NDC Drug Fee Schedule - December 15, 2013 through January 31, … · 2013-11-19 · NDC Drug Fee Schedule - December 15, 2013 through January 31, 2014 Procedure NDC Maximum Allowable

Procedure NDC Maximum Allowable

Effective Date

End Date Procedure NDC Maximum Allowable

Effective Date

End Date

J3490 00002140701 $1.241856 12/15/13 12/31/13 J8499 00002441533 $4.2969124 1/1/14 1/31/14J3490 00002140701 $1.241856 1/1/14 1/31/14 J8499 00002442001 $5.7292041 12/15/13 12/31/13J3490 00002197590 $3.67556 12/15/13 12/31/13 J8499 00002442001 $5.7292041 1/1/14 1/31/14J3490 00002197590 $4.00644 1/1/14 1/31/14 J8499 00002442004 $5.7292041 12/15/13 12/31/13J8499 00002300475 $21.30624 12/15/13 12/31/13 J8499 00002442004 $5.7292041 1/1/14 1/31/14J8499 00002300475 $21.30624 1/1/14 1/31/14 J8499 00002442030 $5.7292041 12/15/13 12/31/13J8499 00002411201 $1.61064 12/15/13 12/31/13 J8499 00002442030 $5.7292041 1/1/14 1/31/14J8499 00002411201 $1.61064 1/1/14 1/31/14 J8499 00002445301 $8.064 12/15/13 12/31/13J8499 00002411204 $1.61064 12/15/13 12/31/13 J8499 00002445301 $8.064 1/1/14 1/31/14J8499 00002411204 $1.61064 1/1/14 1/31/14 J8499 00002445385 $8.064 12/15/13 12/31/13J8499 00002411230 $1.61064 12/15/13 12/31/13 J8499 00002445385 $8.064 1/1/14 1/31/14J8499 00002411230 $1.61064 1/1/14 1/31/14 J8499 00002445401 $11.9040019 12/15/13 12/31/13J8499 00002411233 $1.61064 12/15/13 12/31/13 J8499 00002445401 $11.9040019 1/1/14 1/31/14J8499 00002411233 $1.61064 1/1/14 1/31/14 J8499 00002445485 $11.9040019 12/15/13 12/31/13J8499 00002411501 $1.9009843 12/15/13 12/31/13 J8499 00002445485 $11.9040019 1/1/14 1/31/14J8499 00002411501 $1.9009843 1/1/14 1/31/14 J8499 00002445501 $17.4719980 12/15/13 12/31/13J8499 00002411530 $1.9009843 12/15/13 12/31/13 J8499 00002445501 $17.4719980 1/1/14 1/31/14J8499 00002411530 $1.9009843 1/1/14 1/31/14 J8499 00002445585 $17.4719980 12/15/13 12/31/13J8499 00002411601 $2.3134305 12/15/13 12/31/13 J8499 00002445585 $17.4719980 1/1/14 1/31/14J8499 00002411601 $2.3134305 1/1/14 1/31/14 J8499 00002475901 $6.38 12/15/13 12/31/13J8499 00002411604 $2.3134305 12/15/13 12/31/13 J8499 00002475901 $6.38 1/1/14 1/31/14J8499 00002411604 $2.3134305 1/1/14 1/31/14 J8499 00002475930 $6.38 12/15/13 12/31/13J8499 00002411630 $2.3134305 12/15/13 12/31/13 J8499 00002475930 $6.38 1/1/14 1/31/14J8499 00002411630 $2.3134305 1/1/14 1/31/14 J8499 00002476030 $6.38 12/15/13 12/31/13J8499 00002411633 $2.3134305 12/15/13 12/31/13 J8499 00002476030 $6.38 1/1/14 1/31/14J8499 00002411633 $2.3134305 1/1/14 1/31/14 J8499 00002476076 $6.38 12/15/13 12/31/13J8499 00002411701 $2.8646020 12/15/13 12/31/13 J8499 00002476076 $6.38 1/1/14 1/31/14J8499 00002411701 $2.8646020 1/1/14 1/31/14 J8499 00002512101 $7.58 12/15/13 12/31/13J8499 00002411704 $2.8646020 12/15/13 12/31/13 J8499 00002512101 $7.58 1/1/14 1/31/14J8499 00002411704 $2.8646020 1/1/14 1/31/14 J8499 00002512130 $7.58 12/15/13 12/31/13J8499 00002411730 $2.8646020 12/15/13 12/31/13 J8499 00002512130 $7.58 1/1/14 1/31/14J8499 00002411730 $2.8646020 1/1/14 1/31/14 J8499 00002512152 $7.58 12/15/13 12/31/13J8499 00002411733 $2.8646020 12/15/13 12/31/13 J8499 00002512152 $7.58 1/1/14 1/31/14J8499 00002411733 $2.8646020 1/1/14 1/31/14 J8499 00002512301 $7.58 12/15/13 12/31/13J8499 00002441501 $4.2969124 12/15/13 12/31/13 J8499 00002512301 $7.58 1/1/14 1/31/14J8499 00002441501 $4.2969124 1/1/14 1/31/14 J8499 00002512330 $7.58 12/15/13 12/31/13J8499 00002441504 $4.2969124 12/15/13 12/31/13 J8499 00002512330 $7.58 1/1/14 1/31/14J8499 00002441504 $4.2969124 1/1/14 1/31/14 J8499 00002512377 $7.58 12/15/13 12/31/13J8499 00002441530 $4.2969124 12/15/13 12/31/13 J8499 00002512377 $7.58 1/1/14 1/31/14J8499 00002441530 $4.2969124 1/1/14 1/31/14 J0130 00002714001 $163.90 12/15/13 12/31/13J8499 00002441533 $4.2969124 12/15/13 12/31/13 J0130 00002714001 $163.90 1/1/14 1/31/14

