Injections: List of Codes (inject list)

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 CodesJuly 2007

inject list

2

Codes Codes

A

Abatacept – 10 mg......................................................J0129Acetazolamide– 500 mg/vial......................................X5500Acetylcysteine – 100 mg.............................................J0132ACTH – 25 units dry powder/vial................................X5514ACTH (OR) Corticotropin – 80 units/ml......................X5516ACTH (OR) Corticotropin – 40 units/ml......................X5518ACTH (OR) Corticotropin – 25 units/ml......................X5520ACTH (OR) Corticotropin Gel – 80 units/ml...............X5516ACTH (OR) Corticotropin Gel – 40 units/ml...............X5518Acyclovir – 5 mg..........................................................J0133Adenocrest – 25 mg/ml...............................................X5522Adenosine Phosphate – 25 mg/ml.............................X5522Adrenalin Chloride – 1 mg/ml.....................................X5528Adrenalin Chloride Solution –

1:1,000 solution........................................................X5530Adriamycin – 50 mg/vial w/250 mg lactose................X7500Adriamycin – 10 mg/vial w/50 mg lactose..................X7502Aerosporin – 500,000 units........................................X5534Agalsidase beta – 1.0 mg...........................................J0180Akineton – 5 mg/ml.....................................................X5536Aldesleukin – 22 million IU.........................................X7632Aldomet – 250 mg/5 ml...............................................X5540Alglucosidase alfa – 10 mg.........................................J0220Amcill-S – 1 gm (powder) vials...................................X5582Amcill-S – 500 mg (powder) vials...............................X5586Amcill-S – 250 mg (powder) vials...............................X5588Amcill-S – 125 mg (powder) vials...............................X5550Amcort – 40 mg/ml suspension..................................X5552A-Methapred – 40 mg/ml............................................X5554Amicar – 250 mg/ml....................................................X5556Amifostine – 500 mg...................................................X7642Amikacin Sulfate – 1 gm/4 ml vial..............................X5558Amikacin Sulfate – 500 mg/2 ml vial..........................X5562Amikacin Sulfate – 100 mg/2 ml vial..........................X5560Amikin – 1 gm/4 ml vial...............................................X5558Amikin – 500 mg/2 ml vial...........................................X5562Amikin – 100 mg/2 ml vial...........................................X5560Aminocaproic acid – 250 mg/ml.................................X5556Amitriptyline HCl – 10 mg/ml......................................X5564Amobarbital Sodium – 500 mg...................................X5566Amphotericin B – 50 mg/vial.......................................X5572Ampicillin Sodium, Parenteral –

2 gm (powder) piggyback units...............................X5576Ampicillin Sodium, Parenteral –

2 gm (powder) vials.................................................X5578Ampicillin Sodium, Parenteral –

1 gm (powder) piggyback units...............................X5580Ampicillin Sodium, Parenteral –

1 gm (powder) vials.................................................X5582

Ampicillin Sodium, Parenteral –500 mg (powder) piggyback units...........................X5584

Ampicillin Sodium, Parenteral –500 mg (powder) vials.............................................X5586

Ampicillin Sodium, Parenteral – 250 mg (powder) vials.............................................X5588

Ampicillin Sodium, Parenteral – 125 mg (powder) vials.............................................X5550

Anabolin IM – 50 mg/ml (oil).......................................X5598Anabolin LA 100 – 100 mg/ml (oil).............................X5600Ancef – 10 gm/100 ml vial..........................................X5602Ancef – 1 gm/redi vial.................................................X5604Ancef – 1 gm/100 ml piggyback unit..........................X5606Ancef – 1 gm/10 ml vial..............................................X5608Ancef – 500 mg/100 ml vial........................................X5610Ancef – 500 mg/10 ml vial..........................................X5612Ancef – 250 mg/10 ml vial..........................................X5614Andro-Cyp 100 – 100 mg/ml......................................X5618Andro/Fem – 50-2 mg/ml............................................X5620Android HCG – 1,000 units/ml....................................X5622Android-T – 100 mg/ml...............................................X5626Android-T – 50 mg/ml.................................................X5628Androlone – 50 mg/ml (oil).........................................X5598Androlone – 25 mg/ml (oil).........................................X5630Androlone-D 100 – 100 mg/ml (oil).............................X5600Androlone-D 50 – 50 mg/ml (oil).................................X5632Andronaq – 50 mg/ml.................................................X5628Andronate 100 – 100 mg/ml.......................................X5618Andryl – 200 mg/ml.....................................................X5634Anectine – 20 mg/ml...................................................X5636Anidulafungin – 1 mg...................................................J0348Antilirium – 1 mg/ml....................................................X5640Antispas – 10 mg/ml...................................................X5642Antuitrin – 500 units/ml...............................................X5644AnzemetTM – 10 mg.....................................................J1260A.P.L. Secules – 2,000 units/ml.................................X5646A.P.L. Secules – 1,000 units/ml.................................X5622A.P.L. Secules – 500 units/ml....................................X5644Apresoline – 20 mg/ml................................................X5648Aqua Mephyton – 10 mg/ml........................................X5650Aqua Mephyton – 2 mg/ml..........................................X5652Aquasol A Parenteral – 50,000 IU/ml........................X5654Aralen – 50 mg/ml.......................................................X5656Aramine – 10 mg/ml (1%) (as Bitartrate)....................X5658Ardefem 20 – 20 mg/ml..............................................X5660Ardefem 10 – 10 mg/ml..............................................X5662Arderone – 200 mg/ml................................................X5634Arderone – 100 mg/ml................................................X5626Ardiol 90/4...................................................................X5666

2 – Injections: List of CodesMarch 2009

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Codes Codes

Arfonad – 50 mg/ml....................................................X5668Aripiprazole – 0.25 mg................................................J0400Aristocort Parenteral Forte – 40 mg/ml suspension................................................X5552Aristopan – 20 mg/cc 5 cc..........................................X5672Aristopan – 20 mg/cc 1 cc..........................................X5674Ar-Tet – 250 unit.........................................................X5676Arthrolate – 50 mg/ml.................................................X5678Ascorbic Acid – 500 mg/ml.........................................X5680Ascorbic Acid – 250 mg/ml.........................................X5682Asparaginase – 10,000 IU/10 ml vial..........................X7504Atropine Sulfate – up to 0.3 mg...................................J0460Aurothioglucose – 50 mg/ml.......................................X5708Avastin – 10 mg..........................................................J9035Azacitidine – 1 mg/ml..................................................J9025Azapen – 6 gm vials (powder)....................................X5710Azapen – 4 gm vials (powder)....................................X5712Azapen – 1 gm vials (powder)....................................X5714

B

Bacitracin, Intramuscular – 50,000 unit vials........................................................X5716Bacitracin, Intramuscular – 10,000 unit vials........................................................X5718Baclofen – 10 mg........................................................X7108Bactocill – 4 gm (powder) vials..................................X5720Bactocill – 2 gm (powder) vials..................................X5722Bactocill – 1 gm (powder) vials..................................X5724Bactocill – 500 mg (powder) vials..............................X5726BAL In Oil – 100 mg/ml...............................................X5728Basiliximab – 20 mg....................................................J0480BCG Vaccine, intravesicular.......................................90586BCG Vaccine, percutaneous – 1 mg..........................90585Benadryl – 50 mg/ml...................................................X5738Benadryl – 10 mg/ml...................................................X5740Benahist 50 – 50 mg/ml..............................................X5738Benahist 10 – 10 mg/ml..............................................X5740Bendamustine HCl – 1 mg..........................................J9033Bendylate 50 – 50 mg/ml............................................X5738Bendylate 10 – 10 mg/ml............................................X5740Benoject 50 – 50 mg/ml..............................................X5738Benoject 10 – 10 mg/ml..............................................X5740Bentyl – 10 mg/ml.......................................................X5642Benztropine Mesylate – 1 mg/ml...............................X5744

Berocca-C – 2 ml........................................................X5750Berubigen – 1,000 mcg/ml..........................................X5752Bestrone – 2 mg/ml....................................................X5756Betalin 12 – 1,000 mcg/ml..........................................X5752Betamethasone Acetate 3 mg andBetamethasone Sodium Phosphate 3 mg..............J0702Bethanechol Chloride – 5 mg/ml................................X5762Bevacizumab – 10 mg................................................J9035Bicillin C-R 900/300....................................................X5764Bicillin C-R – 600,000 units........................................X5766Bicillin C-R – 300,000 units/ml...................................X5768Bicillin L-A – 600,000 units/ml....................................X5770Bicillin L-A – 300,000 units/ml....................................X5772BICNU – 100 mg/vial..................................................X7506Biosone – 50 mg/ml suspension................................X5774Biperiden – 5 mg/ml....................................................X5536Blenoxane – 15 units/ampule.....................................X7508Bleomycin Sulfate – 15 units/ampule.........................X7508Bortezomib – 0.1 mg...................................................J9041Botulinum toxin A – per 1 unit.....................................J0585Botulinum toxin B – per 100 units...............................J0587Brethine – 1 mg/ml......................................................X5776Bretylium Tosylate – 50 mg/ml...................................X5778Bretylol – 50 mg/ml.....................................................X5778Brevital Sodium – 5 gm..............................................X5780Brevital Sodium – 2.5 gm...........................................X5782Brevital Sodium – 500 mg/5 ml...................................X5784Bricanyl Subcutaneous – 1 mg/ml..............................X5776Brompheniramine Maleate – 10 mg/ml.......................X5786Bupivacaine HCl – 0.75%...........................................X5790Bupivacaine HCl – 0.25%...........................................X5792Bupivacaine HCl – 0.5%.............................................X5794Butorphanol Tartrate – 2 mg/ml..................................X5796Butorphanol Tartrate – 1 mg/ml..................................X5798

2 – Injections: List of CodesApril 2010

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Codes Codes

C

Caffeine and Sodium Benzoate – 250 mg/ml...........X5800Calciferol – 500,000 IU D2/ml....................................X5802Calcimar – 400 MCR units.........................................X5804Calcitonin – 400 MCR units........................................X5804Calcitriol (Calcijex) – 1 MCG/ml.................................X7510Calcitriol (Calcijex) – 2 MCG/ml.................................X7512Calcium Disodium Edetate – 200 mg/ml....................X5808Calcium Disodium Versenate – 200 mg/ml................X5808Capastat Sulfate – 1 gm/5 ml vial...............................X5810Capreomycin Sulfate – 1 gm/5 ml vial........................X5810Carbocaine – 2%........................................................X5818Carbocaine – 1.5%.....................................................X5820Carbocaine – 1%........................................................X5822Carbocaine HCl – 3%.................................................X5824Carboplatin – 50 mg....................................................J9045Carmustine (BCNU) – 100 mg/vial.............................X7506Cathflo Activase – 2 mg vial (powder)........................X7122Cedilanid-D – 0.2 mg/ml.............................................X5826Cee-B-Complex – 30 ml.............................................X5828Cefamandole Nafate – 500 mg/10 ml vial..................X5840Cefamandole Nafate – 2 gm/100 ml vial....................X5842Cefamandole Nafate – 2 gm/20 ml vial......................X5844Cefamandole Nafate – 1 gm/100 ml vial....................X5846Cefamandole Nafate – 1 gm/10 ml vial......................X5848Cefazolin Sodium – 10 gm/100 ml vial.......................X5602Cefazolin Sodium – 1 gm/redi vial..............................X5604Cefazolin Sodium – 1 gm/10 ml vial...........................X5608Cefazolin Sodium – 1 gm/100 ml piggyback unit...........................................................X5606Cefazolin Sodium – 500 mg/10 ml vial ......................X5612Cefazolin Sodium – 500 mg/100 ml vial.....................X5610Cefazolin Sodium – 250 mg/10 ml vial.......................X5614Cefotaxime Sodium – 2 gm........................................X7027Cefotaxime Sodium – 1 gm........................................X7026Cefotaxime Sodium – 0.5 gm.....................................X7025Cefoxitin Sodium – 2 gm vial......................................X5854Cefoxitin Sodium – 1 gm vial......................................X5856Ceftriaxone Sodium – 250 mg/vial..............................J0696

