Payment Allowance Limits for Medicare Part B Drugs,,,,,,,,,,,,,
,,,,,,,,,,,,,
"Effective October 1, 2016 through December 31, 2016",,,,,,,,,,,,,
,,,,,,,,,,,,,
Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q16 ASP data. ,,,,,,,,,,,,,
"Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment",,,,,,,,,,,,,
allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category.  These determinations shall be made by the local Medicare contractor,,,,,,,,,,,,,
processing the claim.,,,,,,,,,,,,,
,,,,,,,,,,,,,
HCPCS Code,Short Description,HCPCS Code Dosage,Payment Limit,Vaccine AWP%,Vaccine Limit,Infusion AWP%,DME Infusion Limit,Blood AWP%,Blood limit,Clotting Factor,Notes,,
90371,Hep b ig im,1 ML,111.332,,,,,,,,,,
90375,Rabies ig im/sc,150 IU,305.475,,,,,,,,,,
90376,Rabies ig heat treated,150 IU,294.585,,,,,,,,,,
90585,Bcg vaccine percut,50 MG,123.195,,,,,,,,,,
90586,"Bcg vaccine, intravesical",1 EACH,123.195,,,,,,,,,,
90630,Flu vacc iiv4 no preserv id,0.1 ml,20.343,95,20.343,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
90632,"Hep a vaccine, adult im",1 ML,50.854,,,,,,,,,,
90653,Iiv adjuvant vaccine im,0.5 ml,37.383,95,37.383,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates ,,
90656,IIV3 VACC NO PRSV 0.5 ML IM,0.50 ML,17.717,95,17.717,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
90662,Iiv no prsv increased ag im,0.5 ML,42.722,95,42.722,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
90670,"Pneumococcal vacc, 13 val im",0.5 ML,181.061,95,181.061,,,,,,,,
90672,Laiv4 vaccine intranasal,0.2 ml,26.876,95,26.876,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
90673,Riv3 vaccine no preserv im,0.5 ML,40.613,95,40.613,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
90674,CCIIV4 VAC NO PRSV 0.5 ML IM,0.5 ML,22.936,95,22.936,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
90675,Rabies vaccine im,1 ML,272.489,,,,,,,,,,
90685,IIV4 VACC NO PRSV 0.25 ML IM,0.25 mL,26.268,95,26.268,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
90686,IIV4 VACC NO PRSV 0.5 ML IM,0.5 ml,19.032,95,19.032,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
90687,IIV4 VACCINE SPLT 0.25 ML IM,0.25 ML,9.403,95,9.403,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates ,,
90688,IIV4 VACCINE SPLT 0.5 ML IM,0.5 ML,17.835,95,17.835,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates ,,
90691,"Typhoid vaccine, im",0.5 ML,84.037,,,,,,,,,,
90714,"Td vaccine no prsrv >/= 7 yo, im",0.5 ML,24.188,,,,,,,,,,
90715,"Tdap => 7 yo, im",0.5 ML,31.367,,,,,,,,,,
90732,Pneumococcal vaccine,0.5 ML,89.945,95,89.945,,,,,,,,
90740,"Hepb vacc, ill pat 3 dose im",40 MCG,122.957,95,122.957,,,,,,,,
90743,"Hep b vacc, adol, 2 dose, im",1 DOSE,25.392,95,25.392,,,,,,,,
90744,Hepb vacc ped/adol 3 dose im,1 DOSE,25.392,95,25.392,,,,,,,,
90746,"Hep b vaccine, adult, im",20 MCG,61.475,95,61.475,,,,,,,,
90747,"Hepb vacc, ill pat 4 dose im",40 MCG,122.957,95,122.957,,,,,,,,
A9575,Inj gadoterate meglumi 0.1 ml,0.1 ml,0.200,,,,,,,,,,
A9576,Inj prohance multipack,1 ML,1.611,,,,,,,,,,
A9577,Inj multihance,1 ML,2.080,,,,,,,,,,
A9578,Inj multihance multipack,1 ML,2.013,,,,,,,,,,
A9579,"Gad-base MR contrast NOS,1ml",1 ML,1.843,,,,,,,,,,
A9581,Gadoxetate disodium inj,1 ML,13.949,,,,,,,,,,
A9583,Gadofosveset trisodium inj,1 ML,17.925,,,,,,,,,,
A9585,Gadobutrol injection,0.1 ML,0.388,,,,,,,,,,
A9606,Radium ra223 dichloride ther,1 microCurie,N/A,,,,,,,,"
microCurie 100% AWP = $148.660
microCurie 100% WAC = $123.880
",,
J0129,Abatacept injection,10 MG,44.750,,,,,,,,,,
J0130,Abciximab injection,10 MG,1136.511,,,,,,,,,,
J0132,Acetylcysteine injection,100 MG,1.506,,,,,,,,,,
J0133,Acyclovir injection,5 MG,0.074,,,,,,,,,,
J0135,Adalimumab injection,20 MG,861.447,,,,,,,,,,
J0153,Adenosine inj 1mg,1 MG,0.630,,,,,,,,,,
J0171,Adrenalin epinephrine inject,0.1 MG,0.136,,,,,,,,,,
J0178,Aflibercept injection ,1 MG,980.455,,,,,,,,,,