NDC Drug Fee Schedule - December 15, 2013 through January 31, 2014

This schedule is not a guaranty of payment. Variances in reimbursement may occur due to rounding calculations. Services represented are subject to provisions of the health plan including, but not limited to, membership eligibility, premium payment, claim payment logic, provider contract terms and conditions, applicable medical policy and benefits, limitations and exclusions. Maximum allowables and components of rates such as modifiers or conversion factors, and applicable rules such as bundling, may change from time to time subject to notice requirements of applicable law and regulation and the prevailing provider agreement. Values reflect the component of a code related to the place of treatment. CPT codes are copyright American Medical Association. All Rights Reserved. BCBSTX - HCSC Confidential and Proprietary.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Page 1 of 1203 v. 5_121513



Effective Date


Effective Date

End Date

J2941 00002733511 $407.50 12/15/13 12/31/13 J2941 00002814801 $978.00 1/1/14 1/31/14J2941 00002733511 $407.50 1/1/14 1/31/14 J2941 00002814901 $1,956.00 12/15/13 12/31/13J2941 00002733516 $374.75 12/15/13 12/31/13 J2941 00002814901 $1,956.00 1/1/14 1/31/14J2941 00002733516 $374.75 1/1/14 1/31/14 J1815 00002821501 $8.25 12/15/13 12/31/13J2941 00002734901 $374.75 12/15/13 12/31/13 J1817 00002821501 $8.25 12/15/13 12/31/13J2941 00002734901 $374.75 1/1/14 1/31/14 S5550 00002821501 $8.25 12/15/13 12/31/13J9201 00002750101 $47.85408 12/15/13 12/31/13 J1815 00002821501 $8.25 1/1/14 1/31/14J9201 00002750101 $40.41216 1/1/14 1/31/14 J1817 00002821501 $8.25 1/1/14 1/31/14J9201 00002750201 $193.536 12/15/13 12/31/13 S5550 00002821501 $8.25 1/1/14 1/31/14J9201 00002750201 $148.608 1/1/14 1/31/14 J1815 00002821517 $8.25 12/15/13 12/31/13J1815 00002751001 $14.04 12/15/13 12/31/13 J1817 00002821517 $8.25 12/15/13 12/31/13J1817 00002751001 $14.04 12/15/13 12/31/13 S5550 00002821517 $8.25 12/15/13 12/31/13S5551 00002751001 $14.04 12/15/13 12/31/13 J1815 00002821517 $8.25 1/1/14 1/31/14J1815 00002751001 $14.04 1/1/14 1/31/14 J1817 00002821517 $8.25 1/1/14 1/31/14J1817 00002751001 $14.04 1/1/14 1/31/14 S5550 00002821517 $8.25 1/1/14 1/31/14S5551 00002751001 $14.04 1/1/14 1/31/14 J1815 00002821591 $1.815 12/15/13 12/31/13J1815 00002751017 $14.04 12/15/13 12/31/13 J1817 00002821591 $1.815 12/15/13 12/31/13J1817 00002751017 $14.04 12/15/13 12/31/13 S5550 00002821591 $1.815 12/15/13 12/31/13S5551 00002751017 $14.04 12/15/13 12/31/13 J1815 00002821591 $1.815 1/1/14 1/31/14J1815 00002751017 $14.04 1/1/14 1/31/14 J1817 00002821591 $1.815 1/1/14 1/31/14J1817 00002751017 $14.04 1/1/14 1/31/14 S5550 00002821591 $1.815 1/1/14 1/31/14S5551 00002751017 $14.04 1/1/14 1/31/14 J1815 00002831501 $8.25 12/15/13 12/31/13J1815 00002751101 $14.04 12/15/13 12/31/13 S5552 00002831501 $8.25 