• Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
1,488
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
6
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. inject list Injections: List of Codes 1 This section contains a comprehensive list of Medi-Cal reimbursable injection codes. For injection policy information, refer to the Injections and Non-Injectable Drugs sections in this manual. For a list of the most frequently used vaccines, refer to the Chemotherapy and Injections: Medi-Cal Vaccines Code List sections in this manual. 2 – Injections: List of Codes July 2007
  • 2. inject list 2 Codes Codes A Abatacept – 10 mg.....................................................J0129 Ampicillin Sodium, Parenteral – Acetazolamide– 500 mg/vial......................................X5500 500 mg (powder) piggyback units...........................X5584 Acetylcysteine – 100 mg............................................J0132 Ampicillin Sodium, Parenteral – ACTH – 25 units dry powder/vial...............................X5514 500 mg (powder) vials............................................X5586 ACTH (OR) Corticotropin – 80 units/ml.....................X5516 Ampicillin Sodium, Parenteral – ACTH (OR) Corticotropin – 40 units/ml.....................X5518 250 mg (powder) vials............................................X5588 ACTH (OR) Corticotropin – 25 units/ml.....................X5520 Ampicillin Sodium, Parenteral – ACTH (OR) Corticotropin Gel – 80 units/ml...............X5516 125 mg (powder) vials............................................X5550 ACTH (OR) Corticotropin Gel – 40 units/ml...............X5518 Anabolin IM – 50 mg/ml (oil)......................................X5598 Acyclovir – 5 mg........................................................J0133 Anabolin LA 100 – 100 mg/ml (oil).............................X5600 Adenocrest – 25 mg/ml.............................................X5522 Ancef – 10 gm/100 ml vial.........................................X5602 Adenosine Phosphate – 25 mg/ml.............................X5522 Ancef – 1 gm/redi vial................................................X5604 Adrenalin Chloride – 1 mg/ml....................................X5528 Ancef – 1 gm/100 ml piggyback unit..........................X5606 Adrenalin Chloride Solution – Ancef – 1 gm/10 ml vial.............................................X5608 1:1,000 solution......................................................X5530 Ancef – 500 mg/100 ml vial.......................................X5610 Adriamycin – 50 mg/vial w/250 mg lactose................X7500 Ancef – 500 mg/10 ml vial.........................................X5612 Adriamycin – 10 mg/vial w/50 mg lactose..................X7502 Ancef – 250 mg/10 ml vial.........................................X5614 Aerosporin – 500,000 units........................................X5534 Andro-Cyp 100 – 100 mg/ml......................................X5618 Agalsidase beta – 1.0 mg..........................................J0180 Andro/Fem – 50-2 mg/ml...........................................X5620 Akineton – 5 mg/ml....................................................X5536 Android HCG – 1,000 units/ml...................................X5622 Aldesleukin – 22 million IU........................................X7632 Android-T – 100 mg/ml..............................................X5626 Aldomet – 250 mg/5 ml..............................................X5540 Android-T – 50 mg/ml................................................X5628 Alglucosidase alfa – 10 mg........................................J0220 Androlone – 50 mg/ml (oil).........................................X5598 Amcill-S – 1 gm (powder) vials..................................X5582 Androlone – 25 mg/ml (oil).........................................X5630 Amcill-S – 500 mg (powder) vials..............................X5586 Androlone-D 100 – 100 mg/ml (oil)............................X5600 Amcill-S – 250 mg (powder) vials..............................X5588 Androlone-D 50 – 50 mg/ml (oil)................................X5632 Amcill-S – 125 mg (powder) vials..............................X5550 Andronaq – 50 mg/ml................................................X5628 Amcort – 40 mg/ml suspension.................................X5552 Andronate 100 – 100 mg/ml......................................X5618 A-Methapred – 40 mg/ml...........................................X5554 Andryl – 200 mg/ml...................................................X5634 Amicar – 250 mg/ml..................................................X5556 Anectine – 20 mg/ml..................................................X5636 Amifostine – 500 mg..................................................X7642 Anidulafungin – 1 mg.................................................J0348 Amikacin Sulfate – 1 gm/4 ml vial..............................X5558 Antilirium – 1 mg/ml...................................................X5640 Amikacin Sulfate – 500 mg/2 ml vial..........................X5562 Antispas – 10 mg/ml..................................................X5642 Amikacin Sulfate – 100 mg/2 ml vial..........................X5560 Antuitrin – 500 units/ml..............................................X5644 Amikin – 1 gm/4 ml vial..............................................X5558 AnzemetTM – 10 mg....................................................J1260 Amikin – 500 mg/2 ml vial..........................................X5562 A.P.L. Secules – 2,000 units/ml.................................X5646 Amikin – 100 mg/2 ml vial..........................................X5560 A.P.L. Secules – 1,000 units/ml.................................X5622 Aminocaproic acid – 250 mg/ml................................X5556 A.P.L. Secules – 500 units/ml....................................X5644 Amitriptyline HCl – 10 mg/ml.....................................X5564 Apresoline – 20 mg/ml...............................................X5648 Amobarbital Sodium – 500 mg..................................X5566 Aqua Mephyton – 10 mg/ml.......................................X5650 Amphotericin B – 50 mg/vial......................................X5572 Aqua Mephyton – 2 mg/ml.........................................X5652 Ampicillin Sodium, Parenteral – Aquasol A Parenteral – 50,000 IU/ml.......................X5654 2 gm (powder) piggyback units...............................X5576 Aralen – 50 mg/ml.....................................................X5656 Ampicillin Sodium, Parenteral – Aramine – 10 mg/ml (1%) (as Bitartrate)...................X5658 2 gm (powder) vials................................................X5578 Ardefem 20 – 20 mg/ml.............................................X5660 Ampicillin Sodium, Parenteral – Ardefem 10 – 10 mg/ml.............................................X5662 1 gm (powder) piggyback units...............................X5580 Arderone – 200 mg/ml...............................................X5634 Ampicillin Sodium, Parenteral – Arderone – 100 mg/ml...............................................X5626 1 gm (powder) vials................................................X5582 Ardiol 90/4.................................................................X5666 2 – Injections: List of Codes March 2009
  • 3. inject list 3 Codes Codes Arfonad – 50 mg/ml...................................................X5668 Berocca-C – 2 ml......................................................X5750 Aripiprazole – 0.25 mg...............................................J0400 Berubigen – 1,000 mcg/ml.........................................X5752 Aristocort Parenteral Forte – Bestrone – 2 mg/ml...................................................X5756 40 mg/ml suspension..............................................X5552 Betalin 12 – 1,000 mcg/ml.........................................X5752 Aristopan – 20 mg/cc 5 cc.........................................X5672 Betamethasone Acetate 3 mg and Aristopan – 20 mg/cc 1 cc.........................................X5674 Betamethasone Sodium Phosphate 3 mg.............J0702 Ar-Tet – 250 unit........................................................X5676 Bethanechol Chloride – 5 mg/ml................................X5762 Arthrolate – 50 mg/ml................................................X5678 Bevacizumab – 10 mg...............................................J9035 Ascorbic Acid – 500 mg/ml........................................X5680 Bicillin C-R 900/300...................................................X5764 Ascorbic Acid – 250 mg/ml........................................X5682 Bicillin C-R – 600,000 units.......................................X5766 Asparaginase – 10,000 IU/10 ml vial.........................X7504 Bicillin C-R – 300,000 units/ml...................................X5768 Atropine Sulfate – up to 0.3 mg..................................J0460 Bicillin L-A – 600,000 units/ml....................................X5770 Aurothioglucose – 50 mg/ml......................................X5708 Bicillin L-A – 300,000 units/ml....................................X5772 Avastin – 10 mg.........................................................J9035 BICNU – 100 mg/vial.................................................X7506 Azacitidine – 1 mg/ml.................................................J9025 Biosone – 50 mg/ml suspension................................X5774 Azapen – 6 gm vials (powder)...................................X5710 Biperiden – 5 mg/ml...................................................X5536 Azapen – 4 gm vials (powder)...................................X5712 Blenoxane – 15 units/ampule....................................X7508 Azapen – 1 gm vials (powder)...................................X5714 Bleomycin Sulfate – 15 units/ampule.........................X7508 Bortezomib – 0.1 mg..................................................J9041 Botulinum toxin A – per 1 unit....................................J0585 Botulinum toxin B – per 100 units...............................J0587 B Brethine – 1 mg/ml....................................................X5776 Bretylium Tosylate – 50 mg/ml..................................X5778 Bacitracin, Intramuscular – Bretylol – 50 mg/ml....................................................X5778 50,000 unit vials......................................................X5716 Brevital Sodium – 5 gm.............................................X5780 Bacitracin, Intramuscular – Brevital Sodium – 2.5 gm..........................................X5782 10,000 unit vials......................................................X5718 Brevital Sodium – 500 mg/5 ml..................................X5784 Baclofen – 10 mg......................................................X7108 Bricanyl Subcutaneous – 1 mg/ml.............................X5776 Bactocill – 4 gm (powder) vials..................................X5720 Brompheniramine Maleate – 10 mg/ml......................X5786 Bactocill – 2 gm (powder) vials..................................X5722 Bupivacaine HCl – 0.75%..........................................X5790 Bactocill – 1 gm (powder) vials..................................X5724 Bupivacaine HCl – 0.25%..........................................X5792 Bactocill – 500 mg (powder) vials..............................X5726 Bupivacaine HCl – 0.5%............................................X5794 BAL In Oil – 100 mg/ml..............................................X5728 Butorphanol Tartrate – 2 mg/ml.................................X5796 Basiliximab – 20 mg...................................................J0480 Butorphanol Tartrate – 1 mg/ml.................................X5798 BCG Vaccine, intravesicular......................................90586 BCG Vaccine, percutaneous – 1 mg.........................90585 Benadryl – 50 mg/ml.................................................X5738 Benadryl – 10 mg/ml.................................................X5740 Benahist 50 – 50 mg/ml.............................................X5738 Benahist 10 – 10 mg/ml.............................................X5740 Bendamustine HCl – 1 mg.........................................J9033 Bendylate 50 – 50 mg/ml...........................................X5738 Bendylate 10 – 10 mg/ml...........................................X5740 Benoject 50 – 50 mg/ml.............................................X5738 Benoject 10 – 10 mg/ml.............................................X5740 Bentyl – 10 mg/ml......................................................X5642 Benztropine Mesylate – 1 mg/ml..............................X5744 2 – Injections: List of Codes April 2010
