05 IMMUNIZATION RATE Table - Excel by qvs59240

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									                                                                     IMMUNIZATION RATE
                                                                         TABLE 2005


HCPCS Codes   RATE                                              LONG DESCRIPTOR                                                   SHORT DESCRIPTOR
90281            $40.00   IMMUNE GLOBULIN (Ig), HUMAN FOR INTRAMUSCULAR USE                                              Immune glob, IM
90283            $40.00   IMMUNE GLOBULIN (IgIV), HUMAN FOR INTRAVENOUS USE                                              Immune glob, IV
90287            $40.00   BOTULINUM ANTITOXIN, EQUINE, ANY ROUTE                                                         Botulism antitox, equine
90288            $40.00   BOTULISM IMMUNE GLOBULIN, HUMAN, FOR INTRAVENOUS USE                                           Botulism immune glob, IV
90291            $40.00   CYTOMEGALOVIRUS IMMUNE GLOBULIN (CMV-IgIV), HUMAN FOR INTRAVENOUS USE                          CMV IgIV
90296            $40.00   DIPHTHERIA ANTITOXIC, EQUINE, ANY ROUTE                                                        Diphtheria antitox, equine
90371           $113.57   HEP B IG, IM                                                                                   HBlg, IM
90375            $62.06   RABIES IG, IM/SC                                                                               RIg, IM/SC
90376            $66.31   RABIES IG, HEAT TREATED                                                                        Rlg-HT
90379            $16.55   RSV IG, IV                                                                                     RSV IG, IV
90384            $40.00   RHO(D) IMMUNE GLOBULIN, HUMAN, FULL DOSE, INTRAMUSCULAR                                        Rhlg, IM
90385            $25.77   RH IG, MINIDOSE, IM                                                                            Rhlg, mini-dose IM
90389           $114.00   TETANUS IG, IM                                                                                 Tetanus IG, IM
90393            $40.00   VACCINIA IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR USE                                         Vaccinia, IM
90396           $109.82   VARICELLA ZOSTER IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR USE                                 Chicken pox zoster, IM
90399            $40.00   UNLISTED IMMUNE GLOBULIN                                                                       Unlisted immune globulin
90476            $40.00   ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE                                                 Adenovirus vac type 4, oral
90477            $40.00   ADENOVIRUS VACCINE, TYPE 7, LIVE, FOR ORAL USE                                                 Adenovirus vac type 7, oral
90581            $40.00   ANTHRAX VACCINE, FOR SUBCUTANEOUS USE                                                          Anthrax vac, SQ
90585           $122.54   BACILLUS CALMETTA-GUERIN VACCINE (BCG) FOR TUBERCULOSIS, LIVE, OR PERCUTANEOUS USE             BCG vac, percut
90632            $44.43   HEPATITIS A VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE                                       Hep A vac, adult IM
90633            $21.95   HEPATITIS A VACCINE, PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE        Hep A vac, Ped/Adol, 2 dose
90634            $25.60   HEPATITIS A VACCINE, PEDIATRIC/ADOLESCENT DOSAGE-3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE        Hep A vac, Ped/Adol, 3 dose
90636            $40.00   HEPATITIS A AND B VACCINE, ADULT DOSAGE, INTRAMUSCULAR USE                                     Hep A/B vac, adult IM
                          HEMOPHILUS INFLUENZA B VACCINE (HIB), HBOC CONJUGATE (4 DOSE SCHEDULE), FOR INTRAMUSCULAR
90645            $23.52   USE                                                                                            HIB vac, HBOC, IM
90646            $40.00   HEMOPHILUS INFLUENZA B VACCINE (HIB), CONJUGATE, FOR BOOSTER USE ONLY, INTRAMUSCULAR           HIB vac, conjugate, IM
90647            $20.42   HEMOPHILUS INFLUENZA B VACCINE (HIB), CONJUGATE 3 DOSE SCHEDULE, INTRAMUSCULAR                 HIB vac, conjugate, IM
90648            $40.00   HEMOPHILUS INFLUENZA B VACCINE (HIB), CONJUGATE 4 DOSE SCHEDULE, INTRAMUSCULAR                 HIB vac, conjugate, IM
                          INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, FOR CHILDREN 6-35 MONTHS IN AGE,
90655            $40.00   INTRAMUSCULAR                                                                                  Flu vac, 6-35 m, IM
90657            $40.00   INFLUENZA VIRUS VACCINE, SPLIT VIRUS, CHILDREN 6-35 MONTHS OF AGE, INTRAMUSCULAR               Flu vac, 6-35 m, IM
                          INFLUENZA VIRUS VACCINE, SPLIT VIRUS, 6-35 MONTHS DOSAGE, FOR INTRAMUSCULAR OR JET INJECTION
90658            $10.10   USE                                                                                            Flu vac, 3 yrs, IM
90660            $40.00   INFLUENZA VIRUS VACCINE, LIVE, FOR INTRANASAL USE                                              Flu vac, intranasal
90665            $40.00   LYME DISEASE VACCINE, ADULT DOSE, INTRAMUSCULAR                                                Lyme vac, IM

90669            $40.00   PNEUMOCOCCAL CONJUGATE VACCINE, POLYVALENT, FOR CHILDREN UNDER 5 YEARS, INTRAMUSCULAR          Pneumococcal vac <5 yrs, IM
90675           $115.02   RABIES VACCINE, FOR INTRAMUSCULAR USE                                                          Rabies vac, IM
90676            $40.00   RABIES VACCINE, INTRADERMAL USE                                                                Rabies vac, intradermal
90680            $40.00   ROTAVIRUS VACCINE, TETRAVALENT, LIVE, ORAL USE                                                 Rotavirus vac, oral




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Tab: 05 IMMUNIZATION RATE Table                                           Page 1 of 19                                                           Print Date: 8/30/2010
                                                                     IMMUNIZATION RATE
                                                                         TABLE 2005


HCPCS Codes   RATE                                               LONG DESCRIPTOR                                                  SHORT DESCRIPTOR
90690            $40.00   TYPHOID VACCINE, LIVE, ORAL                                                                     Typhoid vac, oral
90691            $34.97   TYPHOID VACCINE, Vi CAPSULAR POLYSACCHARIDE (ViCPs), FOR INTRAMUSCULAR USE                      Typhoid vac, IM
90692            $40.00   TYPHOID VACCINE, HEAT AND PHENOL INACTIVATED, SUBCUTANEOUS OR INTRADERMAL USE                   Typhoid vac, SQ or intradermal
90693            $40.00   TYPHOID VACCINE, ACETONE-KILLED, DRIED, SUBCUTANEOUS USE (US MILITARY)                          Typhoid vac, US Military use only
                          DIPTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZ TYPE B, AND
90698            $40.00   POLIOVIRUS VACCINE, INACTIVATED, INTRAMUSCULAR USE                                              DTAP/HIB/Polio vac, IM
90700            $12.81   DIPTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), FOR INTRAMUSCULAR USE       DTAP vac, IM
90701            $40.00   DIPTHERIA, TETANUS TOXIODS, AND WHOLE CELL PERTUSSIS VACCINE ((DTP), INTRAMUSCULAR              DTP, IM
                          DIPTHERIA AND TETANU TOXOIDS (DT) ABSORBED FOR USE IN INDIVIDUALS YOUNGER THAN SEVEN YEARS,
90702            $40.00   INTRAMUSCULAR USE                                                                               DT, <7 years, IM
90703            $14.53   TETANUS TOXOID ADSORBED, FOR INTRAMUSCULAR OR JET INJECTION USE                                 Tetanus vac, IM
90704            $17.81   MUMPS VIRUS VACCINE, LIVE, FOR SUBCUTANEOUS OR JET INJECTION USE                                Mumps vac, SC
90705            $13.68   MEASLES VIRUS VACCINE, LIVE FOR SUBCUTANEOUS OR JET INJECTION USE                               Measles vac, SC
90706            $14.98   RUBELLA VIRUS VACCINE, LIVE FOR SUBCUTANEOUS OR JET INJECTION USE                               Rubella vac, SC

90707            $35.96   MEASLES, MUMPS, AND RUBELLA VIRUS VACCINE (MMR) LIVE, FOR SUBCUTANEOUS OR JET INJECTION USE MMR vac, SC
90708            $40.00   MEASLES AND RUBELLA VIRUS VACCINE, LIVE FOR SUBCUTANEOUS OR JET INJECTION USE                  MR vac, SQ
90710            $40.00   MEASLES, MUMPS, RUBELLA, AND VARICELLA VIRUS VACCINE (MMVR) LIVE, FOR SUBCUTANEOUS USE         MMVR vac, SQ
90712            $40.00   POLIOVIRUS VACCINE, ANTY TYPES (OPV), LIVE, FOR ORAL USE                                       Poliovirus OPV, oral
90713            $21.65   POLIOVIRUS VACCINE, INACTIVATED, (IPV), FOR SUBCUTANEOUS USE                                   Poliovirus IPV, SC
                          TETANUS AND DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE, FOR USE IN INDIVIDUALS 7 YRS
90715            $40.00   OR OLDER, INTRAMUSCULAR USE                                                                    TD vac > 7, IM
90716            $63.23   VARICELLA VIRUS VACCINE, LIVE, FOR SUBCUTANEOUS USE                                            Chicken pox vac, SC
90717            $49.26   YELLOW FEVER VACCINE, LIVE, FOR SUBCUTANEOUS USE                                               Yellow fever vac, SC
                          TETANUS AND DIPHTHERIA TOXOIDS (TD) ADSORBED FOR USE IN INDIVIDUALS SEVEN YEARS OR OLDER, FOR
90718             $9.25   INTRAMUSCULAR OR JET INJECTION                                                                 TD vac > 7, IM
90719            $40.00   DIPTHERIA TOXOID, FOR INTRAMUSCULAR USE                                                        Diptheria vac, IM
                          DIPTHERIA, TETANUS TOXOIDS, AND WHOLE CELL PERTUSSIS VACCINE AND HEMOPHILUS INFLUENZA
90720            $28.34   VACCINE (DTP-Hib), FOR INTRAMUSCULAR USE                                                       DTP/HIB vac, IM
                          DIPTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEMOPHILUS INFLUENZA B VACCINE (DTAP-
90721            $41.13   HIB), FOR INTRAMUSCULAR USE                                                                    DTAP/HIB vac, IM
                          DIPTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND POLIOVIRUS VACCINE,
90723            $40.00   INACTIVATED (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE                                             DTAP-HEPB-IPV vac, IM
90725            $40.00   CHOLERA VACCINE, FOR INJECTABLE USE                                                            Cholera vac, inj
90727            $40.00   PLAGUE VACCINE, FOR INTRAMUSCULAR OR JET INJECTION USE                                         Plague vac, IM
                          PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT, ADULT OR IMMUNOSUPPRESSED PATIENT
90732            $23.28   DOSAGE, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE                                                  Pneumococcal vac