Celbenin – 6 gm vials (powder)..................................X5710Celbenin – 4 gm vials (powder)..................................X5712Celbenin – 2 gm piggyback units (powder)................X5866Celbenin – 1 gm piggyback units (powder)................X5868Celbenin – 1 gm vials (powder)..................................X5714Celestone Phosphate.................................................X5872Celestone Soluspan (Betamethasone Acetate 3 mg and Betamethasone Sodium Phosphate 3 mg).........J0702Cenocort A-40 – 40 mg/ml suspension......................X5880Cenocort Forte – 40 mg/ml suspension.....................X5552Cenolate – 500 mg/ml.................................................X5882Centrogen – 2 mg/ml..................................................X5756Cephalothin Sodium – 20 gm/200 ml vial...................X5888Cephalothin Sodium – 4 gm/50 ml vial.......................X5890Cephalothin Sodium – 2 gm/100 ml vial.....................X5892Cephalothin Sodium – 2 gm/20 ml vial.......................X5894Cephalothin Sodium – 1 gm/100 ml vial.....................X5896Cephalothin Sodium – 1 gm/10 ml vial.......................X5898Cephradine – 2 gm/100 ml infusion containers ...................................................X5904Cephradine – 1 gm/vial...............................................X5906Cephradine – 500 mg/vial...........................................X5908Cephradine – 250 mg/vial...........................................X5910Certolizumab Pegol – 1 mg........................................C9249Cerubidine – 20 mg/vial unit.......................................X7514Cetuximab – 10 mg.....................................................J9055Cevalin – 500 mg/ml...................................................X5680Cevita – 250 mg/ml.....................................................X5912Chlor-100....................................................................X5914Chloramphenicol – 1 gm vial as dry powder...........................................X5922Chlorazine – 25 mg/ml................................................X5918Chlordiazedoxide – 100 mg/5 ml................................X5920Chloromycetin Sodium Succinate – 1 gm vial as dry powder...........................................X5922Chlorophen – 10 mg/ml..............................................X5932Chloroprocaine HCl – 3%...........................................X5924Chloroprocaine HCl – 2%...........................................X5926Chloroprocaine HCl – 1%...........................................X5928Chloroquine HCl – 50 mg/ml......................................X5656Chlorothiazide – 500 mg/20 ml...................................X5930Chlorpheniramine Maleate – 100 mg/ml.....................X5914Chlorpheniramine Maleate – 10 mg/ml.......................X5932Chlor-Pro – 100 mg/ml...............................................X5914Chlor-Pro – 10 mg......................................................X5932Chlorpromazine HCl – 25 mg/ml................................X5918Chlorprothixene – 12.5 mg/ml....................................X5934Chlor-Trimeton – 100 mg/ml.......................................X5914Chlor-Trimeton – 10 mg/ml.........................................X5932


inject list

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Codes Codes

Cholera Vaccine – 1.5 ml............................................90725Chorex – 1,000 units/ml..............................................X5622Chorex – 500 units/ml.................................................X5644Chorionic Gonadotropin (HCG) –

2,000 units/ml...........................................................X5646Chorionic Gonadotropin (HCG) –

1,000 units/ml...........................................................X5622Chorionic Gonadotropin (HCG) –

500 units/ml..............................................................X5644Chromium Cr-51 Sodium Chromate, 250 µCi...........A9553Chromium phosphate P-32 suspension, 1 mCi.........A9564Cidofovir – 375 mg/5 ml vial.......................................X7434Cino 40.......................................................................X5552Cisplatin – 50 mg.........................................................J9062Citanest HCl – 4% w/1:200,000 Epinephrine.............X5942Citanest HCl – 4%......................................................X5944Cleocin Phosphate – 600 mg/

4 ml ampules............................................................X5956Cleocin Phosphate – 300 mg/

2 ml ampules............................................................X5958Clindamycin – 600 mg

(as phosphate)/4 ml ampules..................................X5956Clindamycin – 300 mg

(as phosphate)/2 ml ampules..................................X5958Clofarabine – 1 mg......................................................J9027Clonidine hydrochloride – 1 mg/ml.............................X7488Cobalasine – 25 mg/ml...............................................X5522Cobalt Co-57/58, cyanocobalamin – 1 µCi................A9546Cobalt Co-57 cyanocobalamin (oral) – 1 µCi.............A9559Cobex 1,000...............................................................X5752Codeine Phosphate – 60 mg/ml.................................X5960Codeine Phosphate – 30 mg/ml.................................X5962Cogentin – 1 mg/ml.....................................................X5744Colchicine – 1 mg/2 ml...............................................X5964Colistimethate Sodium –

150 mg Colistin/vial..................................................X5966Coly-Mycin M –

150 mg Colistin/vial..................................................X5966Compazine – 5 mg/ml.................................................X5970Conjugated Estrogens – 25 mg..................................X5972Cortef – 50 mg/ml.......................................................X5980Cortef Acetate – 50 mg/ml suspension......................X5774Corticorelin ovine triflutate – 1 mcg.............................J0795Cortigel 80 – 80 units/ml.............................................X5516Cortigel 40 – 40 units/ml.............................................X5518Cortisone Acetate – 50 mg/ml....................................X5984Cortone Acetate – 50 mg/ml.......................................X5984Cortril Acetate – 25 mg/ml suspension......................X5988Cortrophin Gel – 80 units/ml.......................................X5516Cortrophin Gel – 40 units/ml.......................................X5518Cosmegen – 0.5-3 mg/ml vial.....................................X7520

Cryptenamine Acetates – 260 CSR/ml......................X5992Crysti-12 – 1,000 mcg/ml...........................................X5752Cyanocobalamin Crystalline –

1,000 mcg/ml...........................................................X5752Cyclophosphamide –

500 mg/30 ml vials...................................................X7522Cyclophosphamide – 200 mg/2 ml vials.....................X7524Cyclophosphamide – 100 mg/10 ml vials...................X7526Cytarabine (Cytosine Arabinoside,

ARA-C) – 500 mg vials............................................X7528Cytarabine (Cytosine Arabinoside,

ARA-C) – 100 mg vials............................................X7530Cytosar – 500 mg vials...............................................X7528Cytosar – 100 mg vials...............................................X7530Cytoxan – 500 mg/30 ml vials....................................X7522Cytoxan – 200 mg/20 ml vials....................................X7524Cytoxan – 100 mg/10 ml vials....................................X7526

D

Dacarbazine (DTIC) – 200 mg/20 ml vial...................X7532Dactinomycin (Actinomycin D) –

0.5 mg/3 ml vial........................................................X7520Daptomycin, 1 mg..........................................................J0878Darbepoetin alfa (ESRD) – 1 mcg..............................J0882Darbepoetin alfa (non-ESRD).....................................J0881D-Diol – 50-2 mg/ml....................................................X5620Decadron-LA – 8 mg/ml suspension..........................X6008Decadron Phosphate – 24 mg/ml...............................X6002Decadron Phosphate – 4 mg/ml.................................X6004Decadron w/Xylocaine................................................X6006Deca-Durabolin – 100 mg/ml (oil)...............................X5600Deca-Durabolin – 50 mg/ml (oil).................................X5632Decameth L.A. – 8 mg/ml suspension.......................X6008Decitabine – 1 mg.......................................................J0894De-Comberol – 50-2 mg/ml........................................X5620Deferoxamine Mesylate –

500 mg/ampule.........................................................X6012Deksone – 4 mg/ml solution.......................................X6004Deladumone – 90-4 mg/ml.........................................X5666Delatestryl – 200 mg/ml..............................................X5634Delcort-E – 25 mg/ml..................................................X6014Delestrogen – 40 mg/ml.............................................X6018Delestrogen – 20 mg/ml.............................................X5660Delestrogen – 10 mg/ml.............................................X5662Demerol HCl – 100 mg/ml..........................................X6020Demerol HCl – 75 mg/ml............................................X6022Demerol HCl – 50 mg/ml............................................X6024Demerol HCl – 25 mg/ml............................................X6026

2 – Injections: List of CodesJanuary 2010

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Codes Codes

Denileukin Diftitox – 300 mcg.....................................J9160Depo-Estradiol Cypionate – 5 mg/ml..........................X6030Depogen – 5 mg/ml....................................................X6030Depo-Medrol – 80 mg/ml suspension.........................X6036Depo-Medrol – 40 mg/ml suspension.........................X6038Depo-Medrol – 20 mg/ml............................................X6040Depo-Provera –

400 mg/ml 10 ml vial, per ml ...................................X6046Depo-Provera –

400 mg/ml 2.5 ml vial, per ml...................................X6048Depo-Provera C – 150 mg/ml 1 ml vial......................X6051Depotest – 100 mg/ml................................................X5618Depo-Testadiol – 50-2 mg/ml.....................................X5620Depotestogen – 50-2 mg/ml.......................................X5620Depo-Testosterone – 100 mg/ml................................X5618Desferal Mesylate – 500 mg/ampule..........................X6012Deslanoside (Desacetyl-Lanatosidec) –

0.2 mg/ml.................................................................X5826D-Est 5 – 5 mg/ml......................................................X6030Dexacen 4 .................................................................X6004Dexacen LA-8.............................................................X6008Dexamethasone (as acetate) –

8 mg/ml suspension.................................................X6008Dexamethasone Sodium Phosphate –

4 mg/ml....................................................................X6004Dexasone – 4 mg/ml...................................................X6004Dexasone-LA – 8 mg/ml.............................................X6008Dexon – 4 mg/ml........................................................X6004Dexpanthenol – 250 mg/ml.........................................X6060Dezone – 4 mg/ml solution.........................................X6004D.H.E. 45 – 1 mg/ml...................................................X6062Diamox – 500 mg/vial.................................................X5500Diazepam – 5 mg/ml...................................................X6064Diazoxide – 300 mg/20 ml..........................................X6070Dibent – 10 mg/ml.......................................................X5642Dicyclomine HCl – 10 mg/ml......................................X5642Diethylstilbesterol Diphosphate –

