Page #1

Average Sales Price

HCPCS Description Labeler name NDC Drug name Dosage Package size Package quantity Billable units Billable units / pkg
A9575 Inj gadoterate meglumi 0.1ml Guerbet LLC 67684-2000-01 Dotarem 0.1 ML 10 10 100 1000
A9575 Inj gadoterate meglumi 0.1ml Guerbet LLC 67684-2000-02 Dotarem 0.1 ML 15 10 150 1500
A9575 Inj gadoterate meglumi 0.1ml Guerbet LLC 67684-2000-03 Dotarem 0.1 ML 20 10 200 2000
A9575 Inj gadoterate meglumi 0.1ml Guerbet LLC 67684-2000-04 Dotarem 0.1 ML 100 6 1000 6000
A9575 Inj gadoterate meglumi 0.1ml Guerbet LLC 67684-2000-05 Dotarem 0.1 ML 10 5 100 500
A9575 Inj gadoterate meglumi 0.1ml Guerbet LLC 67684-2000-06 Dotarem 0.1 ML 15 5 150 750
A9575 Inj gadoterate meglumi 0.1ml Guerbet LLC 67684-2000-07 Dotarem 0.1 ML 20 5 200 1000
A9576 Inj prohance multipack BRACCO DIAGNOSTICS 00270-1111-70 Prohance Multipack 1 ML 50 5 50 250
A9577 Inj multihance BRACCO DIAGNOSTICS 00270-5164-12 Multihance 1 ML 5 5 5 25
A9577 Inj multihance BRACCO DIAGNOSTICS 00270-5164-13 Multihance 1 ML 10 5 10 50
A9577 Inj multihance BRACCO DIAGNOSTICS 00270-5164-14 Multihance 1 ML 15 5 15 75
A9577 Inj multihance BRACCO DIAGNOSTICS 00270-5164-15 Multihance 1 ML 20 5 20 100
A9577 Inj multihance BRACCO DIAGNOSTICS 00270-5164-18 Multihance 1 ML 10 5 10 50
A9577 Inj multihance BRACCO DIAGNOSTICS 00270-5164-19 MULTIHANCE 5X15 ML SYRINGE 1 ML 15 5 15 75
A9577 Inj multihance BRACCO DIAGNOSTICS 00270-5164-20 Multihance 1 ML 20 5 20 100
A9578 Inj multihance multipack BRACCO DIAGNOSTICS 00270-5264-16 Multihance Multipack 1 ML 50 5 50 250
A9578 Inj multihance multipack BRACCO DIAGNOSTICS 00270-5264-17 Multihance Multipack 1 ML 100 5 100 500
A9579 Gad-base mr contrast nos,1ml Liebel Flarsheim 00019-1177-02 Optimark 1 ML 5 10 5 50
A9579 Gad-base mr contrast nos,1ml Liebel Flarsheim 00019-1177-04 Optimark 1 ML 10 10 10 100
A9579 Gad-base mr contrast nos,1ml Liebel Flarsheim 00019-1177-06 Optimark 1 ML 15 10 15 150
A9579 Gad-base mr contrast nos,1ml Liebel Flarsheim 00019-1177-08 Optimark 1 ML 20 10 20 200
A9579 Gad-base mr contrast nos,1ml Liebel Flarsheim 00019-1177-11 Optimark 1 ML 10 10 10 100
A9579 Gad-base mr contrast nos,1ml Liebel Flarsheim 00019-1177-16 Optimark 1 ML 15 10 15 150
A9579 Gad-base mr contrast nos,1ml Liebel Flarsheim 00019-1177-21 Optimark 1 ML 20 10 20 200
A9579 Gad-base mr contrast nos,1ml Liebel Flarsheim 00019-1177-31 Optimark 1 ML 30 10 30 300
A9579 Gad-base mr contrast nos,1ml Liebel Flarsheim 00019-1177-50 Optimark 1 ML 50 5 50 250
A9579 Gad-base mr contrast nos,1ml BRACCO DIAGNOSTICS 00270-1111-01 Prohance 1 ML 10 5 10 50
A9579 Gad-base mr contrast nos,1ml BRACCO DIAGNOSTICS 00270-1111-02 Prohance 1 ML 15 5 15 75
A9579 Gad-base mr contrast nos,1ml BRACCO DIAGNOSTICS 00270-1111-03 Prohance 1 ML 20 5 20 100
A9579 Gad-base mr contrast nos,1ml BRACCO DIAGNOSTICS 00270-1111-04 Prohance 1 ML 5 5 5 25
A9579 Gad-base mr contrast nos,1ml BRACCO DIAGNOSTICS 00270-1111-16 Prohance Prefilled Syringes 1 ML 10 5 10 50
A9579 Gad-base mr contrast nos,1ml BRACCO DIAGNOSTICS 00270-1111-45 Prohance Prefilled Syringes 1 ML 17 5 17 85
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-05 Omniscan 1 ML 5 10 5 50
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-10 Omniscan 1 ML 10 10 10 100
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-12 Omniscan 1 ML 10 10 10 100
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-15 Omniscan 1 ML 15 10 15 150
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-17 Omniscan 1 ML 15 10 15 150
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-20 Omniscan 1 ML 20 10 20 200
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-22 Omniscan 1 ML 20 10 20 200
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-30 NovaPlus® Omniscan 1 ML 10 10 10 100
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-40 NovaPlus® Omniscan 1 ML 15 10 15 150
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-42 NovaPlus® Omniscan 1 ML 15 10 15 150
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-43 NovaPlus® Omniscan 1 ML 20 10 20 200
