January 2024 NDC - HCPCS Crosswalk

Effective January 1, 2024 through March 31, 2024

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 GE HEALTHCARE 00407-2943-01 Clariscan 0.1 ML 10 10 100 1000
A9575 Inj gadoterate meglumi 0.1ml GE HEALTHCARE 00407-2943-02 Clariscan 0.1 ML 15 10 150 1500
A9575 Inj gadoterate meglumi 0.1ml GE HEALTHCARE 00407-2943-05 Clariscan 0.1 ML 20 10 200 2000
A9575 Inj gadoterate meglumi 0.1ml GUERBET LLC 67684-2000-00 Dotarem 0.1 ML 5 10 50 500
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 67684-2000-05 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 67684-2001-00 Dotarem 0.1 ML 5 10 50 500
A9575 Inj gadoterate meglumi 0.1ml GUERBET LLC 67684-2001-01 Dotarem 0.1 ML 10 10 100 1000
A9575 Inj gadoterate meglumi 0.1ml GUERBET LLC 67684-2001-02 Dotarem 0.1 ML 15 10 150 1500
A9575 Inj gadoterate meglumi 0.1ml GUERBET LLC 67684-2001-03 Dotarem 0.1 ML 20 10 200 2000
A9575 Inj gadoterate meglumi 0.1ml GUERBET LLC 67684-2001-04 Dotarem 0.1 ML 100 6 1000 6000
A9575 Inj gadoterate meglumi 0.1ml GUERBET LLC 67684-3001-01 Dotarem 0.1 ML 10 10 100 1000
A9575 Inj gadoterate meglumi 0.1ml GUERBET LLC 67684-3001-02 Dotarem 0.1 ML 15 10 150 1500
A9575 Inj gadoterate meglumi 0.1ml GUERBET LLC 67684-3001-03 Dotarem 0.1 ML 20 10 200 2000
A9575 Inj gadoterate meglumi 0.1ml GE HEALTHCARE 00407-2943-06 Gadoterate Meglumine 0.1 ML 5 10 50 500
A9575 Inj gadoterate meglumi 0.1ml GE HEALTHCARE 00407-2943-12 Gadoterate Meglumine 0.1 ML 10 10 100 1000
A9575 Inj gadoterate meglumi 0.1ml GE HEALTHCARE 00407-2943-17 Gadoterate Meglumine 0.1 ML 15 10 150 1500
A9575 Inj gadoterate meglumi 0.1ml GE HEALTHCARE 00407-2943-22 Gadoterate Meglumine 0.1 ML 20 10 200 2000
A9575 Inj gadoterate meglumi 0.1ml GE HEALTHCARE 00407-2943-70 Gadoterate Meglumine 0.1 ML 100 10 1000 10000
A9575 Inj gadoterate meglumi 0.1ml FRESENIUS KABI USA, LLC 65219-0080-05 GADOTERATE MEGLUMINE 0.1 ML 5 10 50 500
A9575 Inj gadoterate meglumi 0.1ml FRESENIUS KABI USA, LLC 65219-0082-10 GADOTERATE MEGLUMINE 0.1 ML 10 10 100 1000
A9575 Inj gadoterate meglumi 0.1ml FRESENIUS KABI USA, LLC 65219-0084-15 GADOTERATE MEGLUMINE 0.1 ML 15 10 150 1500
A9575 Inj gadoterate meglumi 0.1ml FRESENIUS KABI USA, LLC 65219-0086-20 GADOTERATE MEGLUMINE 0.1 ML 20 10 200 2000
A9575 Inj gadoterate meglumi 0.1ml FRESENIUS KABI USA, LLC 65219-0088-50 GADOTERATE MEGLUMINE 0.1 ML 100 6 1000 6000
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
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 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 00407-0690-70 Omniscan 1 ML 100 10 100 1000
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 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
A9579 Gad-base mr contrast nos,1ml BAYER HEALTHCARE PHARMACEUTICALS INC. 50419-0188-11 Magnevist 46.9% 1 ML 100 10 100 1000
A9579 Gad-base mr contrast nos,1ml BAYER HEALTHCARE PHARMACEUTICALS INC. 50419-0188-15 Magnevist 46.9% 1 ML 15 20 15 300
A9579 Gad-base mr contrast nos,1ml BAYER HEALTHCARE PHARMACEUTICALS INC. 50419-0188-36 Magnevist 46.9% 1 ML 10 5 10 50
A9579 Gad-base mr contrast nos,1ml BAYER HEALTHCARE PHARMACEUTICALS INC. 50419-0188-37 Magnevist 46.9% 1 ML 15 5 15 75
A9579 Gad-base mr contrast nos,1ml BAYER HEALTHCARE PHARMACEUTICALS INC. 50419-0188-38 Magnevist 46.9% 1 ML 20 5 20 100

Average Wholesale Price

HCPCS Description Labeler name NDC Drug name Dosage Package size Package quantity Billable units Billable units / pkg
91304 SARSCOV2 VAC 5MCG/0.5ML IM NOVAVAX 80631-0105-02 NOVAVAX COVID-19 VACCINE, 2023-2024 ADJUVANTED 0.5 ML 2.5 2 5 10
91318 SARSCOV2 VAC 3MCG TRS-SUC IM Pfizer 59267-4315-02 COVID-19 Vaccine 2023-2024 0.3 ML 1 10 3 30
91319 SARSCV2 VAC 10MCG TRS-SUC IM Pfizer 59267-4331-02 COVID-19 Vaccine 2023-2024 0.3 ML 1 10 1 10
91320 SARSCV2 VAC 30MCG TRS-SUC IM Pfizer 00069-2362-10 COMIRNATY 2023-2024 0.3 ML 1 10 1 10
91320 SARSCV2 VAC 30MCG TRS-SUC IM Pfizer 00069-2392-10 COMIRNATY 2023-2024 0.3 ML 1 10 1 10
91320 SARSCV2 VAC 30MCG TRS-SUC IM Pfizer 00069-2377-10 COMIRNATY 2023-2024 0.3 ML 1 10 1 10
91321 SARSCOV2 VAC 25 MCG/.25ML IM Moderna 80777-0287-92 COVID-19 Vaccine 2023-2024 0.25 ML 1 10 1 10
91322 SARSCOV2 VAC 50 MCG/0.5ML IM Moderna 80777-0102-96 SPIKEVAX 2023-2024 0.5 ML 1 10 1 10
91322 SARSCOV2 VAC 50 MCG/0.5ML IM Moderna 80777-0102-93 SPIKEVAX 2023-2024 0.5 ML 1 10 1 10
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 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 Bio Products Laboratory USA, Inc. 64208-2510-01 ALBUMINEX 5% 250 ML 250 1 1 1
P9045 Albumin (human), 5%, 250 ml Bio Products Laboratory USA, Inc. 64208-2510-05 ALBUMINEX 5% 250 ML 500 1 2 2
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 Grifols 68516-5214-02 Albutein® 5% Albumin 500 ml 250 ML 500 1 2 2
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 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 Grifols 68516-5214-01 Albutein® 5% 250 ML 250 1 1 1
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
P9046 Albumin (human), 25%, 20 ml Grifols 68516-5216-05 Albutein 25% 20 ML 20 1 1 1
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 Grifols 68516-5216-01 Albutein® 25% 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Grifols 68516-5216-02 Albutein® 25% Albumin 100 ml 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 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 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 Kedrion Biopharma 76179-0025-04 Kedbumin 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 68516-5216-07 Albutein 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Grifols 68516-5216-08 Albutein 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Bio Products Laboratory USA, Inc. 64208-2512-03 ALBUMINEX 25% 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Bio Products Laboratory USA, Inc. 64208-2512-07 ALBUMINEX 25% 50 ML 100 1 2 2
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 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 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

Not Otherwise Classified

Description Labeler name NDC Drug name Dosage Package size Package quantity Billable units Billable units / pkg
Aminocaproic acid HENRY SCHEIN, INC. 00404-9812-20 Aminocaproic Acid 250 MG 20 1 20 20
Aminocaproic acid AMERICAN REGENT 00517-9191-25 Aminocaproic Acid 250 MG 20 25 20 500
Aminocaproic acid CIVICA INC 72572-0015-25 Aminocaproic Acid 250 MG 20 25 20 500
