Physician Drug Program Procedure Codes and Rates As of August 1, 2008

Physician Drug Program Procedure Codes And Rates as of August 1, 2008

EFFECTIVE CODE DESCRIPTION FACILITY NON-FACILITY DATE Biologics ***J0129 Abatacept (Orencia) 10 mg $18.69 $18.69 10/1/2007 ***J7308 Aminolevulinic Acid HCL, topical 20% single dose, 354gm $109.74 $109.74 8/1/2008 ***J1300 Eculizumab, 10 mg single use vial (Soliris) $176.38 $176.38 1/1/2008 ***J3590 Human Thrombin Topical Protein, 1IU (Evithrom) manual manual 12/1/2007 ***J3590 Human Topical Protein, 1IU (Recothrom) manual manual 1/1/2008 ***S0145 Peginterferon alfa-2a, 180 mcg/ml (Pegasys) $336.41 $336.41 10/1/2007 ***S0146 Pegylated Interferon Alfa-2b, 10 mcg (Peg-Intron) $89.22 $89.22 8/1/2008 ***J2724 Protein C Concentrate, human, 10 IU/vial (Ceprotin) $12.19 $12.19 1/1/2008 ***J2778 Ranibizumab, 0.1 mg (Lucentis) $405.18 $405.18 8/1/2008

