Injections List of Codes (inject list) - DOC

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Injections: List of Codes                                                                                1
This section contains a comprehensive list of Medi-Cal reimbursable injection codes. For injection policy
information, refer to the Injections and Non-Injectable Drugs sections in this manual. For a list of the
most frequently used vaccines, refer to the Chemotherapy and Injections: Medi-Cal Vaccines Code List
sections in this manual.




2 – Injections: List of Codes
                                                                                                   July 2007
inject list
2
                                                                  Codes                                                                             Codes

A
Abatacept – 10 mg.................................................. J0129      Ampicillin Sodium, Parenteral –
Acetazolamide– 500 mg/vial .................................. X5500             500 mg (powder) piggyback units ........................X5584
Acetylcysteine – 100 mg ......................................... J0132        Ampicillin Sodium, Parenteral –
ACTH – 25 units dry powder/vial ............................ X5514              500 mg (powder) vials ..........................................X5586
ACTH (OR) Corticotropin – 80 units/ml .................. X5516                 Ampicillin Sodium, Parenteral –
ACTH (OR) Corticotropin – 40 units/ml .................. X5518                  250 mg (powder) vials ..........................................X5588
ACTH (OR) Corticotropin – 25 units/ml .................. X5520                 Ampicillin Sodium, Parenteral –
ACTH (OR) Corticotropin Gel – 80 units/ml............ X5516                     125 mg (powder) vials ..........................................X5550
ACTH (OR) Corticotropin Gel – 40 units/ml............ X5518                    Anabolin IM – 50 mg/ml (oil) ...................................X5598
Acyclovir – 5 mg ..................................................... J0133   Anabolin LA 100 – 100 mg/ml (oil) ..........................X5600
Adenocrest – 25 mg/ml .......................................... X5522         Ancef – 10 gm/100 ml vial ......................................X5602
Adenosine Phosphate – 25 mg/ml ......................... X5522                 Ancef – 1 gm/redi vial .............................................X5604
Adrenalin Chloride – 1 mg/ml ................................. X5528           Ancef – 1 gm/100 ml piggyback unit .......................X5606
Adrenalin Chloride Solution –                                                  Ancef – 1 gm/10 ml vial ..........................................X5608
 1:1,000 solution ................................................... X5530    Ancef – 500 mg/100 ml vial ....................................X5610
Adriamycin – 50 mg/vial w/250 mg lactose ............ X7500                    Ancef – 500 mg/10 ml vial ......................................X5612
Adriamycin – 10 mg/vial w/50 mg lactose .............. X7502                   Ancef – 250 mg/10 ml vial ......................................X5614
Aerosporin – 500,000 units .................................... X5534          Andro-Cyp 100 – 100 mg/ml ...................................X5618
Agalsidase beta – 1.0 mg ....................................... J0180         Andro/Fem – 50-2 mg/ml ........................................X5620
Akineton – 5 mg/ml ................................................ X5536      Android HCG – 1,000 units/ml ................................X5622
Aldesleukin – 22 million IU ..................................... X7632        Android-T – 100 mg/ml ...........................................X5626
Aldomet – 250 mg/5 ml .......................................... X5540         Android-T – 50 mg/ml .............................................X5628
Alglucosidase alfa – 10 mg ..................................... J0220         Androlone – 50 mg/ml (oil) .....................................X5598
Amcill-S – 1 gm (powder) vials............................... X5582            Androlone – 25 mg/ml (oil) .....................................X5630
Amcill-S – 500 mg (powder) vials ........................... X5586             Androlone-D 100 – 100 mg/ml (oil) .........................X5600
Amcill-S – 250 mg (powder) vials ........................... X5588             Androlone-D 50 – 50 mg/ml (oil) .............................X5632
Amcill-S – 125 mg (powder) vials ........................... X5550             Andronaq – 50 mg/ml .............................................X5628
Amcort – 40 mg/ml suspension.............................. X5552               Andronate 100 – 100 mg/ml ...................................X5618
A-Methapred – 40 mg/ml ....................................... X5554           Andryl – 200 mg/ml ................................................X5634
Amicar – 250 mg/ml ............................................... X5556       Anectine – 20 mg/ml...............................................X5636
Amifostine – 500 mg .............................................. X7642       Anidulafungin – 1 mg .............................................. J0348
Amikacin Sulfate – 1 gm/4 ml vial .......................... X5558             Antilirium – 1 mg/ml ................................................X5640
Amikacin Sulfate – 500 mg/2 ml vial ...................... X5562               Antispas – 10 mg/ml ...............................................X5642
Amikacin Sulfate – 100 mg/2 ml vial ...................... X5560               Antuitrin – 500 units/ml ...........................................X5644
Amikin – 1 gm/4 ml vial .......................................... X5558       AnzemetTM – 10 mg ................................................ J1260
Amikin – 500 mg/2 ml vial ...................................... X5562         A.P.L. Secules – 2,000 units/ml ..............................X5646
Amikin – 100 mg/2 ml vial ...................................... X5560         A.P.L. Secules – 1,000 units/ml ..............................X5622
Aminocaproic acid – 250 mg/ml ............................. X5556              A.P.L. Secules – 500 units/ml.................................X5644
Amitriptyline HCl – 10 mg/ml.................................. X5564           Apresoline – 20 mg/ml ............................................X5648
Amobarbital Sodium – 500 mg............................... X5566               Aqua Mephyton – 10 mg/ml ....................................X5650
Amphotericin B – 50 mg/vial .................................. X5572           Aqua Mephyton – 2 mg/ml ......................................X5652
Ampicillin Sodium, Parenteral –                                                Aquasol A Parenteral – 50,000 IU/ml.....................X5654
 2 gm (powder) piggyback units ............................ X5576              Aralen – 50 mg/ml ..................................................X5656
Ampicillin Sodium, Parenteral –                                                Aramine – 10 mg/ml (1%) (as Bitartrate) ................X5658
 2 gm (powder) vials ............................................. X5578       Ardefem 20 – 20 mg/ml ..........................................X5660
Ampicillin Sodium, Parenteral –                                                Ardefem 10 – 10 mg/ml ..........................................X5662
 1 gm (powder) piggyback units ............................ X5580              Arderone – 200 mg/ml ............................................X5634
Ampicillin Sodium, Parenteral –                                                Arderone – 100 mg/ml ............................................X5626
 1 gm (powder) vials ............................................. X5582       Ardiol 90/4 ..............................................................X5666




2 – Injections: List of Codes
                                                                                                                                             March 2009
                                                                                                                                        inject list
                                                                                                                                                     3
                                                                  Codes                                                                        Codes

Arfonad – 50 mg/ml ............................................... X5668       Berocca-C – 2 ml....................................................X5750
Aripiprazole – 0.25 mg ............................................ J0400      Berubigen – 1,000 mcg/ml ......................................X5752
Aristocort Parenteral Forte –                                                  Bestrone – 2 mg/ml ................................................X5756
 40 mg/ml suspension ........................................... X5552         Betalin 12 – 1,000 mcg/ml ......................................X5752
Aristopan – 20 mg/cc 5 cc ..................................... X5672          Betamethasone Acetate – 1 ml of 3mg/ml ..............X5876
Aristopan – 20 mg/cc 1 cc ..................................... X5674          Bethanechol Chloride – 5 mg/ml .............................X5762
Ar-Tet – 250 unit .................................................... X5676   Bevacizumab – 10 mg ............................................ J9035
Arthrolate – 50 mg/ml ............................................ X5678       Bicillin C-R 900/300 ................................................X5764
Ascorbic Acid – 500 mg/ml .................................... X5680           Bicillin C-R – 600,000 units.....................................X5766
Ascorbic Acid – 250 mg/ml .................................... X5682           Bicillin C-R – 300,000 units/ml ................................X5768
Asparaginase – 10,000 IU/10 ml vial...................... X7504                Bicillin L-A – 600,000 units/ml ................................X5770
Atropine Sulfate – up to 0.3 mg ...........................J0460               Bicillin L-A – 300,000 units/ml ................................X5772
Aurothioglucose – 50 mg/ml .................................. X5708            BICNU – 100 mg/vial ..............................................X7506
Avastin – 10 mg ...................................................... J9035   Biosone – 50 mg/ml suspension .............................X5774
Azacitidine – 1 mg/ml.............................................. J9025      Biperiden – 5 mg/ml ...............................................X5536
Azapen – 6 gm vials (powder) ................................ X5710            Blenoxane – 15 units/ampule .................................X7508
Azapen – 4 gm vials (powder) ................................ X5712            Bleomycin Sulfate – 15 units/ampule ......................X7508
Azapen – 1 gm vials (powder) ................................ X5714            Bortezomib – 0.1 mg .............................................. J9041
                                                                               Botulinum toxin A – per 1 unit ................................. J0585
                                                                               Botulinum toxin B – per 100 units ........................... J0587
                                                                               Brethine – 1 mg/ml .................................................X5776
B                                                                              Bretylium Tosylate – 50 mg/ml ...............................X5778
                                                                               Bretylol – 50 mg/ml.................................................X5778
Bacitracin, Intramuscular –                                                    Brevital Sodium – 5 gm ..........................................X5780
 50,000 unit vials ................................................... X5716   Brevital Sodium – 2.5 gm .......................................X5782
Bacitracin, Intramuscular –                                                    Brevital Sodium – 500 mg/5 ml ...............................X5784
 10,000 unit vials ................................................... X5718   Bricanyl Subcutaneous – 1 mg/ml ..........................X5776
Baclofen – 10 mg ................................................... X7108     Brompheniramine Maleate – 10 mg/ml ...................X5786
Bactocill – 4 gm (powder) vials .............................. X5720           Bupivacaine HCl – 0.75% .......................................X5790
Bactocill – 2 gm (powder) vials .............................. X5722           Bupivacaine HCl – 0.25% .......................................X5792
Bactocill – 1 gm (powder) vials .............................. X5724           Bupivacaine HCl – 0.5% .........................................X5794
Bactocill – 500 mg (powder) vials .......................... X5726             Butorphanol Tartrate – 2 mg/ml ..............................X5796
BAL In Oil – 100 mg/ml .......................................... X5728        Butorphanol Tartrate – 1 mg/ml ..............................X5798
Basiliximab – 20 mg................................................ J0480
BCG Vaccine, intravesicular ...................................90586
BCG Vaccine, percutaneous – 1 mg .......................90585
Benadryl – 50 mg/ml .............................................. X5738
Benadryl – 10 mg/ml .............................................. X5740
Benahist 50 – 50 mg/ml ......................................... X5738
Benahist 10 – 10 mg/ml ......................................... X5740
Bendamustine HCl – 1 mg ...................................... J9033
Bendylate 50 – 50 mg/ml ....................................... X5738
Bendylate 10 – 10 mg/ml ....................................... X5740
Benoject 50 – 50 mg/ml ......................................... X5738
Benoject 10 – 10 mg/ml ......................................... X5740
Bentyl – 10 mg/ml .................................................. X5642
Benztropine Mesylate – 1 mg/ml ............................ X5744




2 – Injections: List of Codes
                                                                                                                                      October 2009
inject list
4
                                                                  Codes                                                                            Codes

