October 2023 NDC - HCPCS Crosswalk

Effective October 1, 2023 - December 31, 2023

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 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 00270-1111-85 PROHANCE 1 ML 100 5 100 500
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
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
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 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
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
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 00944-0490-01 Buminate 50 ML 20 1 0.4 0.4
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 00944-0493-01 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 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
Bumetanide PFIZER INC. 00409-1412-04 Bumetanide 0.25 MG 4 10 4 40
Bumetanide PFIZER INC. 00409-1412-10 Bumetanide 0.25 MG 10 10 10 100
Bumetanide HIKMA PHARMACEUTICALS USA INC. 00641-6007-10 Bumetanide 0.25 MG 10 10 10 100
Bumetanide HIKMA PHARMACEUTICALS USA INC. 00641-6008-10 Bumetanide 0.25 MG 4 10 4 40
Bumetanide HIKMA PHARMACEUTICALS USA INC. 00641-6161-10 Bumetanide 0.25 MG 4 10 4 40
Bumetanide HIKMA PHARMACEUTICALS USA INC. 00641-6162-10 Bumetanide 0.25 MG 10 10 10 100
Bumetanide FRESENIUS KABI USA 65219-0570-04 BUMETANIDE 0.25 MG 4 10 4 40
Bumetanide FRESENIUS KABI USA 65219-0572-10 BUMETANIDE 0.25 MG 10 10 10 100
Bumetanide GLENMARK PHARMACEUTICALS INC., USA 68462-0469-54 BUMETANIDE 0.25 MG 4 10 4 40
Bumetanide GLENMARK PHARMACEUTICALS INC., USA 68462-0470-54 BUMETANIDE 0.25 MG 10 10 10 100
Bumetanide ATHENEX PHARMACEUTICAL 70860-0405-04 Bumetanide 0.25 MG 4 10 4 40
Bumetanide ATHENEX PHARMACEUTICAL 70860-0406-10 Bumetanide 0.25 MG 10 10 10 100
Bumetanide Novadoz Pharmaceuticals, Llc 72205-0101-07 Bumetanide 0.25 MG 4 10 4 40
Bumetanide Novadoz Pharmaceuticals, Llc 72205-0102-07 Bumetanide 0.25 MG 10 10 10 100
Bumetanide CIVICA, INC. 72572-0040-10 Bumetanide 0.25 MG 4 10 4 40
Bumetanide CIVICA, INC. 72572-0041-10 Bumetanide 0.25 MG 10 10 10 100
Carmustine (Accord) ACCORD HEALTHCARE INC. 16729-0545-63 Carmustine 100 MG 1 1 0.5 0.5
Carmustine (Accord) ACCORD HEALTHCARE 16729-0548-63 CARMUSTINE 100 MG 1 1 3 3
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 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
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 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 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
Glycopyrrolate injection Meitheal Pharmaceuticals Inc. 71288-0414-04 Glycopyrrolate 0.2 MG 2 25 2 50
Glycopyrrolate injection Meitheal Pharmaceuticals Inc. 71288-0415-06 Glycopyrrolate 0.2 MG 5 25 5 125
Glycopyrrolate injection (Fresenius Kabi) Fresenius Kabi USA, LLC 76045-0023-30 Glycopyrrolate 0.2 MG 3 10 3 30
Glycopyrrolate injection FRESENIUS KABI 63323-0578-11 Glycopyrrolate (injection) 0.2 MG 1 25 1 25
Glycopyrrolate injection FRESENIUS KABI 63323-0578-12 Glycopyrrolate (injection) 0.2 MG 2 25 2 50
Glycopyrrolate injection MEITHEAL PHARMACEUTICALS 71288-0414-03 Glycopyrrolate (injection) 0.2 MG 1 25 1 25
Glycopyrrolate injection HIKMA PHARMACEUTICALS USA INC. 00143-9584-10 Glycopyrrolate INJECTION 0.2 MG 20 10 20 200
Glycopyrrolate injection HIKMA PHARMACEUTICALS USA INC. 00143-9585-25 Glycopyrrolate INJECTION 0.2 MG 5 25 5 125
Glycopyrrolate injection HIKMA PHARMACEUTICALS USA INC. 00143-9586-25 Glycopyrrolate INJECTION 0.2 MG 2 25 2 50
