2005 Physicians Fee Schedule (PFS) for Related Drugs & Effective January 1, 2005 Note: Medicare drug & payment allowables will vary state to state. Please check with your local carrier for all rules rates and regulations. Below is a list of the 2005 HCPCS codes and descriptions, as well as two reference carriers and their published web site allowables as examples. Some carriers such as Empire pay carrier priced prodcuts like radiopharmaceuticals based on provider invoice cost.

http://www.cms.hhs.gov/physicians/pfs/ http://www.medicarenhic.com/providers/fees/injcarrierprice_0105.htm http://www.noridianmedicare.com/provider/updates/docs/radiopharmacuetical_pricing_2005.pdf 2005 Non Facility Participating 2005 Rate NORIDIAN-AK-AZ-CO-HI- IA-MN-NV-ND-OR-SD- HCPCS Short and Long Descriptions Trade Name NHIC-CA WA-WY Diagnostic imaging agent

Supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified. ICIC A4641 $0.00 Individual Consideration Satumomab pendetide per dose ONCOSCINT

Not Listed On Supply of satumomab pendetide, radiopharmaceutical Website contact ICIC A4642 diagnostic imaging agent, per dose carrier directly Individual Consideration Technetium TC 99m sestamibi CARDIOLITE/ MIRALUMA Supply of radiopharmaceutical diagnostic imaging agent, A9500 technetium Tc 99m sestamibi, per dose $121.70 $121.70 Technetium TC99M tetrofosmin MYOVIEW

Supply of radiopharmaceutical diagnostic imaging agent, A9502 technetium Tc 99m tetrofosmin, per unit dose $125.69 $125.69 Technetium TC 99m medronate MDP

Supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m, medronate, up to 30 millicurie A9503 $33.25 $33.25 Technetium Tc 99m apcitide ACUTECT

Supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m apcitide A9504 $475.00 $475.00 TI-201 per mCi THALLIUM 201

Supply of radiopharmaceutical diagnostic imaging agent, thallous chloride Tl- 201, per millicurie A9505 $33.23 $33.23 In-111 capromab pendetid, per dose PROSTASCINT

Supply of radiopharmaceutical diagnostic imaging agent, indium In-III capromab pendetide, per dose A9507 $2,192.13 $2,815.34 Iobenguane Sulfate I-131, per 0.5 mCi I-131 MIBG

Supply of radiopharmaceutical diagnostic imaging agent, A9508 iobenguane sulfate I-131, per 0.5 millicurie $495.65 $1,140.00 Technetium Tc-99m Disofenin DISIDA

Supply of radiopharmaceutical diagnostic imaging agent, A9510 technetium Tc 99m disofenin, per vial $57.00 $57.00 Technetium 99m Depreotide NEOTEC

Supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m, Depreotide, per millicurie A9511 $760.00 $760.00 Compliments of the SNM Physician Office MPFS Educational Materials 1 of 4 Revised 03/10/05 2005 Non Facility Participating 2005 Rate NORIDIAN-AK-AZ-CO-HI- IA-MN-NV-ND-OR-SD- HCPCS Short and Long Descriptions Trade Name NHIC-CA WA-WY Technetium Tc99m Pertechnatate, per mCi Straight Tech

Not Listed On Supply of radiopharmaceutical diagnostic imaging agent, Website contact A9512 technetium Tc 99m pertechnetate, per mci carrier directly $13.52 Technetium Tc99m Mebrofenin CHOLETEC

Supply of radiopharmaceutical diagnostic imaging agent, A9513 technetium Tc 99m mebrofenin, per mci $51.44 $43.31 Technetium Tc99m Pyrophosphate PYROLITE

Supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m pyrophosphate, per mci

A9514 $25.54 $43.70 Technetium Tc99m Pentetate Tc-99m DTPA

Supply of radiopharmaceutical diagnostic imaging agent, A9515 technetium Tc 99m pentetate, per mci $28.12 $28.12 I-123 Sodium Iodide Capsule Dx I-123 Capsules Supply of radiopharmaceutical diagnostic imaging agent, I- A9516 123 sodium iodide capsule, per 100 uci $65.03 $65.03 Th I131 so iodide cap mCi Rx I-131 Capsules Supply of radiopharmaceutical therapeutic imaging agent, Not Listed On Website contact A9517 I-131 sodium iodide capsule, per mci $164.81 carrier directly Technetium Tc99m Macroag Albu MAA

Supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m macroaggregated albumin, per mci A9519 $20.52 $18.00 Tc99m Sulfur Colloid SULFUR COLLOID (SC) Supply of radiopharmaceutical diagnostic imaging agent, A9520 technetium Tc 99m sulfur colloid, per mci $76.00 $71.25 Technetium 99m Exametazine CERETEC HMPAO Supply of radiopharmaceutical diagnostic imaging agent, Tc 99m exametazime, per dose A9521 $890.63 $296.88 Indium-111 Ibritumonomabtiuxetan Dx In-111 ZEVALIN Supply of radiopharmaceutical diagnostic imaging agent, indium 111 , per mci A9522 $2,769.63 $2,260.00 Yttrium-90 Ibritumonomabtiuxetan Rx Y-90 ZEVALIN Supply of radiopharmaceutical therapeutic imaging agent, yttrium 90 ibritumomab tiuxetan, per mci A9523 $23,976.91 $20,550.00 Iodinated I-131 albumin I-131 Albumin Supply of radiopharmaceutical diagnostic imaging agent, iodinated I-131serum albumin, 5 microcuries Not Listed On Website contact A9524 $53.39 carrier directly Ammonia N-13, per dose Not Listed On Supply of radiopharmaceutical diagnostic imaging agent, Website contact Not Listed On Website contact A9526 ammonia N-13, per dose N-13 carrier directly carrier directly Dx I-131 so iodide cap millic I-131 Dx caps per mCi Supply of radiopharmaceutical diagnostic imaging agent, I- Not Listed On Website contact A9528 131 sodium iodide capsule, per millicurie $27.47 carrier directly

Compliments of the SNM Physician Office MPFS Educational Materials 2 of 4 Revised 03/10/05 2005 Non Facility Participating 2005 Rate NORIDIAN-AK-AZ-CO-HI- IA-MN-NV-ND-OR-SD- HCPCS Short and Long Descriptions Trade Name NHIC-CA WA-WY Dx I-131 so iodide sol millic Dx I-131 sol per mCi Not Listed On Supply of radiopharmaceutical diagnostic imaging agent, I- Website contact Not Listed On Website contact A9529 131 sodium iodide solution, per millicurie carrier directly carrier directly Th I-131 so iodide sol millic Rx I-131 sol per mC Not Listed On Supply of radiopharmaceutical therapeutic agent, I-131 Website contact Not Listed On Website contact A9530 sodium iodide solution, per millicurie carrier directly carrier directly Dx I-131 so iodide microcurie Dx I-131 up to 100 uCi Not Listed On Supply of radiopharmaceutical diagnostic agent, I-131 Website contact Not Listed On Website contact A9531 sodium iodide, per microcurie (up to 100 microcuries) carrier directly carrier directly I-125 serum albumin micro Not Listed On Supply of radiopharmaceutical therapeutic agent, Website contact A9532 iodinated I-125, serum albumin, 5 microcuries carrier directly $21.90 I-131 diagnostic Dx BEXXAR

Supply of radiopharmaceutical diagnostic imaging agent, I- 131 tositumomab, per millicurie A9533 $2,565.00 $2,565.00 I-131 tositumomab therapeut Rx BEXXAR

Supply of radiopharmaceutical therapeutic imaging agent, I-131 tositumomab, per millicurie A9534 $22,230.00 $22,230.00 Supply of therapeutic radiopharmaceutical, strontium 89 Rx METASTRON A9600 chloride, per millicurie $963.42 $963.42 Supply of therapeutic radiopharmaceutical, samarium Sm- Rx QUADRAMET 153 lexidronamm, 50 millicuries

