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Injections: Code List                                                                                   1
This section contains a comprehensive list of Medi-Cal reimbursable injection codes. For injection policy
information, refer to the Injections: An Overview, Injections: Drugs A-L Policy, Injections: Drugs M-Z
Policy, Injections: Hydration and Non-Injectable Drugs sections in this manual. For a list of the most
frequently used vaccines, refer to the Immunizations Code List section in this manual.




2 – Injections: Code List
                                                                                             November 2010
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                                                                  Codes                                                                         Codes

A
Abatacept – 10 mg .................................................. J0129     Anabolin LA 100 – 100 mg/ml (oil) ......................... X5600
AbobotulinumtoxinA (DYSPORT), per 5 units ......... J0586                      Ancef – 10 gm/100 ml vial...................................... X5602
Acetazolamide – 500 mg/vial ................................. X5500            Ancef – 1 gm/redi vial ............................................ X5604
Acetylcysteine – 100 mg ......................................... J0132        Ancef – 1 gm/100 ml piggyback unit ...................... X5606
Acyclovir – 5 mg ..................................................... J0133   Ancef – 1 gm/10 ml vial ......................................... X5608
Adenosine – 6 mg/ml (therapeutic use) ................... J0150                Ancef – 500 mg/100 ml vial.................................... X5610
Adenosine – 30 mg/ml (diagnostic use)................... J0152                 Ancef – 500 mg/10 ml vial...................................... X5612
Adrenalin Chloride – 1 mg/ml ................................. X5528           Ancef – 250 mg/10 ml vial...................................... X5614
Adrenalin Chloride Solution –                                                  Andro-Cyp 100 – 100 mg/ml .................................. X5618
 1:1,000 solution ................................................... X5530    Android HCG – 1,000 units/ml ............................... X5622
Agalsidase beta – 1.0 mg........................................ J0180         Android-T – 50 mg/ml ............................................ X5628
Aldesleukin – 22 million IU ..................................... X7632        Androlone-D 100 – 100 mg/ml (oil) ........................ X5600
Aldomet – 250 mg/5 ml .......................................... X5540         Androlone-D 50 – 50 mg/ml (oil) ............................ X5632
Alglucosidase alfa – 10 mg ..................................... J0220         Andronaq – 50 mg/ml ............................................ X5628
A-Methapred – 40 mg/ml........................................ X5554           Andronate 100 – 100 mg/ml................................... X5618
Amicar – 250 mg/ml ............................................... X5556       Anectine – 20 mg/ml .............................................. X5636
Amifostine – 500 mg .............................................. X7642       Anidulafungin – 1 mg .............................................. J0348
Amikacin Sulfate – 1 gm/4 ml vial........................... X5558             Antilirium – 1 mg/ml ................................................ J3490
Amikacin Sulfate – 500 mg/2 ml vial ....................... X5562              Antispas – 10 mg/ml .............................................. X5642
Amikacin Sulfate – 100 mg/2 ml vial ....................... X5560              Antuitrin – 500 units/ml .......................................... X5644
Amikin – 1 gm/4 ml vial .......................................... X5558       AnzemetTM – 10 mg ................................................ J1260
Amikin – 500 mg/2 ml vial ...................................... X5562         A.P.L. Secules – 2,000 units/ml ............................. X5646
Amikin – 100 mg/2 ml vial ...................................... X5560         A.P.L. Secules – 1,000 units/ml ............................. X5622
Aminocaproic acid – 250 mg/ml ............................. X5556              A.P.L. Secules – 500 units/ml ................................ X5644
Amitriptyline HCl – 10 mg/ml .................................. X5564          Apresoline – 20 mg/ml ........................................... X5648
Amobarbital Sodium – 500 mg ............................... X5566              Aqua Mephyton – 10 mg/ml ................................... X5650
Amphotericin B – 50 mg .......................................... J0285        Aqua Mephyton – 2 mg/ml ..................................... X5652
Amphotericin b lipid complex – 10 mg ..................... J0287               Aralen – 50 mg/ml ................................................. X5656
Amphotericin b cholesteryl sulfate                                             Ardefem 20 – 20 mg/ml ......................................... X5660
 complex – 10 mg .................................................. J0288      Ardefem 10 – 10 mg/ml ......................................... X5662
Amphotericin b liposome – 10 mg ........................... J0289
Ampicillin Sodium, 500 mg...................................J0290




2 – Injections: Code List
                                                                                                                                            April 2011
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                                                                   Codes                                                                             Codes

Aripiprazole – 0.25 mg ............................................ J0400       Berubigen – 1,000 mcg/ml ..................................... X5752
Ascorbic Acid – 500 mg/ml ...................................... J3490          Bestrone – 2 mg/ml ............................................... X5756
Ascorbic Acid – 250 mg/ml ...................................... J3490          Betalin 12 – 1,000 mcg/ml ......................................X5752
Asparaginase – 10,000 IU/10 ml vial ...................... X7504                Betamethasone Acetate 3 mg and
Atropine Sulfate – 0.01 mg...................................... J0461          Betamethasone Sodium Phosphate –
Aurothioglucose – 50 mg/ml ................................... X5708             3 mg .................................................................... J0702
Avastin – 10 mg ...................................................... J9035    Bevacizumab – 10 mg ............................................ J9035
Azacitidine – 1 mg/ml .............................................. J9025      BICNU – 100 mg/vial ............................................. X7506
                                                                                Biosone – 50 mg/ml suspension ............................ X5774
                                                                                Blenoxane – 15 units/ampule................................. X7508
                                                                                Bleomycin Sulfate – 15 units/ampule ..................... X7508
B                                                                               Bortezomib – 0.1 mg............................................... J9041
                                                                                Brethine – 1 mg/ml ................................................ X5776
Bacitracin, Intramuscular –                                                     Brevital Sodium – 500 mg/5 ml ............................... J3490
 50,000 unit vials .................................................... J3490   Bricanyl Subcutaneous – 1 mg/ml.......................... X5776
Bacitracin, Intramuscular –                                                     Brompheniramine Maleate – 10 mg/ml .................. X5786
 10,000 unit vials .................................................... J3490   Bupivacaine HCl – 0.75% ...................................... X5790
Baclofen – 10 mg ................................................... X7108      Bupivacaine HCl – 0.25% ...................................... X5792
Bactocill – 4 gm (powder) vials ............................... X5720           Bupivacaine HCl – 0.5% ........................................ X5794
Bactocill – 2 gm (powder) vials ............................... X5722           Butorphanol Tartrate – 2 mg/ml ............................. X5796
Bactocill – 1 gm (powder) vials ............................... X5724           Butorphanol Tartrate – 1 mg/ml ............................. X5798
Bactocill – 500 mg (powder) vials ........................... X5726
BAL In Oil – 100 mg/ml .......................................... X5728
Basiliximab – 20 mg ................................................ J0480
BCG Vaccine, intravesicular....................................90586
BCG Vaccine, percutaneous – 1 mg .......................90585
Benadryl – 50 mg/ml .............................................. X5738
Benadryl – 10 mg/ml .............................................. X5740
Benahist 50 – 50 mg/ml ......................................... X5738
Benahist 10 – 10 mg/ml ......................................... X5740
Bendamustine HCl – 1 mg ...................................... J9033
Bendylate 50 – 50 mg/ml ....................................... X5738
Bendylate 10 – 10 mg/ml ....................................... X5740
Benoject 50 – 50 mg/ml ......................................... X5738
Benoject 10 – 10 mg/ml ......................................... X5740
Bentyl – 10 mg/ml .................................................. X5642
Benztropine Mesylate – 1 mg/ml ............................ X5744




2 – Injections: Code List
                                                                                                                                                 May 2011
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                                                                  Codes                                                                       Codes