C
Caffeine and Sodium Benzoate – 250 mg/ml ....... X5800                         Celbenin – 6 gm vials (powder) ..............................X5710
Calciferol – 500,000 IU D2/ml ................................ X5802           Celbenin – 4 gm vials (powder) ..............................X5712
Calcimar – 400 MCR units ..................................... X5804           Celbenin – 2 gm piggyback units (powder) .............X5866
Calcitonin – 400 MCR units.................................... X5804           Celbenin – 1 gm piggyback units (powder) .............X5868
Calcitriol (Calcijex) – 1 MCG/ml ............................. X7510           Celbenin – 1 gm vials (powder) ..............................X5714
Calcitriol (Calcijex) – 2 MCG/ml ............................. X7512           Celestone Phosphate .............................................X5872
Calcium Disodium Edetate – 200 mg/ml ................ X5808                    Celestone Soluspan
Calcium Disodium Versenate – 200 mg/ml ............ X5808                        (Betamethasone Acetate) – 1 ml of 3mg/ml.........X5876
Capastat Sulfate – 1 gm/5 ml vial .......................... X5810             Cenocort A-40 – 40 mg/ml suspension ...................X5880
Capreomycin Sulfate – 1 gm/5 ml vial .................... X5810                Cenocort Forte – 40 mg/ml suspension ..................X5552
Carbocaine – 2% ................................................... X5818      Cenolate – 500 mg/ml ............................................X5882
Carbocaine – 1.5% ................................................ X5820       Centrogen – 2 mg/ml ..............................................X5756
Carbocaine – 1% ................................................... X5822      Cephalothin Sodium – 20 gm/200 ml vial ...............X5888
Carbocaine HCl – 3% ............................................ X5824         Cephalothin Sodium – 4 gm/50 ml vial ...................X5890
Carboplatin – 50 mg ............................................... J9045      Cephalothin Sodium – 2 gm/100 ml vial .................X5892
Carmustine (BCNU) – 100 mg/vial ......................... X7506                Cephalothin Sodium – 2 gm/20 ml vial ...................X5894
Cathflo Activase – 2 mg vial (powder) .................... X7122               Cephalothin Sodium – 1 gm/100 ml vial .................X5896
Cedilanid-D – 0.2 mg/ml ........................................ X5826         Cephalothin Sodium – 1 gm/10 ml vial ...................X5898
Cee-B-Complex – 30 ml ......................................... X5828          Cephradine – 2 gm/100 ml
Cefamandole Nafate – 500 mg/10 ml vial .............. X5840                     infusion containers ..............................................X5904
Cefamandole Nafate – 2 gm/100 ml vial ................ X5842                   Cephradine – 1 gm/vial ...........................................X5906
Cefamandole Nafate – 2 gm/20 ml vial .................. X5844                  Cephradine – 500 mg/vial .......................................X5908
Cefamandole Nafate – 1 gm/100 ml vial ................ X5846                   Cephradine – 250 mg/vial .......................................X5910
Cefamandole Nafate – 1 gm/10 ml vial .................. X5848                  Certolizumab Pegol – 1 mg ................................... C9249
Cefazolin Sodium – 10 gm/100 ml vial ................... X5602                 Cerubidine – 20 mg/vial unit ...................................X7514
Cefazolin Sodium – 1 gm/redi vial .......................... X5604             Cetuximab – 10 mg ................................................ J9055
Cefazolin Sodium – 1 gm/10 ml vial ....................... X5608               Cevalin – 500 mg/ml ...............................................X5680
Cefazolin Sodium – 1 gm/100 ml                                                 Cevita – 250 mg/ml ................................................X5912
 piggyback unit ...................................................... X5606   Chlor-100................................................................X5914
Cefazolin Sodium – 500 mg/10 ml vial .................. X5612                  Chloramphenicol –
Cefazolin Sodium – 500 mg/100 ml vial ................. X5610                   1 gm vial as dry powder ........................................X5922
Cefazolin Sodium – 250 mg/10 ml vial ................... X5614                 Chlorazine – 25 mg/ml............................................X5918
Cefotaxime Sodium – 2 gm .................................... X7027            Chlordiazedoxide – 100 mg/5 ml ............................X5920
Cefotaxime Sodium – 1 gm .................................... X7026            Chloromycetin Sodium Succinate –
Cefotaxime Sodium – 0.5 gm ................................. X7025              1 gm vial as dry powder ........................................X5922
Cefoxitin Sodium – 2 gm vial ................................. X5854           Chlorophen – 10 mg/ml ..........................................X5932
Cefoxitin Sodium – 1 gm vial ................................. X5856           Chloroprocaine HCl – 3% .......................................X5924
Ceftriaxone Sodium – 250 mg/vial ..........................J0696               Chloroprocaine HCl – 2% .......................................X5926
                                                                               Chloroprocaine HCl – 1% .......................................X5928
                                                                               Chloroquine HCl – 50 mg/ml...................................X5656
                                                                               Chlorothiazide – 500 mg/20 ml ...............................X5930
                                                                               Chlorpheniramine Maleate – 100 mg/ml .................X5914
                                                                               Chlorpheniramine Maleate – 10 mg/ml ...................X5932
                                                                               Chlor-Pro – 100 mg/ml ...........................................X5914
                                                                               Chlor-Pro – 10 mg ..................................................X5932
                                                                               Chlorpromazine HCl – 25 mg/ml .............................X5918
                                                                               Chlorprothixene – 12.5 mg/ml .................................X5934
                                                                               Chlor-Trimeton – 100 mg/ml ...................................X5914
                                                                               Chlor-Trimeton – 10 mg/ml .....................................X5932




2 – Injections: List of Codes
                                                                                                                                         October 2009
                                                                                                                                                      inject list
                                                                                                                                                                     5
                                                                      Codes                                                                                   Codes

Cholera Vaccine – 1.5 ml ........................................90725             Cryptenamine Acetates – 260 CSR/ml ...................X5992
Chorex – 1,000 units/ml ......................................... X5622            Crysti-12 – 1,000 mcg/ml........................................X5752
Chorex – 500 units/ml ............................................ X5644           Cyanocobalamin Crystalline –
Chorionic Gonadotropin (HCG) –                                                      1,000 mcg/ml .......................................................X5752
 2,000 units/ml...................................................... X5646        Cyclophosphamide –
Chorionic Gonadotropin (HCG) –                                                      500 mg/30 ml vials ...............................................X7522
 1,000 units/ml...................................................... X5622        Cyclophosphamide – 200 mg/2 ml vials .................X7524
Chorionic Gonadotropin (HCG) –                                                     Cyclophosphamide – 100 mg/10 ml vials ...............X7526
 500 units/ml ........................................................ X5644       Cytarabine (Cytosine Arabinoside,
Chromium Cr-51 Sodium Chromate, 250 µCi ....... A9553                               ARA-C) – 500 mg vials ........................................X7528
Chromium phosphate P-32 suspension, 1 mCi ...... A9564                             Cytarabine (Cytosine Arabinoside,
Cidofovir – 375 mg/5 ml vial ................................... X7434              ARA-C) – 100 mg vials ........................................X7530
Cino 40 .................................................................. X5552   Cytosar – 500 mg vials ...........................................X7528
Cisplatin – 50 mg .....................................................J9062       Cytosar – 100 mg vials ...........................................X7530
Citanest HCl – 4% w/1:200,000 Epinephrine.......... X5942                          Cytoxan – 500 mg/30 ml vials .................................X7522
Citanest HCl – 4% ................................................. X5944          Cytoxan – 200 mg/20 ml vials .................................X7524
Cleocin Phosphate – 600 mg/                                                        Cytoxan – 100 mg/10 ml vials .................................X7526
 4 ml ampules ...................................................... X5956
Cleocin Phosphate – 300 mg/
 2 ml ampules ...................................................... X5958
Clindamycin – 600 mg                                                               D
 (as phosphate)/4 ml ampules .............................. X5956
Clindamycin – 300 mg                                                               Dacarbazine (DTIC) – 200 mg/20 ml vial ................X7532
 (as phosphate)/2 ml ampules .............................. X5958                  Dactinomycin (Actinomycin D) –
Clofarabine – 1 mg ................................................. J9027          0.5 mg/3 ml vial ...................................................X7520
Clonidine hydrochloride – 1 mg/ml ......................... X7488                  Daptomycin, 1 mg ................................................................J0878
Cobalasine – 25 mg/ml .......................................... X5522             Darbepoetin alfa (ESRD) – 1 mcg .......................... J0882
Cobalt Co-57/58, cyanocobalamin – 1 µCi ............. A9546                        Darbepoetin alfa (non-ESRD) ................................. J0881
Cobalt Co-57 cyanocobalamin (oral) – 1 µCi .......... A9559                        D-Diol – 50-2 mg/ml ...............................................X5620
Cobex 1,000 .......................................................... X5752       Decadron-LA – 8 mg/ml suspension .......................X6008
Codeine Phosphate – 60 mg/ml ............................. X5960                   Decadron Phosphate – 24 mg/ml ...........................X6002
Codeine Phosphate – 30 mg/ml ............................. X5962                   Decadron Phosphate – 4 mg/ml .............................X6004
Cogentin – 1 mg/ml................................................ X5744           Decadron w/Xylocaine ............................................X6006
Colchicine – 1 mg/2 ml .......................................... X5964            Deca-Durabolin – 100 mg/ml (oil) ...........................X5600
Colistimethate Sodium –                                                            Deca-Durabolin – 50 mg/ml (oil) .............................X5632
 150 mg Colistin/vial ............................................. X5966          Decameth L.A. – 8 mg/ml suspension ....................X6008
Coly-Mycin M –                                                                     Decitabine – 1 mg .................................................. J0894
 150 mg Colistin/vial ............................................. X5966          De-Comberol – 50-2 mg/ml ....................................X5620
Compazine – 5 mg/ml ............................................ X5970             Deferoxamine Mesylate –
Conjugated Estrogens – 25 mg.............................. X5972                    500 mg/ampule .....................................................X6012
Cortef – 50 mg/ml .................................................. X5980         Deksone – 4 mg/ml solution ...................................X6004
Cortef Acetate – 50 mg/ml suspension .................. X5774                      Deladumone – 90-4 mg/ml .....................................X5666
Corticorelin ovine triflutate – 1 mcg ......................... J0795              Delatestryl – 200 mg/ml ..........................................X5634
Cortigel 80 – 80 units/ml ........................................ X5516           Delcort-E – 25 mg/ml ..............................................X6014
Cortigel 40 – 40 units/ml ........................................ X5518           Delestrogen – 40 mg/ml .........................................X6018
Cortisone Acetate – 50 mg/ml................................ X5984                 Delestrogen – 20 mg/ml .........................................X5660
Cortone Acetate – 50 mg/ml .................................. X5984                Delestrogen – 10 mg/ml .........................................X5662
Cortril Acetate – 25 mg/ml suspension .................. X5988                     Demerol HCl – 100 mg/ml ......................................X6020
Cortrophin Gel – 80 units/ml .................................. X5516              Demerol HCl – 75 mg/ml ........................................X6022
Cortrophin Gel – 40 units/ml .................................. X5518              Demerol HCl – 50 mg/ml ........................................X6024
Cosmegen – 0.5-3 mg/ml vial ................................ X7520                 Demerol HCl – 25 mg/ml ........................................X6026




2 – Injections: List of Codes
                                                                                                                                                   January 2010
inject list
6
                                                                    Codes                                                                       Codes

