 |
$5.00 |
| J0770 |
Colistimethate sodium inj |
150mg |
$23.01 |
$19.88 |
| J0780 |
Prochlorperazine injection |
10mg |
$1.11 |
$1.16 |
| J0800 |
Corticotropin injection |
1-40units |
$871.25 |
$2,355.52 |
| J0882 |
Darbepoetin alfa, non-esrd |
1mcg |
$2.89 |
$2.77 |
| J0885 |
Non esrd epoetin alpha inj |
1,000units |
$8.96 |
$9.07 |
| J0895 |
Deferoxamine mesylate inj |
500mg |
$12.35 |
$12.31 |
| J1000 |
Depo-estradiol cypionate inj |
5mg |
$6.15 |
$6.18 |
| J1020 |
Methylprednisolone 20 MG inj |
20mg |
$2.27 |
$2.41 |
| J1030 |
Methylprednisolone 40 MG inj |
40mg |
$4.63 |
$4.47 |
| J1040 |
Methylprednisolone 80 MG inj |
80mg |
$8.71 |
$9.41 |
| J1051 |
Medroxyprogesterone inj |
50mg |
$6.51 |
$6.67 |
| J1070 |
Testosterone cypionat 100 MG |
100mg |
$4.88 |
$4.82 |
| J1080 |
Testosterone cypionat 200 MG |
1cc_200mg |
$12.44 |
$6.96 |
| J1100 |
Dexamethasone sodium phos |
1mg |
$0.11 |
$0.08 |
| J1110 |
Inj dihydroergotamine mesylt |
1mg |
$23.44 |
$16.69 |
| J1120 |
Acetazolamid sodium injectio |
50mg |
$17.53 |
$1.18 |
| J1160 |
Digoxin injection |
0.5mg |
$3.85 |
$0.45 |
| J1165 |
Phenytoin sodium injection |
50mg |
$0.54 |
$0.45 |
| J1190 |
Dexrazoxane HCl injection |
250mg |
$163.84 |
$180.94 |
| J1200 |
Diphenhydramine hcl injectio |
1-50mg |
$0.80 |
$0.75 |
| J1205 |
Chlorothiazide sodium inj |
500mg |
$148.86 |
$165.17 |
| J1230 |
Methadone injection |
10mg |
$3.37 |
$2.95 |
| J1245 |
Dipyridamole injection |
10mg |
$0.96 |
$0.73 |
| J1250 |
Inj dobutamine HCL/250 mg |
250mg |
$5.53 |
$5.14 |
| J1260 |
Dolasetron mesylate |
10mg |
$4.80 |
$4.19 |
| J1265 |
DopAMIne injection |
40mg |
$0.85 |
$0.51 |
| J1270 |
Injection, doxercalciferol |
1mcg |
$2.40 |
$2.80 |
| J1325 |
Epoprostenol injection |
0.5mg |
$14.53 |
$14.36 |
| J1327 |
Eptifibatide injection |
5mg |
$17.64 |
$17.03 |
| J1335 |
Ertapenem injection |
500mg |
$25.30 |
$25.51 |
| J1364 |
Erythro lactobionate /500 MG |
500mg |
$6.91 |
$6.76 |
| J1410 |
Inj estrogen conjugate 25 MG |
25mg |
$71.32 |
$71.25 |
| J1430 |
Ethanolamine oleate 100 mg |
100mg |
$76.48 |
$120.49 |
| J1440 |
Filgrastim 300 mcg injection |
300mcg |
$199.04 |
$199.24 |
| J1441 |
Filgrastim 480 mcg injection |
480mcg |
$305.39 |
$306.63 |
| J1450 |
Fluconazole |
200mg |
$9.04 |
$9.57 |
| J1451 |
Fomepizole, 15 mg |
15mg |
$13.73 |
$14.12 |
| J1455 |
Foscarnet sodium injection |
1000mg |
$10.68 |
$10.38 |
| J1561 |
Gamunex Injection |
500mg |
$32.88 |
$33.45 |
| J1566 |
Inj immune globulin, lyophilzed 500mg |
500mg |