C
C1 Esterase Inhibitor (human) – 10 units ................ J0598                Celestone Soluspan
Caffeine and Sodium Benzoate – 250 mg/ml ..........J3490                         (Betamethasone Acetate 3 mg and
Calcimar – 400 MCR units ..................................... X5804            Betamethasone Sodium Phosphate 3 mg) ........... J0702
Calcitonin – 400 MCR units .................................... X5804          Centrogen – 2 mg/ml ............................................. X5756
Calcitriol – 0.1 mcg ................................................. J0636   Certolizumab Pegol – 1 mg..................................... J0718
Calcitriol (Calcijex) – 1 mcg/ml ............................... X7510         Cetuximab – 10 mg ................................................ J9055
Calcitriol (Calcijex) – 2 mcg/ml ............................... X7512         Cevalin – 500 mg/ml ............................................... J3490
Calcium Disodium Edetate – 200 mg/ml................. X5808                    Chloramphenicol –
Calcium Disodium Versenate – 200 mg/ml ............. X5808                      1 gm vial as dry powder ....................................... X5922
Capastat Sulfate – 1 gm/5 ml vial ............................J3490            Chlorazine – 25 mg/ml ........................................... X5918
Capreomycin Sulfate – 1 gm/5 ml vial .....................J3490                Chlordiazedoxide – 100 mg/5 ml............................ X5920
Carbocaine – 2% ................................................... X5818      Chloromycetin Sodium Succinate –
Carbocaine – 1.5% ................................................ X5820        1 gm vial as dry powder ....................................... X5922
Carbocaine – 1% ................................................... X5822      Chloroprocaine HCl – 3% ...................................... X5924
Carbocaine HCl – 3% ............................................ X5824         Chloroprocaine HCl – 2% ...................................... X5926
Carboplatin – 50 mg................................................ J9045      Chloroprocaine HCl – 1% ...................................... X5928
Carmustine (BCNU) – 100 mg/vial ......................... X7506                Chloroquine HCl – 50 mg/ml .................................. X5656
Cathflo Activase – 2 mg vial (powder) .................... X7122               Chlorothiazide – 500 mg/20 ml .............................. X5930
Cee-B-Complex – 30 ml ..........................................J3490          Chlorpromazine HCl – 25 mg/ml ............................ X5918
Cefazolin Sodium – 10 gm/100 ml vial ................... X5602
Cefazolin Sodium – 1 gm/redi vial .......................... X5604
Cefazolin Sodium – 1 gm/10 ml vial ....................... X5608
Cefazolin Sodium – 1 gm/100 ml
 piggyback unit ...................................................... X5606
Cefazolin Sodium – 500 mg/10 ml vial .................. X5612
Cefazolin Sodium – 500 mg/100 ml vial ................. X5610
Cefazolin Sodium – 250 mg/10 ml vial ................... X5614
Cefotaxime Sodium – 2 gm .................................... X7027
Cefotaxime Sodium – 1 gm .................................... X7026
Cefotaxime Sodium – 0.5 gm ................................. X7025
Cefoxitin Sodium – 2 gm vial .................................. X5854
Cefoxitin Sodium – 1 gm vial .................................. X5856
Ceftriaxone Sodium – 250 mg/vial........................... J0696




2 – Injections: Code List
                                                                                                                                        March 2011
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                                                                     Codes                                                                         Codes

Cholera Vaccine – 1.5 ml ........................................90725            Crysti-12 – 1,000 mcg/ml ....................................... X5752
Chorex – 1,000 units/ml ......................................... X5622           Cyanocobalamin Crystalline – 1,000 mcg/ml ......... X5752
Chorex – 500 units/ml ............................................ X5644          Cyclophosphamide – 100 mg ................................. J9070
Chorionic Gonadotropin (HCG) –                                                    Cytarabine (Cytosine Arabinoside,
 2,000 units/ml ...................................................... X5646       ARA-C) – 500 mg vials........................................ X7528
Chorionic Gonadotropin (HCG) –                                                    Cytarabine (Cytosine Arabinoside,
 1,000 units/ml ...................................................... X5622       ARA-C) – 100 mg vials........................................ X7530
Chorionic Gonadotropin (HCG) –                                                    Cytosar – 500 mg vials .......................................... X7528
 500 units/ml ......................................................... X5644     Cytosar – 100 mg vials .......................................... X7530
Chromium Cr-51 Sodium Chromate, 250 µCi ........ A9553
Chromium Phosphate P-32 suspension, 1 mCi ...... A9564
Cidofovir – 375 mg/5 ml vial ................................... X7434
Cisplatin – 50 mg .................................................... J9062      D
Clindamycin Phosphate 300 mg ............................. S0077
Clofarabine – 1 mg.................................................. J9027        Dacarbazine (DTIC) – 200 mg/20 ml vial ............... X7532
Clonidine hydrochloride – 1 mg/ml ..........................J0735                 Dactinomycin (Actinomycin D) –
Cobalt Co-57/58, cyanocobalamin – 1 µCi ............. A9546                        0.5 mg/3 ml vial ................................................... X7520
Cobalt Co-57 cyanocobalamin (oral) – 1 µCi .......... A9559                       Daptomycin, 1 mg................................................... J0878
Cobex 1,000 .......................................................... X5752      Darbepoetin alfa (ESRD) – 1 mcg........................... J0882
Cogentin – 1 mg/ml ................................................ X5744         Darbepoetin alfa (non-ESRD) ................................. J0881
Collagenase Clostridium Histolyticum –                                            Daunorubicin – 10 mg............................................. J9150
 0.01 mg ................................................................ J0775   Deca-Durabolin – 100 mg/ml (oil) .......................... X5600
Compazine – 5 mg/ml ............................................ X5970            Deca-Durabolin – 50 mg/ml (oil) ............................ X5632
Conjugated Estrogens – 25 mg .............................. X5972                 Decitabine – 1 mg................................................... J0894
Cortef – 50 mg/ml .................................................. X5980        Deferoxamine Mesylate – 500 mg/ampule .............. J0895
Cortef Acetate – 50 mg/ml suspension ................... X5774                    Degarelix – 1 mg .................................................... J9155
Corticorelin ovine triflutate – 1 mcg ......................... J0795             Delcort-E – 25 mg/ml ............................................. X6014
Cortril Acetate – 25 mg/ml suspension ................... X5988                   Delestrogen – 40 mg/ml......................................... X6018
Cosmegen – 0.5-3 mg/ml vial................................. X7520                Delestrogen – 20 mg/ml......................................... X5660
Cosyntropin, not otherwise specified – 0.25 mg ...... J0833                       Delestrogen – 10 mg/ml......................................... X5662
Cosyntropin (Cortrosyn) – 0.25 mg ......................... J0834                 Demerol HCl, per 100 mg/ml .................................. J2175




2 – Injections: Code List
                                                                                                                                               April 2011
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                                                                 Codes                                                                       Codes

Denileukin Diftitox – 300 mcg .................................. J9160       Dioval – 10 mg/ml .................................................. X5662
Denosumab (Prolia and XGEVA) – 1 mg ............... C9272                    Dioval 40 – 40 mg/ml ............................................. X6018
Depo-Estradiol Cypionate – 5 mg/ml ...................... X6030              Dioval XX – 20 mg/ml ............................................ X5660
Depogen – 5 mg/ml................................................ X6030      Diphenhydramine HCl – 50 mg/ml ......................... X5738
Depo-Medrol – 80 mg/ml suspension ..................... X6036                Diphenhydramine HCl – 10 mg/ml ......................... X5740
Depo-Medrol – 40 mg/ml suspension ..................... X6038                Diphtheria, tetanus toxoid (DT) –
Depo-Medrol – 20 mg/ml........................................ X6040          for younger than 7 years of age ........................... 90702
Depotest – 100 mg/ml ............................................ X5618      Diphtheria, tetanus toxoid
Depo-Testosterone – 100 mg/ml ............................ X5618              and acellular pertussis (DTaP) –
D-Est 5 – 5 mg/ml .................................................. X6030    under 7 years of age ............................................ 90700
Dexamethasone Sodium Phosphate – 1 mg ........... J1100                      Diphtheria, tetanus toxoids
Dexpanthenol – 250 mg/ml ..................................... J3490          and whole cell pertussis (DTP) ............................. 90701
D.H.E. 45 – 1 mg/ml............................................... X6062     Diphtheria, tetanus toxoids and whole cell pertussis
Diamox – 500 mg/vial ............................................ X5500       and H. Influenza b vaccine (DTP-Hib) .................. 90720
Diazepam – 5 mg/ml .............................................. X6064      Diphtheria, tetanus toxoids and acellular pertussis
Diazoxide – 300 mg/20 ml...................................... X6070          and H. Influenza b vaccine (DtaP-Hib) ................. 90721
Dibent – 10 mg/ml .................................................. X5642   Diphtheria, tetanus toxoids, acellular pertussis vaccine,
Dicyclomine HCl – 10 mg/ml .................................. X5642           Hepatitis B, and poliovirus vaccine,
Digoxin – 0.25 mg/ml ............................................. X6080      inactivated (DtaP-HepB-IPV)................................ 90723
Digoxin – 0.1 mg/ml ............................................... X6082    Diptheria Toxoid, Adsorbed ................................... 90719
Dihydroergotamine Mesylate – 1 mg/ml ................. X6062                 Di-Spaz – 10 mg/ml ............................................... X5642
Dilantin – 50 mg/ml ................................................ X6084   Diuril – 500 mg/20 ml ............................................. X5930
Dilaudid – 4 mg/ml ................................................. X6086   D-Med – 80 mg/ml suspension .............................. X6036
Dilaudid – 2 mg/ml ................................................. X6090   D-Med – 40 mg/ml suspension .............................. X6038
Dilaudid – 1 mg/ml ................................................. X6092   Dobutamine HCl – per 250 mg ............................... J1250
Dimercaprol – 100 mg/ml ....................................... X5728        Docetaxel (Taxotere) – 1 mg .................................. J9171
Dimetan-Ten – 100 mg/ml...................................... X5786          Dodex – 1,000 mcg/ml ........................................... X5752
                                                                             Dolasetron – 10 mg ................................................ J1260
                                                                             Dolophine HCl – 10 mg/ml ..................................... X6110
                                                                             Dopamine HCl – 40 mg/ml ...................................... J1265
                                                                             Dopram – 20 mg/ml ................................................ J3490
                                                                             Doripenem – 10 mg ................................................ J1267
                                                                             Dornase alfa – 1 mg ............................................... J7639
                                                                             Doxapram HCl – 20 mg/ml...................................... J3490
                                                                             Doxercalciferol – 1 mcg ......................................... J1270
                                                                             Doxorubicin HCl – 10 mg ........................................ J9000
                                                                             Doxorubicin HCl liposome – 10 mg ......................... J9001
                                                                             Doxycycline – 100 mg (as hyclate)/vial ................... J3490
                                                                             Droperidol – 2.5 mg/ml .......................................... X6126
                                                                             Dtic-Dome – 200 mg/20 ml vial .............................. X7532