Glycopyrrolate injection HIKMA PHARMACEUTICALS USA INC. 00143-9587-25 Glycopyrrolate INJECTION 0.2 MG 1 25 1 25
Glycopyrrolate injection HIKMA PHARMACEUTICALS USA INC. 00143-9679-10 Glycopyrrolate INJECTION 0.2 MG 20 10 20 200
Glycopyrrolate injection HIKMA PHARMACEUTICALS USA INC. 00143-9680-25 Glycopyrrolate INJECTION 0.2 MG 5 25 5 125
Glycopyrrolate injection HIKMA PHARMACEUTICALS USA INC. 00143-9681-25 Glycopyrrolate INJECTION 0.2 MG 2 25 2 50
Glycopyrrolate injection HIKMA PHARMACEUTICALS USA INC. 00143-9682-25 Glycopyrrolate INJECTION 0.2 MG 1 25 1 25
Glycopyrrolate injection HENRY SCHEIN, INC. 00404-9867-01 Glycopyrrolate Injection 0.2 MG 1 1 1 1
Glycopyrrolate injection HENRY SCHEIN, INC. 00404-9868-20 Glycopyrrolate Injection 0.2 MG 20 1 20 20
Glycopyrrolate injection HENRY SCHEIN, INC. 00404-9869-02 Glycopyrrolate Injection 0.2 MG 2 1 2 2
Glycopyrrolate injection HENRY SCHEIN, INC. 00404-9870-05 Glycopyrrolate Injection 0.2 MG 5 1 5 5
Glycopyrrolate injection SANDOZ 00781-3825-96 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection SANDOZ 00781-3827-96 Glycopyrrolate Injection 0.2 MG 2 25 2 50
Glycopyrrolate injection SANDOZ 00781-3829-96 Glycopyrrolate Injection 0.2 MG 5 25 5 125
Glycopyrrolate injection SANDOZ 00781-3831-95 Glycopyrrolate Injection 0.2 MG 20 10 20 200
Glycopyrrolate injection A-S MEDICATION SOLUTIONS 50090-5226-00 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection HEALTHFIRST 51662-1487-01 Glycopyrrolate Injection 0.2 MG 1 1 1 1
Glycopyrrolate injection HEALTHFIRST 51662-1487-03 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection HEALTHFIRST 51662-1554-03 Glycopyrrolate Injection 0.2 MG 2 25 2 50
Glycopyrrolate injection HEALTHFIRST 51662-1601-01 Glycopyrrolate Injection 0.2 MG 5 1 5 5
Glycopyrrolate injection HEALTHFIRST 51662-1601-03 Glycopyrrolate Injection 0.2 MG 5 25 5 125
Glycopyrrolate injection AUROMEDICS PHARMA LLC 55150-0292-01 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection AUROMEDICS PHARMA LLC 55150-0293-02 Glycopyrrolate Injection 0.2 MG 2 25 2 50
Glycopyrrolate injection AUROMEDICS PHARMA LLC 55150-0294-05 Glycopyrrolate Injection 0.2 MG 5 25 5 125
Glycopyrrolate injection AUROMEDICS PHARMA LLC 55150-0295-20 Glycopyrrolate Injection 0.2 MG 20 25 20 500
Glycopyrrolate injection APOTEX CORP. 60505-6179-05 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection APOTEX CORP. 60505-6180-05 Glycopyrrolate Injection 0.2 MG 2 25 2 50
Glycopyrrolate injection APOTEX CORP. 60505-6181-05 Glycopyrrolate Injection 0.2 MG 5 25 5 125
Glycopyrrolate injection APOTEX CORP. 60505-6182-04 Glycopyrrolate Injection 0.2 MG 20 10 20 200
Glycopyrrolate injection FRESENIUS KABI 63323-0578-01 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection FRESENIUS KABI 63323-0578-02 Glycopyrrolate Injection 0.2 MG 2 25 2 50
Glycopyrrolate injection FRESENIUS KABI 63323-0578-05 Glycopyrrolate Injection 0.2 MG 5 25 5 125
Glycopyrrolate injection PIRAMAL CRITICAL CARE 66794-0202-42 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection PIRAMAL CRITICAL CARE 66794-0203-42 Glycopyrrolate Injection 0.2 MG 2 25 2 50
Glycopyrrolate injection PIRAMAL CRITICAL CARE 66794-0204-42 Glycopyrrolate Injection 0.2 MG 5 25 5 125
Glycopyrrolate injection PIRAMAL CRITICAL CARE 66794-0205-41 Glycopyrrolate Injection 0.2 MG 20 10 20 200