J0180,Agalsidase beta injection,1 MG,164.415,,,,,,,,,,
J0202,"Injection, Alemtuzumab",1 MG,1738.364,,,,,,,,,,
J0207,Amifostine,500 MG,416.532,,,,,,,,,,
J0221,Lumizyme injection,10 MG,159.385,,,,,,,,,,
J0256,Alpha 1 proteinase inhibitor,10 MG,4.828,,,,,,,,,,
J0257,Glassia injection,10 MG,4.367,,,,,,,,,,
J0278,Amikacin sulfate injection,100 MG,1.479,,,,,,,,,,
J0280,Aminophyllin 250 MG inj,250 MG,8.834,,,,,,,,,,
J0285,Amphotericin B,50 MG,27.935,,,95,10.280,,,,,,
J0287,Amphotericin b lipid complex,10 MG,13.407,,,95,21.850,,,,,,
J0289,Amphotericin b liposome inj,10 MG,19.012,,,95,35.800,,,,,,
J0290,Ampicillin 500 MG inj,500 MG,1.307,,,,,,,,,,
J0295,Ampicillin sodium per 1.5 gm,1.5 GM,3.697,,,,,,,,,,
J0348,Anidulafungin injection,1 MG,0.507,,,,,,,,,,
J0360,Hydralazine hcl injection,20 MG,4.591,,,,,,,,,,
J0401,Inj aripriprazole ext rel 1mg,1 MG,4.383,,,,,,,,,,
J0456,Azithromycin,500 MG,3.307,,,,,,,,,,
J0461,Atropine sulfate injection,0.01 MG,0.036,,,,,,,,,,
J0470,Dimecaprol injection,100 MG,39.337,,,,,,,,,,
J0475,Baclofen 10 MG injection,10 MG,173.425,,,95,215.180,,,,,,
J0476,Baclofen intrathecal trial,50 MCG,76.957,,,95,79.800,,,,,,
J0480,Basiliximab,20 MG,3196.111,,,,,,,,,,
J0485,Belatacept injection,1 MG,3.841,,,,,,,,,,
J0490,Belimumab injection,10 MG,42.018,,,,,,,,,,
J0500,Dicyclomine injection,20 MG,63.589,,,,,,,,,,
J0515,Inj benztropine mesylate,1 MG,34.420,,,,,,,,,,
J0558,PenG benzathine/procaine inj,"100,000 UNITS",7.964,,,,,,,,,,
J0561,Penicillin g benzathine inj,"100,000 UNITS",10.307,,,,,,,,,,
J0583,Bivalirudin,1 MG,1.529,,,,,,,,,,
J0585,"Injection,onabotulinumtoxinA",1 UNIT,5.930,,,,,,,,,,
J0586,AbobotulinumtoxinA,5 Unit,7.902,,,,,,,,,,
J0587,"Inj, rimabotulinumtoxinB",100 UNITS,11.708,,,,,,,,,,
J0588,Incobotulinumtoxin A,1 UNIT,4.907,,,,,,,,,,
J0592,Buprenorphine hydrochloride,0.1 MG,3.372,,,,,,,,,,
J0594,Busulfan injection,1 MG,38.372,,,,,,,,,,
J0595,Butorphanol tartrate 1 mg,1 MG,2.423,,,,,,,,,,
J0597,"C-1 esterase, berinert",10 UNITS,46.515,,,,,,,,,,
J0598,"C-1 esterase, cinryze",10 UNITS,55.546,,,,,,,,,,
J0600,Edetate calcium disodium inj,1000 MG,5594.422,,,,,,,,,,
J0610,Calcium gluconate injection,10 ML,3.508,,,,,,,,,,
J0630,Calcitonin salmon injection,400 UNITS,2321.135,,,,,,,,,,
J0636,Inj calcitriol per 0.1 mcg,0.1 MCG,0.493,,,,,,,,,,
J0637,Caspofungin acetate,5 MG,12.214,,,,,,,,,,
J0638,Canakinumab injection,1 MG,92.494,,,,,,,,,,
J0640,Leucovorin calcium injection,50 MG,3.092,,,,,,,,,,
J0641,Levoleucovorin injection,0.5 MG,0.898,,,,,,,,,,
J0670,Inj mepivacaine HCL/10 ml,10 ML,2.318,,,,,,,,,,
J0690,Cefazolin sodium injection,500 MG,0.948,,,,,,,,,,
J0692,Cefepime HCl for injection,500 MG,2.456,,,,,,,,,,
J0694,Cefoxitin sodium injection,1 GM,4.624,,,,,,,,,,
J0696,Ceftriaxone sodium injection,250 MG,0.496,,,,,,,,,,
J0697,Sterile cefuroxime injection,750 MG,2.873,,,,,,,,,,
J0698,Cefotaxime sodium injection,1 GM,0.460,,,,,,,,,,
J0702,Betamethasone acet&sod phosp,3 MG & 3 MG,6.030,,,,,,,,,,
J0712,Ceftaroline fosamil inj,10 MG,2.480,,,,,,,,,,
J0713,Inj ceftazidime per 500 mg,500 MG,2.255,,,,,,,,,,
J0717,Certolizumab Pegol Inj 1mg,1 MG,7.056,,,,,,,,,,
J0720,Chloramphenicol sodium injec,1 GM,40.361,,,,,,,,,,
J0725,Chorionic gonadotropin/1000u,1000 UNITS,24.619,,,,,,,,,,
J0735,Clonidine hydrochloride,1 MG,14.305,,,,,,,,,,
J0740,Cidofovir injection,375 MG,554.484,,,,,,,,,,
J0743,Cilastatin sodium injection,250 MG,7.079,,,,,,,,,,
J0744,Ciprofloxacin iv,200 MG,1.152,,,,,,,,,,
J0770,Colistimethate sodium inj,150 MG,11.185,,,,,,,,,,
J0775,"Collagenase, clost hist inj",0.01 MG,41.415,,,,,,,,,,
J0780,Prochlorperazine injection,10 MG,11.932,,,,,,,,,,
J0795,Corticorelin ovine triflutal,1 MCG,8.120,,,,,,,,,,
J0800,Corticotropin injection,40 UNITS,3555.346,,,,,,,,,,
J0834,Cosyntropin cortrosyn inj,0.25 MG,43.702,,,,,,,,,,
J0840,Crotalidae poly immune fab,UP TO 1 GM,2670.235,,,,,,,,,,