Drugs ***J3490 17 Alpha Hydroxprogesterone Caporoate, Bulk powder, 250 mg manual manual 4/1/2006 ***J0128 Abarelix, 10 mg, inj. (Plenaxis) $68.62 $68.62 10/1/2007 ***J0130 Abciximab, 10mg, injection (ReoPro) $413.16 $413.16 8/1/2008 ***J1120 Acetazolamide sodium, up to 500 mg, injection (Diamox) $16.54 $16.54 8/1/2008 ***J0133 Acyclovir, 5mg (Zovirax) $0.02 $0.02 10/1/2007 Adenosine, 06mg, injection (not to be used to report any Adenosine ***J0150 phosphate compounds; instead use A9270) (Adenocard) $22.86 $22.86 8/1/2008 Adenosine, 30 mg, inj (not to be used to report any adenosine phosphate ***J0152 compound; use A9270) $69.16 $69.16 8/1/2008 ***J0180 Agalsidase Beta, 1 mg, inj. (Fabrazyme) $127.20 $127.20 8/1/2008 ***P9047 Albumin (human), 25%, 50 ml, infusion $40.13 $40.13 8/1/2008 ***P9041 Albumin (human), 5%, 50 ml, infusion $20.06 $20.06 8/1/2008 ***J9015 Aldesleukin, per single use vial (Proleukin, etc) $767.40 $767.40 8/1/2008 ***J0215 Alefacept, 0.5 mg, inj. (Amevive) $26.66 $26.66 8/1/2008 ***J9010 Alemtuzumab, 10 mg (Campath) $551.07 $551.07 8/1/2008 ***J0205 Alglucerase, per 10 units, injection (Ceredase) $39.22 $39.22 8/1/2008 ***J0220 Alglucosidase Alfa, 10mg (Myozyme) $127.20 $127.20 1/1/2008 ***J0256 Alpha 1-proteinase inhibitor-human, 10mg, injection (Prolastin) $3.28 $3.28 10/1/2007 ***J2997 Alteplase recombinant, 1 mg, injection (Activase) $32.18 $32.18 8/1/2008 ***J0278 Amicacin sulfate, 100 mg $1.15 $1.15 10/1/2007 ***J0207 Amifostine, 500mg, injection (Ethyol) $480.64 $480.64 10/1/2007 ***J0280 Aminophylline, up to 250mg, injection $0.43 $0.43 10/1/2007 ***J0300 Amobarbital, up to 125mg, injection (Amytal) $2.60 $2.60 10/1/2007 ***J0285 Amphotericin B, 50 mg, Injection $10.23 $10.23 10/1/2007 ***J0288 Amphotericin B cholesteryl sulfate complex, 10 mg, injection (Amphotee) $12.00 $12.00 10/1/2007 ***J0287 Amphotericin B lipid complex, 10 mg, injection $10.38 $10.38 10/1/2007 ***J0289 Amphotericin B liposome, 10 mg, injection (Ambisome) $17.24 $17.24 10/1/2007 ***J0290 Ampicillin sodium, 500mg, injection (Omnipen-N, Totacillin-N) $2.48 $2.48 10/1/2007 ***J0295 Ampicillin sodium/sulbactam sodium, per 1.5g, injection (Unasyn) $5.49 $5.49 10/1/2007 ***J7197 Antithrombin III (human), per IU (Throbate III, ATnativ) $1.91 $1.91 8/1/2008 ***J0400 Aripiprazole, 0.25 mg, (Abilify) $0.29 $0.29 1/1/2008 ***J9017 Arsenic trioxide, 1 mg (Trisenox) $34.48 $34.48 8/1/2008 ***J9020 Asparaginase, 10,000 units (Elspar) $57.02 $57.02 8/1/2008 ***J0460 Atropine sulfate, up to 0.3mg, injection $0.59 $0.59 10/1/2007 ***J9025 Azacitidine (Vidaza) 1 mg $4.48 $4.48 8/1/2008 Azithromycin dihydrate, oral, capsules/powder, 1 gm (Zithromax, ***Q0144 Zithromax Z-Pak) $21.74 $21.74 7/24/2006 ***J0456 Azithromycin, 500mg, injection (Zithromax) $19.56 $19.56 10/1/2007 ***J3490 Baclofen Kit 2*5 ml amp, 10mg manual manual 10/1/2007 ***J3490 Baclofen Kit 4*5 ml amp, 10mg manual manual 10/1/2007 ***J0475 Baclofen, 10 mg (Lioresal) $197.04 $197.04 10/1/2007 ***J0476 Baclofen, 50 mcg for intrathecal trial $71.59 $71.59 10/1/2007 ***J9031 BCG live (intravesical), per installation (Tice BCG, Theracys) $113.75 $113.75 8/1/2008 ***J0702 Betamethasone acet&sod phosp, 3 mg $5.75 $5.75 8/1/2008 ***J0704 Betamethasone sodium phosphate, per 4mg, injection $1.13 $1.13 4/1/2007 ***J9035 Bevacizumab, 10 mg, inj. (Avastin) $57.44 $57.44 8/1/2008 ***J9040 Bleomycin sulfate, 15 units (Blenoxane) $29.02 $29.02 8/1/2008 ***J9041 Bortezomib, 0.1 mg, inj. (Velcade) $34.43 $34.43 8/1/2008 ***J0585 Botulinum toxin type A, per unit (Botox) $5.22 $5.22 8/1/2008 ***J0587 Botulinum toxin type B, per 100 units $8.71 $8.71 8/1/2008 ***J0595 Butorphinol tartrate, 1 mg, inj. (Stadol) $0.50 $0.50 8/1/2008 ***J0636 Calcitriol, 0.1 mcg, injection (Calcijex) $0.43 $0.43 8/1/2008 ***J0610 Calcium gluconate, per 10ml, injection (Kaleinate) $0.36 $0.36 8/1/2008 ***J0620 Calcium glycerophosphate and calcium lactate, per 10ml, injection (Calphosan $13.20 $13.20 12/15/2007 ***J9045 Carboplatin, 50 mg (Paraplatin) $6.31 $6.31 8/1/2008 ***J9050 Carmustine, 100 mg (BiCNU) $156.83 $156.83 8/1/2008 ***J0690 Cefazolin Sodium, 500 mg, Injection (Ancef, Kefzol, Zoliicef) $0.66 $0.66 8/1/2008 ***J0692 Cefepime HCL, 500 mg, injection (Maxipime) $6.75 $6.75 8/1/2008 ***J0698 Cefotaxime Sodium, per g (Claforan) $4.29 $4.29 8/1/2008 ***J0694 Cefoxitin Sodium, 1g, injection (Mefoxin) $8.19 $8.19 10/1/2007 ***J0713 Ceftazidime, per 500 mg, Injection (Fortaz, Tazidime) $3.47 $3.47 8/1/2008 ***J0715 Ceftizoxime sodium, per 500mg, injection (Cefizox) $5.24 $5.24 8/1/2008 ***J0696 Ceftriaxone Sodium, per 250mg, Injection (Rocephin) $1.48 $1.48 8/1/2008 ***J9055 Cetuximab, 10 mg, inj. (Erbitux) $49.81 $49.81 8/1/2008 ***J0720 Chloramphenicol sodium succinate, up to 1g, injection (Chloromycetin) $18.38 $18.38 8/1/2008 ***J1990 Chlordiazepoxide HCl, up to 100 mg, injection (Librium) $21.05 $21.05 10/1/2007 ***J2400 Chloroprocaine HCl, per 30 ml, injection (Nesacaine) $12.72 $12.72 8/1/2008 ***J1205 Chlorothiazide sodium, per 500 mg, injection (Diuril Sodium) $165.12 $165.12 8/1/2008 ***J3230 Chlorpromazine HCl, up to 50 mg, injection (Thorazine) $3.22 $3.22 8/1/2008 ***J0725 Chorionic Gonadotropin, per 1,000 USP units, Injection, $3.37 $3.37 8/1/2008 ***J0740 Cidofovir, 375 mg, Injection (Vistide) $762.45 $762.45 8/1/2008 ***J0743 Cilastatin sodium imipenem, per 250mg, injection (Primaxin IM or IV) $14.28 $14.28 8/1/2008 ***S0023 Cimetidine hydrochloride, 300 mg, injection (Tagamet) $0.61 $0.61 10/1/2007 ***J0744 Ciprofloxacin for IV infusion, 200 mg, injection (Cipro) $5.34 $5.34 8/1/2008 ***J9062 Cisplatin, 50 mg (Platinol AQ) $11.32 $11.32 8/1/2008 ***J9060 Cisplatin, powder or solution, per 10 mg (Platinol AQ) $2.27 $2.27 8/1/2008 ***J9065 Cladribine, per 1 mg, injection (Leustatin) $30.63 $30.63 8/1/2008 ***J0735 Clonidine hydrochloride, 1mg, injection (Catapres) $56.00 $56.00 8/1/2008 ***J0745 Codeine phosphate, per 30mg, injection $1.27 $1.27 8/1/2008 ***J0760 Colchicine, per 1mg, injection $5.00 $5.00 8/1/2008 ***J0770 Colistimethate Sodium, up to 150 mg, Injection (Coly-Mycin M) $19.88 $19.88 8/1/2008 ***J0800 Corticotropin, up to 40 units, injection (Acthar, ACTH) $2,355.52 $2,355.52 8/1/2008 ***J0835 Cosyntropin, per 0.25 mg, injection (Cortrosyn) $65.60 $65.60 8/1/2008 ***J9091 Cyclophosphamide, 01 g (Cytoxan, Neosar) $18.71 $18.71 8/1/2008 ***J9092 Cyclophosphamide, 02 g (Cytoxan, Neosar) $37.43 $37.43 8/1/2008 ***J9070 Cyclophosphamide, 100 mg (Cytoxan, Neosar) $1.91 $1.91 10/1/2007 ***J9080 Cyclophosphamide, 200 mg (Cytoxan, Neosar) $3.82 $3.82 10/1/2007 ***J9090 Cyclophosphamide, 500 mg (Cytoxan, Neosar) $16.50 $16.50 10/1/2007 ***J9098 Cyclophosphamide, DepoCyt, 10 mg $414.95 $414.95 8/1/2008 ***J9096 Cyclophosphamide, lyophilized, 01 g (Cytoxan Lyophilized) $18.59 $18.59 8/1/2008 ***J9097 Cyclophosphamide, lyophilized, 02 g (Cytoxan Lyophilized) $37.17 $37.17 8/1/2008 ***J9093 Cyclophosphamide, lyophilized, 100 mg (Cytoxan Lyophilized) $1.86 $1.86 8/1/2008 ***J9094 Cyclophosphamide, lyophilized, 200 mg (Cytoxan Lyophilized) $3.72 $3.72 8/1/2008 ***J9095 Cyclophosphamide, lyophilized, 500 mg (Cytaxan Lyophilized) $9.29 $9.29 8/1/2008 ***J9100 Cytarabine, 100 mg (Cytosar-U) $1.20 $1.20 8/1/2008 ***J9110 Cytarabine, 500 mg ((Cytosar-U) $6.02 $6.02 8/1/2008 ***J7070 D-5-W, 1,000 cc, infusion $2.18 $2.18 8/1/2008 ***J9130 Dacarbazine, 100 mg (DTIC- Dome) $4.60 $4.60 8/1/2008 ***J9140 Dacarbazine, 200 mg (DTIC - Dome) $9.21 $9.21 8/1/2008 ***J7513 Daclizumab, parenteral, 25 mg (Zenapax) $315.68 $315.68 8/1/2008 ***J9120 Dactinomycin, 0.5 mg (Cosmegen) $493.43 $493.43 10/1/2007 ***J1645 Dalteparin sodium, per 2500 IU, injection (Fragmin) $10.79 $10.79 8/1/2008 ***J0878 Daptomycin, 1 mg (Cubicin) $0.35 $0.35 8/1/2008 ***J0881 Darbepoetin alfa (Aranesp) 1 mcg $2.77 $2.77 8/1/2008 ***J0882 Darbepoetin alfa for ESRD on dialysis (Aranesp) 1 mcg $2.77 $2.77 8/1/2008 ***J9150 Daunorubicin HCl, 10 mg (Cerubidine) $17.14 $17.14 8/1/2008 ***J9151 Daunorubicin citrate, liposomal formulation, 10 mg (Daunoxome) $56.06 $56.06 8/1/2008 ***J0894 Decitabine, 1 mg, (Dacogen) $27.11 $27.11 1/1/2008 ***J0895 Deferoxamine Mesylate, 500mg, Injection (Desferal) $12.31 $12.31 8/1/2008 ***J9160 Denileukin Diftitox, 300 mcg (Ontak) $1,410.03 $1,410.03 8/1/2008 ***J1000 Depo-estradiol cypionate, up to 5mg, injection $6.18 $6.18 8/1/2008 ***J2597 Desmopressin acetate, per 1 mcg, injection (DDAVP) $1.87 $1.87 8/1/2008 ***J1094 Dexamethasone acetate, 1 mg, injection (Dalalone - LA) $0.23 $0.23 10/1/2007 ***J1100 Dexamethasone sodium phosphate, 1mg, injection (Cortastat, Dalalone) $0.08 $0.08 8/1/2008 ***J1190 Dexrazoxane hydrochloride, per 250 mg, injection (Zinecard) $180.94 $180.94 8/1/2008 ***J3490 Dexrazoxane, 250mg (Totect) manual manual 1/1/2008 ***J7110 Dextran 75, 500 ml, infusion (Gentran 75) $10.46 $10.46 8/1/2008 ***J7042 Dextrose 5% / normal saline (500 ml = 1 unit) $0.28 $0.28 8/1/2008 ***J7060 Dextrose 5% / water (500 ml = 1 unit) $1.09 $1.09 8/1/2008 ***J3360 Diazepam, up to 5 mg, injection (Valium, Zetran) $0.79 $0.79 8/1/2008 ***J1730 Diazoxide, up to 300 mg, injection (Hyperstat IV) $111.85 $111.85 10/1/2007 ***J0500 Dicyclomine HCl, up to 20mg, injection (Bentyl, Dilomine, Antispas) $14.39 $14.39 10/1/2007 ***J1160 Digoxin, up to 0.5 mg injection (Lanoxin) $1.18 $1.18 8/1/2008 ***J1110 Dihydroergotamine mesylate, per 1mg, injection (DHE 45) $24.50 $24.50 8/1/2008 ***J1240 Dimenhydrinate, up to 50 mg, injection (Dramamine) $3.12 $3.12 8/1/2008 ***J0470 Dimercaprol, per 100mg, injection (BAL in oil) $24.52 $24.52 10/1/2007 ***J1200 Diphenhydramine HCl, up to 50 mg, injection (Benadryl) $0.75 $0.75 8/1/2008 ***J1245 Dipyridamole, per 10 mg, injection (Persantine IV) $0.73 $0.73 8/1/2008 ***J1212 DMSO, dimethyl sulfoxide, 50%, 50 ml, injection $50.49 $50.49 8/1/2008 ***J1250 Dobutamine HCl, per 250 mg, injection (Dobutrex) $5.14 $5.14 8/1/2008 ***J9170 Docetaxel, 20 mg (Taxotere) $325.85 $325.85 8/1/2008 ***J1260 Dolasetron mesylate, 10 mg, injection (Anzemet) $4.19 $4.19 8/1/2008 ***J1265 Dopamine HCL, 40mg $0.51 $0.51 8/1/2008 ***J3490 Doripenem, 500mg (Doribax) manual manual 10/12/2007 ***J1270 Doxercalciferol, 1 mcg, injection (Hectoral) $2.80 $2.80 8/1/2008 ***J9000 Doxorubicin HCl, 10 mg (Adriamycin) $4.75 $4.75 8/1/2008 ***J9001 Doxorubicin HCl,all lipid formulations, 10 mg (Doxil) $413.49 $413.49 8/1/2008 ***J1790 Droperidol, up to 5 mg, injection (Inapsine) $1.32 $1.32 8/1/2008 ***J0600 Edetate calcium disodium, up to 1000mg, injection (Calcium EDTA) $50.23 $50.23 8/1/2008 ***J1650 Enoxaparin sodium, 10 mg, injection (Lovenox) $5.90 $5.90 8/1/2008 ***J0170 Epinephrine, up to 1ml ampule, injection $0.92 $0.92 10/1/2007 ***J9178 Epirubicin HCl, 2 mg, inj. (Ellence) $6.24 $6.24 8/1/2008 ***J0886 Epoetin alfa 1000 units (for ESRD on dialysis) $9.07 $9.07 8/1/2008 ***Q4081 Epoetin Alfa, 100 units (for ESRD on dialysis) $0.91 $0.91 8/1/2008 ***J0885 Epoetin alpha, (for non ESRD use), per 1,000 units (Epogen, Procrit) $9.07 $9.07 8/1/2008 ***J1325 Epoprostenol, 0.5 mg, injection (Flolan) $14.36 $14.36 8/1/2008 ***J1335 Ertapenem injection, 500 mg $25.51 $25.51 8/1/2008 ***J1364 Erythromycin lactobionate, per 500 mg, injection (Erthrocin) $6.76 $6.76 8/1/2008 ***J1380 Estradiol valerate, up to 10 mg, injection (Delestrogen) $8.61 $8.61 8/1/2008 ***J1390 Estradiol valerate, up to 20 mg, injection (Delestrogen) $17.22 $17.22 8/1/2008 ***J0970 Estradiol valerate, up to 40mg, injection (Delestrogen) $34.43 $34.43 8/1/2008 ***J1410 Estrogen conjugated, per 25 mg, injection (Premarin IV) $71.25 $71.25 8/1/2008 ***J1436 Etidronate disodium, 300 mg $71.41 $71.41 1/1/2008 ***J9181 Etoposide, 10 mg (VePesid) $0.40 $0.40 8/1/2008 ***J9182 Etoposide, 100 mg (VePesid) $4.03 $4.03 8/1/2008 ***J7193 Factor IX (antihemophilic factor, purefied, non-recombinant), per I.U. $0.89 $0.89 10/1/2007 ***J7195 Factor IX (antihemophilic factor, recombinant), per I.U. $1.07 $1.07 8/1/2008 ***J7194 Factor IX Complex, per IU $0.80 $0.80 8/1/2008 ***J7189 Factor VIIA (Coagulation factor, recombinant) 1 mg (Novoseven) $1.19 $1.19 8/1/2008 ***J7190 Factor VIII (antihemophilic factor, human) per I.U. $0.76 $0.76 8/1/2008 ***J7191 Factor VIII (antihemophilic factor, porcine) per I.U. $1.86 $1.86 11/1/2005 ***J7192 Factor VIII (antihemophilic factor, recombinant) per I.U. $1.08 $1.08 8/1/2008 ***J3010 Fentanyl Citrate, 0.1 mg, injection (Sublimaze) $0.28 $0.28 8/1/2008 ***J1441 Filgastrim (G-CSF), 480 mcg, injection (Neupogen) $306.63 $306.63 8/1/2008 ***J1440 Filgrastim (G-CSF), 300 mcg, injection (Neupogen) $199.24 $199.24 8/1/2008 ***J9200 Floxuridine, 500 mg (FUDR) $51.12 $51.12 8/1/2008 ***J9185 Fludarabine phosphate, 50 mg, injection (Fludara) $200.75 $200.75 8/1/2008 ***J9190 Fluorouracil, 500 mg (Adrucil) $1.87 $1.87 8/1/2008 ***J2680 Fluphenazine decanoate, up to 25 mg, injection (Prolixin) $2.37 $2.37 8/1/2008 ***J3490 Fosaprepitant dimeglumine, 115mg (Emend) manual manual 10/1/2007 ***J1455 Foscarnet sodium, per 1,000 mg, injection (Foscavir) $10.38 $10.38 8/1/2008 ***J9395 Fulvestrant, 25 mg, inj. (Faslodex) $81.36 $81.36 8/1/2008 ***J1940 Furosemide, up 20 mg, injection (Lasix) $0.19 $0.19 8/1/2008 ***J1570 Ganciclovir sodium, 500 mg, injection (Cytovene) $43.85 $43.85 8/1/2008 ***J7310 Ganciclovir, 4.5 mg, long-acting implant (Vitrasert) $4,770.00 $4,770.00 8/1/2008 ***J1580 Garamycin, gentamicin, up to 80 mg, injection $1.04 $1.04 8/1/2008 ***J9201 Gemcitabine HCl, 200 mg (Gemzar) $131.78 $131.78 8/1/2008 ***J9300 Gemtuzumab Ozogamicin, 5 mg, injection (Mylotarg) $2,428.97 $2,428.97 8/1/2008 ***J1610 Glucagon hydrochloride, per 1 mg, injection) (Glucagen) $68.66 $68.66 8/1/2008 ***J1600 Gold sodium thiomalate, up to 50 mg, injection (Myochrysine) $7.84 $7.84 8/1/2008 ***J9202 Goserelin acetate implant, per 3.6 mg (Zoladex) $189.73 $189.73 8/1/2008 ***J1626 Granisetron hydrochloride, 100 mcg, injection (Kytril) $4.96 $4.96 8/1/2008 ***J1631 Haloperidol decanoate, per 50 mg, injection (Haldol Decanoate-50) $5.66 $5.66 10/1/2007 ***J1630 Haloperidol, up to 5 mg, injection (Haldol) $1.73 $1.73 8/1/2008 ***J1642 Heparin sodium, (Heparin Lock Flush), per 10 units, injection $0.04 $0.04 8/1/2008 ***J1644 Heparin sodium, per 1,000 units, injection (Heparin) $0.07 $0.07 8/1/2008 ***J9226 Histerlin Implant (Supprelin LA) implant kit, 50 mg $14,655.78 $14,655.78 8/1/2008 ***J9225 Histrelin Acetate Implant, (Vantas) implant kit, 50 mg $1,508.09 $1,508.09 8/1/2008 ***J3490 Histrelin Acetate, subcutaneous implant kit, 50 mg (Supprelin) manual manual 7/1/2007 ***J3473 Hyalurondise, recombinant, 1 usp unit (Hylenex) $0.41 $0.41 8/1/2008 ***J3470 Hyaluronidase injection up to 150 units (Wydase) $17.28 $17.28 8/1/2008 ***J0360 Hydralazine HCl, up to 20mg, injection (Apresoline) $7.61 $7.61 10/1/2007 ***J1720 Hydrocortisone sodium succinate, up to 100 mg, injection $2.23 $2.23 8/1/2008 ***J1170 Hydromorphone, up to 4 mg, injection (Dilaudid) $1.28 $1.28 8/1/2008 ***J3410 Hydroxyzine HCl, up to 25 mg, injection (Vistaril) $0.14 $0.14 8/1/2008 ***J1980 Hyoscyamine sulfate, up to 0.25 mg, injection (Levsin) $9.29 $9.29 8/1/2008 ***J7130 Hypertonic saline solution, 50 or 100 mEq, 20 cc vial $0.40 $0.40 6/14/1993 ***J1740 Ibandronate sodium, 1 mg (Boniva) $138.97 $138.97 8/1/2008 ***J1742 Ibutilide fumarate, 1 mg, injection (Corvert) $323.30 $323.30 8/1/2008 ***J9211 Idarubicin HCl, 5 mg (Idamycin) $276.07 $276.07 8/1/2008 ***J9208 Ifosfamide, per 1 g (Ifex) $37.92 $37.92 8/1/2008