90733            $55.21 MENINGCOCCAL POLYSACCHARIDE VACCINE (ANY GROUP(S)), FOR SUBCUTANEOUS OR JET INJECTION USE         Meningcoccal vac, SC
90734            $40.00 MENINGCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND W-135, FOR INTRAMUSCULAR USE               Meningcoccal vac, IM
90735            $82.14 JAPANESE ENCEPHALITIS VIRUS VACCINE, FOR SUBCUTANEOUS USE                                         Encephalitis vac, SC




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Tab: 05 IMMUNIZATION RATE Table                                           Page 2 of 19                                                         Print Date: 8/30/2010
                                                                   IMMUNIZATION RATE
                                                                       TABLE 2005


HCPCS Codes   RATE                                             LONG DESCRIPTOR                                                 SHORT DESCRIPTOR
                          HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT DOSAGE (3 DOSE SCHEDULE), FOR
90740           $116.87   INTRAMUSCULAR USE                                                                           Hep B Vac, Ill Pat 3 dose IM
90743            $67.93   HEPATITIS B VACCINE, ADOLESCENT (2 DOSE SCHEDULE), FOR INTRAMUSCULAR USE                    Hep B vac, adol, 2 dose, IM
90744            $68.38   HEPATITIS B VACCINE, PEDIATRIC/ADOLESCENT DOSAGE (3 DOSE SCHEDULE), FOR INTRAMUSCULAR USE   Hep B vac ped/adol 3 dose IM
90746            $56.96   HEPATITIS B VACCINE, PEDIATRIC/ADOLESCENT DOSAGE (3 DOSE SCHEDULE), FOR INTRAMUSCULAR USE   Hep B vac, adult, IM
                          HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT DOSAGE (4 DOSE SCHEDULE), FOR
90747           $113.91   INTRAMUSCULAR USE                                                                           Hep B vac, Ill pat 4 dose IM
90749            $40.00   UNLISTED VACCINE/TOXOID                                                                     Unlisted vac/tox
J0120            $40.00   INJECTION, TETRACYCLINE, UP TO 250 MG                                                       Tetracyclin injection
J0130           $431.24   INJECTION ABCIXIMAB, 10 MG                                                                  Abciximab injection
J0150            $31.07   INJECTION, ADENOSINE, 6 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE                Injection adenosine 6 MG
                          INJECTION, ADENOSINE, 30 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS;
J0152            $70.00   INSTEAD USE A9270                                                                           Adenosine injection
J0170             $0.29   INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE                                        Adrenalin epinephrin inject
J0190            $40.00   INJECTION, BIPERIDEN LACTATE, PER 5 MG                                                      Inj biperiden lactate/5 mg
J0200            $16.03   INJECTION, ALATROFLOXACIN MESYLATE, 100 MG                                                  Alatrofloxacin mesylate
J0205            $39.22   INJECTION, ALGLUCERASE, PER 10 UNITS                                                        Alglucerase injection
J0207           $417.56   INJECTION, AMIFOSTINE, 500 MG                                                               Amifostine
J0210             $9.03   INJECTION, METHYLDOPATE HCL, UP TO 250 MG                                                   Methyldopate hcl injection
J0215            $26.65   INJECTION, ALEFACEPT, 0.5 MG                                                                Alefacept
J0256             $3.28   INJECTION, ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MG                                    Alpha 1 proteinase inhibitor
                          INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED
J0270             $1.82   UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)    Alprostadil for injection

                          ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED
J0275            $20.75   UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NTO FOR USE WHEN DRUG IS SELF ADMINISTERED)    Alprostadil urethral suppos
J0280             $0.50   INJECTION, AMINOPHYLLIN, UP TO 250 MG                                                       Aminophyllin 250 MG inj
J0282             $5.51   INJECTION, AMIODARONE HYDROCHLORIDE, 30 MG                                                  Amiodarone HCl
J0285            $29.84   INJECTION, AMPHOTERICIN B, 50 MG                                                            Amphotericin B
J0286            $40.00   INJECTION, AMPHOTERICIN B, ANY LIPID FORMULATION, 50 MG                                     Amphotericin B lipid complex
J0287            $21.85   INJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MG                                              Amphotericin b lipid complex
J0288            $15.20   INJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MG                                Ampho b cholesteryl sulfate
J0289            $35.80   INJECTION, AMPHOTERICIN B LIPOSOME, 10 MG                                                   Amphotericin b liposome inj
J0290             $0.21   INJECTION, AMPICILLIN SODIUM, 500 MG                                                        Ampicillin 500 MG inj
J0295             $6.67   INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM                                   Ampicillin sodium per 1.5 gm
J0300             $2.47   INJECTION, AMOBARBITAL, UP TO 125 MG                                                        Amobarbital 125 MG inj
J0330             $0.10   INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG                                            Succinycholine chloride inj
J0340            $40.00   INJECTION, NANDROLONE PHENPROPIONATE, UP TO 50 MG                                           Nandrolon phenpropionate inj
J0350            $40.00   INJECTION, ANISTREPLASE, PER 30 UNITS                                                       Injection anistreplase 30 u
J0360             $7.13   INJECTION, HYDRALAZINE HCL, UP TO 20 MG                                                     Hydralazine hcl injection
J0380             $1.07   INJECTION, METARAMINOL BITARTRATE, PER 10 MG                                                Inj metaraminol bitartrate




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Tab: 05 IMMUNIZATION RATE Table                                         Page 3 of 19                                                          Print Date: 8/30/2010
                                                                   IMMUNIZATION RATE
                                                                       TABLE 2005


HCPCS Codes   RATE                                            LONG DESCRIPTOR                                        SHORT DESCRIPTOR
J0390            $17.27 INJECTION, CHLOROQUINE HYDROCHLORIDE, UP TO 250 MG                                    Chloroquine injection
J0395           $160.00 INJECTION, ARBUTAMINE HCL, 1 MG                                                       Arbutamine HCl injection
J0400            $40.00 INJECTION, TRIMETHAPHAN CAMSYLATE, UP TO 500 MG                                       Inj trimethaphan camsylate
J0456            $23.56 INJECTION, AZITHROMYCIN, 500 MG                                                       Azithromycin
J0460             $0.26 INJECTION, ATROPINE SULFATE, UP TO 0.3 MG                                             Atropine sulfate injection
J0470            $18.62 INJECTION, DIMERCAPROL, PER 100 MG                                                    Dimecaprol injection
J0475           $215.18 INJECTION, BACLOFEN, 10 MG                                                            Baclofen 10 MG injection
J0476            $79.80 INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL                                     Baclofen intrathecal trial
J0500            $13.03 INJECTION, DICYCLOMINE HCL, UP TO 20 MG                                               Dicyclomine injection
J0510            $40.00 INJECTION, BENZQUINAMIDE HCL, UP TO 50 MG                                             Benzquinamide injection
J0515             $3.40 INJECTION, BENZTROPINE MESYLATE, PER 1 MG                                             Inj benztropine mesylate
J0520             $4.49 INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, UP TO 5 MG                Bethanechol chloride inject
J0530            $11.37 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 600,000 UNITS     Penicillin g benzathine inj
J0540            $23.02 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 1,200,000 UNITS   Penicillin g benzathine inj
J0550            $29.91 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 2,400,000 UNITS   Penicillin g benzathine inj
J0560            $17.29 INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS                               Penicillin g benzathine inj
J0570            $30.41 INJECTION, PENICILLIN G BENZATHINE, UP TO 1,200,000 UNITS                             Penicillin g benzathine inj
J0580            $60.28 INJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 UNITS                             Penicillin g benzathine inj
J0583             $0.15 INJECTION, BIVALIRUDIN, 1 MG                                                          Bivalirudin
J0585             $4.71 BOTULINUM TOXIN TYPE A, PER UNIT                                                      Botulinum toxin a per unit
J0587             $7.76 BOTULINUM TOXIN TYPE B, PER 100 UNITS                                                 Botulinum toxin type B
J0590            $40.00 INJECTION, ETHYLNOREPINEPHRINE HCL, 1 ML                                              Ethylnorepinephrine hcl inj
J0592             $0.82 INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG                                        Buprenorphine hydrochloride
J0595             $1.82 INJECTION, BUTORPHANOL TARTRATE, 1 MG                                                 Butorphanol tartrate 1 mg
J0600            $39.74 INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG                                    Edetate calcium disodium inj
J0610             $0.05 INJECTION, CALCIUM GLUCONATE, PER 10 ML                                               Calcium gluconate injection
J0620             $8.53 INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, PER 10 ML                    Calcium glycer & lact/10 ML
J0630            $35.03 INJECTION, CALCITONIN SALMON, UP TO 400 UNITS                                         Calcitonin salmon injection
J0635            $40.00 INJECTION, CALCITRIOL, 1 MCG AMP.                                                     Calcitriol injection
J0636             $0.96 INJECTION, CALCITRIOL, 0.1 MCG                                                        Inj calcitriol per 0.1 mcg
J0637            $31.88 INJECTION, CASPOFUNGIN ACETATE, 5 MG                                                  Caspofungin acetate
J0640             $1.30 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG                                              Leucovorin calcium injection
J0670             $1.60 INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML                                       Inj mepivacaine HCL/10 ml
J0690             $1.28 INJECTION, CEFAZOLIN SODIUM, 500 MG                                                   Cefazolin sodium injection
J0692             $6.89 INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG                                             Cefepime HCl for injection
J0694            $11.90 INJECTION, CEFOXITIN SODIUM, 1 GM                                                     Cefoxitin sodium injection
J0695            $40.00 INJECTION, CEFONICID SODIUM, 1 GRAM                                                   Cefonocid sodium injection
J0696             $6.57 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG                                             Ceftriaxone sodium injection
J0697             $4.35 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG                                      Sterile cefuroxime injection
J0698             $5.02 INJECTION, CEFOTAXIME SODIUM, PER GM                                                  Cefotaxime sodium injection
J0702             $4.51 INJECTION, BETAMETHASONE ACETATE AND BETAMETHASONE SODIUM PHOSPHATE, PER 3 MG         Betamethasone acet&sod phosp