Aminocaproic acid PFIZER INC. 00409-4346-73 AMINOCAPROIC ACID INJ 250 MG 20 25 20 500
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 63323-0401-20 Aztreonam 500 MG 1 10 2 20
Aztreonam FRESENIUS KABI 63323-0401-24 Aztreonam 500 MG 1 10 2 20
Aztreonam FRESENIUS KABI 63323-0401-26 Aztreonam 500 MG 1 10 2 20
Aztreonam FRESENIUS KABI 63323-0402-20 Aztreonam 500 MG 1 10 4 40
Aztreonam FRESENIUS KABI 63323-0402-24 Aztreonam 500 MG 1 10 4 40
Aztreonam FRESENIUS KABI 63323-0402-30 Aztreonam 500 MG 1 10 4 40
Diltiazem Hydrochloride HIKMA PHARMACEUTICALS USA INC. 00641-6013-10 Diltiazem Hcl 5 MG 5 10 5 50
Diltiazem Hydrochloride HIKMA PHARMACEUTICALS USA INC. 00641-6014-10 Diltiazem Hcl 5 MG 10 10 10 100
Diltiazem Hydrochloride HIKMA PHARMACEUTICALS USA INC. 00641-6015-10 Diltiazem Hcl 5 MG 25 10 25 250
Diltiazem Hydrochloride HIKMA PHARMACEUTICALS USA INC. 00641-9217-10 Diltiazem Hcl 5 MG 5 10 5 50
Diltiazem Hydrochloride HIKMA PHARMACEUTICALS USA INC. 00641-9218-10 Diltiazem Hcl 5 MG 10 10 10 100
Diltiazem Hydrochloride HIKMA PHARMACEUTICALS USA INC. 00641-9219-10 Diltiazem Hcl 5 MG 25 10 25 250
Diltiazem Hydrochloride HEALTHFIRST 51662-1335-01 Diltiazem Hcl 5 MG 5 1 5 5
Diltiazem Hydrochloride HEALTHFIRST 51662-1335-02 Diltiazem Hcl 5 MG 5 1 5 5
Diltiazem Hydrochloride HEALTHFIRST 51662-1457-01 Diltiazem Hcl 5 MG 1 1 20 20
Diltiazem Hydrochloride HEALTHFIRST 51662-1457-03 Diltiazem Hcl 5 MG 1 10 20 200
Diltiazem Hydrochloride EUGIA US LLC 55150-0425-10 Diltiazem HCl 5 MG 5 10 5 50
Diltiazem Hydrochloride EUGIA US LLC 55150-0426-10 Diltiazem HCl 5 MG 10 10 10 100
Diltiazem Hydrochloride EUGIA US LLC 55150-0427-10 Diltiazem HCl 5 MG 25 10 25 250
Diltiazem Hydrochloride ATHENEX 70860-0301-05 Diltiazem HCl 5 MG 5 10 5 50
Diltiazem Hydrochloride ATHENEX 70860-0301-10 Diltiazem HCl 5 MG 10 10 10 100
Diltiazem Hydrochloride ATHENEX 70860-0301-25 Diltiazem HCl 5 MG 25 10 25 250
Doxycycline Hyclate FOSUN PHARMA USA INC. 72266-0237-05 DOXYCYCLINE 100 MG 1 5 1 5
Doxycycline Hyclate HIKMA PHARMACEUTICALS USA INC. 00143-9381-10 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate HENRY SCHEIN, INC. 00404-9855-99 Doxycycline Hyclate 100 MG 1 1 1 1
Doxycycline Hyclate FRESENIUS KABI 63323-0130-11 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate FRESENIUS KABI 63323-0130-13 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate FRESENIUS KABI 63323-0130-17 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate PIRAMAL CRITICAL CARE 66794-0237-41 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate MYLAN INSTITUTIONAL LLC 67457-0437-10 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate ZYDUS PHARMACEUTICALS 68382-0910-10 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate HEALTHFIRST 51662-1402-03 Doxycyline Hyclate 100 MG 1 10 1 10
Famotidine HIKMA PHARMACEUTICALS USA INC. 00641-6021-10 Famotidine 10 MG 20 10 20 200
Famotidine HIKMA PHARMACEUTICALS USA INC. 00641-6022-25 Famotidine 10 MG 2 25 2 50
Famotidine HIKMA PHARMACEUTICALS USA INC. 00641-6023-25 Famotidine 10 MG 4 25 4 100
Famotidine FRESENIUS KABI 63323-0738-09 Famotidine 10 MG 4 10 4 40
Famotidine FRESENIUS KABI 63323-0738-20 Famotidine 10 MG 20 10 20 200
Famotidine FRESENIUS KABI 63323-0739-12 Famotidine 10 MG 2 25 2 50
Famotidine FRESENIUS KABI 63323-0739-16 Famotidine 10 MG 2 25 2 50
Famotidine MYLAN INSTITUTIONAL LLC 67457-0448-43 Famotidine 10 MG 4 10 4 40
Famotidine MYLAN INSTITUTIONAL LLC 67457-0457-20 Famotidine 10 MG 20 10 20 200
Famotidine ATHENEX 70860-0751-02 Famotidine 10 MG 2 25 2 50
Famotidine ATHENEX 70860-0753-20 Famotidine 10 MG 20 10 20 200
Famotidine BAXTER 00338-5197-41 Famotidine Premixed 10 MG 50 12 2 24
Flumazenil HIKMA PHARMACEUTICALS USA INC. 00143-9683-10 Flumazenil 0.1 MG 10 10 10 100
Flumazenil HIKMA PHARMACEUTICALS USA INC. 00143-9684-10 Flumazenil 0.1 MG 5 10 5 50
Flumazenil HIKMA PHARMACEUTICALS USA INC. 00143-9783-10 Flumazenil 0.1 MG 10 10 10 100
Flumazenil HIKMA PHARMACEUTICALS USA INC. 00143-9784-10 Flumazenil 0.1 MG 5 10 5 50
Flumazenil HENRY SCHEIN, INC. 00404-9859-10 Flumazenil 0.1 MG 10 1 10 10
Flumazenil HENRY SCHEIN, INC. 00404-9860-05 Flumazenil 0.1 MG 5 1 5 5
Flumazenil BAXTER 36000-0148-10 Flumazenil 0.1 MG 5 10 5 50
Flumazenil BAXTER 36000-0149-10 Flumazenil 0.1 MG 10 10 10 100
Flumazenil HEALTHFIRST 51662-1253-01 Flumazenil 0.1 MG 10 1 10 10
Flumazenil HEALTHFIRST 51662-1253-03 Flumazenil 0.1 MG 10 10 10 100
Flumazenil HEALTHFIRST 51662-1254-01 Flumazenil 0.1 MG 5 1 5 5
Flumazenil HEALTHFIRST 51662-1254-03 Flumazenil 0.1 MG 5 10 5 50
Flumazenil FRESENIUS KABI 63323-0424-05 Flumazenil 0.1 MG 5 10 5 50
Flumazenil FRESENIUS KABI 63323-0424-10 Flumazenil 0.1 MG 10 1 10 10
Folic Acid X-GEN PHARMACEUTICALS INC 39822-1100-01 Folic Acid 5 MG 10 1 10 10
Folic Acid FRESENIUS KABI 63323-0184-10 Folic Acid 5 MG 10 1 10 10
Furosemide (Phlow Corporation) PHLOW CORPORATION 81565-0201-02 Furosemide 20 MG 2 25 1 25
Glycopyrrolate injection (Fresenius Kabi) Fresenius Kabi USA, LLC 76045-0023-30 Glycopyrrolate 0.1 MG 3 10 6 60
Metoprolol Tartrate HIKMA PHARMACEUTICALS USA INC. 00143-9873-25 METOPROLOL INJ 1 MG 5 25 5 125
Metoprolol Tartrate HIKMA PHARMACEUTICALS USA INC. 00143-9660-10 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate PFIZER INC. 00409-1778-05 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate HOSPIRA, INC. 00409-2016-10 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate BAXTER 36000-0033-10 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate ALVOGEN 47781-0587-17 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate HEALTHFIRST 51662-1478-01 Metoprolol Tartrate 1 MG 5 1 5 5
Metoprolol Tartrate FRESENIUS KABI 63323-0660-05 METOPROLOL TARTRATE 1 MG 5 10 5 50
Metoprolol Tartrate FOSUN PHARMA USA 72266-0122-05 Metoprolol Tartrate 1 MG 5 5 5 25
Metoprolol Tartrate FOSUN PHARMA 72266-0122-25 Metoprolol Tartrate 1 MG 5 25 5 125
Metoprolol Tartrate CIVICA INC 72572-0420-10 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate ALMAJECT 72611-0740-10 Metoprolol Tartrate 1 MG 5 10 5 50
Rifampin FRESENIUS KABI 63323-0351-20 Rifampin 600 MG 1 1 1 1
Rifampin MYLAN INSTITUTIONAL LLC 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 00338-0054-03 Sodium Chloride 250 CC 500 1 2 2
Sodium Chloride, Hypertonic (3% - 5% infusion) BAXTER 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. 00703-9514-93 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
