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Home , Arbutamine, Thiethylperazine, Triamcinolone diacetate

Procedure Code Procedure Description Long

RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN (RSV-IGIM), 90378 FOR INTRAMUSCULAR USE, 50 MG, EACH INDIUM IN-111 IBRITUMOMAB TIUXETAN, DIAGNOSTIC, PER A9542 STUDY DOSE, UP TO 5 MILLICURIES YTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAPEUTIC, PER A9543 TREATMENT DOSE, UP TO 40 MILLICURIES

A9544 IODINE I-131 TOSITUMOMAB, DIAGNOSTIC, PER STUDY DOSE IODINE I-131 TOSITUMOMAB, THERAPEUTIC, PER TREATMENT A9545 DOSE RADIOPHARMACEUTICAL, THERAPEUTIC, NOT OTHERWISE A9699 CLASSIFIED J0120 INJECTION, TETRACYCLINE, UP TO 250 MG J0128 INJECTION, ABARELIX, 10 MG INJECTION, ABATACEPT, 10 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS J0129 SELF ADMINISTERED) J0130 INJECTION ABCIXIMAB, 10 MG

J0132 INJECTION, ACETYLCYSTEINE, 100 MG J0133 INJECTION, ACYCLOVIR, 5 MG J0135 INJECTION, ADALIMUMAB, 20 MG INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, J0150 INSTEAD USE A9270) INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, L0151 INSTEAD USE A9270) INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS; J0152 INSTEAD USE A9270) J0170 INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE J0171 INJECTION, ADRENALIN, EPINEPHRINE, 0.1 MG J0178 INJECTION, AFLIBERCEPT, 1 MG J0180 INJECTION, AGALSIDASE J0190 INJECTION, BIPERIDEN LACTATE, PER 5 MG J0200 INJECTION, ALATROFLOXACIN MESYLATE, 100 MG J0205 INJECTION, ALGLUCERASE, PER 10 UNITS J0207 INJECTION, AMIFOSTINE, 500 MG J0210 INJECTION, METHYLDOPATE HCL, UP TO 250 MG J0215 INJECTION, ALEFACEPT, 0.5 MG J0220 INJECTION,AGLUCOSIDASE ALFA, 10MG J0221 INJECTION, ALGLUCOSIDASE ALFA, (LUMIZYME), 10 MG

J0256 INJECTION, ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MG INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), J0257 (GLASSIA), 10 MG J0278 INJECTION, AMIKACIN SULFATE, 100 MG J0280 INJECTION, AMINOPHYLLIN, UP TO 250 MG J0282 INJECTION, AMIODARONE HYDROCHLORIDE, 30 MG J0285 INJECTION, AMPHOTERICIN B, 50 MG J0287 INJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MG INJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, J0288 10 MG J0289 INJECTION, AMPHOTERICIN B LIPOSOME, 10 MG J0290 INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 J0295 GM J0300 INJECTION, AMOBARBITAL, UP TO 125 MG J0330 INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG J0348 INJECTION, ANADULAFUNGIN, 1 MG J0350 INJECTION, ANISTREPLASE, PER 30 UNITS J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG J0364 INJECTION, HYDROCHLORIDE, 1 MG J0365 INJECTION, APROTONIN, 10,000 KIU J0380 INJECTION, BITARTRATE, PER 10 MG J0390 INJECTION, CHLOROQUINE HYDROCHLORIDE, UP TO 250 MG J0395 INJECTION, ARBUTAMINE HCL, 1 MG J0400 INJECTION, , INTRAMUSCULAR, 0.25 MG J0401 INJECTION, ARIPIPRAZOLE, EXTENDED RELEASE, 1 MG J0456 INJECTION, AZITHROMYCIN, 500 MG J0460 INJECTION, SULFATE, UP TO 0.3 MG J0461 INJECTION, ATROPINE SULFATE, 0.01 MG J0470 INJECTION, DIMERCAPROL, PER 100 MG J0475 INJECTION, BACLOFEN, 10 MG J0476 INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL J0480 INJECTION, BASILIXIMAB, 20 MG J0485 INJECTION, BELATACEPT, 1 MG J0490 INJECTION, BELIMUMAB, 10 MG J0500 INJECTION, DICYCLOMINE HCL, UP TO 20 MG J0515 INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR J0520 URECHOLINE, UP TO 5 MG INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G J0530 PROCAINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G J0540 PROCAINE, UP TO 1,200,000 UNITS INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G J0550 PROCAINE, UP TO 2,400,000 UNITS INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G J0558 PROCAINE, 100,000 UNITS INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G J0559 PROCAINE, 2500 UNITS J0560 INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS J0561 INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS

J0570 INJECTION, PENICILLIN G BENZATHINE, UP TO 1,200,000 UNITS

J0580 INJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 UNITS J0583 INJECTION, BIVALIRUDIN, 1 MG J0585 BOTULINUM TOXIN TYPE A, PER UNIT J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS J0587 BOTULINUM TOXIN TYPE B, PER 100 UNITS J0588 INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG J0594 INJECTION, BUSULFAN, 1 MG J0595 INJECTION, BUTORPHANOL TARTRATE, 1 MG INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 J0597 UNITS INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 J0598 UNITS J0600 INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM J0620 LACTATE, PER 10 ML J0630 INJECTION, CALCITONIN SALMON, UP TO 400 UNITS J0636 INJECTION, CALCITRIOL, 0.1 MCG J0637 INJECTION, CASPOFUNGIN ACETATE, 5 MG J0638 INJECTION, CANAKINUMAB, 1 MG J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG J0641 LEVOLEUCOVORIN INJECTION J0670 INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML J0690 INJECTION, CEFAZOLIN SODIUM, 500 MG J0692 INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG J0694 INJECTION, CEFOXITIN SODIUM, 1 GM J0696 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG J0697 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG J0698 INJECTION, CEFOTAXIME SODIUM, PER GM INJECTION, ACETATE 3MG AND J0702 BETAMETHASONE SODIUM PHOSPHATE 3MG

J0704 INJECTION, BETAMETHASONE SODIUM PHOSPHATE, PER 4 MG J0706 INJECTION, CITRATE, 5MG J0710 INJECTION, CEPHAPIRIN SODIUM, UP TO 1 GM J0712 INJECTION, CEFTAROLINE FOSAMIL, 10 MG J0713 INJECTION, CEFTAZIDIME, PER 500 MG J0715 INJECTION, CEFTIZOXIME SODIUM, PER 500 MG INJECTION, CENTRUROIDES IMMUNE F(AB)2, UP TO 120 J0716 MILLIGRAMS INJECTION, CERTOLIZUMAB PEGOL, 1 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS J0717 SELF ADMINISTERED) J0718 INJECTION, CERTOLIZUMAB PEGOL, 1 MG INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 J0720 GM

J0725 INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS J0735 INJECTION, HYDROCHLORIDE, 1 MG J0740 INJECTION, CIDOFOVIR, 375 MG J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, FOR INTRAVENOUS INFUSION, 200 J0744 MG J0745 INJECTION, CODEINE PHOSPHATE, PER 30 MG J0760 INJECTION, COLCHICINE, PER 1MG J0770 INJECTION,, COLISTIMETHATE , SODIUM, UP TO 150 MG , J0775 MG J0780 INJECTION, , UP TO 10 MG J0795 INJECTION, CORTICORELIN OVINE TRIFLUTATE, 1 MICROGRAM J0800 INJECTION, CORTICOTROPIN, UP TO 40 UNITS

J0833 INJECTION, COSYNTROPIN, NOT OTHERWISE SPECIFIED, 0.25 MG J0834 INJECTION, COSYNTROPIN (CORTROSYN), 0.25 MG J0835 INJECTION, COSYNTROPIN, PER 0.25 MG INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN J0850 INTRAVENOUS (HUMAN), PER VIAL J0878 INJECTION, DAPTOMYCIN, 1 MG

J0881 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON J0882 DIALYSIS)

J0885 INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS

J0886 INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS) J0894 INJECTION, DECITABINE, 1 MG J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG J0897 INJECTION, DENOSUMAB, 1 MG INJECTION, TESTOSTERONE ENANTHATE AND ESTRADIOL J0900 VALERATE, UP TO 1 CC J0945 INJECTION, MALEATE, PER 10 MG J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 MG J1000 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG J1020 INJECTION, ACETATE, 20 MG J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG J1050 INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG J1051 INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG INJECTION, MEDROXYPROGESTERONE ACETATE FOR J1055 CONTRACEPTIVE USE, 150 MG INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL J1056 CYPIONATE, 5MG / 25MG INJECTION, TESTOSTERONE CYPIONATE AND ESTRADIOL J1060 CYPIONATE, UP TO 1 ML J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG J1094 INJECTION, ACETATE, 1 MG J1100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG J1110 INJECTION, MESYLATE, PER 1 MG J1120 INJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MG J1160 INJECTION, DIGOXIN, UP TO 0.5 MG J1162 INJECTION, DIGOXIN IMMUNE FAB (OVINE), PER VIAL J1165 INJECTION, PHENYTOIN SODIUM, PER 50 MG J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG J1180 INJECTION, DYPHYLLINE, UP TO 500 MG J1190 INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG J1200 INJECTION, HCL, UP TO 50 MG J1205 INJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MG J1212 INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML J1230 INJECTION, METHADONE HCL, UP TO 10 MG J1240 INJECTION, , UP TO 50 MG J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG J1250 INJECTION, HYDROCHLORIDE, PER 250 MG J1260 INJECTION, MESYLATE, 10 MG J1267 INJECTION, DORIPENEM, 10 MG J1270 INJECTION, DOXERCALCIFEROL, 1 MCG J1290 INJECTION, ECALLANTIDE, 1 MG J1300 INJECTION, ECULIZUMAB, 10 MG J1320 INJECTION, HCL, UP TO 20 MG J1324 INJECTION, ENFUVIRTIDE, 1 MG J1327 INJECTION, EPTIFIBATIDE, 5 MG J1330 INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG J1335 INJECTION, ERTAPENEM SODIUM, 500 MG J1364 INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG J1380 INJECTION, ESTRADIOL VALERATE, UP TO 10 MG J1390 INJECTION, ESTRADIOL VALERATE, UP TO 20 MG J1410 INJECTION, ESTROGEN CONJUGATED, PER 25 MG J1430 INJECTION, ETHANOLAMINE OLEATE, 100 MG J1435 INJECTION, ESTRONE, PER 1 MG J1436 INJECTION, ETIDRONATE DISODIUM, PER 300 MG INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS J1438 SELF ADMINISTERED) J1440 INJECTION, FILGRASTIM (G-CSF), 300 MCG J1441 INJECTION, FILGRASTIM (G-CSF), 480 MCG J1442 INJECTION, FILGRASTIM (G-CSF), 1 MICROGRAM J1446 INJECTION, TBO-FILGRASTIM, 5 MICROGRAMS J1450 INJECTION FLUCONAZOLE, 200 MG J1451 INJECTION, FOMEPIZOLE, 15 MG J1452 INJECTION, FOMIVIRSEN SODIUM, INTRAOCULAR, 1.65 MG J1453 INJECTION J1455 INJECTION, FOSCARNET SODIUM, PER 1000 MG J1457 INJECTION, GALLIUM NITRATE, 1 MG J1458 INJECTION, GALSULFASE, 1 MG J1459 INJ IVIG PRIVIGEN 500 MG J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC J1470 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC J1480 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC J1490 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC J1500 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC J1510 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC J1520 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC J1530 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC J1540 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC J1550 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX), INTRAVENOUS, J1557 NON-LYOPHILIZED (E.G. LIQUID), 500 MG J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG

J1560 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC INJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, J1561 NON-LYOPHILIZED (E.G. LIQUID), 500 MG J1562 INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG INJECTION, RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN, J1565 INTRAVENOUS, 50 MG

INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED J1566 (E.G. POWDER), NOT OTHERWISE SPECIFIED, 500 MG INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, J1568 NON-LYOPHILIZED (E.G. LIQUID), 500 MG INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), J1569 INTRAVENOUS, NON-LYOPHILIZED, (E.G. LIQUID), 500 MG J1570 INJECTION, GANCICLOVIR SODIUM, 500 MG INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), J1573 INTRAVENOUS, 0.5 ML J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG J1590 INJECTION, GATIFLOXACIN, 10MG J1595 INJECTION, GLATIRAMER ACETATE, 20 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON- J1599 LYOPHILIZED (E.G. LIQUID), NOT OTHERWISE SPECIFIED, 500 MG J1600 INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG J1602 INJECTION, GOLIMUMAB, 1 MG, FOR INTRAVENOUS USE J1610 INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG J1620 INJECTION, GONADORELIN HYDROCHLORIDE, PER 100 MCG J1626 INJECTION, HYDROCHLORIDE, 100 MCG J1630 INJECTION, , UP TO 5 MG J1631 INJECTION, ,50MG J1640 INJECTION, HEMIN, 1 MG J1644 INJECTION, HEPARIN SODIUM, PER 1000 UNITS J1645 INJECTION, DALTEPARIN SODIUM, PER 2500 IU J1650 INJECTION, ENOXAPARIN SODIUM, 10 MG J1655 INJECTION, TINZAPARIN SODIUM, 1000 IU INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 J1670 UNITS J1675 INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS J1700 INJECTION, ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 J1710 MG INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 J1720 MG J1730 INJECTION, DIAZOXIDE, UP TO 300 MG J1740 INJECTION, IBANDRONATE SODIUM, 1MG J1741 INJECTION, IBUPROFREN, 100 MG J1742 INJECTION, IBUTILIDE FUMARATE, 1 MG J1743 INJECTION, IDURSULFASE, 1 MG J1744 INJECTION, ICATIBANT, 1 MG J1745 INJECTION INFLIXIMAB, 10 MG J1750 INJ IRON DEXTRAN J1756 INJECTION, IRON SUCROSE, 1 MG J1785 INJECTION, IMIGLUCERASE, PER UNIT J1786 INJECTION, IMIGLUCERASE, 10 UNITS J1790 INJECTION, , UP TO 5 MG J1800 INJECTION, HCL, UP TO 1 MG INJECTION, DROPERIDOL AND FENTANYL CITRATE, UP TO 2 ML J1810 AMPULE J1815 INJECTION, INSULIN, PER 5 UNITS INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN J1817 PUMP) PER 50 UNITS J1825 INJECTION, INTERFERON BETA-1A, 33 MCG J1826 INJECTION, INTERFERON BETA-1A, 30 MCG INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS J1830 SELF ADMINISTERED) J1835 INJECTION, , 50 MG J1840 INJECTION, KANAMYCIN SULFATE, UP TO 500 MG J1850 INJECTION, KANAMYCIN SULFATE, UP TO 75 MG J1885 INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG J1890 INJECTION, CEPHALOTHIN SODIUM, UP TO 1 GRAM J1930 INJECTION, HCL,UP TO 20 MG J1931 INJECTION, LARONIDASE, 0.1 MG J1940 INJECTION, FUROSEMIDE, UP TO 20 MG J1945 INJECTION, LEPIRUDIN, 50 MG INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER J1950 3.75 MG J1953 LEVETIRACETAM INJECTION J1955 INJECTION, LEVOCARNITINE, PER 1 GM J1956 INJECTION, LEVOFLOXACIN, 250 MG J1960 INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG J1980 INJECTION, SULFATE, UP TO 0.25 MG J1990 INJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MG