0.25 gm (as sodium salt)/5 ml ampule.....................X7536Digoxin – 0.25 mg/ml..................................................X6080Digoxin – 0.1 mg/ml....................................................X6082Dihydroergotamine Mesylate – 1 mg/ml.....................X6062Dilantin – 50 mg/ml.....................................................X6084Dilaudid – 4 mg/ml......................................................X6086Dilaudid – 2 mg/ml......................................................X6090Dilaudid – 1 mg/ml......................................................X6092Dimercaprol – 100 mg/ml...........................................X5728Dimetan-Ten – 100 mg/ml..........................................X5786

Dioval – 10 mg/ml.......................................................X5662Dioval 40 – 40 mg/ml..................................................X6018Dioval XX – 20 mg/ml.................................................X5660Diphenhydramine HCl – 50 mg/ml.............................X5738Diphenhydramine HCl – 10 mg/ml.............................X5740Diphtheria, tetanus toxoid (DT) –

for younger than 7 years of age...............................90702Diphtheria, tetanus toxoid

and acellular pertussis (DTaP) – under 7 years of age................................................90700

Diphtheria, tetanus toxoidsand whole cell pertussis (DTP)................................90701

Diphtheria, tetanus toxoids and whole cell pertussisand H. Influenza b vaccine (DTP-Hib).....................90720

Diphtheria, tetanus toxoids and acellular pertussisand H. Influenza b vaccine (DtaP-Hib)....................90721

Diphtheria, tetanus toxoids, acellular pertussis vaccine,Hepatitis B, and poliovirus vaccine,inactivated (DtaP-HepB-IPV)...................................90723

Diptheria Toxoid, Adsorbed .......................................90719Disodium Edetate – 150 mg/ml..................................X6106Di-Spaz – 10 mg/ml....................................................X5642Ditate – 90-4 mg/ml....................................................X5666Diuril – 500 mg/20 ml..................................................X5930D-Med – 80 mg/ml suspension...................................X6036D-Med – 40 mg/ml suspension...................................X6038Dobutamine – 250 mg (as HCl)..................................X6108Dobutrex – 250 mg (as HCl)......................................X6108Docetaxel – 20 mg......................................................X7638Dodex – 1,000 mcg/ml................................................X5752Dolasetron – 10 mg.....................................................J1260Dolophine HCl – 10 mg/ml..........................................X6110Dopamine HCl – 40 mg/ml..........................................J1265Dopram – 20 mg/ml....................................................X6114Doripenem – 10 mg.....................................................J1267Dornase alfa – 1 mg....................................................J7639Doxapram HCl – 20 mg/ml.........................................X6114Doxercalciferol – 1 mcg ..........................................J1270Doxorubicin HCl – 50 mg/vial w/250 mg lactose........X7500Doxorubicin HCl – 10 mg/vial w/50 mg lactose..........X7502Doxorubicin HCl liposome – 10 mg............................J9001Doxycycline – 100 mg (as hyclate)/vial......................X6122Droperidol – 2.5 mg/ml...............................................X6126Dtic-Dome – 200 mg/20 ml vial..................................X7532

2 – Injections: List of CodesFebruary 2010

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Codes Codes

Duo-Cyp – 50-2 mg/ml...............................................X5620Duogen L.A. 90/4........................................................X5666Duoval-P.A.................................................................X5666Durabolin – 50 mg/ml (oil)..........................................X5598Durabolin – 25 mg/ml (oil)..........................................X5630Duracillin A.S. – 600,000 units/unit dose...................X6136Duraestrin – 5 mg/ml..................................................X6030Duragen 40.................................................................X6018Duragen 20.................................................................X5660Duragen – 10 mg/ml...................................................X5662Dura-Meth – 40 mg/ml suspension............................X6038Duranest – 1.5%.........................................................X6138Duranest – 1%............................................................X6140Duratest – 100 mg/ml.................................................X5618Duratestrin – 50-2 mg/ml............................................X5620

E

Eculizumab – 10 mg....................................................J1300Edrophonium Chloride – 10mg/ml..............................X6146Elavil HCl – 10 mg/ml.................................................X5564Eliotts’ B Solution – 1 ml.............................................J9175E-Lonate – 5 mg/ml....................................................X6030Elspar – 10,000 IU/10 ml vial.....................................X7504Endrate – 150 mg/ml..................................................X6106Ephedrine Sulfate – 50 mg/ml 1 ml ampules............................................................X6158Ephedrine Sulfate – 25 mg/ml 1 ml ampules............................................................X6160Epinephrine HCl – 1 mg/ml.........................................X5528Epinephrine HCl – 0.1 mg/ml......................................X6164Epinephrine, Parenteral – 1:1,000 solution........................................................X5530Epinephrine, Parenteral – 1:200 suspension.....................................................X6166Epirubicin (Ellence) – 50 mg/25 ml.............................X7646Epoetin alfa, 1000 units (for ESRD on dialysis)..........J0886Epoetin alfa, 1000 units (for non-ESRD use).............J0885Epogen (ESRD) – 1,000 units....................................J0886Epogen (non-ESRD) – 1,000 units.............................J0885Ergonovine Maleate – 0.2 mg/ml................................X6168Ergotrate Maleate – 0.2 mg/ml...................................X6168Erythromycin I.V. – 1 gm (lactobionate)/30 ml vials..........................................X6174Erythromycin I.V. – 500 mg (as lactobionate)/20 ml vials.....................................X6178

Estradiol In Oil – 5 mg/ml...........................................X6030Estradiol L.A. – 40 mg/ml...........................................X6018Estradiol Valerate In Oil – 40 mg/ml...........................X6018Estradiol Valerate In Oil – 20 mg/ml...........................X5660Estradiol Valerate In Oil – 10 mg/ml...........................X5662Estradurin – 40 mg w/2 cc diluent .............................X7540Estratab 40.................................................................X6018Estratab 20.................................................................X5660Estratab – 10 mg/ml...................................................X5662Estratest – 50-2 mg/ml...............................................X5620Estra-Testrin – 90-4 mg/ml.........................................X5666Estraval – 10 mg/ml....................................................X5662Estraval – 4X..............................................................X6018Estraval – 2X..............................................................X5660Estro-Cyp – 5 mg/ml...................................................X6030Estrogenic Substance Aqueous – 2 mg/ml................X5756Estroject-L.A...............................................................X6030Estrolin – 2 mg/ml.......................................................X5756Estrone – 10 mg/ml....................................................X5662Estrone Aqueous Solution – 5 mg/ml.........................X6196Estrone Aqueous Solution – 2 mg/ml.........................X6198Estronol (Modified) Femogen Aqueous – 2 mg/ml...................................................X5756Ethacrynic Acid – 50 mg/vial......................................X6204Etidocaine HCl – 1.5%................................................X6138Etidocaine HCl – 1%...................................................X6140Etoposide – 20 mg/ml.................................................X7542Euflexxa – per dose....................................................J7323Everone – 200 mg/ml.................................................X5634Everone – 100 mg/ml.................................................X5626

2 – Injections: List of CodesSeptember 2009

inject list

8

Codes Codes

F

Faslodex – 250 mg/ml............................................... X7654Femogen-Cyp – 5 mg/ml............................................X6030Femogen-L.A. – 40 mg/ml..........................................X6018Femogen-L.A. – 20 mg/ml..........................................X5660Femogen-L.A. – 10 mg/ml..........................................X5662Fentanyl – 0.05 mg/ml................................................X6206Fentanyl Citrate and Droperidol – 0.05-2.5 mg...............................................................X6208Fernisolone – 25 mg/ml..............................................X6014Fernisone – 50 mg/ml suspension.............................X5774Ferrlecit – 62.5 mg......................................................X7496Filgrastim (Neupogen) – 300 mcg...............................J1440Filgrastim (Neupogen) – 480 mcg...............................J1441Flaxedil – 20 mg/ml.....................................................X6214Flexon – 30 mg/ml......................................................X6216Floxuridine – 500 mg/5 ml vial....................................X7544Fludarabine – 50 mg...................................................X7644Fluorodeoxyglucose – 45 mCi....................................A9552Fluorouracil – 500 mg/10 ml.......................................X7546Fluphenazine Decanoate – 25 mg/ml.........................X6220Fluphenazine Enanthate – 25/mg/ml..........................X6220Fluphenazine HCl – 2.5 mg/ml...................................X6222Folic Acid – 5 mg/ml...................................................X6226Follutein – 1,000 units/ml............................................X5622Folvite – 5 mg/ml........................................................X6226Fomepizole – 15 mg....................................................J1451Fomivirsen – 0.25 ml vial............................................X7470Fosaprepitant – 1 mg..................................................J1453Foscarnet Sodium – 1000 mg.....................................J1455Foygen – 2 mg/ml.......................................................X6198Foygen Aqueous – 2 mg/ml.......................................X5756FUDR – 500 mg/5 ml vial...........................................X7544Fulvestrant – 250 mg/ml.............................................X7654Fungizone I.V. – 50 mg/vial........................................X5572Furosemide – 10 mg/ml..............................................X6228

G

Gadolinium – not otherwisespecified, per ml.......................................................A9579

Gadoteridol, (ProHance multipack), per ml........................................................................A9576Gadobenate dimeglumine (MultiHance) per ml..................................................A9577Gadobenate dimeglumine (MultiHance multipack), per ml.................................A9578Gadoxetate Disodium – per ml...................................C9246Gallamine Triethiodide – 20 mg/ml.............................X6214Gallium Ga-67 Citrate – 1 mCi...................................A9556Galsulfase – 1 mg.......................................................J1458Ganciclovir 4.5 mg, long-acting Implant......................J7310Ganphen – 50 mg/ml..................................................X6236Garamycin – 40 mg/ml...............................................X6240Garamycin Pediatric – 10 mg/ml................................X6242

Gemcitabine – 200 mg................................................J9201Gentamicin Sulfate – 40 mg/ml..................................X6240Gentamicin Sulfate – 10 mg/ml..................................X6242Glucagon – 10 mg/10 ml............................................X6252Glucagon – 1 mg/ml...................................................X6254Glycohyprolate – 0.2 mg/ml........................................X6258Gold Sodium Thiomalate – 50 mg/ml.........................X6262Gold Sodium Thiomalate – 25 mg/ml.........................X6264Gonadex – 1,000 units/ml..........................................X5622Granisetron Injection – 1 mg/vial................................X7104Granisetron Tablets – 1 mg........................................X7105Gravigen Aqueous – 2 mg/ml.....................................X6198