2 – Injections: Code List
                                                                                                                                         April 2011
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                                                                   Codes                                                                            Codes

Duracillin A.S. – 600,000 units/unit dose ................ X6136                Estradiol In Oil – 5 mg/ml ....................................... X6030
Duraestrin – 5 mg/ml.............................................. X6030        Estradiol L.A. – 40 mg/ml ....................................... X6018
Duragen 40 ............................................................ X6018   Estradiol Valerate In Oil – 40 mg/ml ....................... X6018
Duragen 20 ............................................................ X5660   Estradiol Valerate In Oil – 20 mg/ml ....................... X5660
Duragen – 10 mg/ml .............................................. X5662         Estradiol Valerate In Oil – 10 mg/ml ....................... X5662
Dura-Meth – 40 mg/ml suspension......................... X6038                  Estradurin – 40 mg w/2 cc diluent .......................... J3490
Duratest – 100 mg/ml ............................................. X5618        Estratab 40 ............................................................ X6018
                                                                                Estratab 20 ............................................................ X5660
                                                                                Estratab – 10 mg/ml .............................................. X5662
                                                                                Estraval – 10 mg/ml ............................................... X5662
E                                                                               Estraval – 4X ......................................................... X6018
                                                                                Estraval – 2X ......................................................... X5660
Eculizumab – 10 mg ............................................... J1300        Estro-Cyp – 5 mg/ml .............................................. X6030
Edrophonium Chloride – 10mg/ml ........................... J3490                Estrogenic Substance Aqueous – 2 mg/ml............. X5756
Elavil HCl – 10 mg/ml ............................................. X5564       Estroject-L.A. ......................................................... X6030
Eliotts’ B Solution – 1 ml ......................................... J9175      Estrolin – 2 mg/ml .................................................. X5756
E-Lonate – 5 mg/ml................................................ X6030        Estrone – 10 mg/ml ............................................... X5662
Elspar – 10,000 IU/10 ml vial ................................. X7504           Estronol (Modified) Femogen
Ephedrine Sulfate – 50 mg/ml                                                     Aqueous – 2 mg/ml .............................................. X5756
 1 ml ampules ........................................................ J3490    Etoposide – 20 mg/ml ............................................ X7542
Ephedrine Sulfate – 25 mg/ml                                                    Euflexxa – per dose ................................................ J7323
 1 ml ampules ........................................................ J3490
Epinephrine HCl – 1 mg/ml .................................... X5528
Epinephrine HCl – 0.1 mg/ml ................................. X6164
Epinephrine, Parenteral –
 1:1,000 solution ................................................... X5530
Epinephrine, Parenteral –
 1:200 suspension ................................................. X6166
Epirubicin (Ellence) – 50 mg/25 ml ......................... X7646
Epoetin alfa, 1000 units (for ESRD on dialysis) ....... J0886
Epoetin alfa, 1000 units (for non-ESRD use) ........... J0885
Epogen (ESRD) – 1,000 units ................................. J0886
Epogen (non-ESRD) – 1,000 units .......................... J0885
Eribulin Mesylate – 1 mg ....................................... C9280
Erythromycin I.V. – 1 gm
 (lactobionate)/30 ml vials ..................................... X6174
Erythromycin I.V. – 500 mg
 (as lactobionate)/20 ml vials ................................. X6178




2 – Injections: Code List
                                                                                                                                                May 2011
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                                                                      Codes                                                                            Codes

F
Faslodex – 25 mg ................................................... J9395         Gemcitabine – 200 mg............................................ J9201
Femogen-Cyp – 5 mg/ml........................................ X6030                Gentamicin Sulfate – 40 mg/ml .............................. X6240
Femogen-L.A. – 40 mg/ml...................................... X6018                Gentamicin Sulfate – 10 mg/ml .............................. X6242
Femogen-L.A. – 20 mg/ml...................................... X5660                Glucagon HCI – 1 mg ............................................. J1610
Femogen-L.A. – 10 mg/ml...................................... X5662                Glycohyprolate – 0.2 mg/ml ................................... X6258
Fentanyl – 0.05 mg/ml ........................................... X6206            Gold Sodium Thiomalate – 50 mg/ml ..................... X6262
Fentanyl Citrate and Droperidol –                                                  Gold Sodium Thiomalate – 25 mg/ml ..................... X6264
 0.05-2.5 mg.......................................................... X6208       Gonadex – 1,000 units/ml ...................................... X5622
Fernisolone – 25 mg/ml.......................................... X6014             Granisetron HCl Injection – 100 mcg ...................... J1626
Fernisone – 50 mg/ml suspension.......................... X5774                    Granisetron Tablets – 1 mg ................................... X7105
Ferrlecit – 62.5 mg ................................................. X7496
Ferumoxytol – 1 mg (non-ESRD) ........................... Q0138
Ferumoxytol – 1 mg (ESRD on dialysis) ................. Q0139
Filgrastim (Neupogen) – 300 mcg ........................... J1440                  H
Filgrastim (Neupogen) – 480 mcg ........................... J1441
Flexon – 30 mg/ml ................................................. X6216          Haemophilus Influenzae b (Hib) HbOC ................... 90645
Floxuridine – 500 mg/5 ml vial................................ X7544               Haemophilus Influenzae b (Hib) PRP-D .................. 90646
Fludarabine – 50 mg ............................................... J9185          Haemophilus Influenzae b (Hib) PRP-OMP ............ 90647
Fluorodeoxyglucose – 45 mCi ................................ A9552                 Haemophilus Influenzae b (Hib) PRP-T .................. 90648
Fluorouracil – 500 mg/10 ml ................................... X7546              Haloperidol – up to 5 mg......................................... J1630
Fluphenazine Decanoate – 25 mg/ml ..................... X6220                      Haloperidol Decanoate – 50 mg.............................. J1631
Fluphenazine Enanthate – 25/mg/ml ...................... X6220                     Hectorol – 1 mcg .................................................... J1270
Fluphenazine HCl – 2.5 mg/ml ............................... X6222                 Hematran ............................................................... J1752
Follutein – 1,000 units/ml ....................................... X5622           Hemin injection – 1 mg ........................................... J1640
Fomepizole – 15 mg ............................................... J1451           Heparin Sodium – 1,000 units .............................. J1644
Fosaprepitant – 1 mg .............................................. J1453          Heparin Sodium – 10 units ................................... J1642
Foscarnet Sodium – 1000 mg ................................. J1455
Foygen Aqueous – 2 mg/ml ................................... X5756
FUDR – 500 mg/5 ml vial ....................................... X7544
Fulvestrant – 25 mg ................................................ J9395
Furosemide – 10 mg/ml ......................................... X6228



G
Gadobenate dimeglumine
 (MultiHance) per ml.............................................. A9577
Gadobenate dimeglumine
 (MultiHance multipack), per ml ............................. A9578
Gadofosveset Trisodium – 1 ml.............................. A9583
Gadolinium – not otherwise
  specified, per ml .................................................. A9579
Gadoteridol, (ProHance multipack),
 per ml................................................................... A9576
Gadoxetate Disodium – per ml ............................... A9581
Gallium Ga-67 Citrate – 1 mCi ............................... A9556
Galsulfase – 1 mg ................................................... J1458
Gamma globulin, intramuscular – over 10 cc .....J1560
Gamma globulin, intramuscular – 1 cc ................J1460
Ganciclovir 4.5 mg, long-acting Implant................... J7310
Ganphen – 50 mg/ml ............................................. X6236
Garamycin – 40 mg/ml ........................................... X6240
Garamycin Pediatric – 10 mg/ml ............................ X6242




2 – Injections: Code List
                                                                                                                                                  June 2011
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                                                                                                                                                          9
                                                                     Codes                                                                          Codes

