updated 11.4.14 x-over ndc hcpcs hcpcs description ndc ... ndc... · 4/14/2011  · updated 11.4.14...

Click here to load reader

Post on 22-Jul-2020

13 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule00003-2187-10 J0129 INJECTION, ABCIXIMAB, 10MG ORENCIA 250 MG VIAL 9/1/2010 99/99/9999 E0100002-7140-01 J0130 INJECTION ABCIXIMAB, 10MG REOPRO 2 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0671-01 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-02 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-03 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-04 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-05 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-06 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0155390-0612-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 500 MG VIAL 9/1/2010 2/28/2015 E0155390-0613-20 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 1 GM VIAL 9/1/2010 3/31/2013 E0163323-0105-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0325-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR 500 MG/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0325-20 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR 1,000 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100074-3799-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML SYRINGE 9/1/2010 99/99/9999 E0100074-4339-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML PEN 9/1/2010 99/99/9999 E0100074-4339-06 J0135 INJECTION (HUMIRA) HUMIRA CROHN'S STARTER PACK 9/1/2010 99/99/9999 E0100469-8234-12 J0150 INJECTION, ADENOSINE ADENOCARD 6 MG/2 ML SYRINGE 9/1/2010 99/99/9999 E0100469-8234-14 J0150 INJECTION, ADENOSINE ADENOCARD 12 MG/4 ML SYRINGE 9/1/2010 99/99/9999 E0100703-8771-03 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 9/30/2011 E0100703-8773-01 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 9/30/2011 E0110019-0063-03 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 3/31/2013 E0110019-0063-08 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML SYRINGE 9/1/2010 3/31/2011 E0155390-0067-10 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 3/31/2014 E0155390-0068-01 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 3/31/2014 E0163323-0651-02 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0651-04 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 99/99/9999 E0100469-0871-20 J0152 INJECTION,ADENOSINE ADENOSCAN 3 MG/ML VIAL 9/1/2010 99/99/9999 E0100469-0871-30 J0152 INJECTION,ADENOSINE ADENOSCAN 3 MG/ML VIAL 9/1/2010 99/99/9999 E0100143-9984-90 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-4901-18 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-4921-34 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-7241-01 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0100517-1071-25 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0100517-1130-05 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100548-1016-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 3/31/2011 E0100548-2016-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 3/31/2011 E0100548-3316-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 1/31/2014 E0100548-9061-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 7/31/2014 E0166860-0021-02 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 12/31/2010 E0158468-0040-01 J0180 INJECTION, AGALSIDADE BETA FABRAZYME 35 MG VIAL 9/1/2010 99/99/9999 E0158468-0041-01 J0180 INJECTION, AGALSIDADE BETA FABRAZYME 5 MG VIAL 9/1/2010 99/99/9999 E0158468-1060-01 J0205 INJECTION, ALGLUCERASE CEREDASE 80 UNITS/ML VIAL 9/1/2010 12/31/2012 E0162756-0581-40 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 3/31/2014 E0162756-0581-42 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 3/31/2014 E0155390-0308-03 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 99/99/9999 E0158178-0017-01 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 9/1/2010 9/30/2013 E0158178-0017-03 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 9/1/2010 9/30/2013 E0100517-8905-10 J0210 INJECTION, METHYLDOPATE HCI METHYLDOPATE 250 MG/5 ML VIAL 9/1/2010 99/99/9999 E0158468-0150-01 J0220 INJECTION, ALGLUCOSIDASE ALFA MYOZYME 50 MG VIAL 9/1/2010 99/99/9999 E0100053-7201-02 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ZEMAIRA 1,000 MG VIAL 9/1/2010 99/99/9999 E0100944-2801-01 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ARALAST 500 MG VIAL 9/1/2010 12/31/2010 E0100944-2801-02 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ARALAST 1,000 MG VIAL 9/1/2010 10/27/2010 E0113533-0601-30 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR PROLASTIN 500 MG VIAL 9/1/2010 9/30/2011 E0113533-0601-35 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR PROLASTIN 1,000 MG VIAL 9/1/2010 12/17/2012 E0100009-3169-06 J0270 INJECTION, ALPROSTADIL PROSTIN VR PEDI 500 MCG/ML AMP 9/1/2010 99/99/9999 E0100009-3701-05 J0270 INJECTION, ALPROSTADIL CAVERJECT 20 MCG VIAL 9/1/2010 99/99/9999 E0100009-5181-01 J0270 INJECTION, ALPROSTADIL CAVERJECT IMPULSE 10 MCG KIT 9/1/2010 99/99/9999 E0100009-5182-01 J0270 INJECTION, ALPROSTADIL CAVERJECT IMPULSE 20 MCG KIT 9/1/2010 99/99/9999 E0100009-7686-04 J0270 INJECTION, ALPROSTADIL CAVERJECT 40 MCG VIAL 9/1/2010 99/99/9999 E0100091-1110-16 J0270 INJECTION, ALPROSTADIL EDEX 10 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E0100091-1110-20 J0270 INJECTION, ALPROSTADIL EDEX 10 MCG CARTRIDGE 6-PK KIT 9/1/2010 99/99/9999 E0100091-1120-16 J0270 INJECTION, ALPROSTADIL EDEX 20 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E0100091-1120-20 J0270 INJECTION, ALPROSTADIL EDEX 20 MCG CARTRIDGE 6-PK KIT 9/1/2010 99/99/9999 E0100091-1140-16 J0270 INJECTION, ALPROSTADIL EDEX 40 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E0100091-1140-20 J0270 INJECTION, ALPROSTADIL EDEX 40 MCG CARTRIDGE 6-PK KIT 9/1/2010 5/8/2012 E0100703-1501-02 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 99/99/9999 E0151552-0498-03 J0270 INJECTION, ALPROSTADIL ALPROSTADIL POWDER 9/1/2010 3/31/2011 E0155390-0503-10 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 12/31/2010 E0155390-0506-10 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 9/30/2011 E0162541-0110-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 125 MCG URETHRAL SUPPOS 9/1/2010 3/31/2012 E0162541-0110-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 125 MCG URETHRAL SUPPOS 9/1/2010 3/31/2012 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    62541-0120-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 250 MCG URETHRAL SUPPOS 9/1/2010 12/31/2012 E0162541-0120-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 250 MCG URETHRAL SUPPOS 9/1/2010 12/31/2012 E0162541-0130-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 500 MCG URETHRAL SUPPOS 9/1/2010 7/31/2013 E0162541-0130-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 500 MCG URETHRAL SUPPOS 9/1/2010 7/31/2013 E0162541-0140-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 1,000 MCG URETHRAL SUPP 9/1/2010 7/31/2013 E0162541-0140-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 1,000 MCG URETHRAL SUPP 9/1/2010 7/31/2013 E0100409-1955-01 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 100 MG/2 ML 9/1/2010 9/30/2011 E0100409-1956-01 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 500 MG/2 ML 9/1/2010 11/1/2012 E0100409-1957-01 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 1,000 MG/4 ML 9/1/2010 9/30/2011 E0100703-9032-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 500 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100703-9040-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 1 GRAM/4 ML VIAL 9/1/2010 99/99/9999 E0155390-0223-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN (PF) 100 MG/2 ML 9/1/2010 12/31/2010 E0155390-0224-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 500 MG/2 ML 9/1/2010 12/31/2010 E0155390-0224-04 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 1,000 MG/4 ML 9/1/2010 12/31/2010 E0155390-0225-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN (PF) 100 MG/2 ML 9/1/2010 9/30/2011 E0155390-0226-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 500 MG/2 ML VIAL 9/1/2010 7/31/2015 E0155390-0226-04 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 1 GRAM/4 ML VIAL 9/1/2010 9/30/2013 E0100409-5921-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 9/1/2010 99/99/9999 E0100409-5922-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 9/1/2010 99/99/9999 E0100409-7385-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 9/1/2010 9/30/2011 E0100409-7386-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 9/1/2010 7/1/2011 E0100517-3810-25 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 9/1/2010 12/31/2012 E0100517-3820-25 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 9/1/2010 12/31/2012 E0151552-0313-05 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE ANHYDROUS PWD 9/1/2010 3/31/2011 E0151552-0313-06 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE ANHYDROUS POWDER 9/1/2010 3/31/2011 E0100409-4348-35 J0282 INJECTION,AMIODARONE AMIODARONE 150 MG/3 ML AMP 9/1/2010 99/99/9999 E0100548-3380-00 J0282 INJECTION,AMIODARONE AMIODARONE HCL 50 MG/ML SYRN 9/1/2010 3/31/2011 E0100703-1335-01 J0282 INJECTION,AMIODARONE AMIODARONE 450 MG/9 ML VIAL 9/1/2010 2/28/2011 E0155390-0057-01 J0282 INJECTION,AMIODARONE AMIODARONE 900 MG/18 ML VIAL 9/1/2010 9/30/2011 E0155390-0057-10 J0282 INJECTION,AMIODARONE AMIODARONE 150 MG/3 ML VIAL 9/1/2010 9/30/2011 E0155390-0105-01 J0282 INJECTION,AMIODARONE AMIODARONE 450 MG/9 ML VIAL 9/1/2010 9/30/2011 E0163323-0616-03 J0282 INJECTION,AMIODARONE AMIODARONE 150 MG/3 ML VIAL 9/1/2010 99/99/9999 E0163323-0616-09 J0282 INJECTION,AMIODARONE AMIODARONE 450 MG/9 ML VIAL 9/1/2010 99/99/9999 E0139822-1055-05 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B 50 MG VIAL 9/1/2010 99/99/9999 E0139822-1055-07 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B 50 MG VIAL 9/1/2010 1/31/2014 E0151552-0304-01 