Physician Drug Program Procedure Codes And Rates as of June 30, 2010 Type of ProcCode Modifier Service Description Facility Non-Facility (TOS) BIOLOGICALS ***J0129 3 Abatacept 10 mg, injection (Orencia) $18.02 $18.02 ***J7308 3 Aminolevulinic acid HCI for topical admin. 20% single unit dosage form (354 mg) $105.80 $105.80 (Levulan) ***J3590 3 Antithrombin (recombinant), 1 IU (ATryn) $2.20 $2.20 ***J3590 3 C1 Esterase Inhibitor (human), 10 units (Berinert) $35.91 $35.91 ***J0598 3 Injection, C1 esterase inhibitor (human), 10 units (Cinryze) $41.98 $41.98 ***J3590 3 Canakinumab, 180 mg vial (Ilaris) $1.02 $1.02 ***J0718 3 Certolizumab pegol, 1 mg, injection (Cimzia) $3.59 $3.59 ***J3590 3 Coagulation Factor VIII Complex/von Willebrand Factor (human), 1 IU (Wilate) $1.20 $1.20 ***J3590 3 Collagenase clostridium histolyticum, 0.9 mg (Xiaflex) $3,510.00 $3,510.00 ***J1300 3 Eculizumab, 10 mg, injection (Soliris) $170.04 $170.04 ***J1680 3 Human fibrinogen concentrate, 100 mg, injection (RiaSTAP) $94.56 $94.56 ***J3590 3 Golimumab, 0.5 ml/50 mg (Simponi) $1,701.00 $1,701.00 ***J3590 3 Human Thrombin Topical Protein, 1 IU (Evithrom) $0.12 $0.12 ***J3590 3 Human Topical Protein, 1 IU (Recothrom) $0.02 $0.02 ***J3590 3 Immune Globulin subcutaneous (human), 20% liquid, 100 mg (Hizentra) $13.12 $13.12 ***S0145 3 Peginterferon alfa-2a, 180 mcg/ml (Pegasys) $324.32 $324.32 ***S0146 3 Pegylated interferon alfa-2b, 10 mcg per 0.5 ml (Peg-Intron) $86.01 $86.01 ***J2724 3 Protein C concentrate, intravenous, human, 10 IU, injection (Ceprotin) $11.75 $11.75 ***J2778 3 Ranibizumab, 0.1 mg, injection (Lucentis) $390.62 $390.62 ***J2793 3 Rilonacept, 1 mg injection (Arcalyst) $5,205.06 $5,205.06 ***J3490 3 Tocilizumab, 10 mg (0.5 ml) (Actemra) $34.56 $34.56 ***J3590 3 Ustekinumab, 45 mg/0.5 ml (Stelara) $4,854.25 $4,854.25 ***J3590 3 Velaglucerase Alfa, 400 unit vial (VPRIV) $1,405.37 $1,405.37 ***J3490 3 17 Alpha Hydroxprogesterone Caporoate, Bulk powder, 250 mg (17P) $20.00 $20.00 DRUGS ***J0128 3 Abarelix, 10 mg, inj. (Plenaxis) $66.15 $66.15 ***J0130 3 Abciximab, 10mg, injection (ReoPro) $407.85 $407.85 ***J1120 3 Acetazolamide sodium, up to 500 mg, injection (Diamox) $16.08 $16.08 ***J0133 3 Acyclovir, 5 mg, injection (Zovirax) $0.02 $0.02 ***J0152 3 Adenosine, for diagnostic use, 30 mg, injection (Adenoscan) $65.72 $65.72 ***J0150 3 Adenosine,for therapeutic use, 6mg, injection (Adenocard) $12.39 $12.39 ***J0180 3 Agalsidase Beta, 1 mg, injection (Fabrazyme) $124.93 $124.93 ***P9047 3 Albumin (human), 25%, 50 ml, infusion $38.69 $38.69 ***P9041 3 Albumin (human), 5%, 50 ml, infusion $19.34 $19.34 ***J9015 3 Aldesleukin, per single use vial (Proleukin, etc) $739.83 $739.83 ***J0215 3 Alefacept, 0.5 mg, injection (Amevive) $25.70 $25.70 ***J9010 3 Alemtuzumab, 10 mg (Campath) $531.27 $531.27 ***J0205 3 Alglucerase, per 10 units, injection (Ceredase) $38.24 $38.24 ***J0220 3 Alglucosidase alfa, 10 mg, injection (Myozyme) $122.63 $122.63 ***J0256 3 Alpha 1-proteinase inhibitor-human, 10mg, injection (Prolastin) $3.53 $3.53 ***J2997 3 Alteplase recombinant, 1 mg, injection (Activase) $31.02 $31.02 ***J0207 3 Amifostine, 500mg, injection (Ethyol) $492.85 $492.85 ***J0278 3 Amikacin sulfate, 100 mg, injection (Amikin) $0.70 $0.70 ***J0280 3 Aminophylline, up to 250mg, injection $0.36 $0.36 ***J0300 3 Amobarbital, up to 125mg, injection (Amytal) $11.53 $11.53 ***J0285 3 Amphotericin B, 50 mg, injection (Amphocin) $11.55 $11.55 ***J0288 3 Amphotericin B cholesteryl sulfate complex, 10 mg, injection (Amphotec) $11.57 $11.57 ***J0287 3 Amphotericin B lipid complex, 10 mg, injection (Abelcet) $10.08 $10.08 ***J0289 3 Amphotericin B liposome, 10 mg, injection (Ambisome) $16.54 $16.54 ***J0290 3 Ampicillin sodium, 500mg, injection (Omnipen-N, Totacillin-N) $2.17 $2.17 ***J0295 3 Ampicillin sodium/sulbactam sodium, per 1.5g, injection (Unasyn) $4.24 $4.24 ***J7192 3 Factor VIII (antihemophilic factor, recombinant) per I.U. $1.04 $1.04 ***J7186 3 Antihemophilic factor VIII/von Willebrand factor complex (human), per factor VIII $0.83 $0.83 i.u., injection ***J7197 3 Antithrombin III (human), per IU (Throbate III, ATnativ) $1.84 $1.84 Page 1 of 24 Physician Drug Program Procedure Codes And Rates as of June 30, 2010 Type of ProcCode Modifier Service Description Facility Non-Facility (TOS) ***J0400 3 Aripiprazole, intramuscular, 0.25 mg, injection (Abilify) $0.28 $0.28 ***J9017 3 Arsenic trioxide, 1 mg (Trisenox) $33.24 $33.24 ***J9020 3 Asparaginase, 10,000 units (Elspar) $54.97 $54.97 ***J0461 3 Atropine sulfate, 0.01 mg, injection $0.04 $0.04 ***J9025 3 Azacitidine 1 mg (Vidaza) $4.32 $4.32 ***J0456 3 Azithromycin, 500mg, injection (Zithromax) $17.33 $17.33 ***Q0144 3 Azithromycin dihydrate, oral, capsules/powder, 1 gm (Zithromax, Zithromax Z-Pak) $20.96 $20.96 ***J0475 3 Baclofen, 10mg, injection (Lioresal) $183.99 $183.99 ***J3490 3 Baclofen Kit 2*5 ml amp, 10 mg (Lioresal) invoice required invoice required ***J3490 3 Baclofen Kit 4*5 ml amp, 10 mg (Lioresal) invoice required invoice required ***J0476 3 Baclofen, 50 mcg for intrathecal trial, injection (Lioresal) $67.25 $67.25 J9031 3 BCG live (intravesical), per installation (Tice BCG, Theracys) $109.66 $109.66 J9033 3 Bendamustine HCl, 1 mg, injection $17.94 $17.94 ***J0702 3 Betamethasone acetate and betamethasone sodium phosphate, per 3mg, injection $5.54 $5.54 (Celestone) ***J0704 3 Betamethasone sodium phosphate, per 4mg, injection (Betaject) $1.09 $1.09 ***J9035 3 Bevacizumab, 10 mg, injection (Avastin) $55.38 $55.38 ***J9040 3 Bleomycin sulfate, 15 units (Blenoxane) $27.98 $27.98 ***J9041 3 Bortezomib, 0.1 mg, inj. (Velcade) $33.19 $33.19 ***J0585 3 Botulinum toxin type A, per unit (Botox) $5.03 $5.03 ***J0587 3 Botulinum toxin type B, per 100 units (Myobloc) $8.40 $8.40 ***J0595 3 Butorphinol tartrate, 1 mg, injection (Stadol) $0.48 $0.48 ***J0636 3 Calcitriol, 0.1 mcg, injection (Calcijex) $0.41 $0.41 ***J0610 3 Calcium gluconate, per 10ml, injection (Kaleinate) $0.35 $0.35 ***J0620 3 Calcium glycerophosphate and calcium lactate, per 10ml, injection (Calphosan) $12.73 $12.73 ***J9045 3 Carboplatin, 50 mg (Paraplatin) $6.08 $6.08 ***J9050 3 Carmustine, 100 mg (BiCNU) $151.19 $151.19 ***J0690 3 Cefazolin Sodium, 500 mg, Injection (Ancef, Kefzol, Zoliicef) $0.64 $0.64 ***J0692 3 Cefepime HCL, 500 mg, injection (Maxipime) $6.51 $6.51 ***J0698 3 Cefotaxime