Hepatitis A and Hepatitis B                                                       I
 Combination Vaccine ...........................................90636
Hepatitis A Vaccine (adult) – 1,440 units/ml ............90632                    Ibandronate Sodium (Boniva) – 1 mg...................... J1740
Hepatitis A Vaccine                                                               Ibritumomab Tiuxetan (In-111), 5 mCi.................... A9542
 (pediatric/adolescent) ...........................................90633          Ibritumomab Tiuxetan (Y-90), 40 mCi .................... A9543
Hepatitis B Immune Globulin, 1 ml ..........................90371                 Idursulfase – 1 mg .................................................. J1743
Hepatitis B Immune Globulin, (Hepagam B)                                          Ifosfamide – 1 gm................................................... J9208
 intramuscular – 0.5 ml .......................................... J1571          Ilopan – 250 mg/ml ................................................. J3490
Hepatitis B Immune Globulin (Hepagam B)                                           Imiglucerase – 10 units ........................................... J1786
 intravenous – 0.5 ml ............................................. J1573         Immune globulin, (flebogamma/flebogamma DIF),
Hepatitis B Vaccine, adolescent                                                     I.V., non-lyophilized (e.g. liquid) – 500 mg........ J1572
 (2 dose schedule).................................................90743          Immune globulin, (Gammagard Liquid), I.V.,
Hepatitis B Vaccine, adult dosage ...........................90746                  non-lyophilized (e.g. liquid) – 500 mg ............... J1569
Hepatitis B Vaccine, dialysis or                                                  Immune globulin, (Gammaplex), I.V.,
 immunosuppressed, per 40 mcg                                                       non-lyophilized (e.g. liquid) – 500 mg .............. C9270
 (3 dose schedule).................................................90740          Immune globulin, (Gamunex), I.V.,
Hepatitis B Vaccine, dialysis or                                                    non-lyophilized (e.g. liquid) – 500 mg ............... J1561
 Immunosuppressed, per 40 mcg                                                     Immune globulin, (Hizentra) – 100 mg ................. J1559
 (4 dose schedule).................................................90747          Immune globulin, I.V., lyophilized (e.g. powder),
Hepatitis B Vaccine/Haemophilus                                                     not otherwise specified – 500 mg ..................... J1566
 Influenzae b .........................................................90748      Immune globulin, I.V., non-lyophilized (e.g. liquid),
Hepatitis B Vaccine, pediatric/adolescent                                           not otherwise specified – 500 mg ..................... J1599
 (3 dose schedule).................................................90744          Immune globulin, (Octagam), I.V.,
Hexadrol Phosphate – 10 mg/ml ............................ X6320                    non-lyophilized (e.g. liquid) – 500 mg ............... J1568
Histerone – 100 ..................................................... X6326       Immune globulin, (Privigen), I.V.,
Histerone – 50 ....................................................... X5628        non-lyophilized (e.g. liquid) – 500 mg ............... J1459
Histrelin Acetate – 10 mcg ...................................... J1675           Immune globulin, (Vivaglobin) – 100 mg ............. J1562
Histrelin Implant (Vantas) – 50 mg .......................... J9225               Inapsine – 2.5 mg/ml ............................................. X6126
Human Fibrinogen Concentrate – 100 mg ............... J1680                       IncobotulinumtoxinA, 1 unit .................................... Q2040
Human Papilloma Virus Vaccine, for                                                Inderal – 1 mg/ml ................................................... X6354
 intramuscular use                                                                Indium In-111 Capromab Pendetide – 10 mCi ....... A9507
 19 through 26 years of age) .................................90649               Indium In-111 Ibritumomab Tiuxetan – 5 mCi ........ A9542
Human Papilloma virus (HPV) vaccine,                                              Indium In-111 Oxyquinoline – 0.5 mCi ................... A9547
 types 16, 18, bivalent, 3 dose schedule, for                                     Indium In-111 Pentetate – 0.5 mCi ........................ A9548
 intramuscular use, females                                                       Indium In-111 Pentetreotide – 6 mCi...................... A9572
 10 through 25 years of age ........................................ 90650        Infliximab – 10 mg .................................................. J1745
Hyalgan – 2 ml ........................................................ J7321     Influenza Virus Vaccine, preservative free
Hydeltra T.B.A. – 20 mg/ml suspension .................. J3490                      (6 to 35 months of age) ........................................ 90655
Hydeltrasol – 20 mg/ml solution .............................. J3490              Influenza Virus Vaccine, preservative free
Hydextran ............................................................... J1752     (3 years and older) ............................................... 90656
Hydralazine HCl – 20 mg/ml................................... X5648               Influenza Virus Vaccine
Hydrocortisone – 50 mg/ml .................................... X5980                (6 to 35 months of age) ........................................ 90657
Hydrocortisone – 25 mg/ml .................................... X6332              Influenza Virus Vaccine (3 years and older) ............ 90658
Hydrocortisone Acetate –                                                          Innovar – 0.05 mg/2.5 mg ...................................... X6208
 50 mg/ml suspension .......................................... X5774             Insulin Injection – 100 units/ml ............................... X6366
Hydrocortisone Acetate –                                                          Interferon Alfa-2a (Roferon A, Roche) –
 25 mg/ml suspension .......................................... X5988               1,000,000 IU ....................................................... X7548
Hydrocortisone Phosphate – 50 mg/ml................... X6334                      Interferon Alfa-2b (Intron A, Schering) –
Hydromorphone HCl – up to 4 mg .......................... J1170                     1,000,000 IU ....................................................... X7550
Hydroxo-12 – 1,000 mcg/ml ................................... X5752               Interleukin-2 – 22 million IU ................................... X7632
Hydroxyzine – 50 mg/ml......................................... X6336             Intropin – 40 mg/ml ................................................. J1265
Hyperstat IV – 30 mg/20 ml .................................... X6070             Iodine I-123 Iobenguane, up to 15 mCi .................. A9582
Hyrexin – 50 mg/ml ................................................ X5738         Iodine Iobenguane Sulfate – 0.5 mCi ..................... A9508
Hyrexin – 10 mg/ml ................................................ X5740         Iodine Iodinated Serum Albumin – 5 µCi ................ A9524
                                                                                  Iodine Serum Albumin – 5 µCi ............................... A9532
                                                                                  Iodine Sodium Iodide – 1 µCi ................................. A9531
                                                                                  Iodine Sodium Iodide Capsule(s) – 100 µCi ........... A9516
                                                                                  Iodine Sodium Iodide (diagnostic) – 1 mCi ............. A9528
                                                                                  Iodine Sodium Iodide (therapeutic) – 1 mCi ........... A9517
                                                                                  Iodine Sodium Iothalamate – 10 µCi ...................... A9554
                                                                                  Iodine Tositumomab – study dose ......................... A9544
                                                                                  Iodine Tositumomab – treatment dose ................... A9545



2 – Injections: Code List
                                                                                                                                               June 2011
inject cd list
10

                                                                      Codes                                                                           Codes

                                                                                   L
Iprenol – 1:5,000 sol/1 ml ....................................... X6408           Lacosamide – 1 mg ............................................... C9254
Irinotecan (Camptosar) – 20 mg.............................. J9206                 Lanoxin – 0.25 mg/ml ............................................ X6080
Iron-Based Magnetic Resonance Contrast                                             Lanoxin – 0.1 mg/ml .............................................. X6082
   Agent – 1 ml ........................................................ Q9953     Lanreotide acetate – 1 mg ...................................... J1930
Iron Dextran – 50 mg .............................................. J1750          Laronidase – 0.1 mg ............................................... J1931
Isuprol – 1:5,000 solution ....................................... X6408           Lasix – 10 mg/ml ................................................... X6228
Ixabepilone – 1 mg.................................................. J9207         Lepirudin – 50 mg ................................................... J1945
                                                                                   Leucovorin Calcium – 50 mg .................................. J0640
                                                                                   Leuprolide acetate (for depot suspension)
                                                                                    per 7.50 mg .......................................................... J9217
J (no entry)                                                                       Leuprolide acetate (for depot suspension)
                                                                                    per 3.75 mg .......................................................... J1950
                                                                                   Levarterenol (Norepinephrine) – 1 mg
                                                                                     (as batartrate) per ml............................................ J3490
K                                                                                  Levetiracetam – 10 mg ........................................... J1953
                                                                                   Levoid – 500 mcg/ml............................................... J3490
Kanamycin Sulfate – 1 gm/3 ml vials ...................... X6426                   Levophed – 1 mg (as batartrate) per ml .................. J3490
Kanamycin Sulfate – 500 mg/2 ml vials .................. X6422                     Levothyroxine – 500 mcg/ml ................................... J3490
Kanamycin Sulfate – 75 mg/2 ml vials .................... X6424                    Libigen – 1,000 units/ml ......................................... X5622
Kantrex – 1 gm/3 ml vials ....................................... X6426            Librium – 100 mg/5 ml ........................................... X5920
Kantrex – 500 mg/2 ml vials ................................... X6422              Lidocaine HCl – 10 mg ........................................... J2001
Kantrex – 75 mg/2 ml vials ..................................... X6424
Kaybovite 1,000 – 1,000 mcg/ml ............................ X5752
Kefzol – 10 gm/100 ml vial ..................................... X5602
Kefzol – 1 gm/redi vial ............................................ X5604
Kefzol – 1 gm/100 ml piggyback unit ...................... X5606
Kefzol – 1 gm/10 ml vial ......................................... X5608
Kefzol – 500 mg/100 ml vial ................................... X5610
Kefzol – 500 mg/10 ml vial ..................................... X5612
Kefzol – 250 mg/10 ml vial ..................................... X5614
Kenalog 10 ............................................................ X6432
Kestrin Aqueous – 2 mg/ml .................................... X5756
Ketaject – 100 mg/ml .............................................. J3490
Ketaject – 50 mg/ml ................................................ J3490
Ketaject – 10 mg/ml ................................................ J3490
Ketalar – 100 mg/ml ................................................ J3490
Ketalar – 50 mg/ml .................................................. J3490
Ketalar – 10 mg/ml .................................................. J3490
Ketamine – 100 mg/ml ............................................ J3490
Ketamine – 50 mg/ml .............................................. J3490
Ketamine – 10 mg/ml .............................................. J3490
Ketorolac tromethamine – 15 mg ............................ J1885
Key-Pred 50 ........................................................... X6440
Key-Pred 25 ........................................................... X6014
Key-Pred SP – 20 mg/ml......................................... J3490
K-Feron................................................................... J1752
Konakion – 10 mg/ml ............................................. X5650
Konakion – 2 mg/ml ............................................... X5652
K-Phen – 50 mg/ml ................................................ X6236