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Tab: 05 IMMUNIZATION RATE Table                                         Page 4 of 19                                            Print Date: 8/30/2010
                                                                IMMUNIZATION RATE
                                                                    TABLE 2005


HCPCS Codes   RATE                                          LONG DESCRIPTOR                               SHORT DESCRIPTOR
J0704             $0.90 INJECTION, BETAMETHASONE SODIUM PHOSPHATE, PER 4 MG                        Betamethasone sod phosp/4 MG
J0706             $3.27 INJECTION, CAFFEINE CITRATE, 5MG                                           Caffeine citrate injection
J0710            $40.00 INJECTION, CEPHAPIRIN SODIUM, UP TO 1 GM                                   Cephapirin sodium injection
J0713             $3.74 INJECTION, CEFTAZIDIME, PER 500 MG                                         Inj ceftazidime per 500 mg
J0715             $2.70 INJECTION, CEFTIZOXIME SODIUM, PER 500 MG                                  Ceftizoxime sodium / 500 MG
J0720             $6.10 INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM                    Chloramphenicol sodium injec
J0725             $2.58 INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS                     Chorionic gonadotropin/1000u
J0730            $40.00 INJECTION, CHLORPHENIRAMINE MALEATE, PER 10 MG                             Chlorpheniramin maleate inj
J0735            $56.37 INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG                                   Clonidine hydrochloride
J0740           $762.50 INJECTION, CIDOFOVIR, 375 MG                                               Cidofovir injection
J0743            $11.72 INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG                         Cilastatin sodium injection
J0744             $8.57 INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, 200 MG                  Ciprofloxacin iv
J0745             $0.49 INJECTION, CODEINE PHOSPHATE, PER 30 MG                                    Inj codeine phosphate /30 MG
J0760             $4.07 INJECTION, COLCHICINE, PER 1MG                                             Colchicine injection
J0770            $45.09 INJECTION, COLISTIMETHATE SODIUM, UP TO 150 MG                             Colistimethate sodium inj
J0780             $3.01 INJECTION, PROCHLORPERAZINE, UP TO 10 MG                                   Prochlorperazine injection
J0800            $93.71 INJECTION, CORTICOTROPIN, UP TO 40 UNITS                                   Corticotropin injection
J0810            $40.00 INJECTION, CORTISONE, UP TO 50 MG                                          Cortisone injection
J0835            $15.36 INJECTION, COSYNTROPIN, PER 0.25 MG                                        Inj cosyntropin per 0.25 MG
J0850           $672.61 INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIAL   Cytomegalovirus imm IV /vial
J0878             $0.28 DAPTOMYCIN INJECTION, 1mg                                                  Injection,Daptomycin, 1mg
J0880            $17.72 INJECTION, DARBEPOETIN ALFA, 5 MCG                                         Darbepoetin alfa injection
J0895            $64.60 INJECTION, DEFEROXAMINE MESYLATE, 500 MG                                   Deferoxamine mesylate inj
J0900             $1.38 INJECTION, TESTOSTERONE ENANTHATE AND ESTRADIOL VALERATE, UP TO 1 CC       Testosterone enanthate inj
J0945             $0.73 INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG                              Brompheniramine maleate inj
J0970            $29.67 INJECTION, ESTRADIOL VALERATE, UP TO 40 MG                                 Estradiol valerate injection
J1000             $5.02 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG                            Depo-estradiol cypionate inj
J1020             $2.67 INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG                               Methylprednisolone 20 MG inj
J1030             $5.36 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG                               Methylprednisolone 40 MG inj
J1040             $9.75 INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG                               Methylprednisolone 80 MG inj
J1050            $40.00 INJECTION, MEDROXYPROGESTERONE ACETATE, 100 MG                             Medroxyprogesterone inj
J1051             $4.89 INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG                              Medroxyprogesterone inj
J1055            $40.00 INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150 MG       Medrxyprogester acetate inj
J1056            $21.59 INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG / 25MG   MA/EC contraceptiveinjection
J1060             $3.91 INJECTION, TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE, UP TO 1 ML      Testosterone cypionate 1 ML
J1070             $4.91 INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG                            Testosterone cypionat 100 MG
J1080            $12.62 INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG                            Testosterone cypionat 200 MG
J1090            $40.00 INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 50 MG                             Testosterone cypionate 50 MG
J1094             $0.25 INJECTION, DEXAMETHASONE ACETATE, 1 MG                                     Inj dexamethasone acetate
J1095            $40.00 INJECTION, DEXAMETHASONE ACETATE, PER 8 MG                                 Inj dexamethasone acetate
J1100             $0.14 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG                             Dexamethasone sodium phos




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Tab: 05 IMMUNIZATION RATE Table                                      Page 5 of 19                                    Print Date: 8/30/2010
                                                                   IMMUNIZATION RATE
                                                                       TABLE 2005


HCPCS Codes   RATE                                             LONG DESCRIPTOR                                                SHORT DESCRIPTOR
J1110            $28.75   INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG                                            Inj dihydroergotamine mesylt
J1120            $12.70   INJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MG                                              Acetazolamid sodium injectio
J1160             $3.04   INJECTION, DIGOXIN, UP TO 0.5 MG                                                           Digoxin injection
J1165             $0.61   INJECTION, PHENYTOIN SODIUM, PER 50 MG                                                     Phenytoin sodium injection
J1170             $1.71   INJECTION, HYDROMORPHONE, UP TO 4 MG                                                       Hydromorphone injection
J1180             $4.00   INJECTION, DYPHYLLINE, UP TO 500 MG                                                        Dyphylline injection
J1190           $211.38   INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG                                           Dexrazoxane HCl injection
J1200             $0.94   INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG                                                Diphenhydramine hcl injectio
J1205             $9.13   INJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MG                                               Chlorothiazide sodium inj
J1212            $36.79   INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML                                            Dimethyl sulfoxide 50% 50 ML
J1230             $3.28   INJECTION, METHADONE HCL, UP TO 10 MG                                                      Methadone injection
J1240             $4.73   INJECTION, DIMENHYDRINATE, UP TO 50 MG                                                     Dimenhydrinate injection
J1245             $1.93   INJECTION, DIPYRIDAMOLE, PER 10 MG                                                         Dipyridamole injection
J1250             $5.11   INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG                                            Inj dobutamine HCL/250 mg
J1260             $6.61   INJECTION, DOLASETRON MESYLATE, 10 MG                                                      Dolasetron mesylate
J1270             $2.80   INJECTION, DOXERCALCIFEROL, 1 MCG                                                          Injection, doxercalciferol
J1320             $1.70   INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG                                                  Amitriptyline injection
J1325            $12.64   INJECTION, EPOPROSTENOL, 0.5 MG                                                            Epoprostenol injection
J1327            $12.40   INJECTION, EPTIFIBATIDE, 5 MG                                                              Eptifibatide injection
J1330            $40.00   INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG                                                Ergonovine maleate injection
J1335            $21.30   INJECTION, ERTAPENEM SODIUM, 500 MG                                                        Ertapenem injection
J1362            $40.00   INJECTION, ERYTHROMYCIN GLUCEPTATE, PER 250 MG                                             Erythromycin glucep / 250 MG
J1364             $2.94   INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG                                           Erythro lactobionate /500 MG
J1380            $11.36   INJECTION, ESTRADIOL VALERATE, UP TO 10 MG                                                 Estradiol valerate 10 MG inj
J1390            $14.83   INJECTION, ESTRADIOL VALERATE, UP TO 20 MG                                                 Estradiol valerate 20 MG inj
J1410            $56.71   INJECTION, ESTROGEN CONJUGATED, PER 25 MG                                                  Inj estrogen conjugate 25 MG
J1435             $0.17   INJECTION, ESTRONE, PER 1 MG                                                               Injection estrone per 1 MG
J1436            $67.37   INJECTION, ETIDRONATE DISODIUM, PER 300 MG                                                 Etidronate disodium inj
                          INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER
J1438           $147.16   THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)         Etanercept injection
J1440           $178.94   INJECTION, FILGRASTIM (G-CSF), 300 MCG                                                     Filgrastim 300 mcg injection
J1441           $282.41   INJECTION, FILGRASTIM (G-CSF), 480 MCG                                                     Filgrastim 480 mcg injection
J1450            $44.85   INJECTION FLUCONAZOLE, 200 MG                                                              Fluconazole
J1452           $200.00   INJECTION, FOMIVIRSEN SODIUM, INTRAOCULAR, 1.65 MG                                         Intraocular Fomivirsen na
J1455            $13.07   INJECTION, FOSCARNET SODIUM, PER 1000 MG                                                   Foscarnet sodium injection
J1457             $1.25   GALLIUM NITRATE INJECTION, 1mg                                                             Injection, gallium Nitrate, 1mg
J1460            $10.00   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC                                             Gamma globulin 1 CC inj
J1470            $20.00   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC                                             Gamma globulin 2 CC inj
J1480            $30.00   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC                                             Gamma globulin 3 CC inj
J1490            $40.01   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC                                             Gamma globulin 4 CC inj
J1500            $50.01   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC                                             Gamma globulin 5 CC inj




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Tab: 05 IMMUNIZATION RATE Table                                        Page 6 of 19                                                         Print Date: 8/30/2010
                                                                    IMMUNIZATION RATE
                                                                        TABLE 2005