$27.67 |
$28.07 |
| J1568 |
Octagam Injection |
500mg |
$33.81 |
$34.07 |
| J1569 |
Gammagard Liquid Injection |
500mg |
$31.65 |
$31.79 |
| J1570 |
Ganciclovir sodium injection |
500mg |
$43.34 |
$43.85 |
| J1572 |
Flebogamma Injecton |
500mg |
$32.61 |
$32.53 |
| J1580 |
Garamycin gentamicin inj |
80mg |
$0.80 |
$1.04 |
| J1590 |
Gatifloxacin injection |
10mg |
$1.33 |
$0.80 |
| J1595 |
Injection glatiramer acetate |
20mg |
$52.58 |
$55.28 |
| J1610 |
Glucagon hydrochloride/1 MG |
1mg |
$72.96 |
$68.66 |
| J1626 |
Granisetron HCl injection |
100mcg |
$4.72 |
$4.96 |
| J1630 |
Haloperidol injection |
5mg |
$1.79 |
$1.73 |
| J1631 |
Haloperidol decanoate inj |
50mg |
$5.39 |
$2.41 |
| J1642 |
Inj heparin sodium per 10 u |
10units |
$0.37 |
$0.04 |
| J1644 |
Inj heparin sodium per 1000u |
1000units |
$0.22 |
$0.07 |
| J1645 |
Dalteparin sodium |
2500I.U. |
$11.17 |
$10.79 |
| J1650 |
Inj enoxaparin sodium |
10mg |
$5.81 |
$5.90 |
| J1652 |
Fondaparinux sodium |
0.5mg |
$6.07 |
$5.72 |
| J1655 |
Tinzaparin sodium injection |
1000I.U. |
$2.29 |
$1.95 |
| J1720 |
Hydrocortisone sodium succ i |
100mg |
$2.13 |
$2.23 |
| J1740 |
Ibandronate sodium |
1mg |
$139.04 |
$138.97 |
| J1742 |
Ibutilide fumarate injection |
1mg |
$319.51 |
$323.30 |
| J1745 |
Infliximab injection |
10mg |
$55.21 |
$55.04 |
| J1756 |
Iron sucrose injection |
1mg |
$0.37 |
$0.35 |
| J1785 |
Injection imiglucerase /unit |
1unit |
$3.92 |
$4.00 |
| J1790 |
Droperidol injection |
5mg |
$1.18 |
$1.32 |
| J1800 |
Propranolol injection |
1mg |
$3.27 |
$3.18 |
| J1815 |
Insulin injection |
5units |
$0.28 |
$0.28 |
| J1817 |
Insulin for insulin pump use |
50units |
$2.76 |
$2.84 |
| J1830 |
Interferon beta-1b / .25 MG |
0.25mg |
$116.23 |
$116.62 |
| J1835 |
Itraconazole injection |
50mg |
$40.28 |
$39.90 |
| J1940 |
Furosemide injection |
20mg |
$0.25 |
$0.19 |
| J1945 |
Lepirudin |
50mg |
$160.19 |
$161.01 |
| J1950 |
Leuprolide acetate /3.75 MG |
3.75mg |
$453.31 |
$441.65 |
| J1955 |
Inj levocarnitine per 1 gm |
1gm |
$5.74 |
$5.88 |
| J1956 |
Levofloxacin injection |
250mg |
$6.01 |
$5.87 |
| J1980 |
Hyoscyamine sulfate inj |
0.25mg |
$9.99 |
$9.29 |
| J2001 |
Lidocaine injection |
10mg |
$0.02 |
$0.02 |
| J2010 |
Lincomycin injection |
1-300mg |
$4.39 |
$4.26 |
| J2020 |
Linezolid injection |
200mg |
$26.72 |
$28.09 |
| J2060 |
Lorazepam injection |
2mg |
$0.95 |
$0.64 |
| J2150 |
Mannitol injection |
50ml |
$0.88 |
$0.85 |
| J2185 |
Meropenem |
100mg |
$3.77 |
$3.76 |
| J2210 |