12/15/13 12/31/13J1815 00002751101 $14.04 1/1/14 1/31/14 J1815 00002831501 $8.25 1/1/14 1/31/14J1815 00002751201 $14.04 12/15/13 12/31/13 S5552 00002831501 $8.25 1/1/14 1/31/14J1815 00002751201 $14.04 1/1/14 1/31/14 J1815 00002831517 $8.25 12/15/13 12/31/13J1815 00002751601 $17.39333 12/15/13 12/31/13 S5552 00002831517 $8.25 12/15/13 12/31/13J1817 00002751601 $17.39333 12/15/13 12/31/13 J1815 00002831517 $8.25 1/1/14 1/31/14J1815 00002751601 $17.39333 1/1/14 1/31/14 S5552 00002831517 $8.25 1/1/14 1/31/14J1817 00002751601 $17.39333 1/1/14 1/31/14 J1815 00002831591 $1.815 12/15/13 12/31/13J1815 00002751659 $17.39333 12/15/13 12/31/13 S5552 00002831591 $1.815 12/15/13 12/31/13J1817 00002751659 $17.39333 12/15/13 12/31/13 J1815 00002831591 $1.815 1/1/14 1/31/14J1815 00002751659 $17.39333 1/1/14 1/31/14 S5552 00002831591 $1.815 1/1/14 1/31/14J1817 00002751659 $17.39333 1/1/14 1/31/14 J3110 00002840001 $541.79167 12/15/13 12/31/13J3490 00002755901 $346.85 12/15/13 12/31/13 J3110 00002840001 $541.79167 1/1/14 1/31/14J3490 00002755901 $346.85 1/1/14 1/31/14 J1815 00002850101 $41.25 12/15/13 12/31/13J3490 00002756101 $1,387.40 12/15/13 12/31/13 J1815 00002850101 $41.25 1/1/14 1/31/14J3490 00002756101 $1,387.40 1/1/14 1/31/14 J1815 00002871501 $8.25 12/15/13 12/31/13J3490 00002759701 $20.88 12/15/13 12/31/13 J1815 00002871501 $8.25 1/1/14 1/31/14S0166 00002759701 $20.88 12/15/13 12/31/13 J1815 00002871517 $8.25 12/15/13 12/31/13J3490 00002759701 $20.88 1/1/14 1/31/14 J1815 00002871517 $8.25 1/1/14 1/31/14S0166 00002759701 $20.88 1/1/14 1/31/14 J1815 00002871591 $1.815 12/15/13 12/31/13J9305 00002762301 $2,984.425 12/15/13 12/31/13 J1815 00002871591 $1.815 1/1/14 1/31/14J9305 00002762301 $3,014.089 1/1/14 1/31/14 J1815 00002873001 $17.44333 12/15/13 12/31/13J2358 00002763511 $556.50 12/15/13 12/31/13 J1815 00002873001 $17.44333 1/1/14 1/31/14J2358 00002763511 $556.50 1/1/14 1/31/14 J1815 00002873059 $17.44333 12/15/13 12/31/13J2358 00002763611 $795.00 12/15/13 12/31/13 J1815 00002873059 $17.44333 1/1/14 1/31/14J2358 00002763611 $795.00 1/1/14 1/31/14 J1815 00002877001 $17.44333 12/15/13 12/31/13J2358 00002763711 $1,073.25 12/15/13 12/31/13 J1815 00002877001 $17.44333 1/1/14 1/31/14J2358 00002763711 $1,073.25 1/1/14 1/31/14 J1815 00002877059 $17.44333 12/15/13 12/31/13J9305 00002764001 $596.885 12/15/13 12/31/13 J1815 00002877059 $17.44333 1/1/14 1/31/14J9305 00002764001 $602.8178 1/1/14 1/31/14 J1815 00002879701 $18.07333 12/15/13 12/31/13J1610 00002803101 $151.50 12/15/13 12/31/13 J1815 00002879701 $18.07333 1/1/14 1/31/14J1610 00002803101 $151.50 1/1/14 1/31/14 J1815 00002879759 $18.07333 12/15/13 12/31/13J2941 00002814701 $489.00 12/15/13 12/31/13 J1815 00002879759 $18.07333 1/1/14 1/31/14J2941 00002814701 $489.00 1/1/14 1/31/14 J1815 00002879801 $18.07333 12/15/13 12/31/13J2941 00002814801 $978.00 12/15/13 12/31/13 J1815 00002879801 $18.07333 1/1/14 1/31/14


