October 2024 NDC - HCPCS Crosswalk

Effective October 1, 2024 - December 31, 2024

Page #1

Average Sales Price

HCPCS Description Labeler name NDC Drug name Dosage Package size Package quantity Billable units Billable units / pkg
A9573 Inj gadopiclenol Guerbet LLC 67684-4230-02 Elucirem 1 ML 3 10 3 30
A9573 Inj gadopiclenol Guerbet LLC 67684-4231-02 Elucirem 1 ML 7.5 10 7.5 75
A9573 Inj gadopiclenol Guerbet LLC 67684-4232-02 Elucirem 1 ML 10 10 10 100
A9573 Inj gadopiclenol Guerbet LLC 67684-4240-02 Elucirem 1 ML 7.5 10 7.5 75
A9573 Inj gadopiclenol Guerbet LLC 67684-4241-02 Elucirem 1 ML 10 10 10 100
A9573 Inj gadopiclenol Guerbet LLC 67684-4250-04 Elucirem 1 ML 50 25 50 1250
A9573 Inj gadopiclenol BRACCO DIAGNOSTICS INC. 00270-7015-46 Vueway 1 ML 30 25 30 750
A9573 Inj gadopiclenol BRACCO DIAGNOSTICS INC. 00270-7015-48 Vueway 1 ML 50 25 50 1250
A9573 Inj gadopiclenol BRACCO DIAGNOSTICS INC. 00270-7020-38 Vueway 1 ML 3 10 3 30
A9573 Inj gadopiclenol BRACCO DIAGNOSTICS INC. 00270-7025-40 Vueway 1 ML 7.5 10 7.5 75
A9573 Inj gadopiclenol BRACCO DIAGNOSTICS INC. 00270-7030-42 Vueway 1 ML 10 10 10 100
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 Inc. 00407-2943-01 Clariscan 0.1 ML 10 10 100 1000
A9575 Inj gadoterate meglumi 0.1ml GE Healthcare Inc. 00407-2943-02 Clariscan 0.1 ML 15 10 150 1500
A9575 Inj gadoterate meglumi 0.1ml GE Healthcare Inc. 00407-2943-05 Clariscan 0.1 ML 20 10 200 2000
A9575 Inj gadoterate meglumi 0.1ml GE Healthcare Inc. 00407-2943-06 Gadoterate Meglumine 0.1 ML 5 10 50 500
A9575 Inj gadoterate meglumi 0.1ml GE Healthcare Inc. 00407-2943-12 Gadoterate Meglumine 0.1 ML 10 10 100 1000
A9575 Inj gadoterate meglumi 0.1ml GE Healthcare Inc. 00407-2943-17 Gadoterate Meglumine 0.1 ML 15 10 150 1500
A9575 Inj gadoterate meglumi 0.1ml GE Healthcare Inc. 00407-2943-22 Gadoterate Meglumine 0.1 ML 20 10 200 2000
A9575 Inj gadoterate meglumi 0.1ml GE Healthcare Inc. 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 INC. 00270-1111-70 Prohance Multipack 1 ML 50 5 50 250
A9577 Inj multihance BRACCO DIAGNOSTICS INC. 00270-5164-12 Multihance 1 ML 5 5 5 25
A9577 Inj multihance BRACCO DIAGNOSTICS INC. 00270-5164-13 Multihance 1 ML 10 5 10 50
A9577 Inj multihance BRACCO DIAGNOSTICS INC. 00270-5164-14 Multihance 1 ML 15 5 15 75
A9577 Inj multihance BRACCO DIAGNOSTICS INC. 00270-5164-15 Multihance 1 ML 20 5 20 100
A9578 Inj multihance multipack BRACCO DIAGNOSTICS INC. 00270-5264-16 Multihance Multipack 1 ML 50 5 50 250
A9578 Inj multihance multipack BRACCO DIAGNOSTICS INC. 00270-5264-17 Multihance Multipack 1 ML 100 5 100 500
A9579 Gad-base mr contrast nos,1ml GE Healthcare Inc. 00407-0690-05 Omniscan 1 ML 5 10 5 50
A9579 Gad-base mr contrast nos,1ml GE Healthcare Inc. 00407-0690-10 Omniscan 1 ML 10 10 10 100
A9579 Gad-base mr contrast nos,1ml GE Healthcare Inc. 00407-0690-12 Omniscan 1 ML 10 10 10 100
A9579 Gad-base mr contrast nos,1ml GE Healthcare Inc. 00407-0690-15 Omniscan 1 ML 15 10 15 150
A9579 Gad-base mr contrast nos,1ml GE Healthcare Inc. 00407-0690-17 Omniscan 1 ML 15 10 15 150
A9579 Gad-base mr contrast nos,1ml GE Healthcare Inc. 00407-0690-20 Omniscan 1 ML 20 10 20 200
A9579 Gad-base mr contrast nos,1ml GE Healthcare Inc. 00407-0690-22 Omniscan 1 ML 20 10 20 200

Average Wholesale Price

HCPCS Description Labeler name NDC Drug name Dosage Package size Package quantity Billable units Billable units / pkg
90656 IIV3 VACC NO PRSV 0.5 ML IM Sanofi Pasteur 49281-0424-50 Fluzone Trivalent (2024/2025) Preservative Free 0.5 ML 0.5 10 1 10
90658 IIV3 VACCINE SPLT 0.5 ML IM Sanofi Pasteur 49281-0641-15 Fluzone Trivalent (2024/2025) 0.5 ML 5 1 10 10
91304 SARSCOV2 VAC 5MCG/0.5ML IM Novavax 80631-0107-10 Novavax COVID-19 Vaccine (2024-2025) Preservative Free 0.5 ML 0.5 10 1 10
91318 SARSCOV2 VAC 3MCG TRS-SUC IM Pfizer 59267-4426-02 Pfizer-BioNTech COVID-19 Vaccine mRNA (2024-2025) 0.3 ML 1 10 3 30
91319 SARSCV2 VAC 10MCG TRS-SUC IM Pfizer 59267-4438-02 Pfizer-BioNTech COVID-19 Vaccine mRNA (2024-2025) Preservative Free 0.3 ML 0.3 10 1 10
91321 SARSCOV2 VAC 25 MCG/.25ML IM Moderna 80777-0291-80 Moderna COVID-19 Vaccine (2024-2025) Preservative Free 0.25 ML 0.25 10 1 10
91321 SARSCOV2 VAC 25 MCG/.25ML IM Moderna 80777-0291-81 Moderna COVID-19 Vaccine (2024-2025) Preservative Free 0.25 ML 0.25 10 1 10
91322 SARSCOV2 VAC 50 MCG/0.5ML IM Moderna 90777-0110-96 SPIKEVAX (2024-2025) Preservative Free 0.5 ML 0.5 10 1 10
91322 SARSCOV2 VAC 50 MCG/0.5ML IM Moderna 90777-0110-93 SPIKEVAX (2024-2025) Preservative Free 0.5 ML 0.5 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 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 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 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 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
P9046 Albumin (human), 25%, 20 ml Grifols 68516-5216-05 Albutein 25% 20 ML 20 1 1 1