  • 4. inject list 4 Codes Codes C Caffeine and Sodium Benzoate – 250 mg/ml...........X5800 Celbenin – 6 gm vials (powder).................................X5710 Calciferol – 500,000 IU D2/ml....................................X5802 Celbenin – 4 gm vials (powder).................................X5712 Calcimar – 400 MCR units........................................X5804 Celbenin – 2 gm piggyback units (powder)................X5866 Calcitonin – 400 MCR units.......................................X5804 Celbenin – 1 gm piggyback units (powder)................X5868 Calcitriol (Calcijex) – 1 MCG/ml................................X7510 Celbenin – 1 gm vials (powder).................................X5714 Calcitriol (Calcijex) – 2 MCG/ml................................X7512 Celestone Phosphate................................................X5872 Calcium Disodium Edetate – 200 mg/ml....................X5808 Celestone Soluspan Calcium Disodium Versenate – 200 mg/ml................X5808 (Betamethasone Acetate 3 mg and Capastat Sulfate – 1 gm/5 ml vial..............................X5810 Betamethasone Sodium Phosphate 3 mg).........J0702 Capreomycin Sulfate – 1 gm/5 ml vial.......................X5810 Cenocort A-40 – 40 mg/ml suspension.....................X5880 Carbocaine – 2%.......................................................X5818 Cenocort Forte – 40 mg/ml suspension.....................X5552 Carbocaine – 1.5%....................................................X5820 Cenolate – 500 mg/ml...............................................X5882 Carbocaine – 1%.......................................................X5822 Centrogen – 2 mg/ml.................................................X5756 Carbocaine HCl – 3%................................................X5824 Cephalothin Sodium – 20 gm/200 ml vial..................X5888 Carboplatin – 50 mg...................................................J9045 Cephalothin Sodium – 4 gm/50 ml vial......................X5890 Carmustine (BCNU) – 100 mg/vial............................X7506 Cephalothin Sodium – 2 gm/100 ml vial....................X5892 Cathflo Activase – 2 mg vial (powder).......................X7122 Cephalothin Sodium – 2 gm/20 ml vial......................X5894 Cedilanid-D – 0.2 mg/ml............................................X5826 Cephalothin Sodium – 1 gm/100 ml vial....................X5896 Cee-B-Complex – 30 ml............................................X5828 Cephalothin Sodium – 1 gm/10 ml vial......................X5898 Cefamandole Nafate – 500 mg/10 ml vial..................X5840 Cephradine – 2 gm/100 ml Cefamandole Nafate – 2 gm/100 ml vial....................X5842 infusion containers .................................................X5904 Cefamandole Nafate – 2 gm/20 ml vial......................X5844 Cephradine – 1 gm/vial..............................................X5906 Cefamandole Nafate – 1 gm/100 ml vial....................X5846 Cephradine – 500 mg/vial..........................................X5908 Cefamandole Nafate – 1 gm/10 ml vial......................X5848 Cephradine – 250 mg/vial..........................................X5910 Cefazolin Sodium – 10 gm/100 ml vial.......................X5602 Certolizumab Pegol – 1 mg.......................................C9249 Cefazolin Sodium – 1 gm/redi vial.............................X5604 Cerubidine – 20 mg/vial unit......................................X7514 Cefazolin Sodium – 1 gm/10 ml vial..........................X5608 Cetuximab – 10 mg....................................................J9055 Cefazolin Sodium – 1 gm/100 ml Cevalin – 500 mg/ml..................................................X5680 piggyback unit.........................................................X5606 Cevita – 250 mg/ml...................................................X5912 Cefazolin Sodium – 500 mg/10 ml vial ......................X5612 Chlor-100..................................................................X5914 Cefazolin Sodium – 500 mg/100 ml vial.....................X5610 Chloramphenicol – Cefazolin Sodium – 250 mg/10 ml vial.......................X5614 1 gm vial as dry powder..........................................X5922 Cefotaxime Sodium – 2 gm.......................................X7027 Chlorazine – 25 mg/ml...............................................X5918 Cefotaxime Sodium – 1 gm.......................................X7026 Chlordiazedoxide – 100 mg/5 ml...............................X5920 Cefotaxime Sodium – 0.5 gm....................................X7025 Chloromycetin Sodium Succinate – Cefoxitin Sodium – 2 gm vial.....................................X5854 1 gm vial as dry powder..........................................X5922 Cefoxitin Sodium – 1 gm vial.....................................X5856 Chlorophen – 10 mg/ml.............................................X5932 Ceftriaxone Sodium – 250 mg/vial.............................J0696 Chloroprocaine HCl – 3%..........................................X5924 Chloroprocaine HCl – 2%..........................................X5926 Chloroprocaine HCl – 1%..........................................X5928 Chloroquine HCl – 50 mg/ml.....................................X5656 Chlorothiazide – 500 mg/20 ml..................................X5930 Chlorpheniramine Maleate – 100 mg/ml....................X5914 Chlorpheniramine Maleate – 10 mg/ml......................X5932 Chlor-Pro – 100 mg/ml..............................................X5914 Chlor-Pro – 10 mg.....................................................X5932 Chlorpromazine HCl – 25 mg/ml...............................X5918 Chlorprothixene – 12.5 mg/ml....................................X5934 Chlor-Trimeton – 100 mg/ml......................................X5914 Chlor-Trimeton – 10 mg/ml........................................X5932 2 – Injections: List of Codes April 2010
  • 5. inject list 5 Codes Codes Cholera Vaccine – 1.5 ml...........................................90725 Cryptenamine Acetates – 260 CSR/ml...................X5992 Chorex – 1,000 units/ml............................................X5622 Crysti-12 – 1,000 mcg/ml..........................................X5752 Chorex – 500 units/ml...............................................X5644 Cyanocobalamin Crystalline – Chorionic Gonadotropin (HCG) – 1,000 mcg/ml..........................................................X5752 2,000 units/ml.........................................................X5646 Cyclophosphamide – Chorionic Gonadotropin (HCG) – 500 mg/30 ml vials..................................................X7522 1,000 units/ml.........................................................X5622 Cyclophosphamide – 200 mg/2 ml vials....................X7524 Chorionic Gonadotropin (HCG) – Cyclophosphamide – 100 mg/10 ml vials..................X7526 500 units/ml............................................................X5644 Cytarabine (Cytosine Arabinoside, Chromium Cr-51 Sodium Chromate, 250 µCi...........A9553 ARA-C) – 500 mg vials...........................................X7528 Chromium phosphate P-32 suspension, 1 mCi.........A9564 Cytarabine (Cytosine Arabinoside, Cidofovir – 375 mg/5 ml vial......................................X7434 ARA-C) – 100 mg vials...........................................X7530 Cino 40......................................................................X5552 Cytosar – 500 mg vials..............................................X7528 Cisplatin – 50 mg........................................................J9062 Cytosar – 100 mg vials..............................................X7530 Citanest HCl – 4% w/1:200,000 Epinephrine.............X5942 Cytoxan – 500 mg/30 ml vials...................................X7522 Citanest HCl – 4%.....................................................X5944 Cytoxan – 200 mg/20 ml vials...................................X7524 Cleocin Phosphate – 600 mg/ Cytoxan – 100 mg/10 ml vials...................................X7526 4 ml ampules..........................................................X5956 Cleocin Phosphate – 300 mg/ 2 ml ampules..........................................................X5958 Clindamycin – 600 mg D (as phosphate)/4 ml ampules.................................X5956 Clindamycin – 300 mg Dacarbazine (DTIC) – 200 mg/20 ml vial..................X7532 (as phosphate)/2 ml ampules.................................X5958 Dactinomycin (Actinomycin D) – Clofarabine – 1 mg.....................................................J9027 0.5 mg/3 ml vial......................................................X7520 Clonidine hydrochloride – 1 mg/ml............................X7488 Daptomycin, 1 mg........................................................J0878 Cobalasine – 25 mg/ml..............................................X5522 Darbepoetin alfa (ESRD) – 1 mcg..............................J0882 Cobalt Co-57/58, cyanocobalamin – 1 µCi................A9546 Darbepoetin alfa (non-ESRD)....................................J0881 Cobalt Co-57 cyanocobalamin (oral) – 1 µCi.............A9559 D-Diol – 50-2 mg/ml..................................................X5620 Cobex 1,000..............................................................X5752 Decadron-LA – 8 mg/ml suspension.........................X6008 Codeine Phosphate – 60 mg/ml................................X5960 Decadron Phosphate – 24 mg/ml..............................X6002 Codeine Phosphate – 30 mg/ml................................X5962 Decadron Phosphate – 4 mg/ml................................X6004 Cogentin – 1 mg/ml...................................................X5744 Decadron w/Xylocaine..............................................X6006 Colchicine – 1 mg/2 ml..............................................X5964 Deca-Durabolin – 100 mg/ml (oil)..............................X5600 Colistimethate Sodium – Deca-Durabolin – 50 mg/ml (oil)................................X5632 150 mg Colistin/vial................................................X5966 Decameth L.A. – 8 mg/ml suspension.......................X6008 Coly-Mycin M – Decitabine – 1 mg......................................................J0894 150 mg Colistin/vial................................................X5966 De-Comberol – 50-2 mg/ml.......................................X5620 Compazine – 5 mg/ml................................................X5970 Deferoxamine Mesylate – Conjugated Estrogens – 25 mg.................................X5972 500 mg/ampule........................................................X6012 Cortef – 50 mg/ml......................................................X5980 Deksone – 4 mg/ml solution......................................X6004 Cortef Acetate – 50 mg/ml suspension......................X5774 Deladumone – 90-4 mg/ml........................................X5666 Corticorelin ovine triflutate – 1 mcg............................J0795 Delatestryl – 200 mg/ml.............................................X5634 Cortigel 80 – 80 units/ml............................................X5516 Delcort-E – 25 mg/ml.................................................X6014 Cortigel 40 – 40 units/ml............................................X5518 Delestrogen – 40 mg/ml............................................X6018 Cortisone Acetate – 50 mg/ml...................................X5984 Delestrogen – 20 mg/ml............................................X5660 Cortone Acetate – 50 mg/ml......................................X5984 Delestrogen – 10 mg/ml............................................X5662 Cortril Acetate – 25 mg/ml suspension......................X5988 Demerol HCl – 100 mg/ml.........................................X6020 Cortrophin Gel – 80 units/ml......................................X5516 Demerol HCl – 75 mg/ml...........................................X6022 Cortrophin Gel – 40 units/ml......................................X5518 Demerol HCl – 50 mg/ml...........................................X6024 Cosmegen – 0.5-3 mg/ml vial....................................X7520 Demerol HCl – 25 mg/ml...........................................X6026 2 – Injections: List of Codes January 2010
  • 6. inject list 6 Codes Codes Denileukin Diftitox – 300 mcg....................................J9160 Dioval – 10 mg/ml...................................................X5662 Depo-Estradiol Cypionate – 5 mg/ml.........................X6030 Dioval 40 – 40 mg/ml.................................................X6018 Depogen – 5 mg/ml...................................................X6030 Dioval XX – 20 mg/ml................................................X5660 Depo-Medrol – 80 mg/ml suspension........................X6036 Diphenhydramine HCl – 50 mg/ml.............................X5738 Depo-Medrol – 40 mg/ml suspension........................X6038 Diphenhydramine HCl – 10 mg/ml.............................X5740 Depo-Medrol – 20 mg/ml...........................................X6040 Diphtheria, tetanus toxoid (DT) – Depo-Provera – for younger than 7 years of age..............................90702 400 mg/ml 10 ml vial, per ml ..................................X6046 Diphtheria, tetanus toxoid Depo-Provera – and acellular pertussis (DTaP) – 400 mg/ml 2.5 ml vial, per ml..................................X6048 under 7 years of age...............................................90700 Depo-Provera C – 150 mg/ml 1 ml vial......................X6051 Diphtheria, tetanus toxoids Depotest – 100 mg/ml...............................................X5618 and whole cell pertussis (DTP)...............................90701 Depo-Testadiol – 50-2 mg/ml....................................X5620 Diphtheria, tetanus toxoids and whole cell pertussis Depotestogen – 50-2 mg/ml......................................X5620 and H. Influenza b vaccine (DTP-Hib).....................90720 Depo-Testosterone – 100 mg/ml...............................X5618 Diphtheria, tetanus toxoids and acellular pertussis Desferal Mesylate – 500 mg/ampule.........................X6012 and H. Influenza b vaccine (DtaP-Hib)....................90721 Deslanoside (Desacetyl-Lanatosidec) – Diphtheria, tetanus toxoids, acellular pertussis vaccine, 0.2 mg/ml................................................................X5826 Hepatitis B, and poliovirus vaccine, D-Est 5 – 5 mg/ml.....................................................X6030 inactivated (DtaP-HepB-IPV)..................................90723 Dexacen 4 ................................................................X6004 Diptheria Toxoid, Adsorbed ......................................90719 Dexacen LA-8...........................................................X6008 Disodium Edetate – 150 mg/ml..................................X6106 Dexamethasone (as acetate) – Di-Spaz – 10 mg/ml...................................................X5642 8 mg/ml suspension................................................X6008 