Sulfamethoxazole-Trimethoprim MYLAN INSTITUTIONAL LLC 67457-0778-05 Sulfamethoxazole-Trimethoprim 400-80 MG 5 10 1 10
Sulfamethoxazole-Trimethoprim MYLAN INSTITUTIONAL LLC 67457-0779-30 Sulfamethoxazole-Trimethoprim 400-80 MG 30 1 6 6
Sulfamethoxazole-Trimethoprim MYLAN INSTITUTIONAL LLC 67457-0921-05 Sulfamethoxazole-Trimethoprim 400-80 MG 5 10 1 10
Sulfamethoxazole-Trimethoprim MYLAN INSTITUTIONAL LLC 67457-0922-30 Sulfamethoxazole-Trimethoprim 400-80 MG 30 1 6 6
Glucarpidase BTG INTERNATIONAL INC. 50633-0210-11 Voraxaze 10 UNITS 1 1 100 100

Outpatient Prospective Payment System

HCPCS Description Labeler name NDC Drug name Dosage Package size Package quantity Billable units Billable units / pkg
A9513 Lutetium Lu 177 dotatat ther ADVANCED ACCELERATOR APPLICATIONS 69488-0003-01 LUTATHERA 1 MCI 20 1 200 200
A9543 Y90 ibritumomab, rx SPECTRUM PHARMACEUTICALS 68152-0103-03 ZEVALIN Y-90 UP TO 40 millicuries 1 1 1 1
A9543 Y90 ibritumomab, rx ACROTECH BIOPHARMA 72893-0007-04 ZEVALIN Y-90 UP TO 40 millicuries 1 1 1 1
A9590 Iodine i-131 iobenguane 1mci PROGENICS PHARMACEUTICALS, INC. 71258-0015-22 AZEDRA therapeutic 1 mCi 1 1 1 1
A9593 Gallium ga-68 psma-11 ucsf UCSF RADIOPHARMACEUTICAL FACILITY 24275-0525-01 Gallium Ga 68 PSMA (UCSF) 1 mCi 11 1 1 1
A9594 Gallium ga-68 psma-11, ucla UCLA BIOMEDICAL CYCLOTRON 76394-2642-03 Gallium Ga 68 PSMA (UCLA) 1 mCi 12 1 1 1
A9595 Piflu f-18, dia 1 millicurie PROGENICS PHARMACEUTICALS, INC 71258-0022-00 Pylarify 1 millicurie 1 1 9 9
A9596 Gallium illuccix 1 millicure TELIX PHARMACEUTICALS, INC. 74725-0100-25 ILLUCCIX 1 mCi 1 1 1 1
A9596 Gallium illuccix 1 millicure TELIX PHARMACEUTICALS, INC. 74725-0100-64 ILLUCCIX 1 mCi 1 1 1 1
A9600 Sr89 strontium QBIOMED INC 72928-0089-01 Strontium Chloride Sr 89 PER MILLICURIE 4 1 1 4
A9601 Flortaucipir inj 1 millicuri ELI LILLY AND COMPANY 00002-1220-01 Tauvid 1 MCI 1 1 1 1
A9601 Flortaucipir inj 1 millicuri Eli Lilly and Company 00002-1220-48 Tauvid 1 MCI 100 1 1 1
A9601 Flortaucipir inj 1 millicuri Eli Lilly and Company 00002-1220-50 Tauvid 1 MCI 50 1 1 1
A9602 Fluorodopa f-18 diag per mci THE FEINSTEIN INSTITUTES FOR MEDICAL RESEARCH 13267-0346-57 Fluorodopa F18 1 mCi 1 1 1 1
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
A9607 Lutetium lu 177 vipivotide ADVANCED ACCELERATOR APPLICATIONS USA, INC 69488-0010-61 PLUVICTO 1 mCi 1 1 1 1
A9608 Flotufolastat f18 diag 1 mci Blue Earth Diagnostics 69932-0002-01 Posluma 1 mCi 1 1 1 8
A9608 Flotufolastat f18 diag 1 mci Blue Earth Diagnostics 69932-0002-50 Posluma 1 MILLICURIE 25 1 1 1
A9800 Gallium locametz 1 millicuri ADVANCED ACCELERATOR APPLICATIONS USA, INC 69488-0017-61 LOCAMETZ 1 mCi 1 1 1 1
C9047 Injection, caplacizumab-yhdp GENZYME CORPORATION 58468-0225-01 Cablivi 1 MG 1 1 11 11
C9088 Instill, bupivac and meloxic HERON THERAPEUTICS 47426-0301-02 Zynrelef 1 mg - 0.03 mg 14 1 400 400
C9088 Instill, bupivac and meloxic HERON THERAPEUTICS 47426-0303-01 Zynrelef 1 mg - 0.03 mg 7 1 200 200
C9089 Bupivacaine implant, 1 mg INNOCOLL PHARMACEUTICALS LIMITED 51715-0100-04 Xaracoll 1 mg 1 12 100 1200
C9089 Bupivacaine implant, 1 mg INNOCOLL PHARMACEUTICALS LIMITED 51715-0100-10 Xaracoll 1 mg 1 30 100 3000
C9101 Inj, oliceridine 0.1 mg TREVENA, INC. 71308-0011-10 Olinvyk 0.1 MG 1 10 10 100
C9101 Inj, oliceridine 0.1 mg TREVENA, INC. 71308-0021-10 Olinvyk 0.1 MG 2 10 20 200
C9101 Inj, oliceridine 0.1 mg TREVENA, INC. 71308-0301-10 Olinvyk 0.1 MG 30 10 300 3000
C9144 Inj, bupivacaine (posimir) INNOCOLL PHARMACEUTICALS 51715-0660-10 Posimir 1 MG 5 10 660 6600
C9145 Inj, aponvie, 1 mg HERON THERAPEUTICS, INC. 47426-0401-10 APONVIE 1 MG 4.4 10 32 320
C9159 Inj, balfaxar, per i.u Octapharma USA Inc 68982-0261-01 Balfaxar PER FACTOR IX IU 1 1 1 1
C9159 Inj, balfaxar, per i.u Octapharma USA Inc 68982-0261-02 Balfaxar PER FACTOR IX IU 1 1 1 1
C9160 Inj daxibotulinumtoxinA-lanm Revance Therapeutics, Inc. 72960-0112-01 Daxxify 1 UNIT 1 1 100 100
C9161 Inj, aflibercept hd, 1 mg Regeneron Pharmaceuticals, Inc 61755-0050-01 Eylea HD 1 MG 0.07 1 8 8
C9161 Inj, aflibercept hd, 1 mg Regeneron Pharmaceuticals, Inc 61755-0051-01 Eylea HD 1 MG 0.07 1 8 8
C9162 Inj, avacincaptad peg 0.1 mg IVERIC bio, Inc. 82829-0002-01 Izervay 0.1 MG 0.1 1 20 20
C9163 Inj talquetamab-tgvs 0.25 mg Janssen Biotech 57894-0469-01 Talvey 0.25 MG 1.5 1 12 12
C9163 Inj talquetamab-tgvs 0.25 mg Janssen Biotech 57894-0470-01 Talvey 0.25 MG 1 1 160 160
C9164 Cantharidin top, applicator Verrica Pharmaceuticals 71349-0070-01 Ycanth 1 VIAL 0.45 1 1 1
C9164 Cantharidin top, applicator Verrica Pharmaceuticals 71349-0070-06 Ycanth 1 VIAL 0.45 6 1 6
C9164 Cantharidin top, applicator Verrica Pharmaceuticals 71349-0070-12 Ycanth 1 VIAL 0.45 12 1 12
C9165 Inj, elranatamab-bcmm, 1 mg Pfizer 00069-2522-02 Elrexfio 1 MG 1.1 1 44 44
C9165 Inj, elranatamab-bcmm, 1 mg Pfizer 00069-4494-02 Elrexfio 1 MG 1.9 1 76 76
C9250 Artiss fibrin sealant BAXTER 00338-9637-01 Artiss 2 ML 2 1 1 1
C9250 Artiss fibrin sealant BAXTER 00338-9639-01 Artiss 2 ML 4 1 2 2
C9250 Artiss fibrin sealant BAXTER 00338-9641-01 Artiss 2 ML 10 1 5 5
C9257 Bevacizumab injection GENENTECH, INC. 50242-0060-01 Avastin 0.25 MG 4 1 400 400
C9257 Bevacizumab injection GENENTECH, INC. 50242-0060-10 Avastin 0.25 MG 4 10 400 4000
C9257 Bevacizumab injection GENENTECH, INC. 50242-0061-01 Avastin 0.25 MG 16 1 1600 1600
C9257 Bevacizumab injection GENENTECH, INC. 50242-0061-10 Avastin 0.25 MG 16 10 1600 16000
C9290 Inj, bupivacaine liposome PACIRA PHARMACEUTICALS 65250-0133-04 EXPAREL 1 MG 10 4 133 532
C9290 Inj, bupivacaine liposome PACIRA PHARMACEUTICALS 65250-0133-09 EXPAREL 1 MG 10 10 133 1330
C9290 Inj, bupivacaine liposome PACIRA PHARMACEUTICALS 65250-0266-04 EXPAREL 1 MG 20 4 266 1064
C9290 Inj, bupivacaine liposome PACIRA PHARMACEUTICALS 65250-0266-09 EXPAREL 1 MG 20 10 266 2660
C9460 Injection, cangrelor CHIESI USA, INC. 10122-0620-10 KENGREAL 1 MG 1 10 50 500
C9482 Sotalol hydrochloride IV ALTATHERA PHARMACEUTICALS 69724-0112-10 Sotalol 1MG 10 1 150 150
C9488 Conivaptan HCL CUMBERLAND PHARMACEUTICALS 66220-0160-10 VAPRISOL 1 MG 100 1 20 20
J0135 Adalimumab injection ABBVIE US, LLC 00074-3799-02 Humira 20 MG 0.8 2 2 4
J0135 Adalimumab injection ABBVIE US, LLC 00074-4339-02 Humira 20 MG 0.8 2 2 4
J0135 Adalimumab injection ABBVIE US, LLC 00074-4339-06 Humira 20 MG 0.8 6 2 12
J0135 Adalimumab injection ABBVIE US, LLC 00074-4339-07 Humira 20 MG 0.8 4 2 8
J0184 Inj, amisulpride, 1 mg ACACIA PHARMA, INC. 71390-0125-20 BARHEMSYS 1 MG 2 10 5 50
