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Drug Fee Schedule

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Drug Fee Schedule Drug Fee Schedule Updated for July 1, 2014 Procedure Effective Code Description Rate End Date Code Date A9576 Injection, gadoteridol (ProHance multipack) per ml $1.88 7/1/2013 9/30/2013 A9576 Injection, gadoteridol (ProHance multipack) per ml $1.81 10/1/2013 12/31/2013 A9576 Injection, gadoteridol (ProHance multipack) per ml $2.00 1/1/2014 3/31/2014 A9576 Injection, gadoteridol (ProHance multipack) per ml $1.78 4/1/2014 6/30/2014 A9576 Injection, gadoteridol (ProHance multipack) per ml $1.77 7/1/2014 12/31/2078 A9577 Injection, gadobenate dimeglumine (MultiHance) per ml $3.01 7/1/2013 9/30/2013 A9577 Injection, gadobenate dimeglumine (MultiHance) per ml $2.22 10/1/2013 12/31/2013 A9577 Injection, gadobenate dimeglumine (MultiHance) per ml $2.21 1/1/2014 3/31/2014 A9577 Injection, gadobenate dimeglumine (MultiHance) per ml $2.23 4/1/2014 12/31/2078 A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $2.26 7/1/2013 9/30/2013 A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $2.11 10/1/2013 12/31/2013 A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $1.63 1/1/2014 3/31/2014 A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $1.57 4/1/2014 6/30/2014 A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $1.36 7/1/2014 12/31/2078 A9579 Injection, gadolinium-base MR contrast NOS, per ml $2.17 7/1/2013 9/30/2013 A9579 Injection, gadolinium-base MR contrast NOS, per ml $1.95 10/1/2013 12/31/2013 A9579 Injection, gadolinium-base MR contrast NOS, per ml $1.97 1/1/2014 3/31/2014 A9579 Injection, gadolinium-base MR contrast NOS, per ml $1.95 4/1/2014 6/30/2014 A9579 Injection, gadolinium-base MR contrast NOS, per ml $1.97 7/1/2014 12/31/2078 A9585 Injection, gadobutrol, 0.1 ml $0.41 1/1/2014 12/31/2078 C9131 Injection, ado-trastuzumab emtansine, 1 mg $29.22 10/28/2013 12/31/2013 J0120 Injection, tetracyclin, up to 250 mg $15.76 7/1/2013 12/31/2078 J0129 Injection, abatacept, 10 mg $22.84 7/1/2013 9/30/2013 J0129 Injection, abatacept, 10 mg $23.06 10/1/2013 12/31/2013 J0129 Injection, abatacept, 10 mg $23.43 1/1/2014 3/31/2014 J0129 Injection, abatacept, 10 mg $23.88 4/1/2014 6/30/2014 J0129 Injection, abatacept, 10 mg $32.21 7/1/2014 12/31/2078 J0130 Injection, abciximab, 10 mg $629.40 7/1/2013 9/30/2013 J0130 Injection, abciximab, 10 mg $651.25 10/1/2013 12/31/2013 J0130 Injection, abciximab, 10 mg $683.49 1/1/2014 3/31/2014 J0130 Injection, abciximab, 10 mg $741.89 4/1/2014 6/30/2014 J0130 Injection, abciximab, 10 mg $740.83 7/1/2014 12/31/2078 J0132 Injection, acetylcysteine, 100 mg $3.08 7/1/2013 9/30/2013 J0132 Injection, acetylcysteine, 100 mg $2.65 10/1/2013 12/31/2013 J0132 Injection, acetylcysteine, 100 mg $2.64 1/1/2014 3/31/2014 J0132 Injection, acetylcysteine, 100 mg $2.48 4/1/2014 6/30/2014 J0132 Injection, acetylcysteine, 100 mg $2.29 7/1/2014 12/31/2078 J0133 Ingection, acyclovir, 5 mg $0.02 7/1/2013 9/30/2013 J0133 Ingection, acyclovir, 5 mg $0.05 10/1/2013 12/31/2013 J0133 Ingection, acyclovir, 5 mg $0.06 1/1/2014 3/31/2014 J0133 Ingection, acyclovir, 5 mg $0.07 4/1/2014 6/30/2014 