Drug Fee Schedule Updated for July 1, 2015 Procedure Effective Code Description Rate End Date Code Date A9576 Injection, gadoteridol (ProHance multipack) per ml $1.77 7/1/2014 9/30/2014 A9576 Injection, gadoteridol (ProHance multipack) per ml $1.82 10/1/2014 12/31/2014 A9576 Injection, gadoteridol (ProHance multipack) per ml $1.75 1/1/2015 3/31/2015 A9576 Injection, gadoteridol (ProHance multipack) per ml $1.72 4/1/2015 12/31/2078

A9577 Injection, gadobenate dimeglumine (MultiHance) per ml $2.23 7/1/2014 9/30/2014 A9577 Injection, gadobenate dimeglumine (MultiHance) per ml $2.22 10/1/2014 12/31/2014 A9577 Injection, gadobenate dimeglumine (MultiHance) per ml $2.21 1/1/2015 3/31/2015 A9577 Injection, gadobenate dimeglumine (MultiHance) per ml $2.18 4/1/2015 12/31/2078

A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $1.36 7/1/2014 9/30/2014 A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $1.75 10/1/2014 12/31/2014 A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $2.08 1/1/2015 3/31/2015 A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $2.41 4/1/2015 6/30/2015 A9578 Injection, gadobenate dimeglumine (MultiHance multipack) per ml $1.99 7/1/2015 12/31/2078

A9579 Injection, gadolinium-base MR contrast NOS, per ml $1.97 7/1/2014 9/30/2014 A9579 Injection, gadolinium-base MR contrast NOS, per ml $2.01 10/1/2014 12/31/2014 A9579 Injection, gadolinium-base MR contrast NOS, per ml $2.03 1/1/2015 3/31/2015 A9579 Injection, gadolinium-base MR contrast NOS, per ml $1.99 4/1/2015 6/30/2015 A9579 Injection, gadolinium-base MR contrast NOS, per ml $1.91 7/1/2015 12/31/2078

A9585 Injection, gadobutrol, 0.1 ml $0.41 7/1/2014 12/31/2014 A9585 Injection, gadobutrol, 0.1 ml $0.40 1/1/2015 12/31/2078

J0120 Injection, tetracyclin, up to 250 mg $15.76 7/1/2014 12/31/2014 J0120 Injection, tetracyclin, up to 250 mg $97.97 1/1/2015 3/31/2015 J0120 Injection, tetracyclin, up to 250 mg $38.86 4/1/2015 6/30/2015 J0120 Injection, tetracyclin, up to 250 mg $97.97 7/1/2015 12/31/2078

J0129 Injection, abatacept, 10 mg $32.21 7/1/2014 9/30/2014 J0129 Injection, abatacept, 10 mg $32.25 10/1/2014 12/31/2014 J0129 Injection, abatacept, 10 mg $33.15 1/1/2015 3/31/2015 J0129 Injection, abatacept, 10 mg $34.92 4/1/2015 6/30/2015 J0129 Injection, abatacept, 10 mg $35.81 7/1/2015 12/31/2078

J0130 Injection, abciximab, 10 mg $740.83 7/1/2014 9/30/2014 J0130 Injection, abciximab, 10 mg $739.17 10/1/2014 12/31/2014 J0130 Injection, abciximab, 10 mg $804.37 1/1/2015 3/31/2015 J0130 Injection, abciximab, 10 mg $823.78 4/1/2015 6/30/2015 J0130 Injection, abciximab, 10 mg $895.87 7/1/2015 12/31/2078

J0132 Injection, acetylcysteine, 100 mg $2.29 7/1/2014 9/30/2014 J0132 Injection, acetylcysteine, 100 mg $2.19 10/1/2014 12/31/2014 J0132 Injection, acetylcysteine, 100 mg $1.56 1/1/2015 3/31/2015 J0132 Injection, acetylcysteine, 100 mg $2.10 4/1/2015 6/30/2015 J0132 Injection, acetylcysteine, 100 mg $2.05 7/1/2015 12/31/2078

J0133 Ingection, acyclovir, 5 mg $0.06 7/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J0133 Ingection, acyclovir, 5 mg $0.07 1/1/2015 12/31/2078

J0135 Injection, adalimumab, 20 mg $614.34 7/1/2014 9/30/2014 J0135 Injection, adalimumab, 20 mg $570.94 10/1/2014 12/31/2014 J0135 Injection, adalimumab, 20 mg $630.65 1/1/2015 3/31/2015 J0135 Injection, adalimumab, 20 mg $658.71 4/1/2015 6/30/2015 J0135 Injection, adalimumab, 20 mg $681.16 7/1/2015 12/31/2078

J0150 Injection, adenosine for therapeutic use, 6 mg $6.01 7/1/2014 9/30/2014 J0150 Injection, adenosine for therapeutic use, 6 mg $5.72 10/1/2014 12/31/2014

J0151 Injection, adenosine for diagnostic use, 1 MG $2.65 7/1/2014 9/30/2014 J0151 Injection, adenosine for diagnostic use, 1 MG $2.13 10/1/2014 12/31/2014

J0171 Injection, Adrenalin, epinephrine, 0.1 mg $0.15 7/1/2014 9/30/2014 J0171 Injection, Adrenalin, epinephrine, 0.1 mg $0.13 10/1/2014 12/31/2014 J0171 Injection, Adrenalin, epinephrine, 0.1 mg $0.14 1/1/2015 3/31/2015 J0171 Injection, Adrenalin, epinephrine, 0.1 mg $0.13 4/1/2015 6/30/2015 J0171 Injection, Adrenalin, epinephrine, 0.1 mg $0.11 7/1/2015 12/31/2078

J0178 Injection, aflibercept, 1 mg $980.50 7/1/2014 12/31/2078

J0180 Injection, agalsidase beta, 1 mg $152.02 7/1/2014 9/30/2014 J0180 Injection, agalsidase beta, 1 mg $152.35 10/1/2014 3/31/2015 J0180 Injection, agalsidase beta, 1 mg $152.34 4/1/2015 6/30/2015 J0180 Injection, agalsidase beta, 1 mg $157.93 7/1/2015 12/31/2078

J0190 Injection, biperiden lactate, per 5 mg $3.94 7/1/2014 12/31/2078

J0200 Injection, alatrofloxacin mesylate, 100 mg $16.99 7/1/2014 12/31/2014 J0200 Injection, alatrofloxacin mesylate, 100 mg $38.86 1/1/2015 3/31/2015 J0200 Injection, alatrofloxacin mesylate, 100 mg $16.98 4/1/2015 6/30/2015 J0200 Injection, alatrofloxacin mesylate, 100 mg $38.86 7/1/2015 12/31/2078

J0205 Injection, alglucerase, per 10 units $42.03 7/1/2014 12/31/2078

J0207 Injection amifostine, 500 mg $294.47 7/1/2014 9/30/2014 J0207 Injection amifostine, 500 mg $310.72 10/1/2014 12/31/2014 J0207 Injection amifostine, 500 mg $479.05 1/1/2015 3/31/2015 J0207 Injection amifostine, 500 mg $361.77 4/1/2015 6/30/2015 J0207 Injection amifostine, 500 mg $359.08 7/1/2015 12/31/2078

J0210 Injection, methyldopate HCl, up to 250 mg $42.40 7/1/2014 12/31/2078

J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg $153.64 7/1/2014 12/31/2014 J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg $153.62 1/1/2015 3/31/2015 J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg $153.61 4/1/2015 6/30/2015 J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg $153.60 7/1/2015 12/31/2078

J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $4.17 7/1/2014 9/30/2014 J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $4.11 10/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $4.24 1/1/2015 3/31/2015 J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $4.33 4/1/2015 6/30/2015 J0256 Injection, alpha 1-proteinase inhibitor (human), NOS, 10 mg $4.38 7/1/2015 12/31/2078

J0270 Injection, alprostadil, per 1.25 mcg $0.67 7/1/2014 12/31/2078

J0278 Injection, amikacin sulfate, 100 mg $1.39 7/1/2014 9/30/2014 J0278 Injection, amikacin sulfate, 100 mg $1.27 10/1/2014 12/31/2014 J0278 Injection, amikacin sulfate, 100 mg $1.19 1/1/2015 3/31/2015 J0278 Injection, amikacin sulfate, 100 mg $1.09 4/1/2015 6/30/2015 J0278 Injection, amikacin sulfate, 100 mg $1.13 7/1/2015 12/31/2078

J0280 Injection, aminophyllin, up to 250 mg $3.73 7/1/2014 9/30/2014 J0280 Injection, aminophyllin, up to 250 mg $3.98 10/1/2014 12/31/2014 J0280 Injection, aminophyllin, up to 250 mg $3.21 1/1/2015 3/31/2015 J0280 Injection, aminophyllin, up to 250 mg $3.25 4/1/2015 6/30/2015 J0280 Injection, aminophyllin, up to 250 mg $9.66 7/1/2015 12/31/2078

J0287 Injection, amphotericin B lipid complex, 10 mg $10.60 7/1/2014 9/30/2014 J0287 Injection, amphotericin B lipid complex, 10 mg $10.41 10/1/2014 12/31/2014 J0287 Injection, amphotericin B lipid complex, 10 mg $11.01 1/1/2015 3/31/2015 J0287 Injection, amphotericin B lipid complex, 10 mg $11.65 4/1/2015 6/30/2015 J0287 Injection, amphotericin B lipid complex, 10 mg $12.02 7/1/2015 12/31/2078

J0288 Injection, amphotericin B cholesteryl sulfate complex, 10 mg $14.00 7/1/2014 12/31/2078

J0289 Injection, amphotericin B liposome, 10 mg $16.42 7/1/2014 9/30/2014 J0289 Injection, amphotericin B liposome, 10 mg $16.83 10/1/2014 12/31/2014 J0289 Injection, amphotericin B liposome, 10 mg $16.98 1/1/2015 3/31/2015 J0289 Injection, amphotericin B liposome, 10 mg $17.10 4/1/2015 6/30/2015 J0289 Injection, amphotericin B liposome, 10 mg $17.72 7/1/2015 12/31/2078

J0290 Injection, ampicillin sodium, 500 mg $1.51 7/1/2014 9/30/2014 J0290 Injection, ampicillin sodium, 500 mg $1.25 10/1/2014 12/31/2014 J0290 Injection, ampicillin sodium, 500 mg $1.18 1/1/2015 3/31/2015 J0290 Injection, ampicillin sodium, 500 mg $1.16 4/1/2015 6/30/2015 J0290 Injection, ampicillin sodium, 500 mg $1.06 7/1/2015 12/31/2078

J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $1.63 7/1/2014 9/30/2014 J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $1.82 10/1/2014 12/31/2014 J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $1.86 1/1/2015 3/31/2015 J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $1.69 4/1/2015 6/30/2015 J0295 Injection, ampicillin sodium/sulbactam sodium per 1.5 gm $2.08 7/1/2015 12/31/2078

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 7/1/2014 12/31/2078

J0350 Injection, anistreplase, per 30 units $2,268.46 7/1/2014 12/31/2078

J0360 Injection, hydralazine HCl, up to 20 mg $3.06 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J0360 Injection, hydralazine HCl, up to 20 mg $2.98 10/1/2014 12/31/2014 J0360 Injection, hydralazine HCl, up to 20 mg $2.45 1/1/2015 3/31/2015 J0360 Injection, hydralazine HCl, up to 20 mg $1.85 4/1/2015 6/30/2015 J0360 Injection, hydralazine HCl, up to 20 mg $4.96 7/1/2015 12/31/2078

J0365 Injection, aprotonin, 10,000 kiu $3.42 7/1/2014 12/31/2014 J0365 Injection, aprotonin, 10,000 kiu $174.42 1/1/2015 12/31/2078

J0380 Injection, metaraminol bitartrate, per 10 mg $1.15 7/1/2014 12/31/2078

J0390 Injection, chloroquine HCl, up to 250 mg $17.27 7/1/2014 12/31/2078

J0400 Injection, aripiprazole, intramuscular, 0.25 mg $0.64 7/1/2014 9/30/2014 J0400 Injection, aripiprazole, intramuscular, 0.25 mg $0.65 10/1/2014 6/30/2015 J0400 Injection, aripiprazole, intramuscular, 0.25 mg $0.74 7/1/2015 12/31/2078

J0401 Inj aripiprazole ext release 1MG $2.65 7/1/2014 9/30/2014 J0401 Inj aripiprazole ext release 1MG $3.87 10/1/2014 12/31/2014 J0401 Inj aripiprazole ext release 1MG $3.98 1/1/2015 6/30/2015 J0401 Inj aripiprazole ext release 1MG $4.10 7/1/2015 12/31/2078

J0456 Injection, azithromycin, 500 mg $3.24 7/1/2014 9/30/2014 J0456 Injection, azithromycin, 500 mg $2.34 10/1/2014 12/31/2014 J0456 Injection, azithromycin, 500 mg $2.94 1/1/2015 3/31/2015 J0456 Injection, azithromycin, 500 mg $2.95 4/1/2015 6/30/2015 J0456 Injection, azithromycin, 500 mg $3.53 7/1/2015 12/31/2078

J0461 Injection, atropine sulfate, 0.01 mg $0.04 7/1/2014 9/30/2014 J0461 Injection, atropine sulfate, 0.01 mg $0.05 10/1/2014 3/31/2015 J0461 Injection, atropine sulfate, 0.01 mg $0.04 4/1/2015 6/30/2015 J0461 Injection, atropine sulfate, 0.01 mg $0.06 7/1/2015 12/31/2078

J0470 Injection, dimecaprol, per 100 mg $28.96 7/1/2014 9/30/2014 J0470 Injection, dimecaprol, per 100 mg $29.38 10/1/2014 12/31/2014 J0470 Injection, dimecaprol, per 100 mg $29.01 1/1/2015 3/31/2015 J0470 Injection, dimecaprol, per 100 mg $29.41 4/1/2015 6/30/2015 J0470 Injection, dimecaprol, per 100 mg $45.02 7/1/2015 12/31/2078

J0475 Injection, baclofen. 10 mg $163.54 7/1/2014 9/30/2014 J0475 Injection, baclofen. 10 mg $162.80 10/1/2014 12/31/2014 J0475 Injection, baclofen. 10 mg $159.74 1/1/2015 3/31/2015 J0475 Injection, baclofen. 10 mg $169.81 4/1/2015 6/30/2015 J0475 Injection, baclofen. 10 mg $164.08 7/1/2015 12/31/2078

J0476 Injection, baclofen, 50 mcg for intrathecal trial $76.02 7/1/2014 9/30/2014 J0476 Injection, baclofen, 50 mcg for intrathecal trial $76.29 10/1/2014 12/31/2014 J0476 Injection, baclofen, 50 mcg for intrathecal trial $75.84 1/1/2015 3/31/2015 J0476 Injection, baclofen, 50 mcg for intrathecal trial $76.50 4/1/2015 6/30/2015 J0476 Injection, baclofen, 50 mcg for intrathecal trial $75.95 7/1/2015 12/31/2078

J0480 Injection, basiliximab, 20 mg $2,619.28 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J0480 Injection, basiliximab, 20 mg $2,716.18 10/1/2014 12/31/2014 J0480 Injection, basiliximab, 20 mg $2,723.28 1/1/2015 3/31/2015 J0480 Injection, basiliximab, 20 mg $2,718.40 4/1/2015 6/30/2015 J0480 Injection, basiliximab, 20 mg $2,845.44 7/1/2015 12/31/2078

J0490 Injection, belimumab, 10 mg $39.35 7/1/2014 9/30/2014 J0490 Injection, belimumab, 10 mg $39.48 10/1/2014 12/31/2014 J0490 Injection, belimumab, 10 mg $40.03 1/1/2015 3/31/2015 J0490 Injection, belimumab, 10 mg $40.02 4/1/2015 6/30/2015 J0490 Injection, belimumab, 10 mg $40.54 7/1/2015 12/31/2078

J0500 Injection, dicyclomine HCl, up to 20 mg $40.27 7/1/2014 9/30/2014 J0500 Injection, dicyclomine HCl, up to 20 mg $41.28 10/1/2014 12/31/2014 J0500 Injection, dicyclomine HCl, up to 20 mg $40.88 1/1/2015 3/31/2015 J0500 Injection, dicyclomine HCl, up to 20 mg $46.35 4/1/2015 6/30/2015 J0500 Injection, dicyclomine HCl, up to 20 mg $54.48 7/1/2015 12/31/2078

J0515 Injection, benztropine mesylate, per 1 mg $20.89 7/1/2014 9/30/2014 J0515 Injection, benztropine mesylate, per 1 mg $20.38 10/1/2014 12/31/2014 J0515 Injection, benztropine mesylate, per 1 mg $19.60 1/1/2015 3/31/2015 J0515 Injection, benztropine mesylate, per 1 mg $18.38 4/1/2015 6/30/2015 J0515 Injection, benztropine mesylate, per 1 mg $23.07 7/1/2015 12/31/2078

J0558 Injection, penicillin G benzathine/procaine, 100,000 units $4.76 7/1/2014 9/30/2014 J0558 Injection, penicillin G benzathine/procaine, 100,000 units $4.92 10/1/2014 12/31/2014 J0558 Injection, penicillin G benzathine/procaine, 100,000 units $5.25 1/1/2015 3/31/2015 J0558 Injection, penicillin G benzathine/procaine, 100,000 units $5.28 4/1/2015 6/30/2015 J0558 Injection, penicillin G benzathine/procaine, 100,000 units $5.98 7/1/2015 12/31/2078

J0561 Injection, penicillin G benzathine, 100,000 units $5.99 7/1/2014 9/30/2014 J0561 Injection, penicillin G benzathine, 100,000 units $6.29 10/1/2014 12/31/2014 J0561 Injection, penicillin G benzathine, 100,000 units $6.61 1/1/2015 3/31/2015 J0561 Injection, penicillin G benzathine, 100,000 units $6.65 4/1/2015 6/30/2015 J0561 Injection, penicillin G benzathine, 100,000 units $7.57 7/1/2015 12/31/2078

J0585 Injection, onabotulinumtoxinA, 1 unit $5.57 7/1/2014 9/30/2014 J0585 Injection, onabotulinumtoxinA, 1 unit $5.56 10/1/2014 12/31/2014 J0585 Injection, onabotulinumtoxinA, 1 unit $5.58 1/1/2015 3/31/2015 J0585 Injection, onabotulinumtoxinA, 1 unit $5.57 4/1/2015 6/30/2015 J0585 Injection, onabotulinumtoxinA, 1 unit $5.73 7/1/2015 12/31/2078

J0586 Injection, abobotulinumtoxinA, 5 units $7.46 7/1/2014 9/30/2014 J0586 Injection, abobotulinumtoxinA, 5 units $7.43 10/1/2014 12/31/2014 J0586 Injection, abobotulinumtoxinA, 5 units $7.62 1/1/2015 3/31/2015 J0586 Injection, abobotulinumtoxinA, 5 units $7.95 4/1/2015 6/30/2015 J0586 Injection, abobotulinumtoxinA, 5 units $7.55 7/1/2015 12/31/2078

J0587 Injection, rimabotulinumtoxinB, 100 units $11.30 7/1/2014 12/31/2014 J0587 Injection, rimabotulinumtoxinB, 100 units $11.28 1/1/2015 3/31/2015 J0587 Injection, rimabotulinumtoxinB, 100 units $11.29 4/1/2015 6/30/2015 J0587 Injection, rimabotulinumtoxinB, 100 units $11.63 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date

J0588 Injection, incobotulinumtoxinA, 1 unit $4.48 7/1/2014 12/31/2014 J0588 Injection, incobotulinumtoxinA, 1 unit $4.47 1/1/2015 3/31/2015 J0588 Injection, incobotulinumtoxinA, 1 unit $4.61 4/1/2015 6/30/2015 J0588 Injection, incobotulinumtoxinA, 1 unit $4.63 7/1/2015 12/31/2078

J0592 Injection, buprenorphine HCl, 0.1 mg $3.33 7/1/2014 9/30/2014 J0592 Injection, buprenorphine HCl, 0.1 mg $3.06 10/1/2014 12/31/2014 J0592 Injection, buprenorphine HCl, 0.1 mg $3.01 1/1/2015 3/31/2015 J0592 Injection, buprenorphine HCl, 0.1 mg $2.89 4/1/2015 12/31/2078

J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units $36.33 7/1/2014 9/30/2014 J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units $37.64 10/1/2014 12/31/2014 J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units $38.58 1/1/2015 3/31/2015 J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units $38.57 4/1/2015 6/30/2015 J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units $40.53 7/1/2015 12/31/2078

J0598 Injection, C-1 esterase inhibitor (human), Cinryze, 10 units $51.63 7/1/2014 9/30/2014 J0598 Injection, C-1 esterase inhibitor (human), Cinryze, 10 units $51.86 10/1/2014 12/31/2014 J0598 Injection, C-1 esterase inhibitor (human), Cinryze, 10 units $51.89 1/1/2015 3/31/2015 J0598 Injection, C-1 esterase inhibitor (human), Cinryze, 10 units $51.90 4/1/2015 6/30/2015 J0598 Injection, C-1 esterase inhibitor (human), Cinryze, 10 units $54.36 7/1/2015 12/31/2078

J0600 Injectiom, edetate calcium disodium, to 1,000 mg $1,679.96 7/1/2014 9/30/2014 J0600 Injectiom, edetate calcium disodium, to 1,000 mg $3,477.51 10/1/2014 12/31/2014 J0600 Injectiom, edetate calcium disodium, to 1,000 mg $3,063.72 1/1/2015 3/31/2015 J0600 Injectiom, edetate calcium disodium, to 1,000 mg $4,430.35 4/1/2015 6/30/2015 J0600 Injectiom, edetate calcium disodium, to 1,000 mg $5,594.42 7/1/2015 12/31/2078

J0610 Injection, calcium gluconate, per 10 ml $1.39 7/1/2014 9/30/2014 J0610 Injection, calcium gluconate, per 10 ml $1.27 10/1/2014 12/31/2014 J0610 Injection, calcium gluconate, per 10 ml $2.07 1/1/2015 3/31/2015 J0610 Injection, calcium gluconate, per 10 ml $1.47 4/1/2015 6/30/2015 J0610 Injection, calcium gluconate, per 10 ml $1.72 7/1/2015 12/31/2078

J0620 Injection, calcium glycerophosph/lactate, per 10 ml $8.96 7/1/2014 12/31/2078

J0630 Injection, calcitonin salmon, up to 400 units $69.05 7/1/2014 9/30/2014 J0630 Injection, calcitonin salmon, up to 400 units $69.29 10/1/2014 12/31/2014 J0630 Injection, calcitonin salmon, up to 400 units $358.25 1/1/2015 3/31/2015 J0630 Injection, calcitonin salmon, up to 400 units $956.69 4/1/2015 6/30/2015 J0630 Injection, calcitonin salmon, up to 400 units $1,162.83 7/1/2015 12/31/2078

J0636 Injection, calcitriol, 0.1 mcg $0.36 7/1/2014 9/30/2014 J0636 Injection, calcitriol, 0.1 mcg $0.39 10/1/2014 12/31/2014 J0636 Injection, calcitriol, 0.1 mcg $0.36 1/1/2015 3/31/2015 J0636 Injection, calcitriol, 0.1 mcg $0.38 4/1/2015 6/30/2015 J0636 Injection, calcitriol, 0.1 mcg $0.41 7/1/2015 12/31/2078

J0637 Injection, caspofungin acetate, 5 mg $12.26 7/1/2014 9/30/2014 J0637 Injection, caspofungin acetate, 5 mg $11.84 10/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J0637 Injection, caspofungin acetate, 5 mg $12.32 1/1/2015 3/31/2015 J0637 Injection, caspofungin acetate, 5 mg $11.84 4/1/2015 6/30/2015 J0637 Injection, caspofungin acetate, 5 mg $12.54 7/1/2015 12/31/2078

J0638 Injection, canakinumab, 1 mg $90.98 7/1/2014 9/30/2014 J0638 Injection, canakinumab, 1 mg $90.96 10/1/2014 12/31/2014 J0638 Injection, canakinumab, 1 mg $91.00 1/1/2015 3/31/2015 J0638 Injection, canakinumab, 1 mg $91.01 4/1/2015 6/30/2015 J0638 Injection, canakinumab, 1 mg $91.49 7/1/2015 12/31/2078

J0640 Injection, leucovorin calcium, per 50 mg $4.05 7/1/2014 9/30/2014 J0640 Injection, leucovorin calcium, per 50 mg $3.74 10/1/2014 12/31/2014 J0640 Injection, leucovorin calcium, per 50 mg $3.99 1/1/2015 3/31/2015 J0640 Injection, leucovorin calcium, per 50 mg $3.79 4/1/2015 6/30/2015 J0640 Injection, leucovorin calcium, per 50 mg $3.59 7/1/2015 12/31/2078

J0641 Injection, levoleucovorin calcium, 0.5 mg $1.72 7/1/2014 9/30/2014 J0641 Injection, levoleucovorin calcium, 0.5 mg $1.77 10/1/2014 12/31/2014 J0641 Injection, levoleucovorin calcium, 0.5 mg $1.75 1/1/2015 3/31/2015 J0641 Injection, levoleucovorin calcium, 0.5 mg $1.80 4/1/2015 6/30/2015 J0641 Injection, levoleucovorin calcium, 0.5 mg $1.74 7/1/2015 12/31/2078

J0670 Injection, mepivacaine HCl, per 10 ml $2.28 7/1/2014 9/30/2014 J0670 Injection, mepivacaine HCl, per 10 ml $2.20 10/1/2014 12/31/2014 J0670 Injection, mepivacaine HCl, per 10 ml $2.42 1/1/2015 3/31/2015 J0670 Injection, mepivacaine HCl, per 10 ml $2.30 4/1/2015 12/31/2078

J0690 Injection, cefazolin sodium, 500 mg $0.72 7/1/2014 9/30/2014 J0690 Injection, cefazolin sodium, 500 mg $1.19 10/1/2014 12/31/2014 J0690 Injection, cefazolin sodium, 500 mg $0.90 1/1/2015 3/31/2015 J0690 Injection, cefazolin sodium, 500 mg $0.89 4/1/2015 6/30/2015 J0690 Injection, cefazolin sodium, 500 mg $0.85 7/1/2015 12/31/2078

J0692 Injection, cefepime HCl, 500 mg $2.38 7/1/2014 9/30/2014 J0692 Injection, cefepime HCl, 500 mg $2.40 10/1/2014 12/31/2014 J0692 Injection, cefepime HCl, 500 mg $2.52 1/1/2015 3/31/2015 J0692 Injection, cefepime HCl, 500 mg $2.37 4/1/2015 6/30/2015 J0692 Injection, cefepime HCl, 500 mg $2.58 7/1/2015 12/31/2078

J0694 Injection, cefoxitin sodium, 1 gm $5.08 7/1/2014 9/30/2014 J0694 Injection, cefoxitin sodium, 1 gm $4.99 10/1/2014 12/31/2014 J0694 Injection, cefoxitin sodium, 1 gm $5.03 1/1/2015 3/31/2015 J0694 Injection, cefoxitin sodium, 1 gm $4.88 4/1/2015 6/30/2015 J0694 Injection, cefoxitin sodium, 1 gm $4.82 7/1/2015 12/31/2078

J0696 Injection, ceftriaxone sodium, per 250 mg $0.66 7/1/2014 9/30/2014 J0696 Injection, ceftriaxone sodium, per 250 mg $0.70 10/1/2014 12/31/2014 J0696 Injection, ceftriaxone sodium, per 250 mg $0.68 1/1/2015 3/31/2015 J0696 Injection, ceftriaxone sodium, per 250 mg $0.78 4/1/2015 6/30/2015 J0696 Injection, ceftriaxone sodium, per 250 mg $0.71 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J0697 Injection, sterile cefuroxime sodium, per 750 mg $2.64 7/1/2014 9/30/2014 J0697 Injection, sterile cefuroxime sodium, per 750 mg $2.79 10/1/2014 12/31/2014 J0697 Injection, sterile cefuroxime sodium, per 750 mg $2.72 1/1/2015 3/31/2015 J0697 Injection, sterile cefuroxime sodium, per 750 mg $2.96 4/1/2015 6/30/2015 J0697 Injection, sterile cefuroxime sodium, per 750 mg $2.50 7/1/2015 12/31/2078

J0698 Injection, cefotaxime sodium, per gram $1.91 7/1/2014 9/30/2014 J0698 Injection, cefotaxime sodium, per gram $1.81 10/1/2014 12/31/2014 J0698 Injection, cefotaxime sodium, per gram $1.90 1/1/2015 3/31/2015 J0698 Injection, cefotaxime sodium, per gram $1.78 4/1/2015 6/30/2015 J0698 Injection, cefotaxime sodium, per gram $1.73 7/1/2015 12/31/2078

J0702 Injection, betamethasone acetate & sodium phosphate, per 3 mg $5.59 7/1/2014 9/30/2014 J0702 Injection, betamethasone acetate & sodium phosphate, per 3 mg $5.71 10/1/2014 12/31/2014 J0702 Injection, betamethasone acetate & sodium phosphate, per 3 mg $5.90 1/1/2015 3/31/2015 J0702 Injection, betamethasone acetate & sodium phosphate, per 3 mg $5.92 4/1/2015 6/30/2015 J0702 Injection, betamethasone acetate & sodium phosphate, per 3 mg $5.86 7/1/2015 12/31/2078