Denileukin Diftitox – 300 mcg.................................. J9160            Dioval – 10 mg/ml...................................................X5662
Depo-Estradiol Cypionate – 5 mg/ml...................... X6030                   Dioval 40 – 40 mg/ml ..............................................X6018
Depogen – 5 mg/ml ............................................... X6030          Dioval XX – 20 mg/ml .............................................X5660
Depo-Medrol – 80 mg/ml suspension..................... X6036                     Diphenhydramine HCl – 50 mg/ml ..........................X5738
Depo-Medrol – 40 mg/ml suspension..................... X6038                     Diphenhydramine HCl – 10 mg/ml ..........................X5740
Depo-Medrol – 20 mg/ml ....................................... X6040             Diphtheria, tetanus toxoid (DT) –
Depo-Provera –                                                                    for younger than 7 years of age ........................... 90702
 400 mg/ml 10 ml vial, per ml .............................. X6046               Diphtheria, tetanus toxoid
Depo-Provera –                                                                    and acellular pertussis (DTaP) –
 400 mg/ml 2.5 ml vial, per ml .............................. X6048               under 7 years of age ............................................ 90700
Depo-Provera C – 150 mg/ml 1 ml vial .................. X6051                    Diphtheria, tetanus toxoids
Depotest – 100 mg/ml............................................ X5618            and whole cell pertussis (DTP) ............................ 90701
Depo-Testadiol – 50-2 mg/ml ................................. X5620              Diphtheria, tetanus toxoids and whole cell pertussis
Depotestogen – 50-2 mg/ml ................................... X5620               and H. Influenza b vaccine (DTP-Hib) .................. 90720
Depo-Testosterone – 100 mg/ml............................ X5618                  Diphtheria, tetanus toxoids and acellular pertussis
Desferal Mesylate – 500 mg/ampule ...................... X6012                    and H. Influenza b vaccine (DtaP-Hib) ................. 90721
Deslanoside (Desacetyl-Lanatosidec) –                                            Diphtheria, tetanus toxoids, acellular pertussis vaccine,
 0.2 mg/ml. ........................................................... X5826     Hepatitis B, and poliovirus vaccine,
D-Est 5 – 5 mg/ml ................................................. X6030         inactivated (DtaP-HepB-IPV) ............................... 90723
Dexacen 4 ............................................................ X6004     Diptheria Toxoid, Adsorbed ................................... 90719
Dexacen LA-8 ........................................................ X6008      Disodium Edetate – 150 mg/ml ..............................X6106
Dexamethasone (as acetate) –                                                     Di-Spaz – 10 mg/ml ................................................X5642
 8 mg/ml suspension ............................................ X6008           Ditate – 90-4 mg/ml ................................................X5666
Dexamethasone Sodium Phosphate –                                                 Diuril – 500 mg/20 ml .............................................X5930
 4 mg/ml ............................................................... X6004   D-Med – 80 mg/ml suspension ...............................X6036
Dexasone – 4 mg/ml .............................................. X6004          D-Med – 40 mg/ml suspension ...............................X6038
Dexasone-LA – 8 mg/ml ........................................ X6008             Dobutamine – 250 mg (as HCl) ..............................X6108
Dexon – 4 mg/ml.................................................... X6004        Dobutrex – 250 mg (as HCl) ...................................X6108
Dexpanthenol – 250 mg/ml .................................... X6060              Docetaxel – 20 mg..................................................X7638
Dezone – 4 mg/ml solution .................................... X6004             Dodex – 1,000 mcg/ml............................................X5752
D.H.E. 45 – 1 mg/ml .............................................. X6062         Dolasetron – 10 mg ................................................ J1260
Diamox – 500 mg/vial ............................................ X5500          Dolophine HCl – 10 mg/ml ......................................X6110
Diazepam – 5 mg/ml .............................................. X6064          Dopamine HCl – 40 mg/ml ..................................... J1265
Diazoxide – 300 mg/20 ml ..................................... X6070             Dopram – 20 mg/ml ................................................X6114
Dibent – 10 mg/ml ................................................. X5642        Doripenem – 10 mg ................................................ J1267
Dicyclomine HCl – 10 mg/ml .................................. X5642              Dornase alfa – 1 mg ............................................... J7639
Diethylstilbesterol Diphosphate –                                                Doxapram HCl – 20 mg/ml .....................................X6114
 0.25 gm (as sodium salt)/5 ml ampule ................ X7536                     Doxercalciferol – 1 mcg ...................................... J1270
Digoxin – 0.25 mg/ml ............................................. X6080         Doxorubicin HCl – 50 mg/vial w/250 mg lactose .....X7500
Digoxin – 0.1 mg/ml ............................................... X6082        Doxorubicin HCl – 10 mg/vial w/50 mg lactose .......X7502
Dihydroergotamine Mesylate – 1 mg/ml ................. X6062                     Doxorubicin HCl liposome – 10 mg......................... J9001
Dilantin – 50 mg/ml ................................................ X6084       Doxycycline – 100 mg (as hyclate)/vial ...................X6122
Dilaudid – 4 mg/ml ................................................. X6086       Droperidol – 2.5 mg/ml ...........................................X6126
Dilaudid – 2 mg/ml ................................................. X6090       Dtic-Dome – 200 mg/20 ml vial...............................X7532
Dilaudid – 1 mg/ml ................................................. X6092
Dimercaprol – 100 mg/ml ....................................... X5728
Dimetan-Ten – 100 mg/ml ..................................... X5786




2 – Injections: List of Codes
                                                                                                                                      February 2010
                                                                                                                                             inject list
                                                                                                                                                          7
                                                                   Codes                                                                            Codes

Duo-Cyp – 50-2 mg/ml ........................................... X5620          Estradiol In Oil – 5 mg/ml .......................................X6030
Duogen L.A. 90/4 ................................................... X5666      Estradiol L.A. – 40 mg/ml .......................................X6018
Duoval-P.A. ........................................................... X5666   Estradiol Valerate In Oil – 40 mg/ml .......................X6018
Durabolin – 50 mg/ml (oil) ...................................... X5598         Estradiol Valerate In Oil – 20 mg/ml .......................X5660
Durabolin – 25 mg/ml (oil) ...................................... X5630         Estradiol Valerate In Oil – 10 mg/ml .......................X5662
Duracillin A.S. – 600,000 units/unit dose................ X6136                 Estradurin – 40 mg w/2 cc diluent ..........................X7540
Duraestrin – 5 mg/ml ............................................. X6030        Estratab 40 .............................................................X6018
Duragen 40 ............................................................ X6018   Estratab 20 .............................................................X5660
Duragen 20 ............................................................ X5660   Estratab – 10 mg/ml ...............................................X5662
Duragen – 10 mg/ml .............................................. X5662         Estratest – 50-2 mg/ml ...........................................X5620
Dura-Meth – 40 mg/ml suspension ........................ X6038                  Estra-Testrin – 90-4 mg/ml .....................................X5666
Duranest – 1.5% .................................................... X6138      Estraval – 10 mg/ml................................................X5662
Duranest – 1% ....................................................... X6140     Estraval – 4X ..........................................................X6018
Duratest – 100 mg/ml ............................................ X5618         Estraval – 2X ..........................................................X5660
Duratestrin – 50-2 mg/ml ....................................... X5620          Estro-Cyp – 5 mg/ml ...............................................X6030
                                                                                Estrogenic Substance Aqueous – 2 mg/ml .............X5756
                                                                                Estroject-L.A. ..........................................................X6030
                                                                                Estrolin – 2 mg/ml ..................................................X5756
E                                                                               Estrone – 10 mg/ml ................................................X5662
                                                                                Estrone Aqueous Solution – 5 mg/ml .....................X6196
Eculizumab – 10 mg ............................................... J1300        Estrone Aqueous Solution – 2 mg/ml .....................X6198
Edrophonium Chloride – 10mg/ml .......................... X6146                 Estronol (Modified) Femogen
Elavil HCl – 10 mg/ml ............................................ X5564         Aqueous – 2 mg/ml ..............................................X5756
Eliotts’ B Solution – 1 ml ......................................... J9175      Ethacrynic Acid – 50 mg/vial ..................................X6204
E-Lonate – 5 mg/ml ............................................... X6030        Etidocaine HCl – 1.5%............................................X6138
Elspar – 10,000 IU/10 ml vial ................................. X7504           Etidocaine HCl – 1%...............................................X6140
Endrate – 150 mg/ml ............................................. X6106         Etoposide – 20 mg/ml .............................................X7542
Ephedrine Sulfate – 50 mg/ml                                                    Euflexxa – per dose ................................................ J7323
 1 ml ampules ....................................................... X6158     Everone – 200 mg/ml .............................................X5634
Ephedrine Sulfate – 25 mg/ml                                                    Everone – 100 mg/ml .............................................X5626
 1 ml ampules ....................................................... X6160
Epinephrine HCl – 1 mg/ml .................................... X5528
Epinephrine HCl – 0.1 mg/ml ................................. X6164
Epinephrine, Parenteral –
 1:1,000 solution ................................................... X5530
Epinephrine, Parenteral –
 1:200 suspension................................................. X6166
Epirubicin (Ellence) – 50 mg/25 ml ........................ X7646
Epoetin alfa, 1000 units (for ESRD on dialysis) ....... J0886
Epoetin alfa, 1000 units (for non-ESRD use) .......... J0885
Epogen (ESRD) – 1,000 units ................................. J0886
Epogen (non-ESRD) – 1,000 units .......................... J0885
Ergonovine Maleate – 0.2 mg/ml ........................... X6168
Ergotrate Maleate – 0.2 mg/ml ............................... X6168
Erythromycin I.V. – 1 gm
 (lactobionate)/30 ml vials ..................................... X6174
Erythromycin I.V. – 500 mg
 (as lactobionate)/20 ml vials ................................ X6178




2 – Injections: List of Codes
                                                                                                                                      September 2009
inject list
8
                                                                      Codes                                                                            Codes

F
Faslodex – 250 mg/ml .......................................... X7654              Gemcitabine – 200 mg ........................................... J9201
Femogen-Cyp – 5 mg/ml ....................................... X6030                Gentamicin Sulfate – 40 mg/ml ..............................X6240
Femogen-L.A. – 40 mg/ml ..................................... X6018                Gentamicin Sulfate – 10 mg/ml ..............................X6242
Femogen-L.A. – 20 mg/ml ..................................... X5660                Glucagon – 10 mg/10 ml ........................................X6252
Femogen-L.A. – 10 mg/ml ..................................... X5662                Glucagon – 1 mg/ml ...............................................X6254
Fentanyl – 0.05 mg/ml ........................................... X6206            Glycohyprolate – 0.2 mg/ml ....................................X6258
Fentanyl Citrate and Droperidol –                                                  Gold Sodium Thiomalate – 50 mg/ml .....................X6262
 0.05-2.5 mg ......................................................... X6208       Gold Sodium Thiomalate – 25 mg/ml .....................X6264
Fernisolone – 25 mg/ml ......................................... X6014             Gonadex – 1,000 units/ml .......................................X5622
Fernisone – 50 mg/ml suspension ......................... X5774                    Granisetron Injection – 1 mg/vial ............................X7104
Ferrlecit – 62.5 mg ................................................. X7496        Granisetron Tablets – 1 mg ....................................X7105
Filgrastim (Neupogen) – 300 mcg ........................... J1440                  Gravigen Aqueous – 2 mg/ml .................................X6198
Filgrastim (Neupogen) – 480 mcg ........................... J1441
Flaxedil – 20 mg/ml................................................ X6214
Flexon – 30 mg/ml ................................................. X6216
Floxuridine – 500 mg/5 ml vial ............................... X7544               H
Fludarabine – 50 mg .............................................. X7644
Fluorodeoxyglucose – 45 mCi ................................ A9552                 Haemophilus Influenzae b (Hib) HbOC ................... 90645
Fluorouracil – 500 mg/10 ml .................................. X7546               Haemophilus Influenzae b (Hib) PRP-D.................. 90646
Fluphenazine Decanoate – 25 mg/ml..................... X6220                       Haemophilus Influenzae b (Hib) PRP-OMP ............ 90647
Fluphenazine Enanthate – 25/mg/ml...................... X6220                      Haemophilus Influenzae b (Hib) PRP-T .................. 90648
Fluphenazine HCl – 2.5 mg/ml ............................... X6222                 Haldol – 5 mg/ml ....................................................X6274
Folic Acid – 5 mg/ml .............................................. X6226          Haloperidol – 5 mg/ml.............................................X6274
Follutein – 1,000 units/ml ....................................... X5622           Hectorol – 1 mcg .................................................... J1270
Folvite – 5 mg/ml ................................................... X6226        Hematran ............................................................... J1752
Fomepizole – 15 mg ............................................... J1451           Hemin injection – 1 mg ........................................... J1640
Fomivirsen – 0.25 ml vial ....................................... X7470            Heparin Lock Flush Solution –
Fosaprepitant – 1 mg .............................................. J1453           100 units/ml ..........................................................X6282
Foscarnet Sodium – 1000 mg ................................. J1455                 Heparin Lock Flush Solution –
Foygen – 2 mg/ml .................................................. X6198           10 units/ml ............................................................X6284
Foygen Aqueous – 2 mg/ml ................................... X5756                 Heparin Sodium Inj (USP) –
FUDR – 500 mg/5 ml vial ....................................... X7544               40,000 units/ml .....................................................X6286
Fulvestrant – 250 mg/ml ........................................ X7654             Heparin Sodium Inj (USP) –
Fungizone I.V. – 50 mg/vial ................................... X5572               20,000 units/ml .....................................................X6288
Furosemide – 10 mg/ml ......................................... X6228              Heparin Sodium Inj (USP) –
                                                                                    10,000 units/ml .....................................................X6296
                                                                                   Heparin Sodium Inj (USP) –
                                                                                    7,500 units/ml .......................................................X6298
G                                                                                  Heparin Sodium Inj (USP) –
                                                                                    5,000 units/ml .......................................................X6302
Gadolinium – not otherwise                                                         Heparin Sodium Inj (USP) –
  specified, per ml .................................................. A9579        5,000 units/0.5 ml .................................................X6304
Gadoteridol, (ProHance multipack),                                                 Heparin Sodium Inj (USP) –
 per ml .................................................................. A9576    2,500 units/ml .......................................................X6306
Gadobenate dimeglumine                                                             Heparin Sodium Inj (USP) –
 (MultiHance) per ml ............................................. A9577            1,000 units/ml .......................................................X6308
Gadobenate dimeglumine
 (MultiHance multipack), per ml ............................ A9578
Gadoxetate Disodium – per ml............................... C9246
Gallamine Triethiodide – 20 mg/ml ........................ X6214
Gallium Ga-67 Citrate – 1 mCi ............................... A9556
Galsulfase – 1 mg ................................................... J1458
Ganciclovir 4.5 mg, long-acting Implant .................. J7310
Ganphen – 50 mg/ml ............................................. X6236
Garamycin – 40 mg/ml........................................... X6240
Garamycin Pediatric – 10 mg/ml ............................ X6242