Procedure Effective Code Description Rate End Date Code Date J0133 Ingection, acyclovir, 5 mg $0.06 7/1/2014 12/31/2078 J0135 Injection, adalimumab, 20 mg $526.39 7/1/2013 9/30/2013 J0135 Injection, adalimumab, 20 mg $515.89 10/1/2013 12/31/2013 J0135 Injection, adalimumab, 20 mg $569.27 1/1/2014 3/31/2014 J0135 Injection, adalimumab, 20 mg $567.68 4/1/2014 6/30/2014 J0135 Injection, adalimumab, 20 mg $614.34 7/1/2014 12/31/2078 J0150 Injection, adenosine for therapeutic use, 6 mg $5.30 7/1/2013 9/30/2013 J0150 Injection, adenosine for therapeutic use, 6 mg $5.83 10/1/2013 12/31/2013 J0150 Injection, adenosine for therapeutic use, 6 mg $6.50 1/1/2014 3/31/2014 J0150 Injection, adenosine for therapeutic use, 6 mg $6.08 4/1/2014 6/30/2014 J0150 Injection, adenosine for therapeutic use, 6 mg $6.01 7/1/2014 12/31/2078 J0152 Injection, adenosine for diagnostic use, 30 mg $109.14 7/1/2013 9/30/2013 J0152 Injection, adenosine for diagnostic use, 30 mg $109.38 10/1/2013 12/31/2013 J0171 Injection, Adrenalin, epinephrine, 0.1 mg $0.07 7/1/2013 9/30/2013 J0171 Injection, Adrenalin, epinephrine, 0.1 mg $0.06 10/1/2013 12/31/2013 J0171 Injection, Adrenalin, epinephrine, 0.1 mg $0.10 1/1/2014 3/31/2014 J0171 Injection, Adrenalin, epinephrine, 0.1 mg $0.15 4/1/2014 12/31/2078 J0178 Injection, aflibercept, 1 mg $980.50 7/1/2013 12/31/2078 J0180 Injection, agalsidase beta, 1 mg $145.71 7/1/2013 9/30/2013 J0180 Injection, agalsidase beta, 1 mg $146.19 10/1/2013 3/31/2014 J0180 Injection, agalsidase beta, 1 mg $146.20 4/1/2014 6/30/2014 J0180 Injection, agalsidase beta, 1 mg $152.02 7/1/2014 12/31/2078 J0190 Injection, biperiden lactate, per 5 mg $3.94 7/1/2013 12/31/2078 J0200 Injection, alatrofloxacin mesylate, 100 mg $16.99 7/1/2013 12/31/2078 J0205 Injection, alglucerase, per 10 units $42.03 7/1/2013 12/31/2078 J0207 Injection amifostine, 500 mg $295.95 7/1/2013 9/30/2013 J0207 Injection amifostine, 500 mg $298.54 10/1/2013 12/31/2013 J0207 Injection amifostine, 500 mg $300.68 1/1/2014 3/31/2014 J0207 Injection amifostine, 500 mg $311.76 4/1/2014 6/30/2014 J0207 Injection amifostine, 500 mg $294.47 7/1/2014 12/31/2078 J0210 Injection, methyldopate HCl, up to 250 mg $42.40 7/1/2013 12/31/2078 J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg $153.62 7/1/2013 9/30/2013 J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg $153.60 10/1/2013 3/31/2014 J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg $153.63 4/1/2014 6/30/2014 J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg $153.64 7/1/2014 12/31/2078 J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $3.99 7/1/2013 9/30/2013 J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $4.02 10/1/2013 12/31/2013 J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $4.03 1/1/2014 3/31/2014 J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $4.11 4/1/2014 6/30/2014 J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $4.17 7/1/2014 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J0270 Injection, alprostadil, per 1.25 mcg $0.67 7/1/2013 12/31/2078 J0278 Injection, amikacin sulfate, 100 mg $1.18 7/1/2013 9/30/2013 J0278 Injection, amikacin sulfate, 100 mg $1.08 10/1/2013 12/31/2013 J0278 