2 – Injections: Code List
                                                                                                                                                 June 2011
                                                                                                                                     inject cd list
                                                                                                                                                      11
                                                                 Codes                                                                            Codes

Lidocaine HCl Without Preservatives –                                        Mannitol – 25% ...................................................... X6520
 4% (40 mg/ml) ......................................................J2001   Mannitol – 20% ...................................................... X6522
Lidocaine HCl Without Preservatives –                                        Mannitol – 15% ...................................................... X6524
 2% (20 mg/ml) ..................................................... X6470   Mannitol – 10% ...................................................... X6526
Lidopen Auto-Injector –                                                      Mannitol – 5% ........................................................ X6528
 10% (100 mg/ml).................................................. X6464     Marcaine – 0.75%.................................................. X5790
Lincocin – 300 mg/2 ml U-Ject ............................... X6504          Marcaine – 0.5%.................................................... X6530
Lincomycin – 300 mg/2 ml U-Ject .......................... X6504             Marcaine HCl – 0.25% ........................................... X5792
Low osmolar contrast material 100 – 199 mg/ml                                Measles .................................................................. 90705
 iodine concentration – per ml ............................... Q9965         Measles, mumps, rubella (MMR) ............................ 90707
Low osmolar contrast material 200 – 299 mg/ml                                Measles, mumps, rubella, varicella (MMRV) ........... 90710
 iodine concentration – per ml ............................... Q9966         Measles, rubella ..................................................... 90708
Low osmolar contrast material 300 – 399 mg/ml                                Mechlorethamine HCl – 10 mg/20ml
 iodine concentration – per ml ............................... Q9967          triturated w/100 mg Sodium Chloride ................... X7552
Low osmolar contrast material –                                              Medralone-80 – 80 mg/ml suspension ................... X6036
 400 mg/ml iodine or greater ................................. Q9951         Medralone-40 – 40 mg/ml ...................................... X6038
LTS – 500 mcg/ml ................................................... J3490   Medroxyprogesterone Acetate –
Luminal Sodium – 130 mg/ml ................................. X6506            25 mg and estradiol cypionate 5 mg/0.5 ml .......... X7490
Lunelle – Medroxyprogesterone Acetate –                                      Medroxyprogesterone Acetate – 50 mg .................. J1051
 25 mg and estradiol cypionate 5 mg/0.5 ml .......... X7490                  Medroxyprogesterone Acetate –150 mg ................. J1055
                                                                             Mefoxin – 2 gm vial ................................................ X5854
                                                                             Mefoxin – 1 gm vial ................................................ X5856
                                                                             Meningococcal polysaccharide vaccine,
M                                                                              any groups ........................................................... 90733
                                                                             Meperidine HCl – per 100 mg ................................. J2175
Magnesium Sulfate – 50% ..................................... X6512          Mepivacaine HCl – 3% .......................................... X5824
Magnesium Sulfate – 12.5% .................................. X6514           Mepivacaine HCl – 2% .......................................... X5818
Magnesium Sulfate – 10% ..................................... X6516          Mepivacaine HCl – 1.5% ....................................... X5820
Malogen Cyp – 100 mg/ml ..................................... X5618          Mepivacaine HCl – 1% .......................................... X5822
                                                                             Mepred 80 suspension .......................................... X6036
                                                                             Mepred 40 suspension .......................................... X6038
                                                                             Mesna – 100 mg/ml ............................................... X7586
                                                                             Mestinon Bromide – 5 mg/ml .................................. J3490




2 – Injections: Code List
                                                                                                                                             June 2011
inject cd list
12

                                                                     Codes                                                                             Codes

Metalone T.B.A. –                                                                 Meticortelone Acetate – 25 mg/ml.......................... X6014
 20 mg/ml suspension ............................................J3490            Micafungin sodium - 1 mg ....................................... J2248
Methadone HCl – 10 mg/ml ................................... X6110                Mithracin – 2.5 mg/vial w/100
Methergine – 0.2 mg/ml ......................................... X6566             mg/mannitol ......................................................... X7564
Methocarbamol – 100 mg/ml .................................. X6560                Mithramycin – 2.5 mg/vial w/100
Methohexital Sodium – 500 mg/5 ml .......................J3490                     mg/mannitol ......................................................... X7564
Methotrexate – 50 mg (sodium) vial for                                            Mitomycin – 20 mg/vial .......................................... X7566
 reconstitution ........................................................ J9260    Mitomycin – 5 mg ................................................... J9280
Methotrexate – 50 mg/ml 2 ml vial                                                 Mitoxantrone – 5 mg .............................................. X7624
 (sodium)................................................................ J9260   Morphine Sulfate – 100 mg ..................................... J2271
Methotrexate – 50 mg/vial ....................................... J9260           Morphine Sulfate – up to 10 mg .............................. J2270
Methyldopa and Methyldopate HCl –                                                 Morphine Sulfate – preservative-free sterile
 250 mg/5 ml ......................................................... X5540       solution, 10 mg ..................................................... J2275
Methyldrol 40 ......................................................... X6038     M-Prednisol 80 suspension.................................... X6036
Methylergonovine Maleate –                                                        M-Prednisol 40 suspension.................................... X6038
 0.2 mg/ml ............................................................. X6566    Mumps ................................................................... 90704
Methylprednisolone Acetate –                                                      Mustargen – 10 mg/20 ml triturated
 80 mg/ml ............................................................... J1040    w/100 mg sodium chloride ................................... X7552
Methylprednisolone Acetate –                                                      Mutamycin – 20 mg/vial ......................................... X7566
 40 mg/ml ............................................................... J1030   Mutamycin – 5 mg/vial ........................................... X7568
Methylprednisolone Acetate –                                                      M.V.I. – 10 ml ......................................................... J3490
 20 mg/ml ............................................................... J1020   Mychel-S – 1 gm vial as dry powder ...................... X5922
Methylprednisolone Sodium Succinate – up to                                       Mycifradin Sulfate – 500 mg vials .......................... X6504
 125 mg/ml ............................................................. J2930    Myochrysine – 50 mg/ml ........................................ X6262
Methylprednisolone Sodium Succinate – up to                                       Myochrysine – 25 mg/ml ........................................ X6264
 40 mg/ml ............................................................... J2920   Myolin – 30 mg/ml ................................................. X6216




2 – Injections: Code List
                                                                                                                                                March 2011
                                                                                                                                         inject cd list
                                                                                                                                                        13
                                                                      Codes                                                                          Codes