***J1785 Imiglucerase, per unit, injection (Cerezyme) $4.00 $4.00 8/1/2008 ***J1562 Immune Globulin, subcutaneous 100 mg $7.08 $7.08 8/1/2008 ***J1745 Infliximab, 10 mg, injection (Remicade) $55.04 $55.04 8/1/2008 Injection, Hyaluronan or derivative, Euflexxa, for intra-articular injection, J7323 per dose $110.04 $110.04 8/1/2008 Injection, Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular J7321 injection, per dose $101.24 $101.24 8/1/2008 Injection, Hyaluronan or derivative, Orthovisc, for intra-articular J7324 injection, per dose $177.68 $177.68 8/1/2008 Injection, Hyaluronan or derivative, Synvisc, for intra-articular injection, J7322 per dose $180.06 $180.06 8/1/2008 ***J1743 Injection, Idursulfase, 1 mg $455.03 $455.03 1/1/2008 ***J2323 Injection, Natalizumab, 1 mg (Tysabri) $7.53 $7.53 8/1/2008 ***J9303 Injection, Panitumumab, 10 mg (Vectibix) $82.26 $82.26 8/1/2008 ***J1815 Insulin, per 5 units, injection $0.28 $0.28 8/1/2008 ***J9213 Interferon alfa-2A, recombinant, 3 million units (Roferon-A) $40.92 $40.92 8/1/2008 ***J9214 Interferon alfa-2B, recombinant, 1 million units (Intron-A) $14.16 $14.16 8/1/2008 ***J9212 Interferon Alfacon-1, recombinant, 1 mcg, injection (Infergen) $4.80 $4.80 8/1/2008 ***J9215 Interferon alfa-N3, (human leukocyte derived), 250,000 IU (Alferon N) $19.35 $19.35 8/1/2008 ***J9216 Interferon gamma-1B, 3 million units (Actimmune) $309.58 $309.58 8/1/2008 ***J9206 Irinotecan, 20 mg (Camptosar) $126.24 $126.24 8/1/2008 ***Q4098 Iron dextran, 50mg (Infed Dexferrum) $11.60 $11.60 3/1/2008 ***J1756 Iron sucrose, 1 mg, injection (Venofer) $0.35 $0.35 8/1/2008 ***J9999 Ixabepilone, 1mg (Ixempra) manual manual 8/1/2008 ***J1840 Kanamycin sulfate, up to 500 mg, injection (Kantrex) $5.09 $5.09 8/1/2008 ***J1850 Kanamycin sulfate, up to 75 mg, injection (Kantrex) $0.76 $0.76 8/1/2008 ***J1885 Ketorolac tromethamine, per 15 mg, injection (Toradol) $0.34 $0.34 8/1/2008 ***J3490 Lanreotide, 120mg (Somatuline Depot) manual manual 8/1/2008 ***J1931 Laronidase, 0.1 mg, inj. (Aldurazyme) $24.35 $24.35 8/1/2008 ***J0640 Leucovorin Calcium, per 50 mg, Injection (Wellcovorin) $0.78 $0.78 8/1/2008 ***J9217 Leuprolide acetate (for depot suspension), 7.5 mg $220.86 $220.86 8/1/2008 Leuprolide acetate (for depot suspension), per 3.75 mg, injection (Lupron ***J1950 Depot) $441.65 $441.65 8/1/2008 ***J9219 Leuprolide Acetate Implant 65mg (Viadur) $1,608.17 $1,608.17 8/1/2008 ***J3490 Leuprolide acetate, depot suspension, pediatric kit, 7.5 mg, inj. manual manual 1/3/2008 ***J3490 Leuprolide acetate, pediatric kit, depot suspension, 11.25 mg, inj. manual manual 1/3/2008 ***J3490 Leuprolide acetate, pediatric kit, depot suspension, 15 mg inj manual manual 1/3/2008 ***J9218 Leuprolide acetate, per 1 mg (Lupron) $7.47 $7.47 8/1/2008 ***J3490 Levetiracetam (Keppra), 500 mg/5 ml manual manual 10/1/2006 ***J1955 Levocarnitine, per 1 g, injection (Carnitor) $5.88 $5.88 8/1/2008 ***J1956 Levofloxacin, 250 mg, injection (Levaquin) $5.87 $5.87 8/1/2008 ***J1960 Levorphanol tartrate, up to 2 mg, injection (Levo-Dromoran) $3.17 $3.17 11/1/2005 ***J2001 Lidocaine HCL, for IV infusion, 10 mg, inj (Xylocaine) $0.02 $0.02 10/1/2007 ***J2010 Lincomycin HCl, up to 300 mg, injection (Lincocin) $4.26 $4.26 8/1/2008 ***J2020 Linezolid (Zyvox) 200 mg $28.09 $28.09 8/1/2008 ***J2060 Lorazepam, 2 mg, injection (Ativan) $0.64 $0.64 8/1/2008 ***J3475 Magnesium sulphate, per 500 mg, injection $0.05 $0.05 8/1/2008 ***J2150 Mannitol, 25% in 50 ml, injection $0.86 $0.86 8/1/2008 ***J9230 Mechlorethamine HCl, (nitrogen mustard), 10 mg $144.44 $144.44 8/1/2008 Medroxyprogesterone Acetate for Contraceptive use, 150mg, Injection ***J1055 (Depo-Provera) $40.50 $40.50 7/1/2007 ***J1051 Medroxyprogesterone acetate, 50 mg, injection (Depo-Provera) $6.67 $6.67 8/1/2008 ***J9245 Melphalan HCl, 50 mg, injection (Alkeran) $1,563.63 $1,563.63 8/1/2008 ***J2175 Meperidine HCl, per 100 mg, injection (Demerol) $1.52 $1.52 8/1/2008 ***J0670 Mepivacaine HCl, per 10ml, injection (Carbocaine) $1.15 $1.15 8/1/2008 ***J9209 Mesna, 200 mg (Mesnex) $7.87 $7.87 8/1/2008 ***J0380 Metaraminol bitartrate, per 10mg, injection (Aramine) $1.15 $1.15 11/1/2005 ***J1230 Methadone HCl, up to 10 mg, injection (Dolophine) $2.95 $2.95 8/1/2008 ***J2800 Methocarbamol up to 10 ml, injection (Robaxin) $10.22 $10.22 8/1/2008 ***J9250 Methotrexate sodium, 5 mg $0.21 $0.21 8/1/2008 ***J9260 Methotrexate sodium, 50 mg $2.26 $2.26 8/1/2008 ***J0210 Methyldopate HCl, up to 250mg, injection IV (Aldomet) $10.11 $10.11 10/1/2007 ***J2210 Methylergonovine maleate, up to 0.2 mg, injection (Methergine) $5.04 $5.04 8/1/2008 ***J1020 Methylprednisolone acetate, 20mg, injection (Depo-Medrol) $2.41 $2.41 8/1/2008 ***J1030 Methylprednisolone acetate, 40mg, injection (Depo-Medrol) $4.47 $4.47 8/1/2008 ***J1040 Methylprednisolone acetate, 80mg, injection (Depo-Medrol) $9.41 $9.41 8/1/2008 Methylprednisolone sodium succinate, up to 125 mg, injection (Solu- ***J2930 Medrol) $3.02 $3.02 8/1/2008