J0184 Inj, amisulpride, 1 mg ACACIA PHARMA, INC. 71390-0125-50 BARHEMSYS 1 MG 4 10 10 100
J0208 Inj sodium thiosulfate 100mg FENNEC PHARMACEUTICALS INC. 73077-0010-01 Sodium Thiosulfate 100 MG 100 1 125 125
J0217 Inj velmanase alfa-tycv 1 mg Chiesi USA, 10122-0180-02 Lamzede 1 MG 1 1 10 10
J0217 Inj velmanase alfa-tycv 1 mg Chiesi USA, 10122-0180-05 Lamzede 1 MG 1 5 10 50
J0217 Inj velmanase alfa-tycv 1 mg Chiesi USA, 10122-0180-10 Lamzede 1 MG 1 1 10 10
J0287 Amphotericin b lipid complex LEADIANT BIOSCIENCES, INC. 57665-0101-41 Abelcet 10 MG 20 1 10 10
J0349 Inj, rezafungin, 1 mg Melinta Therapeutics, LLC 70842-0240-01 REZZAYO 1 MG 1 1 200 200
J0391 Inj, artesunate, 1mg AMIVAS (US), LLC 73607-0011-11 Artesunate 1 MG 1 2 110 220
J0470 Dimecaprol injection AKORN 17478-0526-03 Bal In Oil 100 MG 3 10 3 30
J0570 Buprenorphine implant 74.2mg TITAN PHARMACEUTICALS 52440-0100-14 PROBUPHINE SYSTEM KIT 74.2 MG 1 4 1 4
J0576 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0228-01 Brixadi (monthly dosing) 1 MG 0.36 1 128 128
J0576 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0264-01 Brixadi (monthly dosing) 1 MG 0.18 1 64 64
J0576 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0296-01 Brixadi (monthly dosing) 1 MG 0.27 1 96 96
J0576 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0208-01 Brixadi (weekly dosing) 1 MG 0.16 1 8 8
J0576 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0216-01 Brixadi (weekly dosing) 1 MG 0.32 1 16 16
J0576 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0224-01 Brixadi (weekly dosing) 1 MG 0.48 1 24 24
J0576 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0232-01 Brixadi (weekly dosing) 1 MG 0.64 1 32 32
J0600 Edetate calcium disodium inj RISING PHARMACEUTICALS 64980-0588-51 Calcium Disodium Edetate 1000 MG 5 5 1 5
J0600 Edetate calcium disodium inj MEDICIS PHARMACEUTICALS 99207-0240-05 Calcium Disodium Versenate 1000 MG 5 5 1 5
J0606 Inj, etelcalcetide, 0.1 mg AMGEN USA, INC. 55513-0740-10 Parsabiv 0.1 MG 0.5 10 25 250
J0606 Inj, etelcalcetide, 0.1 mg AMGEN USA, INC. 55513-0741-10 Parsabiv 0.1 MG 1 10 50 500
J0606 Inj, etelcalcetide, 0.1 mg AMGEN USA, INC. 55513-0742-10 Parsabiv 0.1 MG 2 10 100 1000
J0691 Inj lefamulin 1 mg NABRIVA THERAPEUTICS US, INC 72000-0120-06 Xenleta 1 MG 150 6 150 900
J0716 Centruroides immune f(ab) RARE DISEASE THERAPEUTICS, INC. 66621-0150-02 ANASCORP UP TO 120MG 1 1 1 1
J0884 Argatroban esrd dialysis 1mg NOVARTIS PHARMACEUTICALS CORPORATION 00078-0930-61 Argatroban 1 MG 2.5 1 250 250
J0884 Argatroban esrd dialysis 1mg HIKMA PHARMACEUTICALS USA INC. 00143-9288-01 Argatroban 1 MG 2.5 1 250 250
J0884 Argatroban esrd dialysis 1mg HIKMA PHARMACEUTICALS USA INC. 00143-9377-01 Argatroban 1 MG 50 1 50 50
J0884 Argatroban esrd dialysis 1mg HIKMA PHARMACEUTICALS USA INC. 00143-9559-01 ARGATROBAN 1 MG 50 1 50 50
J0884 Argatroban esrd dialysis 1mg HIKMA PHARMACEUTICALS USA INC. 00143-9674-01 Argatroban 1 MG 2.5 1 250 250
J0884 Argatroban esrd dialysis 1mg PFIZER INC. 00409-1140-01 Argatroban 1 MG 2.5 1 250 250
J0884 Argatroban esrd dialysis 1mg SAGENT PHARMACEUTICALS INC 25021-0414-50 ARGATROBAN 1 MG 50 1 50 50
J0884 Argatroban esrd dialysis 1mg PAR PHARMACEUTICAL, INC 42023-0182-01 Argatroban 1 MG 2.5 1 250 250
J0884 Argatroban esrd dialysis 1mg PAR PHARMACEUTICAL 42023-0182-89 ARGATROBAN 1 MG 2.5 1 250 250
J0884 Argatroban esrd dialysis 1mg FRESENIUS KABI 63323-0526-03 Argatroban 1 MG 2.5 1 250 250
J0884 Argatroban esrd dialysis 1mg FRESENIUS KABI 65219-0429-50 ARGATROBAN 1 MG 50 1 50 50
J0884 Argatroban esrd dialysis 1mg MYLAN INSTITUTIONAL LLC 67457-0212-02 Argatroban 1 MG 2.5 1 250 250
J0899 Argatroban dialysis, auromed AUROMEDICS PHARMA LLC 55150-0241-01 Argatroban 1 MG 50 1 50 50
J0899 Argatroban dialysis, auromed AUROMEDICS PHARMA LLC 55150-0241-10 ARGATROBAN 1 MG 50 10 50 500
J1096 Dexametha opth insert 0.1 mg OCULAR THERAPEUTIX 70382-0204-01 Dextenza 0.1 MG 1 1 4 4
J1096 Dexametha opth insert 0.1 mg OCULAR THERAPEUTIX 70382-0204-10 Dextenza 0.1 MG 1 10 4 40
J1097 Phenylep ketorolac opth soln OMEROS CORPORATION 62225-0600-04 Omidria (phenylephrine 1% + ketorolac 0.3% irrigation) 1 ML 4 4 4 16
J1105 Dexmedetomidine film, 1 mcg BIOXCEL THERAPEUTICS, INC. 81092-1120-01 IGALMI 1 MCG 10 1 1200 1200
J1105 Dexmedetomidine film, 1 mcg BIOXCEL THERAPEUTICS, INC. 81092-1180-01 IGALMI 1 MCG 10 1 1800 1800
J1327 Eptifibatide injection BAXTER 00338-9558-10 Eptifibatide 5 MG 100 12 15 180
J1327 Eptifibatide injection SAGENT PHARMACEUTICALS INC 25021-0408-51 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection SAGENT PHARMACEUTICALS INC 25021-0409-10 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection AUROMEDICS PHARMA LLC 55150-0218-99 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection AUROMEDICS PHARMA LLC 55150-0219-10 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection AUROMEDICS PHARMA LLC 55150-0220-99 Eptifibatide 5 MG 100 1 40 40
J1327 Eptifibatide injection MYLAN INSTITUTIONAL LLC 67457-0629-10 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection MYLAN INSTITUTIONAL LLC 67457-0630-10 Eptifibatide 5 MG 100 1 40 40
J1327 Eptifibatide injection MYLAN INSTITUTIONAL LLC 67457-0631-10 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection SLATE RUN 70436-0026-80 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection SLATE RUN 70436-0027-80 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection SLATE RUN 70436-0162-80 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection SLATE RUN 70436-0163-80 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection ATHENEX PHARMACEUTICAL 70860-0303-10 EPTIFIBATIDE 5 MG 10 1 4 4
J1327 Eptifibatide injection ATHENEX 70860-0305-51 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection MYLAN INSTITUTIONAL LLC 72078-0025-10 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection MYLAN INSTITUTIONAL LLC 72078-0026-10 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection MYLAN INSTITUTIONAL LLC 72078-0027-10 Eptifibatide 5 MG 100 1 40 40