N                                                                                  O
Nafcil – 2 gm (powder) vial ..................................... X6604            Octafluoropropane Microspheres – 1 ml ................ Q9956
Nafcil – 1 gm (powder) vial ..................................... X6606            Octocaine HCl – 2% w/1:100,000
Nafcillin Sodium – 2 gm (powder) vial .................... X6604                    Epinephrine ......................................................... X6444
Nafcillin Sodium – 1 gm (powder) vial .................... X6606                   Octocaine HCl – 2% w/1:50,000
Nafcillin Sodium – 500 mg vial ............................... X6610                Epinephrine ......................................................... X6476
Nalbuphine HCl – per 10 mg...................................J2300                 OnabotulinumtoxinA (BOTOX), per 1 unit ............... J0585
Naloxone HCl – 0.4 mg/ml ..................................... X6614               Ondansetron HCl – 1 mg ........................................ J2405
Naloxone HCl – 0.02 mg/ml ................................... X6616                Oral Magnetic Resonance Contrast
Nandrolate – 100 mg/ml (oil) .................................. X5600               Agent – 1 ml ........................................................ Q9954
Nandrolate – 50 mg/ml (oil) .................................... X5632             Ormazine – 25 mg/ml ............................................ X5918
Nandrolone Decanoate –                                                             Orphenadrine Citrate – 30 mg/ml ........................... X6216
 100 mg/ml (oil) ..................................................... X5600       Orthovisc – per dose............................................... J7324
Nandrolone Decanoate –                                                             Or-Tyl – 10 mg/ml .................................................. X5642
 50 mg/ml (oil) ....................................................... X5632      Osmitrol – 20% ...................................................... X6522
Narcan – 0.4 mg/ml................................................ X6614           Osmitrol – 15% ...................................................... X6524
Narcan – 0.02 mg/ml.............................................. X6616            Osmitrol – 10% ...................................................... X6526
Natalizumab – 1 mg ................................................ J2323          Osmitrol – 5% ........................................................ X6528
Nebcin – 40 mg/ml ................................................. X6620          Oxacillin Sodium – 4 gm
Nebcin – 10 mg/2 ml vial ........................................ X6622             (powder) vials ...................................................... X5720
Nelarabine – 50 mg................................................. J9261          Oxacillin Sodium – 2 gm
Nembutal Sodium – 50 mg/ml ................................ X6624                   (powder) vials ...................................................... X5722
Neocyten – 30 mg/ml ............................................. X6216            Oxacillin Sodium – 1 gm
Neostigmine Methylsulfate – 1:4,000                                                 (powder) vials ...................................................... X5724
 solution/1 ml ampules .......................................... X6630            Oxacillin Sodium – 500 mg
Neostigmine Methylsulfate –                                                         (powder) vials ...................................................... X5726
 1:2,000 solution ................................................... X6632        Oxacillin Sodium – 250 mg
Neostigmine Methylsulfate –                                                         (powder) vials ...................................................... X6656
 1:1,000 solution ................................................... X6634        Oxaliplatin – 0.5 mg ................................................ J9263
Neo Synephrine – 1% 1 ml ampules ...................... X6626                      Oxytocin – 10 units/ml ........................................... X6666
Nesacaine – 2%..................................................... X5926
Nesacaine – 1%..................................................... X5928
Nesacaine-CE – 3%............................................... X5924
Nesacaine-CE – 2%............................................... X5926
Nesiritide – 0.1 mg ................................................. J2325
Nipride – 50 mg/5ml ................................................ J3490
Nitrogen N-13 Ammonia, Diagnostic – 40 mCi ....... A9526
Nitroprusside Sodium – 50 mg/5 ml ........................ J3490
Norazine HCl – 50 mg/ml ....................................... X6638
Nordryl – 10 mg/ml................................................. X5740
Norferan.................................................................. J1752
Norflex – 30 mg/ml ................................................. X6216
Noroxine – 500 mcg/ml ........................................... J3490
Nor-Pred T.B.A. –
 20 mg/ml suspension ............................................ J3490
Nospaz – 10 mg/ml ................................................ X5642




2 – Injections: Code List
                                                                                                                                                 April 2011
inject cd list
14
                                                                  Codes                                                                             Codes

P                                                                              Penicillin G Potassium – 20,000,000
                                                                                units (powder)/vial ............................................... X6700
Paclitaxel – 30 mg.................................................. X7052     Penicillin G Potassium (or Sodium)
Paclitaxel protein-bound particles – 1 mg ................ J9264                (Aqueous) – 10,000,000 units
Palifermin – 50 mcg ................................................ J2425      (powder)/vial ........................................................ X6702
Paliperidone palmitate – 1 mg ................................ C9255           Penicillin G Potassium (or Sodium)
Palonosetron – 25 mcg ........................................... J2469         (Aqueous) – 5,000,000 units
Pamidronate – 30 mg............................................. X7444          (powder)/vial ........................................................ X6704
Pancuronium Bromide – 2 mg/ml ............................ J3490               Penicillin G Potassium (or Sodium)
Pancuronium Bromide – 1 mg/ml ............................ J3490                (Aqueous) – 1,000,000 units
Panitumumab – 10 mg ............................................ J9303          (powder)/vial ........................................................ X6706
Pantoprazole – 40 mg ............................................ S0164        Penicillin G Procaine (Aqueous) –
Paricalcitol – 1 mcg ................................................. J2501    2,400,000 units/unit dose ..................................... X6714
Pavulon – 2 mg/ml .................................................. J3490     Penicillin G Procaine (Aqueous) –
Pavulon – 1 mg/ml .................................................. J3490      1,200,000 units/unit dose ..................................... X6716
Pegademase Bovine – 25 IU................................... J2504             Penicillin G Procaine (Aqueous) –
Pegaptanib Sodium – 0.3 mg .................................. J2503             600,000 units/unit dose ....................................... X6136
Pegaspargase – single dose vial............................. J9266             Pentamidine – 150 mg ........................................... X6718
Pegfilgrastim (Neulasta) – 6 mg .............................. J2505           Pentazine – 50 mg/ml ............................................ X6236
Pen A/N – 1 gm (powder) vials ............................... X5582            Pentazocine – 30 mg/ml ......................................... J3070
Pen A/N – 500 mg (powder) vials ........................... X5586              Pentobarbital Sodium – 50 mg/ml .......................... X6624
Pen A/N – 250 mg (powder) vials ........................... X5588              Pentothal Sodium – 1 gm ....................................... J3490
Penazine 50 – 50 mg/ml ........................................ X6236          Pentothal Sodium – 500 mg.................................... J3490
Penbritin-S – 2 gm (powder) vials .......................... X5578             Pentothal Sodium – 250 mg.................................... J3490
Penbritin-S – 1 gm (powder) vials .......................... X5582             Perflutren Lipid Microspheres – 1 ml ...................... Q9957
Penbritin-S – 500 mg (powder) vials ...................... X5586               Pfizerpen-AS –
Penbritin-S – 250 mg (powder) vials ...................... X5588                1,200,000 units/unit dose ..................................... X6716
Penbritin-S – 125 mg (powder) vials ...................... X5550               Phenazine 25 ........................................................ X6742
Penicillin G Benzathine and Penicillin                                         Phencen 50 ........................................................... X6236
 G Procaine, 2500 units.......................................... J0559        Phenergan – 50 mg/ml .......................................... X6236
Penicillin G Benzathine, up to 2,400,000 units ........ J0580                  Phenergan – 25 mg/ml .......................................... X6742
Penicillin G Benzathine, up to 1,200,000 units ........ J0570                  Phenobarbital Sodium – 130 mg/ml ....................... X6506
Penicillin G Benzathine, up to 600,000 units ........... J0560                 Phenobarbital Sodium – 65 mg/ml ......................... X6754
                                                                               Phenoject 50 ......................................................... X6236
                                                                               Phentolamine – 5 mg ............................................. X6758
                                                                               Phenylephrine HCl –
                                                                                1% 1 ml ampules ................................................. X6626
                                                                               Phenytoin Sodium,
                                                                                Parenteral – 50 mg/ml ......................................... X6084
                                                                               Physostigmine Salicylate –
                                                                                1 mg/ml ................................................................ J3490




2 – Injections: Code List
                                                                                                                                               June 2011
                                                                                                                                          inject cd list
                                                                                                                                                          15
                                                                      Codes                                                                            Codes

