Procedure Procedure Code Desc Pricing Description Code Rate · 2015. 11. 30. · J1110 INJ., DEHYDROERGOTAMINE, UP TO 1 MG 22.34 General Fee Schedule J1290 INJECTION ECALLANTIDE 1

Physician Administered Drugs

Current Crosswalk

Procedure

CodeProcedure Code Desc

Procedure

RatePricing Description

Q4100 Skin substitute, NOS 0 Manual Price

Q4112 Cymetra injectable 335.65 General Fee Schedule

Q4114 Integra flowable wound matri 937.11 General Fee Schedule

J9202 GOSERELIN ACETATE IMPLANT PER 3.6MG 208.54 General Fee Schedule

J8530 CYCLOPHOSPHAMLIDE; ORAL, 25MG 0.97 General Fee Schedule

J2310 INJ NALOXONE HCL PER 1MG 5.37 General Fee Schedule

J1602 Golimumab for iv use 1mg 25.35 General Fee Schedule

J1720 INJ., HYDROCORTISONE SOD SUCCINATE, 100 3.17 General Fee Schedule

J1120 INJ., ACETAZOLAMIDE SODIUM, UP TO 500 MG 38.15 General Fee Schedule

J9600 Porfimer sodium injection 2894.04 General Fee Schedule

S4993 CONTRACEPTIVE PILLS FOR BC 35.19 General Fee Schedule

J7040 INFUSION, NORMAL SALINE SOLUTION, 500 CC 0.58 General Fee Schedule

J3411 Thiamine hcl 100 mg 2.64 General Fee Schedule

J3490 UNCLASSIFIED DRUGS 0 Manual Price

J0745 INJECTION, CODEINE PHOSPHATE 1.38 General Fee Schedule

J7306 Levonorgestrel implant sys 0 Manual Price

J7599 IMMUNOSUPPRESSIVE DRUG NOC 0 Manual Price

J7635 Atropine comp con 0 Manual Price

J7638 Dexamethasone comp unit 0 Manual Price

S0088 Imatinib 100 mg 20.92 General Fee Schedule

S0093 Morphine 500 mg 24.07 General Fee Schedule

J0190 INJ., BIPERIDEN, 2 MG 5.58 General Fee Schedule

S0169 Calcitrol 0 Manual Price

Q0180 DOLASETRON MESYLATE, 100 MG, ORAL 54.07 General Fee Schedule

J3315 Triptorelin pamoate 172.90 General Fee Schedule

J1230 INJ., METHADONE HCL, UP TO 10 MG 6.12 General Fee Schedule

J7683 Triamcinolone comp con 0 Manual Price

J8520 Capecitabine, oral, 150 mg 6.10 General Fee Schedule

J9155 Degarelix injection 2.95 General Fee Schedule

J1940 INJ., FUROSEMIDE, UP TO 20 MG 0.24 General Fee Schedule

J2793 Rilonacept injection 0 Manual Price

J7515 Cyclosporine oral 25 mg 0.99 General Fee Schedule

J9070 CYCLOPHOSPHAMIDE 100MG 4.28 General Fee Schedule

S4989 Contracept IUD 104.73 General Fee Schedule

J1559 Hizentra injection 7.53 General Fee Schedule

J7310 CANCICLOVIR 4.5MG LONG-ACT IMPLANT 5401.95 General Fee Schedule

J2920 INJ METHYLPREDNISOLN SOD SUC UP TO 40MG 2.92 General Fee Schedule

J9310 Rituximab injection 708.13 General Fee Schedule

J1020 INJ., METHYLPREDNISOLONE ACETATE, 20 MG 1.89 General Fee Schedule

J7620 Albuterol ipratrop non-comp 0.29 General Fee Schedule

S0074 Injection, cefotetan disodiu 8.23 General Fee Schedule

J0153 Adenosine inj 1mg 0 Manual Price

J2562 Plerixafor injection 274.84 General Fee Schedule

J2997 Alteplase recombinant 37.92 General Fee Schedule

Q0515 Sermorelin acetate injection 4.25 General Fee Schedule

J3320 INJ., SPECTINOMYCIN DIHYDROCHLORIDE, 2GM 28.62 General Fee Schedule

J3350 INJ., UREA, UP TO 40 GM 94.10 General Fee Schedule

Data - November 2015


Current Crosswalk

J7676 Pentamidine comp unit dose 0 Manual Price

J8515 Cabergoline, oral 0.25mg 12.60 General Fee Schedule

Q4106 Dermagraft 42.75 General Fee Schedule

Q4119 Matristem wound matrix 0 Manual Price

Q2049 Imported Lipodox inj 491.98 General Fee Schedule

J0586 AbobotulinumtoxinA 8.27 General Fee Schedule

J1212 Dimethyl sulfoxide 50% 50 ml 73.47 General Fee Schedule

J9178 Inj, epirubicin hcl, 2 mg 3.10 General Fee Schedule

J1930 Lanreotide injection 30.93 General Fee Schedule

J2278 Ziconotide injection 6.92 General Fee Schedule

J1655 Tinzaparin sodium injection 2.47 General Fee Schedule

J1327 Eptifibatide injection 19.04 General Fee Schedule

J1335 Ertapenem injection 27.88 General Fee Schedule

J9100 Cytarabine hcl 100 MG inj 1.87 General Fee Schedule

J3489 Zoledronic acid 1mg 107.58 General Fee Schedule

J0744 Ciprofloxacin iv 1.51 General Fee Schedule

J1557 Gammaplex injection 38.82 General Fee Schedule

J1561 Gamunex-C/Gammaked 39.25 General Fee Schedule

J7312 Dexamethasone intra implant 203.38 General Fee Schedule

J7627 Budesonide comp unit 0 Manual Price

J3262 Tocilizumab injection 3.60 General Fee Schedule

Q0139 Ferumoxytol, esrd use 0.64 General Fee Schedule

J1100 Dexamethasone sodium phos 0.11 General Fee Schedule

S0176 Hydroxyurea 500 mg 0 Manual Price

J3303 INJ TRIAMCINOLONE HEXACETONIDE PER 5MG 1.57 General Fee Schedule

J0735 INJ CLONIDINE HCL 1MG 82.55 General Fee Schedule