2 – Injections: List of Codes
                                                                                                                                            February 2010
                                                                                                                                              inject list
                                                                                                                                                           9
                                                                     Codes                                                                           Codes

Hepatitis A and Hepatitis B                                                       Hyparotin – 1.5 ml ..................................................X6346
 Combination Vaccine ...........................................90636             Hyperstat IV – 30 mg/20 ml ....................................X6070
Hepatitis A Vaccine (adult) – 1,440 units/ml............90632                     Hyrexin – 50 mg/ml.................................................X5738
Hepatitis A Vaccine                                                               Hyrexin – 10 mg/ml.................................................X5740
 (pediatric/adolescent) ...........................................90633
Hepatitis B Immune Globulin, 1 ml ..........................90371
Hepatitis B Immune Globulin, (Hepagam B)                                          I
 intramuscular – 0.5 ml .......................................... J1571
Hepatitis B Immune Globulin (Hepagam B)                                           Ibandronate Sodium (Boniva) – 1 mg ..................... J1740
 intravenous – 0.5 ml ............................................. J1573         Ibritumomab Tiuxetan (In-111), 5 mCi ................... A9542
Hepatitis B Vaccine, adolescent                                                   Ibritumomab Tiuxetan (Y-90), 40 mCi .................... A9543
 (2 dose schedule).................................................90743          Idursulfase – 1 mg .................................................. J1743
Hepatitis B Vaccine, adult dosage ..........................90746                 Ifosfamide – 100 mg ...............................................X7584
Hepatitis B Vaccine, dialysis or                                                  Ilopan – 250 mg/ml .................................................X6060
 immunosuppressed, per 40 mcg                                                     Imiglucerase – 1.0 u ............................................... J1785
 (3 dose schedule).................................................90740          Imipramine HCl – 25 mg/ml ....................................X6352
Hepatitis B Vaccine, dialysis or                                                  Immune Serum Globulin, for IM use,
 Immunosuppressed, per 40 mcg                                                        Human, 1 ml ........................................................ 90281
 (4 dose schedule).................................................90747          Immune Serum Globulin I.V., 1 gm ........................ 90283
Hepatitis B Vaccine/Haemophilus                                                   Inapsine – 2.5 mg/ml ..............................................X6126
 Influenzae b .........................................................90748      Inderal – 1 mg/ml....................................................X6354
Hepatitis B Vaccine, pediatric/adolescent                                         Indium In-111 Capromab Pendetide – 10 mCi ....... A9507
 (3 dose schedule).................................................90744          Indium In-111 Ibritumomab Tiuxetan – 5 mCi ........ A9542
Hep-Lock – 100 units/ml ........................................ X6282            Indium In-111 Oxyquinoline – 0.5 mCi ................... A9547
Hep-Lock – 10 units/ml .......................................... X6284           Indium In-111 Pentetate – 0.5 mCi ........................ A9548
Heprinar – 10,000 units/ml ..................................... X6296            Indium In-111 Pentetreotide – 6 mCi ..................... A9572
Heprinar – 5,000 units/ml ....................................... X6302           Infliximab – 10 mg .................................................. J1745
Heprinar – 1,000 units/ml ....................................... X6308           Influenza Virus Vaccine, preservative free
Hexadrol Phosphate – 10 mg/ml ............................ X6320                     (6 to 35 months of age) ........................................ 90655
Hexadrol Phosphate – 4 mg/ml .............................. X6004                 Influenza Virus Vaccine, preservative free
Histerone – 100 ..................................................... X6326          (3 years and older) ............................................... 90656
Histerone – 50 ....................................................... X5628      Influenza Virus Vaccine
Histrelin Acetate – 10 mcg ...................................... J1675              (6 to 35 months of age) ........................................ 90657
Histrelin Implant (Vantas) – 50 mg .......................... J9225               Influenza Virus Vaccine (3 years and older)............ 90658
H.P. Acthar Gel – 80 units/ml................................. X5516              Innovar – 0.05 mg/2.5 mg .......................................X6208
H.P. Acthar Gel – 40 units/ml................................. X5518              Insulin Injection – 100 units/ml ...............................X6366
Human Papilloma Virus Vaccine, for                                                Interferon Alfa-2a (Roferon A, Roche) –
 intramuscular use                                                                   1,000,000 IU ........................................................X7548
 19 through 26 years of age) .................................90649               Interferon Alfa-2b (Intron A, Schering) –
Human Papilloma virus (HPV) vaccine,                                                 1,000,000 IU ........................................................X7550
 types 16, 18, bivalent, 3 dose schedule, for                                     Interferon Alfa-N3 (Alferon N, Purdue
 intramuscular use, females                                                          Frederick) – 250,000 IU .......................................X7551
 10 through 25 years of age ..................................... 90650           Interleukin-2 – 22 million IU ....................................X7632
Humatrope – 1 mg ................................................. X7036          Intropin – 40 mg/ml................................................. J1265
Hyalgan – 2 ml ........................................................J7321      Iodine Iobenguane Sulfate – 0.5 mCi ..................... A9508
Hydeltra T.B.A. – 20 mg/ml suspension ................. X6328                     Iodine Iodinated Serum Albumin – 5 µCi ............... A9524
Hydeltrasol – 20 mg/ml solution ............................. X6330               Iodine Serum Albumin – 5 µCi ............................... A9532
Hydextran ............................................................... J1752   Iodine Sodium Iodide – 1 µCi ................................ A9531
Hydralazine HCl – 20 mg/ml .................................. X5648               Iodine Sodium Iodide Capsule(s) – 100 µCi........... A9516
Hydrocortisone – 50 mg/ml .................................... X5980              Iodine Sodium Iodide (diagnostic) – 1 mCi ............ A9528
Hydrocortisone – 25 mg/ml .................................... X6332              Iodine Sodium Iodide (therapeutic) – 1 mCi ........... A9517
Hydrocortisone Acetate –                                                          Iodine Sodium Iothalamate – 10 µCi ...................... A9554
 50 mg/ml suspension .......................................... X5774             Iodine Tositumomab – study dose ......................... A9544
Hydrocortisone Acetate –                                                          Iodine Tositumomab – treatment dose .................. A9545
 25 mg/ml suspension .......................................... X5988             Iprenol – 1:5,000 sol/1 ml .......................................X6408
Hydrocortisone Phosphate – 50 mg/ml .................. X6334                      Irinotecan (Camptosar) – 20 mg ............................. J9206
Hydromorphone HCl – 4 mg/ml.............................. X6086                   Iron-Based Magnetic Resonance Contrast
Hydromorphone HCl – 2 mg/ml.............................. X6090                      Agent – 1 ml ....................................................... Q9953
Hydromorphone HCl – 1 mg/ml.............................. X6092
Hydroxo-12 – 1,000 mcg/ml ................................... X5752
Hydroxyzine – 50 mg/ml ........................................ X6336



2 – Injections: List of Codes
                                                                                                                                          February 2010
inject list
10
                                                                      Codes                                                                           Codes

Iron Dextran – 50 mg .............................................. J1750          L
Isoniazid (Isonicotintic Acid
  Hydrazide) – 100mg/ml ....................................... X6410              L.A. Dezone – 8 mg/ml suspension ........................X6008
Isuprol – 1:5,000 solution ....................................... X6408           Lanoxin – 0.25 mg/ml .............................................X6080
Ixabepilone – 1 mg ................................................. J9207         Lanoxin – 0.1 mg/ml ...............................................X6082
                                                                                   Lanreotide acetate – 1 mg ...................................... J1930
J (no entry)                                                                       Largon – 20 mg/ml .................................................X6442
                                                                                   Laronidase – 0.1 mg ............................................... J1931
                                                                                   Lasix – 10 mg/ml ....................................................X6228
K                                                                                  L-Caine-E – 2% w/1:1,000,000 Epinephrine ...........X6444
                                                                                   Lepirudin – 50 mg ................................................... J1945
Kanamycin Sulfate – 1 gm/3 ml vials ..................... X6426                    Leucovorin Calcium – 50 mg .................................. J0640
Kanamycin Sulfate – 500 mg/2 ml vials ................. X6422                      Leuprolide acetate (for depot suspension)
Kanamycin Sulfate – 75 mg/2 ml vials ................... X6424                      per 7.50 mg .......................................................... J9217
Kantrex – 1 gm/3 ml vials....................................... X6426             Leuprolide acetate (for depot suspension)
Kantrex – 500 mg/2 ml vials ................................... X6422               per 3.75 mg .......................................................... J1950
Kantrex – 75 mg/2 ml vials..................................... X6424              Levarterenol (Norepinephrine) – 1 mg
Kaybovite 1,000 – 1,000 mcg/ml ............................ X5752                    (as batartrate) per ml ...........................................X6452
Keflin – 20 gm/200 ml vial ...................................... X5888            Levetiracetam – 10 mg ........................................... J1953
Keflin – 4 gm/50 ml vial.......................................... X5890           Levo-Dromoran – 2 mg/ml ......................................X6454
Keflin – 2 gm/100 ml vial ........................................ X5892           Levoid – 500 mcg/ml ..............................................X6456
Keflin – 2 gm/20 ml vial.......................................... X5894           Levophed – 1 mg (as batartrate) per ml ..................X6452
Keflin – 1 gm/100 ml vial ........................................ X5896           Levoprome – 20 mg/ml ...........................................X6458
Keflin – 1 gm/10 ml vial.......................................... X5898           Levorphanol Tartrate – 2 mg/ml ..............................X6454
Kefzol – 10 gm/100 ml vial ..................................... X5602             Levothyroxine – 500 mcg/ml ...................................X6456
Kefzol – 1 gm/redi vial ........................................... X5604          Levsin – 0.25 mg/ml ...............................................X6460
Kefzol – 1 gm/100 ml piggyback unit ..................... X5606                    Libigen – 1,000 units/ml..........................................X5622
Kefzol – 1 gm/10 ml vial ......................................... X5608           Librium – 100 mg/5 ml ............................................X5920
Kefzol – 500 mg/100 ml vial ................................... X5610              Lidocaine HCl – 20% (200 mg/ml) ..........................X6462
Kefzol – 500 mg/10 ml vial ..................................... X5612             Lidocaine HCl – 10% (100 mg/ml) ..........................X6464
Kefzol – 250 mg/10 ml vial ..................................... X5614             Lidocaine HCl – 5% w/7.5% Glucose .....................X6466
Kenalog 40 ............................................................ X5552      Lidocaine HCl – 2% (20 mg/ml) ..............................X6470
Kenalog 10 ............................................................ X6432      Lidocaine HCl – 1.5% .............................................X6478
Kestrin Aqueous – 2 mg/ml .................................... X5756               Lidocaine HCl – 0.5% .............................................X6490
Ketaject – 100 mg/ml ............................................. X6434           Lidocaine HCl – 1.5% w/7.5% Dextrose .................X6480
Ketaject – 50 mg/ml ............................................... X6436          Lidocaine HCl – 2% w/1:200,000 Epinephrine ........X6474
Ketaject – 10 mg/ml ............................................... X6438          Lidocaine HCl – 2% w/1:100,000 Epinephrine ........X6444
Ketalar – 100 mg/ml............................................... X6434           Lidocaine HCl – 2% w/1:50,000 Epinephrine ..........X6476
Ketalar – 50 mg/ml ................................................ X6436          Lidocaine HCl – 1.5% w/1:200,000 Epinephrine .....X6482
Ketalar – 10 mg/ml ................................................ X6438          Lidocaine HCl – 1% w/1:200,000 Epinephrine ........X6486
Ketamine – 100 mg/ml ........................................... X6434             Lidocaine HCl – 1% w/1:100,000 Epinephrine ........X6488
Ketamine – 50 mg/ml ............................................. X6436            Lidocaine HCl – 0.5% w/1:200,000 Epinephrine .....X6492
Ketamine – 10 mg/ml ............................................. X6438
Key-Pred 50 ........................................................... X6440
Key-Pred 25 ........................................................... X6014
Key-Pred SP – 20 mg/ml ....................................... X6330
K-Feron................................................................... J1752
Konakion – 10 mg/ml ............................................. X5650
Konakion – 2 mg/ml ............................................... X5652
K-Phen – 50 mg/ml ................................................ X6236