J0850,Cytomegalovirus imm IV /vial,PER VIAL,1126.546,,,,,,,,,,
J0875,"Injection, dalbavancin",5 MG,15.216,,,,,,,,,,
J0878,Daptomycin injection,1 MG,0.904,,,,,,,,,,
J0881,"Darbepoetin alfa, non-esrd",1 MCG,3.933,,,,,,,,,,
J0882,"Darbepoetin alfa, esrd use",1 MCG,3.933,,,,,,,,,,
J0885,"Epoetin alfa, non-esrd",1000 UNITS,12.591,,,,,,,,,,
J0887,Epoetin beta esrd use,1 MCG,1.479,,,,,,,,,,
J0888,Epoetin beta non esrd,1 MCG,1.479,,,,,,,,,,
J0894,Decitabine injection,1 MG,20.832,,,,,,,,,,
J0895,Deferoxamine mesylate inj,500 MG,8.849,,,95,15.630,,,,,,
J0897,Denosumab injection,1 MG,16.227,,,,,,,,,,
J1000,Depo-estradiol cypionate inj,5 MG,16.798,,,,,,,,,,
J1020,Methylprednisolone 20 MG inj,20 MG,4.821,,,,,,,,,,
J1030,Methylprednisolone 40 MG inj,40 MG,5.222,,,,,,,,,,
J1040,Methylprednisolone 80 MG inj,80 MG,9.800,,,,,,,,,,
J1050,Medroxyprogesterone acetate,1 MG,0.417,,,,,,,,,,
J1071,Inj testosterone cypionate,1 MG,0.023,,,,,,,,,,
J1100,Dexamethasone sodium phos,1 MG,0.117,,,,,,,,,,
J1110,Inj dihydroergotamine mesylt,1 MG,75.490,,,,,,,,,,
J1120,Acetazolamid sodium injectio,500 MG,21.184,,,,,,,,,,
J1160,Digoxin injection,0.5 MG,4.817,,,,,,,,,,
J1162,Digoxin immune fab (ovine),PER VIAL,3039.529,,,,,,,,,,
J1165,Phenytoin sodium injection,50 MG,1.414,,,,,,,,,,
J1170,Hydromorphone injection,4 MG,2.143,,,95,1.490,,,,,,
J1190,Dexrazoxane HCl injection,250 MG,184.046,,,,,,,,,,
J1200,Diphenhydramine hcl injectio,50 MG,0.627,,,,,,,,,,
J1205,Chlorothiazide sodium inj,500 MG,86.677,,,,,,,,,,
J1212,Dimethyl sulfoxide 50% 50 ML,50 ML,481.940,,,,,,,,,,
J1230,Methadone injection,10 MG,17.142,,,95,0.750,,,,,,
J1240,Dimenhydrinate injection,50 MG,6.322,,,,,,,,,,
J1245,Dipyridamole injection,10 MG,0.784,,,,,,,,,,
J1250,Inj dobutamine HCL/250 mg,250 MG,5.272,,,95,4.740,,,,,,
J1260,Dolasetron mesylate,10 MG,6.168,,,,,,,,,,
J1265,Dopamine injection,40 MG,0.649,,,,,,,,,,
J1267,Doripenem injection,10 MG,0.775,,,,,,,,,,
J1270,"Injection, doxercalciferol",1 MCG,0.918,,,,,,,,,,
J1290,Ecallantide injection,1 MG,399.562,,,,,,,,,,
J1300,Eculizumab injection,10 MG,221.116,,,,,,,,,,
J1325,Epoprostenol injection,0.5 MG,15.483,,,95,12.640,,,,,,
J1335,Ertapenem injection,500 MG,45.170,,,,,,,,,,
J1364,Erythro lactobionate /500 MG,500 MG,59.290,,,,,,,,,,
J1380,Estradiol valerate 10 MG inj,10 MG,9.076,,,,,,,,,,
J1410,Inj estrogen conjugate 25 MG,25 MG,261.395,,,,,,,,,,
J1430,Ethanolamine oleate 100 mg,100 MG,404.093,,,,,,,,,,
J1439,Inj ferric carboxymaltos 1mg,1 MG,1.051,,,,,,,,,,
J1442,Inj filgrastim excl biosimil,1 MCG,1.003,,,,,,,,,,
J1447,Inj tbo filgrastim 1 microg,1 MCG,0.742,,,,,,,,,,
J1450,Fluconazole,200 MG,4.336,,,,,,,,,,
J1453,Fosaprepitant injection,1 MG,1.886,,,,,,,,,,
J1458,Galsulfase injection,1 MG,364.405,,,,,,,,,,
J1459,Inj IVIG privigen 500 mg,500 MG,37.898,,,,,,,,,,
J1460,Gamma globulin 1 CC inj,1 CC,36.412,,,,,,,,,,
J1556,"Inj, Imm Glob Bivigam, 500mg",500 MG,39.521,,,,,,,,,,
J1557,Gammaplex injection,500 MG,37.032,,,,,,,,,,
J1559,Hizentra injection,100 MG,9.829,,,,,,,,,,
J1560,Gamma globulin > 10 CC inj,10 CC,364.120,,,,,,,,,,
J1561,Gamunex-C/Gammaked,500 MG,38.582,,,,,,,,,,
J1566,"Immune globulin, powder",500 MG,33.073,,,,,,,,,,
J1568,Octagam injection,500 MG,35.980,,,,,,,,AMP-based payment limit,,
J1569,Gammagard liquid injection,500 MG,39.995,,,,,,,,,,
J1570,Ganciclovir sodium injection,500 MG,58.653,,,95,35.250,,,,AMP-based payment limit,,
J1571,Hepagam b im injection,0.5 ML,56.058,,,,,,,,,,
J1572,Flebogamma injection,500 MG,36.804,,,,,,,,,,
J1575,Hyqvia 100mg immuneglobulin,100 MG,12.744,,,,,,,,,,
J1580,Garamycin gentamicin inj,80 MG,1.405,,,,,,,,,,
J1602,Golimumab for iv use 1mg,1 MG,24.787,,,,,,,,,,
J1610,Glucagon hydrochloride/1 MG,1 MG,199.118,,,,,,,,,,
J1626,Granisetron hcl injection,100 MCG,0.295,,,,,,,,,,
J1630,Haloperidol injection,5 MG,1.520,,,,,,,,,,