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-50 NovaPlus® Omniscan 1 ML 20 10 20 200
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0690-70 Omniscan 1 ML 100 10 100 1000
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0691-62 Omniscan 1 ML 15 10 15 150
A9579 Gad-base mr contrast nos,1ml GE Healthcare 00407-0691-63 Omniscan 1 ML 20 10 20 200
A9579 Gad-base mr contrast nos,1ml Bayer HealthCare Pharmaceuticals Inc. 50419-0188-01 Magnevist 46.9% 1 ML 10 20 10 200
A9579 Gad-base mr contrast nos,1ml Bayer HealthCare Pharmaceuticals Inc. 50419-0188-02 Magnevist 46.9% 1 ML 20 20 20 400
A9579 Gad-base mr contrast nos,1ml Bayer HealthCare Pharmaceuticals Inc. 50419-0188-05 Magnevist 46.9% 1 ML 5 20 5 100

Average Wholesale Price

HCPCS Description Labeler name NDC Drug name Dosage Package size Package quantity Billable units Billable units / pkg
P9041 Albumin (human),5%, 50ml Kedrion Biopharma 76125-0785-05 Albuked 5 50 ML 50 1 1 1
P9041 Albumin (human),5%, 50ml Grifols 68516-5214-05 Albutein 5% 50 ML 50 1 1 1
P9041 Albumin (human),5%, 50ml Octapharma USA 68982-0623-01 ALBUMIN (HUMAN) 50 ML 100 1 2 2
P9045 Albumin (human), 5%, 250 ml Octapharma USA 68982-0623-02 ALBUMIN (HUMAN) 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml Octapharma USA 68982-0623-03 ALBUMIN (HUMAN) 250 ML 500 1 2 2
P9045 Albumin (human), 5%, 250 ml Kedrion Biopharma 76125-0785-25 Albuked 5 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml CSL Behring 00053-7670-03 Albuminar-5 250 ML 1000 1 4 4
P9045 Albumin (human), 5%, 250 ml Kedrion Biopharma 76125-0790-25 Albuked 5 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml CSL Behring 00053-7670-31 Albuminar-5 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml CSL Behring 00053-7670-32 Albuminar-5 250 ML 500 1 2 2
P9045 Albumin (human), 5%, 250 ml Baxter 00944-0491-01 Buminate 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml Baxter 00944-0491-02 Buminate 250 ML 500 1 2 2
P9045 Albumin (human), 5%, 250 ml Talecris 13533-0685-20 Plasbumin-5 250 ML 50 1 0.2 0.2
P9045 Albumin (human), 5%, 250 ml Talecris 13533-0685-25 Plasbumin-5 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml Talecris 13533-0690-20 Plasbumin-5 250 ML 50 1 0.2 0.2
P9045 Albumin (human), 5%, 250 ml Talecris 13533-0690-25 Plasbumin-5 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml CSL Behring 44206-0310-25 Alburx 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml CSL Behring 44206-0310-50 Alburx 250 ML 500 1 2 2
P9045 Albumin (human), 5%, 250 ml Alpine Biologics 63546-0310-25 Albumin-Zlb 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml Alpine Biologics 63546-0310-50 Albumin-Zlb 250 ML 500 1 2 2
P9045 Albumin (human), 5%, 250 ml Octapharma USA 67467-0623-01 Albumin 250 ML 100 1 0.4 0.4
P9045 Albumin (human), 5%, 250 ml Octapharma USA 67467-0623-02 Albumin, 12.5gr 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml Octapharma USA 67467-0623-03 Albumin 5%, 25gr 250 ML 500 1 2 2
P9045 Albumin (human), 5%, 250 ml Octapharma USA 68209-0623-01 Albumin 5%, 5 g in 100 ml 250 ML 100 1 0.4 0.4
P9045 Albumin (human), 5%, 250 ml Octapharma USA 68209-0623-02 Albumin 5%, 12.5 g in 250 ml 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml Octapharma USA 68209-0623-03 Albumin 5%, 25 g in 500 ml 250 ML 500 1 2 2
P9045 Albumin (human), 5%, 250 ml Grifols 68516-5211-01 Albumin (Human) 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml Grifols 68516-5211-02 Albumin (Human) 250 ML 500 1 2 2
P9045 Albumin (human), 5%, 250 ml Grifols 68516-5214-01 Albutein® 5% 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml Grifols 68516-5214-02 Albutein® 5% Albumin 500 ml 250 ML 500 1 2 2
P9046 Albumin (human), 25%, 20 ml CSL Behring 00053-7680-01 Albuminar-25 20 ML 20 1 1 1
P9046 Albumin (human), 25%, 20 ml Grifols 68516-5216-05 Albutein 25% 20 ML 20 1 1 1
