Form CMS-10709 Drug Survey

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Overview

PRA Disclosure
SurveyWorksheet

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Sheet 1: PRA Disclosure

Hospital Survey for Specified Covered Outpatient Drugs (SCODs)
(CMS-10709; OMB 0938-New)

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number.  The valid OMB control number for this mandatory information collection is 0938-XXXX (Expires XX/XX/XXXX).  The time required to complete this information collection is estimated to average 48 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

****CMS Disclosure****  Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact your local Medicare Administrative Contractor.

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Sheet 2: SurveyWorksheet

Step 1:

Please provide the information below for all hospitals that you are submitting this worksheet for. All fields are required for each hospital. This table will expand automatically if you need additional rows.

Hospital Name

Medicare Provider Number (CCN)

NPI

Tax ID Number

Contact Name

Contact Phone

Contact Email

Hospital Address

HCPCS code for each SCOD

Drug Name/Short Descriptor

Dose (as reflected in HCPCS code descriptor)

Q4 2018 Payment Rate (Obtain from OPPS Addendum B for Q4 2018)

Your Q4 2018 Avg. Price

Q1 2019 Payment Rate (Obtain from OPPS Addendum B for Q1 2019)

Your Q1 2019 Avg. Price

Example Hospital

########

########

########

John Doe

1-800-555-12345

[email protected]

123 Main St, Columbia, SC 29212

90371

Hep b ig im

1 ML

112.334

119.537

90375

Rabies ig im/sc

150 IU

334.987

307.024

90376

Rabies ig heat treated

150 IU

324.947

311.99

90378

Rsv mab im 50mg

50 MG EACH

1514.17

1205.05

90396

Varicella-zoster ig im

125 IU

1491.374

1541.495

90634

Hepa vacc ped/adol 3 dose

0.5 ML

N/A

N/A

28.474

90675

Rabies vaccine im

1 ML

291.435

289.976

90676

Rabies vaccine id

0.1 ML

196.54

130.01

A9513

Lutetium lu 177 dotatat ther

1 MCI

N/A

N/A

251.75

A9515

Choline c-11

PER STUDY DOSE

5700

N/A

N/A

A9517

I131 iodide cap, rx

1 MCI

19.98

20.76

A9530

I131 iodide sol, rx

1 MCI

11.88

13.57

A9543

Y90 ibritumomab, rx

UP TO 40 MCI

46661.64

47673.879

A9563

P32 na phosphate

1 MCI

256

730.03

A9586

Florbetapir f18

10 MCI

3023.16

3028.844

A9587

Gallium ga-68

0.1 MCI

66.741

66.7407

A9588

Fluciclovine f-18

1 MCI

389.55

389.55

A9600

Sr89 strontium

1 MCI

1502.356

1495.665

A9604

Sm 153 lexidronam

up to 150 MCI

14658.426

14650.22

A9606

Radium ra223 dichloride ther

1 MCI

136.61

136.694

C9014

Injection, cerliponase alfa

1 MG

95.4

N/A

N/A

C9015

C-1 esterase, haegarda

10 UNITS

9.667

N/A

N/A

C9016

Inj, triptorelin ext rel

3.75 MG

2826.667

N/A

N/A

C9024

Inj, daunorubicin-cytarabine

2.27 MG

186.704

N/A

N/A

C9028

Inj. inotuzumab ozogamicin

0.1 MG

2202.444

N/A

N/A

C9029

Injection, guselkumab

1 MG

101.865

N/A

N/A

C9030

Inj copanlisib

1 MG

77.902

N/A

N/A

C9031

Lutetium Lu 177 dotatate, tx

1 MCI

251.75

N/A

N/A

C9032

Voretigene neparvovec-rzyl

1 BILLION VECTOR GENOME

2963.289

N/A

N/A

C9033

Inj, akynzeo

0.25 MG

540.6

N/A

N/A

C9034

Injection, dexamethasone 9%

1 MCG

1.107

N/A

N/A

C9035

Injection, Aristada Initio

1 MG

N/A

N/A

2.8528

C9036

Injection, patisiran

0.1 MG

N/A

N/A

97.85

C9037

Injection, risperidone

0.5 MG

N/A

N/A

9.785

C9038

Inj mogamulizumab-kpkc

1 MG

N/A

N/A

195.185

C9039

Injection, plazomicin

5 MG

N/A

N/A

3.2445

C9132

Kcentra, per i.u.