P9047 Albumin (human), 25%, 50ml Talecris 13533-0684-16 Plasbumin-25 50 ML 20 1 0.4 0.4
P9047 Albumin (human), 25%, 50ml Talecris 13533-0684-20 Plasbumin-25 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Talecris 13533-0684-71 Plasbumin-25 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Talecris 13533-0692-16 Plasbumin-25 50 ML 20 1 0.4 0.4
P9047 Albumin (human), 25%, 50ml Talecris 13533-0692-20 Plasbumin-25 50 ML 50 1 1 1
P9047 Albumin (human), 25%, 50ml Talecris 13533-0692-71 Plasbumin-25 50 ML 100 1 2 2
P9047 Albumin (human), 25%, 50ml Baxter 00944-0490-01 Buminate 50 ML 20 1 0.4 0.4
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 Takeda Pharmaceuticals America, Inc. 00944-0493-03 Flexbumin 50 ML 50 1 1 1
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 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 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 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 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 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
Q0224 Pemivibart injection Invivyd, Inc 81960-0031-03 Pemgarda 4500 MG 1 1 1 1
Q0249 Tocilizumab for covid-19 Genentech, Inc 50242-0135-01 Actemra IV 1 MG 4 1 80 80
Q0249 Tocilizumab for covid-19 Genentech, Inc 50242-0136-01 Actemra IV 1 MG 10 1 200 200
Q0249 Tocilizumab for covid-19 Genentech, Inc 50242-0137-01 Actemra IV 1 MG 20 1 400 400

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 Pfizer Inc 00409-4346-73 Aminocaproic Acid 250 MG 20 25 20 500
Aminocaproic acid American Regent, Inc. 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
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 HF Acquisition Co. LLC, DBA HealthFirst 51662-1335-01 Diltiazem HCl 5 MG 5 1 5 5
Diltiazem Hydrochloride HF Acquisition Co. LLC, DBA HealthFirst 51662-1335-02 Diltiazem HCl 5 MG 5 1 5 5
Diltiazem Hydrochloride HF Acquisition Co. LLC, DBA HealthFirst 51662-1457-01 Diltiazem HCl 5 MG 1 1 20 20
Diltiazem Hydrochloride HF Acquisition Co. LLC, DBA 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 Pharmaceutical Division, LLC 70860-0301-05 Diltiazem HCl 5 MG 5 10 5 50
Diltiazem Hydrochloride Athenex Pharmaceutical Division, LLC 70860-0301-10 Diltiazem HCl 5 MG 10 10 10 100
Diltiazem Hydrochloride Athenex Pharmaceutical Division, LLC 70860-0301-25 Diltiazem HCl 5 MG 25 10 25 250
Diltiazem Hydrochloride Hikma Injectables USA Inc. 63037-0119-05 Diltiazem in Dextrose 5 MG 125 5 25 125
Diltiazem Hydrochloride Hikma Injectables USA Inc. 63037-0117-05 Diltiazem in Sodium Chloride 5 MG 125 5 25 125
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 HF Acquisition Co. LLC, DBA HealthFirst 51662-1402-01 Doxycycline Hyclate 100 MG 1 1 1 1
Doxycycline Hyclate FreseniUS Kabi USA, LLC 63323-0130-11 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate FreseniUS Kabi USA, LLC 63323-0130-13 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate FreseniUS Kabi USA, LLC 63323-0130-17 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate Piramal Critical Care Inc 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 (USA) Inc. 68382-0910-10 Doxycycline Hyclate 100 MG 1 10 1 10
Doxycycline Hyclate Fosun Pharma USA Inc. 72266-0237-05 Doxycycline Hyclate 100 MG 1 5 1 5
Doxycycline Hyclate HF Acquisition Co. LLC, DBA HealthFirst 51662-1402-03 Doxycyline Hyclate 100 MG 1 10 1 10
Benzylpenicillin Benzathine (Extencilline) PROVEPHARM INC. 81284-0521-01 Extencilline 100,000 UNITS 1 1 12 12
Benzylpenicillin Benzathine (Extencilline) PROVEPHARM INC. 81284-0522-01 Extencilline 100,000 UNITS 1 1 24 24
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. 00641-6023-10 Famotidine 10 MG 4 10 4 40
Famotidine Hikma Pharmaceuticals USA Inc. 00641-6023-25 Famotidine 10 MG 4 25 4 100
Famotidine FreseniUS Kabi USA, LLC 63323-0738-09 Famotidine 10 MG 4 10 4 40
Famotidine FreseniUS Kabi USA, LLC 63323-0738-20 Famotidine 10 MG 20 10 20 200
Famotidine FreseniUS Kabi USA, LLC 63323-0739-12 Famotidine 10 MG 2 25 2 50
Famotidine FreseniUS Kabi USA, LLC 63323-0739-16 Famotidine 10 MG 2 25 2 50
Famotidine Mylan Institutional LLC 67457-0433-22 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 Pharmaceutical Division, LLC 70860-0751-02 Famotidine 10 MG 2 25 2 50
Famotidine Athenex Pharmaceutical Division, LLC 70860-0753-20 Famotidine 10 MG 20 10 20 200
Famotidine Baxter Healthcare Corporation 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 Healthcare Corporation 36000-0148-10 Flumazenil 0.1 MG 5 10 5 50
Flumazenil Baxter Healthcare Corporation 36000-0149-10 Flumazenil 0.1 MG 10 10 10 100
Flumazenil HF Acquisition Co. LLC, DBA HealthFirst 51662-1253-01 Flumazenil 0.1 MG 10 1 10 10
Flumazenil HF Acquisition Co. LLC, DBA HealthFirst 51662-1253-03 Flumazenil 0.1 MG 10 10 10 100
Flumazenil HF Acquisition Co. LLC, DBA HealthFirst 51662-1254-01 Flumazenil 0.1 MG 5 1 5 5