Page 2 of 1203 v. 5_121513



Effective Date


Effective Date

End Date

J1815 00002879859 $18.07333 12/15/13 12/31/13 J0129 00003218831 $558.565 1/1/14 1/31/14J1815 00002879859 $18.07333 1/1/14 1/31/14 J3490 00003223011 $0.66542 12/15/13 12/31/13J1815 00002879901 $18.07333 12/15/13 12/31/13 J3490 00003223011 $0.66542 1/1/14 1/31/14J1817 00002879901 $18.07333 12/15/13 12/31/13 J3490 00003224011 $1.33267 12/15/13 12/31/13J1815 00002879901 $18.07333 1/1/14 1/31/14 J3490 00003224011 $1.33267 1/1/14 1/31/14J1817 00002879901 $18.07333 1/1/14 1/31/14 J9228 00003232711 $636.67905 12/15/13 12/31/13J1815 00002879959 $18.07333 12/15/13 12/31/13 J9228 00003232711 $636.67905 1/1/14 1/31/14J1817 00002879959 $18.07333 12/15/13 12/31/13 J9228 00003232822 $636.67905 12/15/13 12/31/13J1815 00002879959 $18.07333 1/1/14 1/31/14 J9228 00003232822 $636.67905 1/1/14 1/31/14J1817 00002879959 $18.07333 1/1/14 1/31/14 J3490 00003256016 $29.00 12/15/13 12/31/13J3301 00003029305 $8.55 12/15/13 12/31/13 S0073 00003256016 $29.00 12/15/13 12/31/13J3301 00003029305 $8.55 1/1/14 1/31/14 J3490 00003256016 $29.00 1/1/14 1/31/14J3301 00003029320 $8.678 12/15/13 12/31/13 S0073 00003256016 $29.00 1/1/14 1/31/14J3301 00003029320 $8.678 1/1/14 1/31/14 J3490 00003257016 $58.00 12/15/13 12/31/13J3301 00003029328 $6.48 12/15/13 12/31/13 S0073 00003257016 $58.00 12/15/13 12/31/13J3301 00003029328 $6.48 1/1/14 1/31/14 J3490 00003257016 $58.00 1/1/14 1/31/14J0485 00003037113 $923.00 12/15/13 12/31/13 S0073 00003257016 $58.00 1/1/14 1/31/14J0485 00003037113 $923.00 1/1/14 1/31/14 J8499 00003362212 $36.28333 12/15/13 12/31/13J3301 00003049420 $2.208 12/15/13 12/31/13 J8499 00003362212 $36.28333 1/1/14 1/31/14J3301 00003049420 $2.208 1/1/14 1/31/14 J8499 00003362312 $18.31467 12/15/13 12/31/13J8999 00003052411 $151.680375 12/15/13 12/31/13 J8499 00003362312 $18.31467 1/1/14 1/31/14J8999 00003052411 $151.680375 1/1/14 1/31/14 J8499 00003362412 $18.31467 12/15/13 12/31/13J8999 00003052711 $75.840445 12/15/13 12/31/13 J8499 00003362412 $18.31467 1/1/14 1/31/14J8999 00003052711 $75.840445 1/1/14 1/31/14 J8499 00003363112 $18.31467 12/15/13 12/31/13J8999 00003052811 $151.680375 12/15/13 12/31/13 J8499 00003363112 $18.31467 1/1/14 1/31/14J8999 00003052811 $151.680375 1/1/14 1/31/14 J8499 00003421411 $8.198 12/15/13 12/31/13J8999 00003083050 $0.5517936 12/15/13 12/31/13 J8499 00003421411 $8.198 1/1/14 1/31/14S0176 00003083050 $0.5517936 12/15/13 12/31/13 J8499 00003421421 $8.19789 12/15/13 12/31/13J8999 00003083050 $0.5517936 1/1/14 1/31/14 J8499 00003421421 $8.19789 1/1/14 1/31/14S0176 00003083050 $0.5517936 1/1/14 1/31/14 J8499 00003421511 $8.198 12/15/13 12/31/13J8999 00003085222 $294.65313 12/15/13 12/31/13 J8499 00003421511 $8.198 1/1/14 1/31/14J8999 00003085222 $294.65313 1/1/14 1/31/14 J8499 00003421521 $8.19789 12/15/13 12/31/13J8999 00003085522 $294.65313 12/15/13 12/31/13 J8499 00003421521 $8.19789 1/1/14 1/31/14J8999 00003085522 $294.65313 1/1/14 1/31/14 J8499 00003421531 $8.1979 12/15/13 12/31/13J8999 00003085722 $294.65313 12/15/13 12/31/13 J8499 00003421531 $8.1979 1/1/14 1/31/14J8999 00003085722 $294.65313 1/1/14 1/31/14 J8499 00003421541 $8.1979 12/15/13 12/31/13J8499 00003161112 $33.323 12/15/13 12/31/13 J8499 00003421541 $8.1979 1/1/14 1/31/14J8499 00003161112 $34.656 1/1/14 1/31/14 J8499 00003633517 $0.75683 12/15/13 12/31/13J8499 00003161113 $33.32289 12/15/13 12/31/13 J8499 00003633517 $0.75683 1/1/14 1/31/14J8499 00003161113 $34.65578 1/1/14 1/31/14 J8499 00003633617 $0.75683 12/15/13 12/31/13J8499 00003161212 $33.323 12/15/13 12/31/13 J8499 00003633617 $0.75683 1/1/14 1/31/14J8499 00003161212 $34.656 1/1/14 1/31/14 J8499 00003633717 $0.80983 12/15/13 12/31/13J8499 00003161412 $3.33224 12/15/13 12/31/13 J8499 00003633717 $0.80983 1/1/14 1/31/14J8499 00003161412 $3.46552 1/1/14 1/31/14 J8499 00004003822 $56.80933 12/15/13 12/31/13J8499 00003196401 $3.5047699 12/15/13 12/31/13 J8499 00004003822 $59.08167 1/1/14 1/31/14J8499 00003196401 $3.5047699 1/1/14 1/31/14 J8499 00004003909 $7.81489 12/15/13 12/31/13J8499 00003196501 $5.4668131 12/15/13 12/31/13 J8499 00004003909 $8.1275 1/1/14 1/31/14J8499 00003196501 $5.4668131 1/1/14 1/31/14 J8499 00004005801 $0.12312 12/15/13 12/31/13J8499 00003196601 $5.8067971 12/15/13 12/31/13 J8499 00004005801 $0.12312 1/1/14 1/31/14J8499 00003196601 $5.8067971 1/1/14 1/31/14 J8499 00004005832 $0.12312 12/15/13 12/31/13J8499 00003196701 $5.91408 12/15/13 12/31/13 J8499 00004005832 $0.12312 1/1/14 1/31/14J8499 00003196701 $5.91408 1/1/14 1/31/14 J8499 00004008694 $16.5996962 12/15/13 12/31/13J8499 00003196801 $0.2174688 12/15/13 12/31/13 J8499 00004008694 $2.3828572 1/1/14 1/31/14J8499 00003196801 $0.2174688 1/1/14 1/31/14 J8499 00004009801 $0.170496 12/15/13 12/31/13J0129 00003218710 $613.61 12/15/13 12/31/13 J8499 00004009801 $0.170496 1/1/14 1/31/14J0129 00003218710 $613.61 1/1/14 1/31/14 J1740 00004018809 $146.38667 1/1/14 1/31/14J0129 00003218831 $558.565 12/15/13 12/31/13 J1740 00004019109 $150.04667 12/15/13 12/31/13