J0706 Injection, caffeine citrate, 5 mg $0.55 7/1/2014 12/31/2078

J0710 Injection, cephapirin sodium, up to 1 gm $6.90 7/1/2014 12/31/2078

J0715 Injection, ceftizoxime sodium, per 500 mg $5.24 7/1/2014 12/31/2078

J0717 Inj certolizumab pegol 1MG $6.53 7/1/2014 9/30/2014 J0717 Inj certolizumab pegol 1MG $6.56 10/1/2014 12/31/2014 J0717 Inj certolizumab pegol 1MG $6.60 1/1/2015 3/31/2015 J0717 Inj certolizumab pegol 1MG $6.05 4/1/2015 6/30/2015 J0717 Inj certolizumab pegol 1MG $5.99 7/1/2015 12/31/2078

J0720 Injection, chloramphenicol sodium succinate, up to 1 gm $31.74 7/1/2014 12/31/2078

J0725 Injection, chorionic gonadotropin, per 1,000 USP units $16.99 7/1/2014 9/30/2014 J0725 Injection, chorionic gonadotropin, per 1,000 USP units $18.07 10/1/2014 12/31/2014 J0725 Injection, chorionic gonadotropin, per 1,000 USP units $18.40 1/1/2015 3/31/2015 J0725 Injection, chorionic gonadotropin, per 1,000 USP units $19.38 4/1/2015 6/30/2015 J0725 Injection, chorionic gonadotropin, per 1,000 USP units $18.57 7/1/2015 12/31/2078

J0735 Injection, clonidine HCl, 1 mg $20.91 7/1/2014 9/30/2014 J0735 Injection, clonidine HCl, 1 mg $19.17 10/1/2014 12/31/2014 J0735 Injection, clonidine HCl, 1 mg $21.88 1/1/2015 3/31/2015 J0735 Injection, clonidine HCl, 1 mg $20.23 4/1/2015 6/30/2015 J0735 Injection, clonidine HCl, 1 mg $17.49 7/1/2015 12/31/2078

J0740 Injection, cidofovir, 375 mg $600.91 7/1/2014 9/30/2014 J0740 Injection, cidofovir, 375 mg $588.10 10/1/2014 12/31/2014 J0740 Injection, cidofovir, 375 mg $584.51 1/1/2015 3/31/2015 J0740 Injection, cidofovir, 375 mg $553.01 4/1/2015 6/30/2015 J0740 Injection, cidofovir, 375 mg $546.76 7/1/2015 12/31/2078

J0743 Injection, cilastatin sodium; imipenem, per 250 mg $5.35 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J0743 Injection, cilastatin sodium; imipenem, per 250 mg $4.83 10/1/2014 12/31/2014 J0743 Injection, cilastatin sodium; imipenem, per 250 mg $5.12 1/1/2015 3/31/2015 J0743 Injection, cilastatin sodium; imipenem, per 250 mg $4.39 4/1/2015 6/30/2015 J0743 Injection, cilastatin sodium; imipenem, per 250 mg $4.08 7/1/2015 12/31/2078

J0744 Injection, ciprofloxacin for IV infusion, 200 mg $1.18 7/1/2014 9/30/2014 J0744 Injection, ciprofloxacin for IV infusion, 200 mg $1.10 10/1/2014 3/31/2015 J0744 Injection, ciprofloxacin for IV infusion, 200 mg $1.41 4/1/2015 6/30/2015 J0744 Injection, ciprofloxacin for IV infusion, 200 mg $1.61 7/1/2015 12/31/2078

J0745 Injection, codeine phosphate, per 30 mg $1.35 7/1/2014 12/31/2078

J0760 Injection, colchicine, per 1 mg $6.57 7/1/2014 12/31/2078

J0770 Injection, colistimethate sodium, up to 150 mg $11.60 7/1/2014 9/30/2014 J0770 Injection, colistimethate sodium, up to 150 mg $11.50 10/1/2014 12/31/2014 J0770 Injection, colistimethate sodium, up to 150 mg $11.59 1/1/2015 3/31/2015 J0770 Injection, colistimethate sodium, up to 150 mg $11.48 4/1/2015 6/30/2015 J0770 Injection, colistimethate sodium, up to 150 mg $12.06 7/1/2015 12/31/2078

J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg $38.70 7/1/2014 9/30/2014 J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg $38.26 10/1/2014 12/31/2014 J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg $38.45 1/1/2015 3/31/2015 J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg $38.42 4/1/2015 6/30/2015 J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg $38.05 7/1/2015 12/31/2078

J0780 Injection, prochlorperazine, up to 10 mg $9.80 7/1/2014 9/30/2014 J0780 Injection, prochlorperazine, up to 10 mg $9.36 10/1/2014 12/31/2014 J0780 Injection, prochlorperazine, up to 10 mg $13.84 1/1/2015 3/31/2015 J0780 Injection, prochlorperazine, up to 10 mg $13.32 4/1/2015 6/30/2015 J0780 Injection, prochlorperazine, up to 10 mg $11.75 7/1/2015 12/31/2078

J0795 Injection, corticorelin ovine triflutal, 1 mcg $7.77 7/1/2014 9/30/2014 J0795 Injection, corticorelin ovine triflutal, 1 mcg $7.72 10/1/2014 12/31/2014 J0795 Injection, corticorelin ovine triflutal, 1 mcg $7.73 1/1/2015 3/31/2015 J0795 Injection, corticorelin ovine triflutal, 1 mcg $7.74 4/1/2015 12/31/2078

J0800 Injection, corticotropin, up to 40 units $3,299.53 7/1/2014 9/30/2014 J0800 Injection, corticotropin, up to 40 units $3,324.92 10/1/2014 12/31/2014 J0800 Injection, corticotropin, up to 40 units $3,324.95 1/1/2015 3/31/2015 J0800 Injection, corticotropin, up to 40 units $3,339.97 4/1/2015 6/30/2015 J0800 Injection, corticotropin, up to 40 units $3,392.08 7/1/2015 12/31/2078

J0833 Injection, cosyntropin NOS, 0.25 mg $101.68 7/1/2014 12/31/2078

J0834 Injection, cosyntropin (Cortrosyn), 0.25 mg $51.56 7/1/2014 9/30/2014 J0834 Injection, cosyntropin (Cortrosyn), 0.25 mg $51.36 10/1/2014 12/31/2014 J0834 Injection, cosyntropin (Cortrosyn), 0.25 mg $47.02 1/1/2015 3/31/2015 J0834 Injection, cosyntropin (Cortrosyn), 0.25 mg $45.87 4/1/2015 6/30/2015 J0834 Injection, cosyntropin (Cortrosyn), 0.25 mg $44.81 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J0850 Injection, cytomegalovirus immune globulin IV (human), per vial $1,013.87 7/1/2014 6/30/2015 J0850 Injection, cytomegalovirus immune globulin IV (human), per vial $1,063.35 7/1/2015 12/31/2078

J0878 Injection, daptomycin, 1 mg $0.67 7/1/2014 12/31/2014 J0878 Injection, daptomycin, 1 mg $0.71 1/1/2015 6/30/2015 J0878 Injection, daptomycin, 1 mg $0.76 7/1/2015 12/31/2078

J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use) $3.70 7/1/2014 9/30/2014 J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use) $3.77 10/1/2014 12/31/2014 J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use) $3.90 1/1/2015 3/31/2015 J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use) $3.73 4/1/2015 6/30/2015 J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use) $4.06 7/1/2015 12/31/2078

J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD use on dialysis) $3.70 7/1/2014 9/30/2014 J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD use on dialysis) $3.77 10/1/2014 12/31/2014 J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD use on dialysis) $3.90 1/1/2015 3/31/2015 J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD use on dialysis) $3.73 4/1/2015 6/30/2015 J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD use on dialysis) $4.06 7/1/2015 12/31/2078

J0885 Injection, epoetin alfa, (for non-ESRD use), 1,000 units $11.38 7/1/2014 9/30/2014 J0885 Injection, epoetin alfa, (for non-ESRD use), 1,000 units $11.65 10/1/2014 12/31/2014 J0885 Injection, epoetin alfa, (for non-ESRD use), 1,000 units $11.89 1/1/2015 3/31/2015 J0885 Injection, epoetin alfa, (for non-ESRD use), 1,000 units $11.84 4/1/2015 6/30/2015 J0885 Injection, epoetin alfa, (for non-ESRD use), 1,000 units $12.14 7/1/2015 12/31/2078

J0886 Injection, epoetin alfa, 1,000 units (for ESRD on dialysis) $11.38 7/1/2014 9/30/2014 J0886 Injection, epoetin alfa, 1,000 units (for ESRD on dialysis) $11.65 10/1/2014 12/31/2014 J0886 Injection, epoetin alfa, 1,000 units (for ESRD on dialysis) $11.89 1/1/2015 3/31/2015 J0886 Injection, epoetin alfa, 1,000 units (for ESRD on dialysis) $11.84 4/1/2015 6/30/2015 J0886 Injection, epoetin alfa, 1,000 units (for ESRD on dialysis) $12.14 7/1/2015 12/31/2078

J0894 Injection, decitabine, 1 mg $29.40 7/1/2014 9/30/2014 J0894 Injection, decitabine, 1 mg $28.25 10/1/2014 12/31/2014 J0894 Injection, decitabine, 1 mg $27.27 1/1/2015 3/31/2015 J0894 Injection, decitabine, 1 mg $26.11 4/1/2015 6/30/2015 J0894 Injection, decitabine, 1 mg $24.29 7/1/2015 12/31/2078

J0895 Injection, deferoxamine mesylate, 500 mg $8.21 7/1/2014 9/30/2014 J0895 Injection, deferoxamine mesylate, 500 mg $8.66 10/1/2014 12/31/2014 J0895 Injection, deferoxamine mesylate, 500 mg $8.93 1/1/2015 3/31/2015 J0895 Injection, deferoxamine mesylate, 500 mg $8.38 4/1/2015 6/30/2015 J0895 Injection, deferoxamine mesylate, 500 mg $8.87 7/1/2015 12/31/2078

J0897 Injection, denosumab, 1 mg $14.44 7/1/2014 9/30/2014 J0897 Injection, denosumab, 1 mg $14.45 10/1/2014 12/31/2014 J0897 Injection, denosumab, 1 mg $14.69 1/1/2015 3/31/2015 J0897 Injection, denosumab, 1 mg $14.71 4/1/2015 6/30/2015 J0897 Injection, denosumab, 1 mg $15.13 7/1/2015 12/31/2078

J0900 Injection, testosterone enanthate & estradiol valerate, up to 1 cc $33.36 7/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J0945 Injection, brompheniramine maleate, per 10 mg $0.80 7/1/2014 12/31/2078

J1000 Injection, depo-estradiol cypionate, up to 5 mg $10.11 7/1/2014 9/30/2014 J1000 Injection, depo-estradiol cypionate, up to 5 mg $10.35 10/1/2014 12/31/2014 J1000 Injection, depo-estradiol cypionate, up to 5 mg $10.98 1/1/2015 6/30/2015 J1000 Injection, depo-estradiol cypionate, up to 5 mg $12.50 7/1/2015 12/31/2078

J1020 Injection, methylprednisolone acetate, 20 mg $3.48 7/1/2014 12/31/2014 J1020 Injection, methylprednisolone acetate, 20 mg $3.44 1/1/2015 3/31/2015 J1020 Injection, methylprednisolone acetate, 20 mg $3.53 4/1/2015 6/30/2015 J1020 Injection, methylprednisolone acetate, 20 mg $2.97 7/1/2015 12/31/2078

J1030 Injection, methylprednisolone acetate, 40 mg $3.14 7/1/2014 9/30/2014 J1030 Injection, methylprednisolone acetate, 40 mg $3.25 10/1/2014 12/31/2014 J1030 Injection, methylprednisolone acetate, 40 mg $3.35 1/1/2015 3/31/2015 J1030 Injection, methylprednisolone acetate, 40 mg $3.52 4/1/2015 6/30/2015 J1030 Injection, methylprednisolone acetate, 40 mg $3.58 7/1/2015 12/31/2078

J1040 Injection, methylprednisolone acetate, 80 mg $5.95 7/1/2014 9/30/2014 J1040 Injection, methylprednisolone acetate, 80 mg $6.24 10/1/2014 12/31/2014 J1040 Injection, methylprednisolone acetate, 80 mg $6.15 1/1/2015 3/31/2015 J1040 Injection, methylprednisolone acetate, 80 mg $6.62 4/1/2015 6/30/2015 J1040 Injection, methylprednisolone acetate, 80 mg $6.46 7/1/2015 12/31/2078

J1050 Injection, medroxyprogesterone acetate, 1 mg $0.27 7/1/2014 9/30/2014 J1050 Injection, medroxyprogesterone acetate, 1 mg $0.28 10/1/2014 12/31/2014 J1050 Injection, medroxyprogesterone acetate, 1 mg $0.30 1/1/2015 6/30/2015 J1050 Injection, medroxyprogesterone acetate, 1 mg $0.32 7/1/2015 12/31/2078

J1060 Injection, testosterone/estradiol cypionate, up to 1 ml $4.14 7/1/2014 12/31/2014

J1070 Injection, testosterone cypionate, up to 100 mg $5.58 7/1/2014 9/30/2014 J1070 Injection, testosterone cypionate, up to 100 mg $4.94 10/1/2014 12/31/2014

J1071 Inj testosterone cypionate, 1 mg $0.03 1/1/2015 12/31/2078

J1080 Injection, testosterone cypionate, 1 cc, 200 mg $5.76 7/1/2014 9/30/2014 J1080 Injection, testosterone cypionate, 1 cc, 200 mg $4.97 10/1/2014 12/31/2014

J1094 Injection, dexamethasone acetate, 1 mg $0.23 7/1/2014 12/31/2078

J1100 Injection, dexamethosone sodium phosphate, 1 mg $0.15 7/1/2014 9/30/2014 J1100 Injection, dexamethosone sodium phosphate, 1 mg $0.14 10/1/2014 12/31/2014 J1100 Injection, dexamethosone sodium phosphate, 1 mg $0.15 1/1/2015 3/31/2015 J1100 Injection, dexamethosone sodium phosphate, 1 mg $0.13 4/1/2015 6/30/2015 J1100 Injection, dexamethosone sodium phosphate, 1 mg $0.14 7/1/2015 12/31/2078

J1110 Injection, dihydroergotamine mesylate, per 1 mg $33.33 7/1/2014 9/30/2014 J1110 Injection, dihydroergotamine mesylate, per 1 mg $65.27 10/1/2014 12/31/2014 J1110 Injection, dihydroergotamine mesylate, per 1 mg $53.69 1/1/2015 3/31/2015 J1110 Injection, dihydroergotamine mesylate, per 1 mg $51.95 4/1/2015 6/30/2015 Procedure Effective Code Description Rate End Date Code Date J1110 Injection, dihydroergotamine mesylate, per 1 mg $154.63 7/1/2015 12/31/2078

J1120 Injection, acetazolamid sodium, up to 500 mg $23.26 7/1/2014 9/30/2014 J1120 Injection, acetazolamid sodium, up to 500 mg $22.39 10/1/2014 12/31/2014 J1120 Injection, acetazolamid sodium, up to 500 mg $21.40 1/1/2015 3/31/2015 J1120 Injection, acetazolamid sodium, up to 500 mg $20.84 4/1/2015 6/30/2015 J1120 Injection, acetazolamid sodium, up to 500 mg $21.04 7/1/2015 12/31/2078

J1160 Injection, digoxin, up to 0.5 mg $4.25 7/1/2014 9/30/2014 J1160 Injection, digoxin, up to 0.5 mg $5.54 10/1/2014 12/31/2014 J1160 Injection, digoxin, up to 0.5 mg $9.47 1/1/2015 3/31/2015 J1160 Injection, digoxin, up to 0.5 mg $126.01 4/1/2015 6/30/2015 J1160 Injection, digoxin, up to 0.5 mg $23.14 7/1/2015 12/31/2078

J1162 Injection, digoxin immune fab (ovine), per vial $1,645.90 7/1/2014 9/30/2014 J1162 Injection, digoxin immune fab (ovine), per vial $2,051.63 10/1/2014 3/31/2015 J1162 Injection, digoxin immune fab (ovine), per vial $2,361.31 4/1/2015 6/30/2015 J1162 Injection, digoxin immune fab (ovine), per vial $2,359.12 7/1/2015 12/31/2078

J1165 Injection, phenytoin sodium, per 50 mg $0.54 7/1/2014 9/30/2014 J1165 Injection, phenytoin sodium, per 50 mg $0.53 10/1/2014 12/31/2014 J1165 Injection, phenytoin sodium, per 50 mg $0.57 1/1/2015 3/31/2015 J1165 Injection, phenytoin sodium, per 50 mg $0.64 4/1/2015 6/30/2015 J1165 Injection, phenytoin sodium, per 50 mg $0.65 7/1/2015 12/31/2078

J1170 Injection, hydromorphone, up to 4 mg $2.01 7/1/2014 9/30/2014 J1170 Injection, hydromorphone, up to 4 mg $1.83 10/1/2014 12/31/2014 J1170 Injection, hydromorphone, up to 4 mg $2.13 1/1/2015 3/31/2015 J1170 Injection, hydromorphone, up to 4 mg $2.07 4/1/2015 6/30/2015 J1170 Injection, hydromorphone, up to 4 mg $1.83 7/1/2015 12/31/2078

J1180 Injection, dyphylline, up to 500 mg $8.05 7/1/2014 12/31/2078

J1190 Injection, dexrazoxane HCl, per 250 mg $141.05 7/1/2014 9/30/2014 J1190 Injection, dexrazoxane HCl, per 250 mg $144.86 10/1/2014 12/31/2014 J1190 Injection, dexrazoxane HCl, per 250 mg $138.61 1/1/2015 3/31/2015 J1190 Injection, dexrazoxane HCl, per 250 mg $137.57 4/1/2015 6/30/2015 J1190 Injection, dexrazoxane HCl, per 250 mg $138.21 7/1/2015 12/31/2078

J1200 Injection, diphenhydramine HCl, up to 50 mg $0.61 7/1/2014 9/30/2014 J1200 Injection, diphenhydramine HCl, up to 50 mg $0.53 10/1/2014 12/31/2014 J1200 Injection, diphenhydramine HCl, up to 50 mg $0.60 1/1/2015 3/31/2015 J1200 Injection, diphenhydramine HCl, up to 50 mg $0.46 4/1/2015 6/30/2015 J1200 Injection, diphenhydramine HCl, up to 50 mg $0.55 7/1/2015 12/31/2078

J1205 Injection, chlorothiazide sodium, per 500 mg $131.93 7/1/2014 9/30/2014 J1205 Injection, chlorothiazide sodium, per 500 mg $122.65 10/1/2014 12/31/2014 J1205 Injection, chlorothiazide sodium, per 500 mg $119.20 1/1/2015 3/31/2015 J1205 Injection, chlorothiazide sodium, per 500 mg $122.24 4/1/2015 6/30/2015 J1205 Injection, chlorothiazide sodium, per 500 mg $136.43 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J1212 Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml $73.78 7/1/2014 9/30/2014 J1212 Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml $83.54 10/1/2014 12/31/2014 J1212 Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml $88.72 1/1/2015 3/31/2015 J1212 Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml $90.12 4/1/2015 6/30/2015 J1212 Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml $90.07 7/1/2015 12/31/2078

J1230 Injection, methadone HCl, up to 10 mg $7.32 7/1/2014 9/30/2014 J1230 Injection, methadone HCl, up to 10 mg $8.50 10/1/2014 12/31/2014 J1230 Injection, methadone HCl, up to 10 mg $9.31 1/1/2015 3/31/2015 J1230 Injection, methadone HCl, up to 10 mg $9.27 4/1/2015 6/30/2015 J1230 Injection, methadone HCl, up to 10 mg $9.83 7/1/2015 12/31/2078

J1240 Injection, dimenhydrinate, up to 50 mg $5.22 7/1/2014 9/30/2014 J1240 Injection, dimenhydrinate, up to 50 mg $5.32 10/1/2014 12/31/2014 J1240 Injection, dimenhydrinate, up to 50 mg $5.35 1/1/2015 3/31/2015 J1240 Injection, dimenhydrinate, up to 50 mg $5.18 4/1/2015 6/30/2015 J1240 Injection, dimenhydrinate, up to 50 mg $5.15 7/1/2015 12/31/2078

J1245 Injection, dipyridamole, per 10 mg $0.80 7/1/2014 9/30/2014 J1245 Injection, dipyridamole, per 10 mg $0.82 10/1/2014 12/31/2014 J1245 Injection, dipyridamole, per 10 mg $0.80 1/1/2015 3/31/2015 J1245 Injection, dipyridamole, per 10 mg $0.81 4/1/2015 6/30/2015 J1245 Injection, dipyridamole, per 10 mg $0.79 7/1/2015 12/31/2078

J1250 Injection, dobutamine HCl, per 250 mg $5.81 7/1/2014 9/30/2014 J1250 Injection, dobutamine HCl, per 250 mg $5.30 10/1/2014 12/31/2014 J1250 Injection, dobutamine HCl, per 250 mg $6.40 1/1/2015 3/31/2015 J1250 Injection, dobutamine HCl, per 250 mg $5.99 4/1/2015 6/30/2015 J1250 Injection, dobutamine HCl, per 250 mg $5.95 7/1/2015 12/31/2078

J1260 Injection, dolasetron mesylate, 10 mg $5.72 7/1/2014 9/30/2014 J1260 Injection, dolasetron mesylate, 10 mg $6.19 10/1/2014 12/31/2014 J1260 Injection, dolasetron mesylate, 10 mg $6.76 1/1/2015 3/31/2015 J1260 Injection, dolasetron mesylate, 10 mg $7.29 4/1/2015 6/30/2015 J1260 Injection, dolasetron mesylate, 10 mg $7.58 7/1/2015 12/31/2078

J1265 Injection, dopamine HCl, 40 mg $0.39 7/1/2014 9/30/2014 J1265 Injection, dopamine HCl, 40 mg $0.57 10/1/2014 12/31/2014 J1265 Injection, dopamine HCl, 40 mg $0.62 1/1/2015 3/31/2015 J1265 Injection, dopamine HCl, 40 mg $0.54 4/1/2015 6/30/2015 J1265 Injection, dopamine HCl, 40 mg $0.65 7/1/2015 12/31/2078

J1267 Injection, doripenem, 10 mg $0.61 7/1/2014 9/30/2014 J1267 Injection, doripenem, 10 mg $0.63 10/1/2014 12/31/2014 J1267 Injection, doripenem, 10 mg $0.65 1/1/2015 6/30/2015 J1267 Injection, doripenem, 10 mg $0.67 7/1/2015 12/31/2078

J1270 Injection, doxercalciferol, 1 mcg $1.66 7/1/2014 9/30/2014 J1270 Injection, doxercalciferol, 1 mcg $1.46 10/1/2014 12/31/2014 J1270 Injection, doxercalciferol, 1 mcg $1.48 1/1/2015 3/31/2015 J1270 Injection, doxercalciferol, 1 mcg $1.25 4/1/2015 6/30/2015 Procedure Effective Code Description Rate End Date Code Date J1270 Injection, doxercalciferol, 1 mcg $1.21 7/1/2015 12/31/2078

J1290 Injection, ecallantide, 1 mg $368.90 7/1/2014 9/30/2014 J1290 Injection, ecallantide, 1 mg $375.64 10/1/2014 12/31/2014 J1290 Injection, ecallantide, 1 mg $374.64 1/1/2015 3/31/2015 J1290 Injection, ecallantide, 1 mg $375.78 4/1/2015 6/30/2015 J1290 Injection, ecallantide, 1 mg $375.38 7/1/2015 12/31/2078

J1300 Injection, eculizumab, 10 mg $206.14 7/1/2014 12/31/2014 J1300 Injection, eculizumab, 10 mg $210.35 1/1/2015 3/31/2015 J1300 Injection, eculizumab, 10 mg $211.89 4/1/2015 6/30/2015 J1300 Injection, eculizumab, 10 mg $213.93 7/1/2015 12/31/2078

J1320 Injection, amitriptyline HCl, up to 20 mg $2.24 7/1/2014 12/31/2078

J1322 Elosulfase alfa, injection, 1 mg $221.70 1/1/2015 3/31/2015 J1322 Elosulfase alfa, injection, 1 mg $221.75 4/1/2015 6/30/2015 J1322 Elosulfase alfa, injection, 1 mg $221.63 7/1/2015 12/31/2078

J1325 Injection, epoprostenol, 0.5 mg $15.52 7/1/2014 9/30/2014 J1325 Injection, epoprostenol, 0.5 mg $15.46 10/1/2014 12/31/2014 J1325 Injection, epoprostenol, 0.5 mg $15.33 1/1/2015 3/31/2015 J1325 Injection, epoprostenol, 0.5 mg $15.45 4/1/2015 6/30/2015 J1325 Injection, epoprostenol, 0.5 mg $15.43 7/1/2015 12/31/2078

J1327 Injection, eptifibatide, 5 mg $27.23 7/1/2014 9/30/2014 J1327 Injection, eptifibatide, 5 mg $27.29 10/1/2014 12/31/2014 J1327 Injection, eptifibatide, 5 mg $28.57 1/1/2015 3/31/2015 J1327 Injection, eptifibatide, 5 mg $29.17 4/1/2015 6/30/2015 J1327 Injection, eptifibatide, 5 mg $31.56 7/1/2015 12/31/2078

J1330 Injection, ergonovine maleate, up to 0.2 mg $3.94 7/1/2014 12/31/2078

J1364 Injection, erythromycin lactobionate, per 500 mg $45.40 7/1/2014 9/30/2014 J1364 Injection, erythromycin lactobionate, per 500 mg $45.01 10/1/2014 12/31/2014 J1364 Injection, erythromycin lactobionate, per 500 mg $43.93 1/1/2015 3/31/2015 J1364 Injection, erythromycin lactobionate, per 500 mg $43.46 4/1/2015 6/30/2015 J1364 Injection, erythromycin lactobionate, per 500 mg $51.13 7/1/2015 12/31/2078

J1380 Injection, estradiol valerate, up to 10 mg $9.06 7/1/2014 9/30/2014 J1380 Injection, estradiol valerate, up to 10 mg $9.55 10/1/2014 12/31/2014 J1380 Injection, estradiol valerate, up to 10 mg $9.39 1/1/2015 3/31/2015 J1380 Injection, estradiol valerate, up to 10 mg $9.74 4/1/2015 6/30/2015 J1380 Injection, estradiol valerate, up to 10 mg $11.13 7/1/2015 12/31/2078

J1410 Injection, estrogen conjugated, per 25 mg $173.60 7/1/2014 9/30/2014 J1410 Injection, estrogen conjugated, per 25 mg $180.14 10/1/2014 12/31/2014 J1410 Injection, estrogen conjugated, per 25 mg $190.66 1/1/2015 6/30/2015 J1410 Injection, estrogen conjugated, per 25 mg $207.39 7/1/2015 12/31/2078

J1430 Injection, ethanolamine oleate, 100 mg $310.84 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J1430 Injection, ethanolamine oleate, 100 mg $311.06 10/1/2014 12/31/2014 J1430 Injection, ethanolamine oleate, 100 mg $311.12 1/1/2015 6/30/2015 J1430 Injection, ethanolamine oleate, 100 mg $375.09 7/1/2015 12/31/2078

J1435 injection, estrone, per 1 mg $1.54 7/1/2014 12/31/2078

J1436 Injection, etidronate disodium, per 300 mg $71.41 7/1/2014 12/31/2078

J1438 Injection, etanercept, 25 mg $280.13 7/1/2014 9/30/2014 J1438 Injection, etanercept, 25 mg $285.27 10/1/2014 12/31/2014 J1438 Injection, etanercept, 25 mg $299.37 1/1/2015 3/31/2015 J1438 Injection, etanercept, 25 mg $302.37 4/1/2015 6/30/2015 J1438 Injection, etanercept, 25 mg $310.74 7/1/2015 12/31/2078

J1442 Injection filgrastim g-csf 1 MCG $1.00 7/1/2014 9/30/2014 J1442 Injection filgrastim g-csf 1 MCG $0.99 10/1/2014 12/31/2014 J1442 Injection filgrastim g-csf 1 MCG $1.00 1/1/2015 3/31/2015 J1442 Injection filgrastim g-csf 1 MCG $0.99 4/1/2015 6/30/2015 J1442 Injection filgrastim g-csf 1 MCG $1.00 7/1/2015 12/31/2078

J1450 Injection, fluconazole, 200 mg $3.95 7/1/2014 9/30/2014 J1450 Injection, fluconazole, 200 mg $4.22 10/1/2014 12/31/2014 J1450 Injection, fluconazole, 200 mg $3.76 1/1/2015 3/31/2015 J1450 Injection, fluconazole, 200 mg $3.85 4/1/2015 6/30/2015 J1450 Injection, fluconazole, 200 mg $3.92 7/1/2015 12/31/2078

J1451 Injection, fomepizole, 15 mg $6.73 7/1/2014 9/30/2014 J1451 Injection, fomepizole, 15 mg $6.44 10/1/2014 12/31/2014 J1451 Injection, fomepizole, 15 mg $6.34 1/1/2015 3/31/2015 J1451 Injection, fomepizole, 15 mg $5.81 4/1/2015 6/30/2015 J1451 Injection, fomepizole, 15 mg $5.74 7/1/2015 12/31/2078