Flumazenil HF Acquisition Co. LLC, DBA HealthFirst 51662-1254-03 Flumazenil 0.1 MG 5 10 5 50
Flumazenil FreseniUS Kabi USA, LLC 63323-0424-05 Flumazenil 0.1 MG 5 10 5 50
Flumazenil FreseniUS Kabi USA, LLC 63323-0424-10 Flumazenil 0.1 MG 10 1 10 10
Folic Acid XGen Pharmaceuticals DJB, Inc. 39822-1100-01 Folic Acid 5 MG 10 1 10 10
Folic Acid FreseniUS Kabi USA, LLC 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
Metoprolol Tartrate Hikma Pharmaceuticals USA Inc. 00143-9660-10 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate Hikma Pharmaceuticals USA Inc. 00143-9873-25 Metoprolol Tartrate 1 MG 5 25 5 125
Metoprolol Tartrate Pfizer Inc 00409-1778-05 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate Pfizer Inc 00409-2016-10 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate Sagent Pharmaceuticals 25021-0303-05 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate Baxter Healthcare Corporation 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 HF Acquisition Co. LLC, DBA HealthFirst 51662-1365-01 Metoprolol Tartrate 1 MG 5 1 5 5
Metoprolol Tartrate HF Acquisition Co. LLC, DBA HealthFirst 51662-1478-01 Metoprolol Tartrate 1 MG 5 1 5 5
Metoprolol Tartrate HF Acquisition Co. LLC, DBA HealthFirst 51662-1478-03 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate FreseniUS Kabi USA, LLC 63323-0660-05 Metoprolol Tartrate 1 MG 5 10 5 50
Metoprolol Tartrate Fosun Pharma USA Inc. 72266-0122-05 Metoprolol Tartrate 1 MG 5 5 5 25
Metoprolol Tartrate Fosun Pharma USA Inc. 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 Alvogen, Inc. 72611-0740-10 Metoprolol Tartrate 1 MG 5 10 5 50
Rifampin FreseniUS Kabi USA, LLC 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 Healthcare Corporation 00338-0054-03 Sodium Chloride 250 CC 500 1 2 2
Sodium Chloride, Hypertonic (3% - 5% infusion) Baxter Healthcare Corporation 00338-0056-03 Sodium Chloride 250 CC 500 1 2 2
Sulfamethoxazole-Trimethoprim Teva Parenteral Medicines, Inc. 00703-9503-03 Sulfamethoxazole-Trimethoprim 400-80 MG 50 10 10 100
Sulfamethoxazole-Trimethoprim Teva Parenteral Medicines, Inc. 00703-9514-03 Sulfamethoxazole-Trimethoprim 400-80 MG 100 10 20 200
Sulfamethoxazole-Trimethoprim Teva Parenteral Medicines, Inc. 00703-9514-93 Sulfamethoxazole-Trimethoprim 400-80 MG 10 10 2 20
Sulfamethoxazole-Trimethoprim Teva Parenteral Medicines, 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
A9506 Tc-99m graphite crucible CYCLOMEDICA AUSTRALIA PTY LIMITED 73814-0986-20 Technegas EACH 1 50 50 50
A9513 Lutetium Lu 177 dotatat ther Advanced Accelerator Applications USA, Inc. 69488-0003-01 Lutathera 1 MCI 20 1 200 200
A9543 Y90 ibritumomab, rx Acrotech Biopharma LLC 68152-0103-03 Zevalin Y-90 UP TO 40 millicuries 1 1 1 1
A9543 Y90 ibritumomab, rx Acrotech Biopharma LLC 72893-0007-04 Zevalin Y-91 UP TO 40 millicuries 1 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 US Inc. 74725-0100-25 Illuccix 1 mCi 1 1 1 1
A9596 Gallium illuccix 1 millicure Telix Pharmaceuticals US Inc. 74725-0100-64 Illuccix 1 mCi 1 1 1 1
A9600 Sr89 strontium Q Biomed 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
A9602 Fluorodopa f-18 diag per mci THE FEINSTEIN INSTITuTE 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 Limited 69932-0002-01 Posluma 1 mCi 1 1 1 8
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 51715-0100-04 Xaracoll 1 mg 1 12 100 1200
C9089 Bupivacaine implant, 1 mg Innocoll Pharmaceuticals 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 47426-0401-10 Aponvie 1 MG 4.4 10 32 320
C9169 Inj, nogapendekin pmln, 1 mcg Altor BioScience, LLC 81481-0803-01 Anktiva 1 MCG 0.4 1 400 400
C9170 Inj, tarlatamab-dlle, 1 mg Amgen Inc 55513-0059-01 Imdelltra 1 MG 1 1 1 1
C9170 Inj, tarlatamab-dlle, 1 mg Amgen Inc 55513-0077-01 Imdelltra 1 MG 1 1 10 10
C9170 Inj, tarlatamab-dlle, 1 mg Amgen Inc. 55513-077-01 Imdelltra 1 MG 1 1 10 10
C9171 Inj, pegulicianine, 1 mg Lumicell Inc. 82292-0040-10 Lumisight 1 MG 1 10 39 390
C9172 Inj, beqvez, per tx dose Pfizer 00069-2004-04 Beqvez PER THERAPEUTIC DOSE 1 4 1 1
C9172 Inj, beqvez, per tx dose Pfizer 00069-2005-05 Beqvez PER THERAPEUTIC DOSE 1 5 1 1
C9172 Inj, beqvez, per tx dose Pfizer 00069-2006-06 Beqvez PER THERAPEUTIC DOSE 1 6 1 1
C9172 Inj, beqvez, per tx dose Pfizer 00069-2007-07 Beqvez PER THERAPEUTIC DOSE 1 7 1 1
C9250 Artiss fibrin sealant Baxter Healthcare Corporation 00338-9637-01 Artiss 2 ML 2 1 1 1
C9250 Artiss fibrin sealant Baxter Healthcare Corporation 00338-9639-01 Artiss 2 ML 4 1 2 2
C9250 Artiss fibrin sealant Baxter Healthcare Corporation 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, Inc. 65250-0133-04 Exparel 1 MG 10 4 133 532
C9290 Inj, bupivacaine liposome Pacira Pharmaceuticals, Inc. 65250-0133-09 Exparel 1 MG 10 10 133 1330
C9290 Inj, bupivacaine liposome Pacira Pharmaceuticals, Inc. 65250-0266-04 Exparel 1 MG 20 4 266 1064