HCPCS Codes   RATE                                              LONG DESCRIPTOR                                SHORT DESCRIPTOR
J1510            $60.05   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC                               Gamma globulin 6 CC inj
J1520            $69.96   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC                               Gamma globulin 7 CC inj
J1530            $80.02   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC                               Gamma globulin 8 CC inj
J1540            $90.08   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC                               Gamma globulin 9 CC inj
J1550           $100.02   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC                              Gamma globulin 10 CC inj
J1560           $100.02   INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC                         Gamma globulin > 10 CC inj
J1561            $40.00   INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 500 MG                              Immune globulin 500 mg
J1562            $40.00   INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 5 GMS                               Immune globulin 5 gms
J1563            $56.72   INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 1G                                  IV immune globulin
J1564             $0.57   INJECTION, IMMUNE GLOBULIN, 10 MG                                            Immune globulin 10 mg
J1565            $15.26   INJECTION, RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN, INTRAVENOUS, 50 MG   RSV-ivig
J1570            $35.25   INJECTION, GANCICLOVIR SODIUM, 500 MG                                        Ganciclovir sodium injection
J1580             $1.44   INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG                                Garamycin gentamicin inj
J1590             $0.44   INJECTION, GATIFLOXACIN, 10MG                                                Gatifloxacin injection
J1595            $34.85   INJECTION, GLATIRAMER ACETATE, 20 MG                                         Injection glatiramer acetate
J1600            $11.30   INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG                               Gold sodium thiomaleate inj
J1610            $55.17   INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG                                  Glucagon hydrochloride/1 MG
J1620           $164.87   INJECTION, GONADORELIN HYDROCHLORIDE, PER 100 MCG                            Gonadorelin hydroch/ 100 mcg
J1626             $7.09   INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG                                Granisetron HCl injection
J1630             $2.56   INJECTION, HALOPERIDOL, UP TO 5 MG                                           Haloperidol injection
J1631             $5.80   INJECTION, HALOPERIDOL DECANOATE, PER 50 MG                                  Haloperidol decanoate inj
J1642             $0.07   INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS                Inj heparin sodium per 10 u
J1644             $0.10   INJECTION, HEPARIN SODIUM, PER 1000 UNITS                                    Inj heparin sodium per 1000u
J1645             $9.92   INJECTION, DALTEPARIN SODIUM, PER 2500 IU                                    Dalteparin sodium
J1650             $5.15   INJECTION, ENOXAPARIN SODIUM, 10 MG                                          Inj enoxaparin sodium
J1652             $6.74   INJECTION, FONDAPARINUX SODIUM, 0.5 MG                                       Fondaparinux sodium
J1655             $2.60   INJECTION, TINZAPARIN SODIUM, 1000 IU                                        Tinzaparin sodium injection
J1670            $68.47   INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS                   Tetanus immune globulin inj
J1690            $40.00   INJECTION, PREDNISOLONE TEBUTATE, UP TO 20 MG                                Prednisolone tebutate inj
J1700             $0.66   INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG                               Hydrocortisone acetate inj
J1710             $4.69   INJECTION, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 MG                      Hydrocortisone sodium ph inj
J1720             $1.81   INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG                     Hydrocortisone sodium succ i
J1730           $112.01   INJECTION, DIAZOXIDE, UP TO 300 MG                                           Diazoxide injection
J1739            $40.00   INJECTION, HYDROXYPROGESTERONE CAPROATE 125 MG/ML                            Hydroxyprogesterone cap 125
J1741            $40.00   INJECTION, HYDROXYPROGESTERONE CAPROATE, 250 MG/ML                           Hydroxyprogesterone cap 250
J1742           $223.65   INJECTION, IBUTILIDE FUMARATE, 1 MG                                          Ibutilide fumarate injection
J1745            $53.08   INJECTION INFLIXIMAB, 10 MG                                                  Infliximab injection
J1750            $11.06   INJECTION, IRON DEXTRAN, 50 MG                                               Iron dextran
J1755            $40.00   INJECTION, IRON SUCROSE, 20MG                                                Iron sucrose injection
J1756             $0.37   INJECTION, IRON SUCROSE, 1 MG                                                Iron sucrose injection
J1785             $3.91   INJECTION, IMIGLUCERASE, PER UNIT                                            Injection imiglucerase /unit




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Tab: 05 IMMUNIZATION RATE Table                                          Page 7 of 19                                      Print Date: 8/30/2010
                                                                   IMMUNIZATION RATE
                                                                       TABLE 2005


HCPCS Codes   RATE                                             LONG DESCRIPTOR                                     SHORT DESCRIPTOR
J1790             $1.02   INJECTION, DROPERIDOL, UP TO 5 MG                                                Droperidol injection
J1800             $5.10   INJECTION, PROPRANOLOL HCL, UP TO 1 MG                                           Propranolol injection
J1810             $5.92   INJECTION, DROPERIDOL AND FENTANYL CITRATE, UP TO 2 ML AMPULE                    Droperidol/fentanyl inj
J1815             $0.22   INJECTION, INSULIN, PER 5 UNITS                                                  Insulin injection
J1817             $2.80   INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS         Insulin for insulin pump use
J1820            $40.00   INJECTION, INSULIN, UP TO 100 UNITS                                              Insulin injection
J1825            $40.00   INJECTION, INTERFERON BETA-1A, 33 MCG                                            Interferon beta-1a
J1830            $80.53   INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG   Interferon beta-1b / .25 MG
J1835            $36.23   INJECTION, ITRACONAZOLE, 50 MG                                                   Itraconazole injection
J1840             $0.23   INJECTION, KANAMYCIN SULFATE, UP TO 500 MG                                       Kanamycin sulfate 500 MG inj
J1850             $0.42   INJECTION, KANAMYCIN SULFATE, UP TO 75 MG                                        Kanamycin sulfate 75 MG inj
J1885             $0.64   INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG                                     Ketorolac tromethamine inj
J1890             $8.64   INJECTION, CEPHALOTHIN SODIUM, UP TO 1 GRAM                                      Cephalothin sodium injection
J1910            $40.00   INJECTION, KUTAPRESSIN, UP TO 2 ML                                               Kutapressin injection
J1930            $40.00   INJECTION, PROPIOMAZINE HCL, UP TO 20 MG                                         Propiomazine injection
J1931            $22.74   INJECTION, LARONIDASE, 0.1 mg                                                    Laronidase Injection, 0.1 mg
J1940             $0.49   INJECTION, FUROSEMIDE, UP TO 20 MG                                               Furosemide injection
J1950           $445.11   INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG                Leuprolide acetate /3.75 MG
J1955            $14.65   INJECTION, LEVOCARNITINE, PER 1 GM                                               Inj levocarnitine per 1 gm
J1956             $7.64   INJECTION, LEVOFLOXACIN, 250 MG                                                  Levofloxacin injection
J1960             $3.63   INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG                                      Levorphanol tartrate inj
J1970            $40.00   INJECTION, METHOTRIMEPRAZINE, UP TO 20 MG                                        Methotrimeprazine injection
J1980             $4.71   INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG                                    Hyoscyamine sulfate inj
J1990            $21.05   INJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MG                                    Chlordiazepoxide injection
J2001             $0.01   INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG                         Lidocaine injection
J2010             $3.48   INJECTION, LINCOMYCIN HCL, UP TO 300 MG                                          Lincomycin injection
J2020            $23.76   INJECTION, LINEZOLID, 200MG                                                      Linezolid injection
J2060             $1.27   INJECTION, LORAZEPAM, 2 MG                                                       Lorazepam injection
J2150             $1.02   INJECTION, MANNITOL, 25% IN 50 ML                                                Mannitol injection
J2175             $1.37   INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG                                  Meperidine hydrochl /100 MG
J2180             $3.79   INJECTION, MEPERIDINE AND PROMETHAZINE HCL, UP TO 50 MG                          Meperidine/promethazine inj
J2185             $3.40   INJECTION, MEROPENEM, 100 MG                                                     Meropenem
J2210             $4.30   INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG                                Methylergonovin maleate inj
J2240            $40.00   INJECTION, METOCURINE IODIDE, UP TO 2 MG                                         Metocurine iodide injection
J2250             $0.48   INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG                                     Inj midazolam hydrochloride
J2260            $51.58   INJECTION, MILRINONE LACTATE, 5 MG                                               Inj milrinone lactate / 5 MG
J2270             $1.86   INJECTION, MORPHINE SULFATE, UP TO 10 MG                                         Morphine sulfate injection
J2271            $11.07   INJECTION, MORPHINE SULFATE, 100MG                                               Morphine so4 injection 100mg
J2275            $11.75   INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER 10 MG      Morphine sulfate injection
J2280             $3.77   INJECTION, MOXIFLOXACIN, 100 MG                                                  Inj, moxifloxacin 100 mg
J2300             $1.33   INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG                                   Inj nalbuphine hydrochloride




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Tab: 05 IMMUNIZATION RATE Table                                         Page 8 of 19                                           Print Date: 8/30/2010
                                                                   IMMUNIZATION RATE
                                                                       TABLE 2005