***J2920 Methylprednisolone sodium succinate, up to 40 mg, injection (Solu-Medrol) $2.07 $2.07 8/1/2008 ***J2765 Metoclopramide HCl, up to 10 mg, injection (Reglan) $0.34 $0.34 8/1/2008 ***J2250 Midazolam HCl, per 1 mg, injection (Versed) $0.15 $0.15 8/1/2008 ***J2260 Milrinone lactate, per 5 mg, injection (Primacor) $4.55 $4.55 8/1/2008 ***J9290 Mitomycin, 20 mg $52.19 $52.19 8/1/2008 ***J9291 Mitomycin, 40 mg $104.38 $104.38 8/1/2008 ***J9280 Mitomycin, 5 mg $13.05 $13.05 8/1/2008 ***J9293 Mitoxantrone HCl, per 5 mg, injection (Novantrone) $88.70 $88.70 8/1/2008 Morphine Sulfate (preservative-free sterile solution), injection, per 10 mg ***J2275 (Astramorph PF, Duramorph) $2.39 $2.39 8/1/2008 ***J2271 Morphine sulfate 100 mg, injection $3.72 $3.72 8/1/2008 ***J2270 Morphine sulfate, up to 10 mg, injection $1.79 $1.79 8/1/2008 ***J2300 Nalbuphine HCl, per 10 mg, injection (Nubain) $0.96 $0.96 8/1/2008 ***J2310 Naloxone HCl, per 1 mg, injection (Narcan) $3.16 $3.16 8/1/2008 ***J2315 Naltrexone, 1mg (Vivitrol) $1.88 $1.88 1/1/2008 ***J2320 Nandrolone decanoate, up to 050 mg, injection (Deca-Durabolin) $4.76 $4.76 8/1/2008 ***J2321 Nandrolone decanoate, up to 100 mg, injection (Deca-Durabolin) $7.13 $7.13 8/1/2008 ***J2322 Nandrolone decanoate, up to 200 mg, injection (Deca-Durabolin) $19.03 $19.03 8/1/2008 ***J9261 Nelarabine, 50 mg, (Arranon) $91.68 $91.68 8/1/2008 ***J2710 Neostigmine methylsulfate, up to 0.5 mg, injection (Prostigmin) $0.10 $0.10 8/1/2008 ***J7030 Normal saline solution, 1,000 cc, infusion $1.03 $1.03 8/1/2008 ***J7050 Normal saline solution, 250 cc infusion $0.26 $0.26 8/1/2008 ***J7040 Normal saline solution, sterile (500 ml = 1 unit), infusion $0.52 $0.52 8/1/2008 ***J2354 Octreotide non-depot form for SC or IV inj, 25 mcg. $2.21 $2.21 8/1/2008 ***J2353 Octreotide, depot form for IM injection, 1 mg manual manual 4/1/2007 ***J2357 Omalizumab, 5 mg, inj.m (Xolair) $17.82 $17.82 8/1/2008 ***J2405 Ondansetron HCl, per 1 mg, injection (Zofran) $0.22 $0.22 8/1/2008 ***J2355 Oprelvekin, 5 mg, injection (Newmega) $246.98 $246.98 8/1/2008 ***J2360 Orphenadrine citrate, up to 60 mg, injection (Norflex) $9.02 $9.02 8/1/2008 ***J2700 Oxacillin sodium, up to 250 mg, injection (Bactocile, Prostaphlin) $1.58 $1.58 8/1/2008 ***J9263 Oxaliplatin, 0.5 mg, inj. (Eloxatin) $9.49 $9.49 8/1/2008 ***J2410 Oxymorphone HCl, up to 1 mg, injection (Numorphan) $2.51 $2.51 8/1/2008 ***J2460 Oxytetracycline HCl, up to 50 mg, injection (Terramycin IM) $0.94 $0.94 10/1/2007 ***J2590 Oxytocin, up to 10 units, injection (Pitocin) $2.05 $2.05 8/1/2008 ***J9264 Paclitaxel protein-bound particles (Abraxane) 1 mg $8.85 $8.85 8/1/2008 ***J9265 Paclitaxel, 30 mg (Taxol) $11.95 $11.95 8/1/2008 ***J2469 Palonosetron HCl, 25 mcg, inj. (Aloxi) $17.22 $17.22 8/1/2008 ***J2430 Pamidronate disodium, per 30 mg, injection (Aredia) $28.33 $28.33 8/1/2008 ***J2440 Papaverine HCl, up to 60 mg, injection $0.57 $0.57 8/1/2008 ***J2501 Paricalcitol, 1 mcg, injection (Zemplar) $3.92 $3.92 8/1/2008 ***J2503 Pegaptanib sodium (Macugen) 0.3 mg $1,031.02 $1,031.02 8/1/2008 ***J9266 Pegaspargase, per single dose vial (Oncaspar) $2,093.62 $2,093.62 8/1/2008 ***J2505 Pegfilgastrim, 6 mg, inj. (Neulasta) $2,200.10 $2,200.10 8/1/2008 ***J9305 Pemetrexed, 10 mg, inj. (Altima) $46.20 $46.20 8/1/2008 Penicillin G benzathine and Penicillin G procaine, up to 1,200,000 units, ***J0540 injection (Bicillin C-R) $32.90 $32.90 8/1/2008 Penicillin G benzathine and Penicillin G procaine, up to 2,400,000 units, ***J0550 injection (Bicillin C-R) $32.90 $32.90 8/1/2008 Penicillin G benzathine and Penicillin G procaine, up to 600,000 units, ***J0530 injection (Bicillin C-R) $13.41 $13.41 10/1/2007 ***J0570 Penicillin G benzathine, up to 1,200,000 units, injection (Bicillin L-A) $40.75 $40.75 8/1/2008 ***J0580 Penicillin G benzathine, up to 2,400,000 units, injection (Bicillin L-A) $46.07 $46.07 8/1/2008 ***J0560 Penicillin G benzathine, up to 600,000 units, injection (Bicillin L-A) $23.32 $23.32 8/1/2008 ***J2540 Penicillin G potassium, up to 600,000 units, injection (Pfizerpen) $0.94 $0.94 8/1/2008 ***J2510 Penicillin G procaine, aqueous, up to 600,000 units, injection (Wycillin) $10.29 $10.29 8/1/2008 ***94642 Pentamidine Aerosol Therapy, 300mg (Respirgard II Nebulizer) $9.93 $9.93 1/1/2008 ***S0080 Pentamidine isethionate, 300mg, (Pentam-300) $42.48 $42.48 1/1/2008 Pentamidine isethionate, inhalation solution, per 300 mg, administered ***J2545 through a DME (Pentam 300, NebuPent) $54.31 $54.31 8/1/2008 ***J3070 Pentazocine HCl, up to 30 mg, injection (Talwin) $6.11 $6.11 8/1/2008 ***J2515 Pentobarbital sodium, per 50 mg, injection (Nembutal Sodium) $7.61 $7.61 8/1/2008 ***J9268 Pentostatin, per 10 mg (Nipent) $1,828.92 $1,828.92 8/1/2008 ***J2560 Phenobarbital sodium, up to 120 mg, injection $3.00 $3.00 8/1/2008 ***J2760 Phentolamine mesylate, up to 5 mg, injection (Regitine) $21.08 $21.08 8/1/2008 ***J2370 Phenylephrine HCl, up to 1 ml, injection (Neosynephrine) $0.70 $0.70 8/1/2008 ***J1165 Phenytoin sodium, per 50 mg, injection (Dilantin) $0.45 $0.45 8/1/2008 ***J3430 Phytonadione (vitamin K), per 1 mg, injection (AquaMephyton) $3.62 $3.62 8/1/2008 Piperacillin sodium/tazobactam sodium, injection, 1g/0.125g (1.125 g) ***J2543 (Zosyn) $5.15 $5.15 8/1/2008 ***J9600 Porfimer sodium, 75 mg (Photofin) $2,503.55 $2,503.55 8/1/2008 ***J3480 Potassium Chloride, per 2 mEq, injection $0.01 $0.01 8/1/2008 ***J2730 Pralidoxime chloride, up to 1 g, injection (Protopam Chloride) $88.08 $88.08 8/1/2008 ***J2650 Prednisolone acetate, up to 1 ml, injection $0.17 $0.17 10/1/2007 ***J2690 Procainamide HCl, up to 1 g, injection (Pronestyl) $2.65 $2.65 8/1/2008 ***J0780 Prochlorperazine, up to 10 mg, Injection, (Compazine) $1.16 $1.16 8/1/2008 ***J2675 Progesterone, per 50 mg, injection $1.51 $1.51 8/1/2008 ***J2550 Promethazine HCl, up to 50 mg, injection (Phenergan) $1.37 $1.37 8/1/2008 ***J1800 Propranolol HCl, up to 1 mg, injection (Inderal) $3.18 $3.18 8/1/2008 ***J2720 Protamine sulfate, per 10 mg, injection $0.59 $0.59 8/1/2008 ***J2780 Ranitidine hydrochloride, 25 mg, injection (Zantac) $0.74 $0.74 8/1/2008 ***J2993 Reteplase, 18.1 mg, injection (Retavase) $833.74 $833.74 8/1/2008 ***J7120 Ringer's lactate infusion, up to 1,000 cc $0.91 $0.91 8/1/2008 ***J2794 Risperidone, long acting 0.5 mg, inj. (Risperdal Consta) $4.93 $4.93 8/1/2008 ***J9310 Rituximab, 100 mg (Rituxan) $520.57 $520.57 8/1/2008 ***J2820 Sargramostim (GM-CSF), 50 mcg, injection (Leukine) $25.10 $25.10 8/1/2008 ***J3490 Sodium bicarbonate, 7.5%, inj, up to 50 ml manual manual 8/1/2008