Ditate – 90-4 mg/ml...................................................X5666 Dexamethasone Sodium Phosphate – Diuril – 500 mg/20 ml.................................................X5930 4 mg/ml...................................................................X6004 D-Med – 80 mg/ml suspension..................................X6036 Dexasone – 4 mg/ml.................................................X6004 D-Med – 40 mg/ml suspension..................................X6038 Dexasone-LA – 8 mg/ml............................................X6008 Dobutamine – 250 mg (as HCl).................................X6108 Dexon – 4 mg/ml.......................................................X6004 Dobutrex – 250 mg (as HCl)......................................X6108 Dexpanthenol – 250 mg/ml........................................X6060 Docetaxel – 20 mg....................................................X7638 Dezone – 4 mg/ml solution........................................X6004 Dodex – 1,000 mcg/ml..............................................X5752 D.H.E. 45 – 1 mg/ml..................................................X6062 Dolasetron – 10 mg....................................................J1260 Diamox – 500 mg/vial................................................X5500 Dolophine HCl – 10 mg/ml.........................................X6110 Diazepam – 5 mg/ml.................................................X6064 Dopamine HCl – 40 mg/ml.........................................J1265 Diazoxide – 300 mg/20 ml.........................................X6070 Dopram – 20 mg/ml...................................................X6114 Dibent – 10 mg/ml.....................................................X5642 Doripenem – 10 mg...................................................J1267 Dicyclomine HCl – 10 mg/ml.....................................X5642 Dornase alfa – 1 mg...................................................J7639 Diethylstilbesterol Diphosphate – Doxapram HCl – 20 mg/ml........................................X6114 0.25 gm (as sodium salt)/5 ml ampule....................X7536 Doxercalciferol – 1 mcg ..........................................J1270 Digoxin – 0.25 mg/ml.................................................X6080 Doxorubicin HCl – 50 mg/vial w/250 mg lactose.......X7500 Digoxin – 0.1 mg/ml...................................................X6082 Doxorubicin HCl – 10 mg/vial w/50 mg lactose.........X7502 Dihydroergotamine Mesylate – 1 mg/ml....................X6062 Doxorubicin HCl liposome – 10 mg............................J9001 Dilantin – 50 mg/ml....................................................X6084 Doxycycline – 100 mg (as hyclate)/vial.....................X6122 Dilaudid – 4 mg/ml.....................................................X6086 Droperidol – 2.5 mg/ml..............................................X6126 Dilaudid – 2 mg/ml.....................................................X6090 Dtic-Dome – 200 mg/20 ml vial.................................X7532 Dilaudid – 1 mg/ml.....................................................X6092 Dimercaprol – 100 mg/ml..........................................X5728 Dimetan-Ten – 100 mg/ml.........................................X5786 2 – Injections: List of Codes February 2010
  • 7. inject list 7 Codes Codes Duo-Cyp – 50-2 mg/ml..............................................X5620 Estradiol In Oil – 5 mg/ml..........................................X6030 Duogen L.A. 90/4......................................................X5666 Estradiol L.A. – 40 mg/ml..........................................X6018 Duoval-P.A................................................................X5666 Estradiol Valerate In Oil – 40 mg/ml..........................X6018 Durabolin – 50 mg/ml (oil)..........................................X5598 Estradiol Valerate In Oil – 20 mg/ml..........................X5660 Durabolin – 25 mg/ml (oil)..........................................X5630 Estradiol Valerate In Oil – 10 mg/ml..........................X5662 Duracillin A.S. – 600,000 units/unit dose...................X6136 Estradurin – 40 mg w/2 cc diluent ............................X7540 Duraestrin – 5 mg/ml.................................................X6030 Estratab 40................................................................X6018 Duragen 40...............................................................X6018 Estratab 20................................................................X5660 Duragen 20...............................................................X5660 Estratab – 10 mg/ml..................................................X5662 Duragen – 10 mg/ml..................................................X5662 Estratest – 50-2 mg/ml..............................................X5620 Dura-Meth – 40 mg/ml suspension............................X6038 Estra-Testrin – 90-4 mg/ml........................................X5666 Duranest – 1.5%.......................................................X6138 Estraval – 10 mg/ml...................................................X5662 Duranest – 1%..........................................................X6140 Estraval – 4X.............................................................X6018 Duratest – 100 mg/ml................................................X5618 Estraval – 2X.............................................................X5660 Duratestrin – 50-2 mg/ml...........................................X5620 Estro-Cyp – 5 mg/ml.................................................X6030 Estrogenic Substance Aqueous – 2 mg/ml................X5756 Estroject-L.A.............................................................X6030 Estrolin – 2 mg/ml......................................................X5756 E Estrone – 10 mg/ml...................................................X5662 Estrone Aqueous Solution – 5 mg/ml........................X6196 Eculizumab – 10 mg..................................................J1300 Estrone Aqueous Solution – 2 mg/ml........................X6198 Edrophonium Chloride – 10mg/ml.............................X6146 Estronol (Modified) Femogen Elavil HCl – 10 mg/ml................................................X5564 Aqueous – 2 mg/ml.................................................X5756 Eliotts’ B Solution – 1 ml............................................J9175 Ethacrynic Acid – 50 mg/vial.....................................X6204 E-Lonate – 5 mg/ml...................................................X6030 Etidocaine HCl – 1.5%..............................................X6138 Elspar – 10,000 IU/10 ml vial.....................................X7504 Etidocaine HCl – 1%.................................................X6140 Endrate – 150 mg/ml.................................................X6106 Etoposide – 20 mg/ml................................................X7542 Ephedrine Sulfate – 50 mg/ml Euflexxa – per dose...................................................J7323 1 ml ampules...........................................................X6158 Everone – 200 mg/ml................................................X5634 Ephedrine Sulfate – 25 mg/ml Everone – 100 mg/ml................................................X5626 1 ml ampules...........................................................X6160 Epinephrine HCl – 1 mg/ml........................................X5528 Epinephrine HCl – 0.1 mg/ml.....................................X6164 Epinephrine, Parenteral – 1:1,000 solution.......................................................X5530 Epinephrine, Parenteral – 1:200 suspension....................................................X6166 Epirubicin (Ellence) – 50 mg/25 ml............................X7646 Epoetin alfa, 1000 units (for ESRD on dialysis).........J0886 Epoetin alfa, 1000 units (for non-ESRD use).............J0885 Epogen (ESRD) – 1,000 units....................................J0886 Epogen (non-ESRD) – 1,000 units.............................J0885 Ergonovine Maleate – 0.2 mg/ml...............................X6168 Ergotrate Maleate – 0.2 mg/ml..................................X6168 Erythromycin I.V. – 1 gm (lactobionate)/30 ml vials.........................................X6174 Erythromycin I.V. – 500 mg (as lactobionate)/20 ml vials....................................X6178 2 – Injections: List of Codes September 2009
  • 8. inject list 8 Codes Codes F Faslodex – 250 mg/ml.............................................. X7654 Gemcitabine – 200 mg...............................................J9201 Femogen-Cyp – 5 mg/ml...........................................X6030 Gentamicin Sulfate – 40 mg/ml..................................X6240 Femogen-L.A. – 40 mg/ml.........................................X6018 Gentamicin Sulfate – 10 mg/ml..................................X6242 Femogen-L.A. – 20 mg/ml.........................................X5660 Glucagon – 10 mg/10 ml...........................................X6252 Femogen-L.A. – 10 mg/ml.........................................X5662 Glucagon – 1 mg/ml..................................................X6254 Fentanyl – 0.05 mg/ml...............................................X6206 Glycohyprolate – 0.2 mg/ml.......................................X6258 Fentanyl Citrate and Droperidol – Gold Sodium Thiomalate – 50 mg/ml.........................X6262 0.05-2.5 mg.............................................................X6208 Gold Sodium Thiomalate – 25 mg/ml.........................X6264 Fernisolone – 25 mg/ml.............................................X6014 Gonadex – 1,000 units/ml..........................................X5622 Fernisone – 50 mg/ml suspension.............................X5774 Granisetron Injection – 1 mg/vial...............................X7104 Ferrlecit – 62.5 mg....................................................X7496 Granisetron Tablets – 1 mg.......................................X7105 Filgrastim (Neupogen) – 300 mcg..............................J1440 Gravigen Aqueous – 2 mg/ml....................................X6198 Filgrastim (Neupogen) – 480 mcg..............................J1441 Flaxedil – 20 mg/ml...................................................X6214 Flexon – 30 mg/ml.....................................................X6216 Floxuridine – 500 mg/5 ml vial...................................X7544 H Fludarabine – 50 mg..................................................X7644 Fluorodeoxyglucose – 45 mCi...................................A9552 Haemophilus Influenzae b (Hib) HbOC......................90645 Fluorouracil – 500 mg/10 ml......................................X7546 Haemophilus Influenzae b (Hib) PRP-D....................90646 Fluphenazine Decanoate – 25 mg/ml........................X6220 Haemophilus Influenzae b (Hib) PRP-OMP...............90647 Fluphenazine Enanthate – 25/mg/ml.........................X6220 Haemophilus Influenzae b (Hib) PRP-T.....................90648 Fluphenazine HCl – 2.5 mg/ml..................................X6222 Haldol – 5 mg/ml.......................................................X6274 Folic Acid – 5 mg/ml..................................................X6226 Haloperidol – 5 mg/ml................................................X6274 Follutein – 1,000 units/ml...........................................X5622 Hectorol – 1 mcg.......................................................J1270 Folvite – 5 mg/ml.......................................................X6226 Hematran...................................................................J1752 Fomepizole – 15 mg..................................................J1451 Hemin injection – 1 mg...............................................J1640 Fomivirsen – 0.25 ml vial...........................................X7470 Heparin Lock Flush Solution – Fosaprepitant – 1 mg.................................................J1453 100 units/ml.............................................................X6282 Foscarnet Sodium – 1000 mg....................................J1455 Heparin Lock Flush Solution – Foygen – 2 mg/ml......................................................X6198 10 units/ml...............................................................X6284 Foygen Aqueous – 2 mg/ml.......................................X5756 Heparin Sodium Inj (USP) – FUDR – 500 mg/5 ml vial..........................................X7544 40,000 units/ml........................................................X6286 Fulvestrant – 250 mg/ml............................................X7654 Heparin Sodium Inj (USP) – Fungizone I.V. – 50 mg/vial.......................................X5572 20,000 units/ml........................................................X6288 Furosemide – 10 mg/ml.............................................X6228 Heparin Sodium Inj (USP) – 10,000 units/ml........................................................X6296 Heparin Sodium Inj (USP) – 7,500 units/ml..........................................................X6298 G Heparin Sodium Inj (USP) – 5,000 units/ml..........................................................X6302 Gadolinium – not otherwise Heparin Sodium Inj (USP) – specified, per ml.....................................................A9579 5,000 units/0.5 ml....................................................X6304 Gadoteridol, (ProHance multipack), Heparin Sodium Inj (USP) – per ml......................................................................A9576 2,500 units/ml..........................................................X6306 Gadobenate dimeglumine Heparin Sodium Inj (USP) – (MultiHance) per ml.................................................A9577 1,000 units/ml..........................................................X6308 Gadobenate dimeglumine (MultiHance multipack), per ml................................A9578 Gadoxetate Disodium – per ml..................................C9246 Gallamine Triethiodide – 20 mg/ml............................X6214 Gallium Ga-67 Citrate – 1 mCi..................................A9556 Galsulfase – 1 mg......................................................J1458 Ganciclovir 4.5 mg, long-acting Implant.....................J7310 Ganphen – 50 mg/ml.................................................X6236 Garamycin – 40 mg/ml..............................................X6240 Garamycin Pediatric – 10 mg/ml...............................X6242 2 – Injections: List of Codes February 2010