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0100-10 Hemgenix Per Therapeutic Dose 10 10 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0110-11 Hemgenix Per Therapeutic Dose 10 11 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0120-12 Hemgenix Per Therapeutic Dose 10 12 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0130-13 Hemgenix Per Therapeutic Dose 10 13 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0140-14 Hemgenix Per Therapeutic Dose 10 14 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0150-15 Hemgenix Per Therapeutic Dose 10 15 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0160-16 Hemgenix Per Therapeutic Dose 10 16 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0170-17 Hemgenix Per Therapeutic Dose 10 17 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0180-18 Hemgenix Per Therapeutic Dose 10 18 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0190-19 Hemgenix Per Therapeutic Dose 10 19 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0200-20 Hemgenix Per Therapeutic Dose 10 20 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0210-21 Hemgenix Per Therapeutic Dose 10 21 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0220-22 Hemgenix Per Therapeutic Dose 10 22 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0230-23 Hemgenix Per Therapeutic Dose 10 23 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0240-24 Hemgenix Per Therapeutic Dose 10 24 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0250-25 Hemgenix Per Therapeutic Dose 10 25 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0260-26 Hemgenix Per Therapeutic Dose 10 26 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0270-27 Hemgenix Per Therapeutic Dose 10 27 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0280-28 Hemgenix Per Therapeutic Dose 10 28 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0290-29 Hemgenix Per Therapeutic Dose 10 29 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0300-30 Hemgenix Per Therapeutic Dose 10 30 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0310-31 Hemgenix Per Therapeutic Dose 10 31 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0320-32 Hemgenix Per Therapeutic Dose 10 32 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0330-33 Hemgenix Per Therapeutic Dose 10 33 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0340-34 Hemgenix Per Therapeutic Dose 10 34 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0350-35 Hemgenix Per Therapeutic Dose 10 35 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0360-36 Hemgenix Per Therapeutic Dose 10 36 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0370-37 Hemgenix Per Therapeutic Dose 10 37 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0380-38 Hemgenix Per Therapeutic Dose 10 38 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0390-39 Hemgenix Per Therapeutic Dose 10 39 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0400-40 Hemgenix Per Therapeutic Dose 10 40 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0410-41 Hemgenix Per Therapeutic Dose 10 41 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0420-42 Hemgenix Per Therapeutic Dose 10 42 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0430-43 Hemgenix Per Therapeutic Dose 10 43 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0440-44 Hemgenix Per Therapeutic Dose 10 44 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0450-45 Hemgenix Per Therapeutic Dose 10 45 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0460-46 Hemgenix Per Therapeutic Dose 10 46 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0470-47 Hemgenix Per Therapeutic Dose 10 47 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring 00053-0480-48 Hemgenix Per Therapeutic Dose 10 48 1 1
J1412 Inj roctavian ml 2x10^13vc g BioMarin Pharmaceutical Inc. 68135-0927-48 Roctavian 1 ML 8 1 8 8
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0501-10 Elevidys PER THERAPEUTIC DOSE 1 10 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0502-11 Elevidys PER THERAPEUTIC DOSE 1 11 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0503-12 Elevidys PER THERAPEUTIC DOSE 1 12 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0504-13 Elevidys PER THERAPEUTIC DOSE 1 13 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0505-14 Elevidys PER THERAPEUTIC DOSE 1 14 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0506-15 Elevidys PER THERAPEUTIC DOSE 1 15 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0507-16 Elevidys PER THERAPEUTIC DOSE 1 16 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0508-17 Elevidys PER THERAPEUTIC DOSE 1 17 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0509-18 Elevidys PER THERAPEUTIC DOSE 1 18 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0510-19 Elevidys PER THERAPEUTIC DOSE 1 19 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0511-20 Elevidys PER THERAPEUTIC DOSE 1 20 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0512-21 Elevidys PER THERAPEUTIC DOSE 1 21 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0513-22 Elevidys PER THERAPEUTIC DOSE 1 22 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0514-23 Elevidys PER THERAPEUTIC DOSE 1 23 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0515-24 Elevidys PER THERAPEUTIC DOSE 1 24 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0516-25 Elevidys PER THERAPEUTIC DOSE 1 25 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0517-26 Elevidys PER THERAPEUTIC DOSE 1 26 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0518-27 Elevidys PER THERAPEUTIC DOSE 1 27 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0519-28 Elevidys PER THERAPEUTIC DOSE 1 28 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0520-29 Elevidys PER THERAPEUTIC DOSE 1 29 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0521-30 Elevidys PER THERAPEUTIC DOSE 1 30 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0522-31 Elevidys PER THERAPEUTIC DOSE 1 31 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0523-32 Elevidys PER THERAPEUTIC DOSE 1 32 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0524-33 Elevidys PER THERAPEUTIC DOSE 1 33 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0525-34 Elevidys PER THERAPEUTIC DOSE 1 34 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0526-35 Elevidys PER THERAPEUTIC DOSE 1 35 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0527-36 Elevidys PER THERAPEUTIC DOSE 1 36 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0528-37 Elevidys PER THERAPEUTIC DOSE 1 37 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0529-38 Elevidys PER THERAPEUTIC DOSE 1 38 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0530-39 Elevidys PER THERAPEUTIC DOSE 1 39 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0531-40 