Glycopyrrolate injection AMERICAN HEALTH PACKAGING 68001-0351-60 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection AMERICAN HEALTH PACKAGING 68001-0352-71 Glycopyrrolate Injection 0.2 MG 2 25 2 50
Glycopyrrolate injection AMERICAN HEALTH PACKAGING 68001-0353-72 Glycopyrrolate Injection 0.2 MG 5 25 5 125
Glycopyrrolate injection AMNEAL BIOSCIENCES 70121-1394-05 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection AMNEAL BIOSCIENCES 70121-1395-05 Glycopyrrolate Injection 0.2 MG 2 25 2 50
Glycopyrrolate injection AMNEAL BIOSCIENCES 70121-1396-05 Glycopyrrolate Injection 0.2 MG 5 25 5 125
Glycopyrrolate injection AMNEAL BIOSCIENCES 70121-1397-07 Glycopyrrolate Injection 0.2 MG 20 10 20 200
Glycopyrrolate injection AMNEAL PHARMACEUTICALS INC 70121-1698-07 Glycopyrrolate Injection 0.2 MG 1 10 1 10
Glycopyrrolate injection AMNEAL PHARMACEUTICALS INC 70121-1699-07 Glycopyrrolate Injection 0.2 MG 2 10 2 20
Glycopyrrolate injection MEITHEAL PHARMACEUTICALS 71288-0415-21 Glycopyrrolate Injection 0.2 MG 20 10 20 200
Glycopyrrolate injection BE PHARMACEUTICALS, INC. 71839-0123-25 Glycopyrrolate INJECTION 0.2 MG 1 25 1 25
Glycopyrrolate injection BE PHARMACEUTICALS, INC. 71839-0124-25 Glycopyrrolate INJECTION 0.2 MG 2 25 2 50
Glycopyrrolate injection BE PHARMACEUTICALS, INC. 71839-0125-25 Glycopyrrolate INJECTION 0.2 MG 5 25 5 125
Glycopyrrolate injection CIVICA INC 72572-0225-25 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection CIVICA INC 72572-0226-25 Glycopyrrolate Injection 0.2 MG 1 25 1 25
Glycopyrrolate injection FRESENIUS KABI 76045-0203-10 Glycopyrrolate Injection 0.2 MG 1 24 1 24
Glycopyrrolate injection FRESENIUS KABI 76045-0203-20 Glycopyrrolate Injection 0.2 MG 2 24 2 48
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
A9592 Copper cu 64 dotatate diag CURIUM US LLC 69945-0064-01 Detectnet 1 mCi 4 1 4 4
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
A9600 Sr89 strontium GE HEALTHCARE 17156-0524-01 METASTRON PER MILLICURIE 4 1 4 4
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
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, INC. 47426-0302-02 Zynrelef 1 mg - 0.03 mg 10.5 1 300 300
C9088 Instill, bupivac and meloxic HERON THERAPEUTICS 47426-0303-01 Zynrelef 1 mg - 0.03 mg 7 1 200 200
C9088 Instill, bupivac and meloxic HERON THERAPEUTICS, INC. 47426-0304-01 Zynrelef 1 mg - 0.03 mg 2.3 1 60 60
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
C9152 Inj, abilify asimtufii, 1 mg OTSUKA AMERICA PHARMACEUTICALS, INC 59148-0102-80 Abilify Asimtufii 1 MG 2.4 1 720 720
C9152 Inj, abilify asimtufii, 1 mg OTSUKA AMERICA PHARMACEUTICALS, INC 59148-0114-80 Abilify Asimtufii 1 MG 3.2 1 960 960
C9153 Inj, amisulpride, 1 mg ACACIA PHARMA, INC. 71390-0125-20 BARHEMSYS 1 MG 2 10 5 50
C9153 Inj, amisulpride, 1 mg ACACIA PHARMA, INC. 71390-0125-50 BARHEMSYS 1 MG 4 10 10 100
C9154 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0228-01 Brixadi (monthly dosing) 1 MG 0.36 1 128 128
C9154 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0264-01 Brixadi (monthly dosing) 1 MG 0.18 1 64 64
C9154 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0296-01 Brixadi (monthly dosing) 1 MG 0.27 1 96 96
C9154 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0208-01 Brixadi (weekly dosing) 1 MG 0.16 1 8 8
C9154 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0216-01 Brixadi (weekly dosing) 1 MG 0.32 1 16 16