H

Haemophilus Influenzae b (Hib) HbOC......................90645Haemophilus Influenzae b (Hib) PRP-D.....................90646Haemophilus Influenzae b (Hib) PRP-OMP...............90647Haemophilus Influenzae b (Hib) PRP-T.....................90648Haldol – 5 mg/ml.........................................................X6274Haloperidol – 5 mg/ml.................................................X6274Hectorol – 1 mcg........................................................J1270Hematran.....................................................................J1752Hemin injection – 1 mg................................................J1640Heparin Lock Flush Solution – 100 units/ml..............................................................X6282Heparin Lock Flush Solution – 10 units/ml................................................................X6284Heparin Sodium Inj (USP) – 40,000 units/ml.........................................................X6286Heparin Sodium Inj (USP) – 20,000 units/ml.........................................................X6288Heparin Sodium Inj (USP) – 10,000 units/ml.........................................................X6296Heparin Sodium Inj (USP) – 7,500 units/ml...........................................................X6298Heparin Sodium Inj (USP) – 5,000 units/ml...........................................................X6302Heparin Sodium Inj (USP) – 5,000 units/0.5 ml.....................................................X6304Heparin Sodium Inj (USP) – 2,500 units/ml...........................................................X6306Heparin Sodium Inj (USP) – 1,000 units/ml...........................................................X6308


inject list

9

Codes Codes

Hepatitis A and Hepatitis BCombination Vaccine...............................................90636

Hepatitis A Vaccine (adult) – 1,440 units/ml...............90632Hepatitis A Vaccine

(pediatric/adolescent)...............................................90633Hepatitis B Immune Globulin, 1 ml..............................90371Hepatitis B Immune Globulin, (Hepagam B)

intramuscular – 0.5 ml..............................................J1571Hepatitis B Immune Globulin (Hepagam B)

intravenous – 0.5 ml.................................................J1573Hepatitis B Vaccine, adolescent

(2 dose schedule).....................................................90743Hepatitis B Vaccine, adult dosage..............................90746Hepatitis B Vaccine, dialysis or

immunosuppressed, per 40 mcg(3 dose schedule).....................................................90740

Hepatitis B Vaccine, dialysis orImmunosuppressed, per 40 mcg(4 dose schedule).....................................................90747

Hepatitis B Vaccine/HaemophilusInfluenzae b..............................................................90748

Hepatitis B Vaccine, pediatric/adolescent(3 dose schedule).....................................................90744

Hep-Lock – 100 units/ml.............................................X6282Hep-Lock – 10 units/ml...............................................X6284Heprinar – 10,000 units/ml.........................................X6296Heprinar – 5,000 units/ml...........................................X6302Heprinar – 1,000 units/ml...........................................X6308Hexadrol Phosphate – 10 mg/ml................................X6320Hexadrol Phosphate – 4 mg/ml..................................X6004Histerone – 100..........................................................X6326Histerone – 50............................................................X5628Histrelin Acetate – 10 mcg..........................................J1675Histrelin Implant (Vantas) – 50 mg..............................J9225H.P. Acthar Gel – 80 units/ml.....................................X5516H.P. Acthar Gel – 40 units/ml.....................................X5518Human Papilloma Virus Vaccine, for

intramuscular use 19 through 26 years of age).....................................90649

Human Papilloma virus (HPV) vaccine,types 16, 18, bivalent, 3 dose schedule, for intramuscular use, females 10 through 25 years of age...................................90650

Humatrope – 1 mg......................................................X7036Hyalgan – 2 ml............................................................J7321Hydeltra T.B.A. – 20 mg/ml suspension.....................X6328Hydeltrasol – 20 mg/ml solution.................................X6330Hydextran....................................................................J1752Hydralazine HCl – 20 mg/ml.......................................X5648Hydrocortisone – 50 mg/ml........................................X5980Hydrocortisone – 25 mg/ml........................................X6332Hydrocortisone Acetate –

50 mg/ml suspension...............................................X5774Hydrocortisone Acetate –

25 mg/ml suspension...............................................X5988Hydrocortisone Phosphate – 50 mg/ml......................X6334Hydromorphone HCl – 4 mg/ml..................................X6086Hydromorphone HCl – 2 mg/ml..................................X6090Hydromorphone HCl – 1 mg/ml..................................X6092Hydroxo-12 – 1,000 mcg/ml.......................................X5752Hydroxyzine – 50 mg/ml.............................................X6336

Hyparotin – 1.5 ml......................................................X6346Hyperstat IV – 30 mg/20 ml........................................X6070Hyrexin – 50 mg/ml.....................................................X5738Hyrexin – 10 mg/ml.....................................................X5740

I

Ibandronate Sodium (Boniva) – 1 mg.........................J1740Ibritumomab Tiuxetan (In-111), 5 mCi........................A9542Ibritumomab Tiuxetan (Y-90), 40 mCi........................A9543Idursulfase – 1 mg.......................................................J1743Ifosfamide – 100 mg...................................................X7584Ilopan – 250 mg/ml.....................................................X6060Imiglucerase – 1.0 u....................................................J1785Imipramine HCl – 25 mg/ml........................................X6352Immune Serum Globulin, for IM use,

Human, 1 ml.............................................................90281Immune Serum Globulin I.V., 1 gm.............................90283Inapsine – 2.5 mg/ml..................................................X6126Inderal – 1 mg/ml........................................................X6354Indium In-111 Capromab Pendetide – 10 mCi...........A9507Indium In-111 Ibritumomab Tiuxetan – 5 mCi............A9542Indium In-111 Oxyquinoline – 0.5 mCi.......................A9547Indium In-111 Pentetate – 0.5 mCi.............................A9548Indium In-111 Pentetreotide – 6 mCi..........................A9572Infliximab – 10 mg.......................................................J1745Influenza Virus Vaccine, preservative free

(6 to 35 months of age)............................................90655Influenza Virus Vaccine, preservative free

(3 years and older)...................................................90656Influenza Virus Vaccine

(6 to 35 months of age)............................................90657Influenza Virus Vaccine (3 years and older)...............90658Innovar – 0.05 mg/2.5 mg...........................................X6208Insulin Injection – 100 units/ml...................................X6366Interferon Alfa-2a (Roferon A, Roche) –

1,000,000 IU............................................................X7548Interferon Alfa-2b (Intron A, Schering) –

1,000,000 IU............................................................X7550Interferon Alfa-N3 (Alferon N, Purdue

Frederick) – 250,000 IU...........................................X7551Interleukin-2 – 22 million IU........................................X7632Intropin – 40 mg/ml......................................................J1265Iodine Iobenguane Sulfate – 0.5 mCi.........................A9508Iodine Iodinated Serum Albumin – 5 µCi....................A9524Iodine Serum Albumin – 5 µCi....................................A9532Iodine Sodium Iodide – 1 µCi.....................................A9531Iodine Sodium Iodide Capsule(s) – 100 µCi...............A9516Iodine Sodium Iodide (diagnostic) – 1 mCi.................A9528Iodine Sodium Iodide (therapeutic) – 1 mCi...............A9517Iodine Sodium Iothalamate – 10 µCi..........................A9554Iodine Tositumomab – study dose.............................A9544Iodine Tositumomab – treatment dose.......................A9545Iprenol – 1:5,000 sol/1 ml...........................................X6408Irinotecan (Camptosar) – 20 mg.................................J9206Iron-Based Magnetic Resonance Contrast

Agent – 1 ml............................................................Q9953


inject list

10

Codes Codes

Iron Dextran – 50 mg..................................................J1750Isoniazid (Isonicotintic Acid

Hydrazide) – 100mg/ml...........................................X6410Isuprol – 1:5,000 solution...........................................X6408Ixabepilone – 1 mg......................................................J9207

J (no entry)

K

Kanamycin Sulfate – 1 gm/3 ml vials.........................X6426Kanamycin Sulfate – 500 mg/2 ml vials.....................X6422Kanamycin Sulfate – 75 mg/2 ml vials.......................X6424Kantrex – 1 gm/3 ml vials...........................................X6426Kantrex – 500 mg/2 ml vials.......................................X6422Kantrex – 75 mg/2 ml vials.........................................X6424Kaybovite 1,000 – 1,000 mcg/ml................................X5752Keflin – 20 gm/200 ml vial..........................................X5888Keflin – 4 gm/50 ml vial...............................................X5890Keflin – 2 gm/100 ml vial.............................................X5892Keflin – 2 gm/20 ml vial...............................................X5894Keflin – 1 gm/100 ml vial.............................................X5896Keflin – 1 gm/10 ml vial...............................................X5898Kefzol – 10 gm/100 ml vial.........................................X5602Kefzol – 1 gm/redi vial................................................X5604Kefzol – 1 gm/100 ml piggyback unit..........................X5606Kefzol – 1 gm/10 ml vial.............................................X5608Kefzol – 500 mg/100 ml vial.......................................X5610Kefzol – 500 mg/10 ml vial.........................................X5612Kefzol – 250 mg/10 ml vial.........................................X5614Kenalog 40..................................................................X5552Kenalog 10..................................................................X6432Kestrin Aqueous – 2 mg/ml........................................X5756Ketaject – 100 mg/ml..................................................X6434Ketaject – 50 mg/ml....................................................X6436Ketaject – 10 mg/ml....................................................X6438Ketalar – 100 mg/ml....................................................X6434Ketalar – 50 mg/ml......................................................X6436Ketalar – 10 mg/ml......................................................X6438Ketamine – 100 mg/ml................................................X6434Ketamine – 50 mg/ml..................................................X6436Ketamine – 10 mg/ml..................................................X6438Key-Pred 50................................................................X6440Key-Pred 25................................................................X6014Key-Pred SP – 20 mg/ml............................................X6330K-Feron.......................................................................J1752Konakion – 10 mg/ml..................................................X5650Konakion – 2 mg/ml....................................................X5652K-Phen – 50 mg/ml.....................................................X6236

L

L.A. Dezone – 8 mg/ml suspension...........................X6008Lanoxin – 0.25 mg/ml.................................................X6080Lanoxin – 0.1 mg/ml...................................................X6082Lanreotide acetate – 1 mg..........................................J1930Largon – 20 mg/ml......................................................X6442Laronidase – 0.1 mg...................................................J1931Lasix – 10 mg/ml........................................................X6228L-Caine-E – 2% w/1:1,000,000 Epinephrine..............X6444Lepirudin – 50 mg........................................................J1945Leucovorin Calcium – 50 mg......................................J0640Leuprolide acetate (for depot suspension) per 7.50 mg...............................................................J9217Leuprolide acetate (for depot suspension) per 3.75 mg...............................................................J1950Levarterenol (Norepinephrine) – 1 mg