P9047 Albumin (human), 25%, 50ml Octapharma USA 68982-0643-01 ALBUMIN (HUMAN) 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Octapharma USA 68982-0643-02 ALBUMIN (HUMAN) 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Kedrion Biopharma 76125-0784-10 Albuked 25 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Kedrion Biopharma 76125-0784-25 Albuked 25 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Kedrion Biopharma 76179-0025-01 KEDBUMIN 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Kedrion Biopharma 76179-0025-02 KEDBUMIN 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Grifols 68516-5216-01 Albutein® 25% 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml CSL Behring 00053-7680-32 Albuminar-25 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml CSL Behring 00053-7680-33 Albuminar-25 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Baxter 00944-0490-01 Buminate 50 ML 20 1 0.4 0.4
P9047 Albumin (human), 25%, 50ml Baxter 00944-0490-02 Buminate 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Baxter 00944-0490-03 Buminate 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Baxter 00944-0493-01 Flexbumin 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Baxter 00944-0493-02 Flexbumin 50 ML 100 1 1 2
P9047 Albumin (human), 25%, 50ml Talecris 13533-0684-16 Plasbumin-25 50 ML 20 1 0.4 0.4
P9047 Albumin (human), 25%, 50ml Talecris 13533-0684-20 Plasbumin-25 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Talecris 13533-0684-71 Plasbumin-25 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Talecris 13533-0692-16 Plasbumin-25 50 ML 20 1 0.4 0.4
P9047 Albumin (human), 25%, 50ml Talecris 13533-0692-20 Plasbumin-25 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Talecris 13533-0692-71 Plasbumin-25 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml CSL Behring 44206-0251-05 Alburx 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml CSL Behring 44206-0251-10 Alburx 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Grifols 61953-0002-01 Human Albumin Grifols 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Grifols 61953-0002-02 Human Albumin Grifols 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Alpine Biologics 63546-0251-05 Albumin-Zlb 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Alpine Biologics 63546-0251-10 Albumin-Zlb 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Octapharma USA 67467-0643-01 Albumin 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Octapharma USA 67467-0643-02 Albumin (Human) 25% 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Octapharma USA 68209-0643-01 Albumin 25%, 12.5 g in 50 ml 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Octapharma USA 68209-0643-02 Albumin 25%, 25 g in 100 ml 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Grifols 68516-5216-02 Albutein® 25% Albumin 100 ml 50 ML 100 1 2 2
Q2035 Afluria vacc, 3 yrs & >, im bioCSL 33332-0115-10 Afluria 2015/2016 0.5 ML 5 1 10 10
Q2035 Afluria vacc, 3 yrs & >, im Seqirus 33332-0116-10 Afluria 2016/2017 0.5 ML 5 1 10 10
Q2037 Fluvirin vacc, 3 yrs & >, im Novartis 66521-0118-10 Fluvirin 2015/2016 0.5 ML 5 1 10 10
Q2037 Fluvirin vacc, 3 yrs & >, im Seqirus 70461-0119-10 Fluvirin 2016/2017 0.5 ML 5 1 10 10
Q2038 Fluzone vacc, 3 yrs & >, im Sanofi Pasteur 49281-0396-15 Fluzone 2015/2016 0.5 ML 5 1 10 10

Not Otherwise Classified

Description Labeler name NDC Drug name Dosage Package size Package quantity Billable units Billable units / pkg
Alfentanil Hcl Akorn 17478-0067-02 ALFENTA 500 MCG 2 10 2 20
Alfentanil Hcl Akorn 17478-0067-05 Alfenta 500 MCG 5 10 5 50
Allopurinol Sodium WEST-WARD PHARMACEUTICAL CORP. 00143-9533-01 Allopurinol Sodium 500 MG 1 1 1 1
Allopurinol Sodium Mylan Institutional 67457-0187-50 Aloprim 500 MG 1 1 1 1
Aminocaproic acid HOSPIRA, INC 00409-4346-10 Aminocaproic Acid 250 MG 20 25 20 500
Aminocaproic acid HOSPIRA, INC 00409-4346-73 AMINOCAPROIC ACID INJ 250 MG 20 25 20 500
Atezolizumab (Tecentriq) Genentech, Inc. 50242-0917-01 TECENTRIQ (atezolizumab) 10 MG 20 1 120 120
Aztreonam Bristol-Myers Squibb Company 00003-2230-11 Azactam In Galaxy Container 500 MG 50 24 2 48
Aztreonam Bristol-Myers Squibb Company 00003-2240-11 Azactam In Galaxy Container 500 MG 50 24 4 96
Aztreonam Bristol-Myers Squibb Company 00003-2560-16 AZACTAM 500 MG 1 10 2 20
Aztreonam Bristol-Myers Squibb Company 00003-2570-16 AZACTAM 500 MG 1 10 4 40