J1160 INJECTION, DIGOXIN, UP TO 0.5 MG. 1.32 General Fee Schedule

J1240 INJ., DIMENHYDRINATE, UP TO 50 MG 3.51 General Fee Schedule

J0287 Amphotericin b lipid complex 10.58 General Fee Schedule

J9120 Dactinomycin injection 578.36 General Fee Schedule

J2710 INJ., NEOSTIGMINE METHYLSULFATE, TO 0.5 0.11 General Fee Schedule

J1745 Infliximab injection 60.24 General Fee Schedule

J0390 INJ., CHLOROQUINE HCL, UP TO 50 MG 19.06 General Fee Schedule

J7520 Sirolimus, oral 9.38 General Fee Schedule

J3410 INJ., HYDROXYZINE HCL, UP TO 25 MG 0.56 General Fee Schedule

J1562 Vivaglobin, inj 7.47 General Fee Schedule

J9020 Asparaginase, NOS 61.72 General Fee Schedule

J7178 Human fibrinogen conc inj 0 Manual Price

J7181 Factor xiii recomb a-subunit 0 Manual Price

J7191 Factor viii (porcine) 4.27 General Fee Schedule

J7613 Albuterol non-comp unit 0.07 General Fee Schedule

J7641 Flunisolide comp unit 0 Manual Price

S0078 Injection, fosphenytoin sodi 60.31 General Fee Schedule

J0135 Adalimumab injection 385.53 General Fee Schedule

J1756 Iron sucrose injection 0.44 General Fee Schedule

J9213 Interferon alfa-2a inj 39.56 General Fee Schedule

Q4101 Apligraf 35.01 General Fee Schedule

J1170 INJ., HYDROMORPHONE, UP TO 4 MG 1.58 General Fee Schedule

J0330 INJ., SUCCINYCHOLINE CHLORIDE, TO 20 MG 0.18 General Fee Schedule



Current Crosswalk

J0360 INJ., HYDRALAZINE HCL, UP TO 20 MG 5.07 General Fee Schedule

J7686 Treprostinil, non-comp unit 413.38 General Fee Schedule

J7699 Inhalation solution for DME 0 Manual Price

J1955 INJ LEVOCARNITINE PER 1GM 6.66 General Fee Schedule

Q9956 Inj octafluoropropane mic, ml 62.66 General Fee Schedule

J1595 Injection glatiramer acetate 0 Manual Price

J1630 INJECTION, HALDOL, UP TO 5 MG. 1.71 General Fee Schedule

J1645 Dalteparin sodium 12.26 General Fee Schedule

J1742 INJ IBUTILIDE FUMARATE 1MG 436.82 General Fee Schedule

J7665 Mannitol for inhaler 0 Manual Price

J1325 EPO PROSTENOL 0.5MG 15.05 General Fee Schedule

S5000 Prescription drug, generic 0 Manual Price

J3420 INJ., VIT B-12, CYANOCOBALAMIN, TO 1000 0.31 General Fee Schedule

J0897 Denosumab injection 15.10 General Fee Schedule

J7070 INFUSION, D5W, 1,000 CC. 2.36 General Fee Schedule

J7632 Cromolyn sodium comp unit 0 Manual Price

J9270 Plicamycin (mithramycin) inj 104.01 General Fee Schedule

J2505 Injection, pegfilgrastim 6mg 2386.54 General Fee Schedule

J2510 INJ., PENICILLIN G PROCAINE, AQUEOUS TO 11.52 General Fee Schedule

J9215 Interferon alfa-n3 inj 10.51 General Fee Schedule

J9150 Daunorubicin injection 17.10 General Fee Schedule

J9175 Elliotts b solution per ml 4.33 General Fee Schedule

J7681 Terbutaline sulf comp unit 0 Manual Price

Q9959 HOCM 150-199 mg/ml iodine, 1 ml 0.09 General Fee Schedule

J1599 Ivig non-lyophilized, NOS 0 Manual Price

J1626 Granisetron hcl injection 21.96 General Fee Schedule

J1710 INJ., HYDROCORTISONE SOD PHOSPHATE, 50 M 7.59 General Fee Schedule

J0461 Atropine sulfate injection 0.06 General Fee Schedule

J0475 INJECTION BACLOFEN 10MG 216.31 General Fee Schedule

J7505 Monoclonal antibodies 1193.59 General Fee Schedule

J7508 Tacrolimus oral 0.42 General Fee Schedule

J7647 Isoetharine comp con 0 Manual Price

J7189 Factor viia 1.39 General Fee Schedule

J7198 Anti-inhibitor 1.58 General Fee Schedule

J2545 Pentamidine non-comp unit 47.66 General Fee Schedule

J0583 Bivalirudin 2.46 General Fee Schedule

J1810 INJ., DROPERIDOL & FENTANYL CITR, 2ML AM 9.99 General Fee Schedule

J9245 INJ MELPHALAN HCL 50MG 1735.84 General Fee Schedule

Q4105 Integra drt 12.77 General Fee Schedule

J9206 Irinotecan injection 124.26 General Fee Schedule

J1205 INJ., CHLOROTHIAZIDE SODIUM 318.10 General Fee Schedule

J8501 Oral aprepitant 5.84 General Fee Schedule

J9179 Eribulin mesylate injection 93.74 General Fee Schedule

J1950 Arthrodesis Anterior interbody add-on 759.35 General Fee Schedule

J0597 C-1 esterase, berinert 28.57 General Fee Schedule

J7509 METHYLPREDNISOLONE ORAL PER 4MG 0.08 General Fee Schedule

J2426 Paliperidone palmitate inj 7.59 General Fee Schedule

J3480 INJ POTASSIUM CHL PER 2MEG 0.04 General Fee Schedule

J1556 Inj, imm glob bivigam, 500mg 39.43 General Fee Schedule



Current Crosswalk

J9040 Bleomycin sulfate injection 339.37 General Fee Schedule

J1450 INJECTION FLUCONAZOLE, 200 MG 7.05 General Fee Schedule

J7199 Hemophilia clot factor noc 0 Manual Price

J1000 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP 7.22 General Fee Schedule