Methylergonovin maleate inj |
0.2mg |
$5.04 |
$5.04 |
| J2250 |
Inj midazolam hydrochloride |
1mg |
$0.24 |
$0.15 |
| J2260 |
Inj milrinone lactate / 5 MG |
5mg |
$3.40 |
$4.55 |
| J2300 |
Inj nalbuphine hydrochloride |
10mg |
$1.18 |
$0.96 |
| J2310 |
Inj naloxone hydrochloride |
1mg |
$3.06 |
$3.16 |
| J2320 |
Nandrolone decanoate 50 MG |
50mg |
$4.71 |
$4.76 |
| J2321 |
Nandrolone decanoate 100 MG |
100mg |
$7.13 |
$7.13 |
| J2322 |
Nandrolone decanoate 200 MG |
200mg |
$18.84 |
$19.03 |
| J2353 |
Octreotide injection, depot |
1mg |
$101.71 |
$101.76 |
| J2354 |
Octreotide inj, non-depot |
25mcg |
$2.33 |
$2.21 |
| J2355 |
Oprelvekin injection |
5mg |
$249.02 |
$246.98 |
| J2370 |
Phenylephrine hcl injection |
1ml |
$0.67 |
$0.70 |
| J2400 |
Chloroprocaine hcl injection |
30ml |
$13.92 |
$12.72 |
| J2405 |
Ondansetron hcl injection |
1mg |
$0.28 |
$0.22 |
| J2410 |
Oxymorphone hcl injection |
1mg |
$2.27 |
$2.51 |
| J2430 |
Pamidronate disodium /30 MG |
30mg |
$29.63 |
$28.33 |
| J2440 |
Papaverin hcl injection |
60mg |
$0.45 |
$0.57 |
| J2501 |
Paricalcitol |
1mcg |
$3.80 |
$3.92 |
| J2505 |
Injection, pegfilgrastim 6mg |
6mg |
$2,191.41 |
$2,200.10 |
| J2510 |
Penicillin g procaine inj |
600,000units |
$10.32 |
$10.29 |
| J2515 |
Pentobarbital sodium inj |
50mg |
$7.69 |
$7.61 |
| J2543 |
Piperacillin/tazobactam |
1.125gm |
$5.08 |
$5.15 |
| J2550 |
Promethazine hcl injection |
1-50mg |
$1.52 |
$1.37 |
| J2560 |
Phenobarbital sodium inj |
120mg |
$3.62 |
$3.00 |
| J2590 |
Oxytocin injection |
10units |
$2.07 |
$2.05 |
| J2597 |
Inj desmopressin acetate |
1mcg |
$2.13 |
$1.87 |
| J2675 |
Inj progesterone per 50 MG |
50mg |
$1.58 |
$1.51 |
| J2680 |
Fluphenazine decanoate 25 MG |
25mg |
$2.11 |
$2.37 |
| J2690 |
Procainamide hcl injection |
1gm |
$2.65 |
$2.65 |
| J2700 |
Oxacillin sodium injection |
250mg |
$1.48 |
$1.58 |
| J2710 |
Neostigmine methylslfte inj |
0.5mg |
$0.08 |
$0.10 |
| J2730 |
Pralidoxime chloride inj |
1gm |
$88.94 |
$88.08 |
| J2760 |
Phentolaine mesylate inj |
5mg |
$24.00 |
$21.08 |
| J2765 |
Metoclopramide hcl injection |
10mg |
$0.40 |
$0.34 |
| J2770 |
Quinupristin/dalfopristin |
500mg |
$127.81 |
$127.97 |
| J2780 |
Ranitidine hydrochloride inj |
25mg |
$0.61 |
$0.74 |
| J2783 |
Rasburicase |
0.5mg |
$149.54 |
$150.29 |
| J2788 |
Rho d immune globulin 50 mcg |
50mcg |
$27.37 |
$28.43 |
| J2792 |
Rho(D) immune globulin h, sd |
100IU |
$15.65 |
$15.62 |
| J2795 |
Ropivacaine HCl injection |
1mg |
$0.07 |
$0.07 |
| J2810 |
Inj theophylline per 40 MG |