J1631,Haloperidol decanoate inj,50 MG,18.040,,,,,,,,,,
J1640,"Hemin, 1 mg",1 MG,22.858,,,,,,,,,,
J1642,Inj heparin sodium per 10 u,10 UNITS,0.180,,,,,,,,,,
J1644,Inj heparin sodium per 1000u,1000 UNITS,0.212,,,,,,,,,,
J1645,Dalteparin sodium,2500 IU,15.921,,,,,,,,,,
J1650,Inj enoxaparin sodium,10 MG,0.873,,,,,,,,,,
J1652,Fondaparinux sodium,0.5 MG,2.239,,,,,,,,,,
J1670,Tetanus immune globulin inj,250 UNITS,433.063,,,,,,,,,,
J1720,Hydrocortisone sodium succ i,100 MG,8.531,,,,,,,,,,
J1740,Ibandronate sodium injection,1 MG,101.963,,,,,,,,,,
J1742,Ibutilide fumarate injection,1 MG,186.194,,,,,,,,,,
J1743,Idursulfase injection,1 MG,522.035,,,,,,,,,,
J1745,Infliximab injection,10 MG,82.872,,,,,,,,,,
J1750,Inj iron dextran,50 MG,12.405,,,,,,,,,,
J1756,Iron sucrose injection,1 MG,0.255,,,,,,,,,,
J1786,Imuglucerase injection,10 UNITS,41.932,,,,,,,,,,
J1800,Propranolol injection,1 MG,1.145,,,,,,,,,,
J1815,Insulin injection,5 UNITS,0.801,,,,,,,,,,
J1817,Insulin for insulin pump use,50 UNITS,9.098,,,95,2.800,,,,,,
J1885,Ketorolac tromethamine inj,15 MG,0.666,,,,,,,,,,
J1930,Lanreotide injection,1 MG,51.308,,,,,,,,,,
J1931,Laronidase injection,0.1 MG,30.587,,,,,,,,,,
J1940,Furosemide injection,20 MG,2.051,,,,,,,,,,
J1950,Leuprolide acetate /3.75 MG,3.75 MG,1038.696,,,,,,,,,,
J1953,Levetiracetam injection,10 MG,0.142,,,,,,,,,,
J1955,Inj levocarnitine per 1 gm,1 GM,19.888,,,,,,,,,,
J1956,Levofloxacin injection,250 MG,1.663,,,,,,,,,,
J1980,Hyoscyamine sulfate inj,0.25 MG,27.854,,,,,,,,,,
J2001,Lidocaine injection,10 MG,0.018,,,,,,,,,,
J2010,Lincomycin injection,300 MG,12.058,,,,,,,,,,
J2020,Linezolid injection,200 MG,15.779,,,,,,,,,,
J2060,Lorazepam injection,2 MG,0.803,,,,,,,,,,
J2150,Mannitol injection,50 ML,1.849,,,,,,,,,,
J2175,Meperidine hydrochl /100 MG,100 MG,5.094,,,95,0.560,,,,,,
J2185,Meropenem,100 MG,1.308,,,,,,,,,,
J2210,Methylergonovin maleate inj,0.2 MG,8.034,,,,,,,,,,
J2248,Micafungin sodium injection,1 MG,0.965,,,,,,,,,,
J2250,Inj midazolam hydrochloride,1 MG,0.140,,,,,,,,,,
J2270,Morphine sulfate injection,10 MG,1.230,,,95,0.710,,,,,,
J2274,In morphine preservativ free,10MG,9.052,,,,,,,,,,
J2278,Ziconotide injection,1 MCG,7.306,,,,,,,,,,
J2280,"Inj, moxifloxacin 100 mg",100 MG,8.487,,,,,,,,,,
J2300,Inj nalbuphine hydrochloride,10 MG,2.518,,,,,,,,,,
J2310,Inj naloxone hydrochloride,1 MG,32.405,,,,,,,,,,
J2315,"Naltrexone, depot form",1 MG,3.239,,,,,,,,,,
J2323,Natalizumab injection,1 MG,17.894,,,,,,,,,,
J2353,"Octreotide injection, depot",1 MG,168.110,,,,,,,,,,
J2354,"Octreotide inj, non-depot",25 MCG,1.190,,,,,,,,,,
J2355,Oprelvekin injection,5 MG,467.216,,,,,,,,,,
J2357,Omalizumab injection,5 MG,32.306,,,,,,,,,,
J2358,Olanzapine long-acting inj,1 MG,2.917,,,,,,,,,,
J2360,Orphenadrine injection,60 MG,3.671,,,,,,,,,,
J2400,Chloroprocaine hcl injection,30 ML,25.951,,,,,,,,,,
J2405,Ondansetron hcl injection,1 MG,0.130,,,,,,,,,,
J2407,"Injection, oritavancin",10 MG,24.642,,,,,,,,,,
J2410,Oxymorphone hcl injection,1 MG,2.888,,,,,,,,,,
J2425,Palifermin injection,50 MCG,17.679,,,,,,,,,,
J2426,Paliperidone palmitate inj,1 MG,9.117,,,,,,,,,,
J2430,Pamidronate disodium /30 MG,30 MG,10.419,,,,,,,,,,
J2469,Palonosetron hcl,25 MCG,22.882,,,,,,,,,,
J2501,Paricalcitol,1 MCG,3.170,,,,,,,,,,
J2503,Pegaptanib sodium injection,0.3 MG,1054.700,,,,,,,,,,
J2504,"Pegademase bovine, 25 iu",25 IU,319.673,,,,,,,,,,
J2505,"Injection, pegfilgrastim 6mg",6 MG,4040.693,,,,,,,,,,
J2507,Pegloticase injection,1 MG,1642.455,,,,,,,,,,
J2510,Penicillin g procaine inj,600000 UNITS,26.766,,,,,,,,,,
J2515,Pentobarbital sodium inj,50 MG,47.175,,,,,,,,,,
J2540,Penicillin g potassium inj,600000 UNITS,1.029,,,,,,,,,,
J2543,Piperacillin/tazobactam,1.125 GM,2.898,,,,,,,,,,
J2545,Pentamidine non-comp unit,300 MG,118.847,,,,,,,,,,
J2550,Promethazine hcl injection,50 MG,1.637,,,,,,,,,,
J2560,Phenobarbital sodium inj,120 MG,29.803,,,,,,,,,,