Aztreonam Fresenius Kabi USA LLC 63323-0401-20 Aztreonam 500 MG 1 10 2 20
Aztreonam Fresenius Kabi USA LLC 63323-0401-24 Aztreonam 500 MG 1 10 2 20
Aztreonam Fresenius Kabi USA LLC 63323-0401-26 Aztreonam 500 MG 1 10 2 20
Aztreonam Fresenius Kabi USA LLC 63323-0402-20 Aztreonam 500 MG 1 10 4 40
Aztreonam Fresenius Kabi USA LLC 63323-0402-24 Aztreonam 500 MG 1 10 4 40
Aztreonam Fresenius Kabi USA LLC 63323-0402-30 Aztreonam 500 MG 1 10 4 40
Bumetanide HOSPIRA, INC 00409-1412-04 Bumetanide 0.25 MG 4 10 4 40
Bumetanide HOSPIRA, INC 00409-1412-10 Bumetanide 0.25 MG 10 10 10 100
Bumetanide HOSPIRA, INC 00409-1412-49 Bumetanide 0.25 MG 4 10 4 40
Bumetanide HOSPIRA, INC 00409-1412-50 Bumetanide 0.25 MG 10 10 10 100
Bumetanide West-Ward Pharmaceuticals Corp 00641-6007-10 Bumetanide 0.25 MG 10 10 10 100
Bumetanide West-Ward Pharmaceuticals Corp 00641-6008-10 Bumetanide 0.25 MG 4 10 4 40
Bumetanide West-Ward Pharmaceuticals Corp 00641-6161-10 Bumetanide 0.25 MG 4 10 4 40
Bumetanide West-Ward Pharmaceuticals Corp 00641-6162-10 Bumetanide 0.25 MG 10 10 10 100
Bupivacaine HOSPIRA, INC 00409-1158-01 Bupivacaine Hcl 1 ML 30 5 30 150
Bupivacaine HOSPIRA, INC 00409-1159-01 Bupivacaine Hcl 1 ML 10 25 10 250
Bupivacaine HOSPIRA, INC 00409-1159-02 BUPIVICAINE HCL 1 ML 30 25 30 750
Bupivacaine HOSPIRA, INC 00409-1159-10 Bupivacaine HCl 1 ML 30 25 30 750
Bupivacaine HOSPIRA, INC 00409-1160-01 Bupivacaine Hcl 1 ML 50 25 50 1250
Bupivacaine HOSPIRA, INC 00409-1161-01 Bupivacaine Hcl 1 ML 30 5 30 150
Bupivacaine HOSPIRA, INC 00409-1162-01 Bupivacaine Hcl 1 ML 10 25 10 250
Bupivacaine HOSPIRA, INC 00409-1163-01 Bupivacaine Hcl 1 ML 50 25 50 1250
Bupivacaine HOSPIRA, INC 00409-1165-02 Bupivacaine Hcl 1 ML 30 25 30 750
Bupivacaine HOSPIRA, INC 00409-1559-10 MARCAINE 1 ML 10 10 10 100
Bupivacaine HOSPIRA, INC 00409-1559-30 MARCAINE 1 ML 30 10 30 300
Bupivacaine HOSPIRA, INC 00409-1560-10 MARCAINE 1 ML 10 10 10 100
Bupivacaine HOSPIRA, INC 00409-1560-29 MARCAINE 1 ML 30 10 30 300
Bupivacaine HOSPIRA, INC 00409-1582-10 Bupivacaine Hcl 1 ML 10 10 5 50
Bupivacaine HOSPIRA, INC 00409-1582-29 MARCAINE WITHOUT EPI 1 ML 30 10 30 300
Bupivacaine HOSPIRA, INC 00409-4272-01 Bupivacaine Hcl 1 ML 20 5 10 50
Bupivacaine HOSPIRA, INC 00409-4273-01 Bupivacaine Hcl 1 ML 20 5 20 100
Bupivacaine Fresenius Kabi USA LLC 63323-0464-17 SENSORCAINE-MPF 1 ML 10 25 10 250
Bupivacaine Fresenius Kabi USA LLC 63323-0464-37 SENSORCAINE-MPF 1 ML 30 25 30 750
Bupivacaine Fresenius Kabi USA LLC 63323-0465-57 Sensorcaine 1 ML 50 25 50 1250
Bupivacaine Fresenius Kabi USA LLC 63323-0466-17 Sensorcaine-MPF 1 ML 10 25 10 250
Bupivacaine Fresenius Kabi USA LLC 63323-0466-37 SENSORCAINE-MPF 1 ML 30 25 30 750
Bupivacaine Fresenius Kabi USA LLC 63323-0467-57 Sensorcaine 1 ML 50 25 50 1250
Bupivacaine Fresenius Kabi USA LLC 63323-0472-17 Sensorcaine 1 ML 10 25 10 250
Bupivacaine Fresenius Kabi USA LLC 63323-0472-37 SENSORCAINE-MPF 1 ML 30 25 30 750
Clevidipine Butyrate The Medicines Company 65293-0005-11 CLEVIPREX 1 MG 100 10 50 500
Clevidipine Butyrate The Medicines Company 65293-0005-55 CLEVIPREX 1 MG 50 10 25 250
Clindamycin Phosphate PFIZER INC. 00009-0302-25 Clindamycin Phosphate 150 MG 2 25 2 50
Clindamycin Phosphate PFIZER INC. 00009-0602-25 Clindamycin Phosphate 150 MG 4 25 4 100
Clindamycin Phosphate PFIZER INC. 00009-0728-09 Cleocin 150 MG 60 5 1 5
Clindamycin Phosphate PFIZER INC. 00009-0775-26 Cleocin 150 MG 4 25 4 100
Clindamycin Phosphate PFIZER INC. 00009-0870-26 Cleocin 150 MG 2 25 2 50
Clindamycin Phosphate PFIZER INC. 00009-0901-25 Clindamycin Phosphate 150 MG 6 25 6 150
Clindamycin Phosphate PFIZER INC. 00009-0902-18 Cleocin 150 MG 6 25 6 150
Clindamycin Phosphate PFIZER INC. 00009-3375-02 Cleocin In D5W 150 MG 50 24 4 96
Clindamycin Phosphate PFIZER INC. 00009-3381-02 Cleocin In D5W 150 MG 50 24 2 48
Clindamycin Phosphate PFIZER INC. 00009-3382-02 Cleocin In D5W 150 MG 50 24 6 144
Clindamycin Phosphate PFIZER INC. 00009-3470-02 Cleocin in D5W 150 MG 50 24 2 48
Clindamycin Phosphate PFIZER U.S. 00009-6582-01 Cleocin 150 MG 2 25 2 50