HCPCS Codes   RATE                                             LONG DESCRIPTOR                                             SHORT DESCRIPTOR
J2310             $3.00   INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG                                               Inj naloxone hydrochloride
J2320             $3.41   INJECTION, NANDROLONE DECANOATE, UP TO 50 MG                                              Nandrolone decanoate 50 MG
J2321             $6.56   INJECTION, NANDROLONE DECANOATE, UP TO 100 MG                                             Nandrolone decanoate 100 MG
J2322            $13.86   INJECTION, NANDROLONE DECANOATE, UP TO 200 MG                                             Nandrolone decanoate 200 MG
J2324            $73.33   INJECTION, NESIRITIDE, 0.5 MG                                                             Nesiritide
J2330            $40.00   INJECTION, THIOTHIXENE, UP TO 4 MG                                                        Thiothixene injection
J2350            $40.00   INJECTION, NIACINAMIDE, NIACIN, UP TO 100 MG                                              Niacinamide/niacin injection
J2353            $85.39   INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG                       Octreotide injection, depot
J2354             $4.67   INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG   Octreotide inj, non-depot
J2355           $243.35   INJECTION, OPRELVEKIN, 5 MG                                                               Oprelvekin injection
J2357            $15.32   INJECTION, OMALIZUMAB, 5mg                                                                Omalizumab Injection, 5mg
J2360            $15.95   INJECTION, ORPHENADRINE CITRATE, UP TO 60 MG                                              Orphenadrine injection
J2370             $0.63   INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML                                                  Phenylephrine hcl injection
J2400            $16.52   INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML                                        Chloroprocaine hcl injection
J2405             $3.73   INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG                                            Ondansetron hcl injection
J2410             $2.29   INJECTION, OXYMORPHONE HCL, UP TO 1 MG                                                    Oxymorphone hcl injection
J2430            $59.06   INJECTION, PAMIDRONATE DISODIUM, PER 30 MG                                                Pamidronate disodium /30 MG
J2440             $0.76   INJECTION, PAPAVERINE HCL, UP TO 60 MG                                                    Papaverin hcl injection
J2460             $0.88   INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG                                               Oxytetracycline injection
J2469            $18.22   INJECTION, PALONOSECTRON HCI, 25 mg                                                       Palonosetron HCI, 25mg
J2480            $40.00   INJECTION, HYDROCHLORIDES OF OPIUM ALKALOIDS, UP TO 20 MG                                 Hydrochlorides of opium inj
J2500            $40.00   INJECTION, PARICALCITOL, 5 MCG                                                            Paricalcitol
J2501             $4.02   INJECTION, PARICALCITOL, 1 MCG                                                            Paricalcitol
J2505         $2,273.93   INJECTION, PEGFILGRASTIM, 6 MG                                                            Injection, pegfilgrastim 6mg
J2510             $8.28   INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS                            Penicillin g procaine inj
J2512            $40.00   INJECTION, PENTAGASTRIN, PER 2 ML                                                         Inj pentagastrin per 2 ML
J2515             $1.85   INJECTION, PENTOBARBITAL SODIUM, PER 50 MG                                                Pentobarbital sodium inj
J2540             $1.00   INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS                                    Penicillin g potassium inj
J2543             $4.59   INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS (1.125 GRAMS)        Piperacillin/tazobactam
J2545            $39.05   PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, PER 300 MG, ADMINISTERED THROUGH A DME      Pentamidine isethionte/300mg
J2550             $2.15   INJECTION, PROMETHAZINE HCL, UP TO 50 MG                                                  Promethazine hcl injection
J2560             $3.17   INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG                                             Phenobarbital sodium inj
J2590             $1.04   INJECTION, OXYTOCIN, UP TO 10 UNITS                                                       Oxytocin injection
J2597             $2.47   INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG                                                Inj desmopressin acetate
J2640            $40.00   INJECTION, PREDNISOLONE SODIUM PHOSPHATE, TO 20 MG                                        Prednisolone sodium ph inj
J2650             $0.21   INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML                                               Prednisolone acetate inj
J2670             $3.44   INJECTION, TOLAZOLINE HCL, UP TO 25 MG                                                    Totazoline hcl injection
J2675             $1.93   INJECTION, PROGESTERONE, PER 50 MG                                                        Inj progesterone per 50 MG
J2680             $1.14   INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG                                            Fluphenazine decanoate 25 MG
J2690             $0.90   INJECTION, PROCAINAMIDE HCL, UP TO 1 GM                                                   Procainamide hcl injection
J2700             $1.61   INJECTION, OXACILLIN SODIUM, UP TO 250 MG                                                 Oxacillin sodium injeciton




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Tab: 05 IMMUNIZATION RATE Table                                         Page 9 of 19                                                   Print Date: 8/30/2010
                                                                    IMMUNIZATION RATE
                                                                        TABLE 2005


HCPCS Codes   RATE                                              LONG DESCRIPTOR                                             SHORT DESCRIPTOR
J2710             $0.06   INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG                                        Neostigmine methylslfte inj
J2720             $0.36   INJECTION, PROTAMINE SULFATE, PER 10 MG                                                   Inj protamine sulfate/10 MG
J2725            $20.55   INJECTION, PROTIRELIN, PER 250 MCG                                                        Inj protirelin per 250 mcg
J2730            $85.79   INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM                                               Pralidoxime chloride inj
J2760            $22.47   INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG                                              Phentolaine mesylate inj
J2765             $0.45   INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG                                                Metoclopramide hcl injection
J2770           $103.25   INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350)                                    Quinupristin/dalfopristin
J2780             $0.93   INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG                                                Ranitidine hydrochloride inj
J2783           $107.01   INJECTION, RASBURICASE, 0.5 MG                                                            Rasburicase
J2788            $24.47   INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MCG                                 Rho d immune globulin 50 mcg
J2790           $102.36   INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MCG                               Rho d immune globulin inj
J2792            $13.40   INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVENT DETERGENT, 100 IU           Rho(D) immune globulin h, sd
J2794             $4.60   INJECTION, RISPERIDONE, LONG ACTING, 0.5 mg                                               Rrisperidone, Long Acting, 0.5 MG
J2795             $0.08   INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG                                                Ropivacaine HCl injection
J2800             $3.20   INJECTION, METHOCARBAMOL, UP TO 10 ML                                                     Methocarbamol injection
J2810             $0.38   INJECTION, THEOPHYLLINE, PER 40 MG                                                        Inj theophylline per 40 MG
J2820            $21.67   INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG                                                  Sargramostim injection
J2860            $40.00   INJECTION, SECOBARBITAL SODIUM, UP TO 250 MG                                              Secobarbital sodium inj
J2910            $14.62   INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG                                                   Aurothioglucose injeciton
J2912             $0.15   INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML                                                Sodium chloride injection
J2915            $40.00   INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 62.5 MG                  NA Ferric Gluconate Complex
J2916             $4.95   INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG                  Na ferric gluconate complex
J2920             $1.92   INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG                               Methylprednisolone injection
J2930             $2.62   INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG                              Methylprednisolone injection
J2940            $40.16   INJECTION, SOMATREM, 1 MG                                                                 Somatrem injection
J2941            $42.38   INJECTION, SOMATROPIN, 1 MG                                                               Somatropin injection
J2950             $0.38   INJECTION, PROMAZINE HCL, UP TO 25 MG                                                     Promazine hcl injection
J2970            $40.00   INJECTION, METHICILLIN SODIUM, UP TO 1 GM                                                 Methicillin sodium injection
J2993           $877.12   INJECTION, RETEPLASE, 18.1 MG                                                             Reteplase injection
J2994            $40.00   INJECTION RETEPLASE, 37.6 MG (TWO SINGLE USE VIALS)                                       Reteplase double bolus
J2995            $76.32   INJECTION, STREPTOKINASE, PER 250,000 IU                                                  Inj streptokinase /250000 IU
J2996            $40.00   INJECTION, ALTEPLASE RECOMBINANT, PER 10 MG                                               Alteplase recombinant inj
J2997            $31.74   INJECTION, ALTEPLASE RECOMBINANT, 1 MG                                                    Alteplase recombinant
J3000             $5.34   INJECTION, STREPTOMYCIN, UP TO 1 GM                                                       Streptomycin injection
J3010             $0.70   INJECTION, FENTANYL CITRATE, 0.1 MG                                                       Fentanyl citrate injeciton
                          INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG
                          ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF
J3030            $49.03   ADMINISTERED)                                                                             Sumatriptan succinate / 6 MG
J3070             $3.50   INJECTION, PENTAZOCINE, 30 MG                                                             Pentazocine injection
J3080            $40.00   INJECTION, CHLORPROTHIXENE, UP TO 50 MG                                                   Chlorprothixene injection
J3100         $2,040.05   INJECTION, TENECTEPLASE, 50MG                                                             Tenecteplase injection




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Tab: 05 IMMUNIZATION RATE Table                                         Page 10 of 19                                                    Print Date: 8/30/2010
                                                                      IMMUNIZATION RATE
                                                                          TABLE 2005


HCPCS Codes   RATE                                                LONG DESCRIPTOR                  SHORT DESCRIPTOR
J3105            $12.66   INJECTION, TERBUTALINE SULFATE, UP TO 1 MG                       Terbutaline sulfate inj
J3110             $6.99   INJECTION, TERIPARATIDE, 10 MCG                                  Teriparatide Injection, 10 mcg
J3120             $7.49   INJECTION, TESTOSTERONE ENANTHATE, UP TO 100 MG                  Testosterone enanthate inj
J3130            $14.99   INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG                  Testosterone enanthate inj
J3140             $0.56   INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG                  Testosterone suspension inj
J3150             $0.79   INJECTION, TESTOSTERONE PROPIONATE, UP TO 100 MG                 Testosteron propionate inj
J3230             $2.39   INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG                       Chlorpromazine hcl injection
J3240           $699.60   INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG VIAL    Thyrotropin injection
J3246             $7.85   INJECTION, TIROFIBAN HCI,0.25 mg                                 Tirofiban HCI, 0.25 mg
J3250             $4.12   INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG                   Trimethobenzamide hcl inj
J3260             $1.98   INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG                       Tobramycin sulfate injection
J3265             $2.28   INJECTION, TORSEMIDE, 10 MG/ML                                   Injection torsemide 10 mg/ml
J3270            $40.00   INJECTION, IMIPRAMINE HCL, UP TO 25 MG                           Imipramine hcl injection
J3280             $4.76   INJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MG                 Thiethylperazine maleate inj
J3301             $1.32   INJECTION, TRIAMCINOLONE ACETONIDE, PER 10MG                     Triamcinolone acetonide inj
J3302             $0.23   INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG                      Triamcinolone diacetate inj
J3303             $1.76   INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG                   Triamcinolone hexacetonl inj
J3305           $136.93   INJECTION, TRIMETREXATE GLUCURONATE, PER 25 MG                   Inj trimetrexate glucoronate
J3310            $40.00   INJECTION, PERPHENAZINE, UP TO 5 MG                              Perphenazine injeciton
J3315           $180.93   INJECTION, TRIPTORELIN PAMOATE, 3.75 MG                          Triptorelin pamoate
J3320            $28.65   INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GM             Spectinomycn di-hcl inj
J3350            $40.00   INJECTION, UREA, UP TO 40 GM                                     Urea injection
J3360             $0.56   INJECTION, DIAZEPAM, UP TO 5 MG                                  Diazepam injection
J3364             $8.15   INJECTION, UROKINASE, 5000 IU VIAL                               Urokinase 5000 IU injection
J3365           $407.54   INJECTION, IV, UROKINASE, 250,000 I.U. VIAL                      Urokinase 250,000 IU inj
J3370             $2.98   INJECTION, VANCOMYCIN HCL, 500 MG                                Vancomycin hcl injection
J3390            $40.00   INJECTION, METHOXAMINE HCL, UP TO 20 MG                          Methoxamine injection
J3396             $8.99   INJECTION, VERTEPORFIN, 0.1 MG                                   Verteporfin Injection, 0.1 mg
J3400            $40.00   INJECTION, TRIFLUPROMAZINE HCL, UP TO 20 MG                      Triflupromazine hcl inj
J3410             $0.35   INJECTION, HYDROXYZINE HCL, UP TO 25 MG                          Hydroxyzine hcl injection
J3411             $0.58   INJECTION, THIAMINE HCL, 100 MG                                  Thiamine hcl 100 mg
J3415             $2.36   INJECTION, PYRIDOXINE HCL, 100 MG                                Pyridoxine hcl 100 mg
J3420             $0.47   INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG           Vitamin b12 injection
J3430             $0.47   INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG                    Vitamin k phytonadione inj
J3450            $40.00   INJECTION, MEPHENTERMINE SULFATE, UP TO 30 MG                    Mephentermine sulfate inj
J3465             $4.55   INJECTION, VORICONAZOLE, 10 MG                                   Injection, voriconazole
J3470            $20.00   INJECTION, HYALURONIDASE, UP TO 150 UNITS                        Hyaluronidase injection
J3475             $0.01   INJECTION, MAGNESIUM SULFATE, PER 500 MG                         Inj magnesium sulfate
J3480             $0.08   INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ                         Inj potassium chloride
J3485             $0.96   INJECTION, ZIDOVUDINE, 10 MG                                     Zidovudine
J3486            $18.74   INJECTION, ZIPRASIDONE MESYLATE, 10 MG                           Ziprasidone mesylate