J1453 Injection, fosaprepitant, 1 mg $1.72 7/1/2014 9/30/2014 J1453 Injection, fosaprepitant, 1 mg $1.73 10/1/2014 12/31/2078

J1455 Injection, foscarnet sodium, per 1,000 mg $13.32 7/1/2014 12/31/2078

J1457 Injection, gallium nitrate, 1 mg $2.08 7/1/2014 12/31/2078

J1459 Injection, immune globulin (Privigen), IV, nonlyophilized, 500 mg $37.07 7/1/2014 9/30/2014 J1459 Injection, immune globulin (Privigen), IV, nonlyophilized, 500 mg $37.03 10/1/2014 12/31/2014 J1459 Injection, immune globulin (Privigen), IV, nonlyophilized, 500 mg $36.66 1/1/2015 3/31/2015 J1459 Injection, immune globulin (Privigen), IV, nonlyophilized, 500 mg $37.45 4/1/2015 6/30/2015 J1459 Injection, immune globulin (Privigen), IV, nonlyophilized, 500 mg $38.28 7/1/2015 12/31/2078

J1460 Injection, gamma globulin, intramuscular, 1 cc $28.68 7/1/2014 9/30/2014 J1460 Injection, gamma globulin, intramuscular, 1 cc $28.77 10/1/2014 12/31/2014 J1460 Injection, gamma globulin, intramuscular, 1 cc $28.89 1/1/2015 3/31/2015 J1460 Injection, gamma globulin, intramuscular, 1 cc $29.01 4/1/2015 6/30/2015 J1460 Injection, gamma globulin, intramuscular, 1 cc $29.11 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J1556 Injection imm glob bivigam, 500MG $37.92 7/1/2014 9/30/2014 J1556 Injection imm glob bivigam, 500MG $36.21 10/1/2014 12/31/2014 J1556 Injection imm glob bivigam, 500MG $38.47 1/1/2015 3/31/2015 J1556 Injection imm glob bivigam, 500MG $36.35 4/1/2015 6/30/2015 J1556 Injection imm glob bivigam, 500MG $39.01 7/1/2015 12/31/2078

J1559 Injection, immune globulin (Hizentra), 100 mg $7.93 7/1/2014 9/30/2014 J1559 Injection, immune globulin (Hizentra), 100 mg $7.94 10/1/2014 12/31/2014 J1559 Injection, immune globulin (Hizentra), 100 mg $7.95 1/1/2015 3/31/2015 J1559 Injection, immune globulin (Hizentra), 100 mg $8.18 4/1/2015 6/30/2015 J1559 Injection, immune globulin (Hizentra), 100 mg $8.17 7/1/2015 12/31/2078

J1560 Injection, gamma globulin, intramuscular, over 10 cc $286.78 7/1/2014 9/30/2014 J1560 Injection, gamma globulin, intramuscular, over 10 cc $287.67 10/1/2014 12/31/2014 J1560 Injection, gamma globulin, intramuscular, over 10 cc $288.94 1/1/2015 3/31/2015 J1560 Injection, gamma globulin, intramuscular, over 10 cc $290.08 4/1/2015 6/30/2015 J1560 Injection, gamma globulin, intramuscular, over 10 cc $291.10 7/1/2015 12/31/2078

J1561 Injection, immune globulin (Gamunex/gamunex-c/gammaked) 500 mg $40.32 7/1/2014 9/30/2014 J1561 Injection, immune globulin (Gamunex/gamunex-c/gammaked) 500 mg $40.02 10/1/2014 12/31/2014 J1561 Injection, immune globulin (Gamunex/gamunex-c/gammaked) 500 mg $40.22 1/1/2015 3/31/2015 J1561 Injection, immune globulin (Gamunex/gamunex-c/gammaked) 500 mg $39.91 4/1/2015 6/30/2015 J1561 Injection, immune globulin (Gamunex/gamunex-c/gammaked) 500 mg $39.80 7/1/2015 12/31/2078

J1562 Injection, immune globulin (Vivaglobin), 100 mg $12.72 7/1/2014 12/31/2078

J1566 Injection, immune globulin,IV, lyophilized (eg powder) NOS, 500 mg $28.71 7/1/2014 9/30/2014 J1566 Injection, immune globulin,IV, lyophilized (eg powder) NOS, 500 mg $26.75 10/1/2014 12/31/2014 J1566 Injection, immune globulin,IV, lyophilized (eg powder) NOS, 500 mg $26.73 1/1/2015 3/31/2015 J1566 Injection, immune globulin,IV, lyophilized (eg powder) NOS, 500 mg $28.95 4/1/2015 6/30/2015 J1566 Injection, immune globulin,IV, lyophilized (eg powder) NOS, 500 mg $32.25 7/1/2015 12/31/2078

J1568 Injection, immune globulin, (Octagam), IV, nonlyophilized, 500 mg $31.96 7/1/2014 9/30/2014 J1568 Injection, immune globulin, (Octagam), IV, nonlyophilized, 500 mg $36.92 10/1/2014 12/31/2014 J1568 Injection, immune globulin, (Octagam), IV, nonlyophilized, 500 mg $36.87 1/1/2015 3/31/2015 J1568 Injection, immune globulin, (Octagam), IV, nonlyophilized, 500 mg $40.55 4/1/2015 6/30/2015 J1568 Injection, immune globulin, (Octagam), IV, nonlyophilized, 500 mg $38.66 7/1/2015 12/31/2078

J1569 Injection, immune globulin, (Gammagard liquid), nonlyophilized, 500 mg $39.68 7/1/2014 9/30/2014 J1569 Injection, immune globulin, (Gammagard liquid), nonlyophilized, 500 mg $39.36 10/1/2014 12/31/2014 J1569 Injection, immune globulin, (Gammagard liquid), nonlyophilized, 500 mg $39.15 1/1/2015 3/31/2015 J1569 Injection, immune globulin, (Gammagard liquid), nonlyophilized, 500 mg $39.21 4/1/2015 6/30/2015 J1569 Injection, immune globulin, (Gammagard liquid), nonlyophilized, 500 mg $38.78 7/1/2015 12/31/2078

J1570 Injection, ganciclovir sodium, 500 mg $75.09 7/1/2014 9/30/2014 J1570 Injection, ganciclovir sodium, 500 mg $72.11 10/1/2014 12/31/2014 J1570 Injection, ganciclovir sodium, 500 mg $75.47 1/1/2015 3/31/2015 J1570 Injection, ganciclovir sodium, 500 mg $72.64 4/1/2015 6/30/2015 J1570 Injection, ganciclovir sodium, 500 mg $74.84 7/1/2015 12/31/2078

J1571 Injection, hepatitis B immune globulin (HepaGam B) intramuscular, 0.5 ml $51.64 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J1571 Injection, hepatitis B immune globulin (HepaGam B) intramuscular, 0.5 ml $53.70 10/1/2014 12/31/2014 J1571 Injection, hepatitis B immune globulin (HepaGam B) intramuscular, 0.5 ml $52.27 1/1/2015 3/31/2015 J1571 Injection, hepatitis B immune globulin (HepaGam B) intramuscular, 0.5 ml $53.86 4/1/2015 6/30/2015 J1571 Injection, hepatitis B immune globulin (HepaGam B) intramuscular, 0.5 ml $53.84 7/1/2015 12/31/2078

J1572 Injection, immune globulin (Flebogamma/Dif), IV, nonlyophilized, 500 mg $38.80 7/1/2014 9/30/2014 J1572 Injection, immune globulin (Flebogamma/Dif), IV, nonlyophilized, 500 mg $37.76 10/1/2014 12/31/2014 J1572 Injection, immune globulin (Flebogamma/Dif), IV, nonlyophilized, 500 mg $36.14 1/1/2015 3/31/2015 J1572 Injection, immune globulin (Flebogamma/Dif), IV, nonlyophilized, 500 mg $35.54 4/1/2015 6/30/2015 J1572 Injection, immune globulin (Flebogamma/Dif), IV, nonlyophilized, 500 mg $34.75 7/1/2015 12/31/2078

J1573 Injection, hepatitis B immune globulin (Hepagam B) intravenous, 0.5 ml $51.64 7/1/2014 9/30/2014 J1573 Injection, hepatitis B immune globulin (Hepagam B) intravenous, 0.5 ml $53.70 10/1/2014 12/31/2014 J1573 Injection, hepatitis B immune globulin (Hepagam B) intravenous, 0.5 ml $52.27 1/1/2015 3/31/2015 J1573 Injection, hepatitis B immune globulin (Hepagam B) intravenous, 0.5 ml $53.86 4/1/2015 6/30/2015 J1573 Injection, hepatitis B immune globulin (Hepagam B) intravenous, 0.5 ml $53.84 7/1/2015 12/31/2078

J1580 Injection, garamycin gentamicin, up to 80 mg $1.23 7/1/2014 12/31/2014 J1580 Injection, garamycin gentamicin, up to 80 mg $1.45 1/1/2015 3/31/2015 J1580 Injection, garamycin gentamicin, up to 80 mg $1.46 4/1/2015 6/30/2015 J1580 Injection, garamycin gentamicin, up to 80 mg $1.27 7/1/2015 12/31/2078

J1590 Injection, gatifloxacin, 10 mg $86.33 7/1/2014 12/31/2078

J1600 Injection, gold sodium thiomaleate, up to 50 mg $30.15 7/1/2014 12/31/2014 J1600 Injection, gold sodium thiomaleate, up to 50 mg $4.27 1/1/2015 3/31/2015 J1600 Injection, gold sodium thiomaleate, up to 50 mg $235.52 4/1/2015 6/30/2015 J1600 Injection, gold sodium thiomaleate, up to 50 mg $4.27 7/1/2015 12/31/2078

J1602 Injection Golimumab for iv use 1MG $23.93 7/1/2014 9/30/2014 J1602 Injection Golimumab for iv use 1MG $24.16 10/1/2014 12/31/2014 J1602 Injection Golimumab for iv use 1MG $23.92 1/1/2015 3/31/2015 J1602 Injection Golimumab for iv use 1MG $24.20 4/1/2015 6/30/2015 J1602 Injection Golimumab for iv use 1MG $24.04 7/1/2015 12/31/2078

J1610 Injection, glucagon HCl, per 1 mg $140.52 7/1/2014 9/30/2014 J1610 Injection, glucagon HCl, per 1 mg $146.07 10/1/2014 12/31/2014 J1610 Injection, glucagon HCl, per 1 mg $162.08 1/1/2015 3/31/2015 J1610 Injection, glucagon HCl, per 1 mg $156.78 4/1/2015 6/30/2015 J1610 Injection, glucagon HCl, per 1 mg $176.07 7/1/2015 12/31/2078

J1620 Injection, gonadorelin HCl, per 100 mcg $6.06 7/1/2014 12/31/2078

J1626 Injection, granisetron HCl, 100 mcg $0.45 7/1/2014 9/30/2014 J1626 Injection, granisetron HCl, 100 mcg $0.25 10/1/2014 12/31/2014 J1626 Injection, granisetron HCl, 100 mcg $0.49 1/1/2015 3/31/2015 J1626 Injection, granisetron HCl, 100 mcg $0.63 4/1/2015 6/30/2015 J1626 Injection, granisetron HCl, 100 mcg $0.39 7/1/2015 12/31/2078

J1630 Injection, haloperidol, up to 5 mg $1.68 7/1/2014 9/30/2014 J1630 Injection, haloperidol, up to 5 mg $1.98 10/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J1630 Injection, haloperidol, up to 5 mg $2.79 1/1/2015 3/31/2015 J1630 Injection, haloperidol, up to 5 mg $1.73 4/1/2015 6/30/2015 J1630 Injection, haloperidol, up to 5 mg $1.79 7/1/2015 12/31/2078

J1631 Injection, haloperidol decanoate, per 50 mg $19.18 7/1/2014 9/30/2014 J1631 Injection, haloperidol decanoate, per 50 mg $18.98 10/1/2014 12/31/2014 J1631 Injection, haloperidol decanoate, per 50 mg $18.67 1/1/2015 3/31/2015 J1631 Injection, haloperidol decanoate, per 50 mg $18.72 4/1/2015 6/30/2015 J1631 Injection, haloperidol decanoate, per 50 mg $20.21 7/1/2015 12/31/2078

J1640 Injection, hemin, 1 mg $19.02 7/1/2014 9/30/2014 J1640 Injection, hemin, 1 mg $20.73 10/1/2014 6/30/2015 J1640 Injection, hemin, 1 mg $21.58 7/1/2015 12/31/2078

J1642 Injection, heparin sodium, per 10 units $0.18 7/1/2014 9/30/2014 J1642 Injection, heparin sodium, per 10 units $0.17 10/1/2014 12/31/2014 J1642 Injection, heparin sodium, per 10 units $0.19 1/1/2015 3/31/2015 J1642 Injection, heparin sodium, per 10 units $0.17 4/1/2015 6/30/2015 J1642 Injection, heparin sodium, per 10 units $0.18 7/1/2015 12/31/2078

J1644 Injection, heparin sodium, per 1,000 units $0.21 7/1/2014 12/31/2014 J1644 Injection, heparin sodium, per 1,000 units $0.18 1/1/2015 3/31/2015 J1644 Injection, heparin sodium, per 1,000 units $0.03 4/1/2015 6/30/2015 J1644 Injection, heparin sodium, per 1,000 units $0.20 7/1/2015 12/31/2078

J1645 Injection, dalteparin sodium, per 2,500 IU $14.12 7/1/2014 9/30/2014 J1645 Injection, dalteparin sodium, per 2,500 IU $14.22 10/1/2014 12/31/2014 J1645 Injection, dalteparin sodium, per 2,500 IU $12.86 1/1/2015 3/31/2015 J1645 Injection, dalteparin sodium, per 2,500 IU $13.34 4/1/2015 6/30/2015 J1645 Injection, dalteparin sodium, per 2,500 IU $12.67 7/1/2015 12/31/2078

J1650 Injection, enoxaparin sodium, 10 mg $1.93 7/1/2014 9/30/2014 J1650 Injection, enoxaparin sodium, 10 mg $1.47 10/1/2014 12/31/2014 J1650 Injection, enoxaparin sodium, 10 mg $1.55 1/1/2015 3/31/2015 J1650 Injection, enoxaparin sodium, 10 mg $1.32 4/1/2015 6/30/2015 J1650 Injection, enoxaparin sodium, 10 mg $1.36 7/1/2015 12/31/2078

J1652 Injection, fondaparinux sodium, 0.5 mg $4.16 7/1/2014 9/30/2014 J1652 Injection, fondaparinux sodium, 0.5 mg $3.93 10/1/2014 12/31/2014 J1652 Injection, fondaparinux sodium, 0.5 mg $3.89 1/1/2015 3/31/2015 J1652 Injection, fondaparinux sodium, 0.5 mg $3.74 4/1/2015 6/30/2015 J1652 Injection, fondaparinux sodium, 0.5 mg $3.57 7/1/2015 12/31/2078

J1655 Injection, tinzaparin sodium, 1,000 IU $3.49 7/1/2014 12/31/2078

J1670 Injection, tetanus immune globulin, human, up to 250 units $305.82 7/1/2014 9/30/2014 J1670 Injection, tetanus immune globulin, human, up to 250 units $326.32 10/1/2014 12/31/2014 J1670 Injection, tetanus immune globulin, human, up to 250 units $328.40 1/1/2015 3/31/2015 J1670 Injection, tetanus immune globulin, human, up to 250 units $325.95 4/1/2015 6/30/2015 J1670 Injection, tetanus immune globulin, human, up to 250 units $337.36 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J1675 Injection histrelin acetate, 10 mcg $1,100.93 7/1/2014 12/31/2078

J1700 Injection, hydrocortisone acetate, up to 25 mg $0.66 7/1/2014 12/31/2078

J1710 Injection, hydrocortisone sodium phosphate, up to 50 mg $4.69 7/1/2014 12/31/2078

J1720 Injection, hydrocortisone sodium succinate, up to 100 mg $5.77 7/1/2014 9/30/2014 J1720 Injection, hydrocortisone sodium succinate, up to 100 mg $6.08 10/1/2014 12/31/2014 J1720 Injection, hydrocortisone sodium succinate, up to 100 mg $6.35 1/1/2015 3/31/2015 J1720 Injection, hydrocortisone sodium succinate, up to 100 mg $6.48 4/1/2015 6/30/2015 J1720 Injection, hydrocortisone sodium succinate, up to 100 mg $7.12 7/1/2015 12/31/2078

J1730 Injection, diazoxide, up to 300 mg $88.27 7/1/2014 12/31/2078

J1740 Injection, ibandronate sodium, 1 mg $160.36 7/1/2014 9/30/2014 J1740 Injection, ibandronate sodium, 1 mg $151.80 10/1/2014 12/31/2014 J1740 Injection, ibandronate sodium, 1 mg $123.88 1/1/2015 3/31/2015 J1740 Injection, ibandronate sodium, 1 mg $124.12 4/1/2015 6/30/2015 J1740 Injection, ibandronate sodium, 1 mg $114.11 7/1/2015 12/31/2078

J1742 Injection, ibutilide fumarate, 1 mg $140.52 7/1/2014 9/30/2014 J1742 Injection, ibutilide fumarate, 1 mg $112.30 10/1/2014 12/31/2014 J1742 Injection, ibutilide fumarate, 1 mg $110.02 1/1/2015 3/31/2015 J1742 Injection, ibutilide fumarate, 1 mg $114.69 4/1/2015 6/30/2015 J1742 Injection, ibutilide fumarate, 1 mg $139.40 7/1/2015 12/31/2078

J1743 Injection, idursulfase, 1 mg $483.03 7/1/2014 9/30/2014 J1743 Injection, idursulfase, 1 mg $483.05 10/1/2014 12/31/2014 J1743 Injection, idursulfase, 1 mg $483.10 1/1/2015 3/31/2015 J1743 Injection, idursulfase, 1 mg $497.69 4/1/2015 6/30/2015 J1743 Injection, idursulfase, 1 mg $497.41 7/1/2015 12/31/2078

J1745 Infection, infliximab, 10 mg $72.05 7/1/2014 9/30/2014 J1745 Infection, infliximab, 10 mg $74.34 10/1/2014 12/31/2014 J1745 Infection, infliximab, 10 mg $74.11 1/1/2015 3/31/2015 J1745 Infection, infliximab, 10 mg $76.51 4/1/2015 6/30/2015 J1745 Infection, infliximab, 10 mg $76.89 7/1/2015 12/31/2078

J1750 Injection, iron dextran, 50 mg $11.83 7/1/2014 9/30/2014 J1750 Injection, iron dextran, 50 mg $12.16 10/1/2014 12/31/2014 J1750 Injection, iron dextran, 50 mg $12.12 1/1/2015 6/30/2015 J1750 Injection, iron dextran, 50 mg $12.09 7/1/2015 12/31/2078

J1756 Injection, iron sucrose, 1 mg $0.31 7/1/2014 9/30/2014 J1756 Injection, iron sucrose, 1 mg $0.28 10/1/2014 12/31/2014 J1756 Injection, iron sucrose, 1 mg $0.21 1/1/2015 3/31/2015 J1756 Injection, iron sucrose, 1 mg $0.27 4/1/2015 12/31/2078

J1786 Injection, imuglucerase, 10 units $42.01 7/1/2014 3/31/2015 J1786 Injection, imuglucerase, 10 units $42.00 4/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J1790 Injection, droperidol, up to 5 mg $2.14 7/1/2014 12/31/2078

J1800 Injection, propranolol HCl, up to 1 mg $0.71 7/1/2014 9/30/2014 J1800 Injection, propranolol HCl, up to 1 mg $2.42 10/1/2014 12/31/2014 J1800 Injection, propranolol HCl, up to 1 mg $2.95 1/1/2015 3/31/2015 J1800 Injection, propranolol HCl, up to 1 mg $2.24 4/1/2015 6/30/2015 J1800 Injection, propranolol HCl, up to 1 mg $2.58 7/1/2015 12/31/2078

J1810 Injection, droperidol & fentanyl citrate, to 2 ml ampule $5.58 7/1/2014 12/31/2078

J1815 Injection, insulin, per 5 units $0.48 7/1/2014 9/30/2014 J1815 Injection, insulin, per 5 units $0.43 10/1/2014 12/31/2014 J1815 Injection, insulin, per 5 units $0.48 1/1/2015 3/31/2015 J1815 Injection, insulin, per 5 units $0.62 4/1/2015 6/30/2015 J1815 Injection, insulin, per 5 units $0.74 7/1/2015 12/31/2078

J1817 Insulin for administration through DME, (ie insulin pump), per 50 units $5.79 7/1/2014 9/30/2014 J1817 Insulin for administration through DME, (ie insulin pump), per 50 units $5.31 10/1/2014 12/31/2014 J1817 Insulin for administration through DME, (ie insulin pump), per 50 units $5.32 1/1/2015 3/31/2015 J1817 Insulin for administration through DME, (ie insulin pump), per 50 units $5.20 4/1/2015 6/30/2015 J1817 Insulin for administration through DME, (ie insulin pump), per 50 units $7.36 7/1/2015 12/31/2078

J1830 Injection, interferon beta-1b, 0.25 mg $341.80 7/1/2014 9/30/2014 J1830 Injection, interferon beta-1b, 0.25 mg $353.28 10/1/2014 12/31/2014 J1830 Injection, interferon beta-1b, 0.25 mg $347.95 1/1/2015 3/31/2015 J1830 Injection, interferon beta-1b, 0.25 mg $352.37 4/1/2015 6/30/2015 J1830 Injection, interferon beta-1b, 0.25 mg $354.36 7/1/2015 12/31/2078

J1835 Injection, intraconazole, 50 mg $0.28 7/1/2014 12/31/2078

J1840 Injection, kanamycin sulfate, up to 500 mg $7.69 7/1/2014 12/31/2078

J1850 Injection, kanamycin sulfate, up to 75 mg $1.15 7/1/2014 12/31/2078

J1885 Injection, ketorolac tromethamine, per 15 mg $0.31 7/1/2014 9/30/2014 J1885 Injection, ketorolac tromethamine, per 15 mg $0.29 10/1/2014 12/31/2014 J1885 Injection, ketorolac tromethamine, per 15 mg $0.47 1/1/2015 3/31/2015 J1885 Injection, ketorolac tromethamine, per 15 mg $0.49 4/1/2015 6/30/2015 J1885 Injection, ketorolac tromethamine, per 15 mg $0.69 7/1/2015 12/31/2078

J1890 Injection, cephalothin sodium, up to 1 gram $8.64 7/1/2014 12/31/2078

J1930 Injection, lanreotide, 1 mg $39.66 7/1/2014 9/30/2014 J1930 Injection, lanreotide, 1 mg $41.40 10/1/2014 12/31/2014 J1930 Injection, lanreotide, 1 mg $46.70 1/1/2015 3/31/2015 J1930 Injection, lanreotide, 1 mg $46.67 4/1/2015 6/30/2015 J1930 Injection, lanreotide, 1 mg $47.38 7/1/2015 12/31/2078

J1931 Injection, laronidase, 0.1 mg $29.39 7/1/2014 9/30/2014 J1931 Injection, laronidase, 0.1 mg $29.45 10/1/2014 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J1940 Injection, furosemide, up to 20 mg $5.30 7/1/2014 9/30/2014 J1940 Injection, furosemide, up to 20 mg $5.33 10/1/2014 12/31/2014 J1940 Injection, furosemide, up to 20 mg $4.77 1/1/2015 3/31/2015 J1940 Injection, furosemide, up to 20 mg $1.64 4/1/2015 6/30/2015 J1940 Injection, furosemide, up to 20 mg $1.48 7/1/2015 12/31/2078

J1945 Injection, lepirudin, 50 mg $256.73 7/1/2014 12/31/2014 J1945 Injection, lepirudin, 50 mg $235.52 1/1/2015 3/31/2015 J1945 Injection, lepirudin, 50 mg $1,035.10 4/1/2015 6/30/2015 J1945 Injection, lepirudin, 50 mg $235.52 7/1/2015 12/31/2078

J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg $824.50 7/1/2014 9/30/2014 J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg $829.72 10/1/2014 12/31/2014 J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg $810.14 1/1/2015 3/31/2015 J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg $813.38 4/1/2015 6/30/2015 J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg $818.66 7/1/2015 12/31/2078

J1953 Injection, levetiracetam, 10 mg $0.13 7/1/2014 9/30/2014 J1953 Injection, levetiracetam, 10 mg $0.12 10/1/2014 6/30/2015 J1953 Injection, levetiracetam, 10 mg $0.11 7/1/2015 12/31/2078

J1955 Injection, levocarnitine, per 1 gram $8.22 7/1/2014 9/30/2014 J1955 Injection, levocarnitine, per 1 gram $8.00 10/1/2014 12/31/2014 J1955 Injection, levocarnitine, per 1 gram $8.58 1/1/2015 3/31/2015 J1955 Injection, levocarnitine, per 1 gram $9.48 4/1/2015 6/30/2015 J1955 Injection, levocarnitine, per 1 gram $10.60 7/1/2015 12/31/2078

J1960 Injection, levorphanol tartrate, up to 2 mg $3.17 7/1/2014 12/31/2078

J1980 Injection, hyoscyamine sulfate, up to 0.25 mg $18.45 7/1/2014 9/30/2014 J1980 Injection, hyoscyamine sulfate, up to 0.25 mg $18.53 10/1/2014 12/31/2014 J1980 Injection, hyoscyamine sulfate, up to 0.25 mg $18.54 1/1/2015 3/31/2015 J1980 Injection, hyoscyamine sulfate, up to 0.25 mg $20.37 4/1/2015 6/30/2015 J1980 Injection, hyoscyamine sulfate, up to 0.25 mg $24.81 7/1/2015 12/31/2078

J1990 Injection, chlordiazepoxide HCl, up to 100 mg $21.05 7/1/2014 12/31/2078

J2001 Injection, lidocaine HCl for IV infusion, 10 mg $0.02 7/1/2014 12/31/2078

J2010 Injection, lincomycin HCl, up to 300 mg $8.92 7/1/2014 9/30/2014 J2010 Injection, lincomycin HCl, up to 300 mg $9.05 10/1/2014 12/31/2014 J2010 Injection, lincomycin HCl, up to 300 mg $9.56 1/1/2015 3/31/2015 J2010 Injection, lincomycin HCl, up to 300 mg $9.52 4/1/2015 6/30/2015 J2010 Injection, lincomycin HCl, up to 300 mg $10.37 7/1/2015 12/31/2078

J2020 Injection, linezolid, 200 mg $44.67 7/1/2014 9/30/2014 J2020 Injection, linezolid, 200 mg $45.66 10/1/2014 12/31/2014 J2020 Injection, linezolid, 200 mg $47.75 1/1/2015 3/31/2015 J2020 Injection, linezolid, 200 mg $47.71 4/1/2015 6/30/2015 J2020 Injection, linezolid, 200 mg $38.59 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J2060 Injection, lorazepam, 2 mg $0.67 7/1/2014 9/30/2014 J2060 Injection, lorazepam, 2 mg $0.71 10/1/2014 12/31/2014 J2060 Injection, lorazepam, 2 mg $0.70 1/1/2015 3/31/2015 J2060 Injection, lorazepam, 2 mg $0.69 4/1/2015 6/30/2015 J2060 Injection, lorazepam, 2 mg $0.68 7/1/2015 12/31/2078

J2150 Injection, mannitol, 25% in 50 ml $1.99 7/1/2014 9/30/2014 J2150 Injection, mannitol, 25% in 50 ml $2.10 10/1/2014 12/31/2014 J2150 Injection, mannitol, 25% in 50 ml $1.74 1/1/2015 3/31/2015 J2150 Injection, mannitol, 25% in 50 ml $1.52 4/1/2015 6/30/2015 J2150 Injection, mannitol, 25% in 50 ml $1.49 7/1/2015 12/31/2078

J2175 Injection, meperidine HCl, per 100 mg $5.05 7/1/2014 9/30/2014 J2175 Injection, meperidine HCl, per 100 mg $4.98 10/1/2014 12/31/2014 J2175 Injection, meperidine HCl, per 100 mg $5.00 1/1/2015 3/31/2015 J2175 Injection, meperidine HCl, per 100 mg $4.79 4/1/2015 6/30/2015 J2175 Injection, meperidine HCl, per 100 mg $4.52 7/1/2015 12/31/2078

J2180 Injection, meperidine and promethazine HCl, up to 50 mg $3.79 7/1/2014 12/31/2078

J2210 Injection, methylergonovine maleate, up to 0.2 mg $4.75 7/1/2014 9/30/2014 J2210 Injection, methylergonovine maleate, up to 0.2 mg $5.03 10/1/2014 12/31/2014 J2210 Injection, methylergonovine maleate, up to 0.2 mg $5.05 1/1/2015 3/31/2015 J2210 Injection, methylergonovine maleate, up to 0.2 mg $4.70 4/1/2015 6/30/2015 J2210 Injection, methylergonovine maleate, up to 0.2 mg $4.51 7/1/2015 12/31/2078

J2250 Injection, midazolam HCl, per 1 mg $0.12 7/1/2014 9/30/2014 J2250 Injection, midazolam HCl, per 1 mg $0.14 10/1/2014 12/31/2014 J2250 Injection, midazolam HCl, per 1 mg $0.13 1/1/2015 6/30/2015 J2250 Injection, midazolam HCl, per 1 mg $0.12 7/1/2015 12/31/2078