2 – Injections: List of Codes
                                                                                                                                              August 2009
                                                                                                                                           inject list
                                                                                                                                                      11
                                                                 Codes                                                                            Codes

Lidocaine HCl Without Preservatives –                                        M
 4% (40 mg/ml) ..................................................... X6494
Lidocaine HCl Without Preservatives –                                        Magnesium Sulfate – 50% ......................................X6512
 2% (20 mg/ml) ..................................................... X6470   Magnesium Sulfate – 12.5% ...................................X6514
Lidocaine HCl Without Preservatives –                                        Magnesium Sulfate – 10% ......................................X6516
 1% (10 mg/ml) ..................................................... X6496   Malogen Cyp – 100 mg/ml ......................................X5618
Lidopen Auto-Injector –                                                      Malogen L.A. – 200 mg/ml ......................................X5634
 10% (100 mg/ml) ................................................. X6464     Mandol – 2 gm/100 ml vial ......................................X5842
Lincocin – 300 mg/2 ml U-Ject............................... X6504           Mandol – 2 gm/20 ml vial ........................................X5844
Lincomycin – 300 mg/2 ml U-Ject .......................... X6504             Mandol – 1 gm/100 ml vial ......................................X5846
Lipo-Hepin – 40,000 units/ml ................................. X6286         Mandol – 1 gm/10 ml vial ........................................X5848
Lipo-Hepin – 20,000 units/ml ................................. X6288         Mandol – 500 mg/10 ml vial ....................................X5840
Lipo-Hepin – 10,000 units/ml ................................. X6296         Mannitol – 25% .......................................................X6520
Lipo-Hepin – 5,000 units/ml ................................... X6302        Mannitol – 20% .......................................................X6522
Lipo-Hepin – 5,000 units/0.5 ml ............................. X6304          Mannitol – 15% .......................................................X6524
Lipo-Hepin – 1,000 units/ml ................................... X6308        Mannitol – 10% .......................................................X6526
Liquaemin Sodium – 40,000 units/ml ..................... X6286               Mannitol – 5%.........................................................X6528
Liquaemin Sodium – 20,000 units/ml ..................... X6288               Marcaine – 0.75%...................................................X5790
Liquaemin Sodium – 10,000 units/ml ..................... X6296               Marcaine – 0.5% ....................................................X6530
Liquaemin Sodium – 5,000 units/ml ....................... X6302              Marcaine HCl – 0.25% ............................................X5792
Liquaemin Sodium – 1,000 units/ml ....................... X6308              Measles .................................................................. 90705
L-Myoscyamine Sulfate – 0.25 mg/ml .................... X6460                Measles, mumps, rubella (MMR) ............................ 90707
Low osmolar contrast material 100 – 199 mg/ml                                Measles, mumps, rubella, varicella (MMRV) ........... 90710
 iodine concentration – per ml ............................... Q9965         Measles, rubella ..................................................... 90708
Low osmolar contrast material 200 – 299 mg/ml                                Mechlorethamine HCl – 10 mg/20ml
 iodine concentration – per ml ............................... Q9966          triturated w/100 mg Sodium Chloride ....................X7552
Low osmolar contrast material 300 – 399 mg/ml                                Medralone-80 – 80 mg/ml suspension ....................X6036
 iodine concentration – per ml ............................... Q9967         Medralone-40 – 40 mg/ml .......................................X6038
Low osmolar contrast material –                                              Medroxyprogesterone Acetate –
 400 mg/ml iodine or greater ................................. Q9951          25 mg and estradiol cypionate 5 mg/0.5 ml ..........X7490
LTS – 500 mcg/ml ................................................. X6456     Medroxyprogesterone Acetate –
Luminal Sodium – 130 mg/ml ................................ X6506             400 mg/ml 10 ml vial per ml..................................X6046
Lunelle – Medroxyprogesterone Acetate –                                      Medroxyprogesterone Acetate –
 25 mg and estradiol cypionate 5 mg/0.5 ml.......... X7490                    400 mg/ml 2.5 ml vial per ml.................................X6048
Lyme Disease Vaccine ...........................................90665        Mefoxin – 2 gm vial.................................................X5854
                                                                             Mefoxin – 1 gm vial.................................................X5856
                                                                             Menadiol Sodium Diphosphate
                                                                              (K-4) – 37.5 mg/ml................................................X6532
                                                                             Menadiol Sodium Diphosphate
                                                                              (K-4) – 5 mg/ml ....................................................X6534
                                                                             Meningococcal polysaccharide vaccine,
                                                                               any groups ........................................................... 90733
                                                                             Meperidine HCl – 100 mg/ml ..................................X6020
                                                                             Meperidine HCl – 75 mg/ml ....................................X6022
                                                                             Meperidine HCl – 50 mg/ml ....................................X6024
                                                                             Meperidine HCl – 25 mg/ml ....................................X6026
                                                                             Mephentermine Sulfate – 30 mg/ml ........................X6550
                                                                             Mephentermine Sulfate – 15 mg/ml ........................X6552
                                                                             Mepivacaine HCl – 3% ...........................................X5824
                                                                             Mepivacaine HCl – 2% ...........................................X5818
                                                                             Mepivacaine HCl – 1.5% ........................................X5820
                                                                             Mepivacaine HCl – 1% ...........................................X5822
                                                                             Mepred 80 suspension ...........................................X6036
                                                                             Mepred 40 suspension ...........................................X6038
                                                                             Mesna – 100 mg/ml ................................................X7586
                                                                             Mesoridazine – 25 mg/ml .......................................X6556
                                                                             Mestinon Bromide – 5 mg/ml ..................................X6826




2 – Injections: List of Codes
                                                                                                                                              May 2009
inject list
12

                                                                     Codes                                                                             Codes

Metalone T.B.A. –                                                                 Meticortelone Acetate – 25 mg/ml ..........................X6014
 20 mg/ml suspension ........................................... X6328            Metocurine Ioxide – 2 mg/ml...................................X6582
Metaraminol – 10 mg/ml (1%)                                                       Metubine Iodide – 2 mg/ml .....................................X6582
 (as bitartrate) ....................................................... X5658    Micafungin sodium - 1 mg ...................................... J2248
Methadone HCl – 10 mg/ml ................................... X6110                Miconazole – 10 mg/ml...........................................X6588
Methergine – 0.2 mg/ml ......................................... X6566            Minocycline HCl (Minocin) –
Methicillin Sodium –                                                               100 mg/vial ...........................................................X6118
 6 gm vials (powder).............................................. X5710          Mithracin – 2.5 mg/vial w/100
Methicillin Sodium –                                                               mg/mannitol..........................................................X7564
 4 gm piggyback units (powder) ............................ X6558                 Mithramycin – 2.5 mg/vial w/100
Methicillin Sodium –                                                               mg/mannitol..........................................................X7564
 4 gm vials (powder).............................................. X5712          Mitomycin – 20 mg/vial ...........................................X7566
Methicillin Sodium – 2 gm piggyback                                               Mitomycin – 5 mg/vial .............................................X7568
 units (powder) ...................................................... X5866      Mitoxantrone – 5 mg ...............................................X7624
Methicillin Sodium – 1 gm piggyback                                               Monistat – 10 mg/ml ...............................................X6588
 units (powder) ...................................................... X5868      Morphine Sulfate – 100 mg..................................... J2271
Methicillin Sodium –                                                              Morphine Sulfate – up to 10 mg............................. J2270
 1 gm vials (powder).............................................. X5714          Morphine Sulfate – preservative-free sterile
Methocarbamol – 100 mg/ml ................................. X6560                  solution, 10 mg ................................................... J2275
Methohexital Sodium – 500 mg/5 ml ...................... X5784                    M-Prednisol 80 suspension ....................................X6036
Methohexital Sodium – 5 gm.................................. X5780                M-Prednisol 40 suspension ....................................X6038
Methohexital Sodium – 2.5 gm ............................... X5782                Mumps ................................................................... 90704
Methotrexate – 50 mg (sodium) vial for                                            Mustargen – 10 mg/20 ml triturated
 reconstitution ........................................................ J9260     w/100 mg sodium chloride ....................................X7552
Methotrexate – 50 mg/ml 2 ml vial                                                 Mutamycin – 20 mg/vial ..........................................X7566
 (sodium) ............................................................... J9260   Mutamycin – 5 mg/vial ............................................X7568
Methotrexate – 50 mg/vial ....................................... J9260           M.V.I. – 10 ml .........................................................X6598
Methotrimeprazine – 20 mg/ml............................... X6458                 M.V.I. Concentrate – 5 ml .......................................X6600
Methoxamine HCl – 20 mg/ml                                                        Mychel-S – 1 gm vial as dry powder .......................X5922
 1 ml ampules ....................................................... X6562       Mycifradin Sulfate – 500 mg vials ...........................X6504
Methoxamine HCl –                                                                 Myochrysine – 50 mg/ml .........................................X6262
 10 mg/ml 10 ml vials ............................................ X6562          Myochrysine – 25 mg/ml .........................................X6264
Methyldopa and Methyldopate HCl –                                                 Myolin – 30 mg/ml ..................................................X6216
 250 mg/5 ml ......................................................... X5540
Methyldrol 40 ......................................................... X6038
Methylene Blue – 1 ml ........................................... A9535
Methylergonovine Maleate –
 0.2 mg/ml............................................................. X6566
Methylprednisolone Acetate –
 80 mg/ml............................................................... J1040
Methylprednisolone Acetate –
 40 mg/ml............................................................... J1030
Methylprednisolone Acetate –
 20 mg/ml............................................................... J1020
Methylprednisolone Sodium Succinate – up to
 125 mg/ml ............................................................. J2930
Methylprednisolone Sodium Succinate – up to
 40 mg/ml............................................................... J2920




2 – Injections: List of Codes
                                                                                                                                            February 2010
                                                                                                                                              inject list
                                                                                                                                                        13
                                                                      Codes                                                                          Codes