40mg |
$0.02 |
$0.03 |
| J2820 |
Sargramostim injection |
50mcg |
$24.57 |
$25.10 |
| J2916 |
Na ferric gluconate complex |
12.5mg |
$4.85 |
$4.79 |
| J2920 |
Methylprednisolone injection |
40mg |
$1.98 |
$2.07 |
| J2930 |
Methylprednisolone injection |
125mg |
$3.49 |
$3.02 |
| J2941 |
Somatropin injection |
1mg |
$49.24 |
$48.08 |
| J2993 |
Reteplase injection |
18.1mg |
$854.55 |
$833.74 |
| J2997 |
Alteplase recombinant |
1mg |
$34.37 |
$32.18 |
| J3010 |
Fentanyl citrate injection |
0.1mg |
$0.33 |
$0.28 |
| J3030 |
Sumatriptan succinate / 6 MG |
6mg |
$65.85 |
$66.61 |
| J3100 |
Tenecteplase injection |
50mg |
$1,977.98 |
$2,046.33 |
| J3105 |
Terbutaline sulfate inj |
1mg |
$2.52 |
$2.42 |
| J3120 |
Testosterone enanthate inj |
100mg |
$5.29 |
$5.29 |
| J3130 |
Testosterone enanthate inj |
1-200mg |
$10.28 |
$10.12 |
| J3230 |
Chlorpromazine hcl injection |
50mg |
$3.33 |
$3.22 |
| J3240 |
Thyrotropin injection |
0.9mg_1.1mg |
$839.58 |
$838.96 |
| J3246 |
Tirofiban hydrochloride |
0.25mg |
$7.57 |
$7.42 |
| J3250 |
Trimethobenzamide hcl inj |
200mg |
$4.45 |
$4.46 |
| J3260 |
Tobramycin sulfate injection |
80mg |
$1.73 |
$2.32 |
| J3265 |
Injection torsemide 10 mg/ml |
10mg |
$2.62 |
$2.18 |
| J3285 |
Treprostinil, 1 mg |
1mg |
$55.89 |
$55.89 |
| J3301 |
Triamcinolone acetonide inj |
10mg |
$1.50 |
$1.38 |
| J3315 |
Triptorelin pamoate |
3.75mg |
$146.72 |
$149.17 |
| J3360 |
Diazepam injection |
5mg |
$0.86 |
$0.79 |
| J3364 |
Urokinase 5000 IU injection |
5000I.U. |
$9.12 |
$9.16 |
| J3365 |
Urokinase 250,000 IU inj |
250,000I.U. |
$457.73 |
$457.73 |
| J3370 |
Vancomycin hcl injection |
500mg |
$3.45 |
$3.14 |
| J3396 |
Verteporfin injection |
0.1mg |
$9.12 |
$9.15 |
| J3410 |
Hydroxyzine hcl injection |
25mg |
$0.18 |
$0.14 |
| J3420 |
Vitamin b12 injection |
1000mcg |
$0.55 |
$0.25 |
| J3430 |
Vitamin k phytonadione inj |
1mg |
$3.62 |
$3.62 |
| J3465 |
Injection, voriconazole |
10mg |
$5.13 |
$5.24 |
| J3475 |
Inj magnesium sulfate |
500mg |
$0.13 |
$0.05 |
| J3480 |
Inj potassium chloride |
2meq |
$0.04 |
$0.01 |
| J3485 |
Zidovudine |
10mg |
$1.15 |
$1.17 |
| J3486 |
Ziprasidone mesylate |
10mg |
$5.09 |
$5.09 |
| J3487 |
Zoledronic acid |
1mg |
$208.76 |
$210.66 |
| J3488 |
Reclast injection |
1mg |
$216.61 |
$216.59 |
| J7030 |
Normal saline solution infus |
1000cc |
$1.20 |
$1.03 |
| J7040 |
Normal saline solution infus |
500ML |
$0.60 |
$0.52 |
| J7042 |
5% dextrose/normal saline |
500ML |
$0.45 |
$0.28 |
| J7050 |