Clindamycin Phosphate PFIZER INC. 00009-6780-02 Cleocin in D5W 150 MG 50 24 4 96
Clindamycin Phosphate PFIZER INC. 00009-9890-02 Cleocin in D5W 150 MG 50 24 6 144
Clindamycin Phosphate Alvogen, Inc. 00409-4050-01 Clindamycin Phosphate 150 MG 2 25 2 50
Clindamycin Phosphate Alvogen, Inc. 00409-4051-01 Clindamycin Phosphate 150 MG 4 25 4 100
Clindamycin Phosphate Alvogen, Inc. 00409-4052-01 Clindamycin Phosphate 150 MG 6 25 6 150
Clindamycin Phosphate Alvogen, Inc. 00409-4053-03 Clindamycin Phosphate 150 MG 2 25 2 50
Clindamycin Phosphate Alvogen, Inc. 00409-4054-03 Clindamycin Phosphate 150 MG 4 25 4 100
Clindamycin Phosphate Alvogen, Inc. 00409-4055-03 Clindamycin Phosphate 150 MG 6 25 6 150
Clindamycin Phosphate Alvogen, Inc. 00409-4197-01 Clindamycin Phosphate 150 MG 60 1 60 60
Clindamycin Phosphate Sandoz, Inc. 00781-3288-09 Clindamycin Phosphate 150 MG 50 24 2 48
Clindamycin Phosphate Sandoz, Inc. 00781-3289-09 Clindamycin Phosphate 150 MG 50 24 4 96
Clindamycin Phosphate Sandoz, Inc. 00781-3290-09 Clindamycin Phosphate 150 MG 50 24 6 144
Clindamycin Phosphate Sandoz, Inc. 00781-9220-09 Clindamycin in D5W 150 MG 50 24 2 48
Clindamycin Phosphate Sandoz, Inc. 00781-9221-09 Clindamycin in D5W 150 MG 50 24 4 96
Clindamycin Phosphate Sandoz, Inc. 00781-9222-09 Clindamycin in D5W 150 MG 50 24 6 144
Clindamycin Phosphate Akorn 17478-0120-50 Clindamycin In D5W 150 MG 50 1 2 2
Clindamycin Phosphate Akorn 17478-0121-50 Clindamycin In D5W 150 MG 50 1 4 4
Clindamycin Phosphate Akorn 17478-0122-50 Clindamycin In D5W 150 MG 50 1 6 6
Clindamycin Phosphate Sagent Pharmaceuticals Inc 25021-0115-02 Clindamycin Phosphate 150 MG 2 25 2 50
Clindamycin Phosphate Sagent Pharmaceuticals Inc 25021-0115-04 Clindamycin Phosphate 150 MG 4 25 4 100
Clindamycin Phosphate Sagent Pharmaceuticals Inc 25021-0115-06 Clindamycin Phosphate 150 MG 6 25 6 150
Clindamycin Phosphate Sagent Pharmaceuticals Inc 25021-0115-51 Clindamycin Phosphate 150 MG 60 1 60 60
Clindamycin Phosphate Alvogen, Inc. 47781-0459-68 Clindamycin Phosphate 150 MG 2 25 2 50
Clindamycin Phosphate Alvogen, Inc. 47781-0460-68 Clindamycin Phosphate 150 MG 4 25 4 100
Clindamycin Phosphate Alvogen, Inc. 47781-0461-68 Clindamycin Phosphate 150 MG 6 25 6 150
Clindamycin Phosphate Alvogen, Inc. 47781-0462-69 Clindamycin Phosphate 150 MG 2 25 2 50
Clindamycin Phosphate Alvogen, Inc. 47781-0463-69 Clindamycin Phosphate 150 MG 4 25 4 100
Clindamycin Phosphate Alvogen, Inc. 47781-0464-69 Clindamycin Phosphate 150 MG 6 25 6 150
Clindamycin Phosphate Alvogen, Inc. 47781-0465-70 Clindamycin Phosphate 150 MG 60 1 60 60
Clindamycin Phosphate Fresenius Kabi USA LLC 63323-0282-02 Clindamycin Phosphate 150 MG 2 25 2 50
Clindamycin Phosphate Fresenius Kabi USA LLC 63323-0282-04 Clindamycin Phosphate 150 MG 4 25 4 100
Clindamycin Phosphate Fresenius Kabi USA LLC 63323-0282-06 Clindamycin Phosphate 150 MG 6 25 6 150
Clindamycin Phosphate Fresenius Kabi USA LLC 63323-0282-60 Clindamycin Phosphate 150 MG 60 1 60 60
Clindamycin Phosphate BURKE THERAPEUTICS 69101-0715-01 CLIN SINGLE USE KIT 150 MG 2 1 2 2
Coagulation Factor IX (Recombinant) (Ixinity) Cangene BioPharma Inc 53270-0270-05 IXINITY I IU 1 1 1 1
Coagulation Factor IX (Recombinant) (Ixinity) Cangene BioPharma Inc 53270-0271-05 IXINITY I IU 1 1 1 1
Coagulation Factor IX (Recombinant) (Ixinity) Cangene BioPharma Inc 53270-0271-06 IXINITY I IU 1 1 1 1
Coagulation Factor IX (Recombinant) (Ixinity) Cangene BioPharma Inc 53270-0272-05 IXINITY I IU 1 1 1 1
Coagulation Factor IX (Recombinant) (Ixinity) Cangene BioPharma Inc 53270-0272-06 IXINITY I IU 1 1 1 1
Diltiazem Hydrochloride West-Ward Pharmaceuticals Corp 00641-6013-10 Diltiazem Hcl 5 MG 5 10 5 50
Diltiazem Hydrochloride West-Ward Pharmaceuticals Corp 00641-6014-10 Diltiazem Hcl 5 MG 10 10 10 100
Diltiazem Hydrochloride West-Ward Pharmaceuticals Corp 00641-6015-10 Diltiazem Hcl 5 MG 25 10 25 250
Diltiazem Hydrochloride WEST-WARD PHARMACEUTICAL CORP. 00641-9217-10 Diltiazem Hcl 5 MG 5 10 5 50
Diltiazem Hydrochloride WEST-WARD PHARMACEUTICAL CORP. 00641-9218-10 Diltiazem Hcl 5 MG 10 10 10 100
Diltiazem Hydrochloride WEST-WARD PHARMACEUTICAL CORP. 00641-9219-10 Diltiazem Hcl 5 MG 25 10 25 250