Page 3 of 1203 v. 5_121513



Effective Date


Effective Date

End Date

J1740 00004019109 $153.04667 1/1/14 1/31/14 J8520 00004110020 $9.8744349 12/15/13 12/31/13J1626 00004024009 $11.7504 12/15/13 12/31/13 J8520 00004110020 $10.2694399 1/1/14 1/31/14J1626 00004024009 $11.7504 1/1/14 1/31/14 J8521 00004110150 $32.9107351 12/15/13 12/31/13J8499 00004024451 $7.78825 12/15/13 12/31/13 J8521 00004110150 $34.2271575 1/1/14 1/31/14J8499 00004024451 $7.78825 1/1/14 1/31/14 J8521 00004110175 $32.9107351 12/15/13 12/31/13J8499 00004024515 $3.38719 12/15/13 12/31/13 J8521 00004110175 $34.2271575 1/1/14 1/31/14J8499 00004024515 $3.38719 1/1/14 1/31/14 J8499 00004620301 $0.19296 12/15/13 12/31/13J7517 00004025901 $0.5712768 12/15/13 12/31/13 J8499 00004620301 $0.19296 1/1/14 1/31/14J7517 00004025901 $0.5712768 1/1/14 1/31/14 J8499 00004631301 $0.1094688 12/15/13 12/31/13J7517 00004025905 $0.5712768 12/15/13 12/31/13 J8499 00004631301 $0.1094688 1/1/14 1/31/14J7517 00004025905 $0.5712768 1/1/14 1/31/14 J8499 00004631401 $0.1406304 12/15/13 12/31/13J7517 00004025943 $0.5712768 12/15/13 12/31/13 J8499 00004631401 $0.1406304 1/1/14 1/31/14J7517 00004025943 $0.5712768 1/1/14 1/31/14 J8499 00004631601 $0.1717516 12/15/13 12/31/13J7517 00004026001 $1.1425824 12/15/13 12/31/13 J8499 00004631601 $0.1717632 1/1/14 1/31/14J7517 00004026001 $1.1425824 1/1/14 1/31/14 J8499 00004641601 $0.56106 12/15/13 12/31/13J7517 00004026043 $1.1425824 12/15/13 12/31/13 J8499 00004641601 $0.56106 1/1/14 1/31/14J7517 00004026043 $1.1425824 1/1/14 1/31/14 J3490 00004691106 $1.0368 12/15/13 12/31/13J7517 00004026129 $6.19156 12/15/13 12/31/13 J3490 00004691106 $1.0368 1/1/14 1/31/14J7517 00004026129 $6.19156 1/1/14 1/31/14 J3490 00004691206 $1.648512 12/15/13 12/31/13J7599 00004029809 $76.4925 12/15/13 12/31/13 J3490 00004691206 $1.648512 1/1/14 1/31/14J7599 00004029809 $76.4925 1/1/14 1/31/14 J1570 00004694003 $56.028672 12/15/13 12/31/13J3590 00004035009 $713.60025 12/15/13 12/31/13 J1570 00004694003 $56.028672 1/1/14 1/31/14S0145 00004035009 $713.60025 12/15/13 12/31/13 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Q9967 00019133275 $0.346 12/15/13 12/31/13 J7312 00023334807 $1,295.00 1/1/14 1/31/14Q9967 00019133275 $0.346 1/1/14 1/31/14 J3490 00023350730 $6.066 12/15/13 12/31/13Q9967 00019133278 $0.996 12/15/13 12/31/13 J3490 00023350730 $6.066 1/1/14 1/31/14Q9967 00019133278 $0.996 1/1/14 1/31/14 J3490 00023361525 $43.764 12/15/13 12/31/13Q9967 00019133283 $0.95616 12/15/13 12/31/13 J3490 00023361525 $43.764 1/1/14 1/31/14Q9967 00019133283 $0.95616 1/1/14 1/31/14 J0585 00023391950 $289.00 12/15/13 12/31/13Q9967 00019133290 $1.00596 12/15/13 12/31/13 J0585 00023391950 $289.00 1/1/14 1/31/14Q9967 00019133290 $1.00596 1/1/14 1/31/14 J0585 00023392102 $1,050.00 12/15/13 12/31/13Q9967 00019133306 $0.9462 12/15/13 12/31/13 J0585 00023392102 $1,050.00 1/1/14 1/31/14Q9967 00019133306 $0.9462 1/1/14 1/31/14 J3490 00023782410 $0.883296 12/15/13 12/31/13Q9967 00019133311 $0.9462 12/15/13 12/31/13 J3490 00023782410 $0.883296 1/1/14 1/31/14Q9967 00019133311 $0.9462 1/1/14 1/31/14 J0585 00023923201 $525.00 12/15/13 12/31/13Q9967 00019133316 $0.88312 12/15/13 12/31/13 J0585 00023923201 $525.00 1/1/14 1/31/14Q9967 00019133316 $0.88312 1/1/14 1/31/14 J9217 00024022205 $1,269.99 12/15/13 12/31/13Q9967 00019133321 $0.840375 12/15/13 12/31/13 J9217 00024022205 $1,269.99 1/1/14 1/31/14Q9967 00019133321 $0.840375 1/1/14 1/31/14 J9263 00024059010 $13.608 12/15/13 12/31/13Q9967 00019133341 $0.9628 12/15/13 