J7607 Levalbuterol comp con 0 Manual Price

S0077 Injection, clindamycin phosp 16.07 General Fee Schedule

S0092 Hydromorphone 250 mg 91.43 General Fee Schedule

J0133 Acyclovir injection 0.06 General Fee Schedule

J0180 AGALSIDASE BETA, 1 MG 145.58 General Fee Schedule

J9266 Pegaspargase injection 2936.39 General Fee Schedule

J2590 INJ., OXYTOCIN, UP TO 10 UNITS 1.05 General Fee Schedule

Q0175 PERPHENZAINE, 4 MG, ORAL 0.84 General Fee Schedule

Q4111 Gammagraft 7.92 General Fee Schedule

J2700 Oxacillin sodium injeciton 1.82 General Fee Schedule

J0456 Azithromycin 7.86 General Fee Schedule

J1110 INJ., DEHYDROERGOTAMINE, UP TO 1 MG 22.34 General Fee Schedule

J1290 INJECTION ECALLANTIDE 1 MG 285.67 General Fee Schedule

J1410 INJ., ESTROGEN CONJUGATED, 2MG OR 20000 87.67 General Fee Schedule

J7649 Isoetharine non-comp unit 3.03 General Fee Schedule

S5013 5% dextrose/45%saline,1000ml 0 Manual Price

J1455 Foscarnet sodium injection 39.34 General Fee Schedule

J7300 INTRAUTERINE COPPER CONTRACEPTIVE (T38A) 742.70 General Fee Schedule

J0945 INJ., BROMPHENIRAMINE MALEATE 3.14 General Fee Schedule

J7605 Arformoterol non-comp unit 5.41 General Fee Schedule

S0119 Ondansetron 4 mg 0 Manual Price

J0256 Alpha 1 proteinase inhibitor 3.97 General Fee Schedule

J2507 Pegloticase injection 314.49 General Fee Schedule

J2560 INJ., PHENOBARBITAL SODIUM, TO 120 MG 3.44 General Fee Schedule

J3095 Televancin injection 2.01 General Fee Schedule

J0574 Buprenorph/nalox 6.1 to 10mg 6.36 General Fee Schedule

J3360 INJ., DIAZEPAM, UP TO 5 MG 1.10 General Fee Schedule

Q4116 Alloderm skin sub 35.33 General Fee Schedule

J0702 Betamethasone acet&sod phosp 6.81 General Fee Schedule

J0743 INJECTION CILASTATIN SOD IMIPENEM 250MG 13.51 General Fee Schedule

Q9957 Inj perflutren lip micros, ml 66.45 General Fee Schedule


J0558 PenG benzathine/procaine inj 3.34 General Fee Schedule

J0670 INJ., MEPIVACAINE 1.44 General Fee Schedule

J1270 INJECTION, DOXERCALCIFEROL 3.38 General Fee Schedule

J7510 PREDNISOLONE ORAL PER 5MG 0.04 General Fee Schedule

J9098 Cytarabine liposome inj 519.78 General Fee Schedule

J7645 IPRATROPIUM BROMIDE INHALATION COMP MG 0 Manual Price

J0800 INJECTION, CORTICOTROPIN, UP TO 40 UNITS 2556.52 General Fee Schedule

J0834 Cosyntropin cortrosyn inj 93.70 General Fee Schedule

J1560 Gamma globulin > 10 cc inj 158.36 General Fee Schedule

J1566 Immune globulin, powder 32.86 General Fee Schedule

J9043 Cabazitaxel injection 140.73 General Fee Schedule

J7316 Injection ocriplasmin 1046.75 General Fee Schedule

J7131 Hypertonic saline sol 0 Manual Price



Current Crosswalk

J7186 Antihemophilic viii/vwf comp 0.98 General Fee Schedule

J7100 INFUSION, DEXTRAN 40, 500 ML. 23.01 General Fee Schedule

J7525 Tacrolimus injection 149.15 General Fee Schedule

J7628 Bitolterol mesylate comp con 0 Manual Price

J7642 Glycopyrrolate comp con 0 Manual Price

S0142 Colistimethate inh sol mg 0 Manual Price

J0171 Adrenalin epinephrine inject 0.06 General Fee Schedule

J9303 Panitumumab injection 91.42 General Fee Schedule

J2940 SOMATREM INJECTION 49.60 General Fee Schedule

J1094 Inj dexamethasone acetate 0.26 General Fee Schedule

J1830 Interferon beta-1b / .25 MG 79.38 General Fee Schedule

S0174 Dolasetron 50 mg 0 Manual Price

Q0177 HYDROXYZINE PANDATE, 25 MG, ORAL 0.07 General Fee Schedule

Q4104 Integra bmwd 12.77 General Fee Schedule

J0713 INJ CEFTAZIDIME PER 500MG 3.05 General Fee Schedule

J1953 Levetiracetam injection 0.49 General Fee Schedule

Q9964 HOCM>= 400mg/ml iodine, 1 ml 0.33 General Fee Schedule

J2060 INJ LORAZEPA 2MG 0.86 General Fee Schedule

J2175 INJECTION, MEPERDINE 1.61 General Fee Schedule

J0600 INJ., EDETATE CALCIUM DISODIUM, 200 MG 85.93 General Fee Schedule

J0636 Inj calcitriol per 0.1 mcg 0.52 General Fee Schedule

S5010 5% dextrose and 45% saline 16.99 General Fee Schedule

J2469 Palonosetron hcl 18.76 General Fee Schedule

J0850 INJ CYTOMEGALOVIRUS IMMUNE GLOB 939.00 General Fee Schedule

J0888 Epoetin beta non esrd 0 Manual Price

J7608 Acetylcysteine non-comp unit 1.99 General Fee Schedule

S0032 Injection, nafcillin sodium 6.82 General Fee Schedule

J3280 INJ., THIETHYLPERAZINE MALEATE, TO 10 MG 7.63 General Fee Schedule

J2941 Somatropin injection 49.60 General Fee Schedule

J0585 Injection,onabotulinumtoxinA 5.86 General Fee Schedule

J9260 METHOTREXATE SODIUM MTX, 50MG 2.19 General Fee Schedule

J0290 Ampicillin 500 MG inj 2.12 General Fee Schedule

J0350 INJ ANISTREPLASE, PER 30 UNITS 2864.03 General Fee Schedule

J2675 Inj progesterone per 50 MG 1.43 General Fee Schedule

J2788 Rho d immune globulin 50 mcg 27.60 General Fee Schedule

J1740 IBANDRONATE SODIUM, 1 MG 150.42 General Fee Schedule

J2248 Micafungin sodium injection 1.19 General Fee Schedule

J0490 INJECTION BENADRYL HC UP TO-USE J1200 40.17 General Fee Schedule

J2405 INJ ONDANSETRON HCL PER 1MG 0.22 General Fee Schedule

J2430 INJ PAMIDRONATE DRSEDIUM PER 30MG 21.84 General Fee Schedule

J3385 Velaglucerase alfa 363.83 General Fee Schedule

J9328 Temozolomide injection 5.08 General Fee Schedule

J9340 Thiotepa injection 103.55 General Fee Schedule

J7634 Budesonide comp con 0 Manual Price