Normal saline solution infus |
250cc |
$0.30 |
$0.26 |
| J7060 |
5% dextrose/water |
500ML |
$1.46 |
$1.09 |
| J7070 |
D5w infusion |
1000cc |
$2.92 |
$2.18 |
| J7100 |
Dextran 40 infusion |
500ml |
$15.15 |
$13.60 |
| J7110 |
Dextran 75 infusion |
500ml |
$11.13 |
$10.46 |
| J7120 |
Ringers lactate infusion |
1000cc |
$1.03 |
$0.91 |
| J7189 |
Factor viia recombinant |
1mcg |
$1.17 |
$1.19 |
| J7190 |
Factor viii |
1I.U. |
$0.78 |
$0.76 |
| J7192 |
Factor viii recombinant |
1I.U. |
$1.06 |
$1.08 |
| J7193 |
Factor IX non-recombinant |
1I.U. |
$0.90 |
$0.89 |
| J7194 |
Factor ix complex |
1I.U. |
$0.82 |
$0.80 |
| J7195 |
Factor IX recombinant |
1I.U. |
$1.06 |
$1.07 |
| J7197 |
Antithrombin iii injection |
1I.U. |
$1.91 |
$1.91 |
| J7198 |
Anti-inhibitor |
1I.U. |
$1.43 |
$1.43 |
| J7308 |
Aminolevulinic acid hcl top |
354mg |
$110.45 |
$109.74 |
| J7310 |
Ganciclovir long act implant |
4.5mg |
$4,770.00 |
$4,770.00 |
| J7321 |
Hyalgan or Supartz, inj |
PER DOSE |
$102.06 |
$101.24 |
| J7322 |
Synvisc, inj |
PER DOSE |
$178.16 |
$180.06 |
| J7323 |
Euflexxa, inj |
PER DOSE |
$110.87 |
$110.04 |
| J7324 |
Orthovisc, inj |
PER DOSE |
$171.37 |
$177.68 |
| J7330 |
Cultured chondrocytes implnt |
1dose |
$21,219.57 |
$21,847.78 |
| J7340 |
Metabolic active D/E tissue |
1cm2 |
$30.13 |
$30.17 |
| J7342 |
Metabolically active tissue |
1cm2 |
$36.73 |
$36.71 |
| J7500 |
Azathioprine oral 50mg |
50mg |
$0.26 |
$0.15 |
| J7501 |
Azathioprine parenteral |
100mg |
$48.54 |
$50.04 |
| J7502 |
Cyclosporine oral 100 mg |
100mg |
$3.51 |
$3.66 |
| J7504 |
Lymphocyte immune globulin |
250mg |
$377.06 |
$383.79 |
| J7505 |
Monoclonal antibodies |
5mg |
$987.06 |
$986.88 |
| J7506 |
Prednisone oral |
5mg |
$0.18 |
$0.04 |
| J7507 |
Tacrolimus oral per 1 MG |
1mg |
$3.87 |
$3.91 |
| J7509 |
Methylprednisolone oral |
4mg |
$0.06 |
$0.08 |
| J7511 |
Antithymocyte globuln rabbit |
25mg |
$342.29 |
$344.72 |
| J7513 |
Daclizumab, parenteral |
25mg |
$322.12 |
$315.68 |
| J7515 |
Cyclosporine oral 25 mg |
25mg |
$0.89 |
$0.90 |
| J7516 |
Cyclosporin parenteral 250mg |
250mg |
$19.53 |
$19.81 |
| J7517 |
Mycophenolate mofetil oral |
250mg |
$2.81 |
$2.91 |
| J7520 |
Sirolimus, oral |
1mg |
$7.58 |
$7.93 |
| J7525 |
Tacrolimus injection |
5mg |
$139.70 |
$140.03 |
| J7608 |
Acetylcysteine inh sol u d |
1gm |
$2.27 |
$1.73 |
| J7626 |
Budesonide inhalation sol |
0.25-0.50mg |
$5.09 |
$5.02 |
| J7631 |
Cromolyn sodium inh sol u d |
10mg |
$0.07 |
$0.06 |
| J7639 |
Dornase alpha inhal sol u d |