C9290 Inj, bupivacaine liposome Pacira Pharmaceuticals, Inc. 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, LLC 69724-0112-10 Sotalol 1MG 10 1 150 150
C9488 Conivaptan HCL Cumberland Pharmaceuticals Inc. 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 Ltd 71390-0125-20 Barhemsys 1 MG 2 10 5 50
J0208 Inj, pedmark, 100 mg Fennec Pharmaceuticals, Inc. 73077-0010-01 Sodium Thiosulfate 100 MG 100 1 125 125
J0211 Inj, nithiodote, 3mg / 25mg HOPE PHARMACEUTICALS 60267-0812-00 Nithiodote 3 MG AND 125 MG 10 ML 1 EA AND 50 ML 1 EA 1 100 100
J0287 Amphotericin b lipid complex Leadiant Biosciences, Inc. 57665-0101-41 Abelcet 10 MG 20 1 10 10
J0391 Inj, artesunate, 1mg Amivas, Inc 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 74.2 MG 1 4 1 4
J0589 Inj daxibotulinumtoxina-lanm Revance Therapeutics, Inc. 72960-0112-01 Daxxify 1 UNIT 1 1 100 100
J0600 Edetate calcium disodium inj RISING PHARMACEUTICALS INC. 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 Inc 55513-0740-10 Parsabiv 0.1 MG 0.5 10 25 250
J0606 Inj, etelcalcetide, 0.1 mg Amgen Inc 55513-0741-10 Parsabiv 0.1 MG 1 10 50 500
J0606 Inj, etelcalcetide, 0.1 mg Amgen Inc 55513-0742-10 Parsabiv 0.1 MG 2 10 100 1000
J0651 Inj, levothyroxine, freskabi FreseniUS Kabi USA, LLC 63323-0885-10 Levothyroxine Sodium 10 MCG 5 1 10 10
J0651 Inj, levothyroxine, freskabi FreseniUS Kabi USA, LLC 63323-0885-12 Levothyroxine Sodium 10 MCG 5 1 10 10
J0651 Inj, levothyroxine, freskabi FreseniUS Kabi USA, LLC 63323-0885-14 Levothyroxine Sodium 10 MCG 5 1 10 10
J0651 Inj, levothyroxine, freskabi FreseniUS Kabi USA, LLC 63323-0890-10 Levothyroxine Sodium 10 MCG 5 1 20 20
J0651 Inj, levothyroxine, freskabi FreseniUS Kabi USA, LLC 63323-0895-10 Levothyroxine Sodium 10 MCG 5 1 50 50
J0652 Inj, levothyroxine, hikma Hikma Pharmaceuticals USA Inc. 24201-0002-01 Levothyroxine Sodium 10 MCG 1 1 10 10
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 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, Inc. 42023-0182-89 Argatroban 1 MG 2.5 1 250 250
J0884 Argatroban esrd dialysis 1mg FreseniUS Kabi USA, LLC 63323-0526-03 Argatroban 1 MG 2.5 1 250 250
J0884 Argatroban esrd dialysis 1mg FreseniUS Kabi USA, LLC 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
J0892 Argatroban dialysis (accord) ACCORD HEALTHCARE INC 16729-0430-43 Argatroban 1 MG 50 10 50 500
J0893 Inj, decitabine (sun pharma) SUN PHARMACEUTICAL GLOBAL FZE. 47335-0361-41 Decitabine 1 MG 1 1 50 50
J0899 Argatroban dialysis, auromed Eugia US LLC 55150-0241-01 Argatroban 1 MG 50 1 50 50
J0899 Argatroban dialysis, auromed Eugia US LLC 55150-0241-10 Argatroban 1 MG 50 10 50 500
J0911 Inst tauro 1.35mg/hep 100u CORMEDIX INC. 72990-0103-10 Defencath taurolidine 1.35 mg and heparin sodium 100 units 3 10 30 300
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 1 ML 4 4 4 16
J1097 Phenylep ketorolac opth soln Rayner Surgical Inc. 82604-0600-04 Omidria 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 Healthcare Corporation 00338-9558-10 Eptifibatide 5 MG 100 12 15 180
J1327 Eptifibatide injection Sagent Pharmaceuticals 25021-0408-51 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection Sagent Pharmaceuticals 25021-0409-10 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection Eugia US LLC 55150-0218-99 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection Eugia US LLC 55150-0219-10 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection Eugia US 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 Pharmaceuticals 70436-0026-80 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection Slate Run Pharmaceuticals 70436-0027-80 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection Slate Run Pharmaceuticals 70436-0162-80 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection Slate Run Pharmaceuticals 70436-0163-80 Eptifibatide 5 MG 100 1 15 15
J1327 Eptifibatide injection Athenex Pharmaceutical Division, LLC 70860-0303-10 Eptifibatide 5 MG 10 1 4 4
J1327 Eptifibatide injection Athenex Pharmaceutical Division, LLC 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 LLC 00053-0100-10 Hemgenix Per Therapeutic Dose 10 10 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0110-11 Hemgenix Per Therapeutic Dose 10 11 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0120-12 Hemgenix Per Therapeutic Dose 10 12 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0130-13 Hemgenix Per Therapeutic Dose 10 13 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring L.L.C. 00053-0140-14 Hemgenix Per Therapeutic Dose 10 14 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0150-15 Hemgenix Per Therapeutic Dose 10 15 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring L.L.C. 00053-0160-16 Hemgenix Per Therapeutic Dose 10 16 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring L.L.C. 00053-0170-17 Hemgenix Per Therapeutic Dose 10 17 