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Physician Drug Program Procedure Codes and Rates As of October 9, 2008

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Physician Drug Program Procedure Codes and Rates As of October 9, 2008 Physician Drug Program Procedure Codes And Rates as of October 9, 2008 EFFECTIVE CODE DESCRIPTION FACILITY NON-FACILITY DATE Biologics ***J0129 Abatacept (Orencia) 10 mg $18.69 $18.69 10/1/2007 ***J7308 Aminolevulinic Acid HCL, topical 20% single dose, 354gm $109.74 $109.74 8/1/2008 ***J1300 Eculizumab, 10 mg single use vial (Soliris) $176.38 $176.38 1/1/2008 ***J3590 Human Thrombin Topical Protein, 1IU (Evithrom) manual manual 12/1/2007 ***J3590 Human Topical Protein, 1IU (Recothrom) manual manual 1/1/2008 ***S0145 Peginterferon alfa-2a, 180 mcg/ml (Pegasys) $336.41 $336.41 10/1/2007 ***S0146 Pegylated Interferon Alfa-2b, 10 mcg (Peg-Intron) $89.22 $89.22 8/1/2008 ***J2724 Protein C Concentrate, human, 10 IU/vial (Ceprotin) $12.19 $12.19 1/1/2008 ***J2778 Ranibizumab, 0.1 mg (Lucentis) $405.18 $405.18 8/1/2008 Drugs ***J3490 17 Alpha Hydroxprogesterone Caporoate, Bulk powder, 250 mg manual manual 4/1/2006 ***J0128 Abarelix, 10 mg, inj. (Plenaxis) $68.62 $68.62 10/1/2007 ***J0130 Abciximab, 10mg, injection (ReoPro) $413.16 $413.16 8/1/2008 ***J1120 Acetazolamide sodium, up to 500 mg, injection (Diamox) $16.54 $16.54 8/1/2008 ***J0133 Acyclovir, 5mg (Zovirax) $0.02 $0.02 10/1/2007 Adenosine, 06mg, injection (not to be used to report any Adenosine ***J0150 phosphate compounds; instead use A9270) (Adenocard) $22.86 $22.86 8/1/2008 Adenosine, 30 mg, inj (not to be used to report any adenosine phosphate ***J0152 compound; use A9270) $69.16 $69.16 8/1/2008 ***J0180 Agalsidase Beta, 1 mg, inj. (Fabrazyme) $127.20 $127.20 8/1/2008 ***P9047 Albumin (human), 25%, 50 ml, infusion $40.13 $40.13 8/1/2008 ***P9041 Albumin (human), 5%, 50 ml, infusion $20.06 $20.06 8/1/2008 ***J9015 Aldesleukin, per single use vial (Proleukin, etc) $767.40 $767.40 8/1/2008 ***J0215 Alefacept, 0.5 mg, inj. (Amevive) $26.07 $26.07 8/1/2008 ***J9010 Alemtuzumab, 10 mg (Campath) $551.07 $551.07 8/1/2008 ***J0205 Alglucerase, per 10 units, injection (Ceredase) $39.22 $39.22 8/1/2008 ***J0220 Alglucosidase Alfa, 10mg (Myozyme) $127.20 $127.20 1/1/2008 ***J0256 Alpha 1-proteinase inhibitor-human, 10mg, injection (Prolastin) $3.28 $3.28 10/1/2007 ***J2997 Alteplase recombinant, 1 mg, injection (Activase) $32.18 $32.18 8/1/2008 ***J0278 Amicacin sulfate, 100 mg $1.15 $1.15 10/1/2007 ***J0207 Amifostine, 500mg, injection (Ethyol) $480.64 $480.64 10/1/2007 ***J0280 Aminophylline, up to 250mg, injection $0.43 $0.43 10/1/2007 ***J0300 Amobarbital, up to 125mg, injection (Amytal) $2.60 $2.60 10/1/2007 ***J0285 Amphotericin B, 50 mg, Injection $10.23 $10.23 10/1/2007 ***J0288 Amphotericin B cholesteryl sulfate complex, 10 mg, injection (Amphotee) $12.00 $12.00 10/1/2007 ***J0287 Amphotericin B lipid complex, 10 mg, injection $10.38 $10.38 10/1/2007 ***J0289 Amphotericin B liposome, 10 mg, injection (Ambisome) $17.24 $17.24 10/1/2007 ***J0290 Ampicillin sodium, 500mg, injection (Omnipen-N, Totacillin-N) $2.48 $2.48 10/1/2007 ***J0295 Ampicillin sodium/sulbactam sodium, per 1.5g, injection (Unasyn) $5.49 $5.49 10/1/2007 ***J7197 Antithrombin III (human), per IU (Throbate III, ATnativ) $1.91 $1.91 8/1/2008 ***J0400 Aripiprazole, 0.25 mg, (Abilify) $0.29 $0.29 1/1/2008 ***J9017 Arsenic trioxide, 1 mg (Trisenox) $34.48 $34.48 8/1/2008 ***J9020 Asparaginase, 10,000 units (Elspar) $57.02 $57.02 8/1/2008 ***J0460 Atropine sulfate, up to 0.3mg, injection $0.59 $0.59 10/1/2007 ***J9025 Azacitidine (Vidaza) 1 mg $4.48 $4.48 8/1/2008 Azithromycin dihydrate, oral, capsules/powder, 1 gm (Zithromax, ***Q0144 Zithromax Z-Pak) $21.74 $21.74 7/24/2006 ***J0456 Azithromycin, 500mg, injection (Zithromax) $19.56 $19.56 10/1/2007 ***J3490 Baclofen Kit 2*5 ml amp, 10mg manual manual 10/1/2007 ***J3490 Baclofen Kit 4*5 ml amp, 10mg manual manual 10/1/2007 ***J0475 Baclofen, 10 mg (Lioresal) $197.04 $197.04 10/1/2007 ***J0476 Baclofen, 50 mcg for intrathecal trial $71.59 $71.59 10/1/2007 ***J9031 BCG live (intravesical), per installation (Tice BCG, Theracys) $113.75 $113.75 8/1/2008 ***J0702 Betamethasone acet&sod phosp, 3 mg $5.75 $5.75 8/1/2008 ***J0704 Betamethasone sodium phosphate, per 4mg, injection $1.13 $1.13 4/1/2007 ***J9035 Bevacizumab, 10 mg, inj. (Avastin) $57.44 $57.44 8/1/2008 ***J9040 Bleomycin sulfate, 15 units (Blenoxane) $29.02 $29.02 8/1/2008 ***J9041 Bortezomib, 0.1 mg, inj. (Velcade) $34.43 $34.43 8/1/2008 ***J0585 Botulinum toxin type A, per unit (Botox) $5.22 $5.22 8/1/2008 ***J0587 Botulinum toxin type B, per 100 units $8.71 $8.71 8/1/2008 ***J0595 Butorphinol tartrate, 1 mg, inj. (Stadol) $0.50 $0.50 8/1/2008 ***J0636 Calcitriol, 0.1 mcg, injection (Calcijex) $0.43 $0.43 8/1/2008 ***J0610 Calcium gluconate, per 10ml, injection (Kaleinate) $0.36 $0.36 8/1/2008 ***J0620 Calcium glycerophosphate and calcium lactate, per 10ml, injection (Calphosan $13.20 $13.20 12/15/2007 ***J9045 Carboplatin, 50 mg (Paraplatin) $6.31 $6.31 8/1/2008 ***J9050 Carmustine, 100 mg (BiCNU) $156.83 $156.83 8/1/2008 ***J0690 Cefazolin Sodium, 500 mg, Injection (Ancef, Kefzol, Zoliicef) $0.66 $0.66 8/1/2008 ***J0692 Cefepime HCL, 500 mg, injection (Maxipime) $6.75 $6.75 8/1/2008 ***J0698 Cefotaxime Sodium, per g (Claforan) $4.29 $4.29 8/1/2008 ***J0694 Cefoxitin Sodium, 1g, injection (Mefoxin) $8.19 $8.19 10/1/2007 ***J0713 Ceftazidime, per 500 mg, Injection (Fortaz, Tazidime) $3.47 $3.47 8/1/2008 ***J0715 Ceftizoxime sodium, per 500mg, injection (Cefizox) $5.24 $5.24 8/1/2008 ***J0696 Ceftriaxone Sodium, per 250mg, Injection (Rocephin) $1.48 $1.48 8/1/2008 ***J9055 Cetuximab, 10 mg, inj. (Erbitux) $49.81 $49.81 8/1/2008 ***J0720 Chloramphenicol sodium succinate, up to 1g, injection (Chloromycetin) $18.38 $18.38 8/1/2008 ***J1990 Chlordiazepoxide HCl, up to 100 mg, injection (Librium) $21.05 $21.05 10/1/2007 ***J2400 Chloroprocaine HCl, per 30 ml, injection (Nesacaine) $12.72 $12.72 8/1/2008 ***J1205 Chlorothiazide sodium, per 500 mg, injection (Diuril Sodium) $165.12 $165.12 8/1/2008 ***J3230 Chlorpromazine HCl, up to 50 mg, injection (Thorazine) $3.22 $3.22 8/1/2008 ***J0725 Chorionic Gonadotropin, per 1,000 USP units, Injection, $3.37 $3.37 8/1/2008 ***J0740 Cidofovir, 375 mg, Injection (Vistide) $762.45 $762.45 8/1/2008 ***J0743 Cilastatin sodium imipenem, per 250mg, injection (Primaxin IM or IV) $14.28 $14.28 8/1/2008 ***S0023 Cimetidine hydrochloride, 300 mg, injection (Tagamet) $0.61 $0.61 10/1/2007 ***J0744 