(as batartrate) per ml...............................................X6452Levetiracetam – 10 mg................................................J1953Levo-Dromoran – 2 mg/ml..........................................X6454Levoid – 500 mcg/ml..................................................X6456Levophed – 1 mg (as batartrate) per ml.....................X6452Levoprome – 20 mg/ml...............................................X6458Levorphanol Tartrate – 2 mg/ml.................................X6454Levothyroxine – 500 mcg/ml......................................X6456Levsin – 0.25 mg/ml...................................................X6460Libigen – 1,000 units/ml..............................................X5622Librium – 100 mg/5 ml................................................X5920Lidocaine HCl – 20% (200 mg/ml)..............................X6462Lidocaine HCl – 10% (100 mg/ml)..............................X6464Lidocaine HCl – 5% w/7.5% Glucose.........................X6466Lidocaine HCl – 2% (20 mg/ml)..................................X6470Lidocaine HCl – 1.5%.................................................X6478Lidocaine HCl – 0.5%.................................................X6490Lidocaine HCl – 1.5% w/7.5% Dextrose....................X6480Lidocaine HCl – 2% w/1:200,000 Epinephrine...........X6474Lidocaine HCl – 2% w/1:100,000 Epinephrine...........X6444Lidocaine HCl – 2% w/1:50,000 Epinephrine.............X6476Lidocaine HCl – 1.5% w/1:200,000 Epinephrine........X6482Lidocaine HCl – 1% w/1:200,000 Epinephrine...........X6486Lidocaine HCl – 1% w/1:100,000 Epinephrine...........X6488Lidocaine HCl – 0.5% w/1:200,000 Epinephrine........X6492

2 – Injections: List of CodesAugust 2009

inject list

11

Codes Codes

Lidocaine HCl Without Preservatives – 4% (40 mg/ml)..........................................................X6494Lidocaine HCl Without Preservatives – 2% (20 mg/ml)..........................................................X6470Lidocaine HCl Without Preservatives – 1% (10 mg/ml)..........................................................X6496Lidopen Auto-Injector – 10% (100 mg/ml)......................................................X6464Lincocin – 300 mg/2 ml U-Ject...................................X6504Lincomycin – 300 mg/2 ml U-Ject..............................X6504Lipo-Hepin – 40,000 units/ml......................................X6286Lipo-Hepin – 20,000 units/ml......................................X6288Lipo-Hepin – 10,000 units/ml......................................X6296Lipo-Hepin – 5,000 units/ml........................................X6302Lipo-Hepin – 5,000 units/0.5 ml..................................X6304Lipo-Hepin – 1,000 units/ml........................................X6308Liquaemin Sodium – 40,000 units/ml.........................X6286Liquaemin Sodium – 20,000 units/ml.........................X6288Liquaemin Sodium – 10,000 units/ml.........................X6296Liquaemin Sodium – 5,000 units/ml...........................X6302Liquaemin Sodium – 1,000 units/ml...........................X6308L-Myoscyamine Sulfate – 0.25 mg/ml........................X6460Low osmolar contrast material 100 – 199 mg/ml iodine concentration – per ml...................................Q9965Low osmolar contrast material 200 – 299 mg/ml iodine concentration – per ml...................................Q9966Low osmolar contrast material 300 – 399 mg/ml iodine concentration – per ml...................................Q9967Low osmolar contrast material – 400 mg/ml iodine or greater.....................................Q9951LTS – 500 mcg/ml......................................................X6456Luminal Sodium – 130 mg/ml.....................................X6506Lunelle – Medroxyprogesterone Acetate – 25 mg and estradiol cypionate 5 mg/0.5 ml..............X7490

M

Magnesium Sulfate – 50%..........................................X6512Magnesium Sulfate – 12.5%.......................................X6514Magnesium Sulfate – 10%..........................................X6516Malogen Cyp – 100 mg/ml..........................................X5618Malogen L.A. – 200 mg/ml..........................................X5634Mandol – 2 gm/100 ml vial..........................................X5842Mandol – 2 gm/20 ml vial............................................X5844Mandol – 1 gm/100 ml vial..........................................X5846Mandol – 1 gm/10 ml vial............................................X5848Mandol – 500 mg/10 ml vial........................................X5840Mannitol – 25%...........................................................X6520Mannitol – 20%...........................................................X6522Mannitol – 15%...........................................................X6524Mannitol – 10%...........................................................X6526Mannitol – 5%.............................................................X6528Marcaine – 0.75%.......................................................X5790Marcaine – 0.5%.........................................................X6530Marcaine HCl – 0.25%................................................X5792Measles.......................................................................90705Measles, mumps, rubella (MMR)................................90707Measles, mumps, rubella, varicella (MMRV)..............90710Measles, rubella..........................................................90708Mechlorethamine HCl – 10 mg/20ml triturated w/100 mg Sodium Chloride.......................X7552Medralone-80 – 80 mg/ml suspension.......................X6036Medralone-40 – 40 mg/ml...........................................X6038Medroxyprogesterone Acetate – 25 mg and estradiol cypionate 5 mg/0.5 ml..............X7490Medroxyprogesterone Acetate – 400 mg/ml 10 ml vial per ml......................................X6046Medroxyprogesterone Acetate – 400 mg/ml 2.5 ml vial per ml.....................................X6048Mefoxin – 2 gm vial.....................................................X5854Mefoxin – 1 gm vial.....................................................X5856Menadiol Sodium Diphosphate (K-4) – 37.5 mg/ml....................................................X6532Menadiol Sodium Diphosphate (K-4) – 5 mg/ml.........................................................X6534Meningococcal polysaccharide vaccine,

any groups...............................................................90733Meperidine HCl – 100 mg/ml......................................X6020Meperidine HCl – 75 mg/ml........................................X6022Meperidine HCl – 50 mg/ml........................................X6024Meperidine HCl – 25 mg/ml........................................X6026Mephentermine Sulfate – 30 mg/ml............................X6550Mephentermine Sulfate – 15 mg/ml............................X6552Mepivacaine HCl – 3%...............................................X5824Mepivacaine HCl – 2%...............................................X5818Mepivacaine HCl – 1.5%............................................X5820Mepivacaine HCl – 1%...............................................X5822Mepred 80 suspension...............................................X6036Mepred 40 suspension...............................................X6038Mesna – 100 mg/ml....................................................X7586Mesoridazine – 25 mg/ml...........................................X6556Mestinon Bromide – 5 mg/ml......................................X6826


inject list

12

Codes Codes

Metalone T.B.A. – 20 mg/ml suspension................................................X6328Metaraminol – 10 mg/ml (1%) (as bitartrate)............................................................X5658Methadone HCl – 10 mg/ml........................................X6110Methergine – 0.2 mg/ml..............................................X6566Methicillin Sodium – 6 gm vials (powder)..................................................X5710Methicillin Sodium – 4 gm piggyback units (powder)................................X6558Methicillin Sodium – 4 gm vials (powder)..................................................X5712Methicillin Sodium – 2 gm piggyback units (powder)...........................................................X5866Methicillin Sodium – 1 gm piggyback units (powder)...........................................................X5868Methicillin Sodium – 1 gm vials (powder)..................................................X5714Methocarbamol – 100 mg/ml......................................X6560Methohexital Sodium – 500 mg/5 ml..........................X5784Methohexital Sodium – 5 gm......................................X5780Methohexital Sodium – 2.5 gm...................................X5782Methotrexate – 50 mg (sodium) vial for reconstitution.............................................................J9260Methotrexate – 50 mg/ml 2 ml vial

(sodium)....................................................................J9260Methotrexate – 50 mg/vial...........................................J9260Methotrimeprazine – 20 mg/ml...................................X6458Methoxamine HCl – 20 mg/ml 1 ml ampules............................................................X6562Methoxamine HCl – 10 mg/ml 10 ml vials.................................................X6562Methyldopa and Methyldopate HCl – 250 mg/5 ml..............................................................X5540Methyldrol 40..............................................................X6038Methylene Blue – 1 ml................................................A9535Methylergonovine Maleate – 0.2 mg/ml..................................................................X6566Methylprednisolone Acetate – 80 mg/ml....................................................................J1040Methylprednisolone Acetate – 40 mg/ml....................................................................J1030Methylprednisolone Acetate – 20 mg/ml....................................................................J1020Methylprednisolone Sodium Succinate – up to 125 mg/ml..................................................................J2930Methylprednisolone Sodium Succinate – up to 40 mg/ml....................................................................J2920

Meticortelone Acetate – 25 mg/ml..............................X6014Metocurine Ioxide – 2 mg/ml......................................X6582Metubine Iodide – 2 mg/ml.........................................X6582Micafungin sodium - 1 mg...........................................J2248Miconazole – 10 mg/ml...............................................X6588Minocycline HCl (Minocin) – 100 mg/vial...............................................................X6118Mithracin – 2.5 mg/vial w/100 mg/mannitol..............................................................X7564Mithramycin – 2.5 mg/vial w/100 mg/mannitol..............................................................X7564Mitomycin – 20 mg/vial...............................................X7566Mitomycin – 5 mg/vial.................................................X7568Mitoxantrone – 5 mg...................................................X7624Monistat – 10 mg/ml...................................................X6588Morphine Sulfate – 100 mg.........................................J2271Morphine Sulfate – up to 10 mg..................................J2270Morphine Sulfate – preservative-free sterile solution, 10 mg..........................................................J2275M-Prednisol 80 suspension........................................X6036M-Prednisol 40 suspension........................................X6038Mumps........................................................................90704Mustargen – 10 mg/20 ml triturated w/100 mg sodium chloride........................................X7552Mutamycin – 20 mg/vial..............................................X7566Mutamycin – 5 mg/vial................................................X7568M.V.I. – 10 ml..............................................................X6598M.V.I. Concentrate – 5 ml...........................................X6600Mychel-S – 1 gm vial as dry powder..........................X5922Mycifradin Sulfate – 500 mg vials...............................X6504Myochrysine – 50 mg/ml............................................X6262Myochrysine – 25 mg/ml............................................X6264Myolin – 30 mg/ml.......................................................X6216


inject list

13

Codes Codes

N

Nafcil – 2 gm (powder) vial.........................................X6604Nafcil – 1 gm (powder) vial.........................................X6606Nafcillin Sodium – 2 gm (powder) vial........................X6604Nafcillin Sodium – 1 gm (powder) vial........................X6606Nafcillin Sodium – 500 mg vial...................................X6610Nalate – 50 mg/ml.......................................................X5678Nalbuphine HCl – 10 mg/ml........................................X6612Naloxone HCl – 0.4 mg/ml.........................................X6614Naloxone HCl – 0.02 mg/ml.......................................X6616Nandrolate – 100 mg/ml (oil)......................................X5600Nandrolate – 50 mg/ml (oil)........................................X5632Nandrolin – 25 mg/ml (oil)..........................................X5630Nandrolone Decanoate – 100 mg/ml (oil)..........................................................X5600Nandrolone Decanoate – 50 mg/ml (oil)............................................................X5632Nandrolone Phenpropionate – 50 mg/ml (oil)............................................................X5598Nandrolone Phenpropionate – 25 mg/ml (oil)............................................................X5630Narcan – 0.4 mg/ml....................................................X6614Narcan – 0.02 mg/ml..................................................X6616Natalizumab – 1 mg....................................................J2323Navane – 2 mg/ml......................................................X6618Nebcin – 40 mg/ml......................................................X6620Nebcin – 10 mg/2 ml vial............................................X6622Nelarabine – 50 mg.....................................................J9261Nembutal Sodium – 50 mg/ml....................................X6624Neocyten – 30 mg/ml..................................................X6216Neostigmine Methylsulfate – 1:4,000 solution/1 ml ampules...............................................X6630Neostigmine Methylsulfate – 1:2,000 solution........................................................X6632Neostigmine Methylsulfate – 1:1,000 solution........................................................X6634Neo Synephrine – 1% 1 ml ampules..........................X6626Nesacaine – 2%.........................................................X5926Nesacaine – 1%.........................................................X5928Nesacaine-CE – 3%...................................................X5924Nesacaine-CE – 2%...................................................X5926Nesiritide - 0.1 mg......................................................J2325Nipride – 50 mg/5ml....................................................X6636Nitrogen N-13 Ammonia, Diagnostic – 40 mCi..........A9526Nitroprusside Sodium – 50 mg/5 ml...........................X6636Norazine HCl – 50 mg/ml...........................................X6638Norditropin – 1 mg......................................................X7494Nordryl – 10 mg/ml.....................................................X5740Norferan......................................................................J1752Norflex – 30 mg/ml.....................................................X6216Noroxine – 500 mcg/ml...............................................X6456Nor-Pred T.B.A. – 20 mg/ml suspension................................................X6328