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0180-18 Hemgenix Per Therapeutic Dose 10 18 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0190-19 Hemgenix Per Therapeutic Dose 10 19 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0200-20 Hemgenix Per Therapeutic Dose 10 20 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0210-21 Hemgenix Per Therapeutic Dose 10 21 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring L.L.C. 00053-0220-22 Hemgenix Per Therapeutic Dose 10 22 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0230-23 Hemgenix Per Therapeutic Dose 10 23 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0240-24 Hemgenix Per Therapeutic Dose 10 24 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0250-25 Hemgenix Per Therapeutic Dose 10 25 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0260-26 Hemgenix Per Therapeutic Dose 10 26 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0270-27 Hemgenix Per Therapeutic Dose 10 27 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0280-28 Hemgenix Per Therapeutic Dose 10 28 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0290-29 Hemgenix Per Therapeutic Dose 10 29 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0300-30 Hemgenix Per Therapeutic Dose 10 30 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0310-31 Hemgenix Per Therapeutic Dose 10 31 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0320-32 Hemgenix Per Therapeutic Dose 10 32 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0330-33 Hemgenix Per Therapeutic Dose 10 33 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0340-34 Hemgenix Per Therapeutic Dose 10 34 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0350-35 Hemgenix Per Therapeutic Dose 10 35 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0360-36 Hemgenix Per Therapeutic Dose 10 36 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0370-37 Hemgenix Per Therapeutic Dose 10 37 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0380-38 Hemgenix Per Therapeutic Dose 10 38 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0390-39 Hemgenix Per Therapeutic Dose 10 39 1 1
J1411 Inj, hemgenix, per tx dose CSL Behring L.L.C. 00053-0400-40 Hemgenix Per Therapeutic Dose 10 40 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0410-41 Hemgenix Per Therapeutic Dose 10 41 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0420-42 Hemgenix Per Therapeutic Dose 10 42 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0430-43 Hemgenix Per Therapeutic Dose 10 43 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0440-44 Hemgenix Per Therapeutic Dose 10 44 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0450-45 Hemgenix Per Therapeutic Dose 10 45 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0460-46 Hemgenix Per Therapeutic Dose 10 46 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 00053-0470-47 Hemgenix Per Therapeutic Dose 10 47 1 1
J1411 Inj, hemgenix, per tx dose CSL BEHRING LLC 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, Inc. 60923-0503-12 Elevidys PER THERAPEUTIC DOSE 1 12 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0505-14 Elevidys PER THERAPEUTIC DOSE 1 14 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0506-15 Elevidys PER THERAPEUTIC DOSE 1 15 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0507-16 Elevidys PER THERAPEUTIC DOSE 1 16 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0508-17 Elevidys PER THERAPEUTIC DOSE 1 17 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0509-18 Elevidys PER THERAPEUTIC DOSE 1 18 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0510-19 Elevidys PER THERAPEUTIC DOSE 1 19 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0511-20 Elevidys PER THERAPEUTIC DOSE 1 20 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0512-21 Elevidys PER THERAPEUTIC DOSE 1 21 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0513-22 Elevidys PER THERAPEUTIC DOSE 1 22 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0514-23 Elevidys PER THERAPEUTIC DOSE 1 23 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0515-24 Elevidys PER THERAPEUTIC DOSE 1 24 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0516-25 Elevidys PER THERAPEUTIC DOSE 1 25 1 1
J1413 Inj delandistrogene mox rokl SAREPTA 60923-0517-26 Elevidys PER THERAPEUTIC DOSE 1 26 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0518-27 Elevidys PER THERAPEUTIC DOSE 1 27 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0519-28 Elevidys PER THERAPEUTIC DOSE 1 28 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0520-29 Elevidys PER THERAPEUTIC DOSE 1 29 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0521-30 Elevidys PER THERAPEUTIC DOSE 1 30 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0524-33 Elevidys PER THERAPEUTIC DOSE 1 33 1 1