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-02 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-03 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-04 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-05 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-06 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-07 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0151552-0304-09 J0285 INJECTION,AMPHOTERICIN B,50MG AMPHOTERICIN B POWDER 9/1/2010 3/31/2011 E0157665-0101-41 J0287 INJECTION, AMPHOTERICIN ABELCET 100 MG/20 ML VIAL 9/1/2010 99/99/9999 E0166435-0301-51 J0288 INJECTION AMPHOTERICIN B CHOLESTERYL SUL AMPHOTEC 50 MG VIAL 9/1/2010 99/99/9999 E0100469-3051-30 J0289 INJECT, AMPHOTERICIN B LIPOSOME AMBISOME 50 MG VIAL 9/1/2010 99/99/9999 E0100781-3400-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 125 MG VIAL 9/1/2010 99/99/9999 E0100781-3402-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 9/1/2010 99/99/9999 E0100781-3404-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 9/1/2010 99/99/9999 E0100781-3407-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3408-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 9/1/2010 99/99/9999 E0100781-3409-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100781-3412-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM A-V VIAL 9/1/2010 99/99/9999 E0100781-3413-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM A-V VIAL 9/1/2010 99/99/9999 E0100781-9401-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 125 MG VIAL 9/1/2010 99/99/9999 E0100781-9402-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 9/1/2010 99/99/9999 E0100781-9404-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 9/1/2010 99/99/9999 E0100781-9407-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 9/1/2010 99/99/9999 E0100781-9408-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 9/1/2010 99/99/9999 E0100781-9409-95 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100781-9412-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM A-V VIAL 9/1/2010 99/99/9999 E0100781-9413-92 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM A-V VIAL 9/1/2010 99/99/9999 E0163323-0387-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 250 MG VIAL 9/1/2010 99/99/9999 E0163323-0388-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0389-10 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0399-23 J0290 INJECTION, AMPICILLIN, UP TO 500 MG AMPICILLIN 2 GM VIAL 9/1/2010 99/99/9999 E0100049-0013-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 1.5 GM VIAL 9/1/2010 99/99/9999 E0100049-0014-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 3 GM VIAL 9/1/2010 99/99/9999 E0100049-0022-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 1.5 GM PIGGYBACK BOTTLE 9/1/2010 12/31/2013 E0100049-0023-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 3 GM PIGGYBACK BOTTLE 9/1/2010 12/31/2013 E0100049-0024-28 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 15 GM VIAL 9/1/2010 99/99/9999 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    00049-0031-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 1.5 GM ADD-VANTAGE VL 9/1/2010 6/30/2013 E0100049-0032-83 J0295 AMPICILLIN/SULBACTAM 1.5MG UNASYN 3 GM ADD-VANTAGE VIAL 9/1/2010 6/30/2013 E0100409-2687-15 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 99/99/9999 E0100409-2689-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0100409-2689-11 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0100409-2987-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULB 3 GM ADD VIAL 9/1/2010 99/99/9999 E0100409-2987-13 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULB 3 GM ADD VIAL 9/1/2010 99/99/9999 E0100409-2988-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0100409-2998-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 99/99/9999 E0100781-3032-95 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0100781-3033-95 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 99/99/9999 E0100781-3034-46 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 99/99/9999 E0110019-0630-02 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 10/31/2013 E0110019-0631-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 10/31/2013 E0110019-0631-31 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 10/31/2013 E0110019-0632-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 10/31/2013 E0110019-0633-02 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 7/31/2013 E0110019-0634-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 7/31/2013 E0110019-0635-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 2/28/2013 E0110019-0636-01 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 10/31/2013 E0110019-0637-02 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 10/31/2013 E0110019-0638-03 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 10/31/2013 E0163323-0368-20 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 1.5 GM VL 9/1/2010 99/99/9999 E0163323-0369-20 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 3 GM VIAL 9/1/2010 99/99/9999 E0163323-0370-62 J0295 AMPICILLIN/SULBACTAM 1.5MG AMPICILLIN-SULBACTAM 15 GM VL 9/1/2010 99/99/9999 E0163304-0303-10 J0300 INJECTION, AMOBARBITAL, UP TO 125 MG AMYTAL SODIUM 500 MG VIAL 9/1/2010 12/31/2012 E0100409-6629-02 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T QUELICIN 200 MG/10 ML VIAL 9/1/2010 99/99/9999 E0100409-6629-61 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T QUELICIN 200 MG/10 ML VIAL 9/1/2010 9/30/2011 E0100409-6970-10 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T QUELICIN 100 MG/ML VIAL 9/1/2010 8/1/2013 E0100781-3009-95 J0330 INJECTION, SUCCINYCHOLINE CHLORIDE, UP T ANECTINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100049-1010-28 J0348 INJECTION, ANIDULAFUNGIN, 1 MG ERAXIS(ALCOHOL DIL) 50 MG VIAL 9/1/2010 9/1/2010 E0100517-0901-25 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0614-01 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0614-55 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG HYDRALAZINE 20 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0652-01 J0364 INJECTION, APOMORPHINE HYDR., 1 MG APOMORPHINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0652-02 J0364 INJECTION, APOMORPHINE HYDR., 1 MG APOMORPHINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0652-04 J0364 INJECTION, APOMORPHINE HYDR., 1 MG APOMORPHINE HCL POWDER 9/1/2010 3/31/2011 E0100026-8196-36 J0365 INJECTION, APROTONIN TRASYLOL 10,000 UNITS/ML VIAL 9/1/2010 3/31/2011 E0100026-8197-63 J0365 INJECTION, APROTONIN TRASYLOL 10,000 UNITS/ML VIAL 9/1/2010 3/31/2011 E0159148-0016-65 J0400 ARIPIPRAZOLE INJECTION ABILIFY 9.7 MG/1.3 ML VIAL 9/1/2010 99/99/9999 E0100069-3150-14 J0456 INJECTION, AZITHROMYCIN ZITHROMAX I.V. 500 MG VIAL 9/1/2010 5/31/2014 E0100069-3150-83 J0456 INJECTION, AZITHROMYCIN ZITHROMAX I.V. 500 MG VIAL 9/1/2010 99/99/9999 E0100703-9089-01 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN 2.5 GM BULK VIAL 9/1/2010 11/30/2011 E0110019-0648-02 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 9/1/2010 12/31/2011 E0150111-0794-78 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0398-10 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0398-12 J0456 INJECTION, AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL 9/1/2010 99/99/9999 E0100517-1010-25 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-6006-10 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 8 MG/20 ML VIAL 8/29/2012 99/99/9999 E0100409-4910-34 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG ATROPINE 0.1 MG/ML ABBOJECT 9/1/2010 99/99/9999 E0111098-0526-03 J0470 INJECTION, DIMECAPROL, PER 100 MG BAL IN OIL 100 MG/ML AMPULE 9/1/2010 2/28/2014 E0151552-0613-02 J0475 INJECTION, BACLOFEN BACLOFEN POWDER 9/1/2010 3/31/2011 E0151552-0613-04 J0475 INJECTION, BACLOFEN BACLOFEN POWDER 9/1/2010 3/31/2011 E0151552-0613-05 J0475 INJECTION, BACLOFEN BACLOFEN POWDER 9/1/2010 3/31/2011 E0158281-0560-01 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/20 ML KIT 9/1/2010 99/99/9999 E0158281-0560-02 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/20 ML KIT 9/1/2010 99/99/9999 E0158281-0561-02 J0475 INJECTION, BACLOFEN LIORESAL IT 10 MG/5 ML KIT 9/1/2010 99/99/9999 E0158281-0563-01 J0475 INJECTION, BACLOFEN LIORESAL IT 40 MG/20 ML KIT 9/1/2010 99/99/9999 E0158281-0563-02 J0475 INJECTION, BACLOFEN LIORESAL IT 40 MG/20 ML KIT 9/1/2010 99/99/9999 E0158281-0562-01 J0476 BACLOFEN LIORESAL IT 0.05 MG/1 ML AMP 9/1/2010 99/99/9999 E0100078-0331-84 J0480 INJECTION, BASILIXIMAB SIMULECT 20 MG VIAL 9/1/2010 99/99/9999 E0100078-0393-61 J0480 INJECTION, BASILIXIMAB SIMULECT 10 MG VIAL 9/1/2010 99/99/9999 E0151552-0741-04 J0500 INJECTION, DICYCLOMINE, UP TO 20 MG DICYCLOMINE HCL POWDER 9/1/2010 3/31/2011 E0155390-0066-10 J0500 INJECTION, DICYCLOMINE, UP TO 20 MG DICYCLOMINE 10 MG/ML VIAL 9/1/2010 9/30/2011 E0158914-0080-52 J0500 INJECTION, DICYCLOMINE, UP TO 20 MG BENTYL 10 MG/ML AMPUL 9/1/2010 99/99/9999 E0151552-0952-01 J0515 INJECTION, BENZTROPINE BENZTROPINE MESYLATE POWDER 9/1/2010 3/31/2011 E0167386-0611-52 J0515 INJECTION, BENZTROPINE COGENTIN 2 MG/2 ML AMPULE 9/1/2010 11/30/2013 E0160793-0700-10 J0560 INJECTION, PENICILLIN G BENZATHINE, UP T BICILLIN L-A 600,000 UNIT/ML 9/1/2010 99/99/9999 E0160793-0701-10 J0560 INJECTION, PENICILLIN G BENZATHINE, UP T BICILLIN L-A 1,200,000 UNITS 9/1/2010 99/99/9999 E0160793-0702-10 J0560 INJECTION, PENICILLIN G BENZATHINE, UP T BICILLIN L-A 2,400,000 UNITS 9/1/2010 99/99/9999 E0115054-0530-06 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 300 UNIT VIAL 11/29/2010 3/31/2013 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    15054-0500-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT DYSPORT 500 UNITS VIAL 9/1/2010 3/31/2013 E0100023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 9/1/2010 99/99/9999 E0100023-9232-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 100 UNITS VIAL 9/1/2010 