J2562,Plerixafor injection,1 MG,312.108,,,,,,,,,,
J2597,Inj desmopressin acetate,1 MCG,14.043,,,,,,,,,,
J2675,Inj progesterone per 50 MG,50 MG,1.373,,,,,,,,,,
J2680,Fluphenazine decanoate 25 MG,25 MG,22.783,,,,,,,,,,
J2690,Procainamide hcl injection,1 GM,55.602,,,,,,,,,,
J2700,Oxacillin sodium injeciton,250 MG,1.613,,,,,,,,,,
J2704,"Inj, propofol, 10 mg",10 MG,0.123,,,,,,,,,,
J2720,Inj protamine sulfate/10 MG,10 MG,1.118,,,,,,,,,,
J2724,Protein c concentrate,10 UNITS,15.229,,,,,,,,,,
J2765,Metoclopramide hcl injection,10 MG,0.894,,,,,,,,,,
J2770,Quinupristin/dalfopristin,500 MG,413.521,,,,,,,,,,
J2778,Ranibizumab injection,0.1 mg,383.227,,,,,,,,,,
J2780,Ranitidine hydrochloride inj,25 MG,1.094,,,,,,,,,,
J2783,Rasburicase,0.5 MG,254.107,,,,,,,,,,
J2785,Regadenoson injection,0.1 MG,53.896,,,,,,,,,,
J2788,Rho d immune globulin 50 mcg,50 MCG (250 IU),27.014,,,,,,,,,,
J2790,Rho d immune globulin inj,300 MCG (1500 IU),81.446,,,,,,,,,,
J2791,Rhophylac injection,100 IU,4.743,,,,,,,,,,
J2792,"Rho(D) immune globulin h, sd",100 IU,21.329,,,,,,,,,,
J2794,"Risperidone, long acting",0.5 MG,7.819,,,,,,,,,,
J2795,Ropivacaine HCl injection,1 MG,0.074,,,,,,,,,,
J2796,Romiplostim injection,10 MCG,62.137,,,,,,,,,,
J2800,Methocarbamol injection,10 ML,38.570,,,,,,,,,,
J2805,Sincalide injection,5 MCG,97.445,,,,,,,,,,
J2810,Inj theophylline per 40 MG,40 MG,0.299,,,,,,,,,,
J2820,Sargramostim injection,50 MCG,36.228,,,,,,,,,,
J2850,Inj secretin synthetic human,1 MCG,34.781,,,,,,,,,,
J2916,Na ferric gluconate complex,12.5 MG,2.295,,,,,,,,,,
J2920,Methylprednisolone injection,40 MG,3.726,,,,,,,,,,
J2930,Methylprednisolone injection,125 MG,5.126,,,,,,,,,,
J2997,Alteplase recombinant,1 MG,80.290,,,,,,,,,,
J3000,Streptomycin injection,1 GM,13.342,,,,,,,,,,
J3010,Fentanyl citrate injeciton,0.1 MG,0.498,,,95,0.700,,,,,,
J3060,"Inj, Taliglucerace Alfa 10 u",10 UNITS,40.462,,,,,,,,,,
J3070,Pentazocine injection,30 MG,140.385,,,,,,,,,,
J3090,Inj tedizolid phosphate,1 MG,1.277,,,,,,,,,,
J3095,Telavancin injection,10 MG,5.017,,,,,,,,,,
J3101,Tenecteplase injection,1 MG,102.431,,,,,,,,,,
J3105,Terbutaline sulfate inj,1 MG,3.126,,,,,,,,,,
J3121,Inj testostero enanthate 1mg,1 MG,0.040,,,,,,,,,,
J3230,Chlorpromazine hcl injection,50 MG,23.119,,,,,,,,,,
J3240,Thyrotropin injection,0.9 MG,1571.304,,,,,,,,,,
J3243,Tigecycline injection,1 MG,3.129,,,,,,,,,,
J3250,Trimethobenzamide hcl inj,200 MG,25.919,,,,,,,,,,
J3260,Tobramycin sulfate injection,80 MG,1.390,,,,,,,,,,
J3262,Tocilizumab injection,1 MG,4.103,,,,,,,,,,
J3285,Treprostinil injection,1 MG,61.237,,,,,,,,,,
J3300,Triamcinolone A inj PRS-free,1 MG,3.703,,,,,,,,,,
J3301,Triamcinolone acet inj NOS,10 MG,1.769,,,,,,,,,,
J3303,Triamcinolone hexacetonl inj,5 MG,3.612,,,,,,,,,,
J3315,Triptorelin pamoate,3.75 MG,460.851,,,,,,,,,,
J3357,Ustekinumab injection,1 MG,174.572,,,,,,,,,,
J3360,Diazepam injection,5 MG,9.259,,,,,,,,,,
J3370,Vancomycin hcl injection,500 MG,2.979,,,,,,,,,,
J3380,"Injection, vedolizumab",1 MG,17.431,,,,,,,,,,
J3385,Velaglucerase alfa,100 UNITS,343.345,,,,,,,,,,
J3396,Verteporfin injection,0.1 MG,10.883,,,,,,,,,,
J3410,Hydroxyzine hcl injection,25 MG,2.394,,,,,,,,,,
J3411,Thiamine hcl 100 mg,100 MG,3.244,,,,,,,,,,
J3415,Pyridoxine hcl 100 mg,100 MG,9.522,,,,,,,,,,
J3420,Vitamin b12 injection,1000 MCG,4.635,,,,,,,,,,
J3430,Vitamin k phytonadione inj,1 MG,3.492,,,,,,,,,,
J3465,"Injection, voriconazole",10 MG,4.638,,,,,,,,,,
J3471,"Ovine, up to 999 usp units",1 UNIT,0.354,,,,,,,,,,
J3473,Hyaluronidase recombinant,1 USP UNIT,0.358,,,,,,,,,,
J3475,Inj magnesium sulfate,500 MG,0.258,,,,,,,,,,
J3480,Inj potassium chloride,2 MEQ,0.129,,,,,,,,,,
J3485,Zidovudine,10 MG,1.506,,,,,,,,,,
J3486,Ziprasidone mesylate,10 MG,18.876,,,,,,,,,,
J3489,Zoledronic Acid 1mg,1 MG,15.667,,,,,,,,,,
J7030,Normal saline solution infus,1000 ML,1.880,,,,,,,,,,