  • 9. inject list 9 Codes Codes Hepatitis A and Hepatitis B Hyparotin – 1.5 ml..................................................X6346 Combination Vaccine..............................................90636 Hyperstat IV – 30 mg/20 ml.......................................X6070 Hepatitis A Vaccine (adult) – 1,440 units/ml..............90632 Hyrexin – 50 mg/ml...................................................X5738 Hepatitis A Vaccine Hyrexin – 10 mg/ml...................................................X5740 (pediatric/adolescent)..............................................90633 Hepatitis B Immune Globulin, 1 ml.............................90371 Hepatitis B Immune Globulin, (Hepagam B) I intramuscular – 0.5 ml.............................................J1571 Hepatitis B Immune Globulin (Hepagam B) Ibandronate Sodium (Boniva) – 1 mg.........................J1740 intravenous – 0.5 ml................................................J1573 Ibritumomab Tiuxetan (In-111), 5 mCi.......................A9542 Hepatitis B Vaccine, adolescent Ibritumomab Tiuxetan (Y-90), 40 mCi........................A9543 (2 dose schedule)...................................................90743 Idursulfase – 1 mg.....................................................J1743 Hepatitis B Vaccine, adult dosage.............................90746 Ifosfamide – 100 mg..................................................X7584 Hepatitis B Vaccine, dialysis or Ilopan – 250 mg/ml....................................................X6060 immunosuppressed, per 40 mcg Imiglucerase – 1.0 u...................................................J1785 (3 dose schedule)...................................................90740 Imipramine HCl – 25 mg/ml.......................................X6352 Hepatitis B Vaccine, dialysis or Immune Serum Globulin, for IM use, Immunosuppressed, per 40 mcg Human, 1 ml............................................................90281 (4 dose schedule)...................................................90747 Immune Serum Globulin I.V., 1 gm............................90283 Hepatitis B Vaccine/Haemophilus Inapsine – 2.5 mg/ml.................................................X6126 Influenzae b............................................................90748 Inderal – 1 mg/ml.......................................................X6354 Hepatitis B Vaccine, pediatric/adolescent Indium In-111 Capromab Pendetide – 10 mCi...........A9507 (3 dose schedule)...................................................90744 Indium In-111 Ibritumomab Tiuxetan – 5 mCi............A9542 Hep-Lock – 100 units/ml............................................X6282 Indium In-111 Oxyquinoline – 0.5 mCi.......................A9547 Hep-Lock – 10 units/ml..............................................X6284 Indium In-111 Pentetate – 0.5 mCi............................A9548 Heprinar – 10,000 units/ml........................................X6296 Indium In-111 Pentetreotide – 6 mCi.........................A9572 Heprinar – 5,000 units/ml..........................................X6302 Infliximab – 10 mg......................................................J1745 Heprinar – 1,000 units/ml..........................................X6308 Influenza Virus Vaccine, preservative free Hexadrol Phosphate – 10 mg/ml...............................X6320 (6 to 35 months of age)...........................................90655 Hexadrol Phosphate – 4 mg/ml.................................X6004 Influenza Virus Vaccine, preservative free Histerone – 100.........................................................X6326 (3 years and older)..................................................90656 Histerone – 50...........................................................X5628 Influenza Virus Vaccine Histrelin Acetate – 10 mcg.........................................J1675 (6 to 35 months of age)...........................................90657 Histrelin Implant (Vantas) – 50 mg.............................J9225 Influenza Virus Vaccine (3 years and older)..............90658 H.P. Acthar Gel – 80 units/ml....................................X5516 Innovar – 0.05 mg/2.5 mg..........................................X6208 H.P. Acthar Gel – 40 units/ml....................................X5518 Insulin Injection – 100 units/ml...................................X6366 Human Papilloma Virus Vaccine, for Interferon Alfa-2a (Roferon A, Roche) – intramuscular use 1,000,000 IU...........................................................X7548 19 through 26 years of age)....................................90649 Interferon Alfa-2b (Intron A, Schering) – Human Papilloma virus (HPV) vaccine, 1,000,000 IU...........................................................X7550 types 16, 18, bivalent, 3 dose schedule, for Interferon Alfa-N3 (Alferon N, Purdue intramuscular use, females Frederick) – 250,000 IU..........................................X7551 10 through 25 years of age...................................90650 Interleukin-2 – 22 million IU.......................................X7632 Humatrope – 1 mg.....................................................X7036 Intropin – 40 mg/ml....................................................J1265 Hyalgan – 2 ml...........................................................J7321 Iodine Iobenguane Sulfate – 0.5 mCi.........................A9508 Hydeltra T.B.A. – 20 mg/ml suspension....................X6328 Iodine Iodinated Serum Albumin – 5 µCi...................A9524 Hydeltrasol – 20 mg/ml solution................................X6330 Iodine Serum Albumin – 5 µCi...................................A9532 Hydextran..................................................................J1752 Iodine Sodium Iodide – 1 µCi....................................A9531 Hydralazine HCl – 20 mg/ml......................................X5648 Iodine Sodium Iodide Capsule(s) – 100 µCi..............A9516 Hydrocortisone – 50 mg/ml.......................................X5980 Iodine Sodium Iodide (diagnostic) – 1 mCi................A9528 Hydrocortisone – 25 mg/ml.......................................X6332 Iodine Sodium Iodide (therapeutic) – 1 mCi...............A9517 Hydrocortisone Acetate – Iodine Sodium Iothalamate – 10 µCi..........................A9554 50 mg/ml suspension..............................................X5774 Iodine Tositumomab – study dose.............................A9544 Hydrocortisone Acetate – Iodine Tositumomab – treatment dose......................A9545 25 mg/ml suspension..............................................X5988 Iprenol – 1:5,000 sol/1 ml..........................................X6408 Hydrocortisone Phosphate – 50 mg/ml.....................X6334 Irinotecan (Camptosar) – 20 mg................................J9206 Hydromorphone HCl – 4 mg/ml.................................X6086 Iron-Based Magnetic Resonance Contrast Hydromorphone HCl – 2 mg/ml.................................X6090 Agent – 1 ml...........................................................Q9953 Hydromorphone HCl – 1 mg/ml.................................X6092 Hydroxo-12 – 1,000 mcg/ml......................................X5752 Hydroxyzine – 50 mg/ml............................................X6336 2 – Injections: List of Codes February 2010
  • 10. inject list 10 Codes Codes Iron Dextran – 50 mg.................................................J1750 L Isoniazid (Isonicotintic Acid Hydrazide) – 100mg/ml..........................................X6410 L.A. Dezone – 8 mg/ml suspension...........................X6008 Isuprol – 1:5,000 solution..........................................X6408 Lanoxin – 0.25 mg/ml................................................X6080 Ixabepilone – 1 mg.....................................................J9207 Lanoxin – 0.1 mg/ml..................................................X6082 Lanreotide acetate – 1 mg.........................................J1930 J (no entry) Largon – 20 mg/ml.....................................................X6442 Laronidase – 0.1 mg..................................................J1931 Lasix – 10 mg/ml.......................................................X6228 K L-Caine-E – 2% w/1:1,000,000 Epinephrine..............X6444 Lepirudin – 50 mg......................................................J1945 Kanamycin Sulfate – 1 gm/3 ml vials.........................X6426 Leucovorin Calcium – 50 mg.....................................J0640 Kanamycin Sulfate – 500 mg/2 ml vials.....................X6422 Leuprolide acetate (for depot suspension) Kanamycin Sulfate – 75 mg/2 ml vials.......................X6424 per 7.50 mg............................................................J9217 Kantrex – 1 gm/3 ml vials..........................................X6426 Leuprolide acetate (for depot suspension) Kantrex – 500 mg/2 ml vials......................................X6422 per 3.75 mg............................................................J1950 Kantrex – 75 mg/2 ml vials........................................X6424 Levarterenol (Norepinephrine) – 1 mg Kaybovite 1,000 – 1,000 mcg/ml...............................X5752 (as batartrate) per ml..............................................X6452 Keflin – 20 gm/200 ml vial..........................................X5888 Levetiracetam – 10 mg..............................................J1953 Keflin – 4 gm/50 ml vial.............................................X5890 Levo-Dromoran – 2 mg/ml.........................................X6454 Keflin – 2 gm/100 ml vial...........................................X5892 Levoid – 500 mcg/ml.................................................X6456 Keflin – 2 gm/20 ml vial.............................................X5894 Levophed – 1 mg (as batartrate) per ml....................X6452 Keflin – 1 gm/100 ml vial...........................................X5896 Levoprome – 20 mg/ml..............................................X6458 Keflin – 1 gm/10 ml vial.............................................X5898 Levorphanol Tartrate – 2 mg/ml.................................X6454 Kefzol – 10 gm/100 ml vial........................................X5602 Levothyroxine – 500 mcg/ml.....................................X6456 Kefzol – 1 gm/redi vial...............................................X5604 Levsin – 0.25 mg/ml..................................................X6460 Kefzol – 1 gm/100 ml piggyback unit.........................X5606 Libigen – 1,000 units/ml.............................................X5622 Kefzol – 1 gm/10 ml vial............................................X5608 Librium – 100 mg/5 ml...............................................X5920 Kefzol – 500 mg/100 ml vial......................................X5610 Lidocaine HCl – 20% (200 mg/ml).............................X6462 Kefzol – 500 mg/10 ml vial........................................X5612 Lidocaine HCl – 10% (100 mg/ml).............................X6464 Kefzol – 250 mg/10 ml vial........................................X5614 Lidocaine HCl – 5% w/7.5% Glucose........................X6466 Kenalog 40................................................................X5552 Lidocaine HCl – 2% (20 mg/ml).................................X6470 Kenalog 10................................................................X6432 Lidocaine HCl – 1.5%................................................X6478 Kestrin Aqueous – 2 mg/ml.......................................X5756 Lidocaine HCl – 0.5%................................................X6490 Ketaject – 100 mg/ml.................................................X6434 Lidocaine HCl – 1.5% w/7.5% Dextrose....................X6480 Ketaject – 50 mg/ml...................................................X6436 Lidocaine HCl – 2% w/1:200,000 Epinephrine...........X6474 Ketaject – 10 mg/ml...................................................X6438 Lidocaine HCl – 2% w/1:100,000 Epinephrine...........X6444 Ketalar – 100 mg/ml..................................................X6434 Lidocaine HCl – 2% w/1:50,000 Epinephrine.............X6476 Ketalar – 50 mg/ml....................................................X6436 Lidocaine HCl – 1.5% w/1:200,000 Epinephrine........X6482 Ketalar – 10 mg/ml....................................................X6438 Lidocaine HCl – 1% w/1:200,000 Epinephrine...........X6486 Ketamine – 100 mg/ml...............................................X6434 Lidocaine HCl – 1% w/1:100,000 Epinephrine...........X6488 Ketamine – 50 mg/ml.................................................X6436 Lidocaine HCl – 0.5% w/1:200,000 Epinephrine........X6492 Ketamine – 10 mg/ml.................................................X6438 Key-Pred 50..............................................................X6440 Key-Pred 25..............................................................X6014 Key-Pred SP – 20 mg/ml...........................................X6330 K-Feron......................................................................J1752 Konakion – 10 mg/ml.................................................X5650 Konakion – 2 mg/ml...................................................X5652 K-Phen – 50 mg/ml....................................................X6236 2 – Injections: List of Codes August 2009