Elevidys PER THERAPEUTIC DOSE 1 40 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0532-41 Elevidys PER THERAPEUTIC DOSE 1 41 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0533-42 Elevidys PER THERAPEUTIC DOSE 1 42 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0534-43 Elevidys PER THERAPEUTIC DOSE 1 43 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0535-44 Elevidys PER THERAPEUTIC DOSE 1 44 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0536-45 Elevidys PER THERAPEUTIC DOSE 1 45 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0537-46 Elevidys PER THERAPEUTIC DOSE 1 46 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0538-47 Elevidys PER THERAPEUTIC DOSE 1 47 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0539-48 Elevidys PER THERAPEUTIC DOSE 1 48 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0540-49 Elevidys PER THERAPEUTIC DOSE 1 49 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0541-50 Elevidys PER THERAPEUTIC DOSE 1 50 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0542-51 Elevidys PER THERAPEUTIC DOSE 1 51 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0543-52 Elevidys PER THERAPEUTIC DOSE 1 52 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0544-53 Elevidys PER THERAPEUTIC DOSE 1 53 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0545-54 Elevidys PER THERAPEUTIC DOSE 1 54 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0546-55 Elevidys PER THERAPEUTIC DOSE 1 55 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0547-56 Elevidys PER THERAPEUTIC DOSE 1 56 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0548-57 Elevidys PER THERAPEUTIC DOSE 1 57 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0549-58 Elevidys PER THERAPEUTIC DOSE 1 58 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0550-59 Elevidys PER THERAPEUTIC DOSE 1 59 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0551-60 Elevidys PER THERAPEUTIC DOSE 1 60 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0552-61 Elevidys PER THERAPEUTIC DOSE 1 61 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0553-62 Elevidys PER THERAPEUTIC DOSE 1 62 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0554-63 Elevidys PER THERAPEUTIC DOSE 1 63 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0555-64 Elevidys PER THERAPEUTIC DOSE 1 64 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0556-65 Elevidys PER THERAPEUTIC DOSE 1 65 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0557-66 Elevidys PER THERAPEUTIC DOSE 1 66 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0558-67 Elevidys PER THERAPEUTIC DOSE 1 67 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0559-68 Elevidys PER THERAPEUTIC DOSE 1 68 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0560-69 Elevidys PER THERAPEUTIC DOSE 1 69 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics 60923-0561-70 Elevidys PER THERAPEUTIC DOSE 1 70 1 1
J1426 Injection, casimersen, 10 mg SAREPTA 60923-0227-02 Amondys 45 10 MG 2 1 10 10
J1427 Inj. viltolarsen NS PHARMA INC 73292-0011-01 Viltepso 10 MG 5 1 25 25
J1429 Inj golodirsen 10 mg SAREPTA 60923-0465-02 Vyondys 53 10 MG 2 1 10 10
J1438 Etanercept injection AMGEN USA, INC. 58406-0425-34 Enbrel 25 MG 1 4 1 4
J1438 Etanercept injection AMGEN USA, INC. 58406-0445-04 Enbrel 25 MG 1 4 2 8
J1438 Etanercept injection AMGEN USA, INC. 58406-0455-04 Enbrel 25 MG 0.5 4 1 4
J1438 Etanercept injection AMGEN USA, INC. 58406-0435-04 Enbrel (Etanercept) 25 MG 1 4 2 8
J1451 Fomepizole, 15 mg AMERICAN REGENT 00517-0710-01 FOMEPIZOLE 15 MG 1.5 1 100 100
J1451 Fomepizole, 15 mg MYLAN INSTITUTIONAL LLC 67457-0211-02 FOMEPIZOLE 15 MG 1.5 1 100 100
J1451 Fomepizole, 15 mg ZYDUS PHARMACEUTICALS 70710-1478-01 Fomepizole 15 MG 1.5 1 100 100
J1455 Foscarnet sodium injection SAGENT PHARMACEUTICALS INC 25021-0189-84 FOSCARNET SODIUM 1000 MG 250 10 6 60
J1455 Foscarnet sodium injection BAXTER HEALTHCARE CORP 43066-0089-10 FOSCARNET SODIUM 1000 MG 250 10 6 60
J1455 Foscarnet sodium injection FRESENIUS KABI 63323-0875-50 Foscarnet Sodium 1000 MG 250 1 6 6
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0005-01 FLEBOGAMMA 10% DIF 500 MG 50 1 10 10
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0005-02 FLEBOGAMMA 10% DIF 500 MG 100 1 20 20
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0005-03 FLEBOGAMMA 10% DIF 500 MG 200 1 40 40
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0004-02 Flebogamma DIF 500 MG 50 1 5 5
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0004-03 Flebogamma DIF 500 MG 100 1 10 10
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0004-04 Flebogamma DIF 500 MG 200 1 20 20
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0004-05 Flebogamma DIF 500 MG 400 1 40 40
J1573 Hepagam b intravenous, inj SAOL THERAPEUTICS 70257-0051-51 Hepagam B 0.5 ML 5 1 10 10
J1573 Hepagam b intravenous, inj SAOL THERAPEUTICS 70257-0052-51 HEPAGAM B 0.5 ML 1 1 2 2
J1573 Hepagam b intravenous, inj SAOL THERAPEUTICS 70257-0053-51 Hepagam B 0.5 ML 1 1 2 2
J1573 Hepagam b intravenous, inj SAOL THERAPEUTICS 70257-0054-51 Hepagam B 0.5 ML 5 1 10 10
J1595 Injection glatiramer acetate TEVA NEUROSCIENCE, INC. 68546-0317-30 Copaxone 20 MG 1 30 1 30
J1595 Injection glatiramer acetate TEVA NEUROSCIENCE, INC. 68546-0325-12 Copaxone 20 MG 1 12 2 24
J1628 Inj., guselkumab, 1 mg JANSSEN BIOTECH, INC. 57894-0640-01 Tremfya 1 MG 1 1 100 100
J1628 Inj., guselkumab, 1 mg JANSSEN BIOTECH, INC. 57894-0640-11 Tremfya 1 MG 1 1 100 100
J1632 Inj, brexanolone SAGE THERAPEUTICS 72152-0547-20 Zulresso 1 MG 20 1 100 100
J1726 Inj, Makena AMERICAN REGENT 00517-1791-01 Hydroxyprogesterone Caproate 10 MG 1 1 25 25
J1726 Inj, Makena AUROMEDICS PHARMA LLC 55150-0309-01 Hydroxyprogesterone Caproate 10 MG 1 1 25 25
J1726 Inj, Makena AUROMEDICS PHARMA LLC 55150-0310-01 Hydroxyprogesterone Caproate 10 MG 5 1 125 125
J1726 Inj, Makena MYLAN INSTITUTIONAL LLC 67457-0886-05 Hydroxyprogesterone Caproate 10 MG 1 1 125 125
J1726 Inj, Makena MYLAN INSTITUTIONAL LLC 67457-0967-01 Hydroxyprogesterone Caproate 10 MG 1 1 25 25
J1726 Inj, Makena AMNEAL PHARMACEUTICALS, LLC 69238-1797-01 Hydroxyprogesterone Caproate 10 MG 1 1 25 25
J1726 Inj, Makena SLAYBACK PHARMA 71225-0104-01 Hydroxyprogesterone Caproate 10 MG 5 1 125 125
J1726 Inj, Makena SLAYBACK PHARMA 71225-0105-01 Hydroxyprogesterone Caproate 10 MG 1 1 25 25
J1726 Inj, Makena AMERICAN REGENT 00517-1767-01 MAKENA 10 MG 1 1 25 25