J3243 Tigecycline injection 1.25 General Fee Schedule

J0215 Alefacept 30.17 General Fee Schedule

J2950 INJ., PROMAZINE HCL, UP TO 25 MG 2.48 General Fee Schedule

J3302 INJ TRIAMCINOLONE DIACETATE PER 5MG 0.32 General Fee Schedule

J3365 Urokinase 250,000 iu inj 489.08 General Fee Schedule



Current Crosswalk

J1180 INJ., DIPHYLLINE, UP TO 500 MG 7.98 General Fee Schedule

J8540 Oral dexamethasone 0.39 General Fee Schedule

J8705 Topotecan oral 74.82 General Fee Schedule

J0515 INJECTION, BENZTROPINE 35.75 General Fee Schedule

J2300 INJ NALBUPHINE HCL PER 10MG 1.06 General Fee Schedule

J2650 INJ., PREDNISOLONE ACETATE, UP TO 1 ML 0.20 General Fee Schedule

J2680 INJ., FLUPHENAZINE DECANOATE, TO 25 MG 11.33 General Fee Schedule

J2770 Injctn, quinupristin/dalfopristin, 500mg 156.41 General Fee Schedule

Q9965 LOCM 100-199mg/ml iodine,1ml 1.39 General Fee Schedule

J2270 INJ., MORPHINE SULFATE, UP TO 10 MG 2.09 General Fee Schedule

J9390 Vinorelbine tartrate inj 82.44 General Fee Schedule

J7501 Azathioprine parenteral 97.61 General Fee Schedule

J2370 INJ., PHENYLEPHRINE HCL, UP TO 1 ML 0.96 General Fee Schedule

J3473 Hyaluronidase recombinant 0.16 General Fee Schedule

J0770 INJECTION, COLY-MYCIN M, UP TO 150 MG. 17.43 General Fee Schedule

J0840 Crotalidae poly immune fab 2207.64 General Fee Schedule

J2810 INJ., THEOPHYLLINE, UP TO 2 ML 0.04 General Fee Schedule

J7636 Atropine comp unit 3.55 General Fee Schedule

J7637 Dexamethasone comp con 0 Manual Price

S0091 Granisetron 1mg 212.88 General Fee Schedule

J0221 Lumizyme injection 155.08 General Fee Schedule

J9261 Nelarabine injection 107.12 General Fee Schedule

J8597 Antiemetic drug oral NOS 0 Manual Price

J9010 Alemtuzumab injection 606.13 General Fee Schedule

Q4110 Primatrix 36.82 General Fee Schedule

J0289 Amphotericin b liposome inj 15.80 General Fee Schedule

J9185 Fludarabine phosphate inj 173.66 General Fee Schedule

J2274 In morphine preservativ free 0 Manual Price


J2010 INJ., LINCOMYCIN HCL, UP TO 300 MG 5.44 General Fee Schedule

J2185 Meropenem 4.34 General Fee Schedule

J0638 Canakinumab injection 92.54 General Fee Schedule

S5011 5% dextrose in lactated ring 16.85 General Fee Schedule

J2357 Omalizumab injection 21.73 General Fee Schedule

J1459 Inj IVIG privigen 500 mg 37.34 General Fee Schedule

J9306 Injection, pertuzumab, 1 mg 10.42 General Fee Schedule

J7194 FACTOR IX COMPLEX PER I.U. 0.83 General Fee Schedule

J9209 Mesna injection 4.47 General Fee Schedule

J3260 INJ., TOBRAMYCIN SULFATE, UP TO 80 MG 2.19 General Fee Schedule

J0200 Alatrofloxacin mesylate 23.62 General Fee Schedule

J0207 INJ AMIFOSTINE 500MG 392.96 General Fee Schedule

J3030 INJ., SUMATRIPTAN SUCCINATE 88.32 General Fee Schedule

J1890 INJ., CEPHALOTHIN SODIUM, UP TO 1 GM 13.58 General Fee Schedule

Q0166 GRANISETRON HCL, 1MG ORAL 5.63 General Fee Schedule

Q4102 Oasis wound matrix 4.76 General Fee Schedule

J0712 Ceftaroline fosamil inj 0.78 General Fee Schedule

J7684 Triamcinolone comp unit 0 Manual Price

J8560 ETOPOSIDE; ORAL, 50MG 32.42 General Fee Schedule

J9000 Doxorubicin hcl injection 3.80 General Fee Schedule



Current Crosswalk

J0364 Apomorphine hydrochloride 4.21 General Fee Schedule

J7660 ISOPROTERENOL INHALATION COMPOUNDED MG 0 Manual Price

J0610 INJECTION, CALCIUM GLUCONATE, UP TO 10 M 0.34 General Fee Schedule

J1300 Eculizumab 10 mg 193.37 General Fee Schedule

J1380 INJ., ESTRADIOL VALERATE, UP TO 10 MG 10.43 General Fee Schedule

J2360 INJ., ORPENADRINE, UP TO 60 MG 8.05 General Fee Schedule

J3475 INJ MAGNESIUM S04 PER 500MG 0.07 General Fee Schedule

J1572 Flebogamma injection 39.34 General Fee Schedule

J1573 Hepagam b intravenous, inj 52.03 General Fee Schedule

J2916 Na ferric gluconate complex 5.07 General Fee Schedule

J2850 Inj secretin synthetic human 21.70 General Fee Schedule

J9360 Vinblastine sulfate inj 1.08 General Fee Schedule

J7193 Factor IX non-recombinant 0.97 General Fee Schedule

J7615 LEVALBUTEROL INHALATION COMPOUNDED 0.5 M 0 Manual Price

J7629 Bitolterol mesylate comp unt 2.24 General Fee Schedule

J7631 Cromolyn sodium noncomp unit 0.50 General Fee Schedule

S0145 Peg interferon alfa-2A/180 0 Manual Price

J0716 Centruroides immune f(ab) 0 Manual Price

J9201 Gemcitabine hcl injection 150.30 General Fee Schedule

J1931 Laronidase injection 27.18 General Fee Schedule

J1945 Lepirudin 189.53 General Fee Schedule

Q9960 HOCM 200-249 mg/ml iodine, 1ml 0.14 General Fee Schedule

J1744 Icatibant injection 0 Manual Price

J1980 INJ., HYOSCYAMINE SULFATE, UP TO 0.25 MG 10.64 General Fee Schedule

J2250 INJ MIDAZOLAM HCL PER 1MG 0.19 General Fee Schedule

J0395 Arbutamine hcl injection 209.32 General Fee Schedule

J7668 Metaproterenol non-comp con 2.28 General Fee Schedule

J1364 Erythro lactobionate /500 mg 8.22 General Fee Schedule

J9055 Cetuximab injection 52.91 General Fee Schedule

J9060 Cisplatin 10 MG injection 2.48 General Fee Schedule

J3590 Unclassified biologics 0 Manual Price

J7309 Methyl aminolevulinate, top 0 Manual Price

J7183 Wilate injection 0.93 General Fee Schedule

J0887 Epoetin beta esrd use 0 Manual Price

S0136 CLOZAPINE, 25 MG 0 Manual Price

