HCPCS DESCRIPTION DOSE AMT DOSE UNIT PRICE J9190 5FU IVPB - GPH HOME INFUSION 10 mL $468.80 J0129 ABATACEPT (WITH MALTOSE) 250 mg $4,029.30 J8499 ACAMPROSATE,DELAYED RELEASE 333 mg $33.80 J8499 ACAMPROSATE,DELAYED RELEASE 666 mg $42.60 J0131 ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION 1000 mg $152.40 J8499 ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY 80 mg $5.80 J8499 ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY 80 mg $5.90 J8499 ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY 120 mg $6.20 J8499 ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY 120 mg $6.30 J8499 ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY 325 mg $8.20 J8499 ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY 325 mg $8.30 J8499 ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY 650 mg $11.40 J8499 ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY 650 mg $11.60 J8499 ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION 5 mL $32.40 J8499 ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION 325 mg $7.10 J8499 ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION 500 mg $8.20 J8499 ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION 650 mg $9.10 J8499 ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION 650 mg $9.20 J8499 ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION 31.25 mL $11.40 J8499 ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET 1 tablet $32.40 J8499 ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET 2 tablet $39.70 J8499 ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY 80 mg $6.40 J8499 ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY 120 mg $6.40 J8499 ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY 325 mg $6.40 J8499 ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY 650 mg $7.70 J8499 ACETAMINOPHEN 325 MG TABLET 325 mg $5.20 J8499 ACETAMINOPHEN 325 MG TABLET 500 mg $5.20 J8499 ACETAMINOPHEN 325 MG TABLET 650 mg $5.30 J8499 ACETAMINOPHEN 325 MG TABLET 1000 mg $5.40 J3490 ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY 80 mg $5.20 J3490 ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY 120 mg $5.30 J3490 ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105] 325 mg $5.80 J3490 ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105] 650 mg $6.50 J3490 ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105] 1 each $6.50 J1120 ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114] 1 each $269.00 J7608 ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122] 30 mL $66.10 J8499 ACETYLCYSTEINE 20 % (200 MG/ML) SOLN FOR ORAL USE [4080297] 1 mL $40.00 J0132 ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303] 30 mL $1,149.40 J7608 ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123] 4 mL $56.90 J7608 ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123] 30 mL $79.70 J7608 ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123] 30 mL $80.10 J3490 ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [115331] 240 mL $126.00 J3490 ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML ORAL SUSPENSION [115329] 120 mL $94.00 J3490 ACTIVATED CHARCOAL-SORBITOL 50 GRAM/240 ML ORAL SUSPENSION [81428] 240 mL $126.00 J8499 ACYCLOVIR 5 % TOPICAL CREAM [8967] 5 g $1,948.50 J8499 ADAPALENE 0.1 % TOPICAL GEL [16983] 45 g $2,128.90 J0153 ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330] 30 mL $1,118.80 J0153 ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION (OSM) [4081845] 2 mL $157.60 J0153 ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [8975] 2 mL $157.60 J9354 ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [164114] 1 each $10,799.00 J9354 ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [164115] 1 each $17,156.00 P9047 ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981] 50 mL $424.00 P9041 ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION [8982] 250 mL $179.00 J7613 ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION [31577] 3 mL $15.00 J7613 ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250] 3 mL $12.50 J7613 ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250] 3 mL $14.20 J7611 ALBUTEROL SULFATE CONCENTRATE 5 MG/ML(0.5 %) SOLUTION FOR NEBULIZATION [251] 20 mL $130.00 J3535 ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837] 6.7 g $297.10 J3535 ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837] 8 g $352.80 J3535 ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837] 8.5 g $374.20 J3535 ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837] 18 g $781.20 J8499 ALENDRONATE 10 MG TABLET [15661] 5 mg $21.30 J8499 ALENDRONATE 10 MG TABLET [15661] 10 mg $21.30 J8499 ALENDRONATE 10 MG TABLET [15661] 35 mg $47.70 J8499 ALENDRONATE 10 MG TABLET [15661] 70 mg $74.00 J8499 ALISKIREN 150 MG TABLET [78653] 150 mg $32.40 J8499 ALISKIREN 150 MG TABLET [78653] 300 mg $52.20 J8499 ALLOPURINOL 100 MG TABLET [310] 50 mg $14.00 J8499 ALLOPURINOL 100 MG TABLET [310] 100 mg $14.00 J8499 ALLOPURINOL 100 MG TABLET [310] 300 mg $16.90 J8499 ALLOPURINOL 100 MG TABLET [310] 50 mg $17.90 J8499 ALLOPURINOL 100 MG TABLET [310] 100 mg $17.90 J8499 