12/31/13 J9263 00024059010 $13.608 1/1/14 1/31/14Q9967 00019133341 $0.9628 1/1/14 1/31/14 J9263 00024059120 $13.62528 12/15/13 12/31/13Q9967 00019133351 $0.83664 12/15/13 12/31/13 J9263 00024059120 $13.62528 1/1/14 1/31/14Q9967 00019133351 $0.83664 1/1/14 1/31/14 J9263 00024059240 $124.319455 12/15/13 12/31/13Q9967 00019133352 $1.4442 12/15/13 12/31/13 J9263 00024059240 $124.319455 1/1/14 1/31/14Q9967 00019133352 $1.4442 1/1/14 1/31/14 J9217 00024060545 $2,539.98 12/15/13 12/31/13Q9967 00019133361 $0.8217 12/15/13 12/31/13 J9217 00024060545 $2,539.98 1/1/14 1/31/14Q9967 00019133361 $0.8217 1/1/14 1/31/14 J9217 00024061030 $1,693.32 12/15/13 12/31/13Q9967 00019133375 $0.408 12/15/13 12/31/13 J9217 00024061030 $1,693.32 1/1/14 1/31/14Q9967 00019133375 $0.408 1/1/14 1/31/14 J9217 00024079375 $423.33 12/15/13 12/31/13Q9967 00019133377 $1.07568 12/15/13 12/31/13 J9217 00024079375 $423.33 1/1/14 1/31/14Q9967 00019133377 $1.07568 1/1/14 1/31/14 J8499 00024156210 $0.17136 12/15/13 12/31/13Q9967 00019133378 $1.11552 12/15/13 12/31/13 J8499 00024156210 $0.17136 1/1/14 1/31/14Q9967 00019133378 $1.11552 1/1/14 1/31/14 J2916 00024279210 $4.396032 12/15/13 12/31/13Q9967 00019133381 $0.980064 12/15/13 12/31/13 J2916 00024279210 $4.396032 1/1/14 1/31/14Q9967 00019133381 $0.980064 1/1/14 1/31/14 J8499 00024414210 $5.2252 12/15/13 12/31/13Q9967 00019133383 $1.02588 12/15/13 12/31/13 J8499 00024414210 $5.2252 1/1/14 1/31/14Q9967 00019133383 $1.02588 1/1/14 1/31/14 J8499 00024414218 $5.22522 12/15/13 12/31/13Q9967 00019133387 $0.980064 12/15/13 12/31/13 J8499 00024414218 $5.22522 1/1/14 1/31/14Q9967 00019133387 $0.980064 1/1/14 1/31/14 J8499 00024414260 $5.22533 12/15/13 12/31/13Q9967 00019133390 $1.04829 12/15/13 12/31/13 J8499 00024414260 $5.22533 1/1/14 1/31/14Q9967 00019133390 $1.04829 1/1/14 1/31/14 J2783 00024515010 $643.3963701 12/15/13 12/31/13Q9967 00019133391 $1.10888 12/15/13 12/31/13 J2783 00024515010 $656.2645 1/1/14 1/31/14Q9967 00019133391 $1.10888 1/1/14 1/31/14 J2783 00024515175 $3,217.0608 12/15/13 12/31/13Q9967 00019133395 $1.17196 12/15/13 12/31/13 J2783 00024515175 $3,281.4049 1/1/14 1/31/14Q9967 00019133395 $1.17196 1/1/14 1/31/14 J8499 00024540131 $0.6659856 12/15/13 12/31/13Q9960 00019318309 $0.12 12/15/13 12/31/13 J8499 00024540131 $0.6659856 1/1/14 1/31/14Q9960 00019318309 $0.12 1/1/14 1/31/14 J8499 00024542131 $0.6659856 12/15/13 12/31/13Q9960 00019318315 $0.22 12/15/13 12/31/13 J8499 00024542131 $0.6659856 1/1/14 1/31/14Q9960 00019318315 $0.22 1/1/14 1/31/14 J8499 00024542150 $0.6659856 12/15/13 12/31/13Q9963 00019481604 $0.55 12/15/13 12/31/13 J8499 00024542150 $0.6659856 1/1/14 1/31/14Q9963 00019481604 $0.55 1/1/14 1/31/14 J8499 00024580090 $3.5440588 12/15/13 12/31/13Q9963 00019481605 $0.27778 12/15/13 12/31/13 J8499 00024580090 $3.5440588 1/1/14 1/31/14Q9963 00019481605 $0.27778 1/1/14 1/31/14 J8562 00024582020 $79.45729 12/15/13 12/31/13Q9963 00019481606 $0.26042 12/15/13 12/31/13 J8562 00024582020 $79.45729 1/1/14 1/31/14Q9963 00019481606 $0.26042 1/1/14 1/31/14 J9043 00024582411 $5,773.5482701 12/15/13 12/31/13J0585 00023114501 $525.00 12/15/13 12/31/13 J9043 00024582411 $5,773.5482701 1/1/14 1/31/14J0585 00023114501 $525.00 1/1/14 1/31/14 J3490 00024583102 $120.50 12/15/13 12/31/13J3490 00023218105 $6.12144 12/15/13 12/31/13 J3490 00024583102 $120.50 1/1/14 1/31/14J3490 00023218105 $6.12144 1/1/14 1/31/14 J3490 00024583302 $120.50 12/15/13 12/31/13J7312 00023334807 $1,295.00 12/15/13 12/31/13 J3490 00024583302 $120.50 1/1/14 1/31/14