1mg |
$20.85 |
$20.87 |
| J7644 |
Ipratropium brom inh sol u d |
1mg |
$0.21 |
$0.20 |
| J7669 |
Metaproterenol inh sol u d |
10mg |
$0.27 |
$0.26 |
| J7682 |
Tobramycin inhalation sol |
300mg |
$61.00 |
$59.75 |
| J8510 |
Oral busulfan |
2mg |
$2.40 |
$2.50 |
| J8520 |
Capecitabine, oral, 150 mg |
150mg |
$4.59 |
$4.61 |
| J8521 |
Capecitabine, oral, 500 mg |
500mg |
$15.21 |
$15.29 |
| J8530 |
Cyclophosphamide oral 25 MG |
25mg |
$0.86 |
$0.82 |
| J8560 |
Etoposide oral 50 MG |
50mg |
$28.63 |
$29.55 |
| J8610 |
Methotrexate oral 2.5 MG |
2.5mg |
$0.21 |
$0.16 |
| J8700 |
Temozolomide |
5mg |
$7.69 |
$7.67 |
| J9000 |
Doxorubic hcl 10 MG vl chemo |
10mg |
$6.83 |
$4.75 |
| J9001 |
Doxorubicin hcl liposome inj |
10mg |
$412.25 |
$413.49 |
| J9010 |
Alemtuzumab injection |
10mg |
$550.74 |
$551.07 |
| J9015 |
Aldesleukin/single use vial |
pervial |
$796.36 |
$767.40 |
| J9017 |
Arsenic trioxide |
1mg |
$33.99 |
$34.48 |
| J9020 |
Asparaginase injection |
10,000units |
$54.78 |
$57.02 |
| J9031 |
Bcg live intravesical vac |
perinstallation |
$117.34 |
$113.75 |
| J9040 |
Bleomycin sulfate injection |
15units |
$35.88 |
$29.02 |
| J9045 |
Carboplatin injection |
50mg |
$7.05 |
$6.31 |
| J9050 |
Carmus bischl nitro inj |
200mg |
$153.79 |
$156.83 |
| J9060 |
Cisplatin 10 MG injection |
10mg |
$2.55 |
$2.27 |
| J9062 |
Cisplatin 50 MG injection |
50mg |
$12.75 |
$11.32 |
| J9065 |
Inj cladribine per 1 MG |
1mg |
$33.66 |
$30.63 |
| J9090 |
Cyclophosphamide 500 MG inj |
500mg |
$17.06 |
$9.36 |
| J9091 |
Cyclophosphamide 1.0 grm inj |
1gm |
$18.90 |
$18.71 |
| J9092 |
Cyclophosphamide 2.0 grm inj |
2gm |
$37.79 |
$37.43 |
| J9097 |
Cyclophosphamide lyophilized |
2gm |
$38.54 |
$37.17 |
| J9100 |
Cytarabine hcl 100 MG inj |
100mg |
$1.93 |
$1.20 |
| J9110 |
Cytarabine hcl 500 MG inj |
500mg |
$9.66 |
$6.02 |
| J9120 |
Dactinomycin actinomycin d |
0.5mg |
$493.43 |
$493.43 |
| J9140 |
Dacarbazine 200 MG inj |
200mg |
$11.16 |
$9.21 |
| J9150 |
Daunorubicin |
10mg |
$19.95 |
$17.14 |
| J9151 |
Daunorubicin citrate liposom |
10mg |
$56.03 |
$56.06 |
| J9160 |
Denileukin diftitox, 300 mcg |
300mcg |
$1,410.81 |
$1,410.03 |
| J9170 |
Docetaxel |
20mg |
$319.42 |
$325.85 |
| J9175 |
Elliotts b solution per ml |
1ml |
$4.07 |
$4.07 |
| J9178 |
Inj, epirubicin hcl, 2 mg |
2mg |
$11.45 |
$6.24 |
| J9181 |
Etoposide 10 MG inj |
10mg |
$0.42 |
$0.40 |
| J9182 |
Etoposide 100 MG inj |
100mg |
$4.16 |
$4.03 |
| J9185 |
Fludarabine phosphate inj |
50mg |
$237.51 |