J7050 INFUSION, NORMAL SALINE SOLUTION, 250 CC 0.31 General Fee Schedule

J3265 INJ TORSEMIDE 10MG/ML 4.11 General Fee Schedule

J0210 Methyldopate hcl injection 29.40 General Fee Schedule

J0257 Glassia injection 4.10 General Fee Schedule

J3105 TERBUTALINE SULFATE, UP TO 1 MG 3.22 General Fee Schedule

J0706 Caffeine citrate injection 0.60 General Fee Schedule

J1260 Dolasetron mesylate 5.15 General Fee Schedule

J7799 Non-inhalation drug for DME 0 Manual Price

J9015 Aldesleukin injection 901.87 General Fee Schedule

J0295 INJ AMPICILLIN SOD --PER 1.5 GM 3.27 General Fee Schedule

J9165 Diethylstilbestrol injection 18.26 General Fee Schedule

J1956 Levofloxacin injection 5.68 General Fee Schedule

J2315 Naltrexone, depot form 2.97 General Fee Schedule

J2704 Inj, propofol, 10 mg 0.12 General Fee Schedule



Current Crosswalk

J2783 Rasburicase 176.47 General Fee Schedule

J2800 INJ., METHOCARBAMOL, UP TO 10 ML 26.79 General Fee Schedule

J2805 Sincalide injection 69.51 General Fee Schedule

J1652 Fondaparinux sodium 6.64 General Fee Schedule

J7657 Isoproterenol comp con 0 Manual Price

J0595 Butorphanol tartrate 1 mg 0.54 General Fee Schedule

J0696 INJ CEFTRIAXONE SODIUM PER 250MG 1.14 General Fee Schedule

Q4082 Drug/bio NOC part B drug CAP 0 Manual Price

J2400 INJ., CHLOROPROCAINE HCL 13.08 General Fee Schedule

J0780 INJ., PROCHLORPERAZINE, UP TO 10 MG 2.19 General Fee Schedule

J7182 Factor viii recomb novoeight 0 Manual Price

J0894 Decitabine injection 30.37 General Fee Schedule

J1030 INJ., METHYLPREDNISOLONE ACETATEL, 40 MG 4.24 General Fee Schedule

J7609 Albuterol comp unit 0 Manual Price

J9264 Paclitaxel protein bound 9.81 General Fee Schedule

J1800 INJ., PROPRANOLOL HCL, UP TO 1 MG 5.65 General Fee Schedule

J0571 Buprenorphine oral 1mg 1.12 General Fee Schedule

J9214 Interferon alfa-2b inj 16.40 General Fee Schedule

J7682 Tobramycin non-comp unit 72.03 General Fee Schedule

J8999 CHEMOTHERAPEUTIC ORAL DRUG, NOS 0 Manual Price

J0592 Buprenorphine hydrochloride 0.80 General Fee Schedule

J1960 INJ., LEVORPHANOL TARTRATE, UP TO 2 MG 5.62 General Fee Schedule

J1675 Histrelin acetate 3.25 General Fee Schedule

J1725 Hydroxyprogesterone caproate 0 General Fee Schedule

J1435 Injection estrone per 1 mg 2.24 General Fee Schedule

J1438 Etanercept injection 191.84 General Fee Schedule

J7648 Isoetharine non-comp con 2.95 General Fee Schedule

J2323 Natalizumab injection 8.67 General Fee Schedule

J2323 Natalizumab injection 11.56 General Fee Schedule

J3470 INJ., HYALURONIDASE, UP TO 150 UNITS 16.93 General Fee Schedule

J1460 Gamma globulin 1 cc inj 15.84 General Fee Schedule

J7311 Fluocinolone acetonide implt 20669.69 General Fee Schedule

J7330 Cultured chondrocytes implnt 26801.44 General Fee Schedule

J2930 INJ., METHYLPREDNISOLONE SOD SUCC 125 MG 3.96 General Fee Schedule

J9307 Pralatrexate injection 171.12 General Fee Schedule

J0886 Epoetin alfa 1000 units ESRD 10.28 General Fee Schedule

J7633 Budesonide non-comp con 0 Manual Price

S0040 Injection, ticarcillin disod 15.79 General Fee Schedule

S0148 Peg interferon alfa-2b/10 0 Manual Price

J0178 Aflibercept injection 1005.11 General Fee Schedule

J3246 Tirofiban HCl 7.22 General Fee Schedule

J3285 Treprostinil injection 62.05 General Fee Schedule

J9268 Pentostatin injection 1483.26 General Fee Schedule

J2995 INJ., STREPTOKINASE 140.01 General Fee Schedule

Q0167 DRONABINOL, 2.5 MG ORAL 7.27 General Fee Schedule

J9219 Leuprolide acetate implant 5149.87 General Fee Schedule

J3305 INJ TRIMETREXATE GLU PER 25MG 73.24 General Fee Schedule

Q4117 Hyalomatrix 0 Manual Price

J1190 INJ, DEXRAZOXANE HCL PER 250MG 291.60 General Fee Schedule



Current Crosswalk

J1250 INJ DOBUTAMINE HCL PER 250MG 5.73 General Fee Schedule

J1267 Doripenem injection 0.62 General Fee Schedule

J9181 Etoposide injection 0.50 General Fee Schedule

J2260 Injection, milrinone lactate, 5 mg 4.60 General Fee Schedule

J7667 Metaproterenol comp con 0 Manual Price

J7507 Tacrolimus imme rel oral 1mg 4.30 General Fee Schedule

J2353 Octreotide injection, depot 114.09 General Fee Schedule

J2460 INJ., OXYTETRACYCLINE HCL, UP TO 50 MG 2.98 General Fee Schedule

J3230 INJ., CHLORPROMAZINE HCL, UP TO 50 MG 8.61 General Fee Schedule

J3250 INJ., TRIMETHOBENZAMIDE HCL, UP TO 200 M 5.15 General Fee Schedule

J2501 Paricalcitol 3.90 General Fee Schedule

J9200 Floxuridine injection 59.40 General Fee Schedule

Q9951 LOCM>= 400 mg/ml iodine, 1 ml 0 Manual Price

J0476 Baclofen intrathecal trial 77.96 General Fee Schedule

J1600 Gold sodium thiomaleate inj 8.04 General Fee Schedule

J1610 INJ GLUCAGON HCL PR 1MG 86.11 General Fee Schedule

S0021 Injection, ceftoperazone sod 0 Manual Price

J1642 INJ HEPARIN SOD PER 10 UNITS 0.14 General Fee Schedule

J1743 Idursulfase injection 484.02 General Fee Schedule

J9400 Inj, ziv-aflibercept, 1mg 9.57 General Fee Schedule

J0594 Busulfan injection 15.40 General Fee Schedule

J0641 Levoleucovorin injection 1.38 General Fee Schedule

Q4074 Iloprost non-comp unit dose 50.67 General Fee Schedule

J9355 Trastuzumab injection 82.66 General Fee Schedule

J7301 Levonorgestrel iu 13.5 mg 715.85 General Fee Schedule