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J9999 00024584001 $412.00 12/15/13 12/31/13 J8499 00025152551 $5.72702 1/1/14 1/31/14J9999 00024584001 $412.00 1/1/14 1/31/14 J8499 00025153001 $7.8497 12/15/13 12/31/13J9999 00024584101 $412.00 12/15/13 12/31/13 J8499 00025153001 $8.5907 1/1/14 1/31/14J9999 00024584101 $412.00 1/1/14 1/31/14 J8499 00025153002 $7.84967 12/15/13 12/31/13J8499 00025006131 $0.20736 12/15/13 12/31/13 J8499 00025153002 $8.59067 1/1/14 1/31/14J8499 00025006131 $0.20736 1/1/14 1/31/14 J8499 00025182131 $0.405072 12/15/13 12/31/13J3490 00025016608 $153.8875 12/15/13 12/31/13 J8499 00025182131 $0.405072 1/1/14 1/31/14J3490 00025016608 $169.1225 1/1/14 1/31/14 J8499 00025182150 $0.405072 12/15/13 12/31/13J8499 00025103131 $0.8203104 12/15/13 12/31/13 J8499 00025182150 $0.405072 1/1/14 1/31/14J8499 00025103131 $0.8203104 1/1/14 1/31/14 J8499 00025183131 $0.2424268 12/15/13 12/31/13J8499 00025138131 $1.491552 12/15/13 12/31/13 J8499 00025183131 $0.2424268 1/1/14 1/31/14J8499 00025138131 $2.110464 1/1/14 1/31/14 J8499 00025183150 $0.2424268 12/15/13 12/31/13J8499 00025141134 $1.9312128 12/15/13 12/31/13 J8499 00025183150 $0.2424268 1/1/14 1/31/14J8499 00025141134 $1.9312128 1/1/14 1/31/14 J8499 00025186131 $0.0872654 12/15/13 12/31/13J8499 00025141160 $1.9312128 12/15/13 12/31/13 J8499 00025186131 $0.0872654 1/1/14 1/31/14J8499 00025141160 $1.9312128 1/1/14 1/31/14 J8499 00025190131 $0.4634928 12/15/13 12/31/13J8499 00025141190 $1.9312128 12/15/13 12/31/13 J8499 00025190131 $1.2289536 1/1/14 1/31/14J8499 00025141190 $1.9312128 1/1/14 1/31/14 J7192 00026378220 $0.8736 12/15/13 12/31/13J8499 00025142134 $1.9312300 12/15/13 12/31/13 J7192 00026378220 $0.8736 1/1/14 1/31/14J8499 00025142134 $1.9312300 1/1/14 1/31/14 J7192 00026378225 $1.40 1/1/14 1/31/14J8499 00025142160 $1.9312300 12/15/13 12/31/13 J7192 00026378330 $0.8736 12/15/13 12/31/13J8499 00025142160 $1.9312300 1/1/14 1/31/14 J7192 00026378330 $0.8736 1/1/14 1/31/14J8499 00025145120 $0.5196009 12/15/13 12/31/13 J7192 00026378335 $1.40 1/1/14 1/31/14S0191 00025145120 $0.5196009 12/15/13 12/31/13 J7192 00026378550 $0.8736 12/15/13 12/31/13J8499 00025145120 $0.5196009 1/1/14 1/31/14 J7192 00026378550 $0.8736 1/1/14 1/31/14S0191 00025145120 $0.5196009 1/1/14 1/31/14 J7192 00026378555 $1.40 1/1/14 1/31/14J8499 00025145134 $0.5196009 12/15/13 12/31/13 J7192 00026378660 $0.8736 12/15/13 12/31/13S0191 00025145134 $0.5196009 12/15/13 12/31/13 J7192 00026378660 $0.8736 1/1/14 1/31/14J8499 00025145134 $0.5196009 1/1/14 1/31/14 J7192 00026378665 $1.40 1/1/14 1/31/14S0191 00025145134 $0.5196009 