C9154 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0224-01 Brixadi (weekly dosing) 1 MG 0.48 1 24 24
C9154 Inj buprenorph (brixadi) 1mg BRAEBURN INC. 58284-0232-01 Brixadi (weekly dosing) 1 MG 0.64 1 32 32
C9155 Inj epcoritamab-bysp, 0.1 mg GENMAB US, INC. 82705-0002-01 EPKINLY 0.16 MG 0.8 1 25 25
C9155 Inj epcoritamab-bysp, 0.1 mg GENMAB US, INC. 82705-0010-01 EPKINLY 0.16 MG 0.8 1 300 300
C9157 Inj, tofersen, 1 mg BIOGEN MA INC. 64406-0109-01 QALSODY 1 MG 15 1 100 100
C9158 Inj, uzedy, 1 mg TEVA NEUROSCIENCE, INC. 51759-0305-10 UZEDY 1 MG 0.14 1 50 50
C9158 Inj, uzedy, 1 mg TEVA NEUROSCIENCE, INC. 51759-0410-10 UZEDY 1 MG 0.21 1 75 75
C9158 Inj, uzedy, 1 mg TEVA NEUROSCIENCE, INC. 51759-0520-10 UZEDY 1 MG 0.28 1 100 100
C9158 Inj, uzedy, 1 mg TEVA NEUROSCIENCE, INC. 51759-0630-10 UZEDY 1 MG 0.35 1 125 125
C9158 Inj, uzedy, 1 mg TEVA NEUROSCIENCE, INC. 51759-0740-10 UZEDY 1 MG 0.42 1 150 150
C9158 Inj, uzedy, 1 mg TEVA NEUROSCIENCE, INC. 51759-0850-10 UZEDY 1 MG 0.56 1 200 200
C9158 Inj, uzedy, 1 mg TEVA NEUROSCIENCE, INC. 51759-0960-10 UZEDY 1 MG 0.7 1 250 250
C9248 Inj, clevidipine butyrate CHIESI USA, INC. 10122-0610-10 CLEVIPREX 1 MG 50 10 25 250
C9248 Inj, clevidipine butyrate CHIESI USA, INC. 10122-0611-10 CLEVIPREX 1 MG 100 10 50 500
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
J0208 Inj sodium thiosulfate 100mg FENNEC PHARMACEUTICALS INC. 73077-0010-01 Sodium Thiosulfate 100 MG 100 1 125 125
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
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
J0641 Levoleucovorin injection HIKMA PHARMACEUTICALS USA INC. 00143-9558-01 Levoleucovorin Calcium 0.5 MG 1 1 100 100
J0641 Levoleucovorin injection SANDOZ 00781-3201-94 Levoleucovorin Calcium 0.5 MG 17.5 1 350 350
J0641 Levoleucovorin injection DR. REDDY'S LABORATORIES, INC. 43598-0771-11 Levoleucovorin Calcium 0.5 MG 17.5 1 350 350
J0641 Levoleucovorin injection DR. REDDY'S LABORATORIES, INC. 43598-0773-11 Levoleucovorin Calcium 0.5 MG 25 1 500 500
J0641 Levoleucovorin injection INGENUS PHARMACEUTICALS, LLC 50742-0494-17 Levoleucovorin Calcium 0.5 MG 17.5 1 350 350
J0641 Levoleucovorin injection INGENUS PHARMACEUTICALS, LLC 50742-0495-25 Levoleucovorin Calcium 0.5 MG 25 1 500 500
J0641 Levoleucovorin injection AMNEAL BIOSCIENCES 70121-1099-01 Levoleucovorin Calcium 0.5 MG 1 1 100 100
J0641 Levoleucovorin injection AMNEAL BIOSCIENCES 70121-1572-01 Levoleucovorin Calcium 0.5 MG 17.5 1 350 350
J0641 Levoleucovorin injection MEITHEAL PHARMACEUTICALS 71288-0104-10 Levoleucovorin Calcium 0.5 MG 1 1 100 100
J0641 Levoleucovorin injection Meitheal Pharmaceuticals, Inc. 71288-0105-18 Levoleucovorin Calcium 0.5 MG 17.5 1 350 350
J0641 Levoleucovorin injection FOSUN PHARMA 72266-0120-01 Levoleucovorin Calcium 0.5 MG 17.5 1 350 350
J0716 Centruroides immune f(ab) RARE DISEASE THERAPEUTICS, INC. 66621-0150-02 ANASCORP UP TO 120MG 1 1 1 1
J0802 Inj. (ani), up to 40 units Ani Pharmaceuticals, Inc. 62559-0860-15 Cortrophin Gel UP TO 40 UNITS 5 1 10 10
J0802 Inj. (ani), up to 40 units ANI Pharmaceuticals, Inc. 62559-0860-11 PURIFIED CORTROPHIN GEL UP TO 40 UNITS 1 1 2 2
J0879 Difelikefalin, esrd on dialy Vifor 59353-0065-01 Korsuva 0.1 mcg 1.3 1 65 650
J0879 Difelikefalin, esrd on dialy Vifor 59353-0065-12 Korsuva 0.1 mcg 1.3 1 65 7800
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
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