A9605 $1,020.00 $1,357.84 Supply of radiopharmaceutical therapeutic imaging agent, NOC Not Listed On not otherwise classified Website contact Not Listed On Website contact A9699 carrier directly carrier directly Injection, adenosine for therapeutic use, 6 mg (not to be ADENOCARD used to report any adenosine phosphate compounds, instead use A9270) Not Listed On Website contact J0150 $31.07 carrier directly Injection, adenosine, 90 mg (not to be used to report any adenosine phosphate compounds; instead use A9270) Not Listed On Website contact Not Listed On Website contact J0151 carrier directly carrier directly J0152 Adenosine injection, 30 mg Not Listed On Website contact $70.00 carrier directly J0280 Aminophyllin, up to 250mg Not Listed On Website contact $0.50 carrier directly J0460 Atropine sulfate injection, up to 0.3 mg Not Listed On Website contact $0.26 carrier directly J1120 Acetazolamide sodium injection, up to 500 mg Diamox Not Listed On Website contact $12.70 carrier directly J1160 Inj, digoxin, up to 0.5 mg Lanoxin Not Listed On Website contact $3.04 carrier directly Injection, dipyridamole, per 10 mg Persantine IV Not Listed On Website contact J1245 $1.93 carrier directly Injection, dobutamine HCI, per 250 mg Dobutrex Not Listed On Website contact J1250 $5.11 carrier directly J1610 Glucagon hydrochloride per 1MG Not Listed On Website contact $55.17 carrier directly J1642 Inj heparin sodium per 10 units (hep lock flush) Not Listed On Website contact $0.07 carrier directly J1800 Propranolol HCL injection, up to 1 mg Inderal Not Listed On Website contact $5.10 carrier directly J1940 Furosemide injection up to 20 mg Lasix Not Listed On Website contact $0.49 carrier directly J2270 Morphine sulfate injection, up to 10 mg Not Listed On Website contact $1.86 carrier directly J3240 Thyrotropin injection 0.9 mg n 1.1 mg vial Thryogen Not Listed On Website contact $699.60 carrier directly Compliments of the SNM Physician Office MPFS Educational Materials 3 of 4 Revised 03/10/05 2005 Non Facility Participating 2005 Rate NORIDIAN-AK-AZ-CO-HI- IA-MN-NV-ND-OR-SD- HCPCS Short and Long Descriptions Trade Name NHIC-CA WA-WY J3490 Drugs Unclassified injection NOC ICIC Individual Not Listed On Website contact Consideration carrier directly J7030 Normal saline solution infus (1000 CC) Not Listed On Website contact $1.23 carrier directly J7040 Normal saline solution infus (500ML=1) Not Listed On Website contact $0.05 carrier directly J7050 Normal saline solution infus (250 CC) Not Listed On Website contact $0.02 carrier directly J7051 Sterile/Saline Water up to 5 cc Not Listed On Website contact $0.01 carrier directly J9310 Rituximab, 100 mg RituXan Not Listed On Website contact $442.01 carrier directly Supply of radiopharmaceutical diagnostic imaging agent, Rb-82 ICIC ICIC rubidium RB-82, per dose Individual Individual Consideration Q3000 Consideration Supply of Radiopharmaceutical Diagnostic Imaging GALLIUM Agent, Gallium Ga 67, per mCi ICIC Individual Consideration Q3002 $64.08 Supply of Radiopharmaceutical Diagnostic Imaging NEUROLITE Agent, Technetium Tc99m Bicisate, per unit dose Q3003 $424.18 $424.18 Supply of Radiopharmaceutical Diagnostic Imaging Xenon Q3004 Agent, Xenon Xe-133, per 10 mCi $38.96 $38.96 Supply of Radiopharmaceutical Diagnostic Imaging MAG-3 Agent, Technetium Tc99m Mertiatide, per mCi $312.00 Q3005 $355.68 Supply of Radiopharmaceutical Diagnostic Imaging GLUCOSCAN ICIC Agent, Technetium Tc99m Glucepatate, per 5 mCi Q3006 $22.61 Individual Consideration Supply of Radiopharmaceutical Diagnostic Imaging Q3007 Agent, Sodium Phosphate P32, per mCi $117.52 $518.00 Supply of Radiopharmaceutical Diagnostic Imaging OCTREOSCAN Q3008 Agent,Indium 111-In Pentetreotide, per 3 mCi $1,417.02 $1,243.00 Supply of Radiopharmaceutical Diagnostic Imaging HDP Q3009 Agent, Technetium Tc99m Oxidronate, per mCi $20.52 $18.00 Supply of Radiopharmaceutical Diagnostic Imaging ULTRATAG or Cold Agent, Technetium Tc99m Labeled Red Blood Cells, per PYP + 99m Tc Code to be used for both mCi the invivo/invitro methods of tagging Red Blood Cells Q3010 $59.96 $52.60 Supply of Radiopharmaceutical Diagnostic Imaging Agent, Chromic Phosphate P32 Suspension, per mCi Q3011 $209.46 $2,756.00 Supply of Radiopharmaceutical Diagnostic Imaging Agent, Cyanocobalamin Cobalt Co57, per 0.5 mCi Not Listed On ICIC Website contact Individual Consideration Q3012 carrier directly Q4078 Ammonia N-13, per dose, Supply of radiopharmaceutical diagnostic imaging agent, Ammonia N-13, per dose.

NOTE: Although these files may list a drug and an associated Medicare allowed amount, it does not necessarily follow that the drug is covered by Medicare and, if covered, whether payment may be due in a particular circumstance. Medicare contractors separately determine whether a particular drug meets the program's requirements for coverage and, if covered, whether payment may be made for the drug in the circumstance under which it was furnished.

Compliments of the SNM Physician Office MPFS Educational Materials 4 of 4 Revised 03/10/05