  • 11. inject list 11 Codes Codes Lidocaine HCl Without Preservatives – M 4% (40 mg/ml).........................................................X6494 Lidocaine HCl Without Preservatives – Magnesium Sulfate – 50%.........................................X6512 2% (20 mg/ml).........................................................X6470 Magnesium Sulfate – 12.5%......................................X6514 Lidocaine HCl Without Preservatives – Magnesium Sulfate – 10%.........................................X6516 1% (10 mg/ml).........................................................X6496 Malogen Cyp – 100 mg/ml.........................................X5618 Lidopen Auto-Injector – Malogen L.A. – 200 mg/ml.........................................X5634 10% (100 mg/ml).....................................................X6464 Mandol – 2 gm/100 ml vial.........................................X5842 Lincocin – 300 mg/2 ml U-Ject..................................X6504 Mandol – 2 gm/20 ml vial...........................................X5844 Lincomycin – 300 mg/2 ml U-Ject.............................X6504 Mandol – 1 gm/100 ml vial.........................................X5846 Lipo-Hepin – 40,000 units/ml.....................................X6286 Mandol – 1 gm/10 ml vial...........................................X5848 Lipo-Hepin – 20,000 units/ml.....................................X6288 Mandol – 500 mg/10 ml vial.......................................X5840 Lipo-Hepin – 10,000 units/ml.....................................X6296 Mannitol – 25%..........................................................X6520 Lipo-Hepin – 5,000 units/ml.......................................X6302 Mannitol – 20%..........................................................X6522 Lipo-Hepin – 5,000 units/0.5 ml.................................X6304 Mannitol – 15%..........................................................X6524 Lipo-Hepin – 1,000 units/ml.......................................X6308 Mannitol – 10%..........................................................X6526 Liquaemin Sodium – 40,000 units/ml.........................X6286 Mannitol – 5%............................................................X6528 Liquaemin Sodium – 20,000 units/ml.........................X6288 Marcaine – 0.75%.....................................................X5790 Liquaemin Sodium – 10,000 units/ml.........................X6296 Marcaine – 0.5%.......................................................X6530 Liquaemin Sodium – 5,000 units/ml...........................X6302 Marcaine HCl – 0.25%..............................................X5792 Liquaemin Sodium – 1,000 units/ml...........................X6308 Measles.....................................................................90705 L-Myoscyamine Sulfate – 0.25 mg/ml........................X6460 Measles, mumps, rubella (MMR)...............................90707 Low osmolar contrast material 100 – 199 mg/ml Measles, mumps, rubella, varicella (MMRV)..............90710 iodine concentration – per ml..................................Q9965 Measles, rubella.........................................................90708 Low osmolar contrast material 200 – 299 mg/ml Mechlorethamine HCl – 10 mg/20ml iodine concentration – per ml..................................Q9966 triturated w/100 mg Sodium Chloride.......................X7552 Low osmolar contrast material 300 – 399 mg/ml Medralone-80 – 80 mg/ml suspension.......................X6036 iodine concentration – per ml..................................Q9967 Medralone-40 – 40 mg/ml..........................................X6038 Low osmolar contrast material – Medroxyprogesterone Acetate – 400 mg/ml iodine or greater....................................Q9951 25 mg and estradiol cypionate 5 mg/0.5 ml.............X7490 LTS – 500 mcg/ml.....................................................X6456 Medroxyprogesterone Acetate – Luminal Sodium – 130 mg/ml....................................X6506 400 mg/ml 10 ml vial per ml.....................................X6046 Lunelle – Medroxyprogesterone Acetate – Medroxyprogesterone Acetate – 25 mg and estradiol cypionate 5 mg/0.5 ml.............X7490 400 mg/ml 2.5 ml vial per ml....................................X6048 Mefoxin – 2 gm vial...................................................X5854 Mefoxin – 1 gm vial...................................................X5856 Menadiol Sodium Diphosphate (K-4) – 37.5 mg/ml...................................................X6532 Menadiol Sodium Diphosphate (K-4) – 5 mg/ml........................................................X6534 Meningococcal polysaccharide vaccine, any groups..............................................................90733 Meperidine HCl – 100 mg/ml.....................................X6020 Meperidine HCl – 75 mg/ml.......................................X6022 Meperidine HCl – 50 mg/ml.......................................X6024 Meperidine HCl – 25 mg/ml.......................................X6026 Mephentermine Sulfate – 30 mg/ml...........................X6550 Mephentermine Sulfate – 15 mg/ml...........................X6552 Mepivacaine HCl – 3%..............................................X5824 Mepivacaine HCl – 2%..............................................X5818 Mepivacaine HCl – 1.5%...........................................X5820 Mepivacaine HCl – 1%..............................................X5822 Mepred 80 suspension..............................................X6036 Mepred 40 suspension..............................................X6038 Mesna – 100 mg/ml...................................................X7586 Mesoridazine – 25 mg/ml..........................................X6556 Mestinon Bromide – 5 mg/ml.....................................X6826 2 – Injections: List of Codes April 2010
  • 12. inject list 12 Codes Codes Metalone T.B.A. – Meticortelone Acetate – 25 mg/ml.............................X6014 20 mg/ml suspension..............................................X6328 Metocurine Ioxide – 2 mg/ml.....................................X6582 Metaraminol – 10 mg/ml (1%) Metubine Iodide – 2 mg/ml........................................X6582 (as bitartrate)...........................................................X5658 Micafungin sodium - 1 mg..........................................J2248 Methadone HCl – 10 mg/ml.......................................X6110 Miconazole – 10 mg/ml..............................................X6588 Methergine – 0.2 mg/ml.............................................X6566 Minocycline HCl (Minocin) – Methicillin Sodium – 100 mg/vial..............................................................X6118 6 gm vials (powder).................................................X5710 Mithracin – 2.5 mg/vial w/100 Methicillin Sodium – mg/mannitol.............................................................X7564 4 gm piggyback units (powder)...............................X6558 Mithramycin – 2.5 mg/vial w/100 Methicillin Sodium – mg/mannitol.............................................................X7564 4 gm vials (powder).................................................X5712 Mitomycin – 20 mg/vial..............................................X7566 Methicillin Sodium – 2 gm piggyback Mitomycin – 5 mg/vial................................................X7568 units (powder).........................................................X5866 Mitoxantrone – 5 mg..................................................X7624 Methicillin Sodium – 1 gm piggyback Monistat – 10 mg/ml..................................................X6588 units (powder).........................................................X5868 Morphine Sulfate – 100 mg........................................J2271 Methicillin Sodium – Morphine Sulfate – up to 10 mg.................................J2270 1 gm vials (powder).................................................X5714 Morphine Sulfate – preservative-free sterile Methocarbamol – 100 mg/ml.....................................X6560 solution, 10 mg.........................................................J2275 Methohexital Sodium – 500 mg/5 ml..........................X5784 M-Prednisol 80 suspension.......................................X6036 Methohexital Sodium – 5 gm.....................................X5780 M-Prednisol 40 suspension.......................................X6038 Methohexital Sodium – 2.5 gm..................................X5782 Mumps.......................................................................90704 Methotrexate – 50 mg (sodium) vial for Mustargen – 10 mg/20 ml triturated reconstitution...........................................................J9260 w/100 mg sodium chloride.......................................X7552 Methotrexate – 50 mg/ml 2 ml vial Mutamycin – 20 mg/vial.............................................X7566 (sodium)...................................................................J9260 Mutamycin – 5 mg/vial...............................................X7568 Methotrexate – 50 mg/vial..........................................J9260 M.V.I. – 10 ml............................................................X6598 Methotrimeprazine – 20 mg/ml..................................X6458 M.V.I. Concentrate – 5 ml..........................................X6600 Methoxamine HCl – 20 mg/ml Mychel-S – 1 gm vial as dry powder.........................X5922 1 ml ampules...........................................................X6562 Mycifradin Sulfate – 500 mg vials..............................X6504 Methoxamine HCl – Myochrysine – 50 mg/ml...........................................X6262 10 mg/ml 10 ml vials................................................X6562 Myochrysine – 25 mg/ml...........................................X6264 Methyldopa and Methyldopate HCl – Myolin – 30 mg/ml.....................................................X6216 250 mg/5 ml.............................................................X5540 Methyldrol 40.............................................................X6038 Methylene Blue – 1 ml...............................................A9535 Methylergonovine Maleate – 0.2 mg/ml.................................................................X6566 Methylprednisolone Acetate – 80 mg/ml..................................................................J1040 Methylprednisolone Acetate – 40 mg/ml..................................................................J1030 Methylprednisolone Acetate – 20 mg/ml..................................................................J1020 Methylprednisolone Sodium Succinate – up to 125 mg/ml................................................................J2930 Methylprednisolone Sodium Succinate – up to 40 mg/ml..................................................................J2920 2 – Injections: List of Codes February 2010
  • 13. inject list 13 Codes Codes N Nafcil – 2 gm (powder) vial........................................X6604 Nospaz – 10 mg/ml...................................................X5642 Nafcil – 1 gm (powder) vial........................................X6606 Novocain – 10%........................................................X6640 Nafcillin Sodium – 2 gm (powder) vial.......................X6604 Novocain – 2%..........................................................X6642 Nafcillin Sodium – 1 gm (powder) vial.......................X6606 Novocain – 1%..........................................................X6644 Nafcillin Sodium – 500 mg vial...................................X6610 Nubain – 10 mg/ml....................................................X6612 Nalate – 50 mg/ml.....................................................X5678 Numorphan – 1.5 mg/ml............................................X6646 Nalbuphine HCl – 10 mg/ml.......................................X6612 Numorphan – 1 mg/ml...............................................X6648 Naloxone HCl – 0.4 mg/ml.........................................X6614 Nutropin – 1 mg.........................................................X7452 Naloxone HCl – 0.02 mg/ml.......................................X6616 Nutropin AQ – 1 mg...................................................X7454 Nandrolate – 100 mg/ml (oil).....................................X5600 Nydrazid – 100 mg/ml...............................................X6410 Nandrolate – 50 mg/ml (oil).......................................X5632 Nandrolin – 25 mg/ml (oil)..........................................X5630 Nandrolone Decanoate – 100 mg/ml (oil).........................................................X5600 O Nandrolone Decanoate – 50 mg/ml (oil)...........................................................X5632 Octafluoropropane Microspheres – 1 ml...................Q9956 Nandrolone Phenpropionate – Octocaine HCl – 2% w/1:100,000 50 mg/ml (oil)...........................................................X5598 Epinephrine.............................................................X6444 Nandrolone Phenpropionate – Octocaine HCl – 2% w/1:50,000 25 mg/ml (oil)...........................................................X5630 Epinephrine.............................................................X6476 Narcan – 0.4 mg/ml...................................................X6614 Omnipen-N – 2 gm (powder) Narcan – 0.02 mg/ml.................................................X6616 piggyback units.......................................................X5576 Natalizumab – 1 mg...................................................J2323 Omnipen-N – 2 gm (powder) vials.............................X5578 Navane – 2 mg/ml.....................................................X6618 