J1413 Inj delandistrogene mox rokl Sarepta Therapeutics, Inc. 60923-0536-45 Elevidys PER THERAPEUTIC DOSE 1 45 1 1
J1427 Inj. viltolarsen NS Pharma, Inc. 73292-0011-01 Viltepso 10 MG 5 1 25 25
J1429 Inj golodirsen 10 mg Sarepta Therapeutics, Inc. 60923-0465-02 Vyondys 53 10 MG 2 1 10 10
J1434 Inj, focinvez, 1mg AMNEAL PHARMACEUTICALS, LLC 70121-2631-01 Focinvez 1 MG 50 1 150 150
J1434 Inj, focinvez, 1mg SPECS PHARMACEUTICALS 82243-1001-01 Focinvez 1 MG 50 1 150 150
J1438 Etanercept injection AMGEN USA, INC. 58406-0425-34 Enbrel 25 MG 1 4 1 4
J1438 Etanercept injection AMGEN USA, INC. 58406-0435-04 Enbrel 25 MG 1 4 2 8
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
J1451 Fomepizole, 15 mg American Regent, Inc. 00517-0710-01 Fomepizole 15 MG 1.5 1 100 100
J1451 Fomepizole, 15 mg Sagent Pharmaceuticals 25021-0829-02 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 (USA) Inc. 70710-1478-01 Fomepizole 15 MG 1.5 1 100 100
J1455 Foscarnet sodium injection Sagent Pharmaceuticals 25021-0189-84 Foscarnet Sodium 1000 MG 250 10 6 60
J1455 Foscarnet sodium injection Baxter Healthcare Corporation 43066-0089-10 Foscarnet Sodium 1000 MG 250 10 6 60
J1455 Foscarnet sodium injection FreseniUS Kabi USA, LLC 63323-0875-50 Foscarnet Sodium 1000 MG 250 1 6 6
J1455 Foscarnet sodium injection AMNEAL PHARMACEUTICALS INC 70121-1744-02 Foscarnet Sodium 1000 MG 250 12 6 72
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
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0005-01 Flebogamma DIF 500 MG 50 1 10 10
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0005-02 Flebogamma DIF 500 MG 100 1 20 20
J1572 Flebogamma injection GRIFOLS USA, LLC 61953-0005-03 Flebogamma DIF 500 MG 200 1 40 40
J1573 Hepagam b intravenous, inj Kamada Ltd. 49591-0052-51 Hepagam B 0.5 ML 1 1 2 2
J1573 Hepagam b intravenous, inj Kamada Ltd. 70257-0051-51 Hepagam B 0.5 ML 5 1 10 10
J1573 Hepagam b intravenous, inj Kamada Ltd. 70257-0052-51 Hepagam B 0.5 ML 1 1 2 2
J1573 Hepagam b intravenous, inj Kamada Ltd. 70257-0053-51 Hepagam B 0.5 ML 1 1 2 2
J1573 Hepagam b intravenous, inj Kamada Ltd. 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, Inc. 00517-1791-01 Hydroxyprogesterone Caproate 10 MG 1 1 25 25
J1726 Inj, Makena Eugia US LLC 55150-0309-01 Hydroxyprogesterone Caproate 10 MG 1 1 25 25
J1726 Inj, Makena Eugia US 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, Inc. 00517-1767-01 Makena 10 MG 1 1 25 25
J1726 Inj, Makena Covis Pharma US, Inc 64011-0301-03 Makena Auto Injector 10 MG 1.1 1 27.5 27.5
J1742 Ibutilide fumarate injection AVET PHARMACEUTICALS, INC. 23155-0326-31 Ibutilide Fumarate 1 MG 10 1 1 1
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 Hikma Pharmaceuticals USA Inc. 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 Apotex Corp 60505-6214-01 Icatibant 1 MG 3 1 30 30
J1744 Icatibant injection FreseniUS Kabi USA, LLC 63323-0574-86 Icatibant 1 MG 3 1 30 30
J1744 Icatibant injection FreseniUS Kabi USA, LLC 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 Pharma US, Inc. 00469-0420-01 Cresemba 1 MG 1 1 372 372
J1833 Inj, isavuconazonium sulfate Astellas Pharma US, Inc. 00469-0420-99 Cresemba 1mg (as sulfate) 1 10 372 3720
J2186 Inj., meropenem, vaborbactam Melinta Therapeutics, LLC 70842-0120-06 Vabomere (10 MG/10MG) 20 MG 1 6 100 600
J2212 Methylnaltrexone injection Bausch Health US, LLC 65649-0551-02 Relistor 0.1 MG 0.6 1 120 120
J2212 Methylnaltrexone injection Bausch Health US, LLC 65649-0551-03 Relistor 0.1 MG 0.6 7 120 840
J2212 Methylnaltrexone injection Bausch Health US, LLC 65649-0551-07 Relistor 0.1 MG 0.6 1 120 120
J2212 Methylnaltrexone injection Bausch Health US, LLC 65649-0552-04 Relistor 0.1 MG 0.4 7 80 560
J2265 Minocycline hydrochloride Melinta Therapeutics, LLC 70842-0160-10 Minocin 1 MG 1 10 100 1000
J2326 Injection, nusinersen Biogen Inc. 64406-0058-01 Spinraza 0.1 MG 5 1 120 120
J2425 Palifermin injection SOBI 66658-0112-03 Kepivance 50 MCG 1 3 125 375
J2425 Palifermin injection SOBI 66658-0112-06 Kepivance 50 MCG 1 6 125 750
J2425 Palifermin injection SWEDISH ORPHAN BIOVITRuM AB (PuBL) 66658-0113-03 Kepivance 50 MCG 1 3 103.2 310
J2425 Palifermin injection SWEDISH ORPHAN BIOVITRuM AB (PuBL) 66658-0113-06 Kepivance 50 MCG 1 6 103.2 620
J2502 Inj, pasireotide long acting Recordati Rare Diseases Inc. 55292-0139-01 Signifor Lar 1 MG 1 1 10 10
J2502 Inj, pasireotide long acting Recordati Rare Diseases Inc. 55292-0140-01 Signifor Lar 1 MG 1 1 20 20
J2502 Inj, pasireotide long acting Recordati Rare Diseases Inc. 55292-0141-01 Signifor Lar 1 MG 1 1 30 30
J2502 Inj, pasireotide long acting Recordati Rare Diseases Inc. 55292-0142-01 Signifor Lar 1 MG 1 1 40 40
J2502 Inj, pasireotide long acting Recordati Rare Diseases Inc. 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
J2547 Injection, peramivir BioCryst Pharmaceuticals, Inc. 72769-0181-03 Rapivab 1 MG 20 3 200 600