99/99/9999 E0100023-9232-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 9/1/2010 12/31/2012 E0100023-1145-01 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 100 UNITS VIAL 9/1/2010 99/99/9999 E0100023-3919-50 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX COSMETIC 50 UNITS VIAL 8/30/2011 99/99/9999 E0100023-3921-02 J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT BOTOX 200 UNITS VIAL 9/1/2010 99/99/9999 E0115054-0500-01 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 500 UNITS VIAL 4/1/2013 99/99/9999 E0115054-0530-06 J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS DYSPORT 300 UNIT VIAL 4/1/2013 99/99/9999 E0110454-0710-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 2,500 UNIT/0.5 ML VIAL 9/1/2010 99/99/9999 E0110454-0711-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 5,000 UNITS/1 ML VIAL 9/1/2010 99/99/9999 E0110454-0712-10 J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNIT MYOBLOC 10,000 UNITS/2 ML VIAL 9/1/2010 99/99/9999 E0100409-2012-32 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENORPHINE 0.3 MG/ML SYRN 9/1/2010 99/99/9999 E0112496-0757-01 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENEX 0.3 MG/ML AMPUL 9/1/2010 99/99/9999 E0155390-0100-10 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE BUPRENORPHINE 0.3 MG/ML VIAL 9/1/2010 3/31/2014 E0167286-0053-08 J0594 INJECTION, BUSULFAN, 1 MG BUSULFEX 6 MG/ML AMPUL 9/1/2010 9/30/2013 E0167286-0054-08 J0594 INJECTION, BUSULFAN, 1 MG BUSULFEX 60 MG/10 ML VIAL 9/1/2010 9/30/2013 E0100409-1623-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1626-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-1626-02 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 99/99/9999 E0155390-0183-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0184-01 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0184-02 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0185-10 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 3/31/2014 E0160505-0658-00 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 9/1/2010 99/99/9999 E0160505-0659-00 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 99/99/9999 E0160505-0660-00 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 99/99/9999 E0161703-0317-45 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 1 MG/ML VIAL 9/1/2010 9/30/2011 E0161703-0318-45 J0595 BUTORPHANOL TARTRATE, INJECTION BUTORPHANOL 2 MG/ML VIAL 9/1/2010 9/30/2011 E0163833-0825-02 J0598 INJECTION, C1 ESTERASE INHIBITOR, 10 UNI BERINERT 500 UNIT KIT 2/1/2013 99/99/9999 E0151552-0435-05 J0600 INJECTION, EDETATE CALCIUM DISODIUM, UP EDETATE CALCIUM DISODIUM POWD 9/1/2010 3/31/2011 E0100517-3900-25 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0100517-3910-25 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 12/31/2012 E0100517-3950-25 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0163323-0311-10 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0163323-0311-50 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0163323-0311-61 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 99/99/9999 E0163323-0311-63 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML CALCIUM GLUCONATE 10% VIAL 9/1/2010 12/31/2011 E0100078-0149-23 J0630 INJECTION, CALCITONIN SALMON, UP TO 400 MIACALCIN 200 UNIT/ML VIAL 9/1/2010 99/99/9999 E0100074-8110-31 J0636 INJECTION, CALCITRIOL, 0.1. MCG CALCIJEX 1 MCG/ML AMPUL 9/1/2010 8/1/2012 E0100517-0132-25 J0636 INJECTION, CALCITRIOL, 0.1. MCG CALCITRIOL 1 MCG/ML AMPUL 9/1/2010 99/99/9999 E0100703-7311-04 J0636 INJECTION, CALCITRIOL, 0.1. MCG CALCITRIOL 1 MCG/ML VIAL 9/1/2010 9/30/2011 E0163323-0731-01 J0636 INJECTION, CALCITRIOL, 0.1. MCG CALCITRIOL 1 MCG/ML AMPUL 9/1/2010 99/99/9999 E0100006-3822-10 J0637 INJECTION, CASPOFUNGIN ACETATE, 5 MG CANCIDAS IV 50 MG VIAL 9/1/2010 99/99/9999 E0100006-3823-10 J0637 INJECTION, CASPOFUNGIN ACETATE, 5 MG CANCIDAS IV 70 MG VIAL 9/1/2010 99/99/9999 E0125021-0815-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 2/15/2013 99/99/9999 E0125021-0816-30 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 2/15/2013 99/99/9999 E0100703-5140-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 9/1/2010 99/99/9999 E0100703-5145-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 9/1/2010 99/99/9999 E0155390-0009-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 9/1/2010 6/30/2013 E0155390-0051-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 50 MG VIAL 9/1/2010 8/31/2013 E0155390-0052-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 9/1/2010 8/31/2014 E0155390-0053-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 9/1/2010 4/30/2014 E0155390-0054-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 9/1/2010 2/28/2015 E0155390-0818-10 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 100 MG VIAL 9/1/2010 8/31/2014 E0155390-0824-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 9/1/2010 4/30/2014 E0155390-0825-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 350 MG VIAL 9/1/2010 5/31/2013 E0155390-0826-01 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CAL 500 MG/50 ML VL 9/1/2010 6/30/2013 E0163323-0711-00 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 500 MG VL 9/1/2010 99/99/9999 E0163323-0710-50 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG LEUCOVORIN CALCIUM 200 MG VIAL 8/30/2011 99/99/9999 E0168152-0101-00 J0641 INJECTION, LEVOLEUCOVORIN CALCIUM FUSILEV I.V. 50 MG VIAL 9/1/2010 99/99/9999 E0100186-0410-01 J0670 INJECTION, MEPIVACAINE POLOCAINE 1% VIAL 9/1/2010 12/31/2011 E0100186-0412-01 J0670 INJECTION, MEPIVACAINE POLOCAINE 1% VIAL 9/1/2010 9/30/2011 E0100186-0418-01 J0670 INJECTION, MEPIVACAINE POLOCAINE 1.5% VIAL 9/1/2010 8/31/2011 E0100186-0422-01 J0670 INJECTION, MEPIVACAINE POLOCAINE 2% VIAL 9/1/2010 3/31/2012 E0100409-1036-30 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1% VIAL 9/1/2010 99/99/9999 E0100409-1038-50 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1% VIAL 9/1/2010 99/99/9999 E0100409-1041-30 J0670 INJECTION, MEPIVACAINE CARBOCAINE 1.5% VIAL 9/1/2010 99/99/9999 E0100409-1067-20 J0670 INJECTION, MEPIVACAINE CARBOCAINE 2% VIAL 9/1/2010 99/99/9999 E0100409-2047-50 J0670 INJECTION, MEPIVACAINE CARBOCAINE 2% VIAL 9/1/2010 99/99/9999 E0125021-0100-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 99/99/9999 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    00143-9923-90 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 99/99/9999 E0100143-9924-90 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0100143-9983-91 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100264-3103-11 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM-D5W BAG 9/1/2010 99/99/9999 E0100338-3503-41 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM-D5W BAG 9/1/2010 99/99/9999 E0100409-2585-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM ADD-VAN VIAL 9/1/2010 99/99/9999 E0100781-3450-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3451-96 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0100781-3452-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100781-9337-46 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0100781-9337-95 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 9/30/2014 E0110019-0610-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 12/31/2011 E0110019-0611-03 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 12/31/2011 E0110019-0611-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 9/30/2013 E0110019-0612-05 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 12/31/2011 E0160505-0749-04 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0749-05 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0769-00 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0163323-0236-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0237-10 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0238-61 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 99/99/9999 E0163323-0446-61 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 20 GM BULK VIAL 9/1/2010 3/30/2012 E0166860-0001-03 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 500 MG VIAL 9/1/2010 12/31/2010 E0166860-0002-03 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 12/31/2010 E0166860-0003-02 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 10 GM VIAL 9/1/2010 12/31/2010 E0100409-0805-01 J0690 INJECTION, CEFAZOLIN SODIUM, UP TO 500 CEFAZOLIN 1 GM VIAL 9/1/2010 99/99/9999 E0151479-0054-20 J0692 INJECTION, CEFEPIME HCL, 500 MG MAXIPIME 1 GM ADD-VANTAGE VL 9/1/2010 8/30/2012 E0151479-0054-30 J0692 INJECTION, CEFEPIME HCL, 500 MG MAXIPIME 1 GRAM VIAL 9/1/2010 12/31/2010 E0151479-0055-10 J0692 INJECTION, CEFEPIME HCL, 500 MG MAXIPIME 2 GM ADD-VANTAGE VL 9/1/2010 11/30/2012 E0151479-0055-30 J0692 INJECTION, CEFEPIME HCL, 500 MG MAXIPIME 2 GRAM VIAL 9/1/2010 12/31/2010 E0160505-0681-00 J0692 INJECTION, CEFEPIME HCL, 500 MG CEFEPIME HCL 2 GRAM VIAL 9/1/2010 99/99/9999 E0160505-0681-04 J0692 INJECTION, CEFEPIME HCL, 500 MG CEFEPIME HCL 2 GRAM VIAL 9/1/2010 99/99/9999 E0160505-0834-00 J0692 INJECTION, CEFEPIME HCL, 500 MG CEFEPIME HCL 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0834-04 J0692 INJECTION, CEFEPIME HCL, 500 MG CEFEPIME HCL 1 GM VIAL 9/1/2010 99/99/9999 E0100264-3123-11 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM PIGGYBACK BAG 9/1/2010 99/99/9999 E0100264-3125-11 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM PIGGYBACK BAG 9/1/2010 99/99/9999 E0160505-0759-05 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0760-05 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM VIAL 9/1/2010 99/99/9999 E0160505-0761-04 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 10 GM VIAL 9/1/2010 99/99/9999 E0163323-0341-20 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 1 GM VIAL 9/1/2010 8/30/2012 E0163323-0342-20 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 2 GM VIAL 9/1/2010 8/30/2012 E0163323-0343-61 J0694 INJECTION, CEFOXITIN