Nospaz – 10 mg/ml.....................................................X5642Novocain – 10%.........................................................X6640Novocain – 2%...........................................................X6642Novocain – 1%...........................................................X6644Nubain – 10 mg/ml......................................................X6612Numorphan – 1.5 mg/ml.............................................X6646Numorphan – 1 mg/ml................................................X6648Nutropin – 1 mg..........................................................X7452Nutropin AQ – 1 mg....................................................X7454Nydrazid – 100 mg/ml.................................................X6410

O

Octafluoropropane Microspheres – 1 ml....................Q9956Octocaine HCl – 2% w/1:100,000 Epinephrine...............................................................X6444Octocaine HCl – 2% w/1:50,000 Epinephrine...............................................................X6476Omnipen-N – 2 gm (powder) piggyback units.........................................................X5576Omnipen-N – 2 gm (powder) vials.............................X5578Omnipen-N – 1 gm (powder) piggyback units.........................................................X5580Omnipen-N – 1 gm (powder) vials.............................X5582Omnipen-N – 500 mg (powder) piggyback units.........................................................X5584Omnipen-N – 500 mg (powder) vials.........................X5586Omnipen-N – 250 mg (powder) vials.........................X5588Omnipen-N – 125 mg (powder) vials.........................X5550Oncovin – 5 mg w/50 mg lactose per vial..........................................................X7570Oncovin – 1 mg w/10 mg lactose per vial..........................................................X7572Ondansetron HCl – 1 mg............................................J2405Oral Magnetic Resonance Contrast Agent – 1 ml.............................................................Q9954Ormazine – 25 mg/ml.................................................X5918Orphenadrine Citrate – 30 mg/ml...............................X6216Orthovisc – per dose...................................................J7324Or-Tyl – 10 mg/ml.......................................................X5642Osmitrol – 20%...........................................................X6522Osmitrol – 15%...........................................................X6524Osmitrol – 10%...........................................................X6526Osmitrol – 5%.............................................................X6528Oxacillin Sodium – 4 gm (powder) vials...........................................................X5720Oxacillin Sodium – 2 gm (powder) vials...........................................................X5722Oxacillin Sodium – 1 gm (powder) vials...........................................................X5724Oxacillin Sodium – 500 mg (powder) vials...........................................................X5726Oxacillin Sodium – 250 mg (powder) vials...........................................................X6656Oxaliplatin – 0.5 mg....................................................J9263

2 – Injections: List of CodesAugust 2009

inject list

14

Codes Codes

Oxymorphone HCl – 1.5 mg/ml..................................X6646Oxymorphone HCl – 1 mg/ml.....................................X6648Oxytetracycline – 250 mg/vial....................................X6664Oxytetracycline – 125 mg/ml......................................X6658Oxytetracycline – 50 mg/ml........................................X6660Oxytocin – 10 units/ml................................................X6666

P

Paclitaxel protein-bound particles – 1 mg...................J9264Paclitaxel – 30 mg......................................................X7052Palifermin – 50 mcg....................................................J2425Palonosetron – 25 mcg...............................................J2469Pamidronate – 30 mg.................................................X7444Pancuronium Bromide – 2 mg/ml...............................X6670Pancuronium Bromide – 1 mg/ml...............................X6672Panheprin – 40,000 units/ml.......................................X6286Panheprin – 20,000 units/ml.......................................X6288Panheprin – 10,000 units/ml.......................................X6296Panheprin – 5,000 units/ml.........................................X6302Panheprin – 1,000 units/ml.........................................X6308Panheprin Lok – 100 units/ml.....................................X6282Panitumumab – 10 mg................................................J9303Pantoprazole – 40 mg................................................S0164Paricalcitol – 1 mcg.....................................................J2501Pavulon – 2 mg/ml......................................................X6670Pavulon – 1 mg/ml......................................................X6672Pegademase Bovine – 25 IU......................................J2504Pegaptanib Sodium – 0.3 mg......................................J2503Pegaspargase – single dose vial................................J9266Pegfilgrastim (Neulasta) – 6 mg..................................J2505Pen A/N – 1 gm (powder) vials..................................X5582Pen A/N – 500 mg (powder) vials..............................X5586Pen A/N – 250 mg (powder) vials..............................X5588Penazine 50 – 50 mg/ml.............................................X6236Penbritin-S – 4 gm (powder) vials..............................X5574Penbritin-S – 2 gm (powder) vials..............................X5578Penbritin-S – 1 gm (powder) vials..............................X5582Penbritin-S – 500 mg (powder) vials..........................X5586Penbritin-S – 250 mg (powder) vials..........................X5588Penbritin-S – 125 mg (powder) vials..........................X5550Penicillin G Benzathine – 150,000 units and Penicillin G Procaine – 150,000 units/ml.......................................................X5768Penicillin G Benzathine – 300,000 units and Penicillin G Procaine – 300,000 units/1 ml tubex..........................................X5766Penicillin G Benzathine – 600,000 units and Penicillin G Procaine – 600,000 units/2 ml syringe.......................................X7456Penicillin G Benzathine – 900,000 units and Penicillin G Procaine – 300,000 units/2 ml tubex..........................................X5764Penicillin G Benzathine – 1,200,000 units and Penicillin G Procaine – 1,200,000 units/4 ml syringe....................................X7458

Penicillin G Benzathine, Parenteral – 300,000 units/ml 10 ml vials.....................................X5772Penicillin G Benzathine, Parenteral – 600,000 units/ml.......................................................X5770Penicillin G Benzathine, Parenteral – 1,200,000 units/2 ml syringe....................................X7460Penicillin G Benzathine, Parenteral – 2,400,000 units/4 ml syringe....................................X7462Penicillin G Potassium – 20,000,000 units (powder)/vial....................................................X6700Penicillin G Potassium (or Sodium) (Aqueous) – 10,000,000 units (powder)/vial.............................................................X6702Penicillin G Potassium (or Sodium) (Aqueous) – 5,000,000 units (powder)/vial.............................................................X6704Penicillin G Potassium (or Sodium) (Aqueous) – 1,000,000 units (powder)/vial.............................................................X6706Penicillin G Procaine (Aqueous) – 2,400,000 units/unit dose.........................................X6714Penicillin G Procaine (Aqueous) – 1,200,000 units/unit dose.........................................X6716Penicillin G Procaine (Aqueous) – 600,000 units/unit dose ...........................................X6136Pentamidine – 150 mg................................................X6718Pentazine – 50 mg/ml.................................................X6236Pentazocine – 30 mg/ml.............................................X6720Pentobarbital Sodium – 50 mg/ml..............................X6624Pentothal Sodium – 10 gm.........................................X6728Pentothal Sodium – 5 gm...........................................X6730Pentothal Sodium – 1 gm...........................................X6732Pentothal Sodium – 500 mg.......................................X6734Pentothal Sodium – 400 mg.......................................X6736Pentothal Sodium – 250 mg.......................................X6738Perflutren Lipid Microspheres – 1 ml.........................Q9957Perphenazine – 5 mg/ml.............................................X6740Pfizerpen-AS – 1,200,000 units/unit dose.........................................X6716Phenazine 25..............................................................X6742Phencen 50................................................................X6236Phenergan – 50 mg/ml...............................................X6236Phenergan – 25 mg/ml...............................................X6742Phenobarbital Sodium – 130 mg/ml...........................X6506Phenobarbital Sodium – 65 mg/ml.............................X6754Phenoject 50...............................................................X6236Phentolamine – 5 mg..................................................X6758Phenylephrine HCl – 1% 1 ml ampules......................................................X6626Phenytoin Sodium, Parenteral – 50 mg/ml..............................................X6084Physostigmine Salicylate – 1 mg/ml.....................................................................X5640


inject list

15

Codes Codes

Phytonadione (K1) – 10 mg/ml...................................X5650Phytonadione (K1) – 2 mg/ml.....................................X5652Pitocin – 10 units/ml...................................................X6666Pitressin – 20 pressor units/ml...................................X6760Pituitrin – 20 units/ml..................................................X6764Plague Vaccine...........................................................90727Platinol – 10 mg/vial....................................................X7516Plerixafor (Mozobil ® ) – 1 mg ....................................C9252Pneumococcal Conjugate Vaccine, Polyvalent, (for children under 5 years of age)............................90669Pneumococcal Polysaccharide Vaccine – 23-valent..................................................90732Polio, live, oral.............................................................90712Poliomyelitis Vaccine – 1 cc amp...............................90713Polycillin-N – 2 gm (powder) piggyback units.........................................X5576Polycillin-N – 2 gm (powder) vials...........................................................X5578Polycillin-N – 1 gm (powder) piggyback units.........................................X5580Polycillin-N – 1 gm (powder) vials..............................X5582Polycillin-N – 500 mg (powder) piggyback units.........................................X5584Polycillin-N – 500 mg (powder) vials...........................................................X5586Polycillin-N – 250 mg (powder) vials...........................................................X5588Polycillin-N – 125 mg (powder) vials...........................................................X5550Polyestradiol Phosphate – 40 mg/secule w/2 ml ampule of sterile diluent............................................X7540Polymyxin B Sulfate – 500,000 units..........................X6776Pontocaine – 1%........................................................X6778Pontocaine – 0.3% w/6% Dextrose............................X6780Pontocaine – 0.2% w/6% Dextrose............................X6782Posterior Pituitary Injection – 20 units/ml................................................................X6764Pralidoxime Chloride – 1 gm......................................X6784Predcor-50..................................................................X6440Predcor-25..................................................................X6014Pre-Dep – 80 mg/ml...................................................X6036Pre-Dep – 40 mg/ml...................................................X6038Prednisolone Acetate – 50 mg/ml..............................X6440Prednisolone Acetate – 25 mg/ml..............................X6014Prednisolone Tebutate – 20 mg/ml suspension................................................X6328