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Tab: 05 IMMUNIZATION RATE Table                                            Page 11 of 19                         Print Date: 8/30/2010
                                                                    IMMUNIZATION RATE
                                                                        TABLE 2005


HCPCS Codes   RATE                                              LONG DESCRIPTOR                                                  SHORT DESCRIPTOR
J3487           $198.39    INJECTION, ZOLEDRONIC ACID, 1 MG                                                             Zoledronic acid
J3490            $40.00    UNCLASSIFIED DRUGS                                                                           Drugs unclassified injection
J3520            $40.00    EDETATE DISODIUM, PER 150 MG                                                                 Edetate disodium per 150 mg
J3530            $40.00    NASAL VACCINE INHALATION                                                                     Nasal vaccine inhalation
J3535            $40.00    DRUG ADMINISTERED THROUGH A METERED DOSE INHALER                                             Metered dose inhaler drug
J3570            $40.00    LAETRILE, AMYGDALIN, VITAMIN B17                                                             Laetrile amygdalin vit B17
J3590            $40.00    UNCLASSIFIED BIOLOGICS                                                                       Unclassified biologics
J7030             $0.10    INFUSION, NORMAL SALINE SOLUTION , 1000 CC                                                   Normal saline solution infus
J7040             $0.05    INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT)                                    Normal saline solution infus
J7042             $0.14    5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT)                                                  5% dextrose/normal saline
J7050             $0.02    INFUSION, NORMAL SALINE SOLUTION , 250 CC                                                    Normal saline solution infus
J7051             $0.01    STERILE SALINE OR WATER, UP TO 5 CC                                                          Sterile saline/water
J7060             $0.79    5% DEXTROSE/WATER (500 ML = 1 UNIT)                                                          5% dextrose/water
J7070             $2.73    INFUSION, D5W, 1000 CC                                                                       D5w infusion
J7100            $14.05    INFUSION, DEXTRAN 40, 500 ML                                                                 Dextran 40 infusion
J7110            $10.71    INFUSION, DEXTRAN 75, 500 ML                                                                 Dextran 75 infusion
J7120             $0.76    RINGERS LACTATE INFUSION, UP TO 1000 CC                                                      Ringers lactate infusion
J7130             $1.25    HYPERTONIC SALINE SOLUTION, 50 OR 100 MEQ, 20 CC VIAL                                        Hypertonic saline solution
J7190             $0.52    FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.                                          Factor viii
J7191             $1.72    FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U.                                      Factor VIII (porcine)
J7192             $0.92    FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.                                    Factor viii recombinant
J7193             $0.75    FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.                        Factor IX non-recombinant
J7194             $0.49    FACTOR IX, COMPLEX, PER I.U.                                                                 Factor ix complex
J7195             $0.84    FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.                                      Factor IX recombinant
J7197             $1.58    ANTITHROMBIN III (HUMAN), PER I.U.                                                           Antithrombin iii injection
J7198             $1.09    ANTI-INHIBITOR, PER I.U.                                                                     Anti-inhibitor
J7199            $40.00    HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED                                         Hemophilia clot factor noc
J7300            $40.00    INTRAUTERINE COPPER CONTRACEPTIVE                                                            Intraut copper contraceptive
J7302            $40.00    LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG                            Levonorgestrel iu contracept
J7303            $40.00    CONTRACEPTIVE SUPPLY, HORMONE CONTAINING VAGINAL RING, EACH                                  Contraceptive vaginal ring
J7308             $87.65   AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SINGLE UNIT DOSAGE FORM (354 MG)    Aminolevulinic acid hcl top
J7310          $4,240.00   GANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANT                                                     Ganciclovir long act implant
J7315             $40.00   SODIUM HYALURONATE, 20 MG, FOR INTRA ARTICULAR INJECTION                                     Sodium hyaluronate injection
J7316             $40.00   SODIUM HYALURONATE, 5 MG FOR INTRA-ARTICULAR INJECTION                                       Sodium hyaluronate injection
J7317            $110.27   SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR INJECTION                       Sodium hyaluronate injection
J7320            $200.15   HYLAN G-F 20, 16 MG, FOR INTRA ARTICULAR INJECTION                                           Hylan G-F 20 injection
J7330         $16,284.90   AUTOLOGOUS CULTURED CHONDROCYTES, IMPLANT                                                    Cultured chondrocytes implnt
                           DERMAL AND EPIDERMAL TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT BIOENGINEERED OR PROCESSED
J7340            $26.51    ELEMENTS, WITH METABOLICALLY ACTIVE ELEMENTS, PER SQUARE CENTIMETER                          Metabolic active D/E tissue
                           DERMAL TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENGINEERED OR PROCESSED ELEMENTS,
J7342            $15.32    WITH METABOLICALLY ACTIVE ELEMENTS, PER SQUARE CENTIMETER                                    Metabolically active tissue




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                                                                  IMMUNIZATION RATE
                                                                      TABLE 2005


HCPCS Codes   RATE                                           LONG DESCRIPTOR                                                 SHORT DESCRIPTOR

J7343            $6.60 DERMAL AND EPIDERMAL, TISSUE OF NON-HUMAN ORIGIN                                              Nonmetabolic Act D/E Tissue 1 sq. cm

J7344            $59.63 DERMAL TISSUE OF HUMAN ORIGAN, 1 SQ. CM                                                      Nonmetabolic Active Tissue 1 sq. cm
                        DERMAL TISSUE OF HUMAN ORIGIN, INJECTABLE, WITH OR WITHOUT OTHER BIOENGINEERED 'OR
J7350             $4.53 PROCESSED ELEMENTS, BUT WITHOUT METABOLIZED ACTIVE ELEMENTS, PER 10 MG                       Injectable human tissue
J7500             $0.19 AZATHIOPRINE, ORAL, 50 MG                                                                    Azathioprine oral 50mg
J7501            $46.88 AZATHIOPRINE, PARENTERAL, 100 MG                                                             Azathioprine parenteral
J7502             $3.90 CYCLOSPORINE, ORAL, 100 MG                                                                   Cyclosporine oral 100 mg
J7504           $283.59 LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL, 250 MG               Lymphocyte immune globulin
J7505           $830.01 MUROMONAB-CD3, PARENTERAL, 5 MG                                                              Monoclonal antibodies
J7506             $0.22 PREDNISONE, ORAL, PER 5MG                                                                    Prednisone oral
J7507             $3.31 TACROLIMUS, ORAL, PER 1 MG                                                                   Tacrolimus oral per 1 MG
J7508            $40.00 TACROLIMUS, ORAL, PER 5 MG                                                                   Tacrolimus oral per 5 MG
J7509             $0.07 METHYLPREDNISOLONE ORAL, PER 4 MG                                                            Methylprednisolone oral
J7511           $297.78 LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL, 25MG                 Antithymocyte globuln rabbit
J7513           $380.28 DACLIZUMAB, PARENTERAL, 25 MG                                                                Daclizumab, parenteral
J7515             $0.99 CYCLOSPORINE, ORAL, 25 MG                                                                    Cyclosporine oral 25 mg
J7516            $20.59 CYCLOSPORIN, PARENTERAL, 250 MG                                                              Cyclosporin parenteral 250mg
J7517             $2.51 MYCOPHENOLATE MOFETIL, ORAL, 250 MG                                                          Mycophenolate mofetil oral
J7518             $2.42 MYCOPHENOLIC ACID, ORAL, 180 MG                                                              Mycophenolic Acid 180 mg
J7520             $6.73 SIROLIMUS, ORAL, 1 MG                                                                        Sirolimus, oral
J7525           $124.27 TACROLIMUS, PARENTERAL, 5 MG                                                                 Tacrolimus injection
J7599            $40.00 IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED                                             Immunosuppressive drug noc
J7608             $2.30 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM       Acetylcysteine inh sol u d
J7610            $40.00 ACETYLCYSTEINE, 10%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME                    Acetylcysteine 10% injection
J7611            $0.07 ALBUTEROL, INHALATION SOLUTION, ADMINISTEDED THROUGH DME, CONCENTRATED, 1 MG                  Albuterol Concentrated Form, 1 mg
J7612            $0.87 LEVALBUTEROL, INHALATION SOLUTION, ADMINISTERED THROUGH DME, CONCENTRATED, 0.5 CM             Levalbuterol Concentrated, 0.5 mg
J7613            $0.07 ALBUTEROL. INHALATION SOLUTION, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG                     Albuterol Unit Dose, 1 mg
J7614             $1.28 LEVALBUTEROL, INHALATION SOLUTION, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG               Levalbuterol Unit Dose, 0.5 mg
J7615            $40.00 ACETYLCYSTEINE, 20%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME                    Acetylcysteine 20% injection
J7616             $4.03 ALBUTEROL, UP TO 5 MG, COMPOUNDED INHALATION SOLUTION, ADMINISTEDED THROUGH DME              Albuterol Compound Solution 1 Unit
J7626             $4.03 BUDESONIDE INHALATION SOLUTION, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 0.25 TO 0.50 MG    Budesonide inhalation sol
                        CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10
J7631             $0.10 MILLIGRAMS                                                                                   Cromolyn sodium inh sol u d