***J2916 Sodium ferric gluconate complex in sucrose, 12.5 mg, injection (Ferrlecit) $4.78 $4.78 8/1/2008 ***J0697 Sterile Cefuroxime sodium, per 750mg, injection $3.44 $3.44 8/1/2008 ***J2995 Streptokinase, 250,000 IU (Streptase) $79.50 $79.50 7/1/2006 ***J3000 Streptomycin, up to 1 g, injection $6.98 $6.98 8/1/2008 ***J9320 Streptozocin, 1 g (Zanosar) $190.64 $190.64 8/1/2008 ***J0330 Succinylcholine chloride, up to 20 mg, injection (Anectine) $0.09 $0.09 10/1/2007 ***J3030 Sumatriptan Succinate, 6mg $66.61 $66.61 8/1/2008 ***J3490 Temsirolimus, single use kit, 25mg/ml (Torisel) manual manual 8/1/2008 ***J3105 Terbutaline sulfate, up to 1 mg, injection (Brethine) $2.42 $2.42 8/1/2008 ***J1080 Testosterone Cypionate, 1cc, 200mg, injection (Depo-Testosterone) $6.96 $6.96 8/1/2008 ***J1070 Testosterone Cypionate, up to 100mg injection $4.82 $4.82 8/1/2008 ***J3120 Testosterone enanthate, up to 100 mg, injection (Evarone) $5.29 $5.29 8/1/2008 ***J3130 Testosterone enanthate, up to 200 mg, injection (Evarone) $10.12 $10.12 8/1/2008 ***J9340 Thiotepa, 15 mg (Thioplex) $40.40 $40.40 8/1/2008 ***J3240 Thyrotropin alpha, 0.9 mg provided in 1.1 mg vial, injection (Thyrogen) $838.96 $838.96 8/1/2008 ***J3260 Tobramycin sulfate, up to 80 mg, injection (Nebcin) $2.32 $2.32 8/1/2008 ***J9350 Topotecan, 4 mg (Hycamtin) $898.54 $898.54 8/1/2008 ***J3265 Torsemide, 10 mg/ml, injection (Demadex) $2.18 $2.18 8/1/2008 ***J9355 Trastuzumab, 10 mg (Herceptin) $60.08 $60.08 8/1/2008 ***J3301 Triamcinolone acetonide, per 10 mg, injection (Kenalog-10) $1.38 $1.38 8/1/2008 ***J3302 Triamcinolone diacetate, per 5 mg, injection (Aristocort) $0.28 $0.28 10/1/2007 ***J3303 Triamcinolone hexacetonide, per 5mg injection (Aristospan) $1.34 $1.34 8/1/2008 ***J3250 Trimethobenzamide HCl, up to 200 mg, injection (Tigan) $4.46 $4.46 8/1/2008 ***J3305 Trimetrexate glucuronate, per 25 mg, injection (Neutrexin) $149.71 $149.71 8/1/2008 ***J3315 Triptorelin pamoate (trelstar), 3.75 mg $149.17 $149.17 8/1/2008 ***J3365 Urokinase, 250,000 IU, injection IV (Abbokinase) $457.73 $457.73 10/1/2007 ***J3370 Vancomycin HCl, 500 mg, injection (Vancoled) $3.14 $3.14 8/1/2008 ***J3396 Verteporfin, 0.1 mg, inj. (Visudyne) $9.15 $9.15 8/1/2008 ***J9360 Vinblastine sulfate, 1 mg (Velban) $1.07 $1.07 8/1/2008 ***J9370 Vincristine sulfate, 1 mg (Oncovin) $7.02 $7.02 8/1/2008 ***J9375 Vincristine sulfate, 2 mg (Oncovin) $14.04 $14.04 8/1/2008 ***J9380 Vincristine sulfate, 5 mg (Oncovin) $35.09 $35.09 8/1/2008 ***J9390 Vinorelbine tartrate, per 10 mg (Navelbine) $16.22 $16.22 8/1/2008 ***J3420 Vitamin B-12 cyanocobalamin, up to 1,000 mcg, injection $0.25 $0.25 8/1/2008 ***J7187 Von Willebrand Factor Complex (Humate-P) VWF-RCO 1IU $0.89 $0.89 4/1/2008 ***Q4096 Von Willebrand Factor Complex, human, ristocetin cofactor (The Alphanate product) VWF:RCO 1IU $0.66 $0.66 4/1/2008 ***J2278 Ziconotide (Prialt)1 mcg $6.51 $6.51 8/1/2008 ***Q4095 Zoledrodic Acid, Reclast, 1 mg $44.16 $44.16 7/1/2007 ***J3488 Zoledronic acid, 1 mg, injection (Reclast) $216.59 $216.59 8/1/2008 ***J3487 Zoledronic acid, 1 mg, injection (Zometa) $210.66 $210.66 8/1/2008