Injection, amikacin sulfate, 100 mg $0.95 1/1/2014 3/31/2014 J0278 Injection, amikacin sulfate, 100 mg $1.28 4/1/2014 6/30/2014 J0278 Injection, amikacin sulfate, 100 mg $1.39 7/1/2014 12/31/2078 J0280 Injection, aminophyllin, up to 250 mg $0.81 7/1/2013 9/30/2013 J0280 Injection, aminophyllin, up to 250 mg $1.19 10/1/2013 12/31/2013 J0280 Injection, aminophyllin, up to 250 mg $1.40 1/1/2014 3/31/2014 J0280 Injection, aminophyllin, up to 250 mg $1.55 4/1/2014 6/30/2014 J0280 Injection, aminophyllin, up to 250 mg $3.73 7/1/2014 12/31/2078 J0287 Injection, amphotericin B lipid complex, 10 mg $11.41 7/1/2013 9/30/2013 J0287 Injection, amphotericin B lipid complex, 10 mg $11.42 10/1/2013 12/31/2013 J0287 Injection, amphotericin B lipid complex, 10 mg $10.47 1/1/2014 3/31/2014 J0287 Injection, amphotericin B lipid complex, 10 mg $10.43 4/1/2014 6/30/2014 J0287 Injection, amphotericin B lipid complex, 10 mg $10.60 7/1/2014 12/31/2078 J0288 Injection, amphotericin B cholesteryl sulfate complex, 10 mg $14.00 7/1/2013 12/31/2078 J0289 Injection, amphotericin B liposome, 10 mg $14.87 7/1/2013 9/30/2013 J0289 Injection, amphotericin B liposome, 10 mg $15.57 10/1/2013 12/31/2013 J0289 Injection, amphotericin B liposome, 10 mg $16.19 1/1/2014 3/31/2014 J0289 Injection, amphotericin B liposome, 10 mg $16.31 4/1/2014 6/30/2014 J0289 Injection, amphotericin B liposome, 10 mg $16.42 7/1/2014 12/31/2078 J0290 Injection, ampicillin sodium, 500 mg $1.60 7/1/2013 9/30/2013 J0290 Injection, ampicillin sodium, 500 mg $1.67 10/1/2013 12/31/2013 J0290 Injection, ampicillin sodium, 500 mg $1.49 1/1/2014 3/31/2014 J0290 Injection, ampicillin sodium, 500 mg $1.56 4/1/2014 6/30/2014 J0290 Injection, ampicillin sodium, 500 mg $1.51 7/1/2014 12/31/2078 J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $2.05 7/1/2013 9/30/2013 J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $1.66 10/1/2013 12/31/2013 J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $1.75 1/1/2014 3/31/2014 J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $1.76 4/1/2014 6/30/2014 J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $1.63 7/1/2014 12/31/2078 J0300 Injection, amobarbital, up to 125 mg $152.43 7/1/2013 12/31/2013 J0300 Injection, amobarbital, up to 125 mg $179.87 1/1/2014 6/30/2014 J0300 Injection, amobarbital, up to 125 mg $194.26 7/1/2014 12/31/2078 J0330 Injection, succinycholine chloride, up to 20 mg $0.15 7/1/2013 12/31/2078 J0350 Injection, anistreplase, per 30 units $2,268.46 7/1/2013 12/31/2078 J0360 Injection, hydralazine HCl, up to 20 mg $3.72 7/1/2013 9/30/2013 J0360 Injection, hydralazine HCl, up to 20 mg $3.14 10/1/2013 12/31/2013 J0360 Injection, hydralazine HCl, up to 20 mg $3.13 1/1/2014 3/31/2014 J0360 Injection, hydralazine HCl, up to 20 mg $3.19 4/1/2014 6/30/2014 Procedure Effective Code Description Rate End Date Code Date J0360 Injection, hydralazine HCl, up to 20 mg $3.06 7/1/2014 12/31/2078 J0365 Injection, aprotonin, 10,000 kiu $2.65 7/1/2013 12/31/2013 J0365 Injection, aprotonin, 10,000 kiu $3.42 1/1/2014 12/31/2078 J0380 Injection, metaraminol bitartrate, per 10 mg $1.15 7/1/2013 12/31/2078 J0390
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