J2001 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG J2010 INJECTION, LINCOMYCIN HCL, UP TO 300 MG J2020 INJECTION, LINEZOLID, 200MG J2060 INJECTION, , 2 MG J2150 INJECTION, MANNITOL, 25% IN 50 ML J2175 INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG

J2180 INJECTION, MEPERIDINE AND HCL, UP TO 50 MG J2185 INJECTION, MEROPENEM, 100 MG J2210 INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG J2212 INJECTION, METHYLNALTREXONE, 0.1 MG J2248 INJECTION, MICAFUNGIN SODIUM, 1 MG J2250 INJECTION, HYDROCHLORIDE, PER 1 MG J2260 INJECTION, LACTATE, 5 MG J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG J2271 INJECTION, MORPHINE SULFATE, 100MG INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE J2275 SOLUTION), PER 10 MG J2278 INJECTION, ZICONOTIDE, 1 MICROGRAM J2280 INJECTION, MOXIFLOXACIN, 100MG J2300 INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG J2310 INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG J2315 INJECTION, NALTREXONE, DEPOT FORM, 1 MG J2320 INJECTION, NANDROLONE DECANOATE, UP TO 50 MG J2321 INJECTION, NANDROLONE DECANOATE, UP TO 100 MG J2322 INJECTION, NANDROLONE DECANOATE, UP TO 200 MG J2323 INJECTION, NATALIZUMAB, 1 MG J2325 INJECTION, NESIRITIDE, 0.1 MG INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR J2353 INJECTION, 1 MG INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR J2354 SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG J2355 INJECTION, OPRELVEKIN, 5 MG J2357 INJECTION, OMALIZUMAB, 5 MG J2358 INJECTION, , LONG-ACTING, 1 MG J2360 INJECTION, CITRATE, UP TO 60 MG J2370 INJECTION, HCL, UP TO 1 ML J2400 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML J2405 INJECTION, HYDROCHLORIDE, PER 1 MG J2410 INJECTION, OXYMORPHONE HCL, UP TO 1 MG J2425 INJECTION, PALIFERMIN, 50 MICROGRAMS

J2426 INJECTION, PALMITATE EXTENDED RELEASE, 1 MG J2430 INJECTION, PAMIDRONATE DISODIUM, PER 30 MG J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG J2460 INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG J2469 INJECTION, HCL, 25 MCG J2501 INJECTION, PARICALCITOL, 1 MCG J2503 INJECTION, PEGAPTANIB SODIUM, 0.3 MG J2504 INJECTION, PEGADEMASE BOVINE, 25 IU J2505 INJECTION, PEGFILGRASTIM, 6 MG J2507 INJECTION, PEGLOTICASE, 1 MG INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 J2510 UNITS J2513 INJECTION, PENTASTARCH, 10% SOLUTION, 100 ML J2515 INJECTION, PENTOBARBITAL SODIUM, PER 50 MG J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 J2543 GRAM/0.125 GRAMS (1.125 GRAMS)

PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA- APPROVED FINAL PRODUCT, NON-COMPOUNDED, J2545 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG J2560 INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG J2562 INJECTION, PLERIXAFOR, 1 MG J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS J2597 INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG J2650 INJECTION, ACETATE, UP TO 1 ML J2670 INJECTION, HCL, UP TO 25 MG J2675 INJECTION, , PER 50 MG J2680 INJECTION, DECANOATE, UP TO 25 MG J2690 INJECTION, PROCAINAMIDE HCL, UP TO 1 GM J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 MG J2710 INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG J2720 INJECTION, PROTAMINE SULFATE, PER 10 MG INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, J2724 10 IU J2725 INJECTION, PROTIRELIN, PER 250 MCG J2730 INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM J2760 INJECTION, MESYLATE, UP TO 5 MG J2765 INJECTION, HCL, UP TO 10 MG