N
Nafcil – 2 gm (powder) vial..................................... X6604             Nospaz – 10 mg/ml ................................................X5642
Nafcil – 1 gm (powder) vial..................................... X6606             Novocain – 10% .....................................................X6640
Nafcillin Sodium – 2 gm (powder) vial .................... X6604                   Novocain – 2% .......................................................X6642
Nafcillin Sodium – 1 gm (powder) vial .................... X6606                   Novocain – 1% .......................................................X6644
Nafcillin Sodium – 500 mg vial ............................... X6610               Nubain – 10 mg/ml .................................................X6612
Nalate – 50 mg/ml ................................................. X5678          Numorphan – 1.5 mg/ml .........................................X6646
Nalbuphine HCl – 10 mg/ml ................................... X6612                Numorphan – 1 mg/ml ............................................X6648
Naloxone HCl – 0.4 mg/ml ..................................... X6614               Nutropin – 1 mg ......................................................X7452
Naloxone HCl – 0.02 mg/ml ................................... X6616                Nutropin AQ – 1 mg ................................................X7454
Nandrolate – 100 mg/ml (oil) .................................. X5600              Nydrazid – 100 mg/ml.............................................X6410
Nandrolate – 50 mg/ml (oil) .................................... X5632
Nandrolin – 25 mg/ml (oil) ...................................... X5630
Nandrolone Decanoate –
 100 mg/ml (oil) ..................................................... X5600       O
Nandrolone Decanoate –
 50 mg/ml (oil) ....................................................... X5632      Octafluoropropane Microspheres – 1 ml ................ Q9956
Nandrolone Phenpropionate –                                                        Octocaine HCl – 2% w/1:100,000
 50 mg/ml (oil) ....................................................... X5598       Epinephrine ..........................................................X6444
Nandrolone Phenpropionate –                                                        Octocaine HCl – 2% w/1:50,000
 25 mg/ml (oil) ....................................................... X5630       Epinephrine ..........................................................X6476
Narcan – 0.4 mg/ml ............................................... X6614           Omnipen-N – 2 gm (powder)
Narcan – 0.02 mg/ml ............................................. X6616             piggyback units.....................................................X5576
Natalizumab – 1 mg ................................................ J2323          Omnipen-N – 2 gm (powder) vials ..........................X5578
Navane – 2 mg/ml.................................................. X6618           Omnipen-N – 1 gm (powder)
Nebcin – 40 mg/ml ................................................. X6620           piggyback units.....................................................X5580
Nebcin – 10 mg/2 ml vial ....................................... X6622             Omnipen-N – 1 gm (powder) vials ..........................X5582
Nelarabine – 50 mg ................................................ J9261          Omnipen-N – 500 mg (powder)
Nembutal Sodium – 50 mg/ml................................ X6624                    piggyback units.....................................................X5584
Neocyten – 30 mg/ml ............................................. X6216            Omnipen-N – 500 mg (powder) vials ......................X5586
Neostigmine Methylsulfate – 1:4,000                                                Omnipen-N – 250 mg (powder) vials ......................X5588
 solution/1 ml ampules .......................................... X6630            Omnipen-N – 125 mg (powder) vials ......................X5550
Neostigmine Methylsulfate –                                                        Oncovin – 5 mg w/50 mg
 1:2,000 solution ................................................... X6632         lactose per vial .....................................................X7570
Neostigmine Methylsulfate –                                                        Oncovin – 1 mg w/10 mg
 1:1,000 solution ................................................... X6634         lactose per vial .....................................................X7572
Neo Synephrine – 1% 1 ml ampules ...................... X6626                      Ondansetron HCl – 1 mg ........................................ J2405
Nesacaine – 2%..................................................... X5926          Oral Magnetic Resonance Contrast
Nesacaine – 1%..................................................... X5928           Agent – 1 ml ........................................................ Q9954
Nesacaine-CE – 3% .............................................. X5924             Ormazine – 25 mg/ml .............................................X5918
Nesacaine-CE – 2% .............................................. X5926             Orphenadrine Citrate – 30 mg/ml............................X6216
Nesiritide - 0.1 mg.................................................. J2325        Orthovisc – per dose .............................................. J7324
Nipride – 50 mg/5ml............................................... X6636           Or-Tyl – 10 mg/ml...................................................X5642
Nitrogen N-13 Ammonia, Diagnostic – 40 mCi ....... A9526                           Osmitrol – 20% .......................................................X6522
Nitroprusside Sodium – 50 mg/5 ml ....................... X6636                    Osmitrol – 15% .......................................................X6524
Norazine HCl – 50 mg/ml ....................................... X6638              Osmitrol – 10% .......................................................X6526
Norditropin – 1 mg ................................................. X7494         Osmitrol – 5% .........................................................X6528
Nordryl – 10 mg/ml ................................................ X5740          Oxacillin Sodium – 4 gm
Norferan.................................................................. J1752    (powder) vials .......................................................X5720
Norflex – 30 mg/ml................................................. X6216          Oxacillin Sodium – 2 gm
Noroxine – 500 mcg/ml .......................................... X6456              (powder) vials .......................................................X5722
Nor-Pred T.B.A. –                                                                  Oxacillin Sodium – 1 gm
 20 mg/ml suspension ........................................... X6328              (powder) vials .......................................................X5724
                                                                                   Oxacillin Sodium – 500 mg
                                                                                    (powder) vials .......................................................X5726
                                                                                   Oxacillin Sodium – 250 mg
                                                                                    (powder) vials .......................................................X6656
                                                                                   Oxaliplatin – 0.5 mg ................................................ J9263




2 – Injections: List of Codes
                                                                                                                                             August 2009
inject list
14
                                                                 Codes                                                                           Codes

Oxymorphone HCl – 1.5 mg/ml .............................. X6646             Penicillin G Benzathine, Parenteral –
Oxymorphone HCl – 1 mg/ml ................................. X6648             300,000 units/ml 10 ml vials .................................X5772
Oxytetracycline – 250 mg/vial ................................ X6664         Penicillin G Benzathine, Parenteral –
Oxytetracycline – 125 mg/ml .................................. X6658          600,000 units/ml ...................................................X5770
Oxytetracycline – 50 mg/ml .................................... X6660        Penicillin G Benzathine, Parenteral –
Oxytocin – 10 units/ml ........................................... X6666      1,200,000 units/2 ml syringe .................................X7460
                                                                             Penicillin G Benzathine, Parenteral –
                                                                              2,400,000 units/4 ml syringe .................................X7462
                                                                             Penicillin G Potassium – 20,000,000
P                                                                             units (powder)/vial ................................................X6700
                                                                             Penicillin G Potassium (or Sodium)
Paclitaxel protein-bound particles – 1 mg................ J9264               (Aqueous) – 10,000,000 units
Paclitaxel – 30 mg ................................................. X7052    (powder)/vial .........................................................X6702
Palifermin – 50 mcg ................................................ J2425   Penicillin G Potassium (or Sodium)
Palonosetron – 25 mcg ........................................... J2469       (Aqueous) – 5,000,000 units
Pamidronate – 30 mg ............................................ X7444        (powder)/vial .........................................................X6704
Pancuronium Bromide – 2 mg/ml ........................... X6670              Penicillin G Potassium (or Sodium)
Pancuronium Bromide – 1 mg/ml ........................... X6672               (Aqueous) – 1,000,000 units
Panheprin – 40,000 units/ml .................................. X6286          (powder)/vial .........................................................X6706
Panheprin – 20,000 units/ml .................................. X6288         Penicillin G Procaine (Aqueous) –
Panheprin – 10,000 units/ml .................................. X6296          2,400,000 units/unit dose .....................................X6714
Panheprin – 5,000 units/ml .................................... X6302        Penicillin G Procaine (Aqueous) –
Panheprin – 1,000 units/ml .................................... X6308         1,200,000 units/unit dose .....................................X6716
Panheprin Lok – 100 units/ml ................................ X6282          Penicillin G Procaine (Aqueous) –
Panitumumab – 10 mg............................................ J9303         600,000 units/unit dose .......................................X6136
Pantoprazole – 40 mg ............................................ S0164      Pentamidine – 150 mg............................................X6718
Paricalcitol – 1 mcg ..............................................J2501     Pentazine – 50 mg/ml .............................................X6236
Pavulon – 2 mg/ml ................................................. X6670    Pentazocine – 30 mg/ml .........................................X6720
Pavulon – 1 mg/ml ................................................. X6672    Pentobarbital Sodium – 50 mg/ml...........................X6624
Pegademase Bovine – 25 IU .................................. J2504           Pentothal Sodium – 10 gm .....................................X6728
Pegaptanib Sodium – 0.3 mg.................................. J2503           Pentothal Sodium – 5 gm .......................................X6730
Pegaspargase – single dose vial ............................ J9266           Pentothal Sodium – 1 gm .......................................X6732
Pegfilgrastim (Neulasta) – 6 mg .............................. J2505         Pentothal Sodium – 500 mg ...................................X6734
Pen A/N – 1 gm (powder) vials .............................. X5582           Pentothal Sodium – 400 mg ...................................X6736
Pen A/N – 500 mg (powder) vials........................... X5586             Pentothal Sodium – 250 mg ...................................X6738
Pen A/N – 250 mg (powder) vials........................... X5588             Perflexane Lipid Microspheres – 1 ml .................... Q9955
Penazine 50 – 50 mg/ml ........................................ X6236        Perflutren Lipid Microspheres – 1 ml ..................... Q9957
Penbritin-S – 4 gm (powder) vials .......................... X5574           Perphenazine – 5 mg/ml .........................................X6740
Penbritin-S – 2 gm (powder) vials .......................... X5578           Pfizerpen-AS –
Penbritin-S – 1 gm (powder) vials .......................... X5582            1,200,000 units/unit dose .....................................X6716
Penbritin-S – 500 mg (powder) vials ...................... X5586             Phenazine 25 .........................................................X6742
Penbritin-S – 250 mg (powder) vials ...................... X5588             Phencen 50 ............................................................X6236
Penbritin-S – 125 mg (powder) vials ...................... X5550             Phenergan – 50 mg/ml ...........................................X6236
Penicillin G Benzathine – 150,000 units                                      Phenergan – 25 mg/ml ...........................................X6742
 and Penicillin G Procaine –                                                 Phenobarbital Sodium – 130 mg/ml ........................X6506
 150,000 units/ml .................................................. X5768   Phenobarbital Sodium – 65 mg/ml ..........................X6754
Penicillin G Benzathine – 300,000 units                                      Phenoject 50 ..........................................................X6236
 and Penicillin G Procaine –                                                 Phentolamine – 5 mg .............................................X6758
 300,000 units/1 ml tubex ...................................... X5766       Phenylephrine HCl –
Penicillin G Benzathine – 600,000 units                                       1% 1 ml ampules ..................................................X6626
 and Penicillin G Procaine –                                                 Phenytoin Sodium,
 600,000 units/2 ml syringe ................................... X7456         Parenteral – 50 mg/ml ..........................................X6084
Penicillin G Benzathine – 900,000 units                                      Physostigmine Salicylate –
 and Penicillin G Procaine –                                                  1 mg/ml ................................................................X5640
 300,000 units/2 ml tubex ...................................... X5764
Penicillin G Benzathine – 1,200,000 units
 and Penicillin G Procaine –
 1,200,000 units/4 ml syringe ................................ X7458




2 – Injections: List of Codes
                                                                                                                                      February 2010
                                                                                                                                              inject list
                                                                                                                                                        15
                                                                     Codes                                                                           Codes

Phytonadione (K1) – 10 mg/ml............................... X5650                 Pregnyl – 1,000 units/ml .........................................X5622
Phytonadione (K1) – 2 mg/ml ................................ X5652                Premarin IV – 25 mg ..............................................X5972
Pitocin – 10 units/ml .............................................. X6666        Prenisolone Acetate – 25 mg/ml .............................X6014
Pitressin – 20 pressor units/ml ............................... X6760             Prenisolone Sodium Phosphate –
Pituitrin – 20 units/ml ............................................. X6764        20 mg/ml ..............................................................X6330
Plague Vaccine .......................................................90727       Prilocaine HCl – 4%................................................X5944
Platinol – 10 mg/vial............................................... X7516        Prilocaine HCl – 4% w/1:200,000
Plerixafor (Mozobil®) – 1 mg ............................... C9252                 Epinephrine ..........................................................X5942
Pneumococcal Conjugate Vaccine, Polyvalent,                                       Principen/N – 2 gm (powder) vials ..........................X5578
 (for children under 5 years of age) ........................90669                Principen/N – 1 gm (powder) vials ..........................X5582
Pneumococcal Polysaccharide                                                       Principen/N – 500 mg (powder) vials ......................X5586
 Vaccine – 23-valent ..............................................90732          Principen/N – 250 mg (powder) vials ......................X5588
Polio, live, oral. .......................................................90712   Principen/N – 125 mg (powder) vials ......................X5550
Poliomyelitis Vaccine – 1 cc amp............................90713                 Procainamide HCl – 500 mg/ml ..............................X6792
Polycillin-N – 2 gm                                                               Procainamide HCl – 100 mg/ml ..............................X6794
 (powder) piggyback units ..................................... X5576             Procaine HCl – 10% ...............................................X6640
Polycillin-N – 2 gm                                                               Procaine HCl – 2% .................................................X6642
 (powder) vials ...................................................... X5578      Procaine HCl – 1% .................................................X6644
Polycillin-N – 1 gm                                                               Prochlorperazine – 5 mg/ml ....................................X5970
 (powder) piggyback units ..................................... X5580             Procrit (ESRD) – 1,000 units .................................. J0886
Polycillin-N – 1 gm (powder) vials .......................... X5582               Procrit (non-ESRD) – 1,000 units ........................... J0885
Polycillin-N – 500 mg                                                             Progesterone (in oil) – 50 mg/cc .............................X6810
 (powder) piggyback units ..................................... X5584             Prolixin – 2.5 mg/ml ................................................X6222
Polycillin-N – 500 mg                                                             Prolixin Decanoate – 25 mg/ml ...............................X6220
 (powder) vials ...................................................... X5586      Prolixin Enanthate – 25 mg/ml ................................X6220
Polycillin-N – 250 mg                                                             Promaject – 25 mg/ml ............................................X5918
 (powder) vials ...................................................... X5588      Promaz – 25 mg/ml ................................................X5918
Polycillin-N – 125 mg                                                             Promazine HCl – 50 mg/ml .....................................X6638
 (powder) vials ...................................................... X5550      Promethamead 50 ..................................................X6236
Polyestradiol Phosphate –                                                         Promethamead 25 ..................................................X6742
 40 mg/secule w/2 ml                                                              Promethazine HCl – 50 mg/ml ................................X6236
 ampule of sterile diluent ....................................... X7540          Promethazine HCl – 25 mg/ml ................................X6742
Polymyxin B Sulfate – 500,000 units ...................... X6776                  Pronestyl – 500 mg/ml ............................................X6792
Pontocaine – 1%.................................................... X6778         Pronestyl – 100 mg/ml ............................................X6794
Pontocaine – 0.3% w/6% Dextrose ........................ X6780                    Propiomazine HCl – 20 mg/ml ................................X6442
Pontocaine – 0.2% w/6% Dextrose ........................ X6782                    Propranolol HCl – 1 mg/ml .....................................X6354
Posterior Pituitary Injection –                                                   Prorex – 50 mg/ml ..................................................X6236
 20 units/ml ........................................................... X6764    Prorex – 25 mg/ml ..................................................X6742
Pralidoxime Chloride – 1 gm .................................. X6784              Prostaphlin – 4 gm (powder) vials ...........................X5720
Predcor-50 ............................................................. X6440    Prostaphlin – 2 gm (powder) vials ...........................X5722
Predcor-25 ............................................................. X6014    Prostaphlin – 1 gm (powder) vials ...........................X5724
Pre-Dep – 80 mg/ml............................................... X6036           Prostaphlin – 500 mg (powder) vials .......................X5726
Pre-Dep – 40 mg/ml............................................... X6038           Prostaphlin – 250 mg (powder) vials .......................X6656
Prednisolone Acetate – 50 mg/ml .......................... X6440                  Prostigmin – 1:4,000 solution/
Prednisolone Acetate – 25 mg/ml .......................... X6014                   1 ml/ampules ........................................................X6630
Prednisolone Tebutate –                                                           Prostigmin – 1:2,000 solution .................................X6632
 20 mg/ml suspension ........................................... X6328            Prostigmin – 1:1,000 solution .................................X6634