Pregnyl – 1,000 units/ml.............................................X5622Premarin IV – 25 mg...................................................X5972Prenisolone Acetate – 25 mg/ml................................X6014Prenisolone Sodium Phosphate – 20 mg/ml...................................................................X6330Prilocaine HCl – 4%....................................................X5944Prilocaine HCl – 4% w/1:200,000 Epinephrine...............................................................X5942Principen/N – 2 gm (powder) vials.............................X5578Principen/N – 1 gm (powder) vials.............................X5582Principen/N – 500 mg (powder) vials.........................X5586Principen/N – 250 mg (powder) vials.........................X5588Principen/N – 125 mg (powder) vials.........................X5550Procainamide HCl – 500 mg/ml..................................X6792Procainamide HCl – 100 mg/ml..................................X6794Procaine HCl – 10%...................................................X6640Procaine HCl – 2%.....................................................X6642Procaine HCl – 1%.....................................................X6644Prochlorperazine – 5 mg/ml.......................................X5970Procrit (ESRD) – 1,000 units......................................J0886Procrit (non-ESRD) – 1,000 units...............................J0885Progesterone (in oil) – 50 mg/cc................................X6810Prolixin – 2.5 mg/ml....................................................X6222Prolixin Decanoate – 25 mg/ml..................................X6220Prolixin Enanthate – 25 mg/ml....................................X6220Promaject – 25 mg/ml.................................................X5918Promaz – 25 mg/ml....................................................X5918Promazine HCl – 50 mg/ml........................................X6638Promethamead 50......................................................X6236Promethamead 25......................................................X6742Promethazine HCl – 50 mg/ml...................................X6236Promethazine HCl – 25 mg/ml...................................X6742Pronestyl – 500 mg/ml................................................X6792Pronestyl – 100 mg/ml................................................X6794Propiomazine HCl – 20 mg/ml....................................X6442Propranolol HCl – 1 mg/ml.........................................X6354Prorex – 50 mg/ml......................................................X6236Prorex – 25 mg/ml......................................................X6742Prostaphlin – 4 gm (powder) vials..............................X5720Prostaphlin – 2 gm (powder) vials..............................X5722Prostaphlin – 1 gm (powder) vials..............................X5724Prostaphlin – 500 mg (powder) vials..........................X5726Prostaphlin – 250 mg (powder) vials..........................X6656Prostigmin – 1:4,000 solution/ 1 ml/ampules............................................................X6630Prostigmin – 1:2,000 solution.....................................X6632Prostigmin – 1:1,000 solution.....................................X6634

2 – Injections: List of CodesOctober 2009

inject list

16

Codes Codes

Protamine Sulfate – 10 mg/ml....................................X6816Protein C Concentrate intravenous, human – 10 IU......................................J2724Prothazine – 50 mg/ml................................................X6236Prothazine – 25 mg/ml................................................X6742Protopam Chloride - Emergency Kit – 1 gm..............................................X6784Protropin – 1 mg.........................................................X7034Provigan – 50 mg/ml...................................................X6236Provigan – 25 mg/ml...................................................X6742PSP-IV – 20 mg/ml.....................................................X6330Pyridostigmine Bromide – 5 mg/ml.............................X6826

Q

Quelicin – 100 mg/ml..................................................X6828Quelicin – 50 mg/ml....................................................X6830Quelicin – 20 mg/ml....................................................X5636Quinidine Gluconate – 80 mg/ml................................X6832

R

Ranibizumab (Lucentis™) – 0.1 mg...........................J2778Recombinant, GM-CSF, Leukine – 500 mcg/vial.............................................................X7366Recombinant, GM-CSF, Leukine – 250 mcg/vial.............................................................X7364Regadenoson – 0.1 mg...............................................J2785Regitine – 5 mg...........................................................X6758Regonol – 5 mg/ml......................................................X6826Remicade – 10 mg......................................................J1745Repbimone #1............................................................X5666Rep Estra – 10 mg/ml.................................................X5662Reposterone – 200 mg/ml..........................................X5634Rep-Pred 80 suspension............................................X6036Rep-Pred 40...............................................................X6038Respiratory Syncytial Virus Immune Globulin (RSV-IGIM), 50 mg...................................................90378RHO (D) Immune Globulin (Human) – full-dose.........90384RHO (D) Immune Globulin (Human) – mini-dose.......90385RHO (D) Immune Globulin (RhlglV), human for IV use (100 I.U.)...................................................J2792Risperidone, long lasting, 0.5 mg................................J2794Rituximab – 100 mg....................................................J9310

Robaxin – 100 mg/ml..................................................X6560Robinul – 0.2 mg/ml....................................................X6258Romiplostim – 10 mcg................................................C9245Ropredlone – 50 mg/ml..............................................X6440Ropredlone – 25 mg/ml..............................................X6014Rubella Virus Vaccine, Live........................................90706Rubesol 1,000 ...........................................................X5752Rubramin PC – 1,000 mcg/ml....................................X5752Ruvite 1,000 – 1,000 mcg/ml......................................X5752

S

Samarium Sm-153, Therapeutic – 50 mCi.................A9605Sargramostim – 500 mcg/vial.....................................X7366Sargramostim – 250 mcg/vial.....................................X7364Savacort – 100............................................X6014 or X6440Savacort – 25.............................................................X6440Savacort-D – 4 mg/ml.................................................X6004Scopolamine HBr – 1.0 mg/ml....................................X6856Scopolamine HBr – 0.4 mg/ml....................................X6862Scopolamine HBr – 0.3 mg/ml....................................X6864Secobarbital Sodium – 50 mg/ml................................X6870Seconal Sodium – 50 mg/ml.......................................X6870Secretin, Synthetic, Human – 1 mcg..........................J2850Serentil – 25 mg/ml.....................................................X6556Sermorelin Acetate – 1 mcg.......................................Q0515Sincalide – 5 mcg........................................................J2805SK-Ampicillin-N – 500 mg (powder) vials...........................................................X5586Sodium Ascorbate – 500 mg/ml.................................X5882Sodium Ascorbate – 250 mg/ml.................................X5912Sodium Edecrin – 500 mg/vial....................................X6204Sodium Ferric Gluconate Complex in Sucrose – 62.5 mg................................................X7496Sodium Fluoride F-18, up to 30 millicuries.................A9580Sodium Phosphate P-32, Therapeutic – 1 mCi..........A9563Sodium Thiosalicylate – 50 mg/ml..............................X5678Solganal – 50 mg/ml...................................................X5708Sol-Pred – 20 mg/ml solution.....................................X6330Solu-Cortef – 1,000 mg/8 ml vial................................X6888Solu-Cortef – 500 mg/4 ml vial...................................X6890Solu-Cortef – 250 mg/2 ml vial...................................X6892Solu-Cortef – 100 mg/10 ml vial.................................X6894Solu-Medrol – 40 mg/ml..............................................X5554Solurex – 4 mg/ml.......................................................X6004Span-Est 20 ...............................................................X5660Span-Est 10 ...............................................................X5662Span-Est-Test 4 – 90-4 mg/ml...................................X5666Span-F – 5 mg/ml.......................................................X5662Span-Test – 100 mg/ml..............................................X5626Spectinomycin – 400 mg (as HCl)/ml 2 gm vial................................................X6896Spenbolic, Improved – 50 mg/ml (oil).........................X5598Spenbolic, Improved – 25 mg/ml (oil).........................X5630

2 – Injections: List of CodesSeptember 2009

inject list

17

Codes Codes

Spenduo – 50-2 mg/ml...............................................X5620Stadol – 2 mg/ml.........................................................X5796Stadol – 1 mg/ml.........................................................X5798Staphcillin – 4 gm vials (powder)................................X5710Staphcillin – 4 gm piggyback units (powder)....................................................................X6558Staphcillin – 4 gm vials (powder)................................X5712Staphcillin – 1 gm piggyback units (powder)....................................................................X5868Staphcillin – 1 gm vials (powder)................................X5714Stelazine – 2 mg/ml....................................................X6912Stemutrolin – 500 units/ml..........................................X5644Sterane – 25 mg/ml....................................................X6014Stilphostrol – 0.25 gm (as sodium salt)/ 5 ml ampuls..............................................................X7536Streptokinase-Streptodornase – 20,000/5,000 units....................................................X6920Streptomycin Sulfate....................Available free from PfizerStreptozocin – 1 gm vial.............................................X7574Strontium Sr-89 Chloride, Therapeutic – 1 mCi.........A9600Sublimaze – 0.5 mg/ml...............................................X6206Succinylcholine Chloride – 100 mg/ml.......................X6828Succinylcholine Chloride – 50 mg/ml.........................X6830Succinylcholine Chloride – 20 mg/ml.........................X5636Sucostrin – 100 mg/ml................................................X6828Sucostrin – 50 mg/ml..................................................X6830Sucostrin – 20 mg/ml..................................................X5636Supartz – 25 mg/2.5 ml..............................................X7486Supprelin LA Implant – 50mg......................................J9226Sus-Phrine – 1:200 suspension.................................X6166Synagis (RSV-IgIV) – 50 mg......................................90378Synkayvite – 37.5 mg/ml............................................X6532Synkayvite – 5 mg/ml.................................................X6534Synthroid – 500 mcg/ml..............................................X6456Syntocinon – 10 units/ml............................................X6666Synvisc – per dose.....................................................J7322Sytobex – 1,000 mcg/ml.............................................X5752

T

Talwin – 30 mg/ml.......................................................X6720Taractan – 12.5 mg/ml................................................X5934Taxotere – 20 mg.......................................................X7638Technetium Apcitide – 20 mCi...................................A9504

Technetium Bicisate – 25 mCi....................................A9557Technetium Disofenin – 15 mCi.................................A9510Technetium Exametazine – 25 mCi...........................A9521Technetium Fanolesomab – 25 mCi..........................A9566Technetium Labeled Red Blood Cells – 30 mCi......................................................................A9560Technetium Macroaggregated albumin – 10 mCI......................................................................A9540Technetium Mebrofenin – 15 mCi..............................A9537