Immune Globulins ***90291 Cytomegalovirus Immune Globulin (CMV-IgIV), Human,1ml $23.79 $23.79 3/3/2007 ***J1460 Gamma globulin, IM, 01 cc $11.55 $11.55 8/1/2008 ***J1550 Gamma globulin, IM, 10cc $115.53 $115.53 8/1/2008 ***J1470 Gamma globulin, IM, 02cc $23.11 $23.11 8/1/2008 ***J1480 Gamma globulin, IM, 03cc $34.66 $34.66 8/1/2008 ***J1490 Gamma globulin, IM, 04cc $46.21 $46.21 8/1/2008 ***J1500 Gamma globulin, IM, 05cc $57.77 $57.77 8/1/2008 ***J1510 Gamma globulin, IM, 06cc $69.33 $69.33 8/1/2008 ***J1520 Gamma globulin, IM, 07cc $80.83 $80.83 8/1/2008 ***J1530 Gamma globulin, IM, 08cc $92.42 $92.42 8/1/2008 ***J1540 Gamma globulin, IM, 09cc $104.01 $104.01 8/1/2008 ***J1560 Gamma globulin, IM, over 10cc $115.53 $115.53 8/1/2008 ***J1571 Hepatitis B Immune globulin IM, 0.5ml $48.35 $48.35 8/1/2008 ***90371 Hepatitis B Immune globulin (HBIg), human, $119.97 $119.97 1/1/2008 ***J1573 Hepatitis B Immune globulin IV,0.5ml $48.35 $48.35 8/1/2008 ***J1566 Immune globulin, IV lypohilized (powder), 500mg $28.07 $28.07 8/1/2008 ***J1572 Immune Globulin, IV non-lyophilized, eg Liquid, 500mg $32.53 $32.53 8/1/2008 ***J1561 Immune Globulin, IV non-lyophilized, eg Liquid, 500mg $33.45 $33.45 8/1/2008 ***J1569 Immune Globulin,IV non-lyophilized, eg. Liquid, 500mg $31.79 $31.79 8/1/2008 ***Q4097 Immune Globulin, IV, non-lyophilized, eg liquid, 500mg (Privigen) $34.19 $34.19 4/1/2008 ***J1562 Immune Globulin,SQ, 100mg $7.08 $7.08 8/1/2008