J2770 INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350) J2778 INJECTION, RANIBIZUMAB, 0.1 MG J2780 INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG J2783 INJECTION, RASBURICASE, 0.5 MG J2785 REGADENOSON INJECTION INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 J2788 MCG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 J2790 MCG INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), J2791 (RHOPHYLAC), INTRAMUSCULAR OR INTRAVENOUS, 100 IU INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, J2792 SOLVENT DETERGENT, 100 IU J2793 INJECTION, RILONACEPT, 1 MG J2794 J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG J2796 INJECTION, ROMIPLOSTIM, 10 MICROGRAMS J2800 INJECTION, METHOCARBAMOL, UP TO 10 ML J2810 INJECTION, , PER 40 MG J2820 INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG J2850 INJECTION, SECRETIN, SYNTHETIC, HUMAN J2910 INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE J2916 INJECTION, 12.5 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO J2920 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO J2930 125 MG J2950 INJECTION, HCL, UP TO 25 MG J2993 INJECTION, RETEPLASE, 18.1 MG J2995 INJECTION, STREPTOKINASE, PER 250,000 IU J2997 INJECTION, ALTEPLASE RECOMBINANT, 1 MG J3000 INJECTION, STREPTOMYCIN, UP TO 1 GM J3010 INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN J3030 DRUG IS SELF ADMINISTERED) J3060 INJECTION, TALIGLUCERACE ALFA, 10 UNITS J3070 INJECTION, PENTAZOCINE, 30 MG J3095 INJECTION, TELAVANCIN, 10 MG J3101 TENECTEPLASE INJECTION J3105 INJECTION, SULFATE, UP TO 1 MG J3110 INJECTION, TERIPARATIDE, 10MCG J3120 INJECTION, TESTOSTERONE ENANTHATE, UP TO 100 MG J3130 INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG J3140 INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG J3150 INJECTION, TESTOSTERONE PROPIONATE, UP TO 100 MG J3230 INJECTION, HCL, UP TO 50 MG INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG J3240 VIAL J3243 INJECTION, TIGECYCLINE, 1 MG J3246 INJECTION, TIROFIBAN HCL, 0.25MG J3250 INJECTION, HCL, UP TO 200 MG J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG J3262 INJECTION, TOCILIZUMAB, 1 MG J3265 INJECTION, TORSEMIDE, 10 MG/ML J3280 INJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MG J3285 INJECTION, TREPROSTINIL, 1 MG J3300 INJECTION, , UP TO 40 MG INJECTION, , NOT OTHERWISE J3301 SPECIFIED, 10 MG J3302 INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG J3303 INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG J3305 INJECTION, TRIMETREXATE GLUCURONATE, PER 25 MG J3310 INJECTION, , UP TO 5 MG J3315 INJECTION, TRIPTORELIN PAMOATE, 3.75 MG

J3320 INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GM J3350 INJECTION, UREA, UP TO 40 GM J3357 INJECTION, USTEKINUMAB, 1 MG J3360 INJECTION, DIAZEPAM, UP TO 5 MG J3364 INJECTION, UROKINASE, 5000 IU VIAL J3365 INJECTION, IV, UROKINASE, 250,000 I.U. VIAL J3370 INJECTION, VANCOMYCIN HCL, 500 MG J3385 INJECTION, VELAGLUCERASE ALFA, 100 UNITS J3396 INJECTION, VERTEPORFIN, 0.1 MG J3400 INJECTION, HCL, UP TO 20 MG J3410 INJECTION, HCL, UP TO 25 MG J3411 INJECTION, THIAMINE HCL, 100 MG

J3420 INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG J3430 INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG J3465 INJECTION, VORICONAZOLE, 10 MG J3470 INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1 J3471 USP UNIT (UP TO 999 USP UNITS) INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER J3472 1000 USP UNITS J3475 INJECTION, MAGNESIUM SULFATE, PER 500 MG J3480 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ J3485 INJECTION, ZIDOVUDINE, 10 MG J3486 INJECTION, MESYLATE, 10 MG J3487 INJECTION, ZOLEDRONIC ACID (ZOMETA), 1 MG J3488 INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG J3489 INJECTION, ZOLEDRONIC ACID, 1 MG J3490 UNCLASSIFIED DRUGS J3520 EDETATE DISODIUM, PER 150 MG J3535 DRUG ADMINISTERED THROUGH A METERED DOSE INHALER J3590 UNCLASSIFIED BIOLOGICS J7030 INFUSION, NORMAL SALINE SOLUTION , 1000 CC

J7040 INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT) J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) J7050 INFUSION, NORMAL SALINE SOLUTION , 250 CC J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) J7070 INFUSION, D5W, 1000 CC J7100 INFUSION, DEXTRAN 40, 500 ML J7110 INFUSION, DEXTRAN 75, 500 ML J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC J7130 HYPERTONIC SALINE SOLUTION, 50 OR 100 MEQ, 20 CC VIAL J7131 HYPERTONIC SALINE SOLUTION, 1 ML J7178 INJECTION, HUMAN FIBRINOGEN CONCENTRATE, 1 MG INJECTION, FACTOR XIII (ANTIHEMOPHILIC FACTOR, HUMAN), 1 J7180 I.U. INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), J7183 WILATE, 1 I.U. VWF:RCO INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), J7184 WILATE, PER 100 IU VWF:RCO INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, J7185 RECOMBINANT) (XYNTHA), PER I.U. J7186 ANTIHEMOPHILIC VIII/VWF COMP INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), J7187 PER IU VWF:RCO FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 J7189 MICROGRAM J7190 FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.

J7191 FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U. FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., J7192 NOT OTHERWISE SPECIFIED FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON- J7193 RECOMBINANT) PER I.U. J7194 FACTOR IX, COMPLEX, PER I.U.