J7040,Normal saline solution infus,500 ML,0.941,,,,,,,,,,
J7042,5% dextrose/normal saline,500 ML,0.793,,,,,,,,,,
J7050,Normal saline solution infus,250 ML,0.469,,,,,,,,,,
J7060,5% dextrose/water,500 ML,1.853,,,,,,,,,,
J7070,D5w infusion,1000 CC,3.619,,,,,,,,,,
J7120,Ringers lactate infusion,1000 CC,2.149,,,,,,,,,,
J7180,Factor xiii anti-hem factor,1 IU,8.180,,,,,,,1,,,
J7182,Factor viii recomb novoeight,1 IU,1.310,,,,,,,1,,,
J7183,Wilate injection,1 I.U. VWF:RCO,0.973,,,,,,,1,,,
J7185,Xyntha inj,1 IU,1.204,,,,,,,1,,,
J7186,Antihemophilic viii/vwf comp,PER FACTOR VIII IU,0.969,,,,,,,1,,,
J7187,"Humate-P, inj",1 IU,1.035,,,,,,,1,,,
J7189,Factor viia,1 MCG,1.903,,,,,,,1,,,
J7190,Factor viii,1 IU,0.979,,,,,,,1,,,
J7192,Factor viii recombinant NOS,1 IU,1.197,,,,,,,1,,,
J7193,Factor IX non-recombinant,1 IU,1.105,,,,,,,1,,,
J7194,Factor ix complex,1 IU,1.287,,,,,,,1,,,
J7195,Factor IX recombinant NOS,1 IU,1.517,,,,,,,1,,,
J7197,Antithrombin iii injection,1 IU,3.434,,,,,,,,,,
J7198,Anti-inhibitor,1 IU,1.921,,,,,,,1,,,
J7200,Factor ix recombinan rixubis,1 IU,1.248,,,,,,,1,,,
J7201,Factor ix fc fusion recomb,1 IU,2.815,,,,,,,1,,,
J7205,Factor viii fc fusion recomb,1 IU,1.892,,,,,,,1,,,
J7308,Aminolevulinic acid hcl top,354 MG,327.413,,,,,,,,,,
J7311,Fluocinolone acetonide implt,0.59 MG,20126.595,,,,,,,,,,
J7312,Dexamethasone intra implant,0.1 MG,200.903,,,,,,,,,,
J7313,Fluocinol acet intravit imp,0.01 MG,490.947,,,,,,,,,,
J7316,"Inj, Ocriplasmin, 0.125 mg",0.125 MG,1046.750,,,,,,,,,,
J7321,Hyalgan/supartz inj per dose,per dose,87.730,,,,,,,,,,
J7323,Euflexxa inj per dose,per dose,155.315,,,,,,,,,,
J7324,Orthovisc inj per dose,per dose,159.279,,,,,,,,,,
J7325,Synvisc or Synvisc-One,1 MG,12.769,,,,,,,,,,
J7326,Gel-One,per dose,587.579,,,,,,,,,,
J7327,Monovisc inj per dose,Per Dose,917.768,,,,,,,,,,
J7336,Capsaicin 8% patch,1 SQ CM,2.979,,,,,,,,,,
J7500,Azathioprine oral 50mg,50 MG,0.333,,,,,,,,,,
J7502,Cyclosporine oral 100 mg,100 MG,3.365,,,,,,,,,,
J7503,Tacrol envarsus ex rel oral,0.25 MG,1.232,,,,,,,,,,
J7504,Lymphocyte immune globulin,250 MG,1438.737,,,,,,,,,,
J7507,Tacrolimus Imme Rel oral 1mg,1 MG,0.754,,,,,,,,,,
J7508,Tacrol astagraf ex rel oral,0.1 MG,0.393,,,,,,,,,,
J7509,Methylprednisolone oral,4 MG,0.341,,,,,,,,,,
J7510,Prednisolone oral per 5 mg,5 MG,0.101,,,,,,,,,,
J7511,Antithymocyte globuln rabbit,25 MG,690.838,,,,,,,,,,
J7512,Prednisone ir or dr oral 1mg,1 MG,0.007,,,,,,,,,,
J7515,Cyclosporine oral 25 mg,25 MG,0.895,,,,,,,,,,
J7516,Cyclosporin parenteral 250mg,250 MG,41.560,,,,,,,,,,
J7517,Mycophenolate mofetil oral,250 MG,0.949,,,,,,,,,,
J7518,Mycophenolic acid,180 MG,2.878,,,,,,,,,,
J7520,"Sirolimus, oral",1 MG,7.572,,,,,,,,AMP-based payment limit,,
J7525,Tacrolimus injection,5 MG,163.772,,,,,,,,,,
J7527,Oral everolimus,0.25 MG,7.693,,,,,,,,,,
J7605,Arformoterol non-comp unit,15 mcg,8.974,,,,,,,,,,
J7606,"Formoterol fumarate, inh",20 MCG,10.666,,,,,,,,,,
J7608,Acetylcysteine non-comp unit,1 GM,4.826,,,,,,,,,,
J7611,Albuterol non-comp con,1 MG,0.118,,,,,,,,,,
J7612,Levalbuterol non-comp con,0.5 MG,0.204,,,,,,,,,,
J7613,Albuterol non-comp unit,1 MG,0.048,,,,,,,,,,
J7614,Levalbuterol non-comp unit,0.5 MG,0.073,,,,,,,,,,
J7620,Albuterol ipratrop non-comp,2.5 MG/0.5 MG,0.172,,,,,,,,,,
J7626,Budesonide non-comp unit,0.5 MG,3.981,,,,,,,,,,
J7631,Cromolyn sodium noncomp unit,10 MG,0.880,,,,,,,,,,
J7639,Dornase alfa non-comp unit,1 MG,42.501,,,,,,,,,,
J7644,Ipratropium bromide non-comp,1 MG,0.229,,,,,,,,,,
J7674,"Methacholine chloride, neb",1 MG,0.518,,,,,,,,,,
J7682,Tobramycin non-comp unit,300 MG,45.424,,,,,,,,,,
J7686,"Treprostinil, non-comp unit", 1.74 MG,521.876,,,,,,,,,,
J8501,Oral aprepitant,5 MG,11.108,,,,,,,,,,
J8510,Oral busulfan,2 MG,23.693,,,,,,,,,,
J8520,"Capecitabine, oral, 150 mg",150 MG,4.122,,,,,,,,,,
J8521,"Capecitabine, oral, 500 mg",500 MG,13.777,,,,,,,,,,