J1050 Injection,medroxprogesterone acetate 1mg 0.43 General Fee Schedule

J7611 Albuterol non-comp con 0.11 General Fee Schedule

J7640 Formoterol comp unit 5.15 General Fee Schedule

S0137 DIDANOSINE, 25 MG 0 Manual Price

J9267 Paclitaxel injection 1.83 General Fee Schedule

J9293 INJ MITOXANTRONE HCL PER 20MG 72.72 General Fee Schedule

J3070 Pentazocine injection 7.91 General Fee Schedule

J3110 TERIPARATIDE, 10 MCG 39.04 General Fee Schedule

J9228 Ipilimumab injection 130.75 General Fee Schedule

Q4108 Integra matrix 18.91 General Fee Schedule

J0715 INJ CEFTIZOXIM SOD PER 500MG 8.92 General Fee Schedule

J1631 INJ., HALOPERIDOL DECANOATE, PER 50 MG 16.08 General Fee Schedule

Q9953 Inj Fe-based mr contrast, 1ml 32.51 General Fee Schedule

J2730 INJ., PRALIDOXIME CHLORIDE, UP TO 1 GM 97.76 General Fee Schedule

J2020 LINEZOLID INJECTION 32.39 General Fee Schedule

J0401 Inj aripiprazole ext rel 1mg 4.10 General Fee Schedule

J0630 INJ., CALCITONIN SALMON, UP TO 400 UNITS 52.63 General Fee Schedule

J7513 Daclizumab, parenteral 388.45 General Fee Schedule

J2410 INJ., OXYMORPHONE HCL, UP TO 1 MG 2.41 General Fee Schedule

J1569 Gammagard liquid injection 41.06 General Fee Schedule

J1458 Galsulfase injection 361.55 General Fee Schedule

J7323 Euflexxa inj per dose 122.88 General Fee Schedule

J2820 INJ SARGRAMOSTIN (GM-CSF)50MCG 25.75 General Fee Schedule

J9315 Romidepsin injection 226.56 General Fee Schedule



Current Crosswalk

J7196 ANTITHROMBIN RECOM 50 IU 0 Manual Price

J7200 Factor ix recombinan rixubis 0 Manual Price

J0885 Epoetin alfa, non-esrd 10.28 General Fee Schedule

S0179 Megestrol 20 mg 0 Manual Price

S0034 Injection, ofloxacin, 400 mg 30.48 General Fee Schedule

S0073 Injection, aztreonam, 500 mg 10.83 General Fee Schedule

J0130 INJECTION ABCIXIMAB 10 MG 491.38 General Fee Schedule

J9301 Obinutuzumab inj 0 Manual Price

J9250 METHOTREXATE SODIUM MTX, 2 CC. OR 5 MG. 0.24 General Fee Schedule

J9262 Inj, omacetaxine mep, 0.01mg 0 Manual Price

J9263 Oxaliplatin 10.23 General Fee Schedule

J7674 Methacholine chloride, neb 0.49 General Fee Schedule

J8562 Oral fludarabine phosphate 82.53 General Fee Schedule

Q4115 Alloskin skin sub 9.80 General Fee Schedule

Q4121 Theraskin 23.91 General Fee Schedule

J1162 Digoxin immune fab (ovine) 502.30 General Fee Schedule

J0300 INJ., AMOBARBITAL, UP TO 125 MG 4.48 General Fee Schedule

J2720 INJECTION, PROTAMINE SULFATE, UP TO 5 ML 0.65 General Fee Schedule

J2765 INJ., METOCLOPRAMIDE HCL, UP TO 10 MG 0.40 General Fee Schedule

S0014 Tacrine hydrochloride, 10 mg 3.24 General Fee Schedule

J1670 INJ., TETANUS IMMUNE GLOBULIN, HUMAN 250 207.02 General Fee Schedule

J2150 INJECTION, MANVITOL, 25% IN 50 ML. 0.99 General Fee Schedule

J0380 INJ., METARAMINOL, UP TO 10 MG 3.25 General Fee Schedule

J7650 ISOETHARINE HCL INHALATION COMPOUNDED MG 0 Manual Price

J7504 Lymphocyte immune globulin 512.74 General Fee Schedule

J2358 Olanzapine long-acting inj 2.85 General Fee Schedule

J3400 INJ., TRIFLUPROMAZINE HCL, UP TO 20 MG 15.99 General Fee Schedule

J0775 Collagenase, clost hist inj 38.92 General Fee Schedule

J0833 Cosyntropin injection NOS 67.21 General Fee Schedule

J1568 Octagam injection 40.16 General Fee Schedule

J9041 Bortezomib injection 39.61 General Fee Schedule

J1453 Fosaprepitant injection 1.67 General Fee Schedule

J7304 Contraceptive hormone patch 19.00 General Fee Schedule

J9320 Streptozocin injection 300.37 General Fee Schedule

J7180 Factor xiii anti-hem factor 0 Manual Price

J7185 Xyntha inj 1.12 General Fee Schedule

J9208 Ifosfamide injection 150.59 General Fee Schedule

J7612 Levalbuterol non-comp con 0.24 General Fee Schedule

J7644 Ipratropium bromide non-comp 0.23 General Fee Schedule

J0120 Tetracyclin injection 15.10 General Fee Schedule

J0129 Abatacept injection 20.46 General Fee Schedule

J3145 Testosterone undecanoate 1mg 0 Manual Price

J0275 Alprostadil urethral suppos 26.28 General Fee Schedule

J0278 Amikacin sulfate injection 0.71 General Fee Schedule

J0280 INJECTION, AMINOPHYLLIN, UP TO 250 MG. 0.44 General Fee Schedule

J2513 Pentastarch 10% solution 18.37 General Fee Schedule

J1826 Interferon beta-1a inj 0 Manual Price

S0171 Bumetanide 0.5 mg 3.34 General Fee Schedule

Q0162 Ondansetron oral 0.83 General Fee Schedule



Current Crosswalk

Q0174 thiethylperazine maleate, oral 0 Manual Price

J3357 Ustekinumab injection 116.11 General Fee Schedule

J0710 INJ., CEPHAPIRIN SODIUM, UP TO 1 GM 3.69 General Fee Schedule

Q2050 Doxorubicin inj 10mg 493.19 General Fee Schedule

J1200 INJ., DIPHENHYDRAMINE HCL, UP TO 50 MG 0.84 General Fee Schedule

J1265 Dopamine injection 0.53 General Fee Schedule

J0288 Ampho b cholesteryl sulfate 14.95 General Fee Schedule

J2780 INJ, RANITIDINE HCL, 25 MG 1.32 General Fee Schedule

S5551 INSULIN MOST RAPID 5 U 0.36 General Fee Schedule

J0500 INJ., DICYCLOMINE, UP TO 20 MG 19.00 General Fee Schedule

J7658 Isoproterenol non-comp con 0 Manual Price

J0694 INJECTION, CEFOXITIN SODIUM, 1GM 7.31 General Fee Schedule

J7500 Azathioprine oral 50mg 0.14 General Fee Schedule

J7506 PREDNISONE, ORAL, PER 5 MG 0.05 General Fee Schedule

S0166 Inj olanzapine 2.5 mg 7.96 General Fee Schedule