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 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 00517-1767-01 MAKENA 10 MG 1 1 25 25
J1726 Inj, Makena AMAG PHARMACEUTICALS, INC. 64011-0247-02 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
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
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 LEUCADIA PHARMACEUTICALS 24201-0207-03 ICATIBANT 1 MG 3 3 30 90
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
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
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
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
J2515 Pentobarbital sodium inj AKORN 17478-0181-20 Pentobarbital 50 MG 20 1 20 20
J2515 Pentobarbital sodium inj AKORN 17478-0181-50 Pentobarbital 50 MG 50 1 50 50
J2515 Pentobarbital sodium inj LEUCADIA PHARMACEUTICALS 24201-0010-20 Pentobarbital 50 MG 20 1 20 20
J2515 Pentobarbital sodium inj LEUCADIA PHARMACEUTICALS 24201-0010-50 Pentobarbital 50 MG 50 1 50 50
J2515 Pentobarbital sodium inj SAGENT PHARMACEUTICALS INC 25021-0676-20 Pentobarbital 50 MG 20 1 20 20
J2515 Pentobarbital sodium inj SAGENT PHARMACEUTICALS INC 25021-0676-50 Pentobarbital 50 MG 50 1 50 50
J2515 Pentobarbital sodium inj OAK 76478-0501-20 Nembutal 50 MG 20 1 20 20
J2515 Pentobarbital sodium inj OAK 76478-0501-50 Nembutal 50 MG 50 1 50 50
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 70573-0099-01 Ryplazim 1 mg 1 1 68.8 68.8
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
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
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 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
J7342 Inject, ciprofloxacin otic OTONOMY, INC. 69251-0201-01 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
J7519 Inj. mycophenolate mofetil GENENTECH, INC. 00004-0298-09 Cellcept - IV 10 MG 1 4 50 200
J7519 Inj. mycophenolate mofetil AKORN 17478-0422-40 Mycophenolate Mofetil IV 10 MG 1 4 50 200
J7519 Inj. mycophenolate mofetil AKORN 17478-0957-40 Mycophenolate Mofetil IV 10 MG 1 4 50 200
J7519 Inj. mycophenolate mofetil PAR PHARMACEUTICAL, INC 42023-0172-04 Mycophenolate Mofetil IV 10 MG 1 4 50 200
J7519 Inj. mycophenolate mofetil MYLAN INSTITUTIONAL LLC 67457-0386-81 Mycophenolate Mofetil IV 10 MG 1 4 50 200
J7519 Inj. mycophenolate mofetil MEITHEAL PHARMACEUTICALS 71288-0803-21 Mycophenolate Mofetil IV 10 MG 1 4 50 200
J9019 Erwinaze injection JAZZ PHARMACEUTICALS, INC. 57902-0249-05 ERWINAZE 1,000 IU 1 5 10 50
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
J9214 Interferon alfa-2b inj SCHERING CORPORATION 00085-1133-01 Intron-A 1 MIL UNITS 2.5 1 25 25
J9214 Interferon alfa-2b inj SCHERING CORPORATION 00085-1168-01 Intron-A 1 MIL UNITS 3 1 18 18
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
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
J9345 Inj, retifanlimab-dlwr, 1 mg Incyte Corporation 50881-0006-03 Zynyz 1 MG 20 1 500 500
J9371 Inj, Vincristine sul lip 1mg SPECTRUM PHARMACEUTICALS 20536-0322-01 Vincristine Sulfate 1 MG 1 1 5 5
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
Q5120 Inj pegfilgrastim-bmez 0.5mg SANDOZ 61314-0866-01 ZIEXTENZO 0.5 MG 0.6 1 12 12
Q9968 Visualization adjunct AMERICAN REGENT 00517-0374-05 Provayblue 1 MG 10 5 50 250
Q9968 Visualization adjunct MYLAN INSTITUTIONAL LLC 67457-0220-05 ISOSULFAN BLUE INJECTION 1 MG 5 6 50 300

Past NDC - HCPCS Crosswalk