Omnipen-N – 1 gm (powder) Nebcin – 40 mg/ml....................................................X6620 piggyback units.......................................................X5580 Nebcin – 10 mg/2 ml vial...........................................X6622 Omnipen-N – 1 gm (powder) vials.............................X5582 Nelarabine – 50 mg....................................................J9261 Omnipen-N – 500 mg (powder) Nembutal Sodium – 50 mg/ml...................................X6624 piggyback units.......................................................X5584 Neocyten – 30 mg/ml................................................X6216 Omnipen-N – 500 mg (powder) vials.........................X5586 Neostigmine Methylsulfate – 1:4,000 Omnipen-N – 250 mg (powder) vials.........................X5588 solution/1 ml ampules..............................................X6630 Omnipen-N – 125 mg (powder) vials.........................X5550 Neostigmine Methylsulfate – Oncovin – 5 mg w/50 mg 1:2,000 solution.......................................................X6632 lactose per vial........................................................X7570 Neostigmine Methylsulfate – Oncovin – 1 mg w/10 mg 1:1,000 solution.......................................................X6634 lactose per vial........................................................X7572 Neo Synephrine – 1% 1 ml ampules.........................X6626 Ondansetron HCl – 1 mg...........................................J2405 Nesacaine – 2%........................................................X5926 Oral Magnetic Resonance Contrast Nesacaine – 1%........................................................X5928 Agent – 1 ml............................................................Q9954 Nesacaine-CE – 3%..................................................X5924 Ormazine – 25 mg/ml................................................X5918 Nesacaine-CE – 2%..................................................X5926 Orphenadrine Citrate – 30 mg/ml..............................X6216 Nesiritide - 0.1 mg.....................................................J2325 Orthovisc – per dose.................................................J7324 Nipride – 50 mg/5ml..................................................X6636 Or-Tyl – 10 mg/ml......................................................X5642 Nitrogen N-13 Ammonia, Diagnostic – 40 mCi..........A9526 Osmitrol – 20%..........................................................X6522 Nitroprusside Sodium – 50 mg/5 ml...........................X6636 Osmitrol – 15%..........................................................X6524 Norazine HCl – 50 mg/ml..........................................X6638 Osmitrol – 10%..........................................................X6526 Norditropin – 1 mg.....................................................X7494 Osmitrol – 5%............................................................X6528 Nordryl – 10 mg/ml....................................................X5740 Oxacillin Sodium – 4 gm Norferan.....................................................................J1752 (powder) vials..........................................................X5720 Norflex – 30 mg/ml....................................................X6216 Oxacillin Sodium – 2 gm Noroxine – 500 mcg/ml.............................................X6456 (powder) vials..........................................................X5722 Nor-Pred T.B.A. – Oxacillin Sodium – 1 gm 20 mg/ml suspension..............................................X6328 (powder) vials..........................................................X5724 Oxacillin Sodium – 500 mg (powder) vials..........................................................X5726 Oxacillin Sodium – 250 mg (powder) vials..........................................................X6656 Oxaliplatin – 0.5 mg...................................................J9263 2 – Injections: List of Codes August 2009
  • 14. inject list 14 Codes Codes Oxymorphone HCl – 1.5 mg/ml.................................X6646 Penicillin G Benzathine, Parenteral – Oxymorphone HCl – 1 mg/ml....................................X6648 300,000 units/ml 10 ml vials....................................X5772 Oxytetracycline – 250 mg/vial...................................X6664 Penicillin G Benzathine, Parenteral – Oxytetracycline – 125 mg/ml.....................................X6658 600,000 units/ml......................................................X5770 Oxytetracycline – 50 mg/ml.......................................X6660 Penicillin G Benzathine, Parenteral – Oxytocin – 10 units/ml...............................................X6666 1,200,000 units/2 ml syringe....................................X7460 Penicillin G Benzathine, Parenteral – 2,400,000 units/4 ml syringe....................................X7462 Penicillin G Potassium – 20,000,000 P units (powder)/vial...................................................X6700 Penicillin G Potassium (or Sodium) Paclitaxel protein-bound particles – 1 mg..................J9264 (Aqueous) – 10,000,000 units Paclitaxel – 30 mg.....................................................X7052 (powder)/vial............................................................X6702 Palifermin – 50 mcg...................................................J2425 Penicillin G Potassium (or Sodium) Palonosetron – 25 mcg..............................................J2469 (Aqueous) – 5,000,000 units Pamidronate – 30 mg................................................X7444 (powder)/vial............................................................X6704 Pancuronium Bromide – 2 mg/ml..............................X6670 Penicillin G Potassium (or Sodium) Pancuronium Bromide – 1 mg/ml..............................X6672 (Aqueous) – 1,000,000 units Panheprin – 40,000 units/ml......................................X6286 (powder)/vial............................................................X6706 Panheprin – 20,000 units/ml......................................X6288 Penicillin G Procaine (Aqueous) – Panheprin – 10,000 units/ml......................................X6296 2,400,000 units/unit dose........................................X6714 Panheprin – 5,000 units/ml........................................X6302 Penicillin G Procaine (Aqueous) – Panheprin – 1,000 units/ml........................................X6308 1,200,000 units/unit dose........................................X6716 Panheprin Lok – 100 units/ml....................................X6282 Penicillin G Procaine (Aqueous) – Panitumumab – 10 mg...............................................J9303 600,000 units/unit dose ..........................................X6136 Pantoprazole – 40 mg...............................................S0164 Pentamidine – 150 mg...............................................X6718 Paricalcitol – 1 mcg....................................................J2501 Pentazine – 50 mg/ml................................................X6236 Pavulon – 2 mg/ml.....................................................X6670 Pentazocine – 30 mg/ml............................................X6720 Pavulon – 1 mg/ml.....................................................X6672 Pentobarbital Sodium – 50 mg/ml..............................X6624 Pegademase Bovine – 25 IU.....................................J2504 Pentothal Sodium – 10 gm........................................X6728 Pegaptanib Sodium – 0.3 mg.....................................J2503 Pentothal Sodium – 5 gm..........................................X6730 Pegaspargase – single dose vial...............................J9266 Pentothal Sodium – 1 gm..........................................X6732 Pegfilgrastim (Neulasta) – 6 mg.................................J2505 Pentothal Sodium – 500 mg......................................X6734 Pen A/N – 1 gm (powder) vials..................................X5582 Pentothal Sodium – 400 mg......................................X6736 Pen A/N – 500 mg (powder) vials..............................X5586 Pentothal Sodium – 250 mg......................................X6738 Pen A/N – 250 mg (powder) vials..............................X5588 Perflutren Lipid Microspheres – 1 ml.........................Q9957 Penazine 50 – 50 mg/ml............................................X6236 Perphenazine – 5 mg/ml............................................X6740 Penbritin-S – 4 gm (powder) vials.............................X5574 Pfizerpen-AS – Penbritin-S – 2 gm (powder) vials.............................X5578 1,200,000 units/unit dose........................................X6716 Penbritin-S – 1 gm (powder) vials.............................X5582 Phenazine 25............................................................X6742 Penbritin-S – 500 mg (powder) vials.........................X5586 Phencen 50...............................................................X6236 Penbritin-S – 250 mg (powder) vials.........................X5588 Phenergan – 50 mg/ml..............................................X6236 Penbritin-S – 125 mg (powder) vials.........................X5550 Phenergan – 25 mg/ml..............................................X6742 Penicillin G Benzathine – 150,000 units Phenobarbital Sodium – 130 mg/ml...........................X6506 and Penicillin G Procaine – Phenobarbital Sodium – 65 mg/ml.............................X6754 150,000 units/ml......................................................X5768 Phenoject 50.............................................................X6236 Penicillin G Benzathine – 300,000 units Phentolamine – 5 mg.................................................X6758 and Penicillin G Procaine – Phenylephrine HCl – 300,000 units/1 ml tubex.........................................X5766 1% 1 ml ampules.....................................................X6626 Penicillin G Benzathine – 600,000 units Phenytoin Sodium, and Penicillin G Procaine – Parenteral – 50 mg/ml.............................................X6084 600,000 units/2 ml syringe.......................................X7456 Physostigmine Salicylate – Penicillin G Benzathine – 900,000 units 1 mg/ml...................................................................X5640 and Penicillin G Procaine – 300,000 units/2 ml tubex.........................................X5764 Penicillin G Benzathine – 1,200,000 units and Penicillin G Procaine – 1,200,000 units/4 ml syringe....................................X7458 2 – Injections: List of Codes April 2010
  • 15. inject list 15 Codes Codes Phytonadione (K1) – 10 mg/ml..................................X5650 Pregnyl – 1,000 units/ml............................................X5622 Phytonadione (K1) – 2 mg/ml....................................X5652 Premarin IV – 25 mg.................................................X5972 Pitocin – 10 units/ml..................................................X6666 Prenisolone Acetate – 25 mg/ml................................X6014 Pitressin – 20 pressor units/ml..................................X6760 Prenisolone Sodium Phosphate – Pituitrin – 20 units/ml.................................................X6764 20 mg/ml..................................................................X6330 Plague Vaccine..........................................................90727 Prilocaine HCl – 4%..................................................X5944 Platinol – 10 mg/vial..................................................X7516 Prilocaine HCl – 4% w/1:200,000 Plerixafor (Mozobil®) – 1 mg...................................C9252 Epinephrine.............................................................X5942 Pneumococcal Conjugate Vaccine, Polyvalent, Principen/N – 2 gm (powder) vials.............................X5578 (for children under 5 years of age)...........................90669 Principen/N – 1 gm (powder) vials.............................X5582 Pneumococcal Polysaccharide Principen/N – 500 mg (powder) vials.........................X5586 Vaccine – 23-valent.................................................90732 Principen/N – 250 mg (powder) vials.........................X5588 Polio, live, oral...........................................................90712 Principen/N – 125 mg (powder) vials.........................X5550 Poliomyelitis Vaccine – 1 cc amp..............................90713 Procainamide HCl – 500 mg/ml.................................X6792 Polycillin-N – 2 gm Procainamide HCl – 100 mg/ml.................................X6794 (powder) piggyback units........................................X5576 Procaine HCl – 10%..................................................X6640 Polycillin-N – 2 gm Procaine HCl – 2%....................................................X6642 (powder) vials..........................................................X5578 Procaine HCl – 1%....................................................X6644 Polycillin-N – 1 gm Prochlorperazine – 5 mg/ml.......................................X5970 (powder) piggyback units........................................X5580 Procrit (ESRD) – 1,000 units.....................................J0886 Polycillin-N – 1 gm (powder) vials.............................X5582 Procrit (non-ESRD) – 1,000 units..............................J0885 Polycillin-N – 500 mg Progesterone (in oil) – 50 mg/cc................................X6810 (powder) piggyback units........................................X5584 Prolixin – 2.5 mg/ml...................................................X6222 Polycillin-N – 500 mg Prolixin Decanoate – 25 mg/ml..................................X6220 (powder) vials..........................................................X5586 Prolixin Enanthate – 25 mg/ml...................................X6220 Polycillin-N – 250 mg Promaject – 25 mg/ml................................................X5918 (powder) vials..........................................................X5588 Promaz – 25 mg/ml...................................................X5918 Polycillin-N – 125 mg Promazine HCl – 50 mg/ml........................................X6638 (powder) vials..........................................................X5550 Promethamead 50.....................................................X6236 Polyestradiol Phosphate – Promethamead 25.....................................................X6742 40 mg/secule w/2 ml Promethazine HCl – 50 mg/ml...................................X6236 ampule of sterile diluent...........................................X7540 Promethazine HCl – 25 mg/ml...................................X6742 Polymyxin B Sulfate – 500,000 units.........................X6776 Pronestyl – 500 mg/ml...............................................X6792 Pontocaine – 1%.......................................................X6778 Pronestyl – 100 mg/ml...............................................X6794 Pontocaine – 0.3% w/6% Dextrose...........................X6780 Propiomazine HCl – 20 mg/ml...................................X6442 Pontocaine – 0.2% w/6% Dextrose...........................X6782 Propranolol HCl – 1 mg/ml........................................X6354 Posterior Pituitary Injection – Prorex – 50 mg/ml.....................................................X6236 20 units/ml...............................................................X6764 Prorex – 25 mg/ml.....................................................X6742 Pralidoxime Chloride – 1 gm.....................................X6784 Prostaphlin – 4 gm (powder) vials.............................X5720 Predcor-50................................................................X6440 Prostaphlin – 2 gm (powder) vials.............................X5722 Predcor-25................................................................X6014 Prostaphlin – 1 gm (powder) vials.............................X5724 Pre-Dep – 80 mg/ml..................................................X6036 Prostaphlin – 500 mg (powder) vials.........................X5726 Pre-Dep – 40 mg/ml..................................................X6038 Prostaphlin – 250 mg (powder) vials.........................X6656 Prednisolone Acetate – 50 mg/ml..............................X6440 Prostigmin – 1:4,000 solution/ Prednisolone Acetate – 25 mg/ml..............................X6014 1 ml/ampules...........................................................X6630 Prednisolone Tebutate – Prostigmin – 1:2,000 solution....................................X6632 20 mg/ml suspension..............................................X6328 Prostigmin – 1:1,000 solution....................................X6634 2 – Injections: List of Codes October 2009
  • 16. inject list 16 Codes Codes Protamine Sulfate – 10 mg/ml...................................X6816 Robaxin – 100 mg/ml................................................X6560 Protein C Concentrate Robinul – 0.2 mg/ml...................................................X6258 intravenous, human – 10 IU.....................................J2724 Romiplostim – 10 mcg...............................................C9245 Prothazine – 50 mg/ml...............................................X6236 Ropredlone – 50 mg/ml.............................................X6440 Prothazine – 25 mg/ml...............................................X6742 Ropredlone – 25 mg/ml.............................................X6014 Protopam Chloride - Rubella Virus Vaccine, Live.......................................90706 Emergency Kit – 1 gm.............................................X6784 Rubesol 1,000 ..........................................................X5752 Protropin – 1 mg........................................................X7034 Rubramin PC – 1,000 mcg/ml...................................X5752 Provigan – 50 mg/ml.................................................X6236 Ruvite 1,000 – 1,000 mcg/ml.....................................X5752 Provigan – 25 mg/ml.................................................X6742 PSP-IV – 20 mg/ml....................................................X6330 Pyridostigmine Bromide – 5 mg/ml............................X6826 S Samarium Sm-153, Therapeutic – 50 mCi.................A9605 Q Sargramostim – 500 mcg/vial....................................X7366 Sargramostim – 250 mcg/vial....................................X7364 Quelicin – 100 mg/ml.................................................X6828 Savacort – 100...........................................X6014 or X6440 Quelicin – 50 mg/ml...................................................X6830 Savacort – 25............................................................X6440 Quelicin – 20 mg/ml...................................................X5636 Savacort-D – 4 mg/ml................................................X6004 Quinidine Gluconate – 80 mg/ml...............................X6832 Scopolamine HBr – 1.0 mg/ml...................................X6856 Scopolamine HBr – 0.4 mg/ml...................................X6862 Scopolamine HBr – 0.3 mg/ml...................................X6864 Secobarbital Sodium – 50 mg/ml...............................X6870 R Seconal Sodium – 50 mg/ml......................................X6870 Secretin, Synthetic, Human – 1 mcg..........................J2850 Ranibizumab (Lucentis™) – 0.1 mg...........................J2778 Serentil – 25 mg/ml....................................................X6556 Recombinant, GM-CSF, Leukine – Sermorelin Acetate – 1 mcg......................................Q0515 500 mcg/vial............................................................X7366 Sincalide – 5 mcg......................................................J2805 Recombinant, GM-CSF, Leukine – SK-Ampicillin-N – 500 mg 250 mcg/vial............................................................X7364 (powder) vials..........................................................X5586 Regadenoson – 0.1 mg..............................................J2785 Sodium Ascorbate – 500 mg/ml................................X5882 Regitine – 5 mg.........................................................X6758 Sodium Ascorbate – 250 mg/ml................................X5912 Regonol – 5 mg/ml....................................................X6826 Sodium Edecrin – 500 mg/vial...................................X6204 Remicade – 10 mg.....................................................J1745 Sodium Ferric Gluconate Complex Repbimone #1...........................................................X5666 in Sucrose – 62.5 mg..............................................X7496 Rep Estra – 10 mg/ml................................................X5662 Sodium Fluoride F-18, up to 30 millicuries.................A9580 Reposterone – 200 mg/ml.........................................X5634 Sodium Phosphate P-32, Therapeutic – 1 mCi..........A9563 Rep-Pred 80 suspension...........................................X6036 Sodium Thiosalicylate – 50 mg/ml.............................X5678 Rep-Pred 40..............................................................X6038 Solganal – 50 mg/ml..................................................X5708 Respiratory Syncytial Virus Immune Globulin Sol-Pred – 20 mg/ml solution....................................X6330 (RSV-IGIM), 50 mg..................................................90378 Solu-Cortef – 1,000 mg/8 ml vial...............................X6888 RHO (D) Immune Globulin (Human) – full-dose........90384 Solu-Cortef – 500 mg/4 ml vial..................................X6890 RHO (D) Immune Globulin (Human) – mini-dose......90385 Solu-Cortef – 250 mg/2 ml vial..................................X6892 RHO (D) Immune Globulin (RhlglV), human Solu-Cortef – 100 mg/10 ml vial................................X6894 for IV use (100 I.U.).................................................J2792 Solu-Medrol – 40 mg/ml............................................X5554 Risperidone, long lasting, 0.5 mg...............................J2794 Solurex – 4 mg/ml.....................................................X6004 Rituximab – 100 mg...................................................J9310 Span-Est 20 .............................................................X5660 Span-Est 10 .............................................................X5662 Span-Est-Test 4 – 90-4 mg/ml...................................X5666 Span-F – 5 mg/ml......................................................X5662 Span-Test – 100 mg/ml.............................................X5626 Spectinomycin – 400 mg (as HCl)/ml 2 gm vial...............................................X6896 Spenbolic, Improved – 50 mg/ml (oil)........................X5598 Spenbolic, Improved – 25 mg/ml (oil)........................X5630 2 – Injections: List of Codes September 2009
  • 17. inject list 17 Codes Codes Spenduo – 50-2 mg/ml..............................................X5620 Technetium Medronate – 30 mCi..............................A9503 Stadol – 2 mg/ml.......................................................X5796 Technetium Mertiatide – 15 mCi................................A9562 Stadol – 1 mg/ml.......................................................X5798 Technetium Oxidronate – 30 mCi..............................A9561 Staphcillin – 4 gm vials (powder)...............................X5710 Technetium Pentetate – 25 mCi................................A9539 Staphcillin – 4 gm piggyback units Technetium Pentetate (aerosol) – 75 mCi.................A9567 (powder)..................................................................X6558 Technetium Pertechnetate – 1 mCi...........................A9512 Staphcillin – 4 gm vials (powder)...............................X5712 Technetium Pyrophosphate – 25 mCi.......................A9538 Staphcillin – 1 gm piggyback units Technetium Sestamibi – 40 mCi................................A9500 (powder)..................................................................X5868 Technetium Sodium Gluceptate – 25 mCi.................A9550 Staphcillin – 1 gm vials (powder)...............................X5714 Techentium Succimer – 10 mCi................................A9551 Stelazine – 2 mg/ml...................................................X6912 Technetium Sulfur Colloid – 20 mCi..........................A9541 Stemutrolin – 500 units/ml.........................................X5644 Technetium Tetrofosmin – 40 mCi.............................A9502 Sterane – 25 mg/ml...................................................X6014 Teev – 90-4 mg/ml....................................................X5666 Stilphostrol – 0.25 gm (as sodium salt)/ Tega-Flex – 30 mg/ml................................................X6216 5 ml ampuls.............................................................X7536 Temsirolimus – 1 mg..................................................J9330 Streptokinase-Streptodornase – Tensilon – 10 mg/ml..................................................X6146 20,000/5,000 units...................................................X6920 Terbutaline Sulfate – 1 mg/ml....................................X5776 Streptomycin Sulfate....................Available free from Pfizer Terramycin – 50 mg/ml..............................................X6660 Streptozocin – 1 gm vial............................................X7574 Terramycin – 125 mg/ml............................................X6658 Strontium Sr-89 Chloride, Therapeutic – 1 mCi.........A9600 Terramycin – 250 mg/vial..........................................X6664 Sublimaze – 0.5 mg/ml..............................................X6206 Testa-C – 100 mg/ml.................................................X5618 Succinylcholine Chloride – 100 mg/ml.......................X6828 Testadiate-Depo – 50-2 mg/ml..................................X5620 Succinylcholine Chloride – 50 mg/ml.........................X6830 Testa-Estrac – 50-2 mg/ml........................................X5620 Succinylcholine Chloride – 20 mg/ml.........................X5636 Testaqua – 100 mg/ml...............................................X6326 Sucostrin – 100 mg/ml...............................................X6828 Testaqua – 50 mg/ml.................................................X5628 Sucostrin – 50 mg/ml.................................................X6830 Testate – 100 mg/ml..................................................X5626 Sucostrin – 20 mg/ml.................................................X5636 Testoject 50...............................................................X5628 Supartz – 25 mg/2.5 ml.............................................X7486 Testone – 200 mg/ml.................................................X5634 Supprelin LA Implant – 50mg.....................................J9226 Testone L.A. – 100 mg/ml.........................................X5626 Sus-Phrine – 1:200 suspension................................X6166 Testosterone – 100 mg/ml.........................................X6326 Synagis (RSV-IgIV) – 50 mg......................................90378 Testosterone – 50 mg/ml...........................................X5628 Synkayvite – 37.5 mg/ml...........................................X6532 Testosterone – 25 mg/ml...........................................X6942 Synkayvite – 5 mg/ml................................................X6534 Testosterone Aqueous – 100 mg/ml..........................X6326 Synthroid – 500 mcg/ml.............................................X6456 Testosterone Aqueous – 50 mg/ml............................X5628 Syntocinon – 10 units/ml...........................................X6666 Testosterone