Phytonadione (K1) – 10 mg/ml ............................... X5650                 Pregnyl – 1,000 units/ml ........................................ X5622
Phytonadione (K1) – 2 mg/ml ................................. X5652                Premarin IV – 25 mg .............................................. X5972
Pitocin – 10 units/ml ............................................... X6666        Prenisolone Acetate – 25 mg/ml ............................ X6014
Pitressin – 20 pressor units/ml ................................ J3490             Prenisolone Sodium Phosphate –
Pituitrin – 20 units/ml............................................... J3490        20 mg/ml............................................................... J3490
Plague Vaccine .......................................................90727        Procainamide HCl – 500 mg/ml ............................. X6792
Platinol – 10 mg/vial ............................................... X7516        Procainamide HCl – 100 mg/ml ............................. X6794
Plerixafor (Mozobil®) – 1 mg.................................... J2562             Prochlorperazine – 5 mg/ml ................................... X5970
Pneumococcal Conjugate Vaccine, 13-valent,                                         Procrit (ESRD) – 1,000 units................................... J0886
  (for children 6 weeks through 4 years                                            Procrit (non-ESRD) – 1,000 units............................ J0885
  of age)..................................................................90670   Progesterone – per 50 mg ...................................... J2675
Pneumococcal Conjugate Vaccine, Polyvalent,                                        Prolixin – 2.5 mg/ml ............................................... X6222
 (for children under 5 years of age) ........................90669                 Prolixin Decanoate – 25 mg/ml .............................. X6220
Pneumococcal Polysaccharide                                                        Prolixin Enanthate – 25 mg/ml ............................... X6220
 Vaccine – 23-valent ..............................................90732           Promaject – 25 mg/ml ............................................ X5918
Polio, live, oral. .......................................................90712    Promaz – 25 mg/ml ............................................... X5918
Poliomyelitis Vaccine – 1 cc amp ............................90713                 Promazine HCl – 50 mg/ml .................................... X6638
Polyestradiol Phosphate –                                                          Promethamead 50 ................................................. X6236
 40 mg/secule w/2 ml                                                               Promethamead 25 ................................................. X6742
 ampule of sterile diluent ........................................ J3490          Promethazine HCl – 50 mg/ml ............................... X6236
Polymyxin B Sulfate – 500,000 units ....................... J3490                  Promethazine HCl – 25 mg/ml ............................... X6742
Pontocaine – 1% ..................................................... J3490        Pronestyl – 500 mg/ml ........................................... X6792
Pontocaine – 0.3% w/6% Dextrose ......................... J3490                    Pronestyl – 100 mg/ml ........................................... X6794
Posterior Pituitary Injection –                                                    Propranolol HCl – 1 mg/ml ..................................... X6354
 20 units/ml ............................................................ J3490    Prorex – 50 mg/ml ................................................. X6236
Pralatrexate – 1 mg................................................ C9259          Prorex – 25 mg/ml ................................................. X6742
Predcor-50 ............................................................. X6440     Prostaphlin – 4 gm (powder) vials .......................... X5720
Predcor-25 ............................................................. X6014     Prostaphlin – 2 gm (powder) vials .......................... X5722
Pre-Dep – 80 mg/ml ............................................... X6036           Prostaphlin – 1 gm (powder) vials .......................... X5724
Pre-Dep – 40 mg/ml ............................................... X6038           Prostaphlin – 500 mg (powder) vials ...................... X5726
Prednisolone Acetate – 50 mg/ml........................... X6440                   Prostaphlin – 250 mg (powder) vials ...................... X6656
Prednisolone Acetate – 25 mg/ml........................... X6014                   Prostigmin – 1:4,000 solution/
Prednisolone Tebutate –                                                             1 ml/ampules ....................................................... X6630
 20 mg/ml suspension ............................................ J3490            Prostigmin – 1:2,000 solution................................. X6632
                                                                                   Prostigmin – 1:1,000 solution................................. X6634




2 – Injections: Code List
                                                                                                                                                  April 2011
inject cd list
16
                                                                    Codes                                                                          Codes

Protamine Sulfate – 10 mg/ml ................................ X6816              Robaxin – 100 mg/ml ............................................. X6560
Protein C Concentrate                                                            Robinul – 0.2 mg/ml ............................................... X6258
 intravenous, human – 10 IU .................................. J2724             Romiplostim – 10 mcg ............................................ J2796
Prothazine – 50 mg/ml ........................................... X6236          Ropredlone – 50 mg/ml ......................................... X6440
Prothazine – 25 mg/ml ........................................... X6742          Ropredlone – 25 mg/ml ......................................... X6014
Protropin – 1 mg .................................................... X7034      Rubella Virus Vaccine, Live .................................... 90706
Provigan – 50 mg/ml .............................................. X6236         Rubesol 1,000 ...................................................... X5752
Provigan – 25 mg/ml .............................................. X6742         Rubramin PC – 1,000 mcg/ml ................................ X5752
PSP-IV – 20 mg/ml ................................................. J3490        Ruvite 1,000 – 1,000 mcg/ml ................................. X5752
Pyridostigmine Bromide – 5 mg/ml .......................... J3490


                                                                                 S
Q
                                                                                 Samarium SM-153, Therapeutic – up to 150 mCi .. A9604
Quelicin – 100 mg/ml ............................................. X6828         Sargramostim – 500 mcg/vial ................................ X7366
Quelicin – 50 mg/ml ............................................... X6830        Sargramostim – 250 mcg/vial ................................ X7364
Quelicin – 20 mg/ml ............................................... X5636        Savacort – 100 ....................................... X6014 or X6440
                                                                                 Savacort – 25 ........................................................ X6440
                                                                                 Scopolamine HBr – 0.4 mg/ml ................................ J3490
R                                                                                Secretin, Synthetic, Human – 1 mcg ....................... J2850
                                                                                 Sermorelin Acetate – 1 mcg................................... Q0515
Ranibizumab (Lucentis™) – 0.1 mg ........................ J2778                  Sincalide – 5 mcg ................................................... J2805
Recombinant, GM-CSF, Leukine –                                                   Sipuleucel-T – one infusion ................................ Q2043
 500 mcg/vial......................................................... X7366     Sodium Ferric Gluconate Complex
Recombinant, GM-CSF, Leukine –                                                    in Sucrose – 62.5 mg ........................................... X7496
 250 mcg/vial......................................................... X7364     Sodium Fluoride F-18, up to 30 millicuries ............. A9580
Regadenoson – 0.1 mg ........................................... J2785           Sodium Phosphate P-32, Therapeutic – 1 mCi ...... A9563
Regitine – 5 mg...................................................... X6758      Solganal – 50 mg/ml .............................................. X5708
Regonol – 5 mg/ml .................................................. J3490       Sol-Pred – 20 mg/ml solution .................................. J3490
Remicade – 10 mg .................................................. J1745        Solu-Cortef – 1,000 mg/8 ml vial ............................ X6888
Rep Estra – 10 mg/ml ............................................ X5662          Solu-Cortef – 500 mg/4 ml vial ............................... X6890
Rep-Pred 80 suspension........................................ X6036             Solu-Cortef – 250 mg/2 ml vial ............................... X6892
Rep-Pred 40 .......................................................... X6038     Solu-Cortef – 100 mg/10 ml vial ............................. X6894
Respiratory Syncytial Virus Immune Globulin                                      Solu-Medrol – 40 mg/ml......................................... X5554
 (RSV-IGIM), 50 mg ...............................................90378          Span-Est 20 .......................................................... X5660
RHO (D) Immune Globulin (Human) – full-dose ......90384                          Span-Est 10 .......................................................... X5662
RHO (D) Immune Globulin (Human) – mini-dose ....90385                            Span-F – 5 mg/ml .................................................. X5662
RHO (D) Immune Globulin (RhlglV), human
 for IV use (100 I.U.)............................................... J2792
Rilonacept – 1 mg ................................................... J2793
RimabotulinumtoxinB (Myobloc),
 per 100 units ......................................................... J0587
Risperidone, long lasting, 0.5 mg ............................ J2794
Rituximab – 100 mg ................................................ J9310




2 – Injections: Code List
                                                                                                                                              June 2011
                                                                                                                                         inject cd list
                                                                                                                                                         17
                                                                     Codes                                                                            Codes