***J7504 Lymphocyte Immune Globulin, antithymocyt glovulin equine parental, 250mg $383.79 $383.79 8/1/2008 ***90375 Rabies Immune Globulin (Rig), human,150IU $67.83 $67.83 8/1/2008 ***90376 Rabies Immune Globulin, Heat-treated (Rig-HT), human,2ml $78.08 $78.08 8/1/2008 ***90379 Respiratoy Syncytial Virus Immune Globulin (RSV_IgIV), human,1ml $17.17 $17.17 11/1/2005 ***J2790 Rho(D) Immune Globulin (RhIg), full dose,300mcg $89.71 $89.71 8/1/2008 ***J2788 Rho(D) Immune Globulin (RhIg), mini dose,50mcg $28.43 $28.43 8/1/2008 ***J2792 Rho(D) Immune Globulin (RhIgIV), human,100u $15.62 $15.62 8/1/2008 ***J2791 Rho(D) Immune Globulin, (human),100iu $5.33 $5.33 1/1/2008 90389 Tetanus Immune Globulin (Tig) human,250units $139.95 $139.95 1/1/2008 ***90396 Varicella-Zoster Immune Globulin, human,125units $110.41 $110.41 10/1/2007

Radiopharmaceuticals A9564 Chromic phosphate P-32 suspension, therapeutic, per mCi per mCi $ 322.43 $ 322.43 1/1/2008 A9553 Chromium CR-51 sodium chromate, diagnostic up to 250mc $ 645.84 $ 645.84 1/1/2008 Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1mCi A9559 up to 1 mCi manual manual 1/1/2008 Flurodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 mCi per A9552 study dose up to 45 mCi $ 648.96 $ 648.96 1/1/2008 A9578 Gadobenate Dimaglumine (multihance multipack) per ml $ 2.68 $ 2.68 1/1/2008 A9577 Gadobenate Dimeglumine (multihance) per ml $ 2.85 $ 2.85 1/1/2008 Gadolinium-based magnetic response contrast agent, not otherwise A9579 specified per ml $ 2.55 $ 2.55 1/1/2008 A9576 Gadoteridol (prohance multipack) per ml $ 2.46 $ 2.46 1/1/2008 A9556 Gallium GA-67 citrate, diagnostic per mlc $ 46.49 $ 46.49 1/1/2008 Indium IN-111 capromab pendetide, diagnostic, per study dose, up to 10 A9507 mCi up to 10 mCi $ 3,380.95 $ 3,380.95 12/1/2006 A9542 Indium IN-111 ibritumomab tiuxetan, diagnostic up to 5mlc $ 2,623.86 $ 2,623.86 3/18/2002 A9571 Indium IN-111 labeled autologous platelets, diagnostic per study dose $ 2,704.00 $ 2,704.00 1/1/2008 Indium IN-111 labeled autologous white blood cells, diagnostic per study A9570 dose $ 1,836.22 $ 1,836.22 1/1/2008 A9547 Indium IN-111 oxyquinoline, diagnostic per 0.5mc $ 291.61 $ 291.61 1/1/2008 A9548 Indium IN-111 pententate, diagnostic per 0.5mc $ 272.21 $ 272.21 1/1/2008 A9572 Indium IN-111 pentetreotide,diagnostic, per study dose up to 6mCi $ 2,998.95 $ 2,998.95 1/1/2008

A9516 Iodine 1-123 sodium iodide capsule(s), diagnostic, per 100µCi per 100µCi $ 72.80 $ 72.80 1/1/2008 A9509 Iodine 1-123 Sodium iodide, diagnostic per mCi $ 127.17 $ 127.17 1/1/2008 A9532 Iodine I-125 serum albumin, diagnostic, per 5 uCi per 5 uCi $ 47.50 $ 47.50 1/1/2008 A9554 Iodine I-125 sodium iothalamate, diagnostic up to 10mc $ 2,070.00 $ 2,070.00 1/1/2008 Iodine I-131 iobenguane sulfate, diagnostic, per study dose, per 0.5 mCi A9508 per 0.5mCi $ 576.19 $ 576.19 1/1/2008 A9524 Iodine I-131 iodinated serum albumin, diagnostic, per 5 uCi per 5 uCi $ 49.50 $ 49.50 1/1/2008 A9529 Iodine I-131 sodium iodide solution, diagnostic, per mCi per mCi $ 149.50 $ 149.50 1/1/2008 A9531 Iodine I-131 Sodium Iodide , diagnostic per mlc. Up to 100 mlc manual manual 1/1/2008 A9517 Iodine I-131 sodium iodide capsule, therapeutic per mlc $ 163.80 $ 163.80 1/1/2008 A9528 Iodine I-131 sodium iodine solution, diagnostic, per mCi per mCi $ 55.12 $ 55.12 1/1/2008 A9530 Iodine I-131 Sodium iodine solution, therapeutic per mlc manual manual 1/1/2008 A9544 Iodine I-131 Tositumomab, diagnostic per study dose $ 2,607.19 $ 2,607.19 7/19/2006 A9545 Iodine I-131 Tositumomab, therapeutic per treatment dose $ 22,595.63 $ 22,595.63 7/19/2006 Low Osmolar Contrast Material, 100-199 mg/ml Iodine concentration per Q9965 ml $ 1.39 $ 1.39 8/1/2008 Low Osmolar Contrast Material, 200-299 mg/ml Iodine concentration per Q9966 ml $ 0.41 $ 0.41 8/1/2008 Low Osmolar Contrast Material, 300-399mg/ml Iodine concentration per Q9967 ml $ 0.21 $ 0.21 8/1/2008 Low Osmolar Contrast Material, 400 or greater mg/ml iodine Q9951 concentration, per ml. per ml manual manual 1/1/2008 A9535 Methylene Blue, 1 ml per ml $ 4.27 $ 4.27 3/24/1998 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 mCi up to 40 A9526 mCi manual manual 1/1/2008 Q9957 Perflutren lipid microspheres per ml $ 62.61 $ 62.61 8/1/2008 A9699 Radiopharmaceutical, therapeutic, not otherwise classified manual manual 1/1/2008 A4641 Radipharmaceutical diagnostic, not otherwise classified manual manual 1/1/2008 A9555 Rubidium RB-82, diagnostic per study dose, up to 60mc $ 30,875.00 $ 30,875.00 1/1/2008 A9605 Samarium Sm-153 lexidronamm, therapeutic, per 50 mCi per 50 mCi $ 1,603.89 $ 1,603.89 12/1/2006 J2805 Sincalide 5mcg $ 55.37 $ 55.37 8/1/2008 A9563 Sodium phosphate P-31, therapeutic per mlc $ 316.37 $ 316.37 1/1/2008 A9600 Strontium Sr-89 chloride, therapeutic, per mCi per mCi $ 893.75 $ 893.75 1/1/2008 Supply of injectible contrast material for use in echocardiography, per A9700 study per study manual manual 1/1/2008 Technetium TC-99 apcitide, diagnostic, per study dose, up to 20 mCi per A9504 study dose up to 20 mCi manual manual 1/1/2008 Technetium TC-99 medronate, diagnostic, per study dose, up to 30 A9503 mCi per study dose up to 30 mCi $ 40.25 $ 40.25 1/1/2008 Technetium TC-99 sestamibi, diagnostic, per study dose up to 40 mCi per A9500 study dose up to 40 mCi $ 121.69 $ 121.69 1/1/2008 Technetium TC-99 tetrofosmin, diagnostic, per study dose up to 40 A9502 mCi per study dose up to 40 mCi $ 121.05 $ 121.05 1/1/2008 A9557 Technetium TC-99M bicisate, diagnostic per study dose, up to 25mlc $ 920.00 $ 920.00 1/1/2008 Technetium TC-99M depreotide, diagnostic, per study dose, up to 35 A9536 mlc per study dose, up to 35 mlc manual manual 1/1/2008 Technetium TC-99m desofenin, diagnostic, per study dose up to 15 mCi per A9510 study dose up to 15 mCi $ 28.18 $ 28.18 1/1/2008 Technetium TC-99M Exametazime labeled autologous white blood cells, A9569 diagnostic per study dose $ 1,836.22 $ 1,836.22 1/1/2008 Technetium TC-99m exametazime, diagnostic, per study dose, up to 25 A9521 mCi per study dose up to 25 mCi $ 721.85 $ 721.85 1/1/2008 Technetium TC-99M fanolesomab, diagnostic, per study dose, up to 25 A9566 mlc per study dose, up to 25 mlc manual manual 1/1/2008 Technetium TC-99M labeled red blood cells, diagnostic per study dose, up A9560 to 30mlc $ 95.24 $ 95.24 1/1/2008 Technetium TC-99M macroaggregated albumin, diagnostic per study dose, A9540 up to 10mlc $ 40.25 $ 40.25 1/1/2008