SODIUM, 1 GM CEFOXITIN 10 GM VIAL 9/1/2010 99/99/9999 E0155390-0310-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2014 E0125021-0104-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 12/31/2010 E0125021-0105-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0125021-0106-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0125021-0107-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0100517-8711-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 12/31/2012 E0100517-8722-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 12/31/2012 E0100517-8725-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 12/31/2012 E0100517-8750-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2012 E0168330-0005-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/1/2010 9/30/2011 E0155390-0309-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 12/31/2014 E0155390-0311-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 12/31/2014 E0100069-4481-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2011 E0100069-4481-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2011 E0100069-4482-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 5/31/2012 E0100069-4482-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 5/31/2012 E0100703-0315-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 1/31/2013 E0100703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2011 E0100703-0335-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 4/30/2013 E0100703-0346-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 1/31/2013 E0100703-0359-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 1/31/2013 E0100781-3208-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0168330-0006-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 9/1/2010 9/30/2011 E0100781-9328-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100143-9856-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0100143-9857-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100143-9858-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100143-9859-25 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0100703-0325-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2011 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    00004-1963-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 9/1/2010 99/99/9999 E0100004-1963-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 500 MG VIAL 9/1/2010 99/99/9999 E0100004-1964-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 9/1/2010 99/99/9999 E0100004-1964-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG ROCEPHIN 1 GM VIAL 9/1/2010 99/99/9999 E0100264-3153-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM-D5W BAG 9/1/2010 99/99/9999 E0100264-3155-11 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM-D5W BAG 9/1/2010 99/99/9999 E0100338-5002-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/1/2010 99/99/9999 E0100338-5003-41 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 9/1/2010 99/99/9999 E0100409-7332-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100409-7333-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100409-7333-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100409-7334-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0100409-7335-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0100409-7336-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 9/1/2010 99/99/9999 E0100409-7336-49 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM ADD VIAL 9/1/2010 99/99/9999 E0100409-7337-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0100409-7338-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3206-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0100781-9326-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 7/31/2015 E0110019-0098-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0110019-0098-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0110019-0685-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 12/31/2011 E0110019-0685-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 9/30/2013 E0110019-0686-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 12/31/2011 E0110019-0686-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2013 E0110019-0687-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 12/31/2011 E0110019-0687-71 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 9/30/2013 E0110019-0688-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0110019-0688-27 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0110019-0689-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0160505-0679-05 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0160505-0679-08 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM PIGGYBACK 9/1/2010 99/99/9999 E0160505-0679-09 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM PIGGYBACK 9/1/2010 99/99/9999 E0160505-0750-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0160505-0750-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0160505-0751-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0160505-0751-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0160505-0752-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0752-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0160505-0753-00 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0160505-0753-04 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0163323-0344-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0163323-0345-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0346-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0347-20 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0163323-0348-61 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0168180-0611-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0168180-0611-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0168180-0622-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0168180-0622-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0168180-0633-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0168180-0633-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0168180-0644-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0168180-0644-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0168330-0001-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 9/30/2011 E0168330-0001-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 9/30/2011 E0168330-0002-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2011 E0168330-0002-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 9/30/2011 E0168330-0003-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 9/30/2011 E0168330-0003-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 9/30/2011 E0168330-0004-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 9/30/2011 E0168330-0004-10 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 9/30/2011 E0164679-0701-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0164679-0701-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0164679-0701-03 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 9/30/2011 E0164679-0702-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0164679-0703-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0164679-0703-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0164679-0983-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0164679-0983-02 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0164679-0702-01 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    00781-3207-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3208-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100781-3209-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 99/99/9999 E0100781-3210-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 99/99/9999 E0100781-9327-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100781-9328-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 1 GM VIAL 9/1/2010 99/99/9999 E0100781-9329-95 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 2 GM VIAL 9/1/2010 8/31/2015 E0100781-9330-46 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 10 GM VIAL 9/1/2010 6/30/2015 E0100781-3206-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/1/2010 99/99/9999 E0100781-3207-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 9/1/2010 99/99/9999 E0100781-9326-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 250 MG VIAL 9/30/2011 99/99/9999 E0100781-9327-85 J0696 INJECTION,CEFTRIAXONE SODIUM,PER 250 MG CEFTRIAXONE 500 MG VIAL 8/16/2012 99/99/9999 E0100143-9976-91 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 7.5 GM VIAL 9/1/2010 99/99/9999 E0100143-9977-90 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 99/99/9999 E0100143-9979-90 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 99/99/9999 E0100173-0352-10 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 750 MG VIAL 9/1/2010 2/28/2014 E0100173-0354-10 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 1.5 GM VIAL 9/1/2010 2/28/2014 E0100173-0400-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 7.5 GM VIAL 9/1/2010 3/31/2013 E0100173-0424-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF-DEXTROSE 750 MG/50 ML 9/1/2010 9/5/2013 E0100173-0425-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 1.5 GRAM/50 ML 9/1/2010 12/30/2014 E0100173-0436-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 750 MG ADD-VANT VIAL 9/1/2010 6/30/2014 E0100173-0437-00 J0697 INJECTION, STERILE CEFUROXIME SODIUM ZINACEF 1.5 GM ADD-VANT VIAL 9/1/2010 6/30/2014 E0100264-3112-11 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME 750 MG/50 ML BAG 9/1/2010 3/31/2014 E0100264-3114-11 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME 1.5G/50 ML BAG 9/1/2010 9/30/2014 E0110019-0620-01 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 12/31/2011 E0110019-0620-10 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 9/30/2013 E0110019-0621-03 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 12/31/2011 E0110019-0621-20 