J7639            $16.93 DORNASE ALPHA, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM   Dornase alpha inhal sol u d
J7640            $40.00 EPINEPHRINE, 2.25%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME                     Epinephrine injection
                        IPRATROPIUM BROMIDE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER
J7644             $0.29 MILLIGRAM                                                                                    Ipratropium brom inh sol u d
J7645            $40.00 IPRATROPIUM BROMIDE 0.02%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH A DME            Ipratropium bromide .02%/ml




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Tab: 05 IMMUNIZATION RATE Table                                       Page 13 of 19                                                       Print Date: 8/30/2010
                                                                    IMMUNIZATION RATE
                                                                        TABLE 2005


HCPCS Codes   RATE                                              LONG DESCRIPTOR                                                     SHORT DESCRIPTOR
                        ISOETHARINE HCL, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER
J7648            $40.00 MILLIGRAM                                                                                          Isoetharine hcl inh sol con

J7649            $40.00 ISOETHARINE HCL, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Isoetharine hcl inh sol u d
J7650            $40.00 ISOETHARINE HYDROCHLORIDE, 0.1%, PER ML, INHALATION SOLUTION ADMINISTERED TRHOUGH DME              Isoetharine hcl .1% inj
J7651            $40.00 ISOETHARINE HYDROCHLORIDE, 0.125%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME            Isoetharine hcl .125% inj
J7652            $40.00 ISOETHARINE HYDROCHLORIDE, 0.167%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME            Isoetharine hcl .167% inj
J7653            $40.00 ISOETHARINE HYDROCHLORIDE, 0.2%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME              Isoetharine hcl .2%/ inj
J7654            $40.00 ISOETHARINE HYDROCHLORIDE, 0.25%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME             Isoetharine hcl .25% inj
J7655            $40.00 ISOETHARINE HYDROCHLORIDE, 1.0%, PER ML, INHALATION SOLUTION ADMINISTERED TRHOUGH DME              Isoetharine hcl 1% inj
J7660            $40.00 ISOPROTERENOL HYDROCHLORIDE, 0.5%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME            Isoproterenol hcl .5% inj
J7665            $40.00 ISOPROTERENOL HYDROCHLORIDE, 1.0%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME   Isoproterenol hcl 1% inj
                        METAPROTERENOL SULFATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM,
J7668            $40.00 PER 10 MILLIGRAMS                                                                         Metaproterenol inh sol con
                        METAPROTERENOL SULFATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER
J7669             $0.26 10 MILLIGRAMS                                                                             Metaproterenol inh sol u d
J7670            $40.00 METAPROTERENOL SULFATE, 0.4%, PER 2.5 ML, INHALATION SOLUTION ADMINISTERED THROUGH DME             Metaproterenol sulfate .4%
J7672            $40.00 METAPROTERENOL SULFATE, 0.6%, PER 2.5 ML, INHALATION SOLUTION ADMINISTERED THROUGH DME             Metaproterenol sulfate .6%
J7674             $0.41 METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION THROUGH A NEBULIZER, PER 1MG             Methacholine Chloride, Neb, 1 mg
J7675            $40.00 METAPROTERENOL SULFATE, 5.0%, PER ML, INHALATION SOLUTION ADMINISTERED THROUGH DME                 Metaproterenol sulfate 5%
J7682            $46.98 TOBRAMYCIN, UNIT DOSE FORM, 300 MG, INHALATION SOLUTION, ADMINISTERED THROUGH DME                  Tobramycin inhalation sol
J7683             $0.10 TRIAMCINOLONE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PR MG                 Triamcinolone inh sol u d
J8501             $4.62 APREPITANT, ORAL,5MG                                                                               Oral Aprepitant, 5 mg
J8510             $1.91 BUSULFAN; ORAL, 2 MG                                                                               Oral busulfan
J8520             $3.24 CAPECITABINE, ORAL, 150 MG                                                                         Capecitabine, oral, 150 mg
J8521            $10.76 CAPECITABINE, ORAL, 500 MG                                                                         Capecitabine, oral, 500 mg
J8530             $1.02 CYCLOPHOSPHAMIDE; ORAL, 25 MG                                                                      Cyclophosphamide oral 25 MG
J8560            $31.03 ETOPOSIDE; ORAL, 50 MG                                                                             Etoposide oral 50 MG
J8600             $2.19 MELPHALAN; ORAL, 2 MG                                                                              Melphalan oral 2 MG
J8610             $0.21 METHOTREXATE; ORAL, 2.5 MG                                                                         Methotrexate oral 2.5 MG
J8700             $7.17 TEMOZOLOMIDE, ORAL, 5 MG                                                                           Temozolomide
J9000             $4.25 DOXORUBICIN HCL, 10 MG                                                                             Doxorubic hcl 10 MG vl chemo
J9001           $393.48 DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MG                                           Doxorubicin hcl liposome inj
J9010           $511.48 ALEMTUZUMAB, 10 MG                                                                                 Alemtuzumab injection
J9015           $672.06 ALDESLEUKIN, PER SINGLE USE VIAL                                                                   Aldesleukin/single use vial
J9017            $33.30 ARSENIC TRIOXIDE, 1MG                                                                              Arsenic trioxide
J9020            $54.52 ASPARAGINASE, 10,000 UNITS                                                                         Asparaginase injection
J9031           $118.41 BCG (INTRAVESICAL) PER INSTILLATION                                                                Bcg live intravesical vac
J9035            $57.08 INJECTION, BEVACIZUMAB, 10 MG                                                                      Bevacizumab, Injection 10 mg




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Tab: 05 IMMUNIZATION RATE Table                                          Page 14 of 19                                                               Print Date: 8/30/2010
                                                                   IMMUNIZATION RATE
                                                                       TABLE 2005


HCPCS Codes   RATE                                              LONG DESCRIPTOR                 SHORT DESCRIPTOR
J9040           $289.37 BLEOMYCIN SULFATE, 15 UNITS                                    Bleomycin sulfate injection
J9041            $28.38 INJECTION, BORTEZOMIB 0.1 MG                                   Bortezomib Injection, 0.1 mg
J9045           $125.47 CARBOPLATIN, 50 MG                                             Carboplatin injection
J9050           $139.10 CARMUSTINE, 100 MG                                             Carmus bischl nitro inj
J9055            $49.64 INJECTION, CETUXIMAB, 1O MG                                    Cetuximab Injection, 10 mg
J9060             $4.96 CISPLATIN, POWDER OR S0LUTION, PER 10 MG                       Cisplatin 10 MG injection
J9062            $18.37 CISPLATIN, 50 MG                                               Cisplatin 50 MG injection
J9065            $61.72 INJECTION, CLADRIBINE, PER 1 MG                                Inj cladribine per 1 MG
J9070             $2.34 CYCLOPHOSPHAMIDE, 100 MG                                       Cyclophosphamide 100 MG inj
J9080             $4.69 CYCLOPHOSPHAMIDE, 200 MG                                       Cyclophosphamide 200 MG inj
J9090            $13.91 CYCLOPHOSPHAMIDE, 500 MG                                       Cyclophosphamide 500 MG inj
J9091            $23.43 CYCLOPHOSPHAMIDE, 1.0 GRAM                                     Cyclophosphamide 1.0 grm inj
J9092            $46.86 CYCLOPHOSPHAMIDE, 2.0 GRAM                                     Cyclophosphamide 2.0 grm inj
J9093             $0.60 CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MG                          Cyclophosphamide lyophilized
J9094             $1.21 CYCLOPHOSPHAMIDE, LYOPHILIZED, 200 MG                          Cyclophosphamide lyophilized
J9095             $3.02 CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MG                          Cyclophosphamide lyophilized
J9096             $6.04 CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM                        Cyclophosphamide lyophilized
J9097            $12.08 CYCLOPHOSPHAMIDE, LYOPHILIZED, 2.0 GRAM                        Cyclophosphamide lyophilized
J9098           $350.45 CYTARABINE LIPOSOME, 10 MG                                     Cytarabine liposome
J9100             $8.19 CYTARABINE, 100 MG                                             Cytarabine hcl 100 MG inj
J9110             $8.55 CYTARABINE, 500 MG                                             Cytarabine hcl 500 MG inj
J9120            $12.07 DACTINOMYCIN, 0.5 MG                                           Dactinomycin actinomycin d
J9130             $5.29 DACARBAZINE, 100 MG                                            Dacarbazine 100 mg inj
J9140            $11.25 DACARBAZINE, 200 MG                                            Dacarbazine 200 MG inj
J9150            $27.42 DAUNORUBICIN, 10 MG                                            Daunorubicin
J9151            $55.99 DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG             Daunorubicin citrate liposom
J9160         $1,205.53 DENILEUKIN DIFTITOX, 300 MCG                                   Denileukin diftitox, 300 mcg
J9170           $297.58 DOCETAXEL, 20 MG                                               Docetaxel
J9178            $25.41 INJECTION, EPIRUBICIN HCL, 2 MG                                Inj, epirubicin hcl, 2 mg
J9181             $0.45 ETOPOSIDE, 10 MG                                               Etoposide 10 MG inj
J9182             $4.51 ETOPOSIDE, 100 MG                                              Etoposide 100 MG inj
J9185           $272.09 FLUDARABINE PHOSPHATE, 50 MG                                   Fludarabine phosphate inj
J9190             $2.07 FLUOROURACIL, 500 MG                                           Fluorouracil injection
J9200           $136.80 FLOXURIDINE, 500 MG                                            Floxuridine injection
J9201           $115.34 GEMCITABINE HCL, 200 MG                                        Gemcitabine HCl
J9202           $189.79 GOSERELIN ACETATE IMPLANT, PER 3.6 MG                          Goserelin acetate implant
J9206           $125.58 IRINOTECAN, 20 MG                                              Irinotecan injection
J9208           $150.38 IFOSFAMIDE, 1 GM                                               Ifosfomide injection




