Sdpsum-price--web1-2003.xls

HCPCS Drug Pricing File
Effective January 2003
BACILLUS CALMETTE-GUERIN VACCINE, PERCUTANEOUS MEASLES, MUMPS AND RUBELLA VIRUS VACCINE, SC TETANUS AND DIPETHERIA TOXOIDS VACCINE > 7, IM HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT, 3 DOSE IM HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT 4 DOSE IM HCPCS Drug Pricing File
Effective January 2003
INJECTION, ADENOSINE, 6 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE INJECTION, ADENOSINE, 90 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, ALATROFLOXACIN MESYLATE, 100 MG INJECTION, METHYLDOPATE HCL, UP TO 250 MG INJECTION, ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MG INJECTION, AMIODARONE HYDROCHLORIDE, 30 MG INJECTION, AMPHOTERICIN B, ANY LIPID FORMULATION, 50 MG INJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MG INJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MG INJECTION, AMPHOTERICIN B LIPOSOME, 10 MG INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, METARAMINOL BITARTRATE, PER 10 MG INJECTION, CHLOROQUINE HYDROCHLORIDE, UP TO 250 MG INJECTION, ATROPINE SULFATE, UP TO 0.3 MG INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, UP TO 5 MG INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 600,000 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 1,200,000 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 2,400,000 HCPCS Drug Pricing File
Effective January 2003
INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 1,200,000 UNITS INJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 UNITS INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, PER 10 ML INJECTION, CALCITONIN SALMON, UP TO 400 UNITS INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG INJECTION, BETAMETHASONE ACETATE AND BETAMETHASONE SODIUM PHOSPHATE, PER 3 MG INJECTION, BETAMETHASONE SODIUM PHOSPHATE, PER 4 MG INJECTION, CEFTIZOXIME SODIUM, PER 500 MG INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, 200 MG HCPCS Drug Pricing File
Effective January 2003
INJECTION, COLISTIMETHATE SODIUM, UP TO 150 MG INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIAL INJECTION, TESTOSTERONE ENANTHATE AND ESTRADIOL VALERATE, UP TO 1 CC INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, ESTRADIOL VALERATE, UP TO 40 MG INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, MEDROXYPROGESTERONE ACETATE, 100 MG INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG / 25MG INJECTION, TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE, UP TO 1 ML INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, DEXAMETHASONE ACETATE, PER 8 MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG INJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MG INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG INJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MG INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML HCPCS Drug Pricing File
Effective January 2003
INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG INJECTION, ESTRADIOL VALERATE, UP TO 10 MG INJECTION, ESTRADIOL VALERATE, UP TO 20 MG INJECTION, ESTROGEN CONJUGATED, PER 25 MG INJECTION, ETIDRONATE DISODIUM, PER 300 MG INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG INJECTION, FOMIVIRSEN SODIUM, INTRAOCULAR, 1.65 MG INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 500 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 1G INJECTION, RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN, INTRAVENOUS, 50 MG HCPCS Drug Pricing File
Effective January 2003
INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG INJECTION, GONADORELIN HYDROCHLORIDE, PER 100 MCG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG INJECTION, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 MG INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG INJECTION, DROPERIDOL AND FENTANYL CITRATE, UP TO 2 ML AMPULE INJECTION, KANAMYCIN SULFATE, UP TO 500 MG INJECTION, KANAMYCIN SULFATE, UP TO 75 MG HCPCS Drug Pricing File
Effective January 2003
INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG INJECTION, CEPHALOTHIN SODIUM, UP TO 1 GRAM INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG INJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE AND PROMETHAZINE HCL, UP TO 50 MG INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NANDROLONE DECANOATE, UP TO 50 MG INJECTION, NANDROLONE DECANOATE, UP TO 100 MG INJECTION, NANDROLONE DECANOATE, UP TO 200 MG INJECTION, ORPHENADRINE CITRATE, UP TO 60 MG INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML HCPCS Drug Pricing File
Effective January 2003
INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS INJECTION, PENTOBARBITAL SODIUM, PER 50 MG INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS (1.125 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, PER 300 MG, ADMINISTERED THROUGH INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG INJECTION, OXACILLIN SODIUM, UP TO 250 MG INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350) INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MCG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MCG INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVENT DETERGENT, 100 IU INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG HCPCS Drug Pricing File
Effective January 2003
INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 62.5 MG INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG INJECTION, TERBUTALINE SULFATE, UP TO 1 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 100 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG INJECTION, TESTOSTERONE PROPIONATE, UP TO 100 MG INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG VIAL INJECTION, TIROFIBAN HYDROCHLORIDE, 12.5 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG INJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MG INJECTION, TRIAMCINOLONE ACETONIDE, PER 10MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG INJECTION, TRIMETREXATE GLUCURONATE, PER 25 MG HCPCS Drug Pricing File
Effective January 2003
INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GM INJECTION, IV, UROKINASE, 250,000 I.U. VIAL INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INFUSION, NORMAL SALINE SOLUTION , 1000 CC INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) INFUSION, NORMAL SALINE SOLUTION , 250 CC HYPERTONIC SALINE SOLUTION, 50 OR 100 MEQ, 20 CC VIAL FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.
FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U.
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.
FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.
FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.
HCPCS Drug Pricing File
Effective January 2003
SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR INJECTION HYLAN G-F 20, 16 MG, FOR INTRA ARTICULAR INJECTION AUTOLOGOUS CULTURED CHONDROCYTES, IMPLANT DERMAL AND EPIDERMAL TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT BIOENGINEERED OR DERMAL TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENGINEERED OR LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL, 250 MG LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL, 25MG DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MG HCPCS Drug Pricing File
Effective January 2003
DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG HCPCS Drug Pricing File
Effective January 2003
INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, INSULIN LISPRO, UP TO 50 UNITS INFUSION, PLASMA PROTEIN FRACTION (HUMAN), 5%, 50 ML INFUSION, PLASMA PROTEIN FRACTION (HUMAN), 5%, 250ML INJECTION, EPOETIN ALPHA, (FOR NON ESRD USE), PER 1000 UNITS DERMAL TISSUE, OF HUMAN ORIGIN, WITH AND WITHOUT OTHER BIOENGINEERED OR DERMAL TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENGINEERED OR FACTOR VIIA (COAGULATION FACTOR, RECOMBINANT) PER 1.2 MG INJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR USE SODIUM HYALURONATE PER 20 TO 25 MG DOSE, FOR INTRA-ARTICULAR INJECTION

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