Sodium, per g (Claforan) $4.14 $4.14 ***J0694 3 Cefoxitin Sodium, 1g, injection (Mefoxin) $7.90 $7.90 ***J0713 3 Ceftazidime, per 500 mg, injection (Fortaz, Tazidime) $3.35 $3.35 ***J0715 3 Ceftizoxime sodium, per 500mg, injection (Cefizox) $5.05 $5.05 ***J0696 3 Ceftriaxone Sodium, per 250mg, injection (Rocephin) $1.43 $1.43 ***J0697 3 Sterile Cefuroxime sodium, per 750mg, injection (Kefurox Zinacef) $3.32 $3.32 ***J9055 3 Cetuximab, 10 mg, injection (Erbitux) $48.02 $48.02 ***J0720 3 Chloramphenicol sodium succinate, up to 1g, injection (Chloromycetin) $17.72 $17.72 ***J1990 3 Chlordiazepoxide HCl, up to 100 mg, injection (Librium) $20.29 $20.29 ***J2400 3 Chloroprocaine HCl, per 30 ml, injection (Nesacaine) $12.26 $12.26 ***J1205 3 Chlorothiazide sodium, per 500 mg, injection (Diuril Sodium) $159.19 $159.19 ***J3230 3 Chlorpromazine HCl, up to 50 mg, injection (Thorazine) $3.10 $3.10 ***J0725 3 Chorionic Gonadotropin, per 1,000 USP units, injection (Novarei TM) $3.25 $3.25 ***J0740 3 Cidofovir, 375 mg, injection (Vistide) $735.05 $735.05 ***J0743 3 Cilastatin sodium imipenem, per 250mg, injection (Primaxin IM or IV) $13.77 $13.77 ***S0023 3 Cimetidine hydrochloride, 300 mg, injection (Tagamet) $0.59 $0.59 ***J0744 3 Ciprofloxacin for IV infusion, 200 mg, injection (Cipro) $5.15 $5.15 ***J9062 3 Cisplatin, 50 mg (Platinol AQ) $10.91 $10.91 ***J9060 3 Cisplatin, powder or solution, per 10 mg (Platinol AQ) $2.19 $2.19 ***J9065 3 Cladribine, per 1 mg, injection (Leustatin) $29.53 $29.53 ***J0735 3 Clonidine hydrochloride, 1mg, injection (Catapres) $53.99 $53.99 ***J0745 3 Codeine phosphate, per 30mg, injection $1.22 $1.22 ***J0760 3 Colchicine, per 1mg, injection $4.82 $4.82 ***J0770 3 Colistimethate Sodium, up to 150 mg, injection (Coly-Mycin M) $19.17 $19.17 ***J0800 3 Corticotropin, up to 40 units, injection (Acthar, ACTH) $2,270.88 $2,270.88 ***J0834 3 Cosyntropin, 0.25 injection (Cortrosyn) $87.91 $87.91 ***J0833 3 Cosyntropin, not otherwise specified, 0.25 mg, injection $63.06 $63.06 ***J9070 3 Cyclophosphamide, 100 mg (Cytoxan, Neosar) $1.80 $1.80 Page 2 of 24 Physician Drug Program Procedure Codes And Rates as of June 30, 2010 Type of ProcCode Modifier Service Description Facility Non-Facility (TOS) ***J9080 3 Cyclophosphamide, 200 mg (Cytoxan, Neosar) $3.61 $3.61 ***J9090 3 Cyclophosphamide, 500 mg (Cytoxan, Neosar) $9.02 $9.02 ***J9091 3 Cyclophosphamide, 1 g (Cytoxan, Neosar) $18.04 $18.04 ***J9092 3 Cyclophosphamide, 2 g (Cytoxan, Neosar) $36.09 $36.09 ***J9093 3 Cyclophosphamide, lyophilized, 100 mg (Cytoxan Lyophilized) $1.79 $1.79 ***J9096 3 Cyclophosphamide, lyophilized, 1 g (Cytoxan Lyophilized) $17.92 $17.92 ***J9097 3 Cyclophosphamide, lyophilized, 2 g (Cytoxan Lyophilized) $35.83 $35.83 ***J9094 3 Cyclophosphamide, lyophilized, 200 mg (Cytoxan Lyophilized) $3.59 $3.59 ***J9095 3 Cyclophosphamide, lyophilized, 500 mg (Cytaxan Lyophilized) $8.96 $8.96 ***J9100 3 Cytarabine, 100 mg (Cytosar-U) $1.16 $1.16 ***J9098 3 Cytarabine liposome, 10 mg (DepoCyt) $400.04 $400.04 ***J9110 3 Cytarabine, 500 mg (Cytosar-U) $5.80 $5.80 ***J7070 3 D-5-W, 1,000 cc, infusion $2.10 $2.10 ***J9130 3 Dacarbazine, 100 mg (DTIC- Dome) $4.43 $4.43