Diltiazem Hydrochloride Akorn 17478-0817-05 Diltiazem Hcl 5 MG 5 10 5 50
Diltiazem Hydrochloride Akorn 17478-0817-10 Diltiazem Hcl 5 MG 10 10 10 100
Diltiazem Hydrochloride Akorn 17478-0817-25 Diltiazem Hcl 5 MG 25 10 25 25
Diltiazem Hydrochloride Akorn 17478-0817-26 Diltiazem Hcl 5 MG 25 10 25 250
Diltiazem Hydrochloride Akorn 17478-0937-05 Diltiazem Hcl 5 MG 5 10 5 50
Diltiazem Hydrochloride Akorn 17478-0937-10 Diltiazem Hcl 5 MG 10 10 10 100
Diltiazem Hydrochloride Akorn 17478-0937-25 Diltiazem Hcl 5 MG 25 10 25 25
Diltiazem Hydrochloride Akorn 17478-0937-26 Diltiazem Hcl 5 MG 25 10 25 250
Doxycycline Hyclate Fresenius Kabi USA LLC 63323-0130-11 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate Fresenius Kabi USA LLC 63323-0130-13 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate Fresenius Kabi USA LLC 63323-0130-17 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate Mylan Institutional 67457-0437-10 Doxycycline Hyclate 100 MG 1 10 1 10
Esmolol Hydrochloride Baxter Healthcare Corporation 10019-0055-61 Brevibloc In Nacl 10 MG 250 1 250 250
Esmolol Hydrochloride Baxter Healthcare Corporation 10019-0075-87 Brevibloc 10 MG 100 1 200 200
Esmolol Hydrochloride Baxter Healthcare Corporation 10019-0115-01 Brevibloc 10 MG 10 25 10 250
Esmolol Hydrochloride Baxter Healthcare Corporation 10019-0120-01 Esmolol HCl 10 MG 10 25 10 250
Esmolol Hydrochloride Fresenius Kabi USA LLC 63323-0652-10 Esmolol Hcl 10 MG 10 25 10 250
Esmolol Hydrochloride Mylan Institutional 67457-0182-10 Esmolol Hcl 10 MG 10 10 10 100
Famotidine PFIZER INC. 00069-0125-02 Famotidine 10 MG 4 10 4 40
Famotidine Baxter Healthcare Corporation 00338-5197-41 Famotidine Premixed 10 MG 50 12 2 24
Famotidine West-Ward Pharmaceuticals Corp 00641-6021-10 Famotidine 10 MG 20 10 20 200
Famotidine West-Ward Pharmaceuticals Corp 00641-6022-25 Famotidine 10 MG 2 25 2 50
Famotidine West-Ward Pharmaceuticals Corp 00641-6023-25 Famotidine 10 MG 4 25 4 100
Famotidine Fresenius Kabi USA LLC 63323-0738-09 Famotidine 10 MG 4 10 4 40
Famotidine Fresenius Kabi USA LLC 63323-0738-20 Famotidine 10 MG 20 10 20 200
Famotidine Fresenius Kabi USA LLC 63323-0739-12 Famotidine 10 MG 2 25 2 50
Famotidine Fresenius Kabi USA LLC 63323-0739-16 Famotidine 10 MG 2 25 2 50
Famotidine Mylan Institutional 67457-0448-43 Famotidine 10 MG 4 10 4 40
Famotidine Mylan Institutional 67457-0457-20 Famotidine 10 MG 20 10 20 200
Flumazenil West-Ward Pharmaceuticals Corp 00641-6031-10 Flumazenil 0.1 MG 5 10 5 50
Flumazenil West-Ward Pharmaceuticals Corp 00641-6032-10 Flumazenil 0.1 MG 10 10 10 100
Flumazenil Sagent Pharmaceuticals Inc 25021-0600-05 Flumazenil 0.1 MG 5 10 5 50
Flumazenil Sagent Pharmaceuticals Inc 25021-0600-10 Flumazenil 0.1 MG 10 10 10 100
Flumazenil Fresenius Kabi USA LLC 63323-0424-05 Flumazenil 0.1 MG 5 10 5 50
Flumazenil Fresenius Kabi USA LLC 63323-0424-10 Flumazenil 0.1 MG 10 1 10 10
Flumazenil Mylan Institutional 67457-0444-10 Flumazenil 0.1 MG 10 10 10 100
Flumazenil Mylan Institutional 67457-0447-53 Flumazenil 0.1 MG 5 10 5 50
Folic Acid Fresenius Kabi USA LLC 63323-0184-10 Folic Acid 5 MG 10 1 10 10
Glucarpidase BTG International 50633-0210-11 Voraxaze 10 UNITS 1 1 100 100
Glycopyrrolate injection West-Ward Pharmaceuticals Corp 00143-9584-10 Glycopyrrolate INJECTION 0.2 MG 20 10 20 200
Glycopyrrolate injection West-Ward Pharmaceuticals Corp 00143-9585-25 Glycopyrrolate INJECTION 0.2 MG 5 25 5 125
Glycopyrrolate injection West-Ward Pharmaceuticals Corp 00143-9586-25 Glycopyrrolate INJECTION 0.2 MG 2 25 2 50
Glycopyrrolate injection West-Ward Pharmaceuticals Corp 00143-9587-25 Glycopyrrolate INJECTION 0.2 MG 1 25 1 25
Glycopyrrolate injection West-Ward Pharmaceuticals Corp 00143-9679-10 Glycopyrrolate INJECTION 0.2 MG 20 10 20 200
Glycopyrrolate injection West-Ward Pharmaceuticals Corp 00143-9680-25 Glycopyrrolate INJECTION 0.2 MG 5 25 5 125
Glycopyrrolate injection West-Ward Pharmaceuticals Corp 00143-9681-25 Glycopyrrolate INJECTION 0.2 MG 2 25 2 50
Glycopyrrolate injection West-Ward Pharmaceuticals Corp 00143-9682-25 Glycopyrrolate INJECTION 0.2 MG 1 25 1 25