1/1/14 1/31/14 J7192 00026378770 $0.8736 12/15/13 12/31/13J8499 00025145160 $0.5196009 12/15/13 12/31/13 J7192 00026378770 $0.8736 1/1/14 1/31/14S0191 00025145160 $0.5196009 12/15/13 12/31/13 J7192 00026378775 $1.40 1/1/14 1/31/14J8499 00025145160 $0.5196009 1/1/14 1/31/14 J7192 00026379220 $0.8736 12/15/13 12/31/13S0191 00025145160 $0.5196009 1/1/14 1/31/14 J7192 00026379220 $0.8736 1/1/14 1/31/14J8499 00025146131 $0.823392 12/15/13 12/31/13 J7192 00026379330 $0.8736 12/15/13 12/31/13S0191 00025146131 $0.823392 12/15/13 12/31/13 J7192 00026379330 $0.8736 1/1/14 1/31/14J8499 00025146131 $0.823392 1/1/14 1/31/14 J7192 00026379550 $0.8736 12/15/13 12/31/13S0191 00025146131 $0.823392 1/1/14 1/31/14 J7192 00026379550 $0.8736 1/1/14 1/31/14J8499 00025146134 $0.823392 12/15/13 12/31/13 J7192 00026379660 $0.8736 12/15/13 12/31/13S0191 00025146134 $0.823392 12/15/13 12/31/13 J7192 00026379660 $0.8736 1/1/14 1/31/14J8499 00025146134 $0.823392 1/1/14 1/31/14 J7192 00026379770 $0.8736 12/15/13 12/31/13S0191 00025146134 $0.823392 1/1/14 1/31/14 J7192 00026379770 $0.8736 1/1/14 1/31/14J8499 00025146160 $0.823392 12/15/13 12/31/13 J3490 00029152544 $1.116 12/15/13 12/31/13S0191 00025146160 $0.823392 12/15/13 12/31/13 J3490 00029152544 $1.116 1/1/14 1/31/14J8499 00025146160 $0.823392 1/1/14 1/31/14 J8499 00029315818 $2.6285 12/15/13 12/31/13S0191 00025146160 $0.823392 1/1/14 1/31/14 J8499 00029315818 $2.6285 1/1/14 1/31/14J8499 00025152031 $3.1904 12/15/13 12/31/13 J8499 00029315913 $3.90133 12/15/13 12/31/13J8499 00025152031 $3.4916 1/1/14 1/31/14 J8499 00029315913 $3.90133 1/1/14 1/31/14J8499 00025152034 $3.1904 12/15/13 12/31/13 J8499 00029316013 $7.088 12/15/13 12/31/13J8499 00025152034 $3.4916 1/1/14 1/31/14 J8499 00029316013 $7.088 1/1/14 1/31/14J8499 00025152051 $3.19044 12/15/13 12/31/13 J8499 00029460613 $2.083392 12/15/13 12/31/13J8499 00025152051 $3.49162 1/1/14 1/31/14 J8499 00029460613 $2.083392 1/1/14 1/31/14J8499 00025152531 $5.233 12/15/13 12/31/13 J8499 00029608522 $0.43153 12/15/13 12/31/13J8499 00025152531 $5.727 1/1/14 1/31/14 J8499 00029608522 $0.43153 1/1/14 1/31/14J8499 00025152534 $5.233 12/15/13 12/31/13 J8499 00029608523 $0.4403 12/15/13 12/31/13J8499 00025152534 $5.727 1/1/14 1/31/14 J8499 00029608523 $0.4403 1/1/14 1/31/14J8499 00025152551 $5.23302 12/15/13 12/31/13 J8499 00029608539 $0.44067 12/15/13 12/31/13


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Documents

NDC Drug Fee Schedule - December 15, 2013 through January 31, … · 2013-11-19 · NDC Drug Fee Schedule - December 15, 2013 through January 31, 2014 Procedure NDC Maximum Allowable