J1726 Inj, Makena AMAG PHARMACEUTICALS, INC. 64011-0301-03 Makena Auto Injector 10 MG 1.1 1 27.5 27.5
J1742 Ibutilide fumarate injection MYLAN INSTITUTIONAL LLC 67457-0366-10 IBUTILIDE FUMARATE 1 MG 10 1 1 1
J1742 Ibutilide fumarate injection PFIZER INC. 00009-3794-01 Corvert 1 MG 10 1 1 1
J1742 Ibutilide fumarate injection PFIZER INC. 00009-3794-22 Corvert 1 MG 10 1 1 1
J1744 Icatibant injection LEUCADIA PHARMACEUTICALS 24201-0207-01 ICATIBANT 1 MG 3 1 30 30
J1744 Icatibant injection TAKEDA PHARMACEUTICALS AMERICA, INC. 54092-0702-02 ICATIBANT 1 MG 3 1 30 30
J1744 Icatibant injection TAKEDA PHARMACEUTICALS AMERICA, INC. 54092-0702-03 ICATIBANT 1 MG 3 3 30 90
J1744 Icatibant injection FRESENIUS KABI 63323-0574-86 ICATIBANT 1 MG 3 1 30 30
J1744 Icatibant injection FRESENIUS KABI 63323-0574-93 ICATIBANT 1 MG 3 3 30 90
J1744 Icatibant injection CIPLA USA INC. 69097-0664-34 ICATIBANT 1 MG 3 1 30 30
J1744 Icatibant injection CIPLA USA INC. 69097-0664-68 ICATIBANT 1 MG 3 3 30 90
J1833 Inj, isavuconazonium sulfate ASTELLAS 00469-0420-01 CRESEMBA 1 MG 1 1 372 372
J1833 Inj, isavuconazonium sulfate ASTELLAS PHARMA US INC. 00469-0420-99 CRESEMBA injection 1mg (as sulfate) 1 10 372 3720
J2186 Inj., meropenem, vaborbactam MELINTA THERAPEUTICS, INC. 70842-0120-06 Vabomere (meropenem-vaborbactam) (10 MG/10MG) 20 MG 1 6 100 600
J2212 Methylnaltrexone injection SALIX PHARMACEUTICALS 65649-0551-02 RELISTOR 0.1 MG 0.6 1 120 120
J2212 Methylnaltrexone injection SALIX PHARMACEUTICALS 65649-0551-03 RELISTOR 0.1 MG 0.6 7 120 840
J2212 Methylnaltrexone injection SALIX PHARMACEUTICALS 65649-0551-07 RELISTOR 0.1 MG 0.6 1 120 120
J2212 Methylnaltrexone injection SALIX PHARMACEUTICALS 65649-0552-04 RELISTOR 0.1 MG 0.4 7 80 560
J2265 Minocycline hydrochloride MELINTA THERAPEUTICS, INC. 70842-0160-10 MINOCIN 1 MG 1 10 100 1000
J2326 Injection, nusinersen BIOGEN 64406-0058-01 Spinraza 0.1 MG 5 1 120 120
J2403 Chloroprocaine opht gel, 1mg Harrow Eye, Llc. 82667-0300-01 IHEEZO 1 MG 1 1 800 800
J2403 Chloroprocaine opht gel, 1mg Harrow Eye, Llc. 82667-0300-10 IHEEZO 1 MG 1 10 800 8000
J2425 Palifermin injection SOBI 66658-0112-03 Kepivance 50 MCG 1 3 125 375
J2425 Palifermin injection SOBI 66658-0112-06 Kepivance/Palifermin 50 MCG 1 6 125 750
J2502 Inj, pasireotide long acting NOVARTIS PHARMACEUTICALS CORPORATION 00078-0641-81 Signifor LAR 1 MG 1 1 20 20
J2502 Inj, pasireotide long acting NOVARTIS PHARMACEUTICALS CORPORATION 00078-0642-81 Signifor LAR 1 MG 1 1 40 40
J2502 Inj, pasireotide long acting NOVARTIS PHARMACEUTICALS CORPORATION 00078-0643-81 Signifor LAR 1 MG 1 1 60 60
J2502 Inj, pasireotide long acting NOVARTIS PHARMACEUTICALS CORPORATION 00078-0741-81 Signifor LAR 1 MG 1 1 30 30
J2502 Inj, pasireotide long acting NOVARTIS PHARMACEUTICALS CORPORATION 00078-0748-81 Signifor LAR 1 MG 1 1 10 10
J2502 Inj, pasireotide long acting RECORDATI RARE DISEASES 55292-0139-01 Signifor Lar 1 MG 1 1 10 10
J2502 Inj, pasireotide long acting RECORDATI RARE DISEASES 55292-0140-01 Signifor Lar 1 MG 1 1 20 20
J2502 Inj, pasireotide long acting RECORDATI RARE DISEASES 55292-0141-01 Signifor Lar 1 MG 1 1 30 30
J2502 Inj, pasireotide long acting RECORDATI RARE DISEASES 55292-0142-01 Signifor Lar 1 MG 1 1 40 40
J2502 Inj, pasireotide long acting RECORDATI RARE DISEASES 55292-0143-01 Signifor Lar 1 MG 1 1 60 60
J2508 Pegunigalsidase alfa-iwxj Chiesi USA 10122-0160-02 Elfabrio 1 MG 10 1 20 20
J2508 Pegunigalsidase alfa-iwxj Chiesi USA 10122-0160-05 Elfabrio 1 MG 10 5 20 100
J2508 Pegunigalsidase alfa-iwxj Chiesi USA 10122-0160-10 Elfabrio 1 MG 10 10 20 200
J2510 Penicillin g procaine inj PFIZER INC. 60793-0130-10 Penicillin G Procaine up to 600000 UNITS 1 10 1 10
J2510 Penicillin g procaine inj PFIZER INC. 60793-0131-10 Penicillin G Procaine up to 600000 UNITS 2 10 2 20
J2547 Injection, peramivir BIOCRYST 72769-0181-03 Rapivab 1 MG 20 3 200 600
J2770 Quinupristin/dalfopristin PFIZER INC. 61570-0260-10 Synercid 500 MG 1 10 1 10
J2840 Injection, sebelipase alfa ALEXION PHARMACEUTICALS 25682-0007-01 Kanuma 1 MG 10 1 20 20
J2850 Inj secretin synthetic human CHIRHOCLIN, INC. 67066-0005-01 CHIRHOSTIM 1 MCG 1 1 16 16
J2993 Reteplase injection CHIESI USA, INC. 10122-0141-02 RETAVASE KIT 18.1 MG 1 2 1 2
J2998 Inj plasminogen tvmh 1mg Prometic 70573-0099-02 Ryplazim 1 mg 1 1 68.8 68.8
J3031 Inj., fremanezumab-vfrm 1 mg NUPATHE INC 51759-0202-10 Ajovy 1 MG 1.5 1 225 225
J3031 Inj., fremanezumab-vfrm 1 mg NUPATHE INC 51759-0202-22 Ajovy 1 MG 1.5 3 225 675
J3031 Inj., fremanezumab-vfrm 1 mg NUPATHE INC 51759-0204-10 Ajovy 1 MG 1.5 1 225 225
J3244 Inj. tigecycline (accord) ACCORD HEALTHCARE INC. 16729-0364-68 Tigecycline 1 MG 1 10 50 500
J3316 Inj., triptorelin xr 3.75 mg ARBOR PHARMACEUTICAL 24338-0150-20 Triptodur 3.75 MG 1 1 6 6
J3398 Inj luxturna 1 billion vec g SPARK THERAPEUTICS, INC. 71394-0415-01 LUXTURNA 1 billion vector genomes 0.5 1 150 150
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0122-03 Zolgensma 1x5.5 mL vial and 2x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 22.1 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0125-04 Zolgensma 1x5.5 mL vial and 3x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 30.4 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0128-05 Zolgensma 1x5.5 mL vial and 4x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 38.7 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0131-06 Zolgensma 1x5.5 mL vial and 5x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 47 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0134-07 Zolgensma 1x5.5 mL vial and 6x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 55.3 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0137-08 Zolgensma 1x5.5 mL vial and 7x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 63.6 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0140-09 Zolgensma 1x5.5 mL vial and 9x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 71.9 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0121-03 Zolgensma 2x5.5 mL vial and 1x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 19.3 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0124-04 Zolgensma 2x5.5 mL vial and 2x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 27.6 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0127-05 Zolgensma 2x5.5 mL vial and 3x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 35.9 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0130-06 