Glycopyrrolate injection American Regent 00517-4601-25 Glycopyrrolate 0.2 MG 1 25 1 25
Glycopyrrolate injection American Regent 00517-4602-25 Glycopyrrolate 0.2 MG 2 25 2 50
Glycopyrrolate injection American Regent 00517-4605-25 Glycopyrrolate 0.2 MG 5 25 5 125
Glycopyrrolate injection American Regent 00517-4620-25 Glycopyrrolate 0.2 MG 20 25 20 500
Granisetron extended release (Sustol) Heron Therapeutics 47426-0101-06 SUSTOL 0.1 MG 0.4 6 100 600
Hexaminolevulinate HCl GE Healthcare 00407-4086-01 Cysview 100 mg, per study dose 1 1 1 1
Hexaminolevulinate HCl Photocure, Inc. 10511-3001-01 CYSVIEW 100 mg, per study dose 1 1 1 1
Labetalol Hcl Akorn 17478-0420-20 Labetalol Hcl 5 MG 20 1 20 20
Labetalol Hcl Akorn 17478-0420-40 Labetalol Hcl 5 MG 40 1 40 40
Labetalol Hcl Mylan Institutional 67457-0280-20 Labetalol Hcl 5 MG 20 1 20 20
Metoprolol Tartrate West-Ward Pharmaceuticals Corp 00143-9660-10 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate West-Ward Pharmaceuticals Corp 00143-9873-10 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate West-Ward Pharmaceuticals Corp 00143-9873-25 METOPROLOL INJ 1 MG 5 25 5 125
Metoprolol Tartrate HOSPIRA, INC 00409-1778-05 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate Sandoz, Inc. 00781-3071-95 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate Sagent Pharmaceuticals Inc 25021-0303-05 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate Fresenius Kabi USA LLC 63323-0660-05 METOPROLOL TARTRATE 1 MG 5 10 5 50
Metronidazole inj B. Braun Medical Inc. 00264-5535-32 Metronidazole In Nacl 500 MG 100 24 1 24
Metronidazole inj Baxter Healthcare Corporation 00338-1055-48 Metronidazole In Nacl 500 MG 100 24 1 24
Metronidazole inj Baxter Healthcare Corporation 00338-9541-24 METRONIDAZOLE 500 MG 100 24 1 24
Metronidazole inj HOSPIRA, INC 00409-7811-10 METRONIDAZOLE 500 MG 100 24 1 24
Metronidazole inj HOSPIRA, INC 00409-7811-24 METRONIDAZL 500MG 500 MG 100 24 1 24
Metronidazole inj HOSPIRA, INC 00409-7811-37 METRONIDAZOLE 500 MG INJ USP LIFECARE 100ML FILL 500 MG 100 80 1 80
Nitroglycerin Baxter Healthcare Corporation 00338-1047-02 Nitroglycerin In D5W 5 MG 250 12 5 60
Nitroglycerin Baxter Healthcare Corporation 00338-1049-02 Nitroglycerin In D5W 5 MG 250 12 10 120
Nitroglycerin Baxter Healthcare Corporation 00338-1051-02 Nitroglycerin In D5W 5 MG 250 12 20 240
Nitroglycerin American Regent 00517-4810-25 Nitroglycerin 5 MG 10 25 10 250
Olanzapine short acting intramuscular injection Sandoz, Inc. 00781-3159-72 Olanzapine (Immediate Release) 0.5 MG 1 1 20 20
Olanzapine short acting intramuscular injection Sandoz, Inc. 00781-9105-72 Olanzapine (Immediate Release) 0.5 MG 1 1 20 20
Paliperidone Palmitate (Invega Trinza) Janssen Pharmaceuticals, Inc. 50458-0606-01 INVEGA TRINZA 1 MG 0.875 1 273 273
Paliperidone Palmitate (Invega Trinza) Janssen Pharmaceuticals, Inc. 50458-0607-01 INVEGA TRINZA 1 MG 1.315 1 410 410
Paliperidone Palmitate (Invega Trinza) Janssen Pharmaceuticals, Inc. 50458-0608-01 INVEGA TRINZA 1 MG 1.75 1 546 546
Paliperidone Palmitate (Invega Trinza) Janssen Pharmaceuticals, Inc. 50458-0609-01 INVEGA TRINZA 1 MG 2.625 1 819 819
Rifampin Akorn 17478-0151-42 Rifampin 600 MG 1 1 1 1
Rifampin Heritage Pharmaceuticals, Inc. 23155-0340-31 Rifampin 600 MG 1 1 1 1
Rifampin Fresenius Kabi USA LLC 63323-0351-20 Rifampin 600 MG 1 1 1 1
Rifampin Mylan Institutional 67457-0445-60 Rifampin 600 MG 1 1 1 1
Sodium Chloride, Hypertonic (3% - 5% infusion) B. Braun Medical Inc. 00264-7805-10 Sodium Chloride 250 CC 500 24 2 48
Sodium Chloride, Hypertonic (3% - 5% infusion) B. Braun Medical Inc. 00264-7806-10 Sodium Chloride 250 CC 500 24 2 48
Sodium Chloride, Hypertonic (3% - 5% infusion) Baxter Healthcare Corporation 00338-0054-03 Sodium Chloride 250 CC 500 1 2 2
Sodium Chloride, Hypertonic (3% - 5% infusion) Baxter Healthcare Corporation 00338-0056-03 Sodium Chloride 250 CC 500 1 2 2
Sulfamethoxazole-Trimethoprim SICOR PHARMACEUTICALS, INC. 00703-9503-03 Sulfamethoxazole-Trimethoprim 400-80 MG 50 10 10 100