J2260 Injection, milrinone lactate, 5 mg $4.23 7/1/2014 9/30/2014 J2260 Injection, milrinone lactate, 5 mg $3.78 10/1/2014 12/31/2014 J2260 Injection, milrinone lactate, 5 mg $3.20 1/1/2015 3/31/2015 J2260 Injection, milrinone lactate, 5 mg $2.74 4/1/2015 6/30/2015 J2260 Injection, milrinone lactate, 5 mg $3.10 7/1/2015 12/31/2078

J2270 Injection, morphine sulfate, up to 10 mg $2.03 7/1/2014 9/30/2014 J2270 Injection, morphine sulfate, up to 10 mg $1.32 10/1/2014 12/31/2014 J2270 Injection, morphine sulfate, up to 10 mg $1.81 1/1/2015 3/31/2015 J2270 Injection, morphine sulfate, up to 10 mg $1.55 4/1/2015 6/30/2015 J2270 Injection, morphine sulfate, up to 10 mg $1.45 7/1/2015 12/31/2078

J2274 In morphine preservativ free, 10 mg $9.28 1/1/2015 3/31/2015 J2274 In morphine preservativ free, 10 mg $9.40 4/1/2015 6/30/2015 J2274 In morphine preservativ free, 10 mg $8.37 7/1/2015 12/31/2078

J2275 Injection, morphine sulfate sterile, per 10 mg $10.14 7/1/2014 12/31/2014

J2278 Injection, ziconotide, 1 mcg $6.87 7/1/2014 12/31/2014 J2278 Injection, ziconotide, 1 mcg $6.97 1/1/2015 6/30/2015 Procedure Effective Code Description Rate End Date Code Date J2278 Injection, ziconotide, 1 mcg $7.07 7/1/2015 12/31/2078

J2300 Injection, nalbuphine HCl, per 10 mg $2.54 7/1/2014 9/30/2014 J2300 Injection, nalbuphine HCl, per 10 mg $2.49 10/1/2014 12/31/2014 J2300 Injection, nalbuphine HCl, per 10 mg $2.36 1/1/2015 3/31/2015 J2300 Injection, nalbuphine HCl, per 10 mg $2.66 4/1/2015 6/30/2015 J2300 Injection, nalbuphine HCl, per 10 mg $2.51 7/1/2015 12/31/2078

J2310 Injection, naloxone HCl, per 1 mg $48.44 7/1/2014 9/30/2014 J2310 Injection, naloxone HCl, per 1 mg $42.75 10/1/2014 12/31/2014 J2310 Injection, naloxone HCl, per 1 mg $35.93 1/1/2015 3/31/2015 J2310 Injection, naloxone HCl, per 1 mg $30.63 4/1/2015 6/30/2015 J2310 Injection, naloxone HCl, per 1 mg $25.97 7/1/2015 12/31/2078

J2320 Injection, nandrolone decanoate, up to 50 mg $3.75 7/1/2014 12/31/2014 J2320 Injection, nandrolone decanoate, up to 50 mg $122.78 1/1/2015 3/31/2015 J2320 Injection, nandrolone decanoate, up to 50 mg $5.04 4/1/2015 6/30/2015 J2320 Injection, nandrolone decanoate, up to 50 mg $122.78 7/1/2015 12/31/2078

J2323 Injection, natalizumab, 1 mg $14.95 7/1/2014 9/30/2014 J2323 Injection, natalizumab, 1 mg $14.91 10/1/2014 12/31/2014 J2323 Injection, natalizumab, 1 mg $15.49 1/1/2015 3/31/2015 J2323 Injection, natalizumab, 1 mg $15.82 4/1/2015 6/30/2015 J2323 Injection, natalizumab, 1 mg $16.40 7/1/2015 12/31/2078

J2325 Injection, nesiritide, 0.1 mg $65.69 7/1/2014 9/30/2014 J2325 Injection, nesiritide, 0.1 mg $66.66 10/1/2014 12/31/2014 J2325 Injection, nesiritide, 0.1 mg $66.30 1/1/2015 3/31/2015 J2325 Injection, nesiritide, 0.1 mg $66.31 4/1/2015 6/30/2015 J2325 Injection, nesiritide, 0.1 mg $71.84 7/1/2015 12/31/2078

J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg $140.48 7/1/2014 9/30/2014 J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg $141.87 10/1/2014 12/31/2014 J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg $143.32 1/1/2015 3/31/2015 J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg $144.69 4/1/2015 6/30/2015 J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg $156.48 7/1/2015 12/31/2078

J2354 Injection, octreotide, non-depot form for subcutaneous or IV, 25 mcg $1.10 7/1/2014 9/30/2014 J2354 Injection, octreotide, non-depot form for subcutaneous or IV, 25 mcg $1.14 10/1/2014 3/31/2015 J2354 Injection, octreotide, non-depot form for subcutaneous or IV, 25 mcg $1.19 4/1/2015 6/30/2015 J2354 Injection, octreotide, non-depot form for subcutaneous or IV, 25 mcg $1.23 7/1/2015 12/31/2078

J2355 Injection, oprelvekin, 5 mg $317.39 7/1/2014 9/30/2014 J2355 Injection, oprelvekin, 5 mg $321.88 10/1/2014 12/31/2014 J2355 Injection, oprelvekin, 5 mg $322.70 1/1/2015 3/31/2015 J2355 Injection, oprelvekin, 5 mg $322.27 4/1/2015 6/30/2015 J2355 Injection, oprelvekin, 5 mg $402.51 7/1/2015 12/31/2078

J2357 Injection, omalizumab, 5 mg $26.57 7/1/2014 9/30/2014 J2357 Injection, omalizumab, 5 mg $27.85 10/1/2014 12/31/2014 J2357 Injection, omalizumab, 5 mg $27.68 1/1/2015 3/31/2015 Procedure Effective Code Description Rate End Date Code Date J2357 Injection, omalizumab, 5 mg $28.79 4/1/2015 6/30/2015 J2357 Injection, omalizumab, 5 mg $28.86 7/1/2015 12/31/2078

J2360 Injection, orphenadrine citrate, up to 60 mg $5.99 7/1/2014 9/30/2014 J2360 Injection, orphenadrine citrate, up to 60 mg $6.49 10/1/2014 12/31/2014 J2360 Injection, orphenadrine citrate, up to 60 mg $5.75 1/1/2015 3/31/2015 J2360 Injection, orphenadrine citrate, up to 60 mg $5.21 4/1/2015 6/30/2015 J2360 Injection, orphenadrine citrate, up to 60 mg $4.67 7/1/2015 12/31/2078

J2370 Injection, phenylephrine HCl, up to 1 ml $2.94 7/1/2014 9/30/2014 J2370 Injection, phenylephrine HCl, up to 1 ml $3.24 10/1/2014 12/31/2014 J2370 Injection, phenylephrine HCl, up to 1 ml $3.34 1/1/2015 12/31/2078

J2400 Injection, chloroprocaine HCl, per 30 ml $23.06 7/1/2014 9/30/2014 J2400 Injection, chloroprocaine HCl, per 30 ml $19.35 10/1/2014 12/31/2014 J2400 Injection, chloroprocaine HCl, per 30 ml $16.73 1/1/2015 3/31/2015 J2400 Injection, chloroprocaine HCl, per 30 ml $26.98 4/1/2015 6/30/2015 J2400 Injection, chloroprocaine HCl, per 30 ml $24.72 7/1/2015 12/31/2078

J2405 Injection, ondansetron HCl, per 1 mg $0.09 7/1/2014 9/30/2014 J2405 Injection, ondansetron HCl, per 1 mg $0.08 10/1/2014 6/30/2015 J2405 Injection, ondansetron HCl, per 1 mg $0.07 7/1/2015 12/31/2078

J2410 Injection, oxymorphone HCl, up to 1 mg $2.37 7/1/2014 9/30/2014 J2410 Injection, oxymorphone HCl, up to 1 mg $2.90 10/1/2014 12/31/2014 J2410 Injection, oxymorphone HCl, up to 1 mg $2.89 1/1/2015 3/31/2015 J2410 Injection, oxymorphone HCl, up to 1 mg $2.87 4/1/2015 6/30/2015 J2410 Injection, oxymorphone HCl, up to 1 mg $2.88 7/1/2015 12/31/2078

J2425 Injection, palifermin, 50 mcg $14.87 7/1/2014 9/30/2014 J2425 Injection, palifermin, 50 mcg $14.85 10/1/2014 12/31/2014 J2425 Injection, palifermin, 50 mcg $15.22 1/1/2015 3/31/2015 J2425 Injection, palifermin, 50 mcg $15.61 4/1/2015 6/30/2015 J2425 Injection, palifermin, 50 mcg $15.59 7/1/2015 12/31/2078

J2430 Injection, pamidronate disodium, per 30 mg $11.01 7/1/2014 9/30/2014 J2430 Injection, pamidronate disodium, per 30 mg $11.36 10/1/2014 12/31/2014 J2430 Injection, pamidronate disodium, per 30 mg $12.97 1/1/2015 3/31/2015 J2430 Injection, pamidronate disodium, per 30 mg $10.67 4/1/2015 6/30/2015 J2430 Injection, pamidronate disodium, per 30 mg $10.45 7/1/2015 12/31/2078

J2440 Injection, papaverin HCl, up to 60 mg $1.28 7/1/2014 12/31/2078

J2460 Injection, oxytetracycline HCl, up to 50 mg $0.94 7/1/2014 12/31/2078

J2469 Injection, palonosetron HCl 25 mcg $19.26 7/1/2014 9/30/2014 J2469 Injection, palonosetron HCl 25 mcg $20.01 10/1/2014 3/31/2015 J2469 Injection, palonosetron HCl 25 mcg $19.95 4/1/2015 6/30/2015 J2469 Injection, palonosetron HCl 25 mcg $20.84 7/1/2015 12/31/2078

J2501 Injection, paricalcitol, 1 mcg $2.01 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J2501 Injection, paricalcitol, 1 mcg $1.79 10/1/2014 12/31/2014 J2501 Injection, paricalcitol, 1 mcg $1.42 1/1/2015 3/31/2015 J2501 Injection, paricalcitol, 1 mcg $1.81 4/1/2015 6/30/2015 J2501 Injection, paricalcitol, 1 mcg $1.34 7/1/2015 12/31/2078

J2503 Injection, pegaptanib sodium, 0.3 mg $1,036.45 7/1/2014 9/30/2014 J2503 Injection, pegaptanib sodium, 0.3 mg $1,034.02 10/1/2014 12/31/2014 J2503 Injection, pegaptanib sodium, 0.3 mg $1,035.10 1/1/2015 3/31/2015 J2503 Injection, pegaptanib sodium, 0.3 mg $1,040.51 4/1/2015 6/30/2015 J2503 Injection, pegaptanib sodium, 0.3 mg $1,032.16 7/1/2015 12/31/2078

J2504 Injection, pegademase bovine, 25 IU $279.56 7/1/2014 9/30/2014 J2504 Injection, pegademase bovine, 25 IU $281.40 10/1/2014 3/31/2015 J2504 Injection, pegademase bovine, 25 IU $275.40 4/1/2015 6/30/2015 J2504 Injection, pegademase bovine, 25 IU $276.31 7/1/2015 12/31/2078

J2505 Injection, pegfilgrastim, 6 mg $3,368.78 7/1/2014 9/30/2014 J2505 Injection, pegfilgrastim, 6 mg $3,403.54 10/1/2014 12/31/2014 J2505 Injection, pegfilgrastim, 6 mg $3,495.46 1/1/2015 3/31/2015 J2505 Injection, pegfilgrastim, 6 mg $3,500.59 4/1/2015 6/30/2015 J2505 Injection, pegfilgrastim, 6 mg $3,678.61 7/1/2015 12/31/2078

J2507 Injection, pegloticase, 1 mg $740.26 7/1/2014 9/30/2014 J2507 Injection, pegloticase, 1 mg $856.64 10/1/2014 12/31/2014 J2507 Injection, pegloticase, 1 mg $1,006.47 1/1/2015 3/31/2015 J2507 Injection, pegloticase, 1 mg $740.26 4/1/2015 6/30/2015 J2507 Injection, pegloticase, 1 mg $1,167.03 7/1/2015 12/31/2078

J2510 Injection, penicillin G procaine aqueous, up to 600,000 units $16.46 7/1/2014 9/30/2014 J2510 Injection, penicillin G procaine aqueous, up to 600,000 units $17.06 10/1/2014 12/31/2014 J2510 Injection, penicillin G procaine aqueous, up to 600,000 units $17.92 1/1/2015 3/31/2015 J2510 Injection, penicillin G procaine aqueous, up to 600,000 units $18.04 4/1/2015 6/30/2015 J2510 Injection, penicillin G procaine aqueous, up to 600,000 units $21.13 7/1/2015 12/31/2078

J2513 Injection, pentastarch, 10% solution, 100 ml $12.72 7/1/2014 12/31/2078

J2515 Injection, pentobarbital sodium, per 50 mg $34.89 7/1/2014 9/30/2014 J2515 Injection, pentobarbital sodium, per 50 mg $35.82 10/1/2014 12/31/2014 J2515 Injection, pentobarbital sodium, per 50 mg $35.84 1/1/2015 3/31/2015 J2515 Injection, pentobarbital sodium, per 50 mg $36.91 4/1/2015 6/30/2015 J2515 Injection, pentobarbital sodium, per 50 mg $37.94 7/1/2015 12/31/2078

J2540 Injection, penicillin G potassium, up to 600,000 units $0.63 7/1/2014 9/30/2014 J2540 Injection, penicillin G potassium, up to 600,000 units $0.74 10/1/2014 12/31/2014 J2540 Injection, penicillin G potassium, up to 600,000 units $0.72 1/1/2015 3/31/2015 J2540 Injection, penicillin G potassium, up to 600,000 units $0.71 4/1/2015 6/30/2015 J2540 Injection, penicillin G potassium, up to 600,000 units $0.85 7/1/2015 12/31/2078

J2543 Injection, piperacillin/tazobactam sodium, 1.125 g $1.55 7/1/2014 9/30/2014 J2543 Injection, piperacillin/tazobactam sodium, 1.125 g $1.48 10/1/2014 12/31/2014 J2543 Injection, piperacillin/tazobactam sodium, 1.125 g $1.32 1/1/2015 3/31/2015 Procedure Effective Code Description Rate End Date Code Date J2543 Injection, piperacillin/tazobactam sodium, 1.125 g $1.91 4/1/2015 6/30/2015 J2543 Injection, piperacillin/tazobactam sodium, 1.125 g $2.15 7/1/2015 12/31/2078

J2545 Pentamidine isethionte, inhalation solution, per 300 mg, thru DME $86.91 7/1/2014 9/30/2014 J2545 Pentamidine isethionte, inhalation solution, per 300 mg, thru DME $93.25 10/1/2014 12/31/2014 J2545 Pentamidine isethionte, inhalation solution, per 300 mg, thru DME $97.37 1/1/2015 3/31/2015 J2545 Pentamidine isethionte, inhalation solution, per 300 mg, thru DME $97.19 4/1/2015 6/30/2015 J2545 Pentamidine isethionte, inhalation solution, per 300 mg, thru DME $108.94 7/1/2015 12/31/2078

J2550 Injection, promethazine HCl, up to 50 mg $1.58 7/1/2014 9/30/2014 J2550 Injection, promethazine HCl, up to 50 mg $1.57 10/1/2014 12/31/2014 J2550 Injection, promethazine HCl, up to 50 mg $1.56 1/1/2015 3/31/2015 J2550 Injection, promethazine HCl, up to 50 mg $1.65 4/1/2015 6/30/2015 J2550 Injection, promethazine HCl, up to 50 mg $1.60 7/1/2015 12/31/2078

J2560 Injection, phenobarbital sodium, up to 120 mg $19.53 7/1/2014 9/30/2014 J2560 Injection, phenobarbital sodium, up to 120 mg $21.14 10/1/2014 12/31/2014 J2560 Injection, phenobarbital sodium, up to 120 mg $23.51 1/1/2015 3/31/2015 J2560 Injection, phenobarbital sodium, up to 120 mg $28.67 4/1/2015 6/30/2015 J2560 Injection, phenobarbital sodium, up to 120 mg $28.82 7/1/2015 12/31/2078

J2562 Injection, plerixafor, 1 mg $302.12 7/1/2014 9/30/2014 J2562 Injection, plerixafor, 1 mg $301.20 10/1/2014 12/31/2014 J2562 Injection, plerixafor, 1 mg $304.06 1/1/2015 3/31/2015 J2562 Injection, plerixafor, 1 mg $304.00 4/1/2015 6/30/2015 J2562 Injection, plerixafor, 1 mg $305.82 7/1/2015 12/31/2078

J2590 Injection, oxytocin, up to 10 units $0.53 7/1/2014 12/31/2078

J2597 Injection, desmopressin acetate, per 1 mcg $5.16 7/1/2014 9/30/2014 J2597 Injection, desmopressin acetate, per 1 mcg $5.08 10/1/2014 12/31/2014 J2597 Injection, desmopressin acetate, per 1 mcg $5.04 1/1/2015 3/31/2015 J2597 Injection, desmopressin acetate, per 1 mcg $5.52 4/1/2015 6/30/2015 J2597 Injection, desmopressin acetate, per 1 mcg $7.61 7/1/2015 12/31/2078

J2650 Injection, prednisolone acetate, up to 1 ml $0.52 7/1/2014 12/31/2078

J2670 Injection, totazoline HCl, up to 25 mg $40.01 7/1/2014 12/31/2014 J2670 Injection, totazoline HCl, up to 25 mg $1,600.40 1/1/2015 3/31/2015 J2670 Injection, totazoline HCl, up to 25 mg $86.23 4/1/2015 6/30/2015 J2670 Injection, totazoline HCl, up to 25 mg $1,600.40 7/1/2015 12/31/2078

J2680 Injection, fluphenazine decanoate, up to 25 mg $23.07 7/1/2014 9/30/2014 J2680 Injection, fluphenazine decanoate, up to 25 mg $24.00 10/1/2014 12/31/2014 J2680 Injection, fluphenazine decanoate, up to 25 mg $23.28 1/1/2015 3/31/2015 J2680 Injection, fluphenazine decanoate, up to 25 mg $22.64 4/1/2015 6/30/2015 J2680 Injection, fluphenazine decanoate, up to 25 mg $23.93 7/1/2015 12/31/2078

J2690 Injection, procainamide HCl, up to 1 gram $46.03 7/1/2014 9/30/2014 J2690 Injection, procainamide HCl, up to 1 gram $49.94 10/1/2014 12/31/2014 J2690 Injection, procainamide HCl, up to 1 gram $57.27 1/1/2015 3/31/2015 Procedure Effective Code Description Rate End Date Code Date J2690 Injection, procainamide HCl, up to 1 gram $47.50 4/1/2015 6/30/2015 J2690 Injection, procainamide HCl, up to 1 gram $48.49 7/1/2015 12/31/2078

J2700 Injection, oxacillin sodium, up to 250 mg $1.72 7/1/2014 9/30/2014 J2700 Injection, oxacillin sodium, up to 250 mg $1.76 10/1/2014 12/31/2014 J2700 Injection, oxacillin sodium, up to 250 mg $1.73 1/1/2015 3/31/2015 J2700 Injection, oxacillin sodium, up to 250 mg $1.85 4/1/2015 6/30/2015 J2700 Injection, oxacillin sodium, up to 250 mg $1.76 7/1/2015 12/31/2078

J2704 Inj, propofol, 10 mg $0.13 1/1/2015 3/31/2015 J2704 Inj, propofol, 10 mg $0.12 4/1/2015 12/31/2078

J2710 Injection, neostigmine methylsulfate, up to 0.5 gm $0.09 7/1/2014 12/31/2078

J2720 Injection, protamine sulfate, per 10 mg $1.05 7/1/2014 9/30/2014 J2720 Injection, protamine sulfate, per 10 mg $1.04 10/1/2014 3/31/2015 J2720 Injection, protamine sulfate, per 10 mg $1.03 4/1/2015 6/30/2015 J2720 Injection, protamine sulfate, per 10 mg $0.99 7/1/2015 12/31/2078

J2724 Injection, protein C concentrate, intravenous, human, 10 IU $14.53 7/1/2014 9/30/2014 J2724 Injection, protein C concentrate, intravenous, human, 10 IU $14.52 10/1/2014 12/31/2014 J2724 Injection, protein C concentrate, intravenous, human, 10 IU $14.61 1/1/2015 3/31/2015 J2724 Injection, protein C concentrate, intravenous, human, 10 IU $15.10 4/1/2015 6/30/2015 J2724 Injection, protein C concentrate, intravenous, human, 10 IU $15.33 7/1/2015 12/31/2078

J2725 Injection, protirelin, per 250 mcg $29.74 7/1/2014 12/31/2078

J2730 Injection, pralidoxime chloride, up to 1 gram $88.40 7/1/2014 9/30/2014 J2730 Injection, pralidoxime chloride, up to 1 gram $89.16 10/1/2014 12/31/2014 J2730 Injection, pralidoxime chloride, up to 1 gram $87.66 1/1/2015 3/31/2015 J2730 Injection, pralidoxime chloride, up to 1 gram $88.51 4/1/2015 6/30/2015 J2730 Injection, pralidoxime chloride, up to 1 gram $91.90 7/1/2015 12/31/2078

J2760 Injection, phentolaine mesylate, up to 5 gm $106.68 7/1/2014 9/30/2014 J2760 Injection, phentolaine mesylate, up to 5 gm $113.40 10/1/2014 12/31/2014 J2760 Injection, phentolaine mesylate, up to 5 gm $159.00 1/1/2015 3/31/2015 J2760 Injection, phentolaine mesylate, up to 5 gm $127.71 4/1/2015 6/30/2015 J2760 Injection, phentolaine mesylate, up to 5 gm $159.00 7/1/2015 12/31/2078

J2765 Injection, metoclopramide HCl, up to 10 mg $0.80 7/1/2014 9/30/2014 J2765 Injection, metoclopramide HCl, up to 10 mg $0.70 10/1/2014 12/31/2014 J2765 Injection, metoclopramide HCl, up to 10 mg $0.73 1/1/2015 3/31/2015 J2765 Injection, metoclopramide HCl, up to 10 mg $0.71 4/1/2015 6/30/2015 J2765 Injection, metoclopramide HCl, up to 10 mg $0.68 7/1/2015 12/31/2078

J2778 Injection, ranibizumab, 0.1 mg $396.59 7/1/2014 9/30/2014 J2778 Injection, ranibizumab, 0.1 mg $396.43 10/1/2014 12/31/2014 J2778 Injection, ranibizumab, 0.1 mg $396.05 1/1/2015 3/31/2015 J2778 Injection, ranibizumab, 0.1 mg $395.54 4/1/2015 6/30/2015 J2778 Injection, ranibizumab, 0.1 mg $393.53 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J2780 Injection, ranitidine HCl, 25 mg $1.21 7/1/2014 12/31/2014 J2780 Injection, ranitidine HCl, 25 mg $1.08 1/1/2015 3/31/2015 J2780 Injection, ranitidine HCl, 25 mg $1.10 4/1/2015 6/30/2015 J2780 Injection, ranitidine HCl, 25 mg $1.08 7/1/2015 12/31/2078

J2785 Injection, regadenoson, 0.1 mg $52.84 7/1/2014 9/30/2014 J2785 Injection, regadenoson, 0.1 mg $52.75 10/1/2014 12/31/2014 J2785 Injection, regadenoson, 0.1 mg $52.62 1/1/2015 3/31/2015 J2785 Injection, regadenoson, 0.1 mg $52.60 4/1/2015 6/30/2015 J2785 Injection, regadenoson, 0.1 mg $52.63 7/1/2015 12/31/2078

J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg $6.17 7/1/2014 9/30/2014 J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg $25.46 10/1/2014 12/31/2014 J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg $26.20 1/1/2015 3/31/2015 J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg $24.35 4/1/2015 6/30/2015 J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg $23.63 7/1/2015 12/31/2078

J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg $83.69 7/1/2014 9/30/2014 J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg $84.27 10/1/2014 12/31/2014 J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg $83.11 1/1/2015 3/31/2015 J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg $80.50 4/1/2015 6/30/2015 J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg $83.45 7/1/2015 12/31/2078

J2791 Injection, Rho (D) immune globulin (human) (Rhophylac) 100 IU $4.77 7/1/2014 9/30/2014 J2791 Injection, Rho (D) immune globulin (human) (Rhophylac) 100 IU $4.80 10/1/2014 12/31/2014 J2791 Injection, Rho (D) immune globulin (human) (Rhophylac) 100 IU $4.77 1/1/2015 3/31/2015 J2791 Injection, Rho (D) immune globulin (human) (Rhophylac) 100 IU $4.79 4/1/2015 6/30/2015 J2791 Injection, Rho (D) immune globulin (human) (Rhophylac) 100 IU $4.75 7/1/2015 12/31/2078

J2792 Injection, Rho D immune globulin, intravenous, human, SD, 100 IU $18.96 7/1/2014 9/30/2014 J2792 Injection, Rho D immune globulin, intravenous, human, SD, 100 IU $18.85 10/1/2014 12/31/2014 J2792 Injection, Rho D immune globulin, intravenous, human, SD, 100 IU $18.64 1/1/2015 3/31/2015 J2792 Injection, Rho D immune globulin, intravenous, human, SD, 100 IU $18.90 4/1/2015 6/30/2015 J2792 Injection, Rho D immune globulin, intravenous, human, SD, 100 IU $18.86 7/1/2015 12/31/2078

J2793 Injection, rilonacept, 1 mg $24.09 7/1/2014 12/31/2078

J2796 Injection, romiplostim, 10 mcg $53.31 7/1/2014 9/30/2014 J2796 Injection, romiplostim, 10 mcg $53.63 10/1/2014 12/31/2014 J2796 Injection, romiplostim, 10 mcg $54.99 1/1/2015 3/31/2015 J2796 Injection, romiplostim, 10 mcg $55.27 4/1/2015 6/30/2015 J2796 Injection, romiplostim, 10 mcg $56.85 7/1/2015 12/31/2078

J2800 Injection, methocarbamol, up to 10 ml $39.57 7/1/2014 9/30/2014 J2800 Injection, methocarbamol, up to 10 ml $42.10 10/1/2014 12/31/2014 J2800 Injection, methocarbamol, up to 10 ml $46.57 1/1/2015 3/31/2015 J2800 Injection, methocarbamol, up to 10 ml $56.95 4/1/2015 6/30/2015 J2800 Injection, methocarbamol, up to 10 ml $54.62 7/1/2015 12/31/2078

J2805 Injection, sincalide, 5 mcg $82.43 7/1/2014 9/30/2014 J2805 Injection, sincalide, 5 mcg $87.03 10/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J2805 Injection, sincalide, 5 mcg $86.98 1/1/2015 3/31/2015 J2805 Injection, sincalide, 5 mcg $88.24 4/1/2015 6/30/2015 J2805 Injection, sincalide, 5 mcg $90.62 7/1/2015 12/31/2078

J2810 Injection, theophylline, per 40 mg $0.27 7/1/2014 9/30/2014 J2810 Injection, theophylline, per 40 mg $0.31 10/1/2014 12/31/2014 J2810 Injection, theophylline, per 40 mg $0.27 1/1/2015 3/31/2015 J2810 Injection, theophylline, per 40 mg $0.31 4/1/2015 6/30/2015 J2810 Injection, theophylline, per 40 mg $0.29 7/1/2015 12/31/2078

J2820 Injection, sargramostim (GM-CSF), 50 mcg $33.37 7/1/2014 9/30/2014 J2820 Injection, sargramostim (GM-CSF), 50 mcg $30.13 10/1/2014 12/31/2014 J2820 Injection, sargramostim (GM-CSF), 50 mcg $33.15 1/1/2015 3/31/2015 J2820 Injection, sargramostim (GM-CSF), 50 mcg $31.76 4/1/2015 6/30/2015 J2820 Injection, sargramostim (GM-CSF), 50 mcg $31.73 7/1/2015 12/31/2078

J2850 Injection, secretin, synthetic, human, 1 mcg $27.49 7/1/2014 9/30/2014 J2850 Injection, secretin, synthetic, human, 1 mcg $34.78 10/1/2014 12/31/2078

J2910 Injection, aurothioglucose, up to 50 mg $24.50 7/1/2014 12/31/2078

J2920 Injection, methylprednisolone sodium succinate, up to 40 mg $1.93 7/1/2014 9/30/2014 J2920 Injection, methylprednisolone sodium succinate, up to 40 mg $1.94 10/1/2014 12/31/2014 J2920 Injection, methylprednisolone sodium succinate, up to 40 mg $2.05 1/1/2015 3/31/2015 J2920 Injection, methylprednisolone sodium succinate, up to 40 mg $2.11 4/1/2015 6/30/2015 J2920 Injection, methylprednisolone sodium succinate, up to 40 mg $2.42 7/1/2015 12/31/2078

J2930 Injection, methylprednisolone sodium succinate, up to 125 mg $2.90 7/1/2014 9/30/2014 J2930 Injection, methylprednisolone sodium succinate, up to 125 mg $2.87 10/1/2014 12/31/2014 J2930 Injection, methylprednisolone sodium succinate, up to 125 mg $2.97 1/1/2015 3/31/2015 J2930 Injection, methylprednisolone sodium succinate, up to 125 mg $3.04 4/1/2015 6/30/2015 J2930 Injection, methylprednisolone sodium succinate, up to 125 mg $3.54 7/1/2015 12/31/2078

