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Injections: List of Codes (inject list)
Injections: List of Codes (inject list)
Injections: List of Codes (inject list)
Injections: List of Codes (inject list)
Injections: List of Codes (inject list)
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Injections: List of Codes (inject list)

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Injections: List of Codes (inject list)

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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