S5012 5% dextrose with potassium 23.63 General Fee Schedule

J7315 Ophthalmic mitomycin 0 Manual Price

S0140 SAQUINAVIR, 200 MG 0 Manual Price

S0155 Epoprostenol dilutant 0 Manual Price

J0220 Alglucosidase alfa injection 135.80 General Fee Schedule

J1815 Insulin injection 0.49 General Fee Schedule

Q0138 Ferumoxytol, non-esrd 0.64 General Fee Schedule

J9151 Daunorubicin citrate inj 59.89 General Fee Schedule

J9190 Fluorouracil injection 1.55 General Fee Schedule

J2796 Romiplostim injection 44.79 General Fee Schedule


J3486 Ziprasidone mesylate 6.01 General Fee Schedule

J1571 Hepagam b im injection 52.03 General Fee Schedule

J7321 Hyalgan/supartz inj per dose 100.13 General Fee Schedule

J7324 Orthovisc inj per dose 170.40 General Fee Schedule

J7060 INFUSION, D5W, 500 CC. 1.17 General Fee Schedule

J7606 Formoterol fumarate, inh 4.68 General Fee Schedule

J7614 Levalbuterol non-comp unit 0.29 General Fee Schedule

J7639 Dornase alfa non-comp unit 24.26 General Fee Schedule

J3300 Inj triamcinolone acetonide 1 mg 3.46 General Fee Schedule

J9280 Mitomycin injection 15.18 General Fee Schedule

J0282 Amiodarone HCl 0.36 General Fee Schedule

Q0169 PROMETHAZINE HCL, 12.5 MG ORAL 0.49 General Fee Schedule

Q0173 TRIMETHOBENZAMIDE CHL, 250 MG ORAL 0.78 General Fee Schedule

J7680 Terbutaline sulf comp con 0 General Fee Schedule

J7685 Tobramycin comp unit 0 Manual Price

J8700 Temozolmide 9.06 General Fee Schedule

Q4103 Oasis burn matrix 4.76 General Fee Schedule

J9207 Ixabepilone injection 67.80 General Fee Schedule

J0365 Aprotonin, 10,000 kiu 2.83 General Fee Schedule

J2795 Ropivacaine HCl injection 0.09 General Fee Schedule

J1990 INJ., CHLORDIAZEPOXIDE HCL, UP TO 100 MG 23.82 General Fee Schedule

J0637 Caspofungin acetate 12.82 General Fee Schedule

J0697 INJ STERILE CEFUROXIME SOD PER 750MG 3.77 General Fee Schedule



Current Crosswalk

J1322 Elosulfase alfa, injection 0 Manual Price

J7502 Cyclosporine oral 100 mg 4.09 General Fee Schedule

J9025 Azacitidine injection 5.07 General Fee Schedule

J9033 Bendamustine injection 19.75 General Fee Schedule

J9050 Carmustine injection 188.20 General Fee Schedule

J7303 Contraceptive vaginal ring 40.31 General Fee Schedule

J7327 Monovisc inj per dose 963.80 General Fee Schedule

J9357 Valrubicin injection 1038.02 General Fee Schedule

J7120 INJ., RINGERS LACTATE INFUSION, TO 1000C 1.04 General Fee Schedule

J7110 INFUSION, DEXTRAN 75, 500 ML. 13.60 General Fee Schedule

S0183 Prochlorperazine 5 mg 0 Manual Price

J0132 Acetylcysteine injection 2.47 General Fee Schedule

J0205 Alglucerase injection 44.87 General Fee Schedule

J0285 Amphotericin B 14.07 General Fee Schedule

J1850 INJ., KANAMYCIN SULFATE, UP TO 75 MG 0.62 General Fee Schedule

Q0164 PROCHLORPERAZINE MALEATE 5 MG ORAL 0.06 General Fee Schedule

J0698 CEFOTAXIME SODIUM PER GM 4.35 General Fee Schedule

J0720 INJ., CHLORAMPHENICOL SOD SUCCINATE 1 GM 16.59 General Fee Schedule

J0588 Incobotulinumtoxin a 5.76 General Fee Schedule

J8610 METHOTREXATE; ORAL, 2.5MG 0.18 General Fee Schedule

J1640 Hemin, 1 mg 8.39 General Fee Schedule

J0470 INJ., DIMECAPROL, UP TO 100 MG 28.02 General Fee Schedule

S0156 Exemestane, 25 mg 9.68 General Fee Schedule

S0157 Becaplermin gel 1%, 0.5 gm 16.83 General Fee Schedule

S5014 D5W/0.45NS w KCl and MGS04 0 Manual Price

J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UN 0.35 General Fee Schedule

J2354 Octreotide inj, non-depot 1.62 General Fee Schedule

J3396 Verteporfin injection 10.13 General Fee Schedule

J9042 Brentuximab vedotin inj 115.17 General Fee Schedule

J7308 Aminolevulinic acid hcl top 139.42 General Fee Schedule

J7201 Factor ix fc fusion recomb 0 Manual Price

J0882 Darbepoetin alfa, esrd use 3.18 General Fee Schedule

J0895 Deferoxamine mesylate inj 11.58 General Fee Schedule

S0090 Sildenafil citrate, 25 mg 11.43 General Fee Schedule

J9302 Ofatumumab injection 46.88 General Fee Schedule

J2515 Pentobarbital sodium inj 12.79 General Fee Schedule

J1750 Inj iron dextran 12.52 General Fee Schedule

J0573 Buprenorph/nalox 3.1 to 6mg 5.00 General Fee Schedule

J9216 Interferon gamma 1-b inj 319.90 General Fee Schedule

Q2009 Fosphenytoin inj PE 0.63 General Fee Schedule

J3370 Vancomycin hcl injeciton 3.26 General Fee Schedule

J0740 INJ CIDOFOVIR 375MG 813.28 General Fee Schedule

J1165 INJ., PHENYTOIN SODUIM 0.78 General Fee Schedule

J7670 METAPROTERENOL SULFATE INHALATION 10 MG 0 Manual Price

J8521 Capecitabine, oral, 500 mg 20.23 General Fee Schedule

J8650 Nabilone oral 0 Manual Price

J2690 INJ., PROCAINAMIDE HCL, UP TO 1 GM 4.78 General Fee Schedule

J2725 Inj protirelin per 250 mcg 28.49 General Fee Schedule

J2760 Phentolaine mesylate inj 56.51 General Fee Schedule



Current Crosswalk

J2794 Risperidone, long acting 5.92 General Fee Schedule

J0480 Basiliximab, 20 mg 1757.62 General Fee Schedule

J0640 INJ., LEUCOVORIN CALCIUM, PER 50 MG 0.93 General Fee Schedule

J1330 INJ., ERGONOVINE MALEATE, UP TO 0.2 MG 7.09 General Fee Schedule

J1430 Ethanolamine oleate 100 mg 159.53 General Fee Schedule

J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG. 0.69 General Fee Schedule