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                                                                   IMMUNIZATION RATE
                                                                       TABLE 2005


HCPCS Codes   RATE                                             LONG DESCRIPTOR                   SHORT DESCRIPTOR
J9209            $16.69 MESNA, 200 MG                                                   Mesna injection
J9211           $317.27 IDARUBICIN HYDROCHLORIDE, 5 MG                                  Idarubicin hcl injection
J9212             $3.59 INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG             Interferon alfacon-1
J9213            $30.84 INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS               Interferon alfa-2a inj
J9214            $13.12 INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS               Interferon alfa-2b inj
J9215             $8.60 INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU      Interferon alfa-n3 inj
J9216           $292.24 INTERFERON, GAMMA 1-B, 3 MILLION UNITS                          Interferon gamma 1-b inj
J9217           $253.13 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG               Leuprolide acetate suspnsion
J9218            $13.49 LEUPROLIDE ACETATE, PER 1 MG                                    Leuprolide acetate injeciton
J9219         $2,206.27 LEUPROLIDE ACETATE IMPLANT, 65 MG                               Leuprolide acetate implant
J9230            $10.45 MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG        Mechlorethamine hcl inj
J9245           $388.73 INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG                       Inj melphalan hydrochl 50 MG
J9250             $0.20 METHOTREXATE SODIUM, 5 MG                                       Methotrexate sodium inj
J9260             $2.16 METHOTREXATE SODIUM, 50 MG                                      Methotrexate sodium inj
J9263             $8.24 INJECTION, OXALIPLATIN, 0.5 MG                                  Oxaliplatin
J9265            $15.85 PACLITAXEL, 30 MG                                               Paclitaxel injection
J9266         $1,459.21 PEGASPARGASE, PER SINGLE DOSE VIAL                              Pegaspargase/singl dose vial
J9268         $1,870.88 PENTOSTATIN, PER 10 MG                                          Pentostatin injection
J9270            $78.99 PLICAMYCIN, 2.5 MG                                              Plicamycin (mithramycin) inj
J9280           $127.40 MITOMYCIN, 5 MG                                                 Mitomycin 5 MG inj
J9290            $65.91 MITOMYCIN, 20 MG                                                Mitomycin 20 MG inj
J9291           $141.14 MITOMYCIN, 40 MG                                                Mitomycin 40 MG inj
J9293           $321.80 INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG                 Mitoxantrone hydrochl / 5 MG
J9300         $2,203.67 GEMTUZUMAB OZOGAMICIN, 5MG                                      Gemtuzumab ozogamicin
J9305            $40.54 INJECTION, PEMETREXED, 10 MG                                    Pemetrexed Injection 10 mg
J9310           $442.01 RITUXIMAB, 100 MG                                               Rituximab cancer treatment
J9320           $153.82 STREPTOZOCIN, 1 GM                                              Streptozocin injection
J9340            $43.57 THIOTEPA, 15 MG                                                 Thiotepa injection
J9350           $739.69 TOPOTECAN, 4 MG                                                 Topotecan
J9355            $58.13 TRASTUZUMAB, 10 MG                                              Trastuzumab
J9357           $369.60 VALRUBICIN, INTRAVESICAL, 200 MG                                Valrubicin, 200 mg
J9360             $4.10 VINBLASTINE SULFATE, 1 MG                                       Vinblastine sulfate inj
J9370            $33.98 VINCRISTINE SULFATE, 1 MG                                       Vincristine sulfate 1 MG inj
J9375            $67.96 VINCRISTINE SULFATE, 2 MG                                       Vincristine sulfate 2 MG inj
J9380           $169.91 VINCRISTINE SULFATE, 5 MG                                       Vincristine sulfate 5 MG inj
J9390            $69.09 VINORELBINE TARTRATE, PER 10 MG                                 Vinorelbine tartrate/10 mg
J9395            $80.51 INJECTION, FULVESTRANT, 25 MG                                   Injection, Fulvestrant
J9600         $2,285.15 PORFIMER SODIUM, 75 MG                                          Porfimer sodium




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                                                                     IMMUNIZATION RATE
                                                                         TABLE 2005


HCPCS Codes   RATE                                                LONG DESCRIPTOR                  SHORT DESCRIPTOR
P9041            $14.54 ALBUMIN (HUMAN),5%, 50ML                                          Albumin (human) inf 5% 50 ml
P9043            $14.54 PLASMA PROTEIN FRACT,5%,50ML                                      Plasma protein fract inf 5% 50 ml
P9045            $61.25 ALBUMIN (HUMAN), 5%, 250 ML                                       Albumin (human) inf 5% 250 ml
P9046            $14.54 ALBUMIN (HUMAN), 25%, 20 ML                                       Albumin (human) inf 25% 20 ml
P9047            $55.10 ALBUMIN (HUMAN), 25%, 50ML                                        Albumin (human) inf 25% 50 ml
P9048            $29.10 PLASMAPROTEIN FRACT,5%,250ML                                      Plasma protein fract inf 5% 250 ml
Q0136            $10.18 NON ESRD EPOETIN ALPHA INJ                                        Epoetin alpha inj (non ESRD)
Q0137             $3.54 DARBEPOETIN ALFA, NON-ESRD                                        Darbepoetin alfa inj (non ESRD)
Q0163             $0.03 DIPHENHYDRAMINE HCL 50MG                                          Diphenhydramine HCL oral 50 mg
Q0164             $0.06 PROCHLORPERAZINE MALEATE 5MG                                      Prochlorperzine maleate oral 5 mg
Q0165             $0.04 PROCHLORPERAZINE MALEATE10MG                                      Prochlorperzine maleate oral 10 mg
Q0166            $32.54 GRANISETRON HCL 1 MG ORAL                                         Granisetron HCL oral 1 mg
Q0167             $4.00 DRONABINOL 2.5MG ORAL                                             Dronabinol oral 2.5 mg
Q0168             $8.31 DRONABINOL 5MG ORAL                                               Dronabinol oral 5 ma
Q0169             $0.28 PROMETHAZINE HCL 12.5MG ORAL                                      Promethazine HCL oral 12.5 mg
Q0170             $0.16 PROMETHAZINE HCL 25 MG ORAL                                       Promethazine HCL oral 25 mg
Q0171             $0.10 CHLORPROMAZINE HCL 10MG ORAL                                      Chlorpromazine HCL oral 10 mg
Q0172             $0.09 CHLORPROMAZINE HCL 25MG ORAL                                      Chlorpromazine HCL oral 25 mg
Q0175             $0.21 PERPHENAZINE 4MG ORAL                                             Perphenazine oral 4 mg
Q0176             $0.26 PERPHENAZINE 8MG ORAL                                             Perphenazine oral 8 mg
Q0177             $0.07 HYDROXYZINE PAMOATE 25MG                                          Hydroxyzine pamoate oral 25 mg
Q0178             $0.08 HYDROXYZINE PAMOATE 50MG                                          Hydroxyzine pamoate oral 50 mg
Q0179            $30.86 ONDANSETRON HCL 8MG ORAL                                          Ondansetron HCL oral 8 mg
Q0180            $47.42 DOLASETRON MESYLATE ORAL                                          Dolasetron mesylate oral 100 mg
Q0187         $1,043.05 FACTOR VIIA RECOMBINANT PER 1.2 MG                                Factor VIIA recombinant
Q2002             $2.98 INJECTION, ELLIOTT'S B SOLUTION, PER ML                           Elliott's B Solution Per ml
Q2003             $2.15 INJECTION, APROTININ, 10,000 KIU                                  Aprotinin, 10,000 KIU
Q2006           $555.03 INJECTION, DIGOXIN IMMUNE FAB (OVINE), PER VIAL                   Digoxin Immune Fab (ovine) per vial
Q2007            $63.36 INJECTION, ETHANOLAMINE OLEATE, 100 MG                            Ethanolamine Oleate 100 mg
Q2008            $11.55 INJECTION, FOMEPIZOLE, 15 MG                                      Fomepizole, 15 mg
Q2009             $5.10 FOSPHENYTOIN, 50 MG                                               Fosphenytoin inj 50 mg
Q2011             $6.39 HEMIN, PER 1 MG                                                   Hemin inj per 1 mg
Q2012           $154.05 PEGADEMASE BOVINE 25 IU                                           Pegademase inj, 25 IU
Q2014             $8.77 SERMORELIN ACETATE, 0.5 MG                                        Sermorelin inj, 0.5 mg
Q2017           $263.67 TENIPOSIDE 50 MG                                                  Teniposide inj, 50 mg
Q2019         $1,476.21 BASILIXIMAB, 20 MG                                                Basiliximab inj 20 mg
Q2021           $133.75 LEPIRUDIN 50 MG                                                   Lepirudin inj 50 mg
Q2022             $0.72 VONWILLEBRANDFACTRCMPLXPERIU                                      von Willebrand factor




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                                                           IMMUNIZATION RATE
                                                               TABLE 2005


HCPCS Codes   RATE                                      LONG DESCRIPTOR                 SHORT DESCRIPTOR
Q3025            $85.18 IM INJ INTERFERON BETA 1-A                             Interferon beta inj 11 mcg
Q4054             $3.54 DARBEPOETIN ALFA, ESRD USE                             Darbepoetin alfa (ESRD use) inj 1 mcg
Q4055             $9.76 EPOETIN ALFA, ESRD USE                                 Epoetin alfa (ESRD use) inj 1000 units
Q4075             $0.47 ACYCLOVIR, 5 MG                                        Acyclovir inj 5 mg
Q4076             $0.72 INJ OF DOPAMINE HYDROCHLORIDE                          Dopamine hydrochloride inj 40 mg
Q4077            $61.75 INJECTION OF TREPROSTINIL                              Treprostinil inj 1 mg




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Tab: 05 IMMUNIZATION RATE Table                                Page 18 of 19                           Print Date: 8/30/2010
                                                    IMMUNIZATION RATE
                                                        TABLE 2005


HCPCS Codes   RATE                               LONG DESCRIPTOR        SHORT DESCRIPTOR




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Tab: 05 IMMUNIZATION RATE Table                         Page 19 of 19            Print Date: 8/30/2010

								
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