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 9/30/2013 E0163323-0352-10 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 9/30/2011 E0163323-0353-20 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 9/30/2011 E0163323-0354-61 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 7.5 GM VIAL 9/1/2010 9/30/2011 E0166860-0030-03 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 750 MG VIAL 9/1/2010 12/31/2010 E0166860-0031-03 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 1.5 GM VIAL 9/1/2010 12/31/2010 E0166860-0032-02 J0697 INJECTION, STERILE CEFUROXIME SODIUM CEFUROXIME SOD 7.5 GM VIAL 9/1/2010 12/31/2010 E0100039-0017-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 500 MG VIAL 9/1/2010 99/99/9999 E0100039-0018-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM VIAL 9/1/2010 99/99/9999 E0100039-0018-11 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM INFUSION BTL 9/1/2010 12/31/2012 E0100039-0018-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM VIAL 9/1/2010 9/30/2011 E0100039-0018-50 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM VIAL 9/1/2010 9/30/2011 E0100039-0019-10 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM VIAL 9/1/2010 99/99/9999 E0100039-0019-11 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM INFUSION BTL 9/1/2010 12/31/2012 E0100039-0019-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM VIAL 9/1/2010 9/30/2011 E0100039-0019-50 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM VIAL 9/1/2010 12/31/2012 E0100039-0020-01 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 10 GM VIAL 9/1/2010 99/99/9999 E0100039-0023-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM ADD-VANTAGE VL 9/1/2010 99/99/9999 E0100039-0023-50 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM ADD-VANTAGE VL 9/1/2010 9/30/2011 E0100039-0024-25 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM ADD-VANTAGE VL 9/1/2010 99/99/9999 E0100039-0024-50 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM ADD-VANTAGE VL 9/1/2010 12/31/2012 E0100039-0037-05 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 1 GM/50 ML GALAXY 9/1/2010 99/99/9999 E0100039-0038-05 J0698 CEFOTAXIME SODIUM, PER GM CLAFORAN 2 GM/50 ML GALAXY 9/1/2010 99/99/9999 E0100143-9930-03 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 9/1/2010 99/99/9999 E0100143-9931-22 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 99/99/9999 E0100143-9933-22 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 9/1/2010 99/99/9999 E0100143-9935-91 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 10 GM VIAL 9/1/2010 99/99/9999 E0110019-0680-01 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 9/1/2010 12/31/2011 E0110019-0680-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 9/1/2010 9/30/2013 E0110019-0681-02 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 12/31/2011 E0110019-0681-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 9/30/2013 E0110019-0682-03 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 9/1/2010 12/31/2011 E0110019-0682-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 9/1/2010 9/30/2013 E0163323-0331-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0332-15 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 2 GM VIAL 9/1/2010 99/99/9999 E0163323-0333-61 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 10 GM VIAL 9/1/2010 99/99/9999 E0163323-0334-61 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 20 GM VIAL 9/1/2010 9/30/2011 E0163323-0335-10 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 500 MG VIAL 9/1/2010 99/99/9999 E0164679-0986-01 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 11/30/2010 E0164679-0986-02 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 12/31/2011 E0164679-0986-03 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 12/31/2011 E0164679-0986-04 J0698 CEFOTAXIME SODIUM, PER GM CEFOTAXIME SODIUM 1 GM VIAL 9/1/2010 9/30/2011 E0100085-0566-05 J0702 INJECTION, BETAMETHASONE ACETATE CELESTONE SOLUSPAN 6 MG/ML 9/1/2010 99/99/9999 E0100574-0823-01 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CIT 60 MG/3 ML VIAL 9/1/2010 7/31/2015 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    00574-0823-81 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CIT 60 MG/3 ML VIAL 9/1/2010 99/99/9999 E0151552-0178-05 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CITRATE POWD PURIF 9/1/2010 3/31/2011 E0151552-0178-06 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CITRATE POWD PURIF 9/1/2010 3/31/2011 E0163323-0407-03 J0706 INJECTION, CAFFEINE CITRATE, 5 MG CAFFEINE CIT 60 MG/3 ML VIAL 9/1/2010 99/99/9999 E0100007-5085-11 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GM PIGGYBACK VIAL 9/1/2010 12/31/2010 E0100173-0377-10 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 500 MG VIAL 9/1/2010 2/28/2014 E0100173-0378-10 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 1 GM VIAL 9/1/2010 3/31/2014 E0100173-0379-34 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 2 GM VIAL 9/1/2010 1/31/2014 E0100173-0382-37 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 6 GM VIAL 9/1/2010 11/30/2013 E0100173-0434-00 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 1 GM ADD-VANTAGE VIAL 9/1/2010 4/30/2014 E0100173-0435-00 J0713 INJECTION, CEFTAZIDIME, PER 500MG FORTAZ 2 GM ADD-VANTAGE VIAL 9/1/2010 5/31/2014 E0100409-5082-16 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 1 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5082-52 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 1 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5084-11 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5084-51 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5086-11 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 6 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5086-51 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 6 GRAM VIAL 9/1/2010 99/99/9999 E0100409-5092-16 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 1 GM ADD-VANTAGE VIAL 9/1/2010 99/99/9999 E0100409-5092-52 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 1 GM ADD-VANTAGE VIAL 9/1/2010 99/99/9999 E0100409-5093-11 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GM ADD-VANTAGE 9/1/2010 99/99/9999 E0100409-5093-51 J0713 INJECTION, CEFTAZIDIME, PER 500MG TAZICEF 2 GM ADD-VANTAGE 9/1/2010 99/99/9999 E0100781-3177-96 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 1 GM VIAL 9/1/2010 99/99/9999 E0100781-3178-95 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 2 GM VIAL 9/1/2010 99/99/9999 E0100781-3179-86 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 6 GM VIAL 9/1/2010 99/99/9999 E0110019-0691-02 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 1 GM VIAL 9/1/2010 12/31/2011 E0110019-0692-03 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 2 GM VIAL 9/1/2010 12/31/2011 E0110019-0693-04 J0713 INJECTION, CEFTAZIDIME, PER 500MG CEFTAZIDIME 6 GM VIAL 9/1/2010 12/31/2011 E0163323-0011-15 J0720 INJECTION, CHLORAMPHENICOL SODIUM SUCCIN CHLORAMPHEN NA SUCC 1 GM VL 9/1/2010 99/99/9999 E0100052-0315-10 J0725 INJECTION, CHORIONIC GONADOTROPIN PREGNYL 10,000 UNITS VIAL 9/1/2010 99/99/9999 E0155566-1501-01 J0725 INJECTION, CHORIONIC GONADOTROPIN NOVAREL 10,000 UNITS VIAL 9/1/2010 99/99/9999 E0163323-0025-10 J0725 INJECTION, CHORIONIC GONADOTROPIN CHORIONIC GONAD 10,000 UNIT VL 9/1/2010 99/99/9999 E0151552-0480-01 J0735 INJECTION, CLONIDINE HYDROCHLORIDE CLONIDINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0480-02 J0735 INJECTION, CLONIDINE HYDROCHLORIDE CLONIDINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0480-05 J0735 INJECTION, CLONIDINE HYDROCHLORIDE CLONIDINE HCL POWDER 9/1/2010 3/31/2011 E0166479-0520-01 J0735 INJECTION, CLONIDINE HYDROCHLORIDE DURACLON 100 MCG/ML VIAL 9/1/2010 7/31/2012 E0166479-0521-01 J0735 INJECTION, CLONIDINE HYDROCHLORIDE DURACLON 500 MCG/ML VIAL 9/1/2010 7/31/2012 E0161958-0101-01 J0740 INJECTION, CIDOFOVIR, 375 MG. VISTIDE 75 MG/ML VIAL 9/1/2010 5/31/2015 E0100006-3514-58 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 250 MG VIAL 9/1/2010 99/99/9999 E0100006-3516-59 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 500 MG VIAL 9/1/2010 99/99/9999 E0100006-3551-58 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 250 MG VIAL 9/1/2010 99/99/9999 E0100006-3552-59 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN 500 MG VIAL 9/1/2010 99/99/9999 E0100006-3582-75 J0743 INJECTION, CILASTATIN SODIUM; IMIPENEM, PRIMAXIN I.M. 500 MG VIAL 9/1/2010 9/30/2011 E0100085-1741-02 J0744 INJECTION, CIPROFLOXACIN CIPRO I.V. 400 MG/200 ML D5W 9/1/2010 11/14/2012 E0100085-1755-02 J0744 INJECTION, CIPROFLOXACIN CIPRO I.V. 200 MG/100 ML D5W 9/1/2010 11/14/2012 E0100409-4765-86 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 200 MG/20 ML VL 9/1/2010 99/99/9999 E0100409-4778-86 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 400 MG/40 ML VL 9/1/2010 99/99/9999 E0100703-0956-03 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 200 MG/20 ML VL 9/1/2010 3/31/2012 E0100703-0958-03 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 400 MG/40 ML VL 9/1/2010 3/31/2012 E0155390-0197-01 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 200 MG/20 ML VL 9/1/2010 9/30/2011 E0155390-0198-01 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 400 MG/40 ML VL 9/1/2010 9/30/2011 E0155390-0199-01 J0744 INJECTION, CIPROFLOXACIN CIPROFLOXACIN 10 MG/ML VIAL 9/1/2010 9/30/2011 E0100406-1548-32 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0100406-1548-35 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0100409-1097-32 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PH 15 MG/ML SYRINGE 9/1/2010 9/30/2011 E0100409-1102-32 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PH 30 MG/ML SYRINGE 9/1/2010 9/30/2011 E0151552-0688-02 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0151552-0688-03 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0151552-0688-04 