Stadol – 2 mg/ml .................................................... X5796       Technetium Pentetate – 25 mCi............................. A9539
Stadol – 1 mg/ml .................................................... X5798       Technetium Pentetate (aerosol) – 75 mCi .............. A9567
Stemutrolin – 500 units/ml...................................... X5644            Technetium Pertechnetate – 1 mCi ........................ A9512
Sterane – 25 mg/ml................................................ X6014          Technetium Pyrophosphate – 25 mCi .................... A9538
Streptokinase-Streptodornase –                                                    Technetium Tc-99m Sestamibi –
 20,000/5,000 units ............................................... X6920          per study dose ..................................................... A9500
Streptomycin Sulfate ................. Available free from Pfizer                 Technetium Sodium Gluceptate – 25 mCi .............. A9550
Streptozocin – 1 gm ................................................J9320         Techentium Succimer – 10 mCi ............................. A9551
Strontium Sr-89 Chloride, Therapeutic – 1 mCi ...... A9600                        Technetium Sulfur Colloid – 20 mCi ....................... A9541
Sublimaze – 0.5 mg/ml........................................... X6206            Technetium Tetrofosmin – 40 mCi ......................... A9502
Succinylcholine Chloride – 100 mg/ml .................... X6828                   Tega-Flex – 30 mg/ml ............................................ X6216
Succinylcholine Chloride – 50 mg/ml ...................... X6830                  Temozolomide (Temodar) – 1 mg ........................... J9328
Succinylcholine Chloride – 20 mg/ml ...................... X5636                  Temsirolimus – 1 mg .............................................. J9330
Sucostrin – 100 mg/ml ........................................... X6828           Tensilon – 10 mg/ml ............................................... J3490
Sucostrin – 50 mg/ml ............................................. X6830          Terbutaline Sulfate – 1 mg/ml ................................ X5776
Sucostrin – 20 mg/ml ............................................. X5636          Testa-C – 100 mg/ml ............................................. X5618
Supartz – 25 mg/2.5 ml .......................................... X7486           Testaqua – 100 mg/ml ........................................... X6326
Supprelin LA Implant – 50mg .................................. J9226              Testaqua – 50 mg/ml ............................................. X5628
Sus-Phrine – 1:200 suspension ............................. X6166                 Testoject 50 ........................................................... X5628
Synagis (RSV-IgIV) – 50 mg ...................................90378               Testosterone – 100 mg/ml ..................................... X6326
Synthroid – 500 mcg/ml .......................................... J3490           Testosterone – 50 mg/ml ....................................... X5628
Syntocinon – 10 units/ml ........................................ X6666           Testosterone – 25 mg/ml ....................................... X6942
Sytobex – 1,000 mcg/ml......................................... X5752             Testosterone Aqueous – 100 mg/ml ...................... X6326
                                                                                  Testosterone Aqueous – 50 mg/ml ........................ X5628
                                                                                  Testosterone Aqueous – 25 mg/ml ........................ X6942
T                                                                                 Testosterone Cypionate – up to 100 mg ................. J1070
                                                                                  Testosterone Cypionate – 1 cc, 200 mg .................. J1080
Technetium Apcitide – 20 mCi ............................... A9504                Testosterone Enanthate, up to 100 mg ................... J3120
Technetium Bicisate – 25 mCi................................ A9557                Tetanus, diphtheria toxoids, and acellular
Technetium Disofenin – 15 mCi ............................. A9510                  pertussis vaccine [Tdap]
Technetium Exametazine – 25 mCi........................ A9521                      for intramuscular use ............................................ 90715
Technetium Fanolesomab – 25 mCi ....................... A9566                     Tetanus and diphtheria toxoids, adsorbed –
Technetium Labeled Red Blood Cells –                                               for seven years of age and older........................... 90718
 30 mCi ................................................................. A9560   Tetanus Immune Globulin
Technetium Macroaggregated albumin –                                               (human) – 250 unit ............................................... 90389
 10 mCI ................................................................. A9540   Tetanus Toxoid, Adsorbed ...................................... 90703
Technetium Mebrofenin – 15 mCi .......................... A9537                   Tetracaine HCl – 1%............................................... J3490
Technetium Medronate – 30 mCi ........................... A9503                   Tetracaine HCl – 0.3% w/6% Dextrose ................... J3490
Technetium Mertiatide – 15 mCi ............................ A9562                 Thallium TI-201 Thallous Chloride – 1 mCi ............ A9505
Technetium Oxidronate – 30 mCi ........................... A9561




2 – Injections: Code List
                                                                                                                                                 April 2011
inject cd list
18
                                                                    Codes                                                                           Codes

Thiopental Sodium – 1 gm ...................................... J3490            U
Thiopental Sodium – 500 mg .................................. J3490
Thiopental Sodium – 250 mg .................................. J3490              Ultracaine – 2% w/1:100,000
Thiotepa – 15 mg/vial ............................................. X7576         Epinephrine ......................................................... X6444
Thorazine – 25 mg/ml ............................................ X5918          Unclassified Drugs.................................................. J3490
Thyrotropin alfa 0.9 mg/1.1 mg vial ......................... J3240              Unipen – 2 gm (powder) vial .................................. X6604
Thyrotropin – 10 IU ................................................ X6968       Unipen – 1 gm (powder) vial .................................. X6606
Thytropar – 10 IU ................................................... X6968      Unipen – 500 mg vial ............................................. X6610
Tigecycline – 1 mg .................................................. J3243      Ustekinumab – 1 mg .............................................. J3357
Tinzaparin Sodium – 1000 IU ................................. X5509
T-Ionate P.A. – 100 mg/ml ..................................... X5618
Tobramycin Sulfate – 40 mg/ml.............................. X6620
Tobramycin Sulfate – 10 mg/2 ml vial .................... X6622                  V
Tocilizumab (Actemra) – 1 mg ............................... C9264
Topotecan – 4 mg ................................................... J9350       Valergen 40 ........................................................... X6018
Trastuzumab – 10 mg ............................................. J9355          Valergen 20 .......................................................... X5660
Treprostinil – 1 mg .................................................. J3285     Valergen 10 .......................................................... X5662
Triamcinolone Acetonide –                                                        Valium – 5 mg/ml ................................................... X6064
 not otherwise specified, 10 mg .............................. J3301             Vancomycin HCl – 500 mg ..................................... J3370
Triamcinolone Acetonide –                                                        Varicella Vaccine – .5 ml ........................................ 90716
 preservative free, 1 mg ......................................... J3300         Varidase for IM Use – 5,000-20,000 units .............. X6920
Triamcinolone Diacetate –                                                        Vasopressin – 20 pressor units/ml .......................... J3490
 25 mg/ml suspension ........................................... X6976           Velaglucerase alfa .................................................. J3590
Triamcinolone Hexacetonide, 5 mg ......................... J3303                 Velban – 10 mg/10 ml vial...................................... X7578
Triethylenethiophosphoramide –                                                   Venofer – 100 mg .................................................. X7492
 15 mg/vial ............................................................ X7576
Triptorelin (Trelstar) – 3.75 mg ............................... X7648
Tubocurarine Chloride – 3 mg/ml ............................ J3490
Typhoid vaccine, Acetone killed, dried (AKD) ..........90693
Typhoid vaccine, heat and phenol
 inactivated (H-P) ...................................................90692
Typhoid vaccine – live.............................................90690
Typhoid vaccine, Vi Capsular
 polysaccharide (ViCPs) .........................................90691




2 – Injections: Code List
                                                                                                                                               April 2011
                                                                                                                                         inject cd list
                                                                                                                                                         19
                                                                    Codes                                                                             Codes

Vepesid – 20 mg/ml ............................................... X7542         Xylocaine HCl – 1.5% w/7.5% Dextrose ................ X6480
Verteporfin – 0.1 mg ............................................... J3396       Xylocaine – 1.5% w/1:200,000 Epinephrine ........... X6482
V-Gan 50 .............................................................. X6236    Xylocaine HCl – 2% w/1:100,000 Epinephrine ....... X6444
V-Gan 25 ............................................................... X6742   Xylocaine HCl – 2% w/1:200,000 Epinephrine ....... X6474
Vibramycin I.V. – 200 mg (as Hyclate)/vial .............. J3490                  Xylocaine HCl – 1% w/1:200,000 Epinephrine ....... X6486
Vinblastine Sulfate (VLB) – 10 mg/10 ml vial .......... X7578                    Xylocaine HCl – 2% w/1:50,000 Epinephrine ......... X6476
Vincristine Sulfate – 1 mg ...................................... J9370          Xylocaine HCl – 0.5% w/1:200,000 Epinephrine .... X6492
Vinorelbine Tartrate – 10 mg ................................... J9390           Xylocaine HCl – 1% w/1:100,000 Epinephrine ....... X6488
Vistaril – 50 mg/ml ................................................. X6336      Xylocaine HCl – 5% w/7.5% Glucose..................... X6466
Vistaril – 25 mg/ml ................................................. X7010
Vitamin B12 – 1,000 mcg/ml .................................. X5752
Vi-Twel – 1,000 mcg/ml.......................................... X5752
Vivitrol® – 1 mg ...................................................... J2315    Y

                                                                                 Yellow Fever Vaccine ............................................. 90717
                                                                                 Yttrium Ibitumomab Tiuxetan – 40 mCi .................. A9543
W

Wehdryl 50 – 50 mg/ml .......................................... X5738
Wehgen – 2 mg/ml ................................................. X5756         Z
Wycillin – 2,400,000 units/unit dose ....................... X6714
Wycillin – 1,200,000 units/unit dose ....................... X6716               Zemplar – 1 mcg..................................................... J2501
Wycillin – 600,000 units/unit dose .......................... X6136              Ziconotide – 1 mcg ................................................. J2278
                                                                                 Zipan 50 ................................................................ X6236
                                                                                 Zipan 25 ................................................................ X6742
                                                                                 Ziprasidone – 20 mg .............................................. X7498
X                                                                                Zoladex – 3.6 mg ................................................... X7060
                                                                                 Zoladex – 10.8 mg (depot) ..................................... X7061
Xenon Xe-133 Gas, Diagnostic – 10 mCi ............... A9558                      Zoledronic acid – 1 mg (Zometa) ............................ J3487
Xolair – 5 mg........................................................... J2357   Zoledronic acid – 1 mg (Reclast) ............................ J3488
X-Otag – 30 mg/ml ................................................. X6216        Zostavax................................................................. 90736
Xylocaine HCl – 0.5% ............................................ X6490
Xylocaine HCl – 1.5% ............................................ X6478
Xylocaine HCl IM for cardiac arrythmias –
 10% (100 mg/ml) ................................................. X6464
Xylocaine HCl I.V. for cardiac arrythmias –
 2% (20 mg/ml) .................................................... X6470
Xylocaine HCl I.V. for cardiac arrythmias –
 4% (40 mg/ml) ..................................................... X6494
Xylocaine HCl I.V. for cardiac arrythmias –
 20% (200 mg/ml) ................................................. X6462




2 – Injections: Code List
                                                                                                                                                 May 2011

				
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