A9537 Technetium TC-99M mebrofenin, diagnostic per study dose, up to 15 mlc $ 68.02 $ 68.02 1/1/2008 A9562 Technetium TC-99M meriatide, diagnostic per study dose, up to 15mlc $ 258.94 $ 258.94 1/1/2008

A9561 Technetium TC-99M oxidronate, diagnostic per study dose, up to 30mlc $ 42.27 $ 42.27 1/1/2008

A9539 Technetium TC-99M penetetate, diagnostic per study dose, up to 25mlc $ 49.80 $ 49.80 1/1/2008 Technetium TC-99M pentetate, diagnostic, aerosol, per study dose, up to A9567 75 mCi per study dose up to 75 mCi $ 69.45 $ 69.45 1/1/2008 A9512 Technetium TC-99m pertechnetate, diagnostic, per mCi per mCi $ 12.52 $ 12.52 1/1/2008 Technetium TC-99M pyrophosphate, diagnostic, per study dose, up to25 A9538 mCi per study dose, up to 25 mCi $ 52.33 $ 52.33 1/1/2008 Technetium TC-99M sodium gluceptate, diagnostic per study dose, up to A9550 25mlc $ 74.96 $ 74.96 1/1/2008 A9551 Technetium TC-99M succimer, diagnostic per study dose, up to 10mlc $ 126.63 $ 126.63 1/1/2008 A9541 Technetium TC-99M sulfur colloid, diagnostic per study dose, up to 20mlc $ 53.91 $ 53.91 1/1/2008 Technetium TC-99M Teboroxime, Diagnostic, per study dose per study A9501 dose manual manual 1/1/2008 A9505 Thallium TI-201 thallus chloride, diagnostic, per mCi per mCi $ 63.00 $ 63.00 1/1/2008 A9558 Xenon Xe-133 gas, diagnostic, per 10 mCi per 10 mCi $ 43.56 $ 43.56 1/1/2008

A9543 Yttrium Y-90 ibritumomab tiuxetan, diagnostic per study dose, up to 40mlc $ 22,714.97 $ 22,714.97 3/18/2002

Vaccines Bacillus Calmette-Guerin Vaccine (BCG) for Tuberculosis, Live, for 90585 Percutaneous use $116.90 $116.90 8/1/2008

90723 Diphtheria, Tetanus TertussisHepatitis B and Polio, for Intramuscular use $75.34 $75.34 10/1/2007 Diphtheria, Tetanus Toxoids, and Acellular Pertussis Vaccine and 90721 Hemophilus Influenza B Vaccine (DtaP-Hib), for Intramuscular use $42.89 $42.89 10/1/2007 Hemophilus Influenza b Vaccine (HIB) PRP-OMP Conjugate (3 dose 90647 schedule), for Intramuscular use $20.41 $20.41 8/1/2008 Hemophilus Influenza b Vaccine (HIB), HBOC Conjugate (4 dose schedule) 90645 for intramuscular use $20.41 $20.41 8/1/2008 Hemophilus Influenza b Vaccine (HIB), PRP-T Conjugate (4 dose schedule), 90648 Intramuscular use $21.78 $21.78 8/1/2008 Hepatitis A and Hepatitis B Vaccine (HepA-HepB), Adult dosage, for 90636 Intramuscular use $92.84 $92.84 8/6/2007 90632 Hepatitis A Vaccine, Adult dosage, for Intramuscular use $45.81 $45.81 8/1/2008 90746 Hepatitis B Vaccine, Adult dosage, for Intramuscular use $57.26 $57.26 10/1/2007 Hepatitis B Vaccine, dialysis or immunosuppressed patient dosage (3 dose 90740 schedule), for intramuscular use $114.52 $114.52 10/1/2007 Hepatitis B Vaccine, Dialysis or Immunosuppressed Patient dosage (4 dose 90747 schedule), for Intramuscular use $114.52 $114.52 10/1/2007 Human Papilloma Virus (HPV) vaccine, types 6, 11, 16, 18, quadrivalent, 3 90649 dose schedule, for IM use (Gardasil), 0.5 ml $140.79 $140.79 1/31/2008 90660 Influenza Virus Vaccine, Live, for Intranasal us (FluMist) $22.03 $22.03 8/1/2008 Influenza Virus Vaccine, Split Virus, 3 years and above, for Intramuscular 90658 use $13.22 $13.22 8/1/2008 Influenza Virus Vaccine, Split Virus, preservative free, for use in 90656 individuals 3 years & older $17.37 $17.37 8/1/2008 90705 Measles Virus Vaccine, Live, for Subcutaneous use $16.76 $16.76 8/1/2008 Measles, Mumps, and Rubella Virus Vaccine (MMR), Live, for Subcutaneous 90707 use $42.55 $42.55 8/1/2008 Meningococcal conjugate vaccine, serogroups A, C, Y, W-135 (tetravalent) 90734 for IM use. $100.44 $100.44 10/1/2007

90733 Meningococcal Polysaccharide Vaccine (any group(s)), for Subcutaneous use $89.43 $89.43 10/1/2007 90704 Mumps Virus Vaccine, Live, for Subcutaneous use $21.91 $21.91 8/1/2008 Pneumococcal Polysaccharide Vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 yrs or older, for 90732 Subcutaneous or Intramuscular use $27.03 $27.03 10/1/2007 90713 Poliovirus Vaccine, Inactivated, (IPV), for Subcutaneous use $25.71 $25.71 8/1/2008 90675 Rabies Vaccine, for Intramuscular use $152.54 $152.54 8/1/2008 90706 Rubella Virus Vaccine, Live, for Subcutaneus use $18.75 $18.75 8/1/2008 Tetanus And Diptheria Toxoids, Preservative Free, For Use In 7 Years Or 90714 Older, for IM use $19.97 $19.97 8/1/2008 90703 Tetanus Toxoid Adsorbed, for Intramuscular use $21.47 $21.47 8/1/2008 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use 90715 in individuals 7 years or older, for IM use $32.81 $32.81 10/1/2007 90716 Varicella Virus Vaccine, Live for Subcutaneous use $72.44 $72.44 10/1/2007

Miscellaneous Dermal and epidermal tissue of human origin, with or without bioengineered or processed elements, with metabolically active element J7340 per sq cm $30.17 $30.17 8/1/2008 Dermal tissue of human orgin with or without other bioengineered or J7342 processed elements, with metabolically active elements per sq cm $36.71 $36.71 8/1/2008 J7307 Etonogesterel (Implanon), 68 mg implant $637.79 $637.79 8/1/2008 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg ***J7302 (Mirena) $527.30 $527.30 9/10/2007 J7300 Intrauterine copper contraceptive device, Paragard T380A $427.50 $427.50 1/1/2008

Providers should always bill their usual and customary charges. Please use the monthly NC Medicaid Bulletins for additions changes and deletion to this schedule.

*** indicated NDC required