J2940 Injection, somatrem, 1 mg $42.30 7/1/2014 12/31/2078

J2941 Injection, somatropin, 1 mg $69.13 7/1/2014 12/31/2014 J2941 Injection, somatropin, 1 mg $76.03 1/1/2015 3/31/2015 J2941 Injection, somatropin, 1 mg $76.43 4/1/2015 6/30/2015 J2941 Injection, somatropin, 1 mg $81.59 7/1/2015 12/31/2078

J2950 Injection, promazine HCl, up to 25 mg $0.38 7/1/2014 12/31/2078

J2995 Injection, streptokinase, per 250,000 IU $79.50 7/1/2014 12/31/2078

J2997 Injection, alteplase recombinant, 1 mg $63.73 7/1/2014 9/30/2014 J2997 Injection, alteplase recombinant, 1 mg $64.30 10/1/2014 12/31/2014 J2997 Injection, alteplase recombinant, 1 mg $68.19 1/1/2015 3/31/2015 J2997 Injection, alteplase recombinant, 1 mg $68.44 4/1/2015 6/30/2015 J2997 Injection, alteplase recombinant, 1 mg $73.05 7/1/2015 12/31/2078

J3000 Injection, streptomycin, up to 1 gram $11.31 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J3000 Injection, streptomycin, up to 1 gram $12.90 10/1/2014 12/31/2014 J3000 Injection, streptomycin, up to 1 gram $12.53 1/1/2015 3/31/2015 J3000 Injection, streptomycin, up to 1 gram $12.76 4/1/2015 6/30/2015 J3000 Injection, streptomycin, up to 1 gram $12.61 7/1/2015 12/31/2078

J3010 Injection, fentanyl citrate, 0.1 mg $0.54 7/1/2014 9/30/2014 J3010 Injection, fentanyl citrate, 0.1 mg $0.52 10/1/2014 12/31/2014 J3010 Injection, fentanyl citrate, 0.1 mg $0.57 1/1/2015 3/31/2015 J3010 Injection, fentanyl citrate, 0.1 mg $0.54 4/1/2015 6/30/2015 J3010 Injection, fentanyl citrate, 0.1 mg $0.49 7/1/2015 12/31/2078

J3030 Injection, sumatriptan succinate, 6 mg $51.89 7/1/2014 12/31/2078

J3060 Inj, taliglucerace alfa 10 units $30.90 7/1/2014 9/30/2014 J3060 Inj, taliglucerace alfa 10 units $31.94 10/1/2014 12/31/2014 J3060 Inj, taliglucerace alfa 10 units $35.23 1/1/2015 3/31/2015 J3060 Inj, taliglucerace alfa 10 units $35.23 4/1/2015 12/31/2078

J3070 Injection, pentazocine, 30 mg $144.58 7/1/2014 9/30/2014 J3070 Injection, pentazocine, 30 mg $140.12 10/1/2014 12/31/2014 J3070 Injection, pentazocine, 30 mg $113.72 1/1/2015 3/31/2015 J3070 Injection, pentazocine, 30 mg $117.99 4/1/2015 6/30/2015 J3070 Injection, pentazocine, 30 mg $115.51 7/1/2015 12/31/2078

J3095 Injection, telavancin, 10 mg $4.14 7/1/2014 9/30/2014 J3095 Injection, telavancin, 10 mg $4.52 10/1/2014 12/31/2014 J3095 Injection, telavancin, 10 mg $4.79 1/1/2015 3/31/2015 J3095 Injection, telavancin, 10 mg $4.55 4/1/2015 6/30/2015 J3095 Injection, telavancin, 10 mg $4.85 7/1/2015 12/31/2078

J3101 Injection, tenecteplase, 1 mg $79.76 7/1/2014 9/30/2014 J3101 Injection, tenecteplase, 1 mg $86.21 10/1/2014 12/31/2014 J3101 Injection, tenecteplase, 1 mg $86.23 1/1/2015 3/31/2015 J3101 Injection, tenecteplase, 1 mg $86.21 4/1/2015 6/30/2015 J3101 Injection, tenecteplase, 1 mg $88.42 7/1/2015 12/31/2078

J3105 Injection, terbutaline sulfate, up to 1 mg $3.31 7/1/2014 9/30/2014 J3105 Injection, terbutaline sulfate, up to 1 mg $4.09 10/1/2014 12/31/2014 J3105 Injection, terbutaline sulfate, up to 1 mg $4.80 1/1/2015 3/31/2015 J3105 Injection, terbutaline sulfate, up to 1 mg $4.19 4/1/2015 6/30/2015 J3105 Injection, terbutaline sulfate, up to 1 mg $3.43 7/1/2015 12/31/2078

J3110 Injection, teriparatide, 10 mcg $7.55 7/1/2014 12/31/2078

J3120 Injection, testostrone enanthate, up to 100 mg $7.20 7/1/2014 12/31/2014

J3121 Inj testostero enanthate 1 mg $0.06 1/1/2015 3/31/2015 J3121 Inj testostero enanthate 1 mg $0.05 4/1/2015 6/30/2015 J3121 Inj testostero enanthate 1 mg $0.04 7/1/2015 12/31/2015

J3130 Injection, testostrone enanthate, up to 200 mg $9.51 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J3130 Injection, testostrone enanthate, up to 200 mg $8.91 10/1/2014 12/31/2014

J3140 Injection, testosterone suspension, up to 50 mg $0.56 7/1/2014 12/31/2014

J3145 Testosterone undecanoate 1 mg $1.14 1/1/2015 3/30/2015 J3145 Testosterone undecanoate 1 mg $1.16 4/1/2015 6/30/2015 J3145 Testosterone undecanoate 1 mg $1.17 7/1/2015 12/31/2078

J3150 Injection, testostrone propionate, up to 100 mg $0.79 7/1/2014 12/31/2014

J3230 Injection, chlorpromazine HCl, up to 50 mg $22.87 7/1/2014 9/30/2014 J3230 Injection, chlorpromazine HCl, up to 50 mg $23.02 10/1/2014 12/31/2014 J3230 Injection, chlorpromazine HCl, up to 50 mg $23.92 1/1/2015 3/31/2015 J3230 Injection, chlorpromazine HCl, up to 50 mg $22.04 4/1/2015 6/30/2015 J3230 Injection, chlorpromazine HCl, up to 50 mg $23.67 7/1/2015 12/31/2078

J3240 Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial $1,431.81 7/1/2014 9/30/2014 J3240 Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial $1,430.43 10/1/2014 12/31/2014 J3240 Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial $1,428.67 1/1/2015 3/31/2015 J3240 Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial $1,420.44 4/1/2015 6/30/2015 J3240 Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial $1,431.67 7/1/2015 12/31/2078

J3246 Injection, tirofiban HCl, 0.25 mg $9.48 7/1/2014 9/30/2014 J3246 Injection, tirofiban HCl, 0.25 mg $9.17 10/1/2014 12/31/2014 J3246 Injection, tirofiban HCl, 0.25 mg $9.00 1/1/2015 3/31/2015 J3246 Injection, tirofiban HCl, 0.25 mg $8.80 4/1/2015 6/30/2015 J3246 Injection, tirofiban HCl, 0.25 mg $9.12 7/1/2015 12/31/2078

J3250 Injection, trimethobenzamide HCL, up to 200 mg $19.52 7/1/2014 9/30/2014 J3250 Injection, trimethobenzamide HCL, up to 200 mg $19.70 10/1/2014 12/31/2014 J3250 Injection, trimethobenzamide HCL, up to 200 mg $20.72 1/1/2015 3/31/2015 J3250 Injection, trimethobenzamide HCL, up to 200 mg $20.85 4/1/2015 6/30/2015 J3250 Injection, trimethobenzamide HCL, up to 200 mg $23.69 7/1/2015 12/31/2078

J3260 Injection, tobramycin sulfate, up to 80 mg $2.77 7/1/2014 9/30/2014 J3260 Injection, tobramycin sulfate, up to 80 mg $2.46 10/1/2014 12/31/2014 J3260 Injection, tobramycin sulfate, up to 80 mg $2.81 1/1/2015 3/31/2015 J3260 Injection, tobramycin sulfate, up to 80 mg $2.66 4/1/2015 6/30/2015 J3260 Injection, tobramycin sulfate, up to 80 mg $2.29 7/1/2015 12/31/2078

J3262 Injection, tocilizumab, 1 mg $3.69 7/1/2014 9/30/2014 J3262 Injection, tocilizumab, 1 mg $3.68 10/1/2014 12/31/2014 J3262 Injection, tocilizumab, 1 mg $3.80 1/1/2015 3/31/2015 J3262 Injection, tocilizumab, 1 mg $3.77 4/1/2015 6/30/2015 J3262 Injection, tocilizumab, 1 mg $3.87 7/1/2015 12/31/2078

J3265 Injection, torsemide, 10 mg/ml $2.19 7/1/2014 12/31/2078

J3280 Injection, thiethylperazine maleate, up to 10 mg $4.76 7/1/2014 12/31/2078

J3285 Injection, treprostinil, 1 mg $61.24 7/1/2014 12/31/2078 Procedure Effective Code Description Rate End Date Code Date

J3300 Injection, triamcinolone acetonide, preservative free, 1 mg $3.68 7/1/2014 9/30/2014 J3300 Injection, triamcinolone acetonide, preservative free, 1 mg $3.73 10/1/2014 12/31/2014 J3300 Injection, triamcinolone acetonide, preservative free, 1 mg $3.74 1/1/2015 3/31/2015 J3300 Injection, triamcinolone acetonide, preservative free, 1 mg $3.72 4/1/2015 6/30/2015 J3300 Injection, triamcinolone acetonide, preservative free, 1 mg $3.70 7/1/2015 12/31/2078

J3301 Injection, triamcinolone acetonide, NOS, 10 mg $1.78 7/1/2014 9/30/2014 J3301 Injection, triamcinolone acetonide, NOS, 10 mg $1.77 10/1/2014 12/31/2014 J3301 Injection, triamcinolone acetonide, NOS, 10 mg $1.81 1/1/2015 3/31/2015 J3301 Injection, triamcinolone acetonide, NOS, 10 mg $1.79 4/1/2015 6/30/2015 J3301 Injection, triamcinolone acetonide, NOS, 10 mg $1.77 7/1/2015 12/31/2078

J3302 Injection, triamcinolone diacetate, per 5 mg $0.28 7/1/2014 12/31/2078

J3303 Injection, triamcinolone hexacetonide, per 5 mg $1.67 7/1/2014 9/30/2014 J3303 Injection, triamcinolone hexacetonide, per 5 mg $2.44 10/1/2014 12/31/2014 J3303 Injection, triamcinolone hexacetonide, per 5 mg $2.14 1/1/2015 3/31/2015 J3303 Injection, triamcinolone hexacetonide, per 5 mg $1.81 4/1/2015 12/31/2078

J3305 Injection, trimetrexate glucoronate, per 25 mg $149.71 7/1/2014 12/31/2078

J3310 Injection, perphenazine, up to 5 mg $6.90 7/1/2014 12/31/2078

J3315 Injection, triptorelin pamoate, 3.75 mg $185.89 7/1/2014 9/30/2014 J3315 Injection, triptorelin pamoate, 3.75 mg $170.77 10/1/2014 12/31/2014 J3315 Injection, triptorelin pamoate, 3.75 mg $169.45 1/1/2015 3/31/2015 J3315 Injection, triptorelin pamoate, 3.75 mg $180.19 4/1/2015 6/30/2015 J3315 Injection, triptorelin pamoate, 3.75 mg $204.24 7/1/2015 12/31/2078

J3320 Injection, spectinomycin dihydrochloride, up to 2 gm $30.08 7/1/2014 12/31/2078

J3350 Injection, Urea, up to 40 grams $122.40 7/1/2014 12/31/2014 J3350 Injection, Urea, up to 40 grams $39.97 1/1/2015 3/31/2015 J3350 Injection, Urea, up to 40 grams $1.35 4/1/2015 6/30/2015 J3350 Injection, Urea, up to 40 grams $39.97 7/1/2015 12/31/2078

J3360 Injection, diazepam, up to 5 mg $4.64 7/1/2014 9/30/2014 J3360 Injection, diazepam, up to 5 mg $4.79 10/1/2014 12/31/2014 J3360 Injection, diazepam, up to 5 mg $4.60 1/1/2015 3/31/2015 J3360 Injection, diazepam, up to 5 mg $4.67 4/1/2015 6/30/2015 J3360 Injection, diazepam, up to 5 mg $6.18 7/1/2015 12/31/2078

J3364 Injection, urokinase, 5,000 IU vial $9.16 7/1/2014 12/31/2078

J3365 Injection, urokinase, 250,000 IU vial $457.73 7/1/2014 12/31/2078

J3370 Injection, vancomycin HCl, up to 500 mg $2.30 7/1/2014 9/30/2014 J3370 Injection, vancomycin HCl, up to 500 mg $2.18 10/1/2014 12/31/2014 J3370 Injection, vancomycin HCl, up to 500 mg $2.06 1/1/2015 3/31/2015 J3370 Injection, vancomycin HCl, up to 500 mg $2.80 4/1/2015 6/30/2015 Procedure Effective Code Description Rate End Date Code Date J3370 Injection, vancomycin HCl, up to 500 mg $3.53 7/1/2015 12/31/2078

J3385 Injection, velaglucerase alfa, 100 units $353.32 7/1/2014 9/30/2014 J3385 Injection, velaglucerase alfa, 100 units $353.35 10/1/2014 12/31/2014 J3385 Injection, velaglucerase alfa, 100 units $352.81 1/1/2015 3/31/2015 J3385 Injection, velaglucerase alfa, 100 units $350.59 4/1/2015 6/30/2015 J3385 Injection, velaglucerase alfa, 100 units $349.28 7/1/2015 12/31/2078

J3396 Injection, verteporfin, 0.1 mg $10.71 7/1/2014 9/30/2014 J3396 Injection, verteporfin, 0.1 mg $10.79 10/1/2014 12/31/2014 J3396 Injection, verteporfin, 0.1 mg $10.75 1/1/2015 3/31/2015 J3396 Injection, verteporfin, 0.1 mg $10.89 4/1/2015 12/31/2078

J3400 Injection, triflupromazine HCl, up to 20 mg $16.74 7/1/2014 12/31/2078

J3410 Injection, hydroxyzine HCl, up to 25 mg $0.45 7/1/2014 6/30/2015 J3410 Injection, hydroxyzine HCl, up to 25 mg $1.75 7/1/2015 12/31/2078

J3420 Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg $2.20 7/1/2014 9/30/2014 J3420 Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg $1.82 10/1/2014 12/31/2014 J3420 Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg $3.32 1/1/2015 3/31/2015 J3420 Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg $2.05 4/1/2015 6/30/2015 J3420 Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg $4.39 7/1/2015 12/31/2078

J3430 Injection, phytonadione (vitamin K), per 1 mg $1.19 7/1/2014 9/30/2014 J3430 Injection, phytonadione (vitamin K), per 1 mg $1.23 10/1/2014 12/31/2014 J3430 Injection, phytonadione (vitamin K), per 1 mg $2.94 1/1/2015 3/31/2015 J3430 Injection, phytonadione (vitamin K), per 1 mg $3.21 4/1/2015 6/30/2015 J3430 Injection, phytonadione (vitamin K), per 1 mg $3.12 7/1/2015 12/31/2078

J3470 Injection, hyaluronidase, up to 150 units $21.20 7/1/2014 12/31/2078

J3471 Injection, hyaluronidase, ovine, preservative free, up to 999 USP units $0.25 7/1/2014 12/31/2078

J3472 Injection, hyaluronidase, ovine, preservative free, per 1,000 USP units $137.80 7/1/2014 12/31/2078

J3473 Injection, hyaluronidase recombinant, 1 USP unit $0.31 7/1/2014 9/30/2014 J3473 Injection, hyaluronidase recombinant, 1 USP unit $0.33 10/1/2014 3/31/2015 J3473 Injection, hyaluronidase recombinant, 1 USP unit $0.34 4/1/2015 12/31/2078

J3475 Injection, magnesium sulfate, per 500 mg $0.20 7/1/2014 9/30/2014 J3475 Injection, magnesium sulfate, per 500 mg $0.19 10/1/2014 12/31/2014 J3475 Injection, magnesium sulfate, per 500 mg $0.23 1/1/2015 3/31/2015 J3475 Injection, magnesium sulfate, per 500 mg $0.17 4/1/2015 12/31/2078

J3480 Injection, potassium chloride, per 2 mEq $0.12 7/1/2014 12/31/2014 J3480 Injection, potassium chloride, per 2 mEq $0.13 1/1/2015 3/31/2015 J3480 Injection, potassium chloride, per 2 mEq $0.14 4/1/2015 6/30/2015 J3480 Injection, potassium chloride, per 2 mEq $0.13 7/1/2015 12/31/2078

J3489 Injection, zoledronic acid, 1 mg $61.58 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J3489 Injection, zoledronic acid, 1 mg $47.48 10/1/2014 12/31/2014 J3489 Injection, zoledronic acid, 1 mg $41.29 1/1/2015 3/31/2015 J3489 Injection, zoledronic acid, 1 mg $38.23 4/1/2015 6/30/2015 J3489 Injection, zoledronic acid, 1 mg $32.24 7/1/2015 12/31/2078

J3490 Unclassified drugs $3,500.00 7/1/2014 12/31/2078

J3520 Edetate disodium, per 150 mg $3.94 7/1/2014 12/31/2078

J3590 Unclassified biologics $6,240.00 7/1/2014 12/31/2078

J7030 Infusion, normal saline solution, 1,000 cc $1.39 7/1/2014 9/30/2014 J7030 Infusion, normal saline solution, 1,000 cc $1.35 10/1/2014 12/31/2014 J7030 Infusion, normal saline solution, 1,000 cc $1.49 1/1/2015 3/31/2015 J7030 Infusion, normal saline solution, 1,000 cc $1.51 4/1/2015 6/30/2015 J7030 Infusion, normal saline solution, 1,000 cc $1.57 7/1/2015 12/31/2078

J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit) $0.69 7/1/2014 9/30/2014 J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit) $0.68 10/1/2014 12/31/2014 J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit) $0.74 1/1/2015 3/31/2015 J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit) $0.75 4/1/2015 6/30/2015 J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit) $0.79 7/1/2015 12/31/2078

J7042 5% dextrose/normal saline (500 ml = 1 unit) $0.59 7/1/2014 9/30/2014 J7042 5% dextrose/normal saline (500 ml = 1 unit) $0.60 10/1/2014 12/31/2014 J7042 5% dextrose/normal saline (500 ml = 1 unit) $0.57 1/1/2015 3/31/2015 J7042 5% dextrose/normal saline (500 ml = 1 unit) $0.59 4/1/2015 6/30/2015 J7042 5% dextrose/normal saline (500 ml = 1 unit) $0.63 7/1/2015 12/31/2078

J7050 Infusion, normal saline solution, 250 cc $0.35 7/1/2014 9/30/2014 J7050 Infusion, normal saline solution, 250 cc $0.34 10/1/2014 12/31/2014 J7050 Infusion, normal saline solution, 250 cc $0.37 1/1/2015 6/30/2015 J7050 Infusion, normal saline solution, 250 cc $0.39 7/1/2015 12/31/2078

J7060 5% dextrose/water (500 ml = 1 unit) $1.23 7/1/2014 9/30/2014 J7060 5% dextrose/water (500 ml = 1 unit) $1.18 10/1/2014 12/31/2014 J7060 5% dextrose/water (500 ml = 1 unit) $1.28 1/1/2015 3/31/2015 J7060 5% dextrose/water (500 ml = 1 unit) $1.33 4/1/2015 6/30/2015 J7060 5% dextrose/water (500 ml = 1 unit) $1.38 7/1/2015 12/31/2078

J7070 Infusion, D-5-W, 1,000 cc $2.43 7/1/2014 9/30/2014 J7070 Infusion, D-5-W, 1,000 cc $2.32 10/1/2014 12/31/2014 J7070 Infusion, D-5-W, 1,000 cc $2.43 1/1/2015 3/31/2015 J7070 Infusion, D-5-W, 1,000 cc $2.58 4/1/2015 6/30/2015 J7070 Infusion, D-5-W, 1,000 cc $2.57 7/1/2015 12/31/2078

J7100 Infusion, dextran 40, 500 ml $23.65 7/1/2014 9/30/2014 J7100 Infusion, dextran 40, 500 ml $21.59 10/1/2014 12/31/2014 J7100 Infusion, dextran 40, 500 ml $17.77 1/1/2015 12/31/2078

J7110 Infusion, dextran 75, 500 ml $14.52 7/1/2014 12/31/2078 Procedure Effective Code Description Rate End Date Code Date

J7120 Ringers lactate infusion, up to 1,000 cc $1.18 7/1/2014 9/30/2014 J7120 Ringers lactate infusion, up to 1,000 cc $1.16 10/1/2014 12/31/2014 J7120 Ringers lactate infusion, up to 1,000 cc $1.30 1/1/2015 3/31/2015 J7120 Ringers lactate infusion, up to 1,000 cc $1.31 4/1/2015 6/30/2015 J7120 Ringers lactate infusion, up to 1,000 cc $1.47 7/1/2015 12/31/2078

J7131 Hypertonic saline solution, 1 ml $0.03 7/1/2014 12/31/2078

J7181 Factor xiii recomb a-subunit, per IU $13.81 1/1/2015 3/31/2015 J7181 Factor xiii recomb a-subunit, per IU $13.73 4/1/2015 6/30/2015 J7181 Factor xiii recomb a-subunit, per IU $13.77 7/1/2015 12/31/2078

J7182 Injection, factor viii, recombinant novoeight, per IU $1.69 1/1/2015 12/31/2078

J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU $0.94 7/1/2014 9/30/2014 J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU $0.95 10/1/2014 12/31/2014 J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU $0.96 1/1/2015 3/31/2015 J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU $0.98 4/1/2015 6/30/2015 J7183 Injection, von Willebrand factor complex (human), Wilate, 1 IU $0.99 7/1/2015 12/31/2078

J7185 Injection, factor VIII (antihemophilic factor, recombinant) (XYNTHA), per IU $1.19 7/1/2014 9/30/2014 J7185 Injection, factor VIII (antihemophilic factor, recombinant) (XYNTHA), per IU $1.17 10/1/2014 12/31/2014 J7185 Injection, factor VIII (antihemophilic factor, recombinant) (XYNTHA), per IU $1.19 1/1/2015 3/31/2015 J7185 Injection, factor VIII (antihemophilic factor, recombinant) (XYNTHA), per IU $1.18 4/1/2015 6/30/2015 J7185 Injection, factor VIII (antihemophilic factor, recombinant) (XYNTHA), per IU $1.19 7/1/2015 12/31/2078

J7186 Injection, antihemophilic fctr VIII/von Willebrand fctr cmplx (human), per IU $0.93 7/1/2014 9/30/2014 J7186 Injection, antihemophilic fctr VIII/von Willebrand fctr cmplx (human), per IU $0.94 10/1/2014 12/31/2014 J7186 Injection, antihemophilic fctr VIII/von Willebrand fctr cmplx (human), per IU $0.95 1/1/2015 3/31/2015 J7186 Injection, antihemophilic fctr VIII/von Willebrand fctr cmplx (human), per IU $0.96 4/1/2015 12/31/2078

J7187 Injection, von Willebrand facotr complex (Humate-P), per IU VWF:RCO $0.95 7/1/2014 12/31/2014 J7187 Injection, von Willebrand facotr complex (Humate-P), per IU VWF:RCO $0.96 1/1/2015 3/31/2015 J7187 Injection, von Willebrand facotr complex (Humate-P), per IU VWF:RCO $0.99 4/1/2015 12/31/2078

J7189 Factor VIIa (anthihemophilic factor, recombinant), per 1 mcg $1.72 7/1/2014 9/30/2014 J7189 Factor VIIa (anthihemophilic factor, recombinant), per 1 mcg $1.73 10/1/2014 12/31/2014 J7189 Factor VIIa (anthihemophilic factor, recombinant), per 1 mcg $1.77 1/1/2015 3/31/2015 J7189 Factor VIIa (anthihemophilic factor, recombinant), per 1 mcg $1.76 4/1/2015 6/30/2015 J7189 Factor VIIa (anthihemophilic factor, recombinant), per 1 mcg $2.04 7/1/2015 12/31/2078

J7190 Factor VIII (antihemophilic factor, human) per IU $0.93 7/1/2014 12/31/2014 J7190 Factor VIII (antihemophilic factor, human) per IU $0.94 1/1/2015 6/30/2015 J7190 Factor VIII (antihemophilic factor, human) per IU $0.98 7/1/2015 12/31/2078

J7191 Factor VIII (antihemophilic factor (porcine)), per IU $0.20 7/1/2014 3/31/2015 J7191 Factor VIII (antihemophilic factor (porcine)), per IU $588.77 4/1/2015 6/30/2015 J7191 Factor VIII (antihemophilic factor (porcine)), per IU $0.20 7/1/2015 12/31/2078

J7192 Factor VIII (antihemophilc factor, recombinant), per IU, NOS $1.14 7/1/2014 3/31/2015 Procedure Effective Code Description Rate End Date Code Date J7192 Factor VIII (antihemophilc factor, recombinant), per IU, NOS $1.15 4/1/2015 6/30/2015 J7192 Factor VIII (antihemophilc factor, recombinant), per IU, NOS $1.17 7/1/2015 12/31/2078

J7193 Factor IX (antihemophilic factor, purified, nonrecombinant) per IU $1.01 7/1/2014 12/31/2014 J7193 Factor IX (antihemophilic factor, purified, nonrecombinant) per IU $1.04 1/1/2015 3/31/2015 J7193 Factor IX (antihemophilic factor, purified, nonrecombinant) per IU $1.05 4/1/2015 6/30/2015 J7193 Factor IX (antihemophilic factor, purified, nonrecombinant) per IU $1.06 7/1/2015 12/31/2078

J7194 Factor IX complex, per IU $1.12 7/1/2014 12/31/2014 J7194 Factor IX complex, per IU $1.14 1/1/2015 3/31/2015 J7194 Factor IX complex, per IU $1.13 4/1/2015 6/30/2015 J7194 Factor IX complex, per IU $1.16 7/1/2015 12/31/2078

J7195 Factor IX (antihemophilic factor, recombinant) per IU $1.37 7/1/2014 9/30/2014 J7195 Factor IX (antihemophilic factor, recombinant) per IU $1.35 10/1/2014 3/31/2015 J7195 Factor IX (antihemophilic factor, recombinant) per IU $1.37 4/1/2015 6/30/2015 J7195 Factor IX (antihemophilic factor, recombinant) per IU $1.48 7/1/2015 12/31/2078

J7196 Injection, antithrombin recombinant, 50 IU $103.35 7/1/2014 12/31/2078

J7197 Antithrombin III (human), per IU $3.14 7/1/2014 9/30/2014 J7197 Antithrombin III (human), per IU $3.27 10/1/2014 6/30/2015 J7197 Antithrombin III (human), per IU $3.28 7/1/2015 12/31/2078

J7198 Antiinhibitor, per IU $1.70 7/1/2014 12/31/2014 J7198 Antiinhibitor, per IU $1.76 1/1/2015 3/31/2015 J7198 Antiinhibitor, per IU $1.77 4/1/2015 6/30/2015 J7198 Antiinhibitor, per IU $1.83 7/1/2015 12/31/2078

J7200 Factor ix recombinan rixubis, per IU $1.24 1/1/2015 12/31/2078

J7201 Factor ix fc fusion recomb, per IU $2.82 1/1/2015 6/30/2015 J7201 Factor ix fc fusion recomb, per IU $2.81 7/1/2015 12/31/2078

J7300 Intrauterine copper contraceptive $600.00 7/1/2014 12/31/2078

J7301 Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg $675.73 7/1/2014 12/31/2078

J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg $716.00 7/1/2014 7/31/2014 J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg $772.65 8/1/2014 12/31/2078

J7306 Levonorgestrel (contraceptive) implant system, incl implant & supplies $427.50 7/1/2014 12/31/2078

J7308 Aminolevulinic acid HCl for topical admin, 20%, single unit dosage 354 mg $249.10 7/1/2014 9/30/2014 J7308 Aminolevulinic acid HCl for topical admin, 20%, single unit dosage 354 mg $242.30 10/1/2014 12/31/2014 J7308 Aminolevulinic acid HCl for topical admin, 20%, single unit dosage 354 mg $244.25 1/1/2015 3/31/2015 J7308 Aminolevulinic acid HCl for topical admin, 20%, single unit dosage 354 mg $294.15 4/1/2015 12/31/2078

J7309 Methyl aminolevulinate (MAL), for topical administraction, 16.8%, 1 gram $83.69 7/1/2014 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J7310 Ganciclovir, 4.5 MG long-acting implant $16,960.00 7/1/2014 12/31/2078