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0151552-0688-06 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE POWDER 9/1/2010 3/31/2011 E0163304-0748-01 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE 30 MG TAB 9/1/2010 12/31/2012 E0163304-0749-01 J0745 INJECTION, CODEINE PHOSPHATE PER 30 MG CODEINE PHOSPHATE 60 MG TAB 9/1/2010 12/31/2012 E0100574-0858-01 J0770 INJECTION, COLISTIMETHATE SODIUM, UP TO COLISTIMETHATE 150 MG VIAL 9/1/2010 99/99/9999 E0139822-0615-01 J0770 INJECTION, COLISTIMETHATE SODIUM, UP TO COLISTIMETHATE 150 MG VIAL 9/1/2010 99/99/9999 E0155390-0077-01 J0780 INJECTION, PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE 5 MG/ML VIAL 9/1/2010 3/31/2014 E0155390-0077-10 J0780 INJECTION, PROCHLORPERAZINE, UP TO 10 MG PROCHLORPERAZINE 10 MG/2 ML VL 9/1/2010 3/31/2015 E0155566-0302-01 J0795 INJECTION, CORTICORELIN OVINE TRIFLUTATE ACTHREL 100 MCG VIAL 9/1/2010 99/99/9999 E0163004-7731-01 J0800 INJECTION, CORTICOTROPIN, UP TO 40 UNITS HP ACTHAR GEL 80 UNIT/ML VIAL 9/1/2010 99/99/9999 E0100781-3440-71 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG COSYNTROPIN 0.25 MG VIAL 7/1/2013 99/99/9999 E0100548-5900-00 J0833 INJECTION, COSYNTROPIN, NOS, 0.25 MG CORTROSYN 0.25 MG VIAL 9/1/2010 6/30/2014 E0100548-5900-00 J0834 INJECTION, COSYNTROPIN, 0.25 MG CORTROSYN 0.25 MG VIAL 9/1/2010 6/30/2014 E0167919-0011-01 J0878 INJECTION DAPTOMYCIN, 1 MG CUBICIN 500 MG VIAL 9/1/2010 99/99/9999 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    55513-0002-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0002-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0003-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0003-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0004-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0004-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0005-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0005-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0006-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 200 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0021-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/0.4 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0021-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 40 MCG/0.4 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0023-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0023-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 60 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0025-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0025-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 100 MCG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0027-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0027-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0028-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 200 MCG/0.4 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0032-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 500 MCG/1 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0053-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.75 ML VIAL 9/1/2010 99/99/9999 E0155513-0053-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 150 MCG/0.75 ML VIAL 9/1/2010 99/99/9999 E0155513-0057-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/0.42 ML SYRING 9/1/2010 99/99/9999 E0155513-0057-04 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 25 MCG/0.42 ML SYRING 9/1/2010 99/99/9999 E0155513-0110-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 300 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0111-01 J0881 INJECTION, DARBEPOETIN ALFA ARANESP 300 MCG/0.6 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0025-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 100 MCG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0027-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 150 MCG/0.3 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0057-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 25 MCG/0.42 ML SYRING 9/1/2010 99/99/9999 E0155513-0002-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 25 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0003-04 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 40 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0005-01 J0882 INJECTION, DARBEPOETIN ALFA, ARANESP 100 MCG/ML VIAL 9/1/2010 99/99/9999 E0155513-0126-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 2,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0126-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 2,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0144-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 10,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0144-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 10,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0148-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 4,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0148-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 4,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0267-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 3,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0267-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 3,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0283-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/2 ML VIAL 9/1/2010 99/99/9999 E0155513-0283-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/2 ML VIAL 9/1/2010 99/99/9999 E0155513-0478-01 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0155513-0478-10 J0885 INJECTION, EPOETIN ALFA EPOGEN 20,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0302-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 2,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0302-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 2,000 UNITS/ML VIAL 9/1/2010 7/1/2013 E0159676-0303-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 3,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0303-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 3,000 UNITS/ML VIAL 9/1/2010 9/1/2013 E0159676-0304-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 4,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0304-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 4,000 UNITS/ML VIAL 9/1/2010 9/1/2013 E0159676-0310-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 10,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0310-02 J0885 INJECTION, EPOETIN ALFA PROCRIT 10,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0320-04 J0885 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0340-01 J0885 INJECTION, EPOETIN ALFA PROCRIT 40,000 UNITS/ML VIAL 9/1/2010 99/99/9999 E0159676-0320-04 J0886 INJECTION, EPOETIN ALFA PROCRIT 20,000 UNITS/ML VIAL 5/1/2011 99/99/9999 E0158063-0600-50 J0894 INJECTION, DECITABINE, 1 MG DACOGEN 50 MG VIAL 9/1/2010 8/31/2012 E0100078-0347-51 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DESFERAL 2 GRAM VIAL 9/1/2010 99/99/9999 E0100078-0467-91 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DESFERAL MESYLATE 500 MG VL 9/1/2010 99/99/9999 E0100409-2336-10 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 500 MG VIAL 9/1/2010 99/99/9999 E0100409-2337-25 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 2 GRAM VIAL 9/1/2010 99/99/9999 E0100555-1131-11 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 2 GRAM VIAL 9/1/2010 3/31/2014 E0100555-1132-12 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 500 MG VIAL 9/1/2010 3/31/2014 E0155390-0263-10 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 500 MG VIAL 9/1/2010 3/31/2014 E0155390-0265-01 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG DEFEROXAMINE 2 GRAM VIAL 9/1/2010 7/30/2012 E0151552-0894-02 J0945 INJECTION, BROMPHENIRAMINE MALEATE BROMPHENIRAMINE MALEATE POWDER 9/1/2010 3/31/2011 E0151552-0894-04 J0945 INJECTION, BROMPHENIRAMINE MALEATE BROMPHENIRAMINE MALEATE POWDER 9/1/2010 3/31/2011 E0151552-0894-05 J0945 INJECTION, BROMPHENIRAMINE MALEATE BROMPHENIRAMINE MALEATE POWDER 9/1/2010 3/31/2011 E0100781-3031-75 J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 ESTRADIOL VALERATE 40 MG/ML VL 9/1/2010 8/31/2011 E0151552-0888-01 J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 ESTRADIOL VALERATE POWDER 9/1/2010 3/31/2011 E0151552-0888-02 J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 ESTRADIOL VALERATE POWDER 9/1/2010 3/31/2011 E0151552-0888-04 J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 ESTRADIOL VALERATE POWDER 9/1/2010 3/31/2011 E0100009-0271-01 J1000 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP DEPO-ESTRADIOL 5 MG/ML VIAL 9/1/2010 99/99/9999 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    00009-0280-02 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0280-03 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0280-51 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0280-52 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3073-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3073-03 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-0031-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, METHYLPREDNISOLONE 40 MG/ML VL 9/1/2010 99/99/9999 E0100703-0031-04 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, METHYLPREDNISOLONE 40 MG/ML VL 9/1/2010 99/99/9999 E0100703-0043-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, METHYLPREDNISOLONE 40 MG/ML VL 9/1/2010 99/99/9999 E0100703-0045-01 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, METHYLPREDNISOLONE 40 MG/ML VL 9/1/2010 99/99/9999 E0100781-3132-95 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100781-3132-71 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100781-3137-75 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100703-0051-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100703-0051-04 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100703-0063-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE 80 MG/ML VL 9/1/2010 99/99/9999 E0100009-0306-12 