ALLOPURINOL 100 MG TABLET [310] 300 mg $28.70 J0256 ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 1,000 MG INTRAVENOUS SOLUTION - MLH [7143657701] 1 each $2,020.00 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 0.25 mg $12.70 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 0.5 mg $12.80 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 1 mg $13.10 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 2 mg $13.70 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 0.25 mg $14.60 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 0.5 mg $16.70 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 0.5 mg $16.70 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 1 mg $20.90 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 2 mg $29.20 J8499 ALPRAZOLAM 0.25 MG TABLET [324] 2 mg $29.30 J8499 ALPRAZOLAM 0.5 MG TABLET [325] 0.25 mg $15.40 J8499 ALPRAZOLAM 0.5 MG TABLET [325] 0.5 mg $15.40 J8499 ALPRAZOLAM 0.5 MG TABLET [325] 1 mg $18.20 J8499 ALPRAZOLAM 0.5 MG TABLET [325] 2 mg $23.90 J3490 ALPRAZOLAM 1 MG TABLET [326] 0.25 mg $16.00 J3490 ALPRAZOLAM 1 MG TABLET [326] 0.5 mg $16.00 J3490 ALPRAZOLAM 1 MG TABLET [326] 1 mg $16.00 J3490 ALPRAZOLAM 1 MG TABLET [326] 2 mg $19.40 J0270 ALPROSTADIL 500 MCG/ML INJECTION SOLUTION [9001] 1 mL $526.90 J2997 ALTEPLASE 100 MG INTRAVENOUS SOLUTION [9002] 100 mg $31,781.30 J2997 ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310] 1 each $651.10 J8499 ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION 15 mL $5.50 J8499 ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION [24314] 30 mL $5.90 J3490 ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9015] 15 mL $15.40 J3490 ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9015] 30 mL $15.80 J8499 ALVIMOPAN 12 MG CAPSULE [91870] 12 mg $588.50 J8499 AMANTADINE HCL 100 MG CAPSULE [364] 100 mg $22.40 J8499 AMILORIDE 5 MG TABLET [391] 5 mg $16.40 J8499 AMILORIDE 5 MG TABLET [391] 10 mg $20.30 J8499 AMILORIDE 5 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [392] 1 tablet $16.40 J8499 AMILORIDE 5 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [392] 2 tablet $20.20 J8499 AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION [27928] 1000 mL $225.00 J8499 AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION [27933] 1000 mL $240.00 J8499 AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D10W INTRAVENOUS SOLUTION [27951] 1000 mL $225.00 J8499 AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D10W INTRAVENOUS SOLUTION [27951] 2000 mL $260.00 J8499 AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION [27964] 1000 mL $230.00 S0017 AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403] 20 mL $44.00 J8499 AMINOCAPROIC ACID 500 MG TABLET [9063] 1 g $159.20 J8499 AMINOCAPROIC ACID 500 MG TABLET [9063] 2 g $305.80 J8499 AMINOCAPROIC ACID 500 MG TABLET [9063] 3 g $452.50 J8499 AMINOCAPROIC ACID 500 MG TABLET [9063] 5 g $745.70 J0280 AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION [113386] 20 mL $74.20 J3490 AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV [150699] 100 mL $203.00 J3490 AMIODARONE 200 MG TABLET [9066] 100 mg $34.80 J3490 AMIODARONE 200 MG TABLET [9066] 200 mg $34.80 J3490 AMIODARONE 200 MG TABLET [9066] 400 mg $57.00 J3490 AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV [150700] 200 mL $185.60 J0282 AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION (OSM) [4081844] 150 mg $107.40 J0282 AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION (OSM) [4081844] 300 mg $114.70 J0282 AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [9065] 3 mL $107.40 J0282 AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [9065] 18 mL $144.00 J8499 AMITRIPTYLINE 10 MG TABLET [432] 10 mg $13.50 J8499 AMITRIPTYLINE 10 MG TABLET [432] 25 mg $15.40 J8499 AMITRIPTYLINE 10 MG TABLET [432] 50 mg $17.30 J8499 AMITRIPTYLINE 10 MG TABLET [432] 75 mg $20.20 J8499 AMITRIPTYLINE 10 MG TABLET [432] 100 mg $22.10 J8499 AMITRIPTYLINE 25 MG TABLET [435] 10 mg $14.50 J8499 AMITRIPTYLINE 25 MG TABLET [435] 25 mg $14.50 J8499 AMITRIPTYLINE 25 MG TABLET [435] 50 mg $16.40 J8499 AMITRIPTYLINE 25 MG TABLET [435] 75 mg $18.30 J8499 AMITRIPTYLINE 25 MG TABLET [435] 100 mg $20.20 J8499 AMITRIPTYLINE 50 MG TABLET [436] 10 mg $16.40 J8499 AMITRIPTYLINE 50 MG TABLET [436] 25 mg $16.40 J8499 AMITRIPTYLINE 50 MG TABLET [436] 50 mg $16.40 J8499 AMITRIPTYLINE 50 MG TABLET [436] 75 mg $20.20 J8499 AMITRIPTYLINE 50 MG TABLET [436] 100 mg $20.20 J8499 AMLODIPINE 10 MG TABLET [9069] 2.5 mg $19.30 J8499 AMLODIPINE 10 MG TABLET [9069] 5 mg $19.30 J8499 AMLODIPINE 10 MG TABLET [9069] 10 mg $19.30 J8499 AMLODIPINE 10 MG TABLET [9069] 2.5 mg $20.50 J8499 AMLODIPINE 10 MG TABLET [9069] 5 mg $20.50 J8499 AMLODIPINE 10 MG TABLET [9069] 10 mg $20.50 J3490 AMLODIPINE 2.5 MG TABLET [9070] 2.5 mg $17.70 J3490 AMLODIPINE 2.5 MG TABLET [9070] 5 mg $22.90 J3490 AMLODIPINE 2.5 MG TABLET [9070] 10 mg $33.20 J8499 AMLODIPINE 5 MG TABLET [9071] 2.5 mg $18.40 J8499 AMLODIPINE 5 MG TABLET [9071] 5 mg $18.40 J8499 AMLODIPINE 5 MG TABLET [9071] 10 mg $24.20 J8499 AMLODIPINE 5 MG-BENAZEPRIL 10 MG CAPSULE