J7311 Fluocinolone acetonide, intravitreal implant $19,227.80 7/1/2014 9/30/2014 J7311 Fluocinolone acetonide, intravitreal implant $19,641.05 10/1/2014 12/31/2014 J7311 Fluocinolone acetonide, intravitreal implant $19,725.67 1/1/2015 3/31/2015 J7311 Fluocinolone acetonide, intravitreal implant $19,710.73 4/1/2015 6/30/2015 J7311 Fluocinolone acetonide, intravitreal implant $19,882.12 7/1/2015 12/31/2078

J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg $201.40 7/1/2014 9/30/2014 J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg $201.31 10/1/2014 12/31/2014 J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg $201.25 1/1/2015 3/31/2015 J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg $201.21 4/1/2015 6/30/2015 J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg $200.90 7/1/2015 12/31/2078

J7316 Injection, ocriplasmin, 0.125 mg $1,046.75 7/1/2014 12/31/2078

J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular inj per dose $89.86 7/1/2014 9/30/2014 J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular inj per dose $90.81 10/1/2014 12/31/2014 J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular inj per dose $88.90 1/1/2015 3/31/2015 J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular inj per dose $89.21 4/1/2015 6/30/2015 J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular inj per dose $89.31 7/1/2015 12/31/2078

J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose $161.88 7/1/2014 9/30/2014 J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose $160.42 10/1/2014 12/31/2014 J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose $154.62 1/1/2015 3/31/2015 J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose $148.51 4/1/2015 6/30/2015 J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose $152.84 7/1/2015 12/31/2078

J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose $178.89 7/1/2014 9/30/2014 J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose $186.89 10/1/2014 12/31/2014 J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose $174.75 1/1/2015 3/31/2015 J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose $177.07 4/1/2015 6/30/2015 J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose $170.40 7/1/2015 12/31/2078

J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-art injt, 1 mg $12.37 7/1/2014 9/30/2014 J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-art injt, 1 mg $12.50 10/1/2014 12/31/2014 J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-art injt, 1 mg $12.74 1/1/2015 3/31/2015 J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-art injt, 1 mg $12.66 4/1/2015 6/30/2015 J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-art injt, 1 mg $12.72 7/1/2015 12/31/2078

J7327 Monovisc inj per dose $988.38 1/1/2015 3/31/2015 J7327 Monovisc inj per dose $979.01 4/1/2015 6/30/2015 J7327 Monovisc inj per dose $963.80 7/1/2015 12/31/2078

J7336 Capsaicin 8% patch, per sq cm $2.73 1/1/2015 6/30/2015 J7336 Capsaicin 8% patch, per sq cm $2.80 7/1/2015 12/31/2078

J7500 Azathioprine, oral, 50 mg $0.15 7/1/2014 9/30/2014 J7500 Azathioprine, oral, 50 mg $0.19 10/1/2014 12/31/2014 J7500 Azathioprine, oral, 50 mg $0.21 1/1/2015 3/31/2015 J7500 Azathioprine, oral, 50 mg $0.22 4/1/2015 6/30/2015 Procedure Effective Code Description Rate End Date Code Date J7500 Azathioprine, oral, 50 mg $0.25 7/1/2015 12/31/2078

J7501 Azathioprine, parenteral, 100 mg $217.30 7/1/2014 12/31/2078

J7502 Cyclosporine, oral, 100 mg $3.23 7/1/2014 9/30/2014 J7502 Cyclosporine, oral, 100 mg $3.38 10/1/2014 12/31/2014 J7502 Cyclosporine, oral, 100 mg $3.46 1/1/2015 3/31/2015 J7502 Cyclosporine, oral, 100 mg $3.00 4/1/2015 6/30/2015 J7502 Cyclosporine, oral, 100 mg $2.98 7/1/2015 12/31/2078

J7504 Lympho immune/antithymocyte globulin, equine, parenteral, 250 mg $824.12 7/1/2014 9/30/2014 J7504 Lympho immune/antithymocyte globulin, equine, parenteral, 250 mg $852.69 10/1/2014 12/31/2014 J7504 Lympho immune/antithymocyte globulin, equine, parenteral, 250 mg $902.25 1/1/2015 3/31/2015 J7504 Lympho immune/antithymocyte globulin, equine, parenteral, 250 mg $901.42 4/1/2015 6/30/2015 J7504 Lympho immune/antithymocyte globulin, equine, parenteral, 250 mg $1,032.82 7/1/2015 12/31/2078

J7505 Muromonab-CD3, parenteral, 5 mg $6.62 7/1/2014 12/31/2078

J7506 Prednisone, oral, per 5 mg $0.08 7/1/2014 12/31/2078

J7507 Tacrolimus, oral, per 1 mg $1.32 7/1/2014 9/30/2014 J7507 Tacrolimus, oral, per 1 mg $1.24 10/1/2014 12/31/2014 J7507 Tacrolimus, oral, per 1 mg $1.04 1/1/2015 3/31/2015 J7507 Tacrolimus, oral, per 1 mg $1.23 4/1/2015 6/30/2015 J7507 Tacrolimus, oral, per 1 mg $0.93 7/1/2015 12/31/2078

J7508 Tacrolimus extended release, oral, 0.1MG $0.40 7/1/2014 12/31/2014 J7508 Tacrolimus extended release, oral, 0.1MG $0.39 1/1/2015 12/31/2078

J7509 Methylprednisolone, oral, per 4 mg $0.55 7/1/2014 9/30/2014 J7509 Methylprednisolone, oral, per 4 mg $0.66 10/1/2014 12/31/2014 J7509 Methylprednisolone, oral, per 4 mg $0.51 1/1/2015 3/31/2015 J7509 Methylprednisolone, oral, per 4 mg $0.54 4/1/2015 6/30/2015 J7509 Methylprednisolone, oral, per 4 mg $0.51 7/1/2015 12/31/2078

J7510 Prednisolone, oral, per 5 mg $0.13 7/1/2014 9/30/2014 J7510 Prednisolone, oral, per 5 mg $0.09 10/1/2014 12/31/2014 J7510 Prednisolone, oral, per 5 mg $0.11 1/1/2015 3/31/2015 J7510 Prednisolone, oral, per 5 mg $0.12 4/1/2015 6/30/2015 J7510 Prednisolone, oral, per 5 mg $0.10 7/1/2015 12/31/2078

J7511 Lympho immune/antithymocyte globulin rabbit, parenteral 25 mg $602.26 7/1/2014 9/30/2014 J7511 Lympho immune/antithymocyte globulin rabbit, parenteral 25 mg $594.74 10/1/2014 12/31/2014 J7511 Lympho immune/antithymocyte globulin rabbit, parenteral 25 mg $588.77 1/1/2015 3/31/2015 J7511 Lympho immune/antithymocyte globulin rabbit, parenteral 25 mg $594.06 4/1/2015 6/30/2015 J7511 Lympho immune/antithymocyte globulin rabbit, parenteral 25 mg $621.29 7/1/2015 12/31/2078

J7513 Daclizumab, parenteral, 25 mg $526.34 7/1/2014 3/31/2015 J7513 Daclizumab, parenteral, 25 mg $27.70 4/1/2015 6/30/2015 J7513 Daclizumab, parenteral, 25 mg $526.34 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J7515 Cyclosporine, oral, 25 mg $0.87 7/1/2014 9/30/2014 J7515 Cyclosporine, oral, 25 mg $0.88 10/1/2014 12/31/2014 J7515 Cyclosporine, oral, 25 mg $0.89 1/1/2015 3/31/2015 J7515 Cyclosporine, oral, 25 mg $0.80 4/1/2015 6/30/2015 J7515 Cyclosporine, oral, 25 mg $0.84 7/1/2015 12/31/2078

J7516 Cyclosporin, parenteral, 250 mg $40.54 7/1/2014 9/30/2014 J7516 Cyclosporin, parenteral, 250 mg $33.84 10/1/2014 12/31/2014 J7516 Cyclosporin, parenteral, 250 mg $33.02 1/1/2015 3/31/2015 J7516 Cyclosporin, parenteral, 250 mg $34.96 4/1/2015 6/30/2015 J7516 Cyclosporin, parenteral, 250 mg $36.73 7/1/2015 12/31/2078

J7517 Mycophenolate mofetil, oral, 250 mg $1.58 7/1/2014 9/30/2014 J7517 Mycophenolate mofetil, oral, 250 mg $1.53 10/1/2014 12/31/2014 J7517 Mycophenolate mofetil, oral, 250 mg $1.49 1/1/2015 3/31/2015 J7517 Mycophenolate mofetil, oral, 250 mg $1.29 4/1/2015 6/30/2015 J7517 Mycophenolate mofetil, oral, 250 mg $1.27 7/1/2015 12/31/2078

J7518 Mycophenolic acid, oral, 180 mg $3.46 7/1/2014 9/30/2014 J7518 Mycophenolic acid, oral, 180 mg $3.41 10/1/2014 12/31/2014 J7518 Mycophenolic acid, oral, 180 mg $3.31 1/1/2015 3/31/2015 J7518 Mycophenolic acid, oral, 180 mg $3.19 4/1/2015 6/30/2015 J7518 Mycophenolic acid, oral, 180 mg $3.01 7/1/2015 12/31/2078

J7520 Sirolimus, oral, 1 mg $15.74 7/1/2014 9/30/2014 J7520 Sirolimus, oral, 1 mg $16.23 10/1/2014 12/31/2014 J7520 Sirolimus, oral, 1 mg $17.23 1/1/2015 3/31/2015 J7520 Sirolimus, oral, 1 mg $13.34 4/1/2015 6/30/2015 J7520 Sirolimus, oral, 1 mg $13.19 7/1/2015 12/31/2078

INHALATION DRUGS All administered through DME unless noted

J7604 Acetylcysteine, compounded product, unit dose form, per g $0.22 7/1/2014 12/31/2078

J7605 Arformoterol, non-compounded, unit dose form, 15 mcg $6.39 7/1/2014 9/30/2014 J7605 Arformoterol, non-compounded, unit dose form, 15 mcg $6.70 10/1/2014 12/31/2014 J7605 Arformoterol, non-compounded, unit dose form, 15 mcg $6.98 1/1/2015 3/31/2015 J7605 Arformoterol, non-compounded, unit dose form, 15 mcg $7.03 4/1/2015 6/30/2015 J7605 Arformoterol, non-compounded, unit dose form, 15 mcg $7.17 7/1/2015 12/31/2078

J7606 Formoterol fumarate, non-compounded, unit dose form, 20 mcg $6.62 7/1/2014 9/30/2014 J7606 Formoterol fumarate, non-compounded, unit dose form, 20 mcg $7.46 10/1/2014 12/31/2014 J7606 Formoterol fumarate, non-compounded, unit dose form, 20 mcg $7.70 1/1/2015 3/31/2015 J7606 Formoterol fumarate, non-compounded, unit dose form, 20 mcg $8.04 4/1/2015 6/30/2015 J7606 Formoterol fumarate, non-compounded, unit dose form, 20 mcg $8.48 7/1/2015 12/31/2078

J7607 Levalbuterol, compounded product, concentrated form, 0.5 mg $0.03 7/1/2014 12/31/2078

J7608 Acetylcysteine, non-compounded, unit dose form, per gram $5.08 7/1/2014 9/30/2014 J7608 Acetylcysteine, non-compounded, unit dose form, per gram $3.70 10/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J7608 Acetylcysteine, non-compounded, unit dose form, per gram $5.39 1/1/2015 3/31/2015 J7608 Acetylcysteine, non-compounded, unit dose form, per gram $4.43 4/1/2015 6/30/2015 J7608 Acetylcysteine, non-compounded, unit dose form, per gram $4.86 7/1/2015 12/31/2078

J7609 Albuterol, compounded product, unit dose form, 1 mg $0.12 7/1/2014 12/31/2078

J7610 Albuterol, compounded product, concentrated form, 1 mg $5.00 7/1/2014 12/31/2078

J7611 Albuterol, non-compounded, concentrated form, 1 mg $0.12 7/1/2014 9/30/2014 J7611 Albuterol, non-compounded, concentrated form, 1 mg $0.11 10/1/2014 12/31/2014 J7611 Albuterol, non-compounded, concentrated form, 1 mg $0.12 1/1/2015 6/30/2015 J7611 Albuterol, non-compounded, concentrated form, 1 mg $0.13 7/1/2015 12/31/2078

J7612 Levalbuterol, non-compounded, concentrated form, 0.5 mg $0.21 7/1/2014 9/30/2014 J7612 Levalbuterol, non-compounded, concentrated form, 0.5 mg $0.19 10/1/2014 12/31/2014 J7612 Levalbuterol, non-compounded, concentrated form, 0.5 mg $0.17 1/1/2015 3/31/2015 J7612 Levalbuterol, non-compounded, concentrated form, 0.5 mg $0.19 4/1/2015 6/30/2015 J7612 Levalbuterol, non-compounded, concentrated form, 0.5 mg $0.26 7/1/2015 12/31/2078

J7613 Albuterol, non-compounded, unit dose form, 1 mg $0.05 7/1/2014 9/30/2014 J7613 Albuterol, non-compounded, unit dose form, 1 mg $0.06 10/1/2014 12/31/2014 J7613 Albuterol, non-compounded, unit dose form, 1 mg $0.05 1/1/2015 3/31/2015 J7613 Albuterol, non-compounded, unit dose form, 1 mg $0.11 4/1/2015 6/30/2015 J7613 Albuterol, non-compounded, unit dose form, 1 mg $0.05 7/1/2015 12/31/2078

J7614 Levalbuterol, non-compounded, unit dose form, 0.5 mg $0.09 7/1/2014 9/30/2014 J7614 Levalbuterol, non-compounded, unit dose form, 0.5 mg $0.10 10/1/2014 12/31/2014 J7614 Levalbuterol, non-compounded, unit dose form, 0.5 mg $0.09 1/1/2015 3/31/2015 J7614 Levalbuterol, non-compounded, unit dose form, 0.5 mg $0.14 4/1/2015 6/30/2015 J7614 Levalbuterol, non-compounded, unit dose form, 0.5 mg $0.09 7/1/2015 12/31/2078

J7615 Levalbuterol, compounded product, unit dose form, 0.5 mg $3.15 7/1/2014 12/31/2078

J7620 Albuterol, up to 2.5 mg & ipratropium bromide up to 0.5 mg, noncompound $0.18 7/1/2014 12/31/2014 J7620 Albuterol, up to 2.5 mg & ipratropium bromide up to 0.5 mg, noncompound $0.19 1/1/2015 3/31/2015 J7620 Albuterol, up to 2.5 mg & ipratropium bromide up to 0.5 mg, noncompound $0.17 4/1/2015 12/31/2078

J7622 Beclomethasone, compounded product, unit dose form, per mg $0.04 7/1/2014 12/31/2078

J7624 Betamethasone, compounded product, unit dose form, per mg $1.21 7/1/2014 12/31/2078

J7626 Budesonide, non-compounded, unit dose form, up to 0.5 mg $4.90 7/1/2014 9/30/2014 J7626 Budesonide, non-compounded, unit dose form, up to 0.5 mg $5.38 10/1/2014 12/31/2014 J7626 Budesonide, non-compounded, unit dose form, up to 0.5 mg $5.30 1/1/2015 3/31/2015 J7626 Budesonide, non-compounded, unit dose form, up to 0.5 mg $5.57 4/1/2015 6/30/2015 J7626 Budesonide, non-compounded, unit dose form, up to 0.5 mg $5.20 7/1/2015 12/31/2078

J7627 Budesonide, compounded product, unit dose form, up to 0.5 mg $2.76 7/1/2014 12/31/2078

J7628 Bitolterol mesylate, compounded product, concentrates form, per mg $0.18 7/1/2014 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J7629 Bitolterol mesylate, compounded product, unit dose form, per mg $0.18 7/1/2014 12/31/2078

J7631 Cromolyn sodium, noncompounded, unit dose form, per 10 mg $0.41 7/1/2014 9/30/2014 J7631 Cromolyn sodium, noncompounded, unit dose form, per 10 mg $0.46 10/1/2014 12/31/2014 J7631 Cromolyn sodium, noncompounded, unit dose form, per 10 mg $0.63 1/1/2015 3/31/2015 J7631 Cromolyn sodium, noncompounded, unit dose form, per 10 mg $0.78 4/1/2015 6/30/2015 J7631 Cromolyn sodium, noncompounded, unit dose form, per 10 mg $0.80 7/1/2015 12/31/2078

J7632 Cromolyn sodium, compounded product, unit dose form, per 10 mg $0.09 7/1/2014 12/31/2078

J7635 Atropine, compounded product, concentrated form, per mg $0.12 7/1/2014 12/31/2078

J7636 Atropine, compounded product, unit dose form, per mg $0.12 7/1/2014 12/31/2078

J7637 Dexamethasone, compounded product, concentrated form, per mg $0.13 7/1/2014 12/31/2078

J7638 Dexamethasone, compounded product, unit dose form, per mg $0.13 7/1/2014 12/31/2078

J7639 Dornase alfa, non-compounded product, unit dose form, per mg $35.36 7/1/2014 9/30/2014 J7639 Dornase alfa, non-compounded product, unit dose form, per mg $35.75 10/1/2014 6/30/2015 J7639 Dornase alfa, non-compounded product, unit dose form, per mg $38.55 7/1/2015 12/31/2078

J7640 Formoterol, compounded product, unitdose form, 12 mcg $1.69 7/1/2014 12/31/2078

J7641 Flunisolide, compounded product, unit dose form, per mg $0.21 7/1/2014 12/31/2078

J7642 Glycopyrrolate, compounded product, concentrated form, per mg $1.04 7/1/2014 12/31/2078

J7643 Glycopyrrolate, compounded product, unit dose form, per mg $1.04 7/1/2014 12/31/2078

J7644 Ipratropium bromide, non-compounded product, unit dose form, per mg $0.23 7/1/2014 9/30/2014 J7644 Ipratropium bromide, non-compounded product, unit dose form, per mg $0.24 10/1/2014 12/31/2014 J7644 Ipratropium bromide, non-compounded product, unit dose form, per mg $0.23 1/1/2015 6/30/2015 J7644 Ipratropium bromide, non-compounded product, unit dose form, per mg $0.22 7/1/2015 12/31/2078

J7645 Ipratropium bromide, compounded product, unit dose form, per mg $8.50 7/1/2014 12/31/2078

J7647 Isoetharine HCl, compounded product, concentrated form, per mg $0.61 7/1/2014 12/31/2078

J7648 Isoetharine HCl, non-compounded, concentrated form, per mg $0.14 7/1/2014 12/31/2078

J7649 Isoetharine HCl, non-compounded, unit dose form, per mg $0.16 7/1/2014 12/31/2078

J7650 Isoetharine HCl, compounded product, unit dose form, per mg $3.40 7/1/2014 12/31/2078

J7657 Isoproterenol HCl, compounded product, concentrated form, per mg $10.20 7/1/2014 12/31/2078

J7658 Isoproterenol HCl, non-compounded, concentrated form, per mg $2.07 7/1/2014 12/31/2078

J7659 Isoproterenol HCl, non-compounded, unit dose form, per mg $2.07 7/1/2014 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J7660 Isoproterenol HCl, compounded product, unit dose form, per mg $3.40 7/1/2014 12/31/2078

J7665 Mannitol, administered through an inhaler, 5 mg $0.67 7/1/2014 12/31/2078

J7667 Metaproterenol sulfate, compounded, concentrated form, per 10 mg $0.05 7/1/2014 12/31/2078

J7668 Metaproterenol sulfate, non-compounded, concentrated form, per 10 mg $0.22 7/1/2014 12/31/2078

J7669 Metaproterenol sulfate, non-compounded, unit dose form, per 10 mg $0.44 7/1/2014 12/31/2078

J7670 Metaproterenol sulfate, compounded product, unit dose form, per 10 mg $0.05 7/1/2014 12/31/2078

J7674 Methacholine chloride, administered through a nebulizer, per 1 mg $0.50 7/1/2014 9/30/2014 J7674 Methacholine chloride, administered through a nebulizer, per 1 mg $0.52 10/1/2014 3/31/2015 J7674 Methacholine chloride, administered through a nebulizer, per 1 mg $0.51 4/1/2015 12/31/2078

J7676 Pentamidine isethionate, compounded, unit dose form, per 300 mg $103.04 7/1/2014 12/31/2078

J7680 Terbutaline sulfate, compounded product, concentrated form, per mg $0.01 7/1/2014 12/31/2078

J7681 Terbutaline sulfate, compounded product, unit dose form, per mg $0.01 7/1/2014 12/31/2078

J7682 Tobramycin, non-compounded, unit dose form, per 300 mg $97.76 7/1/2014 9/30/2014 J7682 Tobramycin, non-compounded, unit dose form, per 300 mg $95.96 10/1/2014 12/31/2014 J7682 Tobramycin, non-compounded, unit dose form, per 300 mg $89.26 1/1/2015 3/31/2015 J7682 Tobramycin, non-compounded, unit dose form, per 300 mg $80.15 4/1/2015 6/30/2015 J7682 Tobramycin, non-compounded, unit dose form, per 300 mg $67.85 7/1/2015 12/31/2078

J7683 Triamcinolone, compounded product, concentrated form, per mg $0.56 7/1/2014 12/31/2078

J7684 Triamcinolone, compounded product, unit dose form, per mg $0.56 7/1/2014 12/31/2078

J7685 Tobramycin, compounded product, unit dose form, per 300 mg $4.80 7/1/2014 12/31/2078

J7686 Treprostinil, non-compounded product, unit dose form, 1.74 mg $482.99 7/1/2014 9/30/2014 J7686 Treprostinil, non-compounded product, unit dose form, 1.74 mg $483.00 10/1/2014 12/31/2014 J7686 Treprostinil, non-compounded product, unit dose form, 1.74 mg $482.99 1/1/2015 6/30/2015 J7686 Treprostinil, non-compounded product, unit dose form, 1.74 mg $506.44 7/1/2015 12/31/2078

J8498 Antiemetic drug, rectal/suppository, NOS $0.01 7/1/2014 12/31/2078

ORAL CHEMOTHERAPY DRUGS

J8501 Aprepitant, oral, 5 mg $7.43 7/1/2014 9/30/2014 J8501 Aprepitant, oral, 5 mg $7.68 10/1/2014 12/31/2014 J8501 Aprepitant, oral, 5 mg $7.67 1/1/2015 3/31/2015 J8501 Aprepitant, oral, 5 mg $8.48 4/1/2015 6/30/2015 J8501 Aprepitant, oral, 5 mg $9.36 7/1/2015 12/31/2078

J8510 Busulfan, oral, 2 mg $11.02 7/1/2014 9/30/2014 J8510 Busulfan, oral, 2 mg $10.98 10/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J8510 Busulfan, oral, 2 mg $12.62 1/1/2015 3/31/2015 J8510 Busulfan, oral, 2 mg $12.59 4/1/2015 6/30/2015 J8510 Busulfan, oral, 2 mg $12.65 7/1/2015 12/31/2078

J8515 Cabergoline, oral, 0.25 mg $14.57 7/1/2014 12/31/2078

J8520 Capecitabine, oral, 150 mg $9.84 7/1/2014 9/30/2014 J8520 Capecitabine, oral, 150 mg $8.67 10/1/2014 12/31/2014 J8520 Capecitabine, oral, 150 mg $8.10 1/1/2015 3/31/2015 J8520 Capecitabine, oral, 150 mg $6.96 4/1/2015 6/30/2015 J8520 Capecitabine, oral, 150 mg $6.32 7/1/2015 12/31/2078

J8521 Capecitabine, oral, 500 mg $32.83 7/1/2014 9/30/2014 J8521 Capecitabine, oral, 500 mg $28.63 10/1/2014 12/31/2014 J8521 Capecitabine, oral, 500 mg $26.34 1/1/2015 3/31/2015 J8521 Capecitabine, oral, 500 mg $23.22 4/1/2015 6/30/2015 J8521 Capecitabine, oral, 500 mg $20.60 7/1/2015 12/31/2078

J8530 Cyclophosphamide, oral, 25 mg $1.09 7/1/2014 9/30/2014 J8530 Cyclophosphamide, oral, 25 mg $1.07 10/1/2014 12/31/2014 J8530 Cyclophosphamide, oral, 25 mg $4.82 1/1/2015 3/31/2015 J8530 Cyclophosphamide, oral, 25 mg $4.27 4/1/2015 6/30/2015 J8530 Cyclophosphamide, oral, 25 mg $4.11 7/1/2015 12/31/2078

J8560 Etoposide, oral, 50 mg $57.88 7/1/2014 9/30/2014 J8560 Etoposide, oral, 50 mg $57.09 10/1/2014 12/31/2014 J8560 Etoposide, oral, 50 mg $56.88 1/1/2015 3/31/2015 J8560 Etoposide, oral, 50 mg $57.50 4/1/2015 6/30/2015 J8560 Etoposide, oral, 50 mg $59.77 7/1/2015 12/31/2078

J8597 Antiemetic drug, oral, NOS $0.01 7/1/2014 12/31/2078

J8600 Melphalan, oral, 2 mg $9.43 7/1/2014 9/30/2014 J8600 Melphalan, oral, 2 mg $9.42 10/1/2014 12/31/2014 J8600 Melphalan, oral, 2 mg $9.80 1/1/2015 3/31/2015 J8600 Melphalan, oral, 2 mg $9.77 4/1/2015 6/30/2015 J8600 Melphalan, oral, 2 mg $10.78 7/1/2015 12/31/2078

J8610 Methotrexate, oral, 2.5 mg $0.96 7/1/2014 9/30/2014 J8610 Methotrexate, oral, 2.5 mg $1.08 10/1/2014 12/31/2014 J8610 Methotrexate, oral, 2.5 mg $1.87 1/1/2015 3/31/2015 J8610 Methotrexate, oral, 2.5 mg $2.00 4/1/2015 6/30/2015 J8610 Methotrexate, oral, 2.5 mg $0.98 7/1/2015 12/31/2078

J8705 Topotecan, oral, 0.25 mg $94.65 7/1/2014 9/30/2014 J8705 Topotecan, oral, 0.25 mg $94.74 10/1/2014 12/31/2014 J8705 Topotecan, oral, 0.25 mg $97.56 1/1/2015 3/31/2015 J8705 Topotecan, oral, 0.25 mg $97.67 4/1/2015 6/30/2015 J8705 Topotecan, oral, 0.25 mg $100.49 7/1/2015 12/31/2078

INJECTABLE CHEMOTHERAPY DRUGS Procedure Effective Code Description Rate End Date Code Date

J9000 Injection, doxorubicin HCl, 10 mg $2.95 7/1/2014 9/30/2014 J9000 Injection, doxorubicin HCl, 10 mg $3.00 10/1/2014 12/31/2014 J9000 Injection, doxorubicin HCl, 10 mg $3.48 1/1/2015 3/31/2015 J9000 Injection, doxorubicin HCl, 10 mg $3.58 4/1/2015 6/30/2015 J9000 Injection, doxorubicin HCl, 10 mg $2.73 7/1/2015 12/31/2078

J9010 Injection, alemtuzumab, 10 mg $582.30 7/1/2014 12/31/2078

J9015 Injection, aldesleukin, per single use vial $1,828.73 7/1/2014 9/30/2014 J9015 Injection, aldesleukin, per single use vial $2,110.63 10/1/2014 12/31/2014 J9015 Injection, aldesleukin, per single use vial $2,319.58 1/1/2015 3/31/2015 J9015 Injection, aldesleukin, per single use vial $2,667.51 4/1/2015 12/31/2078

J9017 Injection, arsenic trioxide, 1 mg $51.04 7/1/2014 9/30/2014 J9017 Injection, arsenic trioxide, 1 mg $53.58 10/1/2014 12/31/2014 J9017 Injection, arsenic trioxide, 1 mg $53.72 1/1/2015 3/31/2015 J9017 Injection, arsenic trioxide, 1 mg $53.85 4/1/2015 6/30/2015 J9017 Injection, arsenic trioxide, 1 mg $59.06 7/1/2015 12/31/2078

J9020 Injection, asparaginase, NOS, 10,000 units $64.57 7/1/2014 6/30/2015 J9020 Injection, asparaginase, NOS, 10,000 units $64.56 7/1/2015 12/31/2078

J9025 Injection, azacitidine, 1 mg $4.43 7/1/2014 9/30/2014 J9025 Injection, azacitidine, 1 mg $4.08 10/1/2014 12/31/2014 J9025 Injection, azacitidine, 1 mg $3.67 1/1/2015 3/31/2015 J9025 Injection, azacitidine, 1 mg $3.46 4/1/2015 6/30/2015 J9025 Injection, azacitidine, 1 mg $3.26 7/1/2015 12/31/2078

J9027 Injection, clofarabine, 1 mg $132.93 7/1/2014 9/30/2014 J9027 Injection, clofarabine, 1 mg $134.10 10/1/2014 12/31/2014 J9027 Injection, clofarabine, 1 mg $134.03 1/1/2015 3/31/2015 J9027 Injection, clofarabine, 1 mg $134.31 4/1/2015 6/30/2015 J9027 Injection, clofarabine, 1 mg $137.99 7/1/2015 12/31/2078

J9031 BCG (intravesical) per instillation $122.18 7/1/2014 9/30/2014 J9031 BCG (intravesical) per instillation $121.96 10/1/2014 12/31/2014 J9031 BCG (intravesical) per instillation $120.44 1/1/2015 3/31/2015 J9031 BCG (intravesical) per instillation $121.95 4/1/2015 6/30/2015 J9031 BCG (intravesical) per instillation $122.44 7/1/2015 12/31/2078