Ciprofloxacin for IV infusion, 200 mg, injection (Cipro) $5.34 $5.34 8/1/2008 ***J9062 Cisplatin, 50 mg (Platinol AQ) $11.32 $11.32 8/1/2008 ***J9060 Cisplatin, powder or solution, per 10 mg (Platinol AQ) $2.27 $2.27 8/1/2008 ***J9065 Cladribine, per 1 mg, injection (Leustatin) $30.63 $30.63 8/1/2008 ***J0735 Clonidine hydrochloride, 1mg, injection (Catapres) $56.00 $56.00 8/1/2008 ***J0745 Codeine phosphate, per 30mg, injection $1.27 $1.27 8/1/2008 ***J0760 Colchicine, per 1mg, injection $5.00 $5.00 8/1/2008 ***J0770 Colistimethate Sodium, up to 150 mg, Injection (Coly-Mycin M) $19.88 $19.88 8/1/2008 ***J0800 Corticotropin, up to 40 units, injection (Acthar, ACTH) $2,355.52 $2,355.52 8/1/2008 ***J0835 Cosyntropin, per 0.25 mg, injection (Cortrosyn) $65.60 $65.60 8/1/2008 ***J9091 Cyclophosphamide, 01 g (Cytoxan, Neosar) $18.71 $18.71 8/1/2008 ***J9092 Cyclophosphamide, 02 g (Cytoxan, Neosar) $37.43 $37.43 8/1/2008 ***J9070 Cyclophosphamide, 100 mg (Cytoxan, Neosar) $1.91 $1.91 10/1/2007 ***J9080 Cyclophosphamide, 200 mg (Cytoxan, Neosar) $3.82 $3.82 10/1/2007 ***J9090 Cyclophosphamide, 500 mg (Cytoxan, Neosar) $16.50 $16.50 10/1/2007 ***J9098 Cyclophosphamide, DepoCyt, 10 mg $414.95 $414.95 8/1/2008 ***J9096 Cyclophosphamide, lyophilized, 01 g (Cytoxan Lyophilized) $18.59 $18.59 8/1/2008 ***J9097 Cyclophosphamide, lyophilized, 02 g (Cytoxan Lyophilized) $37.17 $37.17 8/1/2008 ***J9093 Cyclophosphamide, lyophilized, 100 mg (Cytoxan Lyophilized) $1.86 $1.86 8/1/2008 ***J9094 Cyclophosphamide, lyophilized, 200 mg (Cytoxan Lyophilized) $3.72 $3.72 8/1/2008 ***J9095 Cyclophosphamide, lyophilized, 500 mg (Cytaxan Lyophilized) $9.29 $9.29 8/1/2008 ***J9100 Cytarabine, 100 mg (Cytosar-U) $1.20 $1.20 8/1/2008 ***J9110 Cytarabine, 500 mg ((Cytosar-U) $6.02 $6.02 8/1/2008 ***J7070 D-5-W, 1,000 cc, infusion $2.18 $2.18 8/1/2008 ***J9130 Dacarbazine, 100 mg (DTIC- Dome) $4.60 $4.60 8/1/2008 ***J9140 Dacarbazine, 200 mg (DTIC - Dome) $9.21 $9.21 8/1/2008 ***J7513 Daclizumab, parenteral, 25 mg (Zenapax) $315.68 $315.68 8/1/2008 ***J9120 Dactinomycin, 0.5 mg (Cosmegen) $493.43 $493.43 10/1/2007 ***J1645 Dalteparin sodium, per 2500 IU, injection (Fragmin) $10.79 $10.79 8/1/2008 ***J0878 Daptomycin, 1 mg (Cubicin) $0.35 $0.35 8/1/2008 ***J0881 Darbepoetin alfa (Aranesp) 1 mcg $2.77 $2.77 8/1/2008 ***J0882 Darbepoetin alfa for ESRD on dialysis (Aranesp) 1 mcg $2.77 $2.77 8/1/2008 ***J9150 Daunorubicin HCl, 10 mg (Cerubidine) $17.14 $17.14 8/1/2008 ***J9151 Daunorubicin citrate, liposomal formulation, 10 mg (Daunoxome) $56.06 $56.06 8/1/2008 ***J0894 Decitabine, 1 mg, (Dacogen) $27.11 $27.11 1/1/2008 ***J0895 Deferoxamine Mesylate, 500mg, Injection (Desferal) $12.31 $12.31 8/1/2008 ***J9160 Denileukin Diftitox, 300 mcg (Ontak) $1,410.03 $1,410.03 8/1/2008 ***J1000 Depo-estradiol cypionate, up to 5mg, injection $6.18 $6.18 8/1/2008 ***J2597 Desmopressin acetate, per 1 mcg, injection (DDAVP) $1.87 $1.87 8/1/2008 ***J1094 Dexamethasone acetate, 1 mg, injection (Dalalone - LA) $0.23 $0.23 10/1/2007 ***J1100 Dexamethasone sodium phosphate, 1mg, injection (Cortastat, Dalalone) $0.08 $0.08 8/1/2008 ***J1190 Dexrazoxane hydrochloride, per 250 mg, injection (Zinecard) $180.94 $180.94 8/1/2008 ***J3490 Dexrazoxane,
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