J3415 Pyridoxine hcl 100 mg 5.16 General Fee Schedule

J7325 Synvisc or Synvisc-One 12.72 General Fee Schedule

J0881 Darbepoetin alfa, non-esrd 3.18 General Fee Schedule

J7643 Glycopyrrolate comp unit 0 Manual Price

S0039 Injection, sulfamethoxazole 19.72 General Fee Schedule

J3010 Fentanyl citrate injeciton 0.37 General Fee Schedule

J3121 Inj testostero enanthate 1mg 0.44 General Fee Schedule

J1790 INJ., DROPERIDOL, UP TO 5 MG 1.70 General Fee Schedule

J0575 Buprenorph/nalox over 10mg 7.00 General Fee Schedule

J3301 Triamcinolone acet inj NOS 1.67 General Fee Schedule

Q4113 Graftjacket xpress 335.65 General Fee Schedule

J9130 Dacarbazine 100 mg inj 4.26 General Fee Schedule

Q9958 HOCM


Current Crosswalk

J9395 Injection, Fulvestrant 87.77 General Fee Schedule

J7511 Antithymocyte globuln rabbit 475.28 General Fee Schedule

J3465 Injection, voriconazole 5.84 General Fee Schedule

J3485 Zidovudine 1.34 General Fee Schedule

J1580 INJECTION, GARAMYCIN, GENTAMYCIN, UP TO 0.90 General Fee Schedule

J9031 BCG (INTRAVESICAL) PER INSTALLATION 125.31 General Fee Schedule

J9035 Bevacizumab injection 67.22 General Fee Schedule

J9045 Carboplatin injection 112.48 General Fee Schedule

J1439 Inj ferric carboxymaltos 1mg 0 Manual Price

J2910 INJ AUROTHIOGLUCOSE UP TO 50MG 17.43 General Fee Schedule

J0878 Daptomycin injection 0.63 General Fee Schedule

S0081 Injection, piperacillin sodi 5.31 General Fee Schedule

S0189 Testosterone pellet 75 mg 0 Manual Price

J2503 Pegaptanib sodium injection 1102.39 General Fee Schedule

J2504 Pegademase bovine, 25 iu 263.08 General Fee Schedule

J2550 INJ., PROMETHAZINE HCL, UP TO 50 MG 1.75 General Fee Schedule

J2993 Reteplase injection 1119.49 General Fee Schedule

J1786 Imuglucerase injection 43.38 General Fee Schedule

J1817 Insulin for insulin pump use 3.51 General Fee Schedule

Q0161 Chlorpromazine hydrochloride 0.15 General Fee Schedule

J9225 Vantas implant 1687.47 General Fee Schedule

Q0511 Sup fee antiem,antica,immuno 5.12 General Fee Schedule

Q2017 Teniposide, 50 mg 348.15 General Fee Schedule

J1245 INJECTION DIPYRIDAMOLE PER 10MG 1.04 General Fee Schedule

J9171 Docetaxel injection 18.02 General Fee Schedule


J1644 INJ HEPARIN SOD PER 1000 UNITS 0.35 General Fee Schedule

J1730 Diazoxide injection 107.20 General Fee Schedule

J2180 INJ., MEPERIDINE & PROMETH AZINE HCL, 50 6.43 General Fee Schedule

J0598 C-1 esterase, cinryze 44.37 General Fee Schedule

J0620 INJ., CALCIUM GLYCEROPHOSPHATE/LACTATE 5 7.42 General Fee Schedule

J0692 Cefepime HCl for injection 4.71 General Fee Schedule

J1324 Enfuvirtide injection 0 Manual Price

Q4081 Epoetin alfa, 100 units ESRD 1.03 General Fee Schedule

J1590 Gatifloxacin injection 2.98 General Fee Schedule

J7190 Factor viii 0.93 General Fee Schedule

J7302 Levonorgestrel iu 52 mg 892.99 General Fee Schedule

J7610 ALBUTEROL INHALATION CONCENTRATED 1 MG 0 Manual Price

J7626 Budesonide non-comp unit 6.48 General Fee Schedule

J3240 Thyrotropin injection 1031.95 General Fee Schedule

J9305 Pemetrexed injection 52.62 General Fee Schedule

J2320 Nandrolone decanoate 50 mg 7.13 General Fee Schedule

J2543 Piperacillin/tazobactam 6.25 General Fee Schedule

J3000 INJECTION, STREPTOMYCIN, UP TO 1 GM. 6.71 General Fee Schedule

Q0163 diphenhydramine hcl 50 mg oral 0.04 General Fee Schedule

J9217 LEUPROLIDE ACETATE FOR DEPOT SUSP 7.5MG 917.64 General Fee Schedule

J0725 Chorionic gonadotropin/1000u 3.14 General Fee Schedule

J9017 Arsenic trioxide injection 39.94 General Fee Schedule

S0023 Injection, cimetidine hydroc 11.34 General Fee Schedule



Current Crosswalk

S0028 Injection, famotidine, 20 mg 6.24 General Fee Schedule

J1700 INJ., HYDROCORTISONE ACETATE, UP TO 25 M 2.99 General Fee Schedule

J7659 Isoproterenol non-comp unit 0 Manual Price

J0690 Cefazolin sodium injection 0.68 General Fee Schedule

J1436 INJ ETIDRONATE DISODIUM PER 300MG 74.00 General Fee Schedule

J7336 Capsaicin 8% patch 0 Manual Price

J9065 INJ CLADRIBINE PER 1MG 28.78 General Fee Schedule

J1446 Inj, tbo-filgrastim, 5 mcg 0.89 General Fee Schedule

J7307 Etonogestrel implant system 777.37 General Fee Schedule

J7604 Acetylcysteine comp unit 0 Manual Price

J0131 Acetaminophen injection 0 Manual Price

J9300 Gemtuzumab ozogamicin inj 2721.17 General Fee Schedule

J2540 INJ., PENICILLIN G POTASSIUM, 600000 UNI 0.82 General Fee Schedule

J1071 Inj testosterone cypionate 0.04 General Fee Schedule

J1835 Intraconazole injection 44.96 General Fee Schedule

J9218 Leuprolide acetate injeciton 7.16 General Fee Schedule

J0717 Certolizumab pegol inj 1mg 6.57 General Fee Schedule

J0587 Inj, rimabotulinumtoxinB 10.05 General Fee Schedule

J8510 Oral busulfan 3.24 General Fee Schedule

J9160 Denileukin diftitox inj 1515.25 General Fee Schedule

J2670 Totazoline hcl injection 6.00 General Fee Schedule

J2778 Ranibizumab injection 433.76 General Fee Schedule

J2785 Regadenoson injection 53.86 General Fee Schedule

J2791 Rhophylac injection 5.62 General Fee Schedule

J2001 Lidocaine injection 0.04 General Fee Schedule

J2325 Nesiritide injection 38.57 General Fee Schedule

J2425 Palifermin injection 11.96 General Fee Schedule

J3430 INJ., VIT K, PHYTONADIONE, MENADIONE, ME 4.54 General Fee Schedule

J1570 Ganciclovir sodium injection 50.21 General Fee Schedule

J9027 Clofarabine injection 123.96 General Fee Schedule

J1452 Intraocular fomivirsen na 1085.47 General Fee Schedule

J1040 INJ., METHYLPREDNISILONE ACETATE, 80 MG 8.00 General Fee Schedule

S0182 Procarbazine, oral 0 Manual Price

S0195 Pneumo conj vac, polyva, 5-9 yrs 0 General Fee Schedule

J0270 Alprostadil for injection 0.62 General Fee Schedule

J3060 Injection, taliglucerace alfa 31.68 General Fee Schedule

J3101 Tenecteplase injection 44.77 General Fee Schedule

J0572 Buprenorphin/nalox up to 3mg 3.97 General Fee Schedule

J9212 Interferon alfacon-1 inj 6.97 General Fee Schedule

J9230 Mechlorethamine hcl inj 157.27 General Fee Schedule

Q2004 Bladder calculi irrig sol 0 Manual Price

Q9955 Inj perflexane lip micros, ml 0 Manual Price

J2170 MECASERMIN, 1 MG 0 Manual Price

J0520 INJECTION, BETHANECHOL CHLORIDE, MYOTONA 7.80 General Fee Schedule

J7669 Metaproterenol non-comp unit 0.29 General Fee Schedule

J7516 Cyclosporin parenteral 250mg 22.45 General Fee Schedule

J7518 Mycophenolic acid 3.17 General Fee Schedule

J7030 INFUSION, NORMAL SALINE SOLUTION, 1,000 0.50 General Fee Schedule

J0760 INJECTION, COLCHICINE, UP TO 2 MG. 7.01 General Fee Schedule



Current Crosswalk

J0795 Corticorelin ovine triflutal 4.75 General Fee Schedule

J9047 Injection, carfilzomib, 1 mg 29.89 General Fee Schedule

J1451 Fomepizole, 15 mg 9.31 General Fee Schedule

J9370 VINCRISTINE SULFATE, 1MG 41.95 General Fee Schedule

J7192 Factor viii recombinant NOS 1.16 General Fee Schedule

J7195 Factor ix recombinant nos 1.14 General Fee Schedule

J9211 Idarubicin hcl injection 136.93 General Fee Schedule

J1840 INJ., KANAMYCIN SULFATE, UP TO 500 MG 4.09 General Fee Schedule

J9226 Supprelin LA implant 15896.88 General Fee Schedule

J3364 INJECTION UROKINASE 5000IU VIAL 9.75 General Fee Schedule


Documents

Procedure Procedure Code Desc Pricing Description Code Rate · 2015. 11. 30. · J1110 INJ., DEHYDROERGOTAMINE, UP TO 1 MG 22.34 General Fee Schedule J1290 INJECTION ECALLANTIDE 1