J9033 Injection, bendamustine HCl, 1 mg $21.72 7/1/2014 9/30/2014 J9033 Injection, bendamustine HCl, 1 mg $22.21 10/1/2014 12/31/2014 J9033 Injection, bendamustine HCl, 1 mg $22.72 1/1/2015 3/31/2015 J9033 Injection, bendamustine HCl, 1 mg $23.29 4/1/2015 6/30/2015 J9033 Injection, bendamustine HCl, 1 mg $24.13 7/1/2015 12/31/2078

J9035 Injection, bevacizumab, 10 mg $66.55 7/1/2014 9/30/2014 J9035 Injection, bevacizumab, 10 mg $66.65 10/1/2014 12/31/2014 J9035 Injection, bevacizumab, 10 mg $67.90 1/1/2015 3/31/2015 J9035 Injection, bevacizumab, 10 mg $68.48 4/1/2015 6/30/2015 Procedure Effective Code Description Rate End Date Code Date J9035 Injection, bevacizumab, 10 mg $69.61 7/1/2015 12/31/2078

J9040 Injection, bleomycin sulfate, 15 units $21.21 7/1/2014 9/30/2014 J9040 Injection, bleomycin sulfate, 15 units $20.72 10/1/2014 12/31/2014 J9040 Injection, bleomycin sulfate, 15 units $23.32 1/1/2015 3/31/2015 J9040 Injection, bleomycin sulfate, 15 units $26.44 4/1/2015 6/30/2015 J9040 Injection, bleomycin sulfate, 15 units $21.45 7/1/2015 12/31/2078

J9041 Injection, bortezomib, 0.1 mg $46.08 7/1/2014 12/31/2014 J9041 Injection, bortezomib, 0.1 mg $46.55 1/1/2015 3/31/2015 J9041 Injection, bortezomib, 0.1 mg $46.57 4/1/2015 6/30/2015 J9041 Injection, bortezomib, 0.1 mg $46.75 7/1/2015 12/31/2078

J9042 Injection, brentuximab vedotin, 1 mg $110.93 7/1/2014 9/30/2014 J9042 Injection, brentuximab vedotin, 1 mg $110.82 10/1/2014 12/31/2014 J9042 Injection, brentuximab vedotin, 1 mg $115.39 1/1/2015 3/31/2015 J9042 Injection, brentuximab vedotin, 1 mg $115.17 4/1/2015 6/30/2015 J9042 Injection, brentuximab vedotin, 1 mg $119.81 7/1/2015 12/31/2078

J9043 Injection, cabazitaxel, 1 mg $143.11 7/1/2014 9/30/2014 J9043 Injection, cabazitaxel, 1 mg $142.42 10/1/2014 12/31/2014 J9043 Injection, cabazitaxel, 1 mg $142.38 1/1/2015 3/31/2015 J9043 Injection, cabazitaxel, 1 mg $145.55 4/1/2015 6/30/2015 J9043 Injection, cabazitaxel, 1 mg $146.67 7/1/2015 12/31/2078

J9045 Injection, carboplatin, 50 mg $3.47 7/1/2014 9/30/2014 J9045 Injection, carboplatin, 50 mg $3.45 10/1/2014 12/31/2014 J9045 Injection, carboplatin, 50 mg $3.55 1/1/2015 3/31/2015 J9045 Injection, carboplatin, 50 mg $4.16 4/1/2015 6/30/2015 J9045 Injection, carboplatin, 50 mg $3.85 7/1/2015 12/31/2078

J9047 Injection, carfilzomib, 1 MG $29.61 7/1/2014 9/30/2014 J9047 Injection, carfilzomib, 1 MG $29.81 10/1/2014 12/31/2014 J9047 Injection, carfilzomib, 1 MG $30.03 1/1/2015 3/31/2015 J9047 Injection, carfilzomib, 1 MG $30.46 4/1/2015 6/30/2015 J9047 Injection, carfilzomib, 1 MG $30.56 7/1/2015 12/31/2078

J9050 Injection, carmustine. 100 mg $1,422.77 7/1/2014 9/30/2014 J9050 Injection, carmustine. 100 mg $1,861.12 10/1/2014 12/31/2014 J9050 Injection, carmustine. 100 mg $1,982.07 1/1/2015 3/31/2015 J9050 Injection, carmustine. 100 mg $1,983.52 4/1/2015 6/30/2015 J9050 Injection, carmustine. 100 mg $2,350.27 7/1/2015 12/31/2078

J9055 Injection, cetuximab, 10 mg $53.38 7/1/2014 9/30/2014 J9055 Injection, cetuximab, 10 mg $53.29 10/1/2014 12/31/2014 J9055 Injection, cetuximab, 10 mg $53.75 1/1/2015 3/31/2015 J9055 Injection, cetuximab, 10 mg $53.27 4/1/2015 6/30/2015 J9055 Injection, cetuximab, 10 mg $53.57 7/1/2015 12/31/2078

J9060 Injection, cisplatin, powder or solution, 10 mg $1.97 7/1/2014 9/30/2014 J9060 Injection, cisplatin, powder or solution, 10 mg $2.04 10/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J9060 Injection, cisplatin, powder or solution, 10 mg $2.18 1/1/2015 3/31/2015 J9060 Injection, cisplatin, powder or solution, 10 mg $2.04 4/1/2015 12/31/2078

J9065 Injection, cladribine, per 1 mg $21.83 7/1/2014 9/30/2014 J9065 Injection, cladribine, per 1 mg $21.21 10/1/2014 12/31/2014 J9065 Injection, cladribine, per 1 mg $21.98 1/1/2015 3/31/2015 J9065 Injection, cladribine, per 1 mg $22.96 4/1/2015 6/30/2015 J9065 Injection, cladribine, per 1 mg $19.82 7/1/2015 12/31/2078

J9070 Cyclophosphamide, 100 mg $64.55 7/1/2014 9/30/2014 J9070 Cyclophosphamide, 100 mg $63.16 10/1/2014 12/31/2014 J9070 Cyclophosphamide, 100 mg $58.02 1/1/2015 3/31/2015 J9070 Cyclophosphamide, 100 mg $58.40 4/1/2015 6/30/2015 J9070 Cyclophosphamide, 100 mg $55.60 7/1/2015 12/31/2078

J9098 Injection, cytarabine liposome, 10 mg $553.83 7/1/2014 9/30/2014 J9098 Injection, cytarabine liposome, 10 mg $561.39 10/1/2014 12/31/2014 J9098 Injection, cytarabine liposome, 10 mg $559.09 1/1/2015 3/31/2015 J9098 Injection, cytarabine liposome, 10 mg $560.53 4/1/2015 6/30/2015 J9098 Injection, cytarabine liposome, 10 mg $572.40 7/1/2015 12/31/2078

J9100 Injection, cytarabine, 100 mg $0.91 7/1/2014 9/30/2014 J9100 Injection, cytarabine, 100 mg $0.94 10/1/2014 12/31/2014 J9100 Injection, cytarabine, 100 mg $0.92 1/1/2015 3/31/2015 J9100 Injection, cytarabine, 100 mg $0.89 4/1/2015 6/30/2015 J9100 Injection, cytarabine, 100 mg $0.88 7/1/2015 12/31/2078

J9120 Injection, dactinomycin, 0.5 mg $685.42 7/1/2014 9/30/2014 J9120 Injection, dactinomycin, 0.5 mg $807.19 10/1/2014 3/31/2015 J9120 Injection, dactinomycin, 0.5 mg $913.30 4/1/2015 6/30/2015 J9120 Injection, dactinomycin, 0.5 mg $928.84 7/1/2015 12/31/2078

J9130 Dacarbazine, 100 mg $4.10 7/1/2014 9/30/2014 J9130 Dacarbazine, 100 mg $3.64 10/1/2014 12/31/2014 J9130 Dacarbazine, 100 mg $4.32 1/1/2015 3/31/2015 J9130 Dacarbazine, 100 mg $3.90 4/1/2015 6/30/2015 J9130 Dacarbazine, 100 mg $3.92 7/1/2015 12/31/2078

J9150 Injection, daunorubicin, 10 mg $23.87 7/1/2014 9/30/2014 J9150 Injection, daunorubicin, 10 mg $22.56 10/1/2014 12/31/2014 J9150 Injection, daunorubicin, 10 mg $27.70 1/1/2015 3/31/2015 J9150 Injection, daunorubicin, 10 mg $26.27 4/1/2015 6/30/2015 J9150 Injection, daunorubicin, 10 mg $27.19 7/1/2015 12/31/2078

J9151 Injection, daunorubicin citrate, liposomal formulation, 10 mg $238.92 7/1/2014 9/30/2014 J9151 Injection, daunorubicin citrate, liposomal formulation, 10 mg $239.10 10/1/2014 12/31/2014 J9151 Injection, daunorubicin citrate, liposomal formulation, 10 mg $238.92 1/1/2015 3/31/2015 J9151 Injection, daunorubicin citrate, liposomal formulation, 10 mg $239.09 4/1/2015 6/30/2015 J9151 Injection, daunorubicin citrate, liposomal formulation, 10 mg $239.00 7/1/2015 12/31/2078

J9155 Injection, degarelix, 1 mg $3.44 7/1/2014 9/30/2014 Procedure Effective Code Description Rate End Date Code Date J9155 Injection, degarelix, 1 mg $3.55 10/1/2014 12/31/2014 J9155 Injection, degarelix, 1 mg $3.42 1/1/2015 3/31/2015 J9155 Injection, degarelix, 1 mg $3.48 4/1/2015 6/30/2015 J9155 Injection, degarelix, 1 mg $3.58 7/1/2015 12/31/2078

J9160 Injection, denileukin diftitox, 300 mcg $1,646.18 7/1/2014 12/31/2078

J9165 Injection, diethylstilbestrol diphosphte, 250 mg $12.14 7/1/2014 12/31/2078

J9171 Injection, docetaxel, 1 mg $4.97 7/1/2014 9/30/2014 J9171 Injection, docetaxel, 1 mg $4.66 10/1/2014 12/31/2014 J9171 Injection, docetaxel, 1 mg $3.98 1/1/2015 3/31/2015 J9171 Injection, docetaxel, 1 mg $2.77 4/1/2015 6/30/2015 J9171 Injection, docetaxel, 1 mg $3.79 7/1/2015 12/31/2078

J9175 Injection, Elliotts'B solution, 1 ml $4.16 7/1/2014 12/31/2078

J9178 Injection, epirubicin HCl 2 mg $1.46 7/1/2014 9/30/2014 J9178 Injection, epirubicin HCl 2 mg $1.35 10/1/2014 12/31/2014 J9178 Injection, epirubicin HCl 2 mg $1.28 1/1/2015 3/31/2015 J9178 Injection, epirubicin HCl 2 mg $1.74 4/1/2015 6/30/2015 J9178 Injection, epirubicin HCl 2 mg $1.54 7/1/2015 12/31/2078

J9179 Injection, eribulin mesylate, 0.1 mg $99.22 7/1/2014 9/30/2014 J9179 Injection, eribulin mesylate, 0.1 mg $99.01 10/1/2014 12/31/2014 J9179 Injection, eribulin mesylate, 0.1 mg $100.08 1/1/2015 3/31/2015 J9179 Injection, eribulin mesylate, 0.1 mg $100.42 4/1/2015 6/30/2015 J9179 Injection, eribulin mesylate, 0.1 mg $101.93 7/1/2015 12/31/2078

J9181 Injection, etoposide, 10 mg $0.73 7/1/2014 9/30/2014 J9181 Injection, etoposide, 10 mg $0.68 10/1/2014 12/31/2014 J9181 Injection, etoposide, 10 mg $0.67 1/1/2015 3/31/2015 J9181 Injection, etoposide, 10 mg $0.65 4/1/2015 12/31/2078

J9185 Injection, fludarabine phosphate, 50 mg $78.21 7/1/2014 9/30/2014 J9185 Injection, fludarabine phosphate, 50 mg $70.98 10/1/2014 12/31/2014 J9185 Injection, fludarabine phosphate, 50 mg $88.90 1/1/2015 3/31/2015 J9185 Injection, fludarabine phosphate, 50 mg $69.70 4/1/2015 6/30/2015 J9185 Injection, fludarabine phosphate, 50 mg $73.85 7/1/2015 12/31/2078

J9190 Injection, fluorouracil, 500 mg $1.87 7/1/2014 9/30/2014 J9190 Injection, fluorouracil, 500 mg $2.06 10/1/2014 12/31/2014 J9190 Injection, fluorouracil, 500 mg $2.00 1/1/2015 3/31/2015 J9190 Injection, fluorouracil, 500 mg $1.88 4/1/2015 6/30/2015 J9190 Injection, fluorouracil, 500 mg $2.21 7/1/2015 12/31/2078

J9200 Injection, floxuridine, 500 mg $68.14 7/1/2014 9/30/2014 J9200 Injection, floxuridine, 500 mg $55.65 10/1/2014 12/31/2014 J9200 Injection, floxuridine, 500 mg $60.25 1/1/2015 3/31/2015 J9200 Injection, floxuridine, 500 mg $38.01 4/1/2015 6/30/2015 J9200 Injection, floxuridine, 500 mg $60.24 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date

J9201 Injection, gemcitabine HCl, 200 mg $6.27 7/1/2014 9/30/2014 J9201 Injection, gemcitabine HCl, 200 mg $6.66 10/1/2014 12/31/2014 J9201 Injection, gemcitabine HCl, 200 mg $7.12 1/1/2015 3/31/2015 J9201 Injection, gemcitabine HCl, 200 mg $8.13 4/1/2015 6/30/2015 J9201 Injection, gemcitabine HCl, 200 mg $8.20 7/1/2015 12/31/2078

J9202 Goserelin acetate implant, per 3.6 mg $221.53 7/1/2014 9/30/2014 J9202 Goserelin acetate implant, per 3.6 mg $225.02 10/1/2014 12/31/2014 J9202 Goserelin acetate implant, per 3.6 mg $230.01 1/1/2015 3/31/2015 J9202 Goserelin acetate implant, per 3.6 mg $269.92 4/1/2015 6/30/2015 J9202 Goserelin acetate implant, per 3.6 mg $249.84 7/1/2015 12/31/2078

J9206 Injection, irinotecan, 20 mg $4.35 7/1/2014 9/30/2014 J9206 Injection, irinotecan, 20 mg $4.31 10/1/2014 12/31/2014 J9206 Injection, irinotecan, 20 mg $4.17 1/1/2015 3/31/2015 J9206 Injection, irinotecan, 20 mg $4.04 4/1/2015 6/30/2015 J9206 Injection, irinotecan, 20 mg $3.62 7/1/2015 12/31/2078

J9207 Injection, ixabepilone, 1 mg $70.32 7/1/2014 9/30/2014 J9207 Injection, ixabepilone, 1 mg $70.21 10/1/2014 12/31/2014 J9207 Injection, ixabepilone, 1 mg $71.34 1/1/2015 3/31/2015 J9207 Injection, ixabepilone, 1 mg $70.99 4/1/2015 6/30/2015 J9207 Injection, ixabepilone, 1 mg $72.16 7/1/2015 12/31/2078

J9208 Injection, ifosfomide, 1 gram $31.77 7/1/2014 9/30/2014 J9208 Injection, ifosfomide, 1 gram $33.41 10/1/2014 12/31/2014 J9208 Injection, ifosfomide, 1 gram $30.83 1/1/2015 3/31/2015 J9208 Injection, ifosfomide, 1 gram $32.44 4/1/2015 6/30/2015 J9208 Injection, ifosfomide, 1 gram $30.99 7/1/2015 12/31/2078

J9209 Injection, mesna, 200 mg $2.84 7/1/2014 12/31/2014 J9209 Injection, mesna, 200 mg $2.76 1/1/2015 3/31/2015 J9209 Injection, mesna, 200 mg $2.92 4/1/2015 6/30/2015 J9209 Injection, mesna, 200 mg $3.26 7/1/2015 12/31/2078

J9211 Injection, idarubicin HCl, 5 mg $46.76 7/1/2014 9/30/2014 J9211 Injection, idarubicin HCl, 5 mg $49.11 10/1/2014 12/31/2014 J9211 Injection, idarubicin HCl, 5 mg $42.26 1/1/2015 3/31/2015 J9211 Injection, idarubicin HCl, 5 mg $40.15 4/1/2015 6/30/2015 J9211 Injection, idarubicin HCl, 5 mg $38.85 7/1/2015 12/31/2078

J9212 Injection, interferon alfacon-1, recombinant, 1 mcg $17.06 7/1/2014 12/31/2078

J9213 Injection, interferon alfa-2A, recombinant, 3 million units $53.66 7/1/2014 12/31/2014 J9213 Injection, interferon alfa-2A, recombinant, 3 million units $733.57 1/1/2015 3/31/2015 J9213 Injection, interferon alfa-2A, recombinant, 3 million units $29.17 4/1/2015 6/30/2015 J9213 Injection, interferon alfa-2A, recombinant, 3 million units $733.57 7/1/2015 12/31/2078

J9214 Injection, interferon alfa-2B, recombinant, 1 million units $20.72 7/1/2014 9/30/2014 J9214 Injection, interferon alfa-2B, recombinant, 1 million units $21.17 10/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J9214 Injection, interferon alfa-2B, recombinant, 1 million units $21.28 1/1/2015 3/31/2015 J9214 Injection, interferon alfa-2B, recombinant, 1 million units $22.58 4/1/2015 6/30/2015 J9214 Injection, interferon alfa-2B, recombinant, 1 million units $22.61 7/1/2015 12/31/2078

J9215 Injection, interferon alfa-N3, (human leukocyte derived), 250,000 IU $31.80 7/1/2014 12/31/2078

J9217 Leuprolide acetate (for depot suspension), 7.5 mg $233.76 7/1/2014 9/30/2014 J9217 Leuprolide acetate (for depot suspension), 7.5 mg $229.26 10/1/2014 12/31/2014 J9217 Leuprolide acetate (for depot suspension), 7.5 mg $237.16 1/1/2015 3/31/2015 J9217 Leuprolide acetate (for depot suspension), 7.5 mg $228.17 4/1/2015 6/30/2015 J9217 Leuprolide acetate (for depot suspension), 7.5 mg $220.88 7/1/2015 12/31/2078

J9218 Leuprolide acetate, per 1 mg $7.29 7/1/2014 9/30/2014 J9218 Leuprolide acetate, per 1 mg $7.18 10/1/2014 12/31/2014 J9218 Leuprolide acetate, per 1 mg $7.07 1/1/2015 3/31/2015 J9218 Leuprolide acetate, per 1 mg $6.82 4/1/2015 6/30/2015 J9218 Leuprolide acetate, per 1 mg $7.44 7/1/2015 12/31/2078

J9225 Histrelin implant (Vantas), 50 mg $2,981.71 7/1/2014 9/30/2014 J9225 Histrelin implant (Vantas), 50 mg $3,001.59 10/1/2014 12/31/2014 J9225 Histrelin implant (Vantas), 50 mg $3,000.24 1/1/2015 3/31/2015 J9225 Histrelin implant (Vantas), 50 mg $2,980.19 4/1/2015 6/30/2015 J9225 Histrelin implant (Vantas), 50 mg $2,953.82 7/1/2015 12/31/2078

J9226 Histrelin implant (Supprelin LA), 50 mg $16,885.87 7/1/2014 9/30/2014 J9226 Histrelin implant (Supprelin LA), 50 mg $18,317.24 10/1/2014 12/31/2014 J9226 Histrelin implant (Supprelin LA), 50 mg $20,115.46 1/1/2015 3/31/2015 J9226 Histrelin implant (Supprelin LA), 50 mg $21,173.64 4/1/2015 6/30/2015 J9226 Histrelin implant (Supprelin LA), 50 mg $22,185.62 7/1/2015 12/31/2078

J9228 Injection, ipilimumab, 1 mg $131.68 7/1/2014 9/30/2014 J9228 Injection, ipilimumab, 1 mg $133.61 10/1/2014 12/31/2014 J9228 Injection, ipilimumab, 1 mg $133.66 1/1/2015 3/31/2015 J9228 Injection, ipilimumab, 1 mg $135.59 4/1/2015 6/30/2015 J9228 Injection, ipilimumab, 1 mg $136.95 7/1/2015 12/31/2078

J9230 Injection, mechlorethamine HCl, (nitrogen mustard), 10 mg $154.70 7/1/2014 9/30/2014 J9230 Injection, mechlorethamine HCl, (nitrogen mustard), 10 mg $189.63 10/1/2014 12/31/2014 J9230 Injection, mechlorethamine HCl, (nitrogen mustard), 10 mg $194.13 1/1/2015 3/31/2015 J9230 Injection, mechlorethamine HCl, (nitrogen mustard), 10 mg $193.37 4/1/2015 6/30/2015 J9230 Injection, mechlorethamine HCl, (nitrogen mustard), 10 mg $232.93 7/1/2015 12/31/2078

J9245 Injection, melphalan HCl, 50 mg $1,220.50 7/1/2014 9/30/2014 J9245 Injection, melphalan HCl, 50 mg $1,226.63 10/1/2014 12/31/2014 J9245 Injection, melphalan HCl, 50 mg $1,292.71 1/1/2015 3/31/2015 J9245 Injection, melphalan HCl, 50 mg $1,292.39 4/1/2015 6/30/2015 J9245 Injection, melphalan HCl, 50 mg $1,305.75 7/1/2015 12/31/2078

J9250 Methotrexate sodium, 5 mg $0.22 7/1/2014 9/30/2014 J9250 Methotrexate sodium, 5 mg $0.21 10/1/2014 12/31/2014 J9250 Methotrexate sodium, 5 mg $0.25 1/1/2015 3/31/2015 Procedure Effective Code Description Rate End Date Code Date J9250 Methotrexate sodium, 5 mg $0.23 4/1/2015 12/31/2078

J9260 Methotrexate sodium, 50 mg $2.21 7/1/2014 9/30/2014 J9260 Methotrexate sodium, 50 mg $2.11 10/1/2014 12/31/2014 J9260 Methotrexate sodium, 50 mg $2.49 1/1/2015 3/31/2015 J9260 Methotrexate sodium, 50 mg $2.32 4/1/2015 6/30/2015 J9260 Methotrexate sodium, 50 mg $2.26 7/1/2015 12/31/2078

J9262 Injection, omacetaxine mep, 0.01 mg $2.48 7/1/2014 12/31/2078

J9263 Injection, oxaliplatin, 0.5 mg $0.57 7/1/2014 9/30/2014 J9263 Injection, oxaliplatin, 0.5 mg $0.58 10/1/2014 12/31/2014 J9263 Injection, oxaliplatin, 0.5 mg $0.59 1/1/2015 3/31/2015 J9263 Injection, oxaliplatin, 0.5 mg $0.52 4/1/2015 6/30/2015 J9263 Injection, oxaliplatin, 0.5 mg $0.54 7/1/2015 12/31/2078

J9264 Injection, paclitaxel protein bound, 1 mg $9.80 7/1/2014 9/30/2014 J9264 Injection, paclitaxel protein bound, 1 mg $9.70 10/1/2014 12/31/2014 J9264 Injection, paclitaxel protein bound, 1 mg $9.69 1/1/2015 3/31/2015 J9264 Injection, paclitaxel protein bound, 1 mg $9.68 4/1/2015 6/30/2015 J9264 Injection, paclitaxel protein bound, 1 mg $9.84 7/1/2015 12/31/2078

J9265 Injection, paclitaxel, 30 mg $4.30 7/1/2014 9/30/2014 J9265 Injection, paclitaxel, 30 mg $3.82 10/1/2014 12/31/2014

J9266 Injection, pegaspargase, per single dose vial $6,144.57 7/1/2014 9/30/2014 J9266 Injection, pegaspargase, per single dose vial $6,220.80 10/1/2014 12/31/2014 J9266 Injection, pegaspargase, per single dose vial $6,200.82 1/1/2015 3/31/2015 J9266 Injection, pegaspargase, per single dose vial $6,218.44 4/1/2015 6/30/2015 J9266 Injection, pegaspargase, per single dose vial $6,233.87 7/1/2015 12/31/2078

J9267 Paclitaxel injection, 1 mg $0.16 1/1/2015 3/31/2015 J9267 Paclitaxel injection, 1 mg $0.18 4/1/2015 6/30/2015 J9267 Paclitaxel injection, 1 mg $0.17 7/1/2015 12/31/2078

J9268 Injection, pentostatin, per 10 mg $1,432.43 7/1/2014 9/30/2014 J9268 Injection, pentostatin, per 10 mg $1,483.27 10/1/2014 12/31/2014 J9268 Injection, pentostatin, per 10 mg $1,510.36 1/1/2015 3/31/2015 J9268 Injection, pentostatin, per 10 mg $1,489.23 4/1/2015 6/30/2015 J9268 Injection, pentostatin, per 10 mg $1,507.59 7/1/2015 12/31/2078

J9270 Injection, plicamycin, 2.5 mg $78.99 7/1/2014 12/31/2078

J9280 Injection, mitomycin, 5 mg $22.96 7/1/2014 9/30/2014 J9280 Injection, mitomycin, 5 mg $20.88 10/1/2014 12/31/2014 J9280 Injection, mitomycin, 5 mg $39.86 1/1/2015 3/31/2015 J9280 Injection, mitomycin, 5 mg $65.85 4/1/2015 6/30/2015 J9280 Injection, mitomycin, 5 mg $75.80 7/1/2015 12/31/2078

J9293 Injection, mitoxantrone HCl, per 5 mg $34.46 7/1/2014 9/30/2014 J9293 Injection, mitoxantrone HCl, per 5 mg $32.34 10/1/2014 12/31/2014 Procedure Effective Code Description Rate End Date Code Date J9293 Injection, mitoxantrone HCl, per 5 mg $34.79 1/1/2015 3/31/2015 J9293 Injection, mitoxantrone HCl, per 5 mg $31.95 4/1/2015 6/30/2015 J9293 Injection, mitoxantrone HCl, per 5 mg $31.71 7/1/2015 12/31/2078

J9300 Injection, gemtuzumab ozogamicin, 5 mg $2,742.59 7/1/2014 12/31/2078

J9301 Obinutuzumab inj, 10 mg $54.24 1/1/2015 3/31/2015 J9301 Obinutuzumab inj, 10 mg $54.21 4/1/2015 6/30/2015 J9301 Obinutuzumab inj, 10 mg $54.19 7/1/2015 12/31/2078

J9302 Injection, ofatumumab, 10 mg $47.72 7/1/2014 9/30/2014 J9302 Injection, ofatumumab, 10 mg $47.76 10/1/2014 12/31/2014 J9302 Injection, ofatumumab, 10 mg $48.35 1/1/2015 3/31/2015 J9302 Injection, ofatumumab, 10 mg $48.32 4/1/2015 6/30/2015 J9302 Injection, ofatumumab, 10 mg $48.97 7/1/2015 12/31/2078

J9303 Injection, panitumumab, 10 mg $94.57 7/1/2014 9/30/2014 J9303 Injection, panitumumab, 10 mg $94.79 10/1/2014 12/31/2014 J9303 Injection, panitumumab, 10 mg $96.98 1/1/2015 3/31/2015 J9303 Injection, panitumumab, 10 mg $97.27 4/1/2015 6/30/2015 J9303 Injection, panitumumab, 10 mg $100.35 7/1/2015 12/31/2078

J9305 Injection, pemetrexed, 10 mg $60.33 7/1/2014 9/30/2014 J9305 Injection, pemetrexed, 10 mg $60.27 10/1/2014 12/31/2014 J9305 Injection, pemetrexed, 10 mg $60.70 1/1/2015 3/31/2015 J9305 Injection, pemetrexed, 10 mg $60.84 4/1/2015 6/30/2015 J9305 Injection, pemetrexed, 10 mg $61.33 7/1/2015 12/31/2078

J9306 Injection, pertuzumab, 1 mg $10.22 7/1/2014 12/31/2078

J9307 Injection, pralatrexate, 1 mg $197.28 7/1/2014 9/30/2014 J9307 Injection, pralatrexate, 1 mg $197.12 10/1/2014 12/31/2014 J9307 Injection, pralatrexate, 1 mg $204.47 1/1/2015 3/31/2015 J9307 Injection, pralatrexate, 1 mg $204.81 4/1/2015 6/30/2015 J9307 Injection, pralatrexate, 1 mg $212.37 7/1/2015 12/31/2078

J9310 Injection, rituximab, 100 mg $707.47 7/1/2014 9/30/2014 J9310 Injection, rituximab, 100 mg $708.68 10/1/2014 12/31/2014 J9310 Injection, rituximab, 100 mg $725.44 1/1/2015 3/31/2015 J9310 Injection, rituximab, 100 mg $731.98 4/1/2015 6/30/2015 J9310 Injection, rituximab, 100 mg $747.57 7/1/2015 12/31/2078

J9315 Injection, romidepsin, 1 mg $265.43 7/1/2014 9/30/2014 J9315 Injection, romidepsin, 1 mg $270.64 10/1/2014 12/31/2014 J9315 Injection, romidepsin, 1 mg $279.81 1/1/2015 3/31/2015 J9315 Injection, romidepsin, 1 mg $278.64 4/1/2015 6/30/2015 J9315 Injection, romidepsin, 1 mg $290.02 7/1/2015 12/31/2078