J8530,Cyclophosphamide oral 25 MG,25 MG,3.344,,,,,,,,,,
J8540,Oral dexamethasone,0.25 MG,0.026,,,,,,,,,,
J8560,Etoposide oral 50 MG,50 MG,71.609,,,,,,,,,,
J8600,Melphalan oral 2 MG,2 MG,11.708,,,,,,,,,,
J8610,Methotrexate oral 2.5 MG,2.5 MG,1.006,,,,,,,,,,
J8655,Netupitant palonosetron oral,0.5 MG,461.966,,,,,,,,,,
J8700,Temozolomide,5 MG,2.664,,,,,,,,,,
J8705,Topotecan oral,0.25 mg,103.853,,,,,,,,,,
J9000,Doxorubicin hcl injection,10 MG,2.534,,,,,,,,,,
J9017,Arsenic trioxide injection,1 MG,64.619,,,,,,,,,,
J9019,Erwinaze injection,"1,000 IU",402.743,,,,,,,,,,
J9025,Azacitidine injection,1 MG,2.844,,,,,,,,,,
J9027,Clofarabine injection,1 MG,152.442,,,,,,,,,,
J9031,Bcg live intravesical vac,1 EA,123.195,,,,,,,,,,
J9032,"Injection, belinostat, 10mg",10 MG,33.538,,,,,,,,,,
J9033,Bendamustine injection,1 MG,27.014,,,,,,,,,,
J9035,Bevacizumab injection,10 MG,72.310,,,,,,,,,,
J9040,Bleomycin sulfate injection,15 UNITS,28.196,,,95,289.370,,,,,,
J9041,Bortezomib injection,0.1 MG,46.523,,,,,,,,,,
J9042,Brentuximab vedotin inj,1 MG,129.089,,,,,,,,,,
J9043,Cabazitaxel injection,1 MG,154.569,,,,,,,,,,
J9045,Carboplatin injection,50 MG,3.551,,,,,,,,,,
J9047,"Injection, Carfilzomib, 1 mg",1 MG,31.948,,,,,,,,,,
J9050,Carmustine injection,100 MG,3847.562,,,,,,,,,,
J9055,Cetuximab injection,10 MG,55.631,,,,,,,,,,
J9060,Cisplatin 10 MG injection,10 MG,2.069,,,,,,,,,,
J9065,Inj cladribine per 1 MG,1 MG,21.747,,,95,61.720,,,,,,
J9070,Cyclophosphamide 100 MG inj,100 MG,43.971,,,,,,,,,,
J9098,Cytarabine liposome inj,10 MG,595.763,,,,,,,,,,
J9100,Cytarabine hcl 100 MG inj,100 MG,0.904,,,95,8.190,,,,,,
J9120,Dactinomycin injection,0.5 MG,1276.378,,,,,,,,,,
J9130,Dacarbazine 100 mg inj,100 MG,3.958,,,,,,,,,,
J9150,Daunorubicin injection,10 MG,40.026,,,,,,,,,,
J9155,Degarelix injection,1 MG,3.623,,,,,,,,,,
J9171,Docetaxel injection,1 MG,2.717,,,,,,,,,,
J9178,"Inj, epirubicin hcl, 2 mg",2 MG,1.167,,,,,,,,AMP-based payment limit,,
J9179,Eribulin mesylate injection,0.1 MG,106.076,,,,,,,,,,
J9181,Etoposide injection,10 MG,0.687,,,,,,,,,,
J9185,Fludarabine phosphate inj,50 MG,59.773,,,,,,,,,,
J9190,Fluorouracil injection,500 MG,1.699,,,95,2.070,,,,AMP-based payment limit,,
J9200,Floxuridine injection,500 MG,52.795,,,95,136.800,,,,AMP-based payment limit,,
J9201,Gemcitabine hcl injection,200 MG,6.307,,,,,,,,,,
J9202,Goserelin acetate implant,3.6 MG,327.120,,,,,,,,,,
J9206,Irinotecan injection,20 MG,4.011,,,,,,,,,,
J9207,Ixabepilone injection,1 MG,77.872,,,,,,,,,,
J9208,Ifosfamide injection,1 GM,28.182,,,95,150.380,,,,,,
J9209,Mesna injection,200 MG,2.385,,,,,,,,,,
J9211,Idarubicin hcl injection,5 MG,29.757,,,,,,,,,,
J9214,Interferon alfa-2b inj,1 MIL UNITS,26.856,,,,,,,,,,
J9217,Leuprolide acetate suspnsion,7.5 MG,225.012,,,,,,,,,,
J9218,Leuprolide acetate injeciton,1 MG,17.900,,,,,,,,,,
J9225,Vantas implant,50 MG,3138.039,,,,,,,,,,
J9226,Supprelin LA implant,50 MG,26205.503,,,,,,,,,,
J9228,Ipilimumab injection,1 MG,142.653,,,,,,,,,,
J9230,Mechlorethamine hcl inj,10 MG,265.888,,,,,,,,,,
J9245,Inj melphalan hydrochl 50 MG,50 MG,1871.626,,,,,,,,,,
J9250,Methotrexate sodium inj,5 MG,0.238,,,,,,,,,,
J9260,Methotrexate sodium inj,50 MG,2.375,,,,,,,,,,
J9261,Nelarabine injection,50 MG,152.209,,,,,,,,,,
J9263,Oxaliplatin,0.5 MG,0.390,,,,,,,,,,
J9264,Paclitaxel protein bound,1 MG,10.322,,,,,,,,,,
J9266,Pegaspargase injection,1 EA,13911.229,,,,,,,,,,
J9267,Paclitaxel injection,1 MG,0.175,,,,,,,,,,
J9268,Pentostatin injection,10 MG,1887.770,,,,,,,,,,
J9271,Inj pembrolizumab,1 MG,46.495,,,,,,,,,,
J9280,Mitomycin injection,5 MG,103.169,,,,,,,,,,
J9293,Mitoxantrone hydrochl / 5 MG,5 MG,36.746,,,,,,,,,,
J9299,"Injection, nivolumab",1 MG,26.064,,,,,,,,,,
J9301,Obinutuzumab inj,10 MG,56.203,,,,,,,,,,
J9302,Ofatumumab injection,10 MG,51.868,,,,,,,,,,
J9303,Panitumumab injection,10 MG,105.599,,,,,,,,,,