$200.75 |
| J9190 |
Fluorouracil injection |
500mg |
$1.81 |
$1.87 |
| J9200 |
Floxuridine injection |
500mg |
$56.49 |
$51.12 |
| J9201 |
Gemcitabine HCl |
200mg |
$131.65 |
$131.78 |
| J9202 |
Goserelin acetate implant |
3.6mg |
$191.86 |
$189.73 |
| J9206 |
Irinotecan injection |
20mg |
$126.31 |
$126.24 |
| J9208 |
Ifosfomide injection |
1gm |
$35.55 |
$37.92 |
| J9209 |
Mesna injection |
200mg |
$7.90 |
$7.87 |
| J9211 |
Idarubicin hcl injection |
5mg |
$290.42 |
$276.07 |
| J9212 |
Interferon alfacon-1 |
1mcg |
$4.66 |
$4.80 |
| J9213 |
Interferon alfa-2a inj |
3millionunits |
$41.80 |
$40.92 |
| J9214 |
Interferon alfa-2b inj |
1millionunits |
$14.28 |
$14.16 |
| J9216 |
Interferon gamma 1-b inj |
3millionunits |
$309.58 |
$309.58 |
| J9217 |
Leuprolide acetate suspnsion |
7.5mg |
$242.79 |
$220.86 |
| J9218 |
Leuprolide acetate injection |
1mg |
$7.75 |
$7.47 |
| J9219 |
Leuprolide acetate implant |
65mg |
$1,714.87 |
$1,608.17 |
| J9230 |
Mechlorethamine hcl inj |
10mg |
$144.44 |
$144.44 |
| J9245 |
Inj melphalan hydrochl 50 MG |
50mg |
$1,563.63 |
$1,563.63 |
| J9250 |
Methotrexate sodium inj |
5mg |
$0.26 |
$0.21 |
| J9260 |
Methotrexate sodium inj |
50mg |
$2.74 |
$0.26 |
| J9263 |
Oxaliplatin |
0.5mg |
$9.47 |
$9.49 |
| J9265 |
Paclitaxel injection |
30mg |
$13.58 |
$11.95 |
| J9268 |
Pentostatin injection |
10mg |
$1,858.68 |
$1,828.92 |
| J9280 |
Mitomycin 5 MG inj |
5mg |
$15.06 |
$13.05 |
| J9290 |
Mitomycin 20 MG inj |
20mg |
$60.26 |
$52.19 |
| J9291 |
Mitomycin 40 MG inj |
40mg |
$120.51 |
$104.38 |
| J9293 |
Mitoxantrone hydrochl / 5 MG |
5mg |
$105.14 |
$88.70 |
| J9300 |
Gemtuzumab ozogamicin |
5mg |
$2,434.95 |
$2,428.97 |
| J9310 |
Rituximab cancer treatment |
100mg |
$508.66 |
$520.57 |
| J9320 |
Streptozocin injection |
1gm |
$157.94 |
$190.64 |
| J9340 |
Thiotepa injection |
15mg |
$41.21 |
$40.40 |
| J9350 |
Topotecan |
4mg |
$875.46 |
$898.54 |
| J9355 |
Trastuzumab |
10mg |
$59.02 |
$60.08 |
| J9360 |
Vinblastine sulfate inj |
1mg |
$1.07 |
$1.07 |
| J9370 |
Vincristine sulfate 1 MG inj |
1mg |
$7.73 |
$7.02 |
| J9375 |
Vincristine sulfate 2 MG inj |
2mg |
$15.46 |
$14.04 |
| J9380 |
Vincristine sulfate 5 MG inj |
5mg |
$38.66 |
$35.09 |
| J9390 |
Vinorelbine tartrate/10 mg |
20mg |
$18.86 |
$16.22 |
| J9395 |
Injection, Fulvestrant |
25mg |
$81.37 |
$81.36 |
| J9600 |
Porfimer sodium |
75mg |
$2,556.53 |
$2,503.55 |
| Q0167 |
Dronabinol 2.5mg oral |
2.5mg |
$4.88 |
$5.42 |
| Q0168 |
Dronabinol 5mg oral |
5mg |
$10.98 |
$10.84 |