J7195 FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U. J7197 ANTITHROMBIN III (HUMAN), PER I.U. J7198 ANTI-INHIBITOR, PER I.U. J7199 HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED J7300 INTRAUTERINE COPPER CONTRACEPTIVE LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE J7301 SYSTEM (SKYLA), 13.5 MG LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE J7302 SYSTEM, 52 MG CONTRACEPTIVE SUPPLY, HORMONE CONTAINING VAGINAL J7303 RING, EACH

J7304 CONTRACEPTIVE SUPPLY, HORMONE CONTAINING PATCH, EACH LEVONORGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, J7306 INCLUDING IMPLANTS AND SUPPLIES (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING J7307 IMPLANT AND SUPPLIES

AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, J7308 20%, SINGLE UNIT DOSAGE FORM (354 MG) J7310 GANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANT

J7311 ACETONIDE, INTRAVITREAL IMPLANT

J7312 INJECTION, DEXAMETHASONE, INTRAVITREAL IMPLANT, 0.1 MG J7316 INJECTION, OCRIPLASMIN, 0.125 MG J7335 CAPSAICIN 8% PATCH, PER 10 SQUARE CENTIMETERS LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, J7504 EQUINE, PARENTERAL, 250 MG J7505 MUROMONAB-CD3, PARENTERAL, 5 MG J7507 TACROLIMUS, ORAL, PER 1 MG J7508 TACROLIMUS, EXTENDED RELEASE, ORAL, 0.1 MG J7509 METHYLPREDNISOLONE ORAL, PER 4 MG J7510 PREDNISOLONE ORAL, PER 5 MG LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, J7511 RABBIT, PARENTERAL, 25MG J7513 DACLIZUMAB, PARENTERAL, 25 MG J7515 CYCLOSPORINE, ORAL, 25 MG J7516 CYCLOSPORIN, PARENTERAL, 250 MG J7517 MYCOPHENOLATE MOFETIL, ORAL, 250 MG J7520 SIROLIMUS, ORAL, 1 MG J7525 TACROLIMUS, PARENTERAL, 5 MG J7527 EVEROLIMUS, ORAL, 0.25 MG J7599 IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J7604 PER GRAM , INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, J7605 UNIT DOSE FORM, 15 MICROGRAMS ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH J7608 DME, UNIT DOSE FORM, PER GRAM J7611 ALBUTEROL NON-COMP CON J7612 LEVALBUTEROL NON-COMP CON J7613 ALBUTEROL NON-COMP UNIT J7614 LEVALBUTEROL NON-COMP UNIT ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, J7620 ADMINISTERED THROUGH DME BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J7622 PER MILLIGRAM BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J7624 PER MILLIGRAM , INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, J7626 UNIT DOSE FORM, UP TO 0.5 MG BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J7627 UP TO 0.5 MG MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED J7628 FORM, PER MILLIGRAM BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J7629 PER MILLIGRAM

CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED J7631 THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER J7635 MILLIGRAM ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER J7636 MILLIGRAM DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED J7637 FORM, PER MILLIGRAM DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J7638 PER MILLIGRAM DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, J7639 UNIT DOSE FORM, PER MG , INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 12 J7640 MICROGRAMS

FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, J7641 ADMINISTERED THROUGH DME, UNIT DOSE, PER MILLIGRAM GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED J7642 FORM, PER MILLIGRAM GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J7643 PER MILLIGRAM IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA- APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER J7644 MILLIGRAM ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED J7648 THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED J7649 THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED J7658 THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM

ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED J7659 THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM J7665 MANNITOL, ADMINISTERED THROUGH AN INHALER, 5 MG METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA- APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 10 J7668 MILLIGRAMS METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA- APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 J7669 MILLIGRAMS METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION J7674 SOLUTION THROUGH A NEBULIZER, PER 1 MG TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED J7680 FORM, PER MILLIGRAM TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J7681 PER MILLIGRAM TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, UNIT DOSE FORM, J7682 ADMINISTERED THROUGH DME, PER 300 MILLIGRAMS TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED J7683 FORM, PER MILLIGRAM TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J7684 PER MILLIGRAM TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, J7686 UNIT DOSE FORM, 1.74 MG NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH J7699 DME NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED J7799 THROUGH DME DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE J8498 SPECIFIED J8501 , ORAL, 5 MG J8510 BUSULFAN; ORAL, 2 MG J8515 , ORAL, 0.25 MG J8520 CAPECITABINE, ORAL, 150 MG J8521 CAPECITABINE, ORAL, 500 MG J8530 CYCLOPHOSPHAMIDE; ORAL, 25 MG J8540 DEXAMETHASONE, ORAL, 0.25 MG J8560 ETOPOSIDE; ORAL, 50 MG J8561 EVEROLIMUS, ORAL, 0.25 MG J8562 FLUDARABINE PHOSPHATE, ORAL, 10 MG J8597 ANTIEMETIC DRUG, ORAL, NOT OTHERWISE SPECIFIED J8600 MELPHALAN; ORAL, 2 MG J8610 METHOTREXATE; ORAL, 2.5 MG J8650 , ORAL, 1 MG J8700 TEMOZOLMIDE, ORAL, 5 MG J8705 TOPOTECAN ORAL J9000 DOXORUBICIN HCL, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, DOXIL, J9002 10 MG J9010 ALEMTUZUMAH, 10 MG J9015 ALDESLEUKIN, PER SINGLE USE VIAL J9017 ARSENIC TRIOXIDE, 1MG J9019 INJECTION, ASPARAGINASE (ERWINAZE), 1,000 IU J9020 ASPARAGINASE, 10,000 UNITS J9025 INJECTION, AZACITIDINE, 1 MG J9027 INJECTION, CLOFARABINE, 1 MG J9031 BCG (INTRAVESICAL) PER INSTILLATION J9033 BENDAMUSTINE INJECTION J9035 INJECTION, BEVACIZUMAB, 10 MG J9040 BLEOMYCIN SULFATE, 15 UNITS J9041 INJECTION, BORTEZOMIB, 0.1 MG J9042 INJECTION, BRENTUXIMAB VEDOTIN, 1 MG J9043 INJECTION, CABAZITAXEL, 1 MG J9045 CARBOPLATIN, 50 MG J9047 INJECTION, CARFILZOMIB, 1 MG J9050 CARMUSTINE, 100 MG J9055 INJECTION, CETUXIMAB, 10 MG J9060 CISPLATIN, POWDER OR S0LUTION, PER 10 MG J9062 CISPLATIN, 50 MG J9065 INJECTION, CLADRIBINE, PER 1 MG J9070 CYCLOPHOSPHAMIDE, 100 MG J9080 CYCLOPHOSPHAMIDE, 200 MG J9090 CYCLOPHOSPHAMIDE, 500 MG J9091 CYCLOPHOSPHAMIDE, 1.0 GRAM J9092 CYCLOPHOSPHAMIDE, 2.0 GRAM J9093 CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MG J9094 CYCLOPHOSPHAMIDE, LYOPHILIZED, 200 MG J9095 CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MG J9096 CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM J9097 CYCLOPHOSPHAMIDE, LYOPHILIZED, 2.0 GRAM J9098 CYTARABINE LIPOSOME, 10 MG J9100 CYTARABINE, 100 MG J9110 CYTARABINE, 500 MG J9120 DACTINOMYCIN, 0.5 MG J9130 DACARBAZINE, 100 MG J9140 DACARBAZINE, 200 MG J9150 INJECTION, DAUNORUBICIN, 10 MG

J9151 DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG J9155 INJECTION, DEGARELIX, 1 MG J9160 DENILEUKIN DIFTITOX, 300 MCG J9165 DIETHYLSTILBESTROL DIPHOSPHATE, 250 MG J9170 DOCETAXEL, 20 MG J9171 INJECTION, DOCETAXEL, 1 MG J9175 INJECTION, ELLIOTTS' B SOLUTION, 1 ML J9178 INJECTION, EPIRUBICIN HCL, 2 MG J9179 INJECTION, ERIBULIN MESYLATE, 0.1 MG J9181 ETOPOSIDE, 10 MG J9185 FLUDARABINE PHOSPHATE, 50 MG J9190 FLUOROURACIL, 500 MG J9200 INJECTION, FLOXURIDINE, 500 MG J9201 INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 MG J9206 IRINOTECAN, 20 MG J9207 IXABEPILONE INJECTION J9208 INJECTION, IFOSFAMIDE, 1 GRAM J9209 MESNA, 200 MG J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 J9212 MICROGRAM INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION J9213 UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION J9214 UNITS INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE J9215 DERIVED), 250,000 IU J9216 INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS J9217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG J9218 LEUPROLIDE ACETATE, PER 1 MG J9219 LEUPROLIDE ACETATE IMPLANT, 65 MG J9225 HISTRELIN IMPLANT (VANTAS), 50 MG J9226 HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG J9228 INJECTION, IPILIMUMAB, 1 MG MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), J9230 10 MG J9245 INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG J9250 METHOTREXATE SODIUM, 5 MG J9260 METHOTREXATE SODIUM, 50 MG J9261 INJECTION, NELARABINE, 50 MG J9262 INJECTION, OMACETAXINE MEPESUCCINATE, 0.01 MG J9263 INJECTION, OXALIPLATIN, 0.5 MG J9264 INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG J9265 INJECTION, PACLITAXEL, 30 MG J9266 PEGASPARGASE, PER SINGLE DOSE VIAL J9268 PENTOSTATIN, PER 10 MG J9270 PLICAMYCIN, 2.5 MG J9280 MITOMYCIN, 5 MG J9290 MITOMYCIN, 20 MG J9291 MITOMYCIN, 40 MG J9293 INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG J9300 GEMTUZUMAB OZOGAMICIN, 5MG J9302 INJECTION, OFATUMUMAB, 10 MG J9303 INJECTION, PANITUMUMAB, 10 MG J9305 INJECTION, PEMETREXED, 10 MG J9306 INJECTION, PERTUZUMAB, 1 MG J9307 INJECTION, PRALATREXATE, 1 MG J9310 RITUXIMAB, 100 MG J9315 INJECTION, ROMIDEPSIN, 1 MG J9320 STREPTOZOCIN, 1 GM J9328 INJECTION, TEMOZOLOMIDE, 1 MG J9330 TESTLACTONE, TESLAC , 250 MGM J9340 THIOTEPA, 15 MG J9350 TOPOTECAN, 4 MG J9351 INJECTION, TOPOTECAN, 0.1 MG J9354 INJECTION, ADO-TRASTUZUMAB EMTANSINE, 1 MG J9355 TRASTUZUMAB, 10 MG J9357 VALRUBICIN, INTRAVESICAL, 200 MG J9360 VINBLASTINE SULFATE, 1 MG J9370 VINCRISTINE SULFATE, 1 MG J9371 INJECTION, VINCRISTINE SULFATE LIPOSOME, 1 MG J9375 VINCRISTINE SULFATE, 2 MG J9380 VINCRISTINE SULFATE, 5 MG J9390 VINORELBINE TARTRATE, PER 10 MG J9395 INJECTION, FULVESTRANT, 25 MG J9400 INJECTION, ZIV-AFLIBERCEPT, 1 MG J9600 PORFIMER SODIUM, 75 MG J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON Q0138 DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE) INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON Q0139 DEFICIENCY ANEMIA, 1 MG (FOR ESRD ON DIALYSIS) CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED Q0161 A 48 HOUR DOSAGE REGIMEN ONDANSETRON 1 MG, ORAL, FDA-APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0162 DOSAGE REGIMEN

DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED A 48 Q0163 HOUR DOSAGE REGIMEN PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0164 DOSAGE REGIMEN PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0165 DOSAGE REGIMEN GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 HOUR Q0166 DOSAGE REGIMEN , 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0167 DOSAGE REGIMEN

DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI- EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY Q0168 TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED Q0169 A 48 HOUR DOSAGE REGIMEN PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED Q0170 A 48 HOUR DOSAGE REGIMEN

CHLORPROMAZINE HYDROCHLORIDE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED Q0171 A 48 HOUR DOSAGE REGIMEN CHLORPROMAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED Q0172 A 48 HOUR DOSAGE REGIMEN TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED Q0173 A 48 HOUR DOSAGE REGIMEN THIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0174 DOSAGE REGIMEN PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0175 DOSAGE REGIMEN

PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI- EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY Q0176 TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN

HYDROXYZINE PAMOATE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0177 DOSAGE REGIMEN HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0178 DOSAGE REGIMEN ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0179 DOSAGE REGIMEN DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 HOUR Q0180 DOSAGE REGIMEN UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR A IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR Q0181 DOSAGE REGIMEN

Q0515 INJECTION, SERMORELIN ACETATE, 1 MICROGRAM INJECTION,FACTOR VIII (ANTIHEMOPHILIC FACTOR, Q2023 FECOMBINANT)(XYNTHA), PER I.U.

Q2024 INJECTION, BEVACIZUMAB, 0.25MG Q2025 FLUDARABINE PHOSPHATE, ORAL, 10MG Q2028 INJECTION, SCULPTRA, 0.5 MG Q2045 INJECTION, HUMAN FIBRINOGEN CONCENTRATE, 1MG Q2046 INJECTION, AFLIBERCEPT, 1MG INJECTION, DOXORUBICIN HYDROCHLORIDE, KIPOSOMAL, DOXIL, Q2048 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, Q2049 IMPORTED LIPODOX, 10MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, NOT Q2050 OTHERWISE SPECIFIED, 10MG

Q2051 INJECTION, ZOLEDRONIC ACID, NOT OTHERWISE SPECIFIED, 1MG INJECTION, INTERFERON BETA-1A, 1 MCG FOR INTRAMUSCULAR Q3027 USE INJECTION, INTERFERON BETA-1A, 1 MCG FOR SUBCUTANEOUS Q3028 USE ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, Q4074 UNIT DOSE FORM, UP TO 20 MICROGRAMS

Q4081 INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS) DRUG OR BIOLOGICAL, NOT OTHERWISE CLASSIFIED, PART B Q4082 DRUG COMPETITIVE ACQUISITION PROGRAM (CAP)

INJECTION, NON-RADIOACTIVE, NON-CONTRAST, VISUALIZATION A9968 ADJUNCT (E.G., , ISOSULFAN BLUE), 1 MG Q9970 INJECTION, FERRIC CARBOXYMALTOSE, 1MG S0028 INJECTION, FAMOTIDINE, 20 MG S0073 INJECTION, AZTREONAM, 500 MG S0147 ALGLUCOSIDASE ALFA 20 MG S0180 ETONOGESTREL IMPLANT SYSTEM S0189 TESTOSTERONE PELLET, 75MG S4993 CONTRACEPTIVE PILLS FOR BIRTH CONTROL

**UPDATED 7/17/2014**