J2601 Inj, vasopressin (baxter) Baxter Healthcare Corporation 00338-9640-12 Vasopressin 1 UNIT 100 12 20 240
J2601 Inj, vasopressin (baxter) Baxter Healthcare Corporation 00338-9647-12 Vasopressin 1 UNIT 100 12 40 480
J2801 Inj, rykindo, 0.5 mg SHANGONG LUYE PHARMACEUTICA 72526-0101-11 Rykindo 0.5 MG 1 1 25 25
J2801 Inj, rykindo, 0.5 mg SHANGONG LUYE PHARMACEUTICA 72526-0102-11 Rykindo 0.5 MG 1 1 50 50
J2801 Inj, rykindo, 0.5 mg SHANGONG LUYE PHARMACEUTICA 72526-0103-11 Rykindo 0.5 MG 1 1 75 75
J2801 Inj, rykindo, 0.5 mg SHANGONG LUYE PHARMACEUTICA 72526-0104-11 Rykindo 0.5 MG 1 1 100 100
J2840 Injection, sebelipase alfa Alexion Pharmaceuticals, Inc. 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 18.1 MG 1 2 1 2
J2998 Inj plasminogen tvmh 1mg Kedrion Biopharma Inc 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 Azurity Pharmaceuticals, Inc. 24338-0150-20 Triptodur 3.75 MG 1 1 6 6
J3393 Inj, betibeglogene autotemce bluebird bio, Inc. 73554-3111-01 Zynteglo PER THERAPEUTIC DOSE 20 1 1 1
J3394 Inj, lovotibeglogene autotem Bluebird Bio, Inc. 73554-1111-01 Lyfgenia per treatment 20 1 1 1
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 Novartis Gene Therapies, Inc. 71894-0120-02 Zolgensma per tx dose (up to 5 x10^15 vg?) 16.6 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0121-03 Zolgensma per tx dose (up to 5 x10^15 vg?) 19.3 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0122-03 Zolgensma per tx dose (up to 5 x10^15 vg?) 22.1 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0123-03 Zolgensma per tx dose (up to 5 x10^15 vg?) 24.9 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0124-04 Zolgensma per tx dose (up to 5 x10^15 vg?) 27.6 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0125-04 Zolgensma per tx dose (up to 5 x10^15 vg?) 30.4 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0126-04 Zolgensma per tx dose (up to 5 x10^15 vg?) 33.2 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0127-05 Zolgensma per tx dose (up to 5 x10^15 vg?) 35.9 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0128-05 Zolgensma per tx dose (up to 5 x10^15 vg?) 38.7 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0129-05 Zolgensma per tx dose (up to 5 x10^15 vg?) 41.5 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0130-06 Zolgensma per tx dose (up to 5 x10^15 vg?) 44.2 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0131-06 Zolgensma per tx dose (up to 5 x10^15 vg?) 47 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0132-06 Zolgensma per tx dose (up to 5 x10^15 vg?) 49.8 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0133-07 Zolgensma per tx dose (up to 5 x10^15 vg?) 52.5 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0134-07 Zolgensma per tx dose (up to 5 x10^15 vg?) 55.3 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0135-07 Zolgensma per tx dose (up to 5 x10^15 vg?) 58.1 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0136-08 Zolgensma per tx dose (up to 5 x10^15 vg?) 60.8 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0137-08 Zolgensma per tx dose (up to 5 x10^15 vg?) 63.6 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0138-08 Zolgensma per tx dose (up to 5 x10^15 vg?) 66.4 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0139-09 Zolgensma per tx dose (up to 5 x10^15 vg?) 69.1 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0140-09 Zolgensma per tx dose (up to 5 x10^15 vg?) 71.9 1 1 1
J3399 Inj onase abepar-xioi treat Novartis Gene Therapies, Inc. 71894-0141-09 Zolgensma per tx dose (up to 5 x10^15 vg?) 74.7 1 1 1
J3424 Inj hydroxocobalamin iv 25mg BTG International Inc. 50633-0310-11 Cyanokit 25 MG 1 1 200 200
J7165 Inj, human-lans, per i.u Octapharma USA Inc. 68982-0261-01 Balfaxar PER FACTOR IX IU 1 1 1 1
J7165 Inj, human-lans, per i.u Octapharma USA Inc. 68982-0261-02 Balfaxar PER FACTOR IX IU 1 1 1 1
J7168 Prothrombin complex kcentra CSL Behring L.L.C. 63833-0386-02 Kcentra 1 IU 1 1 1 1
J7168 Prothrombin complex kcentra CSL Behring L.L.C. 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 AstraZeneca Pharmaceuticals LP 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 INC. 73372-0116-01 Scenesse 1 MG 1 1 16 16
J7353 Anacaulase-bcdb 8.8% gel 1 g Vericel Corporation 69866-2005-03 NexoBrid 1 GM (OF 8.8% GEL) 1 1 55 55
J7355 Inj travoprost intra impl Glaukos Corporation 25357-0100-01 iDose TR 1 MCG 1 1 75 75
J7501 Azathioprine parenteral Hikma Pharmaceuticals USA Inc. 00143-9566-01 Azathioprine 100 MG 1 1 1 1
J8611 Oral methotrexate (jylamvo) SHORLA ONCOLOGY INC. 81927-0204-01 Jylamvo 2.5 MG 60 1 48 48
J8612 Oral methotrexate (xatmep) Azurity Pharmaceuticals, Inc. 52652-2001-01 Xatmep 2.5 MG 120 1 120 120
J8612 Oral methotrexate (xatmep) Azurity Pharmaceuticals, Inc. 52652-2001-06 Xatmep 2.5 MG 60 1 60 60
J9036 Inj., belrapzo 1 mg Eagle Pharmaceuticals, Inc. 42367-0521-25 Belrapzo 1 MG 4 1 100 100
