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NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only Fee Schedule00003-2187-10 J0129 INJECTION, ABCIXIMAB, 10MG ORENCIA 250 MG VIAL 9/1/2010 99/99/9999 E0100002-7140-01 J0130 INJECTION ABCIXIMAB, 10MG REOPRO 2 MG/ML VIAL 9/1/2010 99/99/9999 E0151552-0671-01 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-02 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-03 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-04 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-05 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0151552-0671-06 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR POWDER 9/1/2010 3/31/2011 E0155390-0612-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 500 MG VIAL 9/1/2010 99/99/9999 E0155390-0613-20 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 1 GM VIAL 9/1/2010 99/99/9999 E0163323-0105-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR SODIUM 500 MG VIAL 9/1/2010 99/99/9999 E0163323-0325-10 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR 500 MG/10 ML VIAL 9/1/2010 99/99/9999 E0163323-0325-20 J0133 INJECTION,ACYCLOVIR, 5MG ACYCLOVIR 1,000 MG/20 ML VIAL 9/1/2010 99/99/9999 E0100074-3799-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML SYRINGE 9/1/2010 99/99/9999 E0100074-4339-02 J0135 INJECTION (HUMIRA) HUMIRA 40 MG/0.8 ML PEN 9/1/2010 99/99/9999 E0100074-4339-06 J0135 INJECTION (HUMIRA) HUMIRA CROHN'S STARTER PACK 9/1/2010 99/99/9999 E0100469-8234-12 J0150 INJECTION, ADENOSINE ADENOCARD 6 MG/2 ML SYRINGE 9/1/2010 99/99/9999 E0100469-8234-14 J0150 INJECTION, ADENOSINE ADENOCARD 12 MG/4 ML SYRINGE 9/1/2010 99/99/9999 E0100703-8771-03 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 9/30/2011 E0100703-8773-01 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 9/30/2011 E0110019-0063-03 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 3/31/2013 E0110019-0063-08 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML SYRINGE 9/1/2010 3/31/2011 E0155390-0067-10 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 99/99/9999 E0155390-0068-01 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 99/99/9999 E0163323-0651-02 J0150 INJECTION, ADENOSINE ADENOSINE 6 MG/2 ML VIAL 9/1/2010 99/99/9999 E0163323-0651-04 J0150 INJECTION, ADENOSINE ADENOSINE 12 MG/4 ML VIAL 9/1/2010 99/99/9999 E0100469-0871-20 J0152 INJECTION,ADENOSINE ADENOSCAN 3 MG/ML VIAL 9/1/2010 99/99/9999 E0100469-0871-30 J0152 INJECTION,ADENOSINE ADENOSCAN 3 MG/ML VIAL 9/1/2010 99/99/9999 E0100143-9984-90 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100409-4901-18 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-4921-34 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 99/99/9999 E0100409-7241-01 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0100517-1071-25 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 99/99/9999 E0100517-1130-05 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 99/99/9999 E0100548-1016-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 3/31/2011 E0100548-2016-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 3/31/2011 E0100548-3316-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 0.1 MG/ML SYRINGE 9/1/2010 3/31/2011 E0100548-9061-00 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML VIAL 9/1/2010 3/31/2011 E01

NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only Fee Schedule66860-0021-02 J0170 INJECTION, ADRENALIN EPINEPHRINE 1 MG/ML AMPUL 9/1/2010 12/31/2010 E0158468-0040-01 J0180 INJECTION, AGALSIDADE BETA FABRAZYME 35 MG VIAL 9/1/2010 99/99/9999 E0158468-0041-01 J0180 INJECTION, AGALSIDADE BETA FABRAZYME 5 MG VIAL 9/1/2010 99/99/9999 E0158468-1060-01 J0205 INJECTION, ALGLUCERASE CEREDASE 80 UNITS/ML VIAL 9/1/2010 12/31/2012 E0162756-0581-40 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 99/99/9999 E0162756-0581-42 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 99/99/9999 E0155390-0308-03 J0207 INJECTION, AMIFOSTINE AMIFOSTINE 500 MG VIAL 9/1/2010 99/99/9999 E0158178-0017-01 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 9/1/2010 99/99/9999 E0158178-0017-03 J0207 INJECTION, AMIFOSTINE ETHYOL 500 MG VIAL 9/1/2010 99/99/9999 E0100517-8905-10 J0210 INJECTION, METHYLDOPATE HCI METHYLDOPATE 250 MG/5 ML VIAL 9/1/2010 99/99/9999 E0158468-0150-01 J0220 INJECTION, ALGLUCOSIDASE ALFA MYOZYME 50 MG VIAL 9/1/2010 99/99/9999 E0100053-7201-02 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ZEMAIRA 1,000 MG VIAL 9/1/2010 99/99/9999 E0100944-2801-01 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ARALAST 500 MG VIAL 9/1/2010 12/31/2010 E0100944-2801-02 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR ARALAST 1,000 MG VIAL 9/1/2010 10/27/2010 E0113533-0601-30 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR PROLASTIN 500 MG VIAL 9/1/2010 9/30/2011 E0113533-0601-35 J0256 INJECTION, ALPHA 1-PROTEINASE INHIBITOR PROLASTIN 1,000 MG VIAL 9/1/2010 12/17/2012 E0100009-3169-06 J0270 INJECTION, ALPROSTADIL PROSTIN VR PEDI 500 MCG/ML AMP 9/1/2010 99/99/9999 E0100009-3701-05 J0270 INJECTION, ALPROSTADIL CAVERJECT 20 MCG VIAL 9/1/2010 99/99/9999 E0100009-5181-01 J0270 INJECTION, ALPROSTADIL CAVERJECT IMPULSE 10 MCG KIT 9/1/2010 99/99/9999 E0100009-5182-01 J0270 INJECTION, ALPROSTADIL CAVERJECT IMPULSE 20 MCG KIT 9/1/2010 99/99/9999 E0100009-7686-04 J0270 INJECTION, ALPROSTADIL CAVERJECT 40 MCG VIAL 9/1/2010 99/99/9999 E0100091-1110-16 J0270 INJECTION, ALPROSTADIL EDEX 10 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E0100091-1110-20 J0270 INJECTION, ALPROSTADIL EDEX 10 MCG CARTRIDGE 6-PK KIT 9/1/2010 99/99/9999 E0100091-1120-16 J0270 INJECTION, ALPROSTADIL EDEX 20 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E0100091-1120-20 J0270 INJECTION, ALPROSTADIL EDEX 20 MCG CARTRIDGE 6-PK KIT 9/1/2010 99/99/9999 E0100091-1140-16 J0270 INJECTION, ALPROSTADIL EDEX 40 MCG CARTRIDGE 2-PK KIT 9/1/2010 99/99/9999 E0100091-1140-20 J0270 INJECTION, ALPROSTADIL EDEX 40 MCG CARTRIDGE 6-PK KIT 9/1/2010 5/8/2012 E0100703-1501-02 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 99/99/9999 E0151552-0498-03 J0270 INJECTION, ALPROSTADIL ALPROSTADIL POWDER 9/1/2010 3/31/2011 E0155390-0503-10 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 12/31/2010 E0155390-0506-10 J0270 INJECTION, ALPROSTADIL ALPROSTADIL 500 MCG/ML VIAL 9/1/2010 9/30/2011 E0162541-0110-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 125 MCG URETHRAL SUPPOS 9/1/2010 3/31/2012 E0162541-0110-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 125 MCG URETHRAL SUPPOS 9/1/2010 3/31/2012 E0162541-0120-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 250 MCG URETHRAL SUPPOS 9/1/2010 12/31/2012 E0162541-0120-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 250 MCG URETHRAL SUPPOS 9/1/2010 12/31/2012 E0162541-0130-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 500 MCG URETHRAL SUPPOS 9/1/2010 7/31/2013 E0162541-0130-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 500 MCG URETHRAL SUPPOS 9/1/2010 7/31/2013 E0162541-0140-01 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 1,000 MCG URETHRAL SUPP 9/1/2010 7/31/2013 E01

NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only Fee Schedule62541-0140-06 J0275 ALPROSTADIL URETHRAL SUPPOSITORY MUSE 1,000 MCG URETHRAL SUPP 9/1/2010 7/31/2013 E0100409-1955-01 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 100 MG/2 ML 9/1/2010 9/30/2011 E0100409-1956-01 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 500 MG/2 ML 9/1/2010 11/1/2012 E0100409-1957-01 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 1,000 MG/4 ML 9/1/2010 9/30/2011 E0100703-9032-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN 500 MG/2 ML 9/1/2010 99/99/9999 E0100703-9040-03 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN 1,000 MG/4 ML VIAL 9/1/2010 99/99/9999 E0155390-0223-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN (PF) 100 MG/2 ML 9/1/2010 12/31/2010 E0155390-0224-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 500 MG/2 ML 9/1/2010 12/31/2010 E0155390-0224-04 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 1,000 MG/4 ML 9/1/2010 12/31/2010 E0155390-0225-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN (PF) 100 MG/2 ML 9/1/2010 9/30/2011 E0155390-0226-02 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULFATE 500 MG/2 ML 9/1/2010 99/99/9999 E0155390-0226-04 J0278 INJECTION, AMIKACIN SULFATE AMIKACIN SULF 1 GRAM/4 ML VIAL 9/1/2010 99/99/9999 E0100409-5921-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 9/1/2010 99/99/9999 E0100409-5922-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 9/1/2010 99/99/9999 E0100409-7385-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 9/1/2010 9/30/2011 E0100409-7386-01 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 9/1/2010 7/1/2011 E0100517-3810-25 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 250 MG/10 ML VL 9/1/2010 12/31/2012 E0100517-3820-25 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE 500 MG/20 ML VL 9/1/2010 12/31/2012 E0151552-0313-05 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE ANHYDROUS PWD 9/1/2010 3/31/2011 E0151552-0313-06 J0280 INJECTIONM AMINOPHYLLIN,UP TO 250 MG AMINOPHYLLINE ANHYDROUS POWDER 9/1/2010 3/31/2011 E0100409-4348-35 J0282 INJECTION,AMIODARONE AMIODARONE 150 MG/3 ML AMP 9/1/2010 99/99/9999 E0100548-3380-00 J0282 INJECTION,AMIODARONE AMIODARONE HCL 50 MG/ML SYRN 9/1/2010 3/31/2011 E0100703-1335-01 J0282 INJECTION,AMIODARONE AMIODARONE 450 MG/9 ML VIAL 9/1/2010 2/28/2011 E0155390-0057-01 J0282 INJECTION,AMIODARONE AMIODARONE 900 MG/18 ML VIAL 9/1/2010 9/30/2011 E0155390-0057-10 J0282 INJECTION,AMIODARONE AMIODARONE 150 MG/3 ML VIAL 9/1/2010 9/30/2011 E0155390-0105-01 J0282 INJECTION,AMIODARONE AMIODARONE 450 MG/9 ML VIAL 9/1/2010 9/30/2011 E0163323-0616-03 J0282 INJE

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