Aqueous – 25 mg/ml............................X6942 Synvisc – per dose....................................................J7322 Testosterone Cypionate – up to 100 mg....................J1070 Sytobex – 1,000 mcg/ml............................................X5752 Testosterone Cypionate – 1 cc, 200 mg....................J1080 Testosterone Cypionate and Estradiol Cypionate – 50-2 mg/ml............................X5620 T Testosterone Enanthate – 200 mg/ml........................X5634 Testosterone Enanthate – 100 mg/ml........................X5626 Talwin – 30 mg/ml.....................................................X6720 Testosterone Enanthate and Taractan – 12.5 mg/ml...............................................X5934 Estradiol Valerate – 90-4 mg/ml..............................X5666 Taxotere – 20 mg......................................................X7638 Testosterone Propionate – 100 mg/ml.......................X6944 Technetium Apcitide – 20 mCi...................................A9504 Testostroval P.A. – 200 mg/ml..................................X5634 Testradiol 90/4...........................................................X5666 Technetium Bicisate – 25 mCi...................................A9557 Tetanus, diphtheria toxoids, and acellular Technetium Disofenin – 15 mCi................................A9510 pertussis vaccine [Tdap] Technetium Exametazine – 25 mCi...........................A9521 for intramuscular use...............................................90715 Technetium Fanolesomab – 25 mCi..........................A9566 Tetanus and diphtheria toxoids, adsorbed – Technetium Labeled Red Blood Cells – for seven years of age and older.............................90718 30 mCi.....................................................................A9560 Tetanus Immune Globulin Technetium Macroaggregated albumin – (human) – 250 unit...................................................90389 10 mCI.....................................................................A9540 Tetanus Toxoid, Adsorbed.........................................90703 Technetium Mebrofenin – 15 mCi..............................A9537 Tetracaine HCl – 1%.................................................X6778 Tetracaine HCl – 0.3% w/6% Dextrose.....................X6780 Tetracaine HCl – 0.2% w/6% Dextrose.....................X6782 Thallium TI-201 Thallous Chloride – 1 mCi................A9505 2 – Injections: List of Codes March 2010
  • 18. inject list 18 Codes Codes Theelin Aqueous – 5 mg/ml.......................................X6196 Trifluoperazine – 2 mg/ml..........................................X6912 Theelin Aqueous – 2 mg/ml.......................................X6198 Triflupromazine HCl – 20 mg/ml................................X6978 Thiodyne – 50 mg/ml.................................................X5678 Triflupromazine HCl – 10 mg/ml................................X6980 Thiolate – 50 mg/ml...................................................X5678 Trilafon – 5 mg/ml......................................................X6740 Thiopental Sodium – 10 gm.......................................X6728 Trilone – 40 mg/ml suspension..................................X5552 Thiopental Sodium – 5 gm.........................................X6730 Trimethaphan Camsylate – 50 mg/ml........................X5668 Thiopental Sodium – 1 gm.........................................X6732 Triptorelin (Trelstar) – 3.75 mg..................................X7648 Thiopental Sodium – 500 mg.....................................X6734 Tristoject – 40 mg/ml suspension..............................X5552 Thiopental Sodium – 400 mg.....................................X6736 Trobicin – 400 mg Thiopental Sodium – 250 mg.....................................X6738 (as HCl)/ml 2 gm vial...............................................X6896 Thiosul – 50 mg/ml....................................................X5678 Tubocurarine Chloride – 3 mg/ml..............................X6984 Thiotepa – 15 mg/vial................................................X7576 Typhoid vaccine, Acetone killed, dried (AKD)............90693 Thiothixene – 2 mg/ml...............................................X6618 Typhoid vaccine, heat and phenol Thorazine – 25 mg/ml................................................X5918 inactivated (H-P)......................................................90692 TH Sal – 50 mg/ml.....................................................X5678 Typhoid vaccine – live...............................................90690 Thyrotropin – 10 IU....................................................X6968 Typhoid vaccine, Vi Capsular Thyrotropin alfa 0.9 mg/1.1 mg vial..........................J3240 polysaccharide (ViCPs)...........................................90691 Thytropar – 10 IU......................................................X6968 Ticar – 6 gm (powder) vials.......................................X6970 Ticar – 3 gm (powder) vials.......................................X6972 Ticar – 1 gm (powder) vials.......................................X6974 U Ticarcillin Disodium – 6 gm (powder) vials.................................................X6970 Ultracaine – 2% w/1:100,000 Ticarcillin Disodium – Epinephrine.............................................................X6444 3 gm (powder) vials.................................................X6972 Unclassified Drugs.....................................................J3490 Ticarcillin Disodium – Unipen – 2 gm (powder) vial......................................X6604 1 gm (powder) vials.................................................X6974 Unipen – 1 gm (powder) vial......................................X6606 Tigecycline – 1 mg.....................................................J3243 Unipen – 500 mg vial.................................................X6610 Tinzaparin Sodium – 1000 IU....................................X5509 Unitensen Aqueous – 260 CSR/ml............................X5992 T-Ionate P.A. – 100 mg/ml.........................................X5618 Urea – 40 gm/150 ml.................................................X6996 Tobramycin Sulfate – 40 mg/ml.................................X6620 Ureaphil – 40 gm/150 ml...........................................X6996 Tobramycin Sulfate – 10 mg/2 ml vial........................X6622 Urecholine – 5 mg/ml................................................X5762 Tofranil – 25 mg/ml....................................................X6352 Topotecan – 4 mg......................................................J9350 Totacillin-N – 2 gm (powder) piggyback units.......................................................X5576 V Totacillin-N – 2 gm (powder) vials.............................X5578 Totacillin-N – 1 gm (powder) Valergen 40...............................................................X6018 piggyback units.......................................................X5580 Valergen 20 ..............................................................X5660 Totacillin-N – 1 gm (powder) vials.............................X5582 Valergen 10 ..............................................................X5662 Totacillin-N – 500 mg (powder) Valertest No. 1 – 90-4 mg/ml.....................................X5666 piggyback units.......................................................X5584 Valium – 5 mg/ml.......................................................X6064 Totacillin-N – 500 mg (powder) vials.........................X5586 Vancocin – 500 mg (as HCl)/10 ml vial.....................X6998 Totacillin-N – 250 mg (powder) vials.........................X5588 Vancomycin – 500 mg (as HCl)/10 ml vial.................X6998 Totacillin-N – 125 mg (powder) vials.........................X5550 Varicella Vaccine – .5 ml...........................................90716 Trastuzumab – 10 mg...............................................X7640 Varidase for IM Use – 20,000-5,000 units.................X6920 Treprostinil – 1 mg.....................................................J3285 Vasopressin – 20 pressor units/ml............................X6760 Triamcinolone – 40 mg/ml suspension......................X5552 Vasoxyl – 20 mg/ml 1 ml ampules.............................X6562 Triamcinolone Acetate – Velban – 10 mg/10 ml vial.........................................X7578 40 mg/ml suspension..............................................X5880 Velosef – 2 gm/100 ml infusion containers................X5904 Triamcinolone Acetonide – Velosef – 1 gm/vial....................................................X5906 preservative free, 1 mg............................................J3300 Velosef – 500 mg/vial................................................X5908 Triamcinolone Diacetate – Velosef – 250 mg/vial................................................X5910 25 mg/ml suspension..............................................X6976 Venofer – 100 mg......................................................X7492 Triam-Forte – 40 mg/ml suspension..........................X5552 Triethylenethiophosphoramide – 15 mg/vial................................................................X7576 2 – Injections: List of Codes April 2010
  • 19. inject list 19 Codes Codes Vepesid – 20 mg/ml...................................................X7542 Xylocaine HCl – 1.5% w/7.5% Dextrose.................X6480 Verteporfin – 0.1 mg..................................................J3396 Xylocaine – 1.5% w/1:200,000 Epinephrine..............X6482 Vespirin – 20 mg/ml...................................................X6978 Xylocaine HCl – 2% w/1:100,000 Epinephrine..........X6444 Vespirin – 10 mg/ml...................................................X6980 Xylocaine HCl – 2% w/1:200,000 Epinephrine..........X6474 V-Gan 50 ..................................................................X6236 Xylocaine HCl – 1% w/1:200,000 Epinephrine..........X6486 V-Gan 25...................................................................X6742 Xylocaine HCl – 2% w/1:50,000 Epinephrine............X6476 Vibramycin I.V. – 200 mg (as Hyclate)/vial................X6122 Xylocaine HCl – 0.5% w/1:200,000 Epinephrine.......X6492 Vinblastine Sulfate (VLB) – 10 mg/10 ml vial.............X7578 Xylocaine HCl – 1% w/1:100,000 Epinephrine..........X6488 Vincristine Sulfate (VCR) – 5 mg Xylocaine HCl – 5% w/7.5% Glucose........................X6466 w/50 mg lactose per vial.........................................X7570 Vincristine Sulfate (VCR) – 1 mg w/10 mg lactose per vial.........................................X7572 Vinorelbine Tartrate – 10 mg......................................J9390 Y Vistaril – 50 mg/ml.....................................................X6336 Vistaril – 25 mg/ml.....................................................X7010 Yellow Fever Vaccine................................................90717 Vitamin A – 50,000 IU/ml...........................................X5654 Yttrium Ibitumomab Tiuxetan – 40 mCi......................A9543 Vitamin B12 – 1,000 mcg/ml......................................X5752 Vitamin D – 500,000 IU D2/ml...................................X5802 Vitamin D2 – 500,000 IU D2/ml.................................X5802 Vitravene – 0.25 ml...................................................X7470 Z Vi-Twel – 1,000 mcg/ml.............................................X5752 Vivitrol® – 1 mg.........................................................J2315 Zemplar – 1 mcg........................................................J2501 Ziconotide – 1 mcg.....................................................J2278 Zipan 50....................................................................X6236 Zipan 25....................................................................X6742 W Ziprasidone – 20 mg..................................................X7498 Zoladex – 3.6 mg.......................................................X7060 Wehdryl 50 – 50 mg/ml..............................................X5738 Zoladex – 10.8 mg (depot)........................................X7061 Wehgen – 2 mg/ml....................................................X5756 Zoledronic acid – 4 mg............................................J3487 Win Rho SDF – 600 IU..............................................X7472 Zoledronic acid – 1mg (Reclast)................................J3488 Win Rho SDF – 1,500 IU...........................................X7474 Zostavax....................................................................90736 Win Rho SDF – 5,000 IU...........................................X7476 Wyamine Sulfate – 30 mg/ml.....................................X6550 Wyamine Sulfate – 15 mg/ml.....................................X6552 Wycillin – 2,400,000 units/unit dose..........................X6714 Wycillin – 1,200,000 units/unit dose..........................X6716 Wycillin – 600,000 units/unit dose.............................X6136 X Xenon Xe-133 Gas, Diagnostic – 10 mCi..................A9558 Xolair – 5 mg..............................................................J2357 X-Otag – 30 mg/ml....................................................X6216 Xylocaine HCl – 0.5%................................................X6490 Xylocaine HCl – 1.5%................................................X6478 Xylocaine HCl IM for cardiac arrythmias – 10% (100 mg/ml)....................................................X6464 Xylocaine HCl I.V. for cardiac arrythmias – 2% (20 mg/ml).......................................................X6470 Xylocaine HCl I.V. for cardiac arrythmias – 4% (40 mg/ml)........................................................X6494 Xylocaine HCl I.V. for cardiac arrythmias – 20% (200 mg/ml)....................................................X6462 2 – Injections: List of Codes April 2010