J9036 Inj., belrapzo 1 mg EAGLE PHARMACEUTICALS, INC. 42367-0520-25 Bendamustine 1 MG 4 1 100 100
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
J9052 Inj, carmustine (accord) ACCORD HEALTHCARE INC 16729-0545-63 Carmustine 100 MG 1 1 0.5 0.5
J9052 Inj, carmustine (accord) ACCORD HEALTHCARE INC 16729-0548-63 Carmustine 100 MG 1 1 3 3
J9057 Inj., copanlisib, 1 mg Bayer HealthCare Pharmaceuticals Inc. 50419-0385-01 Aliqopa 1 MG 1 1 60 60
J9074 Inj, cyclophosphamd, sandoz SANDOZ 00781-3528-10 Cyclophosphamide 5 MG 5 1 100 100
J9074 Inj, cyclophosphamd, sandoz SANDOZ 00781-3529-10 Cyclophosphamide 5 MG 10 1 200 200
J9074 Inj, cyclophosphamd, sandoz SANDOZ 00781-3530-10 Cyclophosphamide 5 MG 20 1 400 400
J9172 Docetaxel (ingenus), 1 mg Avyxa Pharma 83831-0101-02 Docivyx 1 MG 2 1 20 20
J9172 Docetaxel (ingenus), 1 mg Avyxa Pharma 83831-0102-08 Docivyx 1 MG 8 1 80 80
J9172 Docetaxel (ingenus), 1 mg Avyxa Pharma 83831-0103-16 Docivyx 1 MG 16 1 160 160
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0008-60 Infugem 100 MG 130 1 13 13
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0073-60 Infugem 100 MG 120 1 12 12
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0102-60 Infugem 100 MG 140 1 14 14
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0219-60 Infugem 100 MG 150 1 15 15
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0321-60 Infugem 100 MG 160 1 16 16
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0438-60 Infugem 100 MG 170 1 17 17
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0533-60 Infugem 100 MG 180 1 18 18
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0614-60 Infugem 100 MG 190 1 19 19
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0746-60 Infugem 100 MG 200 1 20 20
J9198 Inj. infugem, 100 mg SUN PHARMACEUTICAL INDUSTRIES, LTD. 62756-0974-60 Infugem 100 MG 220 1 22 22
J9248 Inj melphalan (hepzato) 1 mg Delcath Systems Incorporated 75833-0601-01 Hepzato Kit 1 MG 1 5 50 250
J9248 Inj melphalan (hepzato) 1 mg DELCATH SYSTEMS 75833-0601-02 Hepzato Kit 1 MG 1 5 50 250
J9262 Inj, omacetaxine mep, 0.01mg Cephalon, LLC 63459-0177-14 Synribo 0.01 mg 1 1 350 350
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 INC 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
J9313 Inj., lumoxiti, 0.01 mg AstraZeneca Pharmaceuticals LP 00310-4700-01 Lumoxiti 0.01 MG 1 1 100 100
J9313 Inj., lumoxiti, 0.01 mg AstraZeneca Pharmaceuticals LP 73380-4700-01 Lumoxiti 0.01 MG 1 1 100 100
J9318 Inj romidepsin non-lyo 0.1mg Teva Parenteral Medicines, Inc. 00703-4004-01 Romidepsin non-lyophilized 0.1 MG 5.5 1 275 275
J9320 Streptozocin injection Teva Parenteral Medicines, Inc. 00703-4636-01 Zanosar 1 GM 1 1 1 1
J9323 Inj pemetrexed ditromethamin Pfizer Inc 00409-1060-01 Pemetrexed ditromethamine 10 mg 1 1 10 10
J9323 Inj pemetrexed ditromethamin Pfizer Inc 00409-1061-01 Pemetrexed ditromethamine 10 mg 1 1 50 50
J9324 Inj, pemrydi rtu, 10 mg AMNEAL PHARMACEUTICALS LLC 70121-2453-01 Pemrydi rtu 10 MG 10 1 10 10
J9324 Inj, pemrydi rtu, 10 mg AMNEAL PHARMACEUTICALS LLC 70121-2461-01 Pemrydi rtu 10 MG 50 1 50 50
J9324 Inj, pemrydi rtu, 10 mg AMNEAL PHARMACEUTICALS LLC 70121-2462-01 Pemrydi rtu 10 MG 100 1 100 100
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 USA, LLC 63323-0403-02 Fosphenytoin Sodium 50 MG PE/ML 2 25 2 50
Q2009 Fosphenytoin inj PE FreseniUS Kabi USA, LLC 63323-0403-10 Fosphenytoin Sodium 50 MG PE/ML 10 10 10 100
Q2009 Fosphenytoin inj PE Glenmark Pharmaceuticals Inc., USA 68462-0621-54 Fosphenytoin Sodium 50 MG PE/ML 2 25 2 50
Q2009 Fosphenytoin inj PE Glenmark Pharmaceuticals Inc., USA 68462-0622-64 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 Inc. 61314-0866-01 Ziextenzo 0.5 MG 0.6 1 12 12
Q5131 Inj, idacio, 20 mg FreseniUS Kabi USA, LLC 65219-0554-08 Idacio 20 MG 0.8 2 2 4
Q5131 Inj, idacio, 20 mg FreseniUS Kabi USA, LLC 65219-0554-28 Idacio 20 MG 0.8 4 2 8
Q5131 Inj, idacio, 20 mg FreseniUS Kabi USA, LLC 65219-0554-38 Idacio 20 MG 0.8 6 2 12
Q5131 Inj, idacio, 20 mg FreseniUS Kabi USA, LLC 65219-0556-18 Idacio 20 MG 0.8 2 2 4
Q5131 Inj, idacio, 20 mg FreseniUS Kabi USA, LLC 65219-0612-99 Idacio 20 MG 0.8 2 2 4
Q5133 Inj, tofidence, 1 mg BIOGEN 64406-0022-01 Tofidence 1 MG 10 1 200 200
Q5133 Inj, tofidence, 1 mg BIOGEN 64406-0023-01 Tofidence 1 MG 20 1 400 400
Q5133 Inj, tofidence, 1 mg BIOGEN 64406-0024-01 Tofidence 1 MG 4 1 80 80
Q5135 Inj, tyenne, 1 mg FRESENIUS KABI USA, LLC 65219-0590-04 Tyenne 1 MG 4 1 80 80
Q5135 Inj, tyenne, 1 mg FRESENIUS KABI USA, LLC 65219-0592-10 Tyenne 1 MG 10 1 200 200
Q5135 Inj, tyenne, 1 mg FRESENIUS KABI USA, LLC 65219-0594-20 Tyenne 1 MG 20 1 400 400
Q9968 Visualization adjunct American Regent, Inc. 00517-0374-05 Provayblue 1 MG 10 5 50 250
Q9968 Visualization adjunct Mylan Institutional LLC 67457-0220-05 Isosulfan Blue 1 MG 5 6 50 300

Past NDC - HCPCS Crosswalk