J9320 Injection, streptozocin, 1 gram $335.13 7/1/2014 9/30/2014 J9320 Injection, streptozocin, 1 gram $335.28 10/1/2014 12/31/2014 J9320 Injection, streptozocin, 1 gram $336.01 1/1/2015 3/31/2015 Procedure Effective Code Description Rate End Date Code Date J9320 Injection, streptozocin, 1 gram $336.91 4/1/2015 6/30/2015 J9320 Injection, streptozocin, 1 gram $328.98 7/1/2015 12/31/2078

J9328 Injection, temozolomide, 1 mg $5.17 7/1/2014 9/30/2014 J9328 Injection, temozolomide, 1 mg $5.68 10/1/2014 12/31/2014 J9328 Injection, temozolomide, 1 mg $5.71 1/1/2015 3/31/2015 J9328 Injection, temozolomide, 1 mg $6.23 4/1/2015 6/30/2015 J9328 Injection, temozolomide, 1 mg $6.27 7/1/2015 12/31/2078

J9330 Injection, temsirolimus, 1 mg $58.22 7/1/2014 9/30/2014 J9330 Injection, temsirolimus, 1 mg $58.83 10/1/2014 12/31/2014 J9330 Injection, temsirolimus, 1 mg $60.04 1/1/2015 3/31/2015 J9330 Injection, temsirolimus, 1 mg $60.08 4/1/2015 6/30/2015 J9330 Injection, temsirolimus, 1 mg $61.83 7/1/2015 12/31/2078

J9340 Injection, thiotepa, 15 mg $630.70 7/1/2014 12/31/2078

J9351 Injection, topotecan, 0.1 mg $2.06 7/1/2014 9/30/2014 J9351 Injection, topotecan, 0.1 mg $1.83 10/1/2014 12/31/2014 J9351 Injection, topotecan, 0.1 mg $1.53 1/1/2015 3/31/2015 J9351 Injection, topotecan, 0.1 mg $2.16 4/1/2015 6/30/2015 J9351 Injection, topotecan, 0.1 mg $1.48 7/1/2015 12/31/2078

J9354 Injection ado-trastuzumab emt 1 mg $29.14 7/1/2014 12/31/2014 J9354 Injection ado-trastuzumab emt 1 mg $29.17 1/1/2015 3/31/2015 J9354 Injection ado-trastuzumab emt 1 mg $29.22 4/1/2015 12/31/2078

J9355 Injection, trastuzumab, 10 mg $82.37 7/1/2014 9/30/2014 J9355 Injection, trastuzumab, 10 mg $82.49 10/1/2014 12/31/2014 J9355 Injection, trastuzumab, 10 mg $84.45 1/1/2015 3/31/2015 J9355 Injection, trastuzumab, 10 mg $85.22 4/1/2015 6/30/2015 J9355 Injection, trastuzumab, 10 mg $87.24 7/1/2015 12/31/2078

J9357 Injection, valrubicin, intravesical, 200 mg $1,071.33 7/1/2014 9/30/2014 J9357 Injection, valrubicin, intravesical, 200 mg $1,085.29 10/1/2014 12/31/2014 J9357 Injection, valrubicin, intravesical, 200 mg $1,098.82 1/1/2015 3/31/2015 J9357 Injection, valrubicin, intravesical, 200 mg $1,100.04 4/1/2015 6/30/2015 J9357 Injection, valrubicin, intravesical, 200 mg $1,100.38 7/1/2015 12/31/2078

J9360 Injection, vinblastine sulfate, 1 mg $2.01 7/1/2014 9/30/2014 J9360 Injection, vinblastine sulfate, 1 mg $2.71 10/1/2014 12/31/2014 J9360 Injection, vinblastine sulfate, 1 mg $2.64 1/1/2015 3/31/2015 J9360 Injection, vinblastine sulfate, 1 mg $2.59 4/1/2015 6/30/2015 J9360 Injection, vinblastine sulfate, 1 mg $2.76 7/1/2015 12/31/2078

J9370 Vincristine sulfate, 1 mg $6.80 7/1/2014 9/30/2014 J9370 Vincristine sulfate, 1 mg $4.91 10/1/2014 12/31/2014 J9370 Vincristine sulfate, 1 mg $4.86 1/1/2015 3/31/2015 J9370 Vincristine sulfate, 1 mg $4.79 4/1/2015 6/30/2015 J9370 Vincristine sulfate, 1 mg $4.76 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date J9371 Injection vincristine sul lip 1 mg $2,062.34 7/1/2014 9/30/2014 J9371 Injection vincristine sul lip 1 mg $2,148.20 10/1/2014 12/31/2014 J9371 Injection vincristine sul lip 1 mg $2,142.60 1/1/2015 3/31/2015 J9371 Injection vincristine sul lip 1 mg $2,226.99 4/1/2015 6/30/2015 J9371 Injection vincristine sul lip 1 mg $2,228.61 7/1/2015 12/31/2078

J9390 Injection, vinorelbine tartrate, per 10 mg $10.98 7/1/2014 9/30/2014 J9390 Injection, vinorelbine tartrate, per 10 mg $10.87 10/1/2014 12/31/2014 J9390 Injection, vinorelbine tartrate, per 10 mg $10.40 1/1/2015 3/31/2015 J9390 Injection, vinorelbine tartrate, per 10 mg $10.04 4/1/2015 6/30/2015 J9390 Injection, vinorelbine tartrate, per 10 mg $10.02 7/1/2015 12/31/2078

J9395 Injection, fulvestrant, 25 mg $90.93 7/1/2014 9/30/2014 J9395 Injection, fulvestrant, 25 mg $91.27 10/1/2014 12/31/2014 J9395 Injection, fulvestrant, 25 mg $91.30 1/1/2015 3/31/2015 J9395 Injection, fulvestrant, 25 mg $92.35 4/1/2015 6/30/2015 J9395 Injection, fulvestrant, 25 mg $92.18 7/1/2015 12/31/2078

J9400 Injection ziv-aflibercept, 1 mg $7.10 7/1/2014 9/30/2014 J9400 Injection ziv-aflibercept, 1 mg $8.12 10/1/2014 12/31/2014 J9400 Injection ziv-aflibercept, 1 mg $7.62 1/1/2015 3/31/2015 J9400 Injection ziv-aflibercept, 1 mg $8.15 4/1/2015 6/30/2015 J9400 Injection ziv-aflibercept, 1 mg $8.27 7/1/2015 12/31/2078

Q0138 Injection, ferumoxytol, for treatment of anemia, 1 mg (non-ESRD use) $0.73 7/1/2014 9/30/2014 Q0138 Injection, ferumoxytol, for treatment of anemia, 1 mg (non-ESRD use) $0.74 10/1/2014 12/31/2014 Q0138 Injection, ferumoxytol, for treatment of anemia, 1 mg (non-ESRD use) $0.78 1/1/2015 3/31/2015 Q0138 Injection, ferumoxytol, for treatment of anemia, 1 mg (non-ESRD use) $0.79 4/1/2015 6/30/2015 Q0138 Injection, ferumoxytol, for treatment of anemia, 1 mg (non-ESRD use) $0.81 7/1/2015 12/31/2078

Q0139 Injection, ferumoxytol, for treatment of anemia, 1 mg (for ESRD on dialysis) $0.73 7/1/2014 9/30/2014 Q0139 Injection, ferumoxytol, for treatment of anemia, 1 mg (for ESRD on dialysis) $0.74 10/1/2014 12/31/2014 Q0139 Injection, ferumoxytol, for treatment of anemia, 1 mg (for ESRD on dialysis) $0.78 1/1/2015 3/31/2015 Q0139 Injection, ferumoxytol, for treatment of anemia, 1 mg (for ESRD on dialysis) $0.79 4/1/2015 6/30/2015 Q0139 Injection, ferumoxytol, for treatment of anemia, 1 mg (for ESRD on dialysis) $0.81 7/1/2015 12/31/2078

Q0162 Ondansetron 1 mg, oral, not to exceed 48 hr dose $0.06 7/1/2014 9/30/2014 Q0162 Ondansetron 1 mg, oral, not to exceed 48 hr dose $0.07 10/1/2014 12/31/2014 Q0162 Ondansetron 1 mg, oral, not to exceed 48 hr dose $0.06 1/1/2015 3/31/2015 Q0162 Ondansetron 1 mg, oral, not to exceed 48 hr dose $0.07 4/1/2015 6/30/2015 Q0162 Ondansetron 1 mg, oral, not to exceed 48 hr dose $0.05 7/1/2015 12/31/2078

Q2050 Injection, doxorubicin, 10mg $490.84 7/1/2014 9/30/2014 Q2050 Injection, doxorubicin, 10mg $490.49 10/1/2014 12/31/2014 Q2050 Injection, doxorubicin, 10mg $489.99 1/1/2015 3/31/2015 Q2050 Injection, doxorubicin, 10mg $488.48 4/1/2015 6/30/2015 Q2050 Injection, doxorubicin, 10mg $482.84 7/1/2015 12/31/2078

Q4074 Iloprost, inhalation solution, noncompounded, unit dose form up to 20 mcg $88.06 7/1/2014 9/30/2014 Q4074 Iloprost, inhalation solution, noncompounded, unit dose form up to 20 mcg $95.01 10/1/2014 12/31/2014 Q4074 Iloprost, inhalation solution, noncompounded, unit dose form up to 20 mcg $101.91 1/1/2015 3/31/2015 Procedure Effective Code Description Rate End Date Code Date Q4074 Iloprost, inhalation solution, noncompounded, unit dose form up to 20 mcg $102.80 4/1/2015 6/30/2015 Q4074 Iloprost, inhalation solution, noncompounded, unit dose form up to 20 mcg $109.47 7/1/2015 12/31/2078

Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) $1.14 7/1/2014 9/30/2014 Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) $1.17 10/1/2014 12/31/2014 Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) $1.19 1/1/2015 3/31/2015 Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) $1.18 4/1/2015 6/30/2015 Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) $1.21 7/1/2015 12/31/2078

Q4101 Apligraf (skin substitute), per sq cm $33.78 7/1/2014 9/30/2014 Q4101 Apligraf (skin substitute), per sq cm $33.61 10/1/2014 12/31/2014 Q4101 Apligraf (skin substitute), per sq cm $32.13 1/1/2015 3/31/2015 Q4101 Apligraf (skin substitute), per sq cm $31.99 4/1/2015 6/30/2015 Q4101 Apligraf (skin substitute), per sq cm $31.28 7/1/2015 12/31/2078

Q4106 Dermagraft (skin substitute), per sq cm $39.82 7/1/2014 9/30/2014 Q4106 Dermagraft (skin substitute), per sq cm $38.60 10/1/2014 12/31/2014 Q4106 Dermagraft (skin substitute), per sq cm $35.42 1/1/2015 3/31/2015 Q4106 Dermagraft (skin substitute), per sq cm $34.21 4/1/2015 6/30/2015 Q4106 Dermagraft (skin substitute), per sq cm $34.36 7/1/2015 12/31/2078

Q4121 TheraSkin, per sq cm $21.56 7/1/2014 9/30/2014 Q4121 TheraSkin, per sq cm $32.42 10/1/2014 12/31/2014 Q4121 TheraSkin, per sq cm $36.34 1/1/2015 3/31/2015 Q4121 TheraSkin, per sq cm $35.13 4/1/2015 6/30/2015 Q4121 TheraSkin, per sq cm $36.18 7/1/2015 12/31/2078

Q9953 Injection, iron-based magnetic resonance contrast agent, per ml $62.05 7/1/2014 12/31/2078

Q9954 Oral magnetic resonance contrast agent, per 100 ml $11.66 7/1/2014 12/31/2078

Q9956 Injection, octafluoropropane microspheres, per ml $37.59 7/1/2014 9/30/2014 Q9956 Injection, octafluoropropane microspheres, per ml $37.24 10/1/2014 12/31/2014 Q9956 Injection, octafluoropropane microspheres, per ml $37.19 1/1/2015 3/31/2015 Q9956 Injection, octafluoropropane microspheres, per ml $35.93 4/1/2015 6/30/2015 Q9956 Injection, octafluoropropane microspheres, per ml $35.41 7/1/2015 12/31/2078

Q9957 Injection, perflutren lipid microspheres, per ml $56.38 7/1/2014 9/30/2014 Q9957 Injection, perflutren lipid microspheres, per ml $55.86 10/1/2014 12/31/2014 Q9957 Injection, perflutren lipid microspheres, per ml $55.79 1/1/2015 3/31/2015 Q9957 Injection, perflutren lipid microspheres, per ml $53.90 4/1/2015 6/30/2015 Q9957 Injection, perflutren lipid microspheres, per ml $53.12 7/1/2015 12/31/2078

Q9960 High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml $0.18 7/1/2014 9/30/2014 Q9960 High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml $0.17 10/1/2014 3/31/2015 Q9960 High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml $0.18 4/1/2015 6/30/2015 Q9960 High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml $0.19 7/1/2015 12/31/2078

Q9961 High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml $0.18 7/1/2014 9/30/2014 Q9961 High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml $0.20 10/1/2014 6/30/2015 Q9961 High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml $0.21 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date

Q9962 High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml $0.18 7/1/2014 12/31/2078

Q9963 High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml $0.19 7/1/2014 9/30/2014 Q9963 High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml $0.20 10/1/2014 3/31/2015 Q9963 High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml $0.19 4/1/2015 6/30/2015 Q9963 High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml $0.20 7/1/2015 12/31/2078

Q9964 High osmolar contrast material, 400 or greater mg/ml iodine concent, per ml $0.29 7/1/2014 12/31/2078

Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml $1.06 7/1/2014 9/30/2014 Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml $1.12 10/1/2014 12/31/2014 Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml $0.99 1/1/2015 3/31/2015 Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml $1.09 4/1/2015 6/30/2015 Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml $0.94 7/1/2015 12/31/2078

Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml $0.23 7/1/2014 9/30/2014 Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml $0.21 10/1/2014 12/31/2014 Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml $0.20 1/1/2015 3/31/2015 Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml $0.22 4/1/2015 6/30/2015 Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml $0.20 7/1/2015 12/31/2078

Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml $0.17 7/1/2014 9/30/2014 Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml $0.24 10/1/2014 12/31/2014 Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml $0.16 1/1/2015 3/31/2015 Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml $0.17 4/1/2015 6/30/2015 Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml $0.14 7/1/2015 12/31/2078

Q9968 Injection, nonradioactive, noncontrast, visualization adjunct, 1 mg $1.43 7/1/2014 12/31/2014 Q9968 Injection, nonradioactive, noncontrast, visualization adjunct, 1 mg $1.61 1/1/2015 3/31/2015 Q9968 Injection, nonradioactive, noncontrast, visualization adjunct, 1 mg $10.46 4/1/2015 6/30/2015 Q9968 Injection, nonradioactive, noncontrast, visualization adjunct, 1 mg $10.70 7/1/2015 12/31/2078

S0020 Injection, bupivicaine HCl, 30 ml $1.97 7/1/2014 12/31/2078

90371 Hepatitis b immune globulin(HBlg), human, for intramuscular use $118.22 7/1/2014 9/30/2014 90371 Hepatitis b immune globulin(HBlg), human, for intramuscular use $117.38 10/1/2014 12/31/2014 90371 Hepatitis b immune globulin(HBlg), human, for intramuscular use $116.67 1/1/2015 3/31/2015 90371 Hepatitis b immune globulin(HBlg), human, for intramuscular use $104.56 4/1/2015 6/30/2015 90371 Hepatitis b immune globulin(HBlg), human, for intramuscular use $119.96 7/1/2015 12/31/2078

90375 Rabies immune globulin (Rig), human, for intramuscular/subcutaneous use $241.04 7/1/2014 9/30/2014 90375 Rabies immune globulin (Rig), human, for intramuscular/subcutaneous use $247.57 10/1/2014 12/31/2014 90375 Rabies immune globulin (Rig), human, for intramuscular/subcutaneous use $243.58 1/1/2015 3/31/2015 90375 Rabies immune globulin (Rig), human, for intramuscular/subcutaneous use $248.30 4/1/2015 6/30/2015 90375 Rabies immune globulin (Rig), human, for intramuscular/subcutaneous use $244.73 7/1/2015 12/31/2078

90376 Rabies ig, heat-treated (RIg-HT), human, for intramuscular/subcutaneous use $230.99 7/1/2014 9/30/2014 90376 Rabies ig, heat-treated (RIg-HT), human, for intramuscular/subcutaneous use $237.82 10/1/2014 12/31/2014 90376 Rabies ig, heat-treated (RIg-HT), human, for intramuscular/subcutaneous use $225.42 1/1/2015 3/31/2015 90376 Rabies ig, heat-treated (RIg-HT), human, for intramuscular/subcutaneous use $242.39 4/1/2015 6/30/2015 Procedure Effective Code Description Rate End Date Code Date 90376 Rabies ig, heat-treated (RIg-HT), human, for intramuscular/subcutaneous use $254.03 7/1/2015 12/31/2078

90378 Respiratory syncytial virus, monoclonal antibody, recombinant, im use 50 mg $1,308.40 7/1/2014 12/31/2014 90378 Respiratory syncytial virus, monoclonal antibody, recombinant, im use 50 mg $1,947.79 1/1/2015 6/30/2015 90378 Respiratory syncytial virus, monoclonal antibody, recombinant, im use 50 mg $1,947.49 7/1/2015 12/31/2078

90384 Rho(D) immune globulin (RhIg), human, full-dose, for intermuscular use $114.63 7/1/2014 12/31/2078

90385 Rho(D) immune globulin (RhIg), human, mini-dose,for intramuscular use $34.66 7/1/2014 12/31/2078

90386 Rho(D) immune globulin (RhIgIV), human, for intravenous use $115.32 7/1/2014 12/31/2078

90389 Tetanus immune globulin (TIg), human, for intramuscular use $188.20 7/1/2014 12/31/2078

90396 Varicella-zoster immune globulin, human, for intramuscular use $675.22 7/1/2014 3/31/2015 90396 Varicella-zoster immune globulin, human, for intramuscular use $709.07 4/1/2015 6/30/2015 90396 Varicella-zoster immune globulin, human, for intramuscular use $708.98 7/1/2015 12/31/2078

90581 Anthrax vaccine, for subcutaneous or intramuscular use $94.05 7/1/2014 12/31/2078

90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for perq use $122.18 7/1/2014 9/30/2014 90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for perq use $121.96 10/1/2014 12/31/2014 90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for perq use $120.44 1/1/2015 3/31/2015 90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for perq use $121.95 4/1/2015 6/30/2015 90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for perq use $122.44 7/1/2015 12/31/2078

90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, intravesical $122.18 7/1/2014 9/30/2014 90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, intravesical $121.96 10/1/2014 12/31/2014 90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, intravesical $120.44 1/1/2015 3/31/2015 90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, intravesical $121.95 4/1/2015 6/30/2015 90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, intravesical $122.44 7/1/2015 12/31/2078

90632 Hepatitis A vaccine, adult dose, for intramuscular use $50.68 7/1/2014 9/30/2014 90632 Hepatitis A vaccine, adult dose, for intramuscular use $49.54 10/1/2014 12/31/2014 90632 Hepatitis A vaccine, adult dose, for intramuscular use $50.88 1/1/2015 3/31/2015 90632 Hepatitis A vaccine, adult dose, for intramuscular use $51.48 4/1/2015 6/30/2015 90632 Hepatitis A vaccine, adult dose, for intramuscular use $48.43 7/1/2015 12/31/2078

90633 Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for im $21.90 7/1/2014 12/31/2078

90634 Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for im $23.41 7/1/2014 12/31/2078

90636 Hepatitis A & B vaccine (HepA-HepB), adult dosage, for intramuscular use $110.64 7/1/2014 12/31/2078

90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose sch), for im $23.34 7/1/2014 12/31/2078

90646 Hemophilus influenza b vaccine (Hib), PRP-D conj, booster use only, im $28.68 7/1/2014 12/31/2078

90647 Hemophilus influenza b vaccine (Hib), PRP-OMP conj, (3 dose sch), for im $22.16 7/1/2014 12/31/2078

90648 Hemophilus influenza b vaccine (Hib), PRP-T conj, ( 4 dose sch), for im $23.41 7/1/2014 12/31/2078 Procedure Effective Code Description Rate End Date Code Date

90649 Human papilloma virus (HPV) vaccine, (quadrivalent), 3 dose sch, for im $120.00 7/1/2014 12/31/2078

90655 Influenza virus vaccine, trivalent, prsrv free, admin to children 6-35 mo, for im $17.24 7/1/2014 12/31/2078

90656 Influenza virus vaccine, split, prsrv free, admin to 3 years and older, for im $12.40 7/1/2014 7/31/2014 90656 Influenza virus vaccine, split, prsrv free, admin to 3 years and older, for im $14.10 8/1/2014 12/31/2078

90657 Influenza virus vaccine, trivalent, split virus, admin to children 6-35 mo, for im $6.02 7/1/2014 12/31/2078

90658 Influenza virus vaccine, trivalent, split virus, admin to 3 years and older, for im $11.37 7/1/2014 12/31/2078

90660 Influenza virus vaccine, trivalent, live, for intranasal use $23.46 7/1/2014 12/31/2078

90669 Pneumococcal conjugate vaccine, 7 valent, for intramuscular use $95.49 7/1/2014 12/31/2078

90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use $153.96 7/1/2014 3/31/2015 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use $173.15 4/1/2015 12/31/2078

90673 Influenza virus vaccine, trivalent, riv3, preservative free, for intramuscular use $36.48 7/1/2014 3/31/2015 90673 Influenza virus vaccine, trivalent, riv3, preservative free, for intramuscular use $37.19 4/1/2015 12/31/2078

90675 Rabies vaccine, for intramuscular use $230.92 7/1/2014 9/30/2014 90675 Rabies vaccine, for intramuscular use $223.78 10/1/2014 12/31/2014 90675 Rabies vaccine, for intramuscular use $234.29 1/1/2015 3/31/2015 90675 Rabies vaccine, for intramuscular use $237.38 4/1/2015 6/30/2015 90675 Rabies vaccine, for intramuscular use $234.93 7/1/2015 12/31/2078

90676 Rabies vaccine, for intradermal use $158.42 7/1/2014 12/31/2014 90676 Rabies vaccine, for intradermal use $172.30 1/1/2015 12/31/2078

90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use $39.59 7/1/2014 12/31/2078

90681 Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use $108.65 7/1/2014 12/31/2078

90685 Influenza virus vaccine, 4 valent, prsrv free, 6-35 mo, for intramuscular use $23.23 7/1/2014 7/31/2014 90685 Influenza virus vaccine, 4 valent, prsrv free, 6-35 mo, for intramuscular use $23.90 8/1/2014 12/31/2078

90686 Influenza virus vaccine, 4 valent, prsrv free, 3 yrs plus, for intramuscular use $19.41 7/1/2014 7/31/2014 90686 Influenza virus vaccine, 4 valent, prsrv free, 3 yrs plus, for intramuscular use $17.98 8/1/2014 12/31/2078

90688 Influenza virus vaccine, 4 valent, 3 yrs plus, for intramuscular use $16.82 7/1/2014 7/31/2014 90688 Influenza virus vaccine, 4 valent, 3 yrs plus, for intramuscular use $16.84 8/1/2014 12/31/2078

90690 Typhoid vaccine, live, oral $6.69 7/1/2014 12/31/2078

90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs) for intramuscular use $67.87 7/1/2014 9/30/2014 90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs) for intramuscular use $68.55 10/1/2014 12/31/2014 90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs) for intramuscular use $80.12 1/1/2015 3/31/2015 90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs) for intramuscular use $79.39 4/1/2015 6/30/2015 90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs) for intramuscular use $90.34 7/1/2015 12/31/2078 Procedure Effective Code Description Rate End Date Code Date

90692 Typhoid vaccine, heat- & phenol-inactivated (H-P), for subq/intradermal use $29.21 7/1/2014 12/31/2078

90696 DTaP-IPV inactivated, admin to children 4 - 6 years of age, for im use $49.92 7/1/2014 12/31/2078

90698 DTaP-Hib-IPV inactivated vaccine, for intramuscular use $85.41 7/1/2014 12/31/2078

90700 Diphtheria, tetanus tox, & acellular pertussis vaccine, admin >7 years, for im $16.15 7/1/2014 12/31/2078

90702 Diphtheria and tetanus toxoids (DT) adsorbed >7 years, for im $32.27 7/1/2014 12/31/2078

90703 Tetanus toxoid adsorbed, for intramuscular use $41.11 7/1/2014 9/30/2014 90703 Tetanus toxoid adsorbed, for intramuscular use $41.27 10/1/2014 12/31/2014 90703 Tetanus toxoid adsorbed, for intramuscular use $39.71 1/1/2015 3/31/2015 90703 Tetanus toxoid adsorbed, for intramuscular use $42.77 4/1/2015 12/31/2078

90704 Mumps virus vaccine, live, for subcutaneous use $162.34 7/1/2014 12/31/2078

90705 Measles virus vaccine, live, for subcutaneous use $17.43 7/1/2014 12/31/2078

90706 Rubella virus vaccine, live, for subcutaneous use $19.51 7/1/2014 12/31/2078

90707 Measles, mumps & rubella virus vaccine (MMR), live, for subcutaneous use $47.07 7/1/2014 12/31/2078

90708 Measles and rubella virus vaccine, live, for subcutaneous use $19.64 7/1/2014 12/31/2078

90710 Measles, mumps, rubella & varicella vac (MMRV), live, for subcutaneous use $162.18 7/1/2014 12/31/2078

90712 Poliovirus vaccine, (any type)(OPV), live, for oral use $19.73 7/1/2014 12/31/2078

90713 Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use $28.14 7/1/2014 12/31/2078

90714 Td toxoids, adsorbed, preservative free, admin to 7 years & older, for im $21.10 7/1/2014 9/30/2014 90714 Td toxoids, adsorbed, preservative free, admin to 7 years & older, for im $21.96 10/1/2014 12/31/2014 90714 Td toxoids, adsorbed, preservative free, admin to 7 years & older, for im $21.59 1/1/2015 3/31/2015 90714 Td toxoids, adsorbed, preservative free, admin to 7 years & older, for im $18.76 4/1/2015 6/30/2015 90714 Td toxoids, adsorbed, preservative free, admin to 7 years & older, for im $19.94 7/1/2015 12/31/2078

90715 Tdap vaccine, when administered to 7 years or older, for intramuscular use $35.83 7/1/2014 9/30/2014 90715 Tdap vaccine, when administered to 7 years or older, for intramuscular use $33.32 10/1/2014 12/31/2014 90715 Tdap vaccine, when administered to 7 years or older, for intramuscular use $36.27 1/1/2015 3/31/2015 90715 Tdap vaccine, when administered to 7 years or older, for intramuscular use $32.83 4/1/2015 6/30/2015 90715 Tdap vaccine, when administered to 7 years or older, for intramuscular use $30.36 7/1/2015 12/31/2078

90716 Varicella virus vaccine, live, for subcutaneous use $81.67 7/1/2014 12/31/2078

90717 Yellow fever vaccine, live, for subcutaneous use $75.06 7/1/2014 12/31/2078

90719 Diphtheria toxoid, for intramuscular use $26.74 7/1/2014 12/31/2078

90720 DTP-Hib vaccine, for intramuscular use $28.34 7/1/2014 12/31/2078 Procedure Effective Code Description Rate End Date Code Date

90721 DtaP-Hib vaccine, for intramuscular use $46.35 7/1/2014 12/31/2078

90723 Dtap-HepB-IPV vaccine, for intramuscular use $81.65 7/1/2014 12/31/2078

90725 Cholera vaccine, for injectable use $14.77 7/1/2014 12/31/2078

90727 Plague vaccine, for intramuscular use $23.00 7/1/2014 12/31/2078

90732 Pneumococcal polysaccharide vaccine, 23-v, 2 years or older, for subq/im $77.85 7/1/2014 3/31/2015 90732 Pneumococcal polysaccharide vaccine, 23-v, 2 years or older, for subq/im $82.52 4/1/2015 6/30/2015 90732 Pneumococcal polysaccharide vaccine, 23-v, 2 years or older, for subq/im $82.51 7/1/2015 12/31/2078

90733 Meningococcal polysaccharide vaccine, for subcutaneous use $106.49 7/1/2014 12/31/2078

90734 Meningococcal conjugate vaccine, tetravalent, for intramuscular use $90.16 7/1/2014 9/30/2014 90734 Meningococcal conjugate vaccine, tetravalent, for intramuscular use $100.46 10/1/2014 12/31/2078

90735 Japanese encephalitis virus vaccine, for subcutaneous use $104.13 7/1/2014 12/31/2014 90735 Japanese encephalitis virus vaccine, for subcutaneous use $108.29 1/1/2015 12/31/2078

90740 Hepatitis B vaccine, dialysis dosage,(3 dose schedule) for intramuscular use $119.42 7/1/2014 12/31/2078

90743 Hepatitis B vaccine, adolescent, (2 dose schedule) for intramuscular use $24.22 7/1/2014 12/31/2078

90744 Hepatitis B vaccine, pediatric dosage (3 dose sch) for intramuscular use $24.22 7/1/2014 12/31/2078

90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use $59.71 7/1/2014 12/31/2078

90747 Hepatitis B vaccine, dialysis dosage (4 dose schedule) for intramuscular use $119.42 7/1/2014 12/31/2078

90748 HepB-Hib vaccine, for intramuscular use $66.47 7/1/2014 12/31/2078