2 – Injections: List of Codes
                                                                                                                                            October 2009
inject list
16
                                                                  Codes                                                                          Codes

Protamine Sulfate – 10 mg/ml................................ X6816             Robaxin – 100 mg/ml..............................................X6560
Protein C Concentrate                                                          Robinul – 0.2 mg/ml ...............................................X6258
 intravenous, human – 10 IU .................................. J2724           Romiplostim – 10 mcg ........................................... C9245
Prothazine – 50 mg/ml ........................................... X6236        Ropredlone – 50 mg/ml ..........................................X6440
Prothazine – 25 mg/ml ........................................... X6742        Ropredlone – 25 mg/ml ..........................................X6014
Protopam Chloride -                                                            Rubella Virus Vaccine, Live .................................... 90706
 Emergency Kit – 1 gm ......................................... X6784          Rubesol 1,000 .......................................................X5752
Protropin – 1 mg .................................................... X7034    Rubramin PC – 1,000 mcg/ml ................................X5752
Provigan – 50 mg/ml .............................................. X6236       Ruvite 1,000 – 1,000 mcg/ml ..................................X5752
Provigan – 25 mg/ml .............................................. X6742
PSP-IV – 20 mg/ml ................................................ X6330
Pyridostigmine Bromide – 5 mg/ml ........................ X6826
                                                                               S
                                                                               Samarium Sm-153, Therapeutic – 50 mCi ............. A9605
Q                                                                              Sargramostim – 500 mcg/vial .................................X7366
                                                                               Sargramostim – 250 mcg/vial .................................X7364
Quelicin – 100 mg/ml ............................................. X6828       Savacort – 100 ....................................... X6014 or X6440
Quelicin – 50 mg/ml ............................................... X6830      Savacort – 25 .........................................................X6440
Quelicin – 20 mg/ml ............................................... X5636      Savacort-D – 4 mg/ml .............................................X6004
Quinidine Gluconate – 80 mg/ml ............................ X6832              Scopolamine HBr – 1.0 mg/ml ................................X6856
                                                                               Scopolamine HBr – 0.4 mg/ml ................................X6862
                                                                               Scopolamine HBr – 0.3 mg/ml ................................X6864
                                                                               Secobarbital Sodium – 50 mg/ml ............................X6870
R                                                                              Seconal Sodium – 50 mg/ml...................................X6870
                                                                               Secretin, Synthetic, Human – 1 mcg ...................... J2850
Ranibizumab (Lucentis™) – 0.1 mg ........................ J2778                Serentil – 25 mg/ml ................................................X6556
Recombinant, GM-CSF, Leukine –                                                 Sermorelin Acetate – 1 mcg .................................. Q0515
 500 mcg/vial ........................................................ X7366   Sincalide – 5 mcg ................................................... J2805
Recombinant, GM-CSF, Leukine –                                                 SK-Ampicillin-N – 500 mg
 250 mcg/vial ........................................................ X7364    (powder) vials .......................................................X5586
Regadenoson – 0.1 mg........................................... J2785          Sodium Ascorbate – 500 mg/ml .............................X5882
Regitine – 5 mg ..................................................... X6758    Sodium Ascorbate – 250 mg/ml .............................X5912
Regonol – 5 mg/ml................................................. X6826       Sodium Edecrin – 500 mg/vial ................................X6204
Remicade – 10 mg.................................................. J1745       Sodium Ferric Gluconate Complex
Repbimone #1 ....................................................... X5666      in Sucrose – 62.5 mg ...........................................X7496
Rep Estra – 10 mg/ml ............................................ X5662        Sodium Fluoride F-18, up to 30 millicuries ............. A9580
Reposterone – 200 mg/ml...................................... X5634            Sodium Phosphate P-32, Therapeutic – 1 mCi ...... A9563
Rep-Pred 80 suspension ....................................... X6036           Sodium Thiosalicylate – 50 mg/ml ..........................X5678
Rep-Pred 40 .......................................................... X6038   Solganal – 50 mg/ml ...............................................X5708
Respiratory Syncytial Virus Immune Globulin                                    Sol-Pred – 20 mg/ml solution .................................X6330
 (RSV-IGIM), 50 mg ...............................................90378        Solu-Cortef – 1,000 mg/8 ml vial ............................X6888
RHO (D) Immune Globulin (Human) – full-dose ......90384                        Solu-Cortef – 500 mg/4 ml vial ...............................X6890
RHO (D) Immune Globulin (Human) – mini-dose ....90385                          Solu-Cortef – 250 mg/2 ml vial ...............................X6892
RHO (D) Immune Globulin (RhlglV), human                                        Solu-Cortef – 100 mg/10 ml vial .............................X6894
 for IV use (100 I.U.) .............................................. J2792    Solu-Medrol – 40 mg/ml .........................................X5554
Risperidone, long lasting, 0.5 mg ............................ J2794           Solurex – 4 mg/ml ..................................................X6004
Rituximab – 100 mg ................................................ J9310      Span-Est 20 ..........................................................X5660
                                                                               Span-Est 10 ..........................................................X5662
                                                                               Span-Est-Test 4 – 90-4 mg/ml ................................X5666
                                                                               Span-F – 5 mg/ml ...................................................X5662
                                                                               Span-Test – 100 mg/ml ..........................................X5626
                                                                               Spectinomycin – 400 mg
                                                                                (as HCl)/ml 2 gm vial ............................................X6896
                                                                               Spenbolic, Improved – 50 mg/ml (oil) .....................X5598
                                                                               Spenbolic, Improved – 25 mg/ml (oil) .....................X5630




2 – Injections: List of Codes
                                                                                                                                    September 2009
                                                                                                                                              inject list
                                                                                                                                                        17
                                                                     Codes                                                                           Codes

Spenduo – 50-2 mg/ml .......................................... X5620             Technetium Medronate – 30 mCi........................... A9503
Stadol – 2 mg/ml.................................................... X5796        Technetium Mertiatide – 15 mCi ............................ A9562
Stadol – 1 mg/ml.................................................... X5798        Technetium Oxidronate – 30 mCi .......................... A9561
Staphcillin – 4 gm vials (powder) ........................... X5710               Technetium Pentetate – 25 mCi ............................ A9539
Staphcillin – 4 gm piggyback units                                                Technetium Pentetate (aerosol) – 75 mCi ............. A9567
 (powder) .............................................................. X6558    Technetium Pertechnetate – 1 mCi ....................... A9512
Staphcillin – 4 gm vials (powder) ........................... X5712               Technetium Pyrophosphate – 25 mCi .................... A9538
Staphcillin – 1 gm piggyback units                                                Technetium Sestamibi – 40 mCi ............................ A9500
 (powder) .............................................................. X5868    Technetium Sodium Gluceptate – 25 mCi ............. A9550
Staphcillin – 1 gm vials (powder) ........................... X5714               Techentium Succimer – 10 mCi ............................ A9551
Stelazine – 2 mg/ml ............................................... X6912         Technetium Sulfur Colloid – 20 mCi ...................... A9541
Stemutrolin – 500 units/ml ..................................... X5644            Technetium Tetrofosmin – 40 mCi......................... A9502
Sterane – 25 mg/ml ............................................... X6014          Teev – 90-4 mg/ml .................................................X5666
Stilphostrol – 0.25 gm (as sodium salt)/                                          Tega-Flex – 30 mg/ml.............................................X6216
 5 ml ampuls ......................................................... X7536      Temsirolimus – 1 mg .............................................. J9330
Streptokinase-Streptodornase –                                                    Tensilon – 10 mg/ml ...............................................X6146
 20,000/5,000 units ............................................... X6920         Terbutaline Sulfate – 1 mg/ml .................................X5776
Streptomycin Sulfate................. Available free from Pfizer                  Terramycin – 50 mg/ml ...........................................X6660
Streptozocin – 1 gm vial......................................... X7574           Terramycin – 125 mg/ml .........................................X6658
Strontium Sr-89 Chloride, Therapeutic – 1 mCi ...... A9600                        Terramycin – 250 mg/vial .......................................X6664
Sublimaze – 0.5 mg/ml .......................................... X6206            Testa-C – 100 mg/ml ..............................................X5618
Succinylcholine Chloride – 100 mg/ml ................... X6828                    Testadiate-Depo – 50-2 mg/ml ...............................X5620
Succinylcholine Chloride – 50 mg/ml ..................... X6830                   Testa-Estrac – 50-2 mg/ml .....................................X5620
Succinylcholine Chloride – 20 mg/ml ..................... X5636                   Testaqua – 100 mg/ml ............................................X6326
Sucostrin – 100 mg/ml ........................................... X6828           Testaqua – 50 mg/ml ..............................................X5628
Sucostrin – 50 mg/ml ............................................. X6830          Testate – 100 mg/ml...............................................X5626
Sucostrin – 20 mg/ml ............................................. X5636          Testoject 50............................................................X5628
Supartz – 25 mg/2.5 ml .......................................... X7486           Testone – 200 mg/ml ..............................................X5634
Supprelin LA Implant – 50mg.................................. J9226               Testone L.A. – 100 mg/ml ......................................X5626
Sus-Phrine – 1:200 suspension ............................. X6166                 Testosterone – 100 mg/ml ......................................X6326
Synagis (RSV-IgIV) – 50 mg ...................................90378               Testosterone – 50 mg/ml ........................................X5628
Synkayvite – 37.5 mg/ml ........................................ X6532            Testosterone – 25 mg/ml ........................................X6942
Synkayvite – 5 mg/ml............................................. X6534           Testosterone Aqueous – 100 mg/ml .......................X6326
Synthroid – 500 mcg/ml ......................................... X6456            Testosterone Aqueous – 50 mg/ml .........................X5628
Syntocinon – 10 units/ml ........................................ X6666           Testosterone Aqueous – 25 mg/ml .........................X6942
Synvisc – per dose ................................................. J7322        Testosterone Cypionate – up to 100 mg ................ J1070
Sytobex – 1,000 mcg/ml ........................................ X5752             Testosterone Cypionate – 1 cc, 200 mg .............. J1080
                                                                                  Testosterone Cypionate and
                                                                                   Estradiol Cypionate – 50-2 mg/ml .........................X5620
T                                                                                 Testosterone Enanthate – 200 mg/ml .....................X5634
                                                                                  Testosterone Enanthate – 100 mg/ml .....................X5626
Talwin – 30 mg/ml.................................................. X6720         Testosterone Enanthate and
Taractan – 12.5 mg/ml ........................................... X5934            Estradiol Valerate – 90-4 mg/ml ...........................X5666
Taxotere – 20 mg................................................... X7638         Testosterone Propionate – 100 mg/ml ....................X6944
Technetium Apcitide – 20 mCi ............................... A9504                Testostroval P.A. – 200 mg/ml ...............................X5634
                                                                                  Testradiol 90/4........................................................X5666
Technetium Bicisate – 25 mCi ............................... A9557                Tetanus, diphtheria toxoids, and acellular
Technetium Disofenin – 15 mCi ............................. A9510                  pertussis vaccine [Tdap]
Technetium Exametazine – 25 mCi ....................... A9521                      for intramuscular use ............................................ 90715
Technetium Fanolesomab – 25 mCi ...................... A9566                      Tetanus and diphtheria toxoids, adsorbed –
Technetium Labeled Red Blood Cells –                                               for seven years of age and older .......................... 90718
 30 mCi ................................................................. A9560   Tetanus Immune Globulin
Technetium Macroaggregated albumin –                                               (human) – 250 unit ............................................... 90389
 10 mCI ................................................................. A9540   Tetanus Toxoid, Adsorbed ...................................... 90703
Technetium Mebrofenin – 15 mCi .......................... A9537                   Tetracaine HCl – 1% ..............................................X6778
                                                                                  Tetracaine HCl – 0.3% w/6% Dextrose ...................X6780
                                                                                  Tetracaine HCl – 0.2% w/6% Dextrose ...................X6782
                                                                                  Thallium TI-201 Thallous Chloride – 1 mCi ............ A9505