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0306-02 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3475-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3475-03 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3073-01 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3073-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3475-22 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-3475-23 J1040 INJECTION, METHYLPREDNISOLONE ACETATE DEPO-MEDROL 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-0626-01 J1051 INJECTION, MEDROXYPREGESTERONE ACETATE DEPO-PROVERA 400 MG/ML VIAL 9/1/2010 99/99/9999 E0100009-4709-01 J1051 INJECTION, MEDROXYPREGESTERONE ACETATE DEPO-SUBQ PROVERA 104 SYRINGE 9/1/2010 9/30/2013 E0100009-0746-30 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML VIAL 9/1/2010 12/31/2012 E0100009-0746-35 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML VIAL 9/1/2010 12/31/2012 E0100009-7376-04 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML SYRN 9/1/2010 12/31/2012 E0100703-6801-01 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0100703-6801-04 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0100703-6811-21 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 4/30/2012 E0159762-4537-01 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0159762-4537-02 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0159762-4538-01 J1055 INJECTION, MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE 150 MG/ML 9/1/2010 12/31/2012 E0100009-0347-02 J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO DEPO-TESTOSTERONE 100 MG/ML VL 9/1/2010 99/99/9999 E0100781-3073-70 J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO TESTOSTERONE CYP 100 MG/ML 9/1/2010 99/99/9999 E0151552-0104-02 J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO TESTOSTERONE CYPIONATE POWDER 9/1/2010 3/31/2011 E0151552-0104-05 J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO TESTOSTERONE CYPIONATE POWDER 9/1/2010 3/31/2011 E0100009-0417-01 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC DEPO-TESTOSTERONE 200 MG/ML 9/1/2010 99/99/9999 E0100009-0417-02 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC DEPO-TESTOSTERONE 200 MG/ML 9/1/2010 99/99/9999 E0100591-3223-79 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERON CYP 2,000 MG/10 ML 9/1/2010 99/99/9999 E0100703-6121-01 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERONE CYP 200 MG/ML 9/1/2010 7/31/2011 E0100703-6125-01 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERONE CYP 200 MG/ML 9/1/2010 12/31/2012 E0100781-3074-71 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERONE CYP 200 MG/ML 9/1/2010 99/99/9999 E0100781-3074-70 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC TESTOSTERONE CYP 200 MG/ML 9/1/2010 99/99/9999 E0151552-0024-01 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0024-02 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0024-03 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0024-04 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE POWDER 9/1/2010 3/31/2011 E0151552-0024-05 J1094 INJECTION, DEXAMETHASONE ACETATE DEXAMETHASONE POWDER MICRON 9/1/2010 3/31/2011 E0100641-0367-21 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100069-4541-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/16/2012 8/31/2015 E0100069-4543-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/16/2012 3/31/2015 E0100069-4543-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 8/30/2011 3/31/2015 E0100069-4545-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 8/30/2011 4/30/2015 E0100069-4541-02 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 8/30/2011 8/31/2015 E0100517-4901-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-4905-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100517-4930-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 9/1/2010 99/99/9999 E0100641-0367-25 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-3524-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 2/28/2011 E0100703-3524-03 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 3/31/2011 E0163323-0165-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 4 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0165-05 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 20 MG/5 ML VIAL 9/1/2010 99/99/9999 E0163323-0165-30 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 120 MG/30 ML VL 9/1/2010 99/99/9999 E0163323-0506-01 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0163323-0516-10 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE 100 MG/10 ML VL 9/1/2010 99/99/9999 E0100054-3176-44 J1100 DEXAMETHOSONE SODIUM PHOSPHATE, 1MG DEXAMETHASONE INTENSOL 1MG/1ML 9/1/2010 99/99/9999 E0100574-0850-05 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML AM 9/1/2010 99/99/9999 E0100574-0850-10 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML AM 9/1/2010 99/99/9999 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    51552-0233-01 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE POWDER 9/1/2010 3/31/2011 E0151552-0233-02 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE POWDER 9/1/2010 3/31/2011 E0151552-0233-05 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE POWDER 9/1/2010 3/31/2011 E0155390-0013-10 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG DIHYDROERGOTAMINE 1 MG/ML VL 9/1/2010 3/31/2014 E0166490-0041-01 J1110 INJECTION, DEHYDROERGOTAMINE, PER 1 MG D.H.E.45 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0155390-0460-01 J1120 INJECTION, ACETAZOLAMIDE SODIUM, UP TO 5 ACETAZOLAMIDE SOD 500 MG VIAL 9/1/2010 3/31/2014 E0100173-0260-10 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG LANOXIN 500 MCG/2 ML AMPULE 9/1/2010 3/31/2014 E0100173-0260-35 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG LANOXIN 0.25 MG/ML AMPUL 9/1/2010 9/30/2012 E0100173-0262-10 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG LANOXIN PED 0.1 MG/ML AMPUL 9/1/2010 7/31/2014 E0100409-2169-31 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 0.25 MG/ML SYRINGE 9/1/2010 9/30/2011 E0100641-1410-35 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 0.25 MG/ML AMPUL 9/1/2010 99/99/9999 E0100781-3059-95 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG DIGOXIN 0.25 MG/ML AMPUL 9/1/2010 99/99/9999 E0100173-0230-44 J1162 INJECTION,DIGOXIN IMMUNE FAB DIGIBIND 38 MG VIAL 9/1/2010 1/31/2013 E0100281-0365-10 J1162 INJECTION,DIGOXIN IMMUNE FAB DIGIFAB 40 MG VIAL 9/1/2010 8/31/2012 E0100143-9881-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 250 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100143-9882-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 100 MG/2 ML VIAL 9/1/2010 99/99/9999 E0100409-1317-01 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML AMPUL 9/1/2010 9/30/2011 E0100409-1317-02 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML AMPUL 9/1/2010 99/99/9999 E0100409-1844-32 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML SYRINGE 9/1/2010 6/30/2014 E0100641-0493-25 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-2555-45 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-7101-04 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG FOSPHENYTOIN 100 MG PE/2 ML VL 9/1/2010 8/31/2011 E0100703-7105-03 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG FOSPHENYTOIN 500 MG PE/10 ML 9/1/2010 3/31/2011 E0151552-0532-04 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG PHENYTOIN SODIUM POWDER 9/1/2010 3/31/2011 E0160505-0765-04 J1165 INJECTION, PHENYTOIN SODIUM,PER 50 MG FOSPHENYTOIN 500 MG PE/10 ML 9/1/2010 99/99/9999 E0117478-0540-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML VL 11/10/2010 99/99/9999 E0100409-2634-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2634-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 50 MG/5 ML VIAL 9/1/2010 99/99/9999 E0100409-2634-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 500 MG/50 ML VIA 9/1/2010 99/99/9999 E0159011-0441-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0442-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0442-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0444-10 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0445-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0445-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML AMPUL 9/1/2010 99/99/9999 E0159011-0445-50 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 10 MG/ML VIAL 9/1/2010 99/99/9999 E0159011-0446-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID-HP 250 MG VIAL 9/1/2010 99/99/9999 E0100074-2332-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 1 MG/ML AMPUL 9/1/2010 3/31/2011 E0100074-2333-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 9/1/2010 3/31/2011 E0100074-2333-26 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 2 MG/ML AMPUL 9/1/2010 3/1/2011 E0100074-2334-11 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG DILAUDID 4 MG/ML AMPUL 9/1/2010 3/31/2011 E0100406-3245-52 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 9/1/2010 3/31/2011 E0100409-1283-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 1 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-1304-31 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 4 MG/ML SYRIN 9/1/2010 99/99/9999 E0100409-1312-30 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-2172-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 9/1/2010 7/1/2011 E0100409-2172-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 10 MG/ML AMP 9/1/2010 9/30/2011 E0100409-2540-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 4 MG/ML AMP 9/1/2010 99/99/9999 E0100409-2552-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 1 MG/ML AMP 9/1/2010 99/99/9999 E0100409-3356-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL 2 MG/ML AMP 9/1/2010 99/99/9999 E0100409-3365-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100555-1117-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 9/1/2010 