Technetium Medronate – 30 mCi...............................A9503Technetium Mertiatide – 15 mCi.................................A9562Technetium Oxidronate – 30 mCi...............................A9561Technetium Pentetate – 25 mCi.................................A9539Technetium Pentetate (aerosol) – 75 mCi.................A9567Technetium Pertechnetate – 1 mCi............................A9512Technetium Pyrophosphate – 25 mCi........................A9538Technetium Sestamibi – 40 mCi................................A9500Technetium Sodium Gluceptate – 25 mCi.................A9550Techentium Succimer – 10 mCi.................................A9551Technetium Sulfur Colloid – 20 mCi...........................A9541Technetium Tetrofosmin – 40 mCi.............................A9502Teev – 90-4 mg/ml......................................................X5666Tega-Flex – 30 mg/ml.................................................X6216Temsirolimus – 1 mg...................................................J9330Tensilon – 10 mg/ml...................................................X6146Terbutaline Sulfate – 1 mg/ml.....................................X5776Terramycin – 50 mg/ml...............................................X6660Terramycin – 125 mg/ml.............................................X6658Terramycin – 250 mg/vial...........................................X6664Testa-C – 100 mg/ml..................................................X5618Testadiate-Depo – 50-2 mg/ml...................................X5620Testa-Estrac – 50-2 mg/ml.........................................X5620Testaqua – 100 mg/ml................................................X6326Testaqua – 50 mg/ml..................................................X5628Testate – 100 mg/ml...................................................X5626Testoject 50................................................................X5628Testone – 200 mg/ml..................................................X5634Testone L.A. – 100 mg/ml..........................................X5626Testosterone – 100 mg/ml..........................................X6326Testosterone – 50 mg/ml............................................X5628Testosterone – 25 mg/ml............................................X6942Testosterone Aqueous – 100 mg/ml..........................X6326Testosterone Aqueous – 50 mg/ml............................X5628Testosterone Aqueous – 25 mg/ml............................X6942Testosterone Cypionate – up to 100 mg.....................J1070Testosterone Cypionate – 1 cc, 200 mg.....................J1080Testosterone Cypionate and Estradiol Cypionate – 50-2 mg/ml............................X5620Testosterone Enanthate – 200 mg/ml........................X5634Testosterone Enanthate – 100 mg/ml........................X5626Testosterone Enanthate and Estradiol Valerate – 90-4 mg/ml...............................X5666Testosterone Propionate – 100 mg/ml.......................X6944Testostroval P.A. – 200 mg/ml...................................X5634Testradiol 90/4............................................................X5666Tetanus, diphtheria toxoids, and acellular pertussis vaccine [Tdap] for intramuscular use................................................90715Tetanus and diphtheria toxoids, adsorbed – for seven years of age and older..............................90718Tetanus Immune Globulin (human) – 250 unit....................................................90389Tetanus Toxoid, Adsorbed..........................................90703Tetracaine HCl – 1%..................................................X6778Tetracaine HCl – 0.3% w/6% Dextrose......................X6780Tetracaine HCl – 0.2% w/6% Dextrose......................X6782Thallium TI-201 Thallous Chloride – 1 mCi................A9505

2 – Injections: List of CodesMarch 2010

inject list

18

Codes Codes

Theelin Aqueous – 5 mg/ml........................................X6196Theelin Aqueous – 2 mg/ml........................................X6198Thiodyne – 50 mg/ml..................................................X5678Thiolate – 50 mg/ml....................................................X5678Thiopental Sodium – 10 gm........................................X6728Thiopental Sodium – 5 gm..........................................X6730Thiopental Sodium – 1 gm..........................................X6732Thiopental Sodium – 500 mg......................................X6734Thiopental Sodium – 400 mg......................................X6736Thiopental Sodium – 250 mg......................................X6738Thiosul – 50 mg/ml.....................................................X5678Thiotepa – 15 mg/vial.................................................X7576Thiothixene – 2 mg/ml................................................X6618Thorazine – 25 mg/ml.................................................X5918TH Sal – 50 mg/ml......................................................X5678Thyrotropin – 10 IU.....................................................X6968Thyrotropin alfa 0.9 mg/1.1 mg vial...........................J3240Thytropar – 10 IU........................................................X6968Ticar – 6 gm (powder) vials........................................X6970Ticar – 3 gm (powder) vials........................................X6972Ticar – 1 gm (powder) vials........................................X6974Ticarcillin Disodium – 6 gm (powder) vials..................................................X6970Ticarcillin Disodium – 3 gm (powder) vials..................................................X6972Ticarcillin Disodium – 1 gm (powder) vials..................................................X6974Tigecycline – 1 mg......................................................J3243Tinzaparin Sodium – 1000 IU.....................................X5509T-Ionate P.A. – 100 mg/ml..........................................X5618Tobramycin Sulfate – 40 mg/ml..................................X6620Tobramycin Sulfate – 10 mg/2 ml vial........................X6622Tofranil – 25 mg/ml.....................................................X6352Topotecan – 4 mg.......................................................J9350Totacillin-N – 2 gm (powder) piggyback units.........................................................X5576Totacillin-N – 2 gm (powder) vials..............................X5578Totacillin-N – 1 gm (powder) piggyback units.........................................................X5580Totacillin-N – 1 gm (powder) vials..............................X5582Totacillin-N – 500 mg (powder) piggyback units.........................................................X5584Totacillin-N – 500 mg (powder) vials..........................X5586Totacillin-N – 250 mg (powder) vials..........................X5588Totacillin-N – 125 mg (powder) vials..........................X5550Trastuzumab – 10 mg.................................................X7640Treprostinil – 1 mg......................................................J3285Triamcinolone – 40 mg/ml suspension.......................X5552Triamcinolone Acetate – 40 mg/ml suspension................................................X5880Triamcinolone Acetonide – preservative free, 1 mg.............................................J3300Triamcinolone Diacetate – 25 mg/ml suspension................................................X6976Triam-Forte – 40 mg/ml suspension...........................X5552Triethylenethiophosphoramide – 15 mg/vial.................................................................X7576

Trifluoperazine – 2 mg/ml...........................................X6912Triflupromazine HCl – 20 mg/ml.................................X6978Triflupromazine HCl – 10 mg/ml.................................X6980Trilafon – 5 mg/ml.......................................................X6740Trilone – 40 mg/ml suspension..................................X5552Trimethaphan Camsylate – 50 mg/ml........................X5668Triptorelin (Trelstar) – 3.75 mg...................................X7648Tristoject – 40 mg/ml suspension...............................X5552Trobicin – 400 mg (as HCl)/ml 2 gm vial................................................X6896Tubocurarine Chloride – 3 mg/ml...............................X6984Typhoid vaccine, Acetone killed, dried (AKD)............90693Typhoid vaccine, heat and phenol inactivated (H-P).......................................................90692Typhoid vaccine – live................................................90690Typhoid vaccine, Vi Capsular polysaccharide (ViCPs)............................................90691

U

Ultracaine – 2% w/1:100,000 Epinephrine...............................................................X6444Unclassified Drugs......................................................J3490Unipen – 2 gm (powder) vial......................................X6604Unipen – 1 gm (powder) vial......................................X6606Unipen – 500 mg vial..................................................X6610Unitensen Aqueous – 260 CSR/ml............................X5992Urea – 40 gm/150 ml..................................................X6996Ureaphil – 40 gm/150 ml.............................................X6996Urecholine – 5 mg/ml..................................................X5762

V

Valergen 40................................................................X6018Valergen 20 ...............................................................X5660Valergen 10 ...............................................................X5662Valertest No. 1 – 90-4 mg/ml......................................X5666Valium – 5 mg/ml........................................................X6064Vancocin – 500 mg (as HCl)/10 ml vial......................X6998Vancomycin – 500 mg (as HCl)/10 ml vial.................X6998Varicella Vaccine – .5 ml............................................90716Varidase for IM Use – 20,000-5,000 units..................X6920Vasopressin – 20 pressor units/ml.............................X6760Vasoxyl – 20 mg/ml 1 ml ampules..............................X6562Velban – 10 mg/10 ml vial..........................................X7578Velosef – 2 gm/100 ml infusion containers................X5904Velosef – 1 gm/vial.....................................................X5906Velosef – 500 mg/vial.................................................X5908Velosef – 250 mg/vial.................................................X5910Venofer – 100 mg.......................................................X7492


inject list

19

Codes Codes

Vepesid – 20 mg/ml....................................................X7542Verteporfin – 0.1 mg....................................................J3396Vespirin – 20 mg/ml....................................................X6978Vespirin – 10 mg/ml....................................................X6980V-Gan 50 ...................................................................X6236V-Gan 25....................................................................X6742Vibramycin I.V. – 200 mg (as Hyclate)/vial................X6122Vinblastine Sulfate (VLB) – 10 mg/10 ml vial.............X7578Vincristine Sulfate (VCR) – 5 mg

w/50 mg lactose per vial..........................................X7570Vincristine Sulfate (VCR) – 1 mg

w/10 mg lactose per vial..........................................X7572Vinorelbine Tartrate – 10 mg.......................................J9390Vistaril – 50 mg/ml......................................................X6336Vistaril – 25 mg/ml......................................................X7010Vitamin A – 50,000 IU/ml............................................X5654Vitamin B12 – 1,000 mcg/ml.......................................X5752Vitamin D – 500,000 IU D2/ml....................................X5802Vitamin D2 – 500,000 IU D2/ml..................................X5802Vitravene – 0.25 ml.....................................................X7470Vi-Twel – 1,000 mcg/ml..............................................X5752Vivitrol® – 1 mg...........................................................J2315

W

Wehdryl 50 – 50 mg/ml...............................................X5738Wehgen – 2 mg/ml......................................................X5756Win Rho SDF – 600 IU...............................................X7472Win Rho SDF – 1,500 IU............................................X7474Win Rho SDF – 5,000 IU............................................X7476Wyamine Sulfate – 30 mg/ml......................................X6550Wyamine Sulfate – 15 mg/ml......................................X6552Wycillin – 2,400,000 units/unit dose...........................X6714Wycillin – 1,200,000 units/unit dose...........................X6716Wycillin – 600,000 units/unit dose..............................X6136

X

Xenon Xe-133 Gas, Diagnostic – 10 mCi..................A9558Xolair – 5 mg...............................................................J2357X-Otag – 30 mg/ml.....................................................X6216Xylocaine HCl – 0.5%.................................................X6490Xylocaine HCl – 1.5%.................................................X6478Xylocaine HCl IM for cardiac arrythmias –

10% (100 mg/ml)......................................................X6464Xylocaine HCl I.V. for cardiac arrythmias –

2% (20 mg/ml).........................................................X6470Xylocaine HCl I.V. for cardiac arrythmias –

4% (40 mg/ml)..........................................................X6494Xylocaine HCl I.V. for cardiac arrythmias –

20% (200 mg/ml)......................................................X6462

Xylocaine HCl – 1.5% w/7.5% Dextrose....................X6480Xylocaine – 1.5% w/1:200,000 Epinephrine...............X6482Xylocaine HCl – 2% w/1:100,000 Epinephrine...........X6444Xylocaine HCl – 2% w/1:200,000 Epinephrine...........X6474Xylocaine HCl – 1% w/1:200,000 Epinephrine...........X6486Xylocaine HCl – 2% w/1:50,000 Epinephrine.............X6476Xylocaine HCl – 0.5% w/1:200,000 Epinephrine........X6492Xylocaine HCl – 1% w/1:100,000 Epinephrine...........X6488Xylocaine HCl – 5% w/7.5% Glucose........................X6466

Y

Yellow Fever Vaccine.................................................90717Yttrium Ibitumomab Tiuxetan – 40 mCi......................A9543

Z

Zemplar – 1 mcg.........................................................J2501Ziconotide – 1 mcg......................................................J2278Zipan 50......................................................................X6236Zipan 25......................................................................X6742Ziprasidone – 20 mg...................................................X7498Zoladex – 3.6 mg........................................................X7060Zoladex – 10.8 mg (depot).........................................X7061Zoledronic acid – 4 mg.............................................J3487Zoledronic acid – 1mg (Reclast).................................J3488Zostavax.....................................................................90736


Injections: List of Codes (inject list)

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