2 – Injections: List of Codes
                                                                                                                                              March 2010
inject list
18
                                                                    Codes                                                                           Codes

Theelin Aqueous – 5 mg/ml ................................... X6196              Trifluoperazine – 2 mg/ml .......................................X6912
Theelin Aqueous – 2 mg/ml ................................... X6198              Triflupromazine HCl – 20 mg/ml .............................X6978
Thiodyne – 50 mg/ml ............................................. X5678          Triflupromazine HCl – 10 mg/ml .............................X6980
Thiolate – 50 mg/ml ............................................... X5678        Trilafon – 5 mg/ml...................................................X6740
Thiopental Sodium – 10 gm ................................... X6728              Trilone – 40 mg/ml suspension ...............................X5552
Thiopental Sodium – 5 gm ..................................... X6730             Trimethaphan Camsylate – 50 mg/ml .....................X5668
Thiopental Sodium – 1 gm ..................................... X6732             Triptorelin (Trelstar) – 3.75 mg ...............................X7648
Thiopental Sodium – 500 mg ................................. X6734               Tristoject – 40 mg/ml suspension ...........................X5552
Thiopental Sodium – 400 mg ................................. X6736               Trobicin – 400 mg
Thiopental Sodium – 250 mg ................................. X6738                (as HCl)/ml 2 gm vial ............................................X6896
Thiosul – 50 mg/ml ................................................ X5678        Tubocurarine Chloride – 3 mg/ml............................X6984
Thiotepa – 15 mg/vial ............................................ X7576         Typhoid vaccine, Acetone killed, dried (AKD) ......... 90693
Thiothixene – 2 mg/ml ........................................... X6618          Typhoid vaccine, heat and phenol
Thorazine – 25 mg/ml ............................................ X5918           inactivated (H-P) ................................................... 90692
TH Sal – 50 mg/ml ................................................. X5678        Typhoid vaccine – live ............................................ 90690
Thyrogen 1.1 mg.................................................... X7464        Typhoid vaccine, Vi Capsular
Thyrotropin – 10 IU ................................................ X6968        polysaccharide (ViCPs) ........................................ 90691
Thytropar – 10 IU ................................................... X6968
Ticar – 6 gm (powder) vials .................................... X6970
Ticar – 3 gm (powder) vials .................................... X6972
Ticar – 1 gm (powder) vials .................................... X6974           U
Ticarcillin Disodium –
 6 gm (powder) vials.............................................. X6970         Ultracaine – 2% w/1:100,000
Ticarcillin Disodium –                                                            Epinephrine ..........................................................X6444
 3 gm (powder) vials.............................................. X6972         Unclassified Drugs ................................................. J3490
Ticarcillin Disodium –                                                           Unipen – 2 gm (powder) vial ...................................X6604
 1 gm (powder) vials.............................................. X6974         Unipen – 1 gm (powder) vial ...................................X6606
Tigecycline – 1 mg .................................................. J3243      Unipen – 500 mg vial ..............................................X6610
Tinzaparin Sodium – 1000 IU................................. X5509               Unitensen Aqueous – 260 CSR/ml .........................X5992
T-Ionate P.A. – 100 mg/ml ..................................... X5618            Urea – 40 gm/150 ml ..............................................X6996
Tobramycin Sulfate – 40 mg/ml ............................. X6620                Ureaphil – 40 gm/150 ml ........................................X6996
Tobramycin Sulfate – 10 mg/2 ml vial .................... X6622                  Urecholine – 5 mg/ml .............................................X5762
Tofranil – 25 mg/ml ................................................ X6352
Topotecan – 4 mg ................................................... J9350
Totacillin-N – 2 gm (powder)
 piggyback units .................................................... X5576      V
Totacillin-N – 2 gm (powder) vials .......................... X5578
Totacillin-N – 1 gm (powder)                                                     Valergen 40 ............................................................X6018
 piggyback units .................................................... X5580      Valergen 20 ...........................................................X5660
Totacillin-N – 1 gm (powder) vials .......................... X5582              Valergen 10 ...........................................................X5662
Totacillin-N – 500 mg (powder)                                                   Valertest No. 1 – 90-4 mg/ml ..................................X5666
 piggyback units .................................................... X5584      Valium – 5 mg/ml ...................................................X6064
Totacillin-N – 500 mg (powder) vials ...................... X5586                Vancocin – 500 mg (as HCl)/10 ml vial ...................X6998
Totacillin-N – 250 mg (powder) vials ...................... X5588                Vancomycin – 500 mg (as HCl)/10 ml vial ..............X6998
Totacillin-N – 125 mg (powder) vials ...................... X5550                Varicella Vaccine – .5 ml ........................................ 90716
Trastuzumab – 10 mg ............................................ X7640           Varidase for IM Use – 20,000-5,000 units ...............X6920
Treprostinil – 1 mg .................................................. J3285     Vasopressin – 20 pressor units/ml ..........................X6760
Triamcinolone – 40 mg/ml suspension ................... X5552                    Vasoxyl – 20 mg/ml 1 ml ampules ..........................X6562
Triamcinolone Acetate –                                                          Velban – 10 mg/10 ml vial ......................................X7578
 40 mg/ml suspension ........................................... X5880           Velosef – 2 gm/100 ml infusion containers .............X5904
Triamcinolone Acetonide –                                                        Velosef – 1 gm/vial .................................................X5906
 preservative free, 1 mg ......................................... J3300         Velosef – 500 mg/vial .............................................X5908
Triamcinolone Diacetate –                                                        Velosef – 250 mg/vial .............................................X5910
 25 mg/ml suspension ........................................... X6976           Venofer – 100 mg ...................................................X7492
Triam-Forte – 40 mg/ml suspension ...................... X5552
Triethylenethiophosphoramide –
 15 mg/vial ............................................................ X7576




2 – Injections: List of Codes
                                                                                                                                            August 2009
                                                                                                                                              inject list
                                                                                                                                                         19
                                                                    Codes                                                                             Codes

Vepesid – 20 mg/ml ............................................... X7542         Xylocaine HCl – 1.5% w/7.5% Dextrose .................X6480
Verteporfin – 0.1 mg ............................................... J3396       Xylocaine – 1.5% w/1:200,000 Epinephrine ............X6482
Vespirin – 20 mg/ml ............................................... X6978        Xylocaine HCl – 2% w/1:100,000 Epinephrine ........X6444
Vespirin – 10 mg/ml ............................................... X6980        Xylocaine HCl – 2% w/1:200,000 Epinephrine ........X6474
V-Gan 50 .............................................................. X6236    Xylocaine HCl – 1% w/1:200,000 Epinephrine ........X6486
V-Gan 25 ............................................................... X6742   Xylocaine HCl – 2% w/1:50,000 Epinephrine ..........X6476
Vibramycin I.V. – 200 mg (as Hyclate)/vial............. X6122                    Xylocaine HCl – 0.5% w/1:200,000 Epinephrine .....X6492
Vinblastine Sulfate (VLB) – 10 mg/10 ml vial ......... X7578                     Xylocaine HCl – 1% w/1:100,000 Epinephrine ........X6488
Vincristine Sulfate (VCR) – 5 mg                                                 Xylocaine HCl – 5% w/7.5% Glucose .....................X6466
 w/50 mg lactose per vial ...................................... X7570
Vincristine Sulfate (VCR) – 1 mg
 w/10 mg lactose per vial ...................................... X7572
Vinorelbine Tartrate – 10 mg................................... J9390            Y
Vistaril – 50 mg/ml ................................................. X6336
Vistaril – 25 mg/ml ................................................. X7010      Yellow Fever Vaccine ............................................. 90717
Vitamin A – 50,000 IU/ml ....................................... X5654           Yttrium Ibitumomab Tiuxetan – 40 mCi.................. A9543
Vitamin B12 – 1,000 mcg/ml .................................. X5752
Vitamin D – 500,000 IU D2/ml ............................... X5802
Vitamin D2 – 500,000 IU D2/ml ............................. X5802
Vitravene – 0.25 ml ................................................ X7470       Z
Vi-Twel – 1,000 mcg/ml ......................................... X5752
Vivitrol® – 1 mg ...................................................... J2315    Zemplar – 1 mcg .................................................... J2501
                                                                                 Ziconotide – 1 mcg ................................................. J2278
                                                                                 Zipan 50 .................................................................X6236
                                                                                 Zipan 25 .................................................................X6742
W                                                                                Ziprasidone – 20 mg ...............................................X7498
                                                                                 Zoladex – 3.6 mg ....................................................X7060
Wehdryl 50 – 50 mg/ml .......................................... X5738           Zoladex – 10.8 mg (depot) ......................................X7061
Wehgen – 2 mg/ml ................................................ X5756          Zoledronate – 4 mg ................................................X7650
Win Rho SDF – 600 IU .......................................... X7472            Zoledronic acid – 1mg (Reclast) ............................. J3488
Win Rho SDF – 1,500 IU ....................................... X7474             Zostavax................................................................. 90736
Win Rho SDF – 5,000 IU ....................................... X7476
Wyamine Sulfate – 30 mg/ml ................................. X6550
Wyamine Sulfate – 15 mg/ml ................................. X6552
Wycillin – 2,400,000 units/unit dose ....................... X6714
Wycillin – 1,200,000 units/unit dose ....................... X6716
Wycillin – 600,000 units/unit dose .......................... X6136



X

Xenon Xe-133 Gas, Diagnostic – 10 mCi ............... A9558
Xolair – 5 mg .......................................................... J2357
X-Otag – 30 mg/ml................................................. X6216
Xylocaine HCl – 0.5% ............................................ X6490
Xylocaine HCl – 1.5% ............................................ X6478
Xylocaine HCl IM for cardiac arrythmias –
 10% (100 mg/ml) ................................................. X6464
Xylocaine HCl I.V. for cardiac arrythmias –
 2% (20 mg/ml).................................................... X6470
Xylocaine HCl I.V. for cardiac arrythmias –
 4% (40 mg/ml)..................................................... X6494
Xylocaine HCl I.V. for cardiac arrythmias –
 20% (200 mg/ml) ................................................. X6462




2 – Injections: List of Codes
                                                                                                                                           February 2010