8/31/2011 E0100555-1117-06 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 9/1/2010 9/30/2011 E0100555-1117-07 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 10 MG/ML VIAL 9/1/2010 6/30/2011 E0100574-2017-01 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 9/1/2010 3/31/2011 E0100641-0121-25 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-2341-41 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0138779-0731-05 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL POWDER 9/1/2010 3/31/2011 E0100641-0121-21 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE 2 MG/ML VIAL 9/1/2010 99/99/9999 E0100013-8715-62 J1190 INJECTION, DEXTAZOXANE HCL ZINECARD 250 MG VIAL 9/1/2010 12/31/2012 E0100013-8725-89 J1190 INJECTION, DEXTAZOXANE HCL ZINECARD 500 MG VIAL 9/1/2010 12/31/2012 E0155390-0014-02 J1190 INJECTION, DEXTAZOXANE HCL DEXRAZOXANE 250 MG VIAL 9/1/2010 3/31/2014 E0155390-0060-02 J1190 INJECTION, DEXTAZOXANE HCL DEXRAZOXANE 500 MG VIAL 9/1/2010 5/31/2013 E0100409-2290-31 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML SYRNG 9/1/2010 99/99/9999 E0100548-1390-00 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML SYN 9/1/2010 3/31/2011 E0100641-0376-25 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0124-02 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0124-04 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0124-05 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0124-06 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE HCL POWDER 9/1/2010 3/31/2011 E0163323-0664-01 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 DIPHENHYDRAMINE 50 MG/ML VIAL 9/1/2010 99/99/9999 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    67386-0711-55 J1205 INJECTION, CHLOROTHIAZIDE SODIUM DIURIL SODIUM 500 MG VIAL 9/1/2010 11/30/2012 E0151552-1053-06 J1212 INJECTION, DMSO, DIMETHYL SULFOXIDE DIMETHYL SULFOXIDE LIQUID 9/1/2010 3/31/2011 E0100406-1510-56 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0100406-1510-57 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0100406-1510-59 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0151552-0728-01 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0151552-0728-02 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0151552-0728-04 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL POWDER 9/1/2010 3/31/2011 E0166479-0530-02 J1230 INJECTION, METHADONE HCL, UP TO 10 MG METHADONE HCL 10 MG/ML VIAL 9/1/2010 9/30/2011 E0163323-0366-01 J1240 INJECTION, DIMENHYDRINATE, UP TO 50 MG DIMENHYDRINATE 50 MG/ML VIAL 9/1/2010 99/99/9999 E0100641-2569-44 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 99/99/9999 E0100703-1652-02 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 12/31/2010 E0100703-1654-02 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 12/31/2010 E0155390-0555-10 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 9/30/2011 E0155390-0555-90 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG DIPYRIDAMOLE 5 MG/ML VIAL 9/1/2010 9/30/2011 E0100338-1073-02 J1250 DOBUTAMINE HCL DOBUTAMINE 250 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100338-1075-02 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100338-1077-02 J1250 DOBUTAMINE HCL DOBUTAMINE 1 GM-D5W 250 ML 9/1/2010 99/99/9999 E0100409-2025-20 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2025-54 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2344-01 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2344-02 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2344-88 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-2346-32 J1250 DOBUTAMINE HCL DOBUTAMINE 250 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-2346-34 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 500 ML 9/1/2010 9/30/2011 E0100409-2347-32 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-2347-33 J1250 DOBUTAMINE HCL DOBUTAMINE 500 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-3724-32 J1250 DOBUTAMINE HCL DOBUTAMINE 1 GM-D5W 250 ML 9/1/2010 99/99/9999 E0155390-0560-90 J1250 DOBUTAMINE HCL DOBUTAMINE 12.5 MG/ML VIAL 9/1/2010 3/31/2014 E0100088-1206-32 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100088-1208-06 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100088-1208-69 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 12.5 MG CARPUJECT 9/1/2010 9/30/2013 E0100088-1209-26 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG ANZEMET 20 MG/ML VIAL 9/1/2010 99/99/9999 E0100264-1441-55 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 500 ML 9/1/2010 3/31/2011 E0100264-1481-55 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 500 ML 9/1/2010 3/31/2011 E0100264-1482-55 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE-D5W 400 MG/250 ML 9/1/2010 8/31/2012 E0100264-1492-55 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 250 ML 9/1/2010 3/31/2011 E0100338-1005-02 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 200 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100338-1005-03 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 500 ML 9/1/2010 99/99/9999 E0100338-1007-02 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100338-1007-03 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 500 ML 9/1/2010 99/99/9999 E0100338-1009-02 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-4142-02 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 250 ML 9/1/2010 9/30/2011 E0100409-4265-01 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 80 MG/ML VIAL 9/1/2010 9/30/2011 E0100409-5820-01 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-7808-22 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 200 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-7808-24 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 500 ML 9/1/2010 99/99/9999 E0100409-7809-22 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 400 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-7809-24 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 500 ML 9/1/2010 99/99/9999 E0100409-7810-22 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 800 MG-D5W 250 ML 9/1/2010 99/99/9999 E0100409-9104-20 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-1305-25 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 160 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-1805-25 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 40 MG/ML VIAL 9/1/2010 99/99/9999 E0100517-1905-25 J1265 INJECTION, DOPAMINE HCL, 40 MG DOPAMINE 80 MG/ML VIAL 9/1/2010 99/99/9999 E0100062-4010-02 J1267 DORIPENEM INJECTION DORIBAX 500 MG VIAL 9/1/2010 2/28/2011 E0158468-0126-01 J1270 INJECTION, DOXERCALCIFEROL, 1 MCG HECTOROL 2 MCG/ML VIAL 1/1/2011 99/99/9999 E0158468-0122-01 J1270 INJECTION, DOXERCALCIFEROL, 1 MCG HECTOROL 4 MCG/2 ML AMPUL 9/1/2010 9/30/2010 E0125682-0001-01 J1300 INJECTION, ECULIZUMAB, 10 MG SOLIRIS 300 MG/30 ML VIAL 9/1/2010 99/99/9999 E0151552-0464-02 J1320 INJECTION, AMITRIPTYLINE HCL, UP TO AMITRIPTYLINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0464-04 J1320 INJECTION, AMITRIPTYLINE HCL, UP TO AMITRIPTYLINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0464-05 J1320 INJECTION, AMITRIPTYLINE HCL, UP TO AMITRIPTYLINE HCL POWDER 9/1/2010 3/31/2011 E0151552-0464-06 J1320 INJECTION, AMITRIPTYLINE HCL, UP TO AMITRIPTYLINE HCL POWDER 9/1/2010 3/31/2011 E0100004-0380-39 J1324 INJECTION, ENFUVIRTIDE, 1 MG FUZEON CONVENIENCE KIT 9/1/2010 6/30/2013 E0100173-0517-00 J1325 INJECTION, EPOPROSTENOL, 0.5 MG FLOLAN 0.5 MG VIAL 9/1/2010 99/99/9999 E0100173-0519-00 J1325 INJECTION, EPOPROSTENOL, 0.5 MG FLOLAN 1.5 MG VIAL 9/1/2010 99/99/9999 E0151552-0188-01 J1330 INJECTION, ERGONOVINE MALEATE, UP TO 0.2 ERGONOVINE MALEATE POWDER 9/1/2010 3/31/2011 E0151552-0188-07 J1330 INJECTION, ERGONOVINE MALEATE, UP TO 0.2 ERGONOVINE MALEATE POWDER 9/1/2010 3/31/2011 E0100006-3843-71 J1335 ERTAPENEM SODIUM INJECTION INVANZ 1 GM VIAL 9/1/2010 99/99/9999 E0100006-3845-71 J1335 ERTAPENEM SODIUM INJECTION INVANZ 1 GM ADD-VANTAGE VIAL 9/1/2010 99/99/9999 E0100409-6476-44 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 500 MG ADDVNT VL 9/1/2010 99/99/9999 E0100409-6478-44 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 1 GM ADDVANT VIAL 9/1/2010 9/30/2011 E01

  • Updated 11.4.14

    NDC HCPCS HCPCS Description NDC Description Effective Date End DateX-Over

    Only Fee Schedule

    00409-6482-01 J1364 ERYTHROMYCIN LACTOBIONATE ERYTHROCIN 500 MG VIAL 9/1/2010 99/99/9999 E0100781-3030-75 J1380 INJECTION, ESTRADIOL VALERATE, UP TO 10 ESTRADIOL VALERATE 10 MG/ML VL 9/1/2010 12/31/2012 E0100781-3029-75 J1390 INJECTION, ESTRADIOL VALERATE, UP TO 20 ESTRADIOL VALERATE 20 MG/ML VL 9/1/2010 3/31/2013 E0100046-0749-05 J1410 INJECTION, ESTROGEN CONJUGATED PREMARIN 25 MG VIAL 9/1/2010 99/99/9999 E0151552-0445-01 J1435 INJECTION, ESTRONE, PER 1 MG ESTRONE CRYSTAL 9/1/2010 3/31/2011 E0151552-0445-02 J1435 INJECTION, ESTRONE, PER 1 MG ESTRONE CRYSTAL 9/1/2010 3/31/2011 E0151552-0445-04 J1435 INJECTION, ESTRONE, PER 1 MG ESTRONE CRYSTAL 9/1/2010 3/31/2011 E0158406-0425-34 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 25 MG KIT 9/1/2010 99/99/9999 E0158406-0425-41 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 25 MG KIT 9/1/2010 99/99/9999 E0158406-0435-01 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 50 MG/ML SYRINGE 9/1/2010 99/99/9999 E0158406-0435-04 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 50 MG/ML SYRINGE 9/1/2010 99/99/9999 E0158406-0445-01 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 50 MG/ML SURECLICK SYR 9/1/2010 99/99/9999 E0158406-0445-04 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 50 MG/ML SURECLICK SYR 9/1/2010 99/99/9999 E0158406-0455-01 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 25 MG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0158406-0455-04 J1438 INJECTION, ETANERCEPT, 25 MG ENBREL 25 MG/0.5 ML SYRINGE 9/1/2010 99/99/9999 E0155513-0530-01 J1440 NJECTION, FILGRASTIM NEUPOGEN 300 MCG/ML VIAL 9/1/2010