Zolgensma 2x5.5 mL vial and 4x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 44.2 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0133-07 Zolgensma 2x5.5 mL vial and 5x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 52.5 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0136-08 Zolgensma 2x5.5 mL vial and 6x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 60.8 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0139-09 Zolgensma 2x5.5 mL vial and 7x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 69.1 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0120-02 Zolgensma 2x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 16.6 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0123-03 Zolgensma 3x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 24.9 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0126-04 Zolgensma 4x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 33.2 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0129-05 Zolgensma 5x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 41.5 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0132-06 Zolgensma 6x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 49.8 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0135-07 Zolgensma 7x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 58.1 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0138-08 Zolgensma 8x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 66.4 1 1 1
J3399 Inj onase abepar-xioi treat AVEXIS 71894-0141-09 Zolgensma 9x8.3 mL vial Kit per tx dose (up to 5 x10^15 vg?) 74.7 1 1 1
J3401 Vyjuvek 5x10^9pfu/ml, 0.1 ml Krystal Biotech 82194-0510-02 Vyjuvek 0.1 ML 1 1 10 10
J7168 Prothrombin complex kcentra CSL BEHRING LLC 63833-0386-02 Kcentra 1 IU 1 1 1 1
J7168 Prothrombin complex kcentra CSL BEHRING LLC 63833-0387-02 Kcentra 1 IU 1 1 1 1
J7169 Inj andexxa, 10 mg ASTRAZENECA PHARMACEUTICALS, LP 00310-3200-04 Andexxa 10 MG 1 4 20 80
J7169 Inj andexxa, 10 mg ASTRAZENECA PHARMACEUTICALS, LP 00310-3200-05 ANDEXXA 10 MG 1 5 20 100
J7169 Inj andexxa, 10 mg ALEXION PHARMACEUTICALS 69853-0102-01 Andexxa 10 MG 1 4 20 80
J7342 Inject, ciprofloxacin otic ALK-ABELLO INC. 00268-8200-01 OTIPRIO 6 MG 1 1 10 10
J7352 Afamelanotide implant, 1 mg CLINUVEL 73372-0116-01 Scenesse 1 MG 1 1 16 16
J7501 Azathioprine parenteral HIKMA PHARMACEUTICALS USA INC. 00143-9566-01 AZATHIOPRINE INJECTION 100 MG 1 1 1 1
J9019 Erwinaze injection JAZZ PHARMACEUTICALS, INC. 57902-0249-05 ERWINAZE 1,000 IU 1 5 10 50
J9029 Instill adstiladrin, tx dose Ferring Pharmaceuticals 55566-1050-01 Adstiladrin PER THERAPEUTIC DOSE 20 4 1 1
J9037 Inj belantamab mafodont blmf GLAXOSMITHKLINE 00173-0896-01 Blenrep 0.5 MG 1 1 200 200
J9046 Inj, bortezomib, dr. reddy’s DR. REDDY'S LABORATORIES, INC. 43598-0865-60 Bortezomib 0.1 MG 1 1 35 35
J9048 Inj, bortezomib freseniuskab FRESENIUS KABI 63323-0721-10 Bortezomib 0.1 MG 1 1 35 35
J9057 Inj., copanlisib, 1 mg BAYER HEALTHCARE PHARMACEUTICALS INC. 50419-0385-01 ALIQOPA 1 MG 1 1 60 60
J9072 Inj cyclophos dr.reddy's 5mg Dr. Reddy's Laboratories Inc. 43598-0660-11 Cyclophosphamide (Dr. Reddy's) 5 MG 1 1 100 100
J9072 Inj cyclophos dr.reddy's 5mg Dr. Reddy's Laboratories Inc. 43598-0661-11 Cyclophosphamide (Dr. Reddy's) 5 MG 2 1 200 200
J9072 Inj cyclophos dr.reddy's 5mg Dr. Reddy's Laboratories Inc. 43598-0662-11 Cyclophosphamide (Dr. Reddy's) 5 MG 4 1 400 400
J9214 Interferon alfa-2b inj SCHERING CORPORATION 00085-4350-01 Intron-A 1 MIL UNITS 1 1 10 10
J9214 Interferon alfa-2b inj SCHERING CORPORATION 00085-4351-01 Intron-A 1 MIL UNITS 1 1 18 18
J9214 Interferon alfa-2b inj SCHERING CORPORATION 00085-4352-01 Intron-A 1 MIL UNITS 1 1 50 50
J9225 Vantas implant ENDO PHARMACEUTICALS VALERA INC. 67979-0500-01 Vantas implant 50 MG 1 1 1 1
J9247 Inj, melphalan flufenami 1mg ONCOPEPTIDES, INC. 73657-0020-01 Pepaxto 1 MG 1 1 20 20
J9296 Inj pemetrexed (accord) 10mg Accord Healthcare Inc. 16729-0522-05 Pemetrexed 10 mg 20 1 50 50
J9296 Inj pemetrexed (accord) 10mg ACCORD HEALTHCARE 16729-0522-28 PEMETREXED 10 MG 34 1 85 85
J9296 Inj pemetrexed (accord) 10mg Accord Healthcare Inc. 16729-0522-35 Pemetrexed 10 mg 40 1 100 100
J9296 Inj pemetrexed (accord) 10mg Accord Healthcare Inc. 16729-0522-64 Pemetrexed 10 mg 4 1 10 10
J9302 Ofatumumab injection NOVARTIS PHARMACEUTICALS CORPORATION 00078-0669-13 ARZERRA 10 MG 5 3 10 30
J9302 Ofatumumab injection NOVARTIS PHARMACEUTICALS CORPORATION 00078-0690-61 ARZERRA 10 MG 50 1 100 100
J9314 Inj pemetrexed (teva) 10mg TEVA PHARMACEUTICALS USA, INC. 00480-4514-01 Pemetrexed 10 MG 20 1 50 50
J9314 Inj pemetrexed (teva) 10mg TEVA PHARMACEUTICALS USA, INC. 00480-4515-01 Pemetrexed 10 MG 40 1 100 100
J9314 Inj pemetrexed (teva) 10mg TEVA PHARMACEUTICALS USA, INC. 00480-4516-01 Pemetrexed 10 MG 4 1 10 10
J9318 Inj romidepsin non-lyo 0.1mg SICOR PHARMACEUTICALS, INC. 00703-4004-01 Romidepsin non-lyophilized 0.1 MG 5.5 1 275 275
J9320 Streptozocin injection SICOR PHARMACEUTICALS, INC. 00703-4636-01 Zanosar 1 GM 1 1 1 1
J9333 Inj ronzanolixizum-noli 1 mg UCB 50474-0980-79 Rystiggo 1 MG 2 1 280 280
J9334 Inj efgart-alfa 2mg hya-qvfc Argenx US 73475-3102-03 Vyvgart Hytrulo 2 MG 5.6 1 504 504
J9371 Inj, Vincristine sul lip 1mg ACROTECH BIOPHARMA 72893-0008-03 Vincristine Sulfate 1 MG 1 1 5 5
J9393 Inj, fulvestrant (teva) ACTAVIS PHARMA, INC. 00591-5019-02 FULVESTRANT 25 MG 5 2 10 20
J9600 Porfimer sodium injection PINNACLE BIOLOGICS, INC. 76128-0155-75 Photofrin 75 MG 1 1 1 1
Q2009 Fosphenytoin inj PE HIKMA PHARMACEUTICALS USA INC. 00641-6136-25 FOSPHENYTOIN SODIUM 50 MG PE/ML 2 25 2 50
Q2009 Fosphenytoin inj PE FRESENIUS KABI 63323-0403-02 FOSPHENYTOIN SODIUM 50 MG PE/ML 2 25 2 50
Q2009 Fosphenytoin inj PE FRESENIUS KABI 63323-0403-10 FOSPHENYTOIN SODIUM 50 MG PE/ML 10 10 10 100
Q2009 Fosphenytoin inj PE PFIZER INC. 00069-5471-02 CEREBYX 50 MG PE/ML 2 25 2 50
Q2009 Fosphenytoin inj PE PFIZER INC. 00069-5474-02 CEREBYX 50 MG PE/ML 10 10 10 100
Q2009 Fosphenytoin inj PE PFIZER INC. 00069-6001-21 CEREBYX 50 MG PE/ML 10 10 10 100
Q2009 Fosphenytoin inj PE PFIZER INC. 00069-6001-25 CEREBYX 50 MG PE/ML 2 25 2 50
Q5120 Inj pegfilgrastim-bmez 0.5mg SANDOZ 61314-0866-01 ZIEXTENZO 0.5 MG 0.6 1 12 12
Q9968 Visualization adjunct MYLAN INSTITUTIONAL LLC 67457-0220-05 ISOSULFAN BLUE INJECTION 1 MG 5 6 50 300
Q9968 Visualization adjunct AMERICAN REGENT 00517-0374-05 Provayblue 1 MG 10 5 50 250

Past NDC - HCPCS Crosswalk