Sulfamethoxazole-Trimethoprim SICOR PHARMACEUTICALS, INC. 00703-9514-03 Sulfamethoxazole-Trimethoprim 400-80 MG 100 10 20 200
Sulfamethoxazole-Trimethoprim SICOR PHARMACEUTICALS, INC. 00703-9514-83 Sulfamethoxazole-Trimethoprim 400-80 MG 10 10 2 20
Sulfamethoxazole-Trimethoprim SICOR PHARMACEUTICALS, INC. 00703-9526-01 Sulfamethoxazole-Trimethoprim 400-80 MG 30 1 6 6
Ustekinumab (Stelara IV infusion) Janssen Biotech, Inc. 57894-0054-27 STELARA (IV Infusion) 1 MG 26 1 130 130
Vasopressin PAR STERILE PRODUCTS LLC 42023-0117-25 Vasopressin 20 UNITS 1 25 1 25
Vasopressin PAR STERILE PRODUCTS LLC 42023-0164-25 Vasopressin 20 UNITS 1 25 1 25
Vasopressin Fresenius Kabi USA LLC 63323-0302-01 Vasopressin 20 UNITS 1 25 1 25
Vasopressin Fresenius Kabi USA LLC 63323-0302-09 Vasopressin 20 UNITS 1 25 1 25

Outpatient Prospective Payment System

HCPCS Description Labeler name NDC Drug name Dosage Package size Package quantity Billable units Billable units / pkg
A9515 Choline C 11, diagnostic ZEVACOR MOLECULAR 69126-0004-01 CHOLINE C 11 Per Study Dose 30 1 1 1
A9517 I131 iodide cap, rx Mallinckrodt 00019-N452-FA SODIUM IODIDE I 131 CAPSULE 1 mCi 1 1 10 10
A9543 Y90 ibritumomab, rx Spectrum Pharmaceuticals 68152-0103-03 ZEVALIN Y-90 UP TO 40 millicuries 1 1 1 1
A9587 Gallium Ga-68 Advanced Accelerator Applications 69488-0001-40 NETSPOT 0.1 mCi 1 1 54 54
A9588 Fluciciovine F-18 Blue Earth Diagnostics 69932-0001-01 AXUMIN 1 mCi 5 1 10 10
A9600 Sr89 strontium GE Healthcare 17156-0524-01 METASTRON PER MILLICURIE 4 1 4 4
A9604 Sm 153 lexidronam Lantheus Medical Imaging, Inc. 11994-0016-01 QUADRAMET up to 150 millicuries 3 1 1 1
A9606 Radium Ra223 dichloride ther Bayer HealthCare Pharmaceuticals Inc. 50419-0208-01 Xofigo 1 mCi 6 1 1 1
C9132 Kcentra, per i.u. CSL Behring GmbH 63833-0386-02 Kcentra 1 IU 1 1 1 1
C9132 Kcentra, per i.u. CSL Behring GmbH 63833-0387-02 Kcentra 1 IU 1 1 1 1
C9140 Afstyla Factor VIII recomb CSL BEHRING LLC 69911-0474-02 AFSTYLA 1 IU 1 1 1 1
C9140 Afstyla Factor VIII recomb CSL BEHRING LLC 69911-0475-02 AFSTYLA 1 IU 1 1 1 1
C9140 Afstyla Factor VIII recomb CSL BEHRING LLC 69911-0476-02 AFSTYLA 1 IU 1 1 1 1
C9140 Afstyla Factor VIII recomb CSL BEHRING LLC 69911-0477-02 AFSTYLA 1 IU 1 1 1 1
C9140 Afstyla Factor VIII recomb CSL BEHRING LLC 69911-0478-02 AFSTYLA 1 IU 1 1 1 1
C9248 Inj, clevidipine butyrate The Medicines Company 65293-0005-11 CLEVIPREX 1 MG 100 10 50 500
C9248 Inj, clevidipine butyrate The Medicines Company 65293-0005-55 CLEVIPREX 1 MG 50 10 25 250
C9250 Artiss fibrin sealant Baxter Healthcare Corporation 00944-8503-02 ARTISS 2 ML 1 1 1 1
C9250 Artiss fibrin sealant Baxter Healthcare Corporation 00944-8503-04 ARTISS 2 ML 1 1 2 2
C9250 Artiss fibrin sealant Baxter Healthcare Corporation 00944-8503-10 ARTISS 2 ML 1 1 5 5
C9257 Bevacizumab injection Genentech, Inc. 50242-0060-01 Avastin 0.25 MG 4 1 400 400
C9257 Bevacizumab injection Genentech, Inc. 50242-0061-01 Avastin 0.25 MG 16 1 1600 1600
C9293 Injection, glucarpidase BTG International 50633-0210-11 Voraxaze 10 Units 1 1 100 100
C9447 Inj, phenylephrine ketorolac Omeros 62225-0600-04 Omidria (phenylephrine + ketorolac irrigation) 4 ML 4 4 1 4
C9460 Injection, cangrelor The Medicines Company 65293-0003-10 KENGREAL 1 MG 1 10 50 500
C9482 Sotalol hydrochloride IV ALTATHERA PHARMACEUTICALS LLC 69724-0112-10 Sotalol 1MG 10 1 150 150
C9483 Injection, atezolizumab Genentech, Inc. 50242-0917-01 TECENTRIQ (atezolizumab) 10mg 20 1 120 120
C9484 Injection, eteplirsen Sarepta Therapeutics 60923-0284-10 EXONDYS 51 10mL 10 MG 10 1 50 50
C9484 Injection, eteplirsen Sarepta Therapeutics 60923-0363-02 EXONDYS 51 10 MG 2 1 10 10
C9485 Injection, olaratumab Eli Lilly and Company 00002-8926-01 LARTRUVO 10 MG 50 1 50 50
C9486 Inj, granisetron ext Heron Therapeutics 47426-0101-06 SUSTOL 0.1 MG 0.4 6 100 600
C9487 Ustekinumab IV inj, 1 mg Janssen Biotech, Inc. 57894-0054-27 STELARA (IV Infusion) 1 MG 26 1 130 130
C9488 Conivaptan HCL CUMBERLAND PHARMACEUTICALS, INC. 66220-0160-10 VAPRISOL 1 MG 100 1 20 20
C9497 Loxapine, inhalation powder GATE PHARMACEUTICALS 57844-0510-55 ADASUVE 10 MG 1 5 1 5

Past NDC - HCPCS Crosswalk