J9305,Pemetrexed injection,10 MG,62.779,,,,,,,,,,
J9306,"Injection, Pertuzumab, 1 mg",1 MG,10.645,,,,,,,,,,
J9307,Pralatrexate injection,1 MG,229.719,,,,,,,,,,
J9308,"Injection, ramucirumab",5 MG,55.934,,,,,,,,,,
J9310,Rituximab injection,100 MG,792.920,,,,,,,,,,
J9315,Romidepsin injection,1 MG,306.787,,,,,,,,,,
J9320,Streptozocin injection,1 GM,323.601,,,,,,,,,,
J9328,Temozolomide injection,1 MG,8.242,,,,,,,,,,
J9330,Temsirolimus injection,1 MG,66.674,,,,,,,,,,
J9351,Topotecan injection,0.1 MG,3.056,,,,,,,,,,
J9354,"Inj, Ado-trastuzumab Emt 1mg",1 MG,29.215,,,,,,,,,,
J9355,Trastuzumab injection,10 MG,92.091,,,95,58.130,,,,,,
J9357,Valrubicin injection,200 MG,1148.727,,,,,,,,,,
J9360,Vinblastine sulfate inj,1 MG,3.541,,,95,4.100,,,,,,
J9370,Vincristine sulfate 1 MG inj,1 MG,4.246,,,95,33.980,,,,,,
J9371,"Inj, vincristine sul lip 1 mg",1 MG,2506.488,,,,,,,,,,
J9390,Vinorelbine tartrate inj,10 MG,10.346,,,,,,,,,,
J9395,"Injection, Fulvestrant",25 MG,95.774,,,,,,,,,,
J9400,"Inj, ziv-aflibercept, 1mg",1 MG,8.446,,,,,,,,,,
P9041,"Albumin (human),5%, 50ml",50 ML,11.020,,,,,95,11.020,,,,
P9045,"Albumin (human), 5%, 250 ml",250 ML,54.720,,,,,95,54.720,,,,
P9046,"Albumin (human), 25%, 20 ml",20 ML,22.488,,,,,95,22.488,,,,
P9047,"Albumin (human), 25%, 50ml",50 ML,53.438,,,,,95,53.438,,,,
Q0138,"Ferumoxytol, non-esrd",1 MG,0.883,,,,,,,,,,
Q0139,"Ferumoxytol, esrd use",1 MG,0.883,,,,,,,,,,
Q0162,Ondansetron oral,1 MG,1.009,,,,,,,,,,
Q0163,Diphenhydramine HCl 50mg,50 MG,0.266,,,,,,,,,,
Q0164,Prochlorperazine maleate 5mg,5 MG,0.040,,,,,,,,,,
Q0166,Granisetron hcl 1 mg oral,1 MG,0.411,,,,,,,,AMP-based payment limit,,
Q0167,Dronabinol 2.5mg oral,2.5 MG,2.463,,,,,,,,AMP-based payment limit,,
Q0169,Promethazine HCl 12.5mg oral,12.5 MG,0.021,,,,,,,,,,
Q0180,Dolasetron mesylate oral,100 MG,94.760,,,,,,,,,,
Q2035,"Afluria vacc, 3 yrs & >, im",0.5 ml,16.284,95,16.284,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
Q2037,"Fluvirin vacc, 3 yrs & >, im",0.5 ML,16.284,95,16.284,,,,,,see the Seasonal Influenza Vaccines Pricing webpage for current payment limits and effective dates,,
Q2043,Sipuleucel-T auto CD54+,Per infusion (minimum 50 million cells),38034.649,,,,,,,,updated January 2017,,
Q2050,Doxorubicin inj 10mg,10 MG,435.442,,,,,,,,,,
Q3027,Inj beta interferon im 1 mcg,1 MCG,45.372,,,,,,,,,,
Q4074,Iloprost non-comp unit dose,UP TO 20 MCG,123.932,,,,,,,,,,
Q4081,"Epoetin alfa, 100 units ESRD",100 UNITS,1.259,,,,,,,,,,
Q4101,Apligraf skin sub,1 SQ CM,31.022,,,,,,,,,,
Q4102,Oasis wound matrix skin sub,1 SQ CM,11.010,,,,,,,,,,
Q4104,Integra BMWD skin sub,1 SQ CM,38.891,,,,,,,,,,
Q4105,Integra DRT skin sub,1 SQ CM,30.362,,,,,,,,,,
Q4106,Dermagraft skin sub,1 SQ CM,33.441,,,,,,,,,,
Q4107,Graftjacket skin sub,1 SQ CM,88.334,,,,,,,,,,
Q4108,Integra matrix skin sub,1 SQ CM,40.700,,,,,,,,,,
Q4110,Primatrix skin sub,1 SQ CM,50.720,,,,,,,,,,
Q4111,Gammagraft skin sub,1 SQ CM,6.880,,,,,,,,,,
Q4112,Cymetra allograft,1 CC,223.468,,,,,,,,,,
Q4113,Graftjacket express allograf,1 CC,223.468,,,,,,,,,,
Q4115,Alloskin,1 SQ CM,9.976,,,,,,,,,,
Q4116,Alloderm skin sub,1 SQ CM,32.202,,,,,,,,,,
Q4121,Theraskin,1 SQ CM,42.709,,,,,,,,,,
Q4123,Alloskin RT,1 SQ CM,20.060,,,,,,,,,,
Q4131,Epifix,1 SQ CM,169.401,,,,,,,,,,
Q5101,Inj filgrastim g-csf biosim,1 MCG,0.828,,,,,,,,,,
Q9950,Inj sulf hexa lipid microsph,1 ML,22.329,,,,,,,,,,
Q9956,"Inj octafluoropropane mic,ml",1 ML,34.549,,,,,,,,,,
Q9957,"Inj perflutren lip micros,ml",1 ML,51.824,,,,,,,,,,
Q9958,"HOCM <=149 mg/ml iodine, 1ml",1 ML,0.077,,,,,,,,,,
Q9960,"HOCM 200-249mg/ml iodine,1ml",1 ML,0.225,,,,,,,,,,
Q9961,"HOCM 250-299mg/ml iodine,1ml",1 ML,0.202,,,,,,,,,,
Q9963,"HOCM 350-399mg/ml iodine,1ml",1 ML,0.195,,,,,,,,,,
Q9965,"LOCM 100-199mg/ml iodine,1ml",1 ML,0.853,,,,,,,,,,
Q9966,"LOCM 200-299mg/ml iodine,1ml",1 ML,0.179,,,,,,,,,,
Q9967,"LOCM 300-399mg/ml iodine,1ml",1 ML,0.124,,,,,,,,,,