1 IU

1.931

1.936

C9248

Inj, clevidipine butyrate

1 MG

N/A

N/A

2.783

C9250

Artiss fibrin sealant

2 ML

175.118

156.8418

C9257

Bevacizumab injection

0.25 MG

1.981

2.029

C9293

Injection, glucarpidase

10 UNITS

313.31

313.198

C9407

Iodine i-131 iobenguane, dx

1 MCI

N/A

N/A

311.06

C9408

Iodine i-131 iobenguane, tx

1 MCI

N/A

N/A

311.06

C9447

Inj, phenylephrine ketorolac

4 ML

473.24

473.244

C9460

Injection, cangrelor

1 MG

15.457

15.458

C9462

Injection, delafloxacin

1 MG

0.459

0.449

C9463

Injection, aprepitant

1 MG

2.104

N/A

N/A

C9464

Injection, rolapitant

0.5 MG

0.939

N/A

N/A

C9465

Injection, Durolane

PER DOSE

1033.5

N/A

N/A

C9466

Injection, benralizumab

1 MG

167.471

N/A

N/A

C9467

Inj rituximab hyaluronidase

10 MG

45.722

N/A

N/A

C9468

Inj, factor ix, Rebinyn

1 IU

3.883

N/A

N/A

C9482

Sotalol hydrochloride iv

1MG

9.985

9.9852

C9488

Conivaptan hcl

1 MG

31.097

32.067

C9492

Injection, durvalumab

10 MG

73.971

N/A

N/A

C9493

Injection, edaravone

1 MG

19.179

N/A

N/A

C9497

Loxapine, inhalation powder

10 MG

150.801

N/A

N/A

J0129

Abatacept injection

10 MG

52.929

51.614

J0135

Adalimumab injection

20 MG

1291.088

1291.088

J0178

Aflibercept injection

1 MG

967.327

963.537

J0180

Agalsidase beta injection

1 MG

175.621

178.166

J0185

Inj., aprepitant, 1 mg

1 MG

N/A

N/A

2.109

J0202

Injection, alemtuzumab

1 MG

1842.129

1882.06

J0207

Amifostine

500 MG

973.411

979.745

J0220

Alglucosidase alfa injection

10 MG

159.63

141.14

J0221

Lumizyme injection

10 MG

163.83

166.2

J0256

Alpha 1 proteinase inhibitor

10 MG

4.46

4.55

J0257

Glassia injection

10 MG

4.653

4.696

J0287

Amphotericin b lipid complex

10 MG

17.723

8.071

J0289

Amphotericin b liposome inj

10 MG

48.067

22.193

J0300

Amobarbital 125 mg inj

UP TO 125 MG

46.328

56.62

J0400

Aripiprazole injection

0.25 MG

0.757

N/A

N/A

J0401

Inj aripiprazole ext rel 1mg

1 MG

5.238

5.471

J0470

Dimecaprol injection

100 MG

54.421

N/A

N/A

J0475

Baclofen 10 mg injection

10 MG

176.022

169.748

J0476

Baclofen intrathecal trial

50 MCG

54.655

N/A

N/A

J0480

Basiliximab

20 MG

3686.128

3677.611

J0485

Belatacept injection

1 MG

3.807

3.792

J0490

Belimumab injection

10 MG

44.16

44.161

J0517

Inj., benralizumab, 1 mg

1 MG

N/A

N/A

167.04

J0558

Peng benzathine/procaine inj

100,000 UNITS

N/A

N/A

10.964

J0561

Penicillin g benzathine inj

100,000 UNITS

13.902

13.853

J0565

Inj, bezlotoxumab, 10 mg

10 MG

40.162

40.093

J0567

Inj., cerliponase alfa 1 mg

1 MG

N/A

N/A

93.617

J0570

Buprenorphine implant 74.2mg

74.2 MG

1260.234

1269.907

J0584

Injection, burosumab-twza 1m

1 MG

N/A

N/A

353.401

J0585

Injection,onabotulinumtoxina

1 UNIT

6.138

6.137

J0586

Abobotulinumtoxina

5 Unit

8.423

8.533

J0587

Inj, rimabotulinumtoxinb

100 UNITS

12.031

12.002

J0588

Incobotulinumtoxin a

1 UNIT

5.084

5.08

J0594

Busulfan injection

1 MG

10.373

10.821

J0596

Injection, ruconest

10 UNITS

27.651

27.463

J0597

C-1 esterase, berinert

10 UNITS

48.943

48.918

J0598

C-1 esterase, cinryze

10 UNITS

54.258

54.023

J0599

Inj., haegarda 10 units

10 UNITS

N/A

N/A

9.667

J0600

Edetate calcium disodium inj

1000 MG

5594.422

5594.422

J0606

Inj, etelcalcetide, 0.1 mg

0.1 MG

2.983

2.879

J0630

Calcitonin salmon injection

400 UNITS

2629.525

2651.097

J0637

Caspofungin acetate

5 MG

12.639

10.023

J0638

Canakinumab injection

1 MG

111.002

110.989

J0641

Levoleucovorin injection

0.5 MG

0.236

0.122

J0695

Inj ceftolozane tazobactam

75 MG (50 MG CFT/25 MG TAZ)

5.458

5.426

J0712

Ceftaroline fosamil inj

10 MG

2.892

2.907

J0714

Ceftazidime and avibactam

0.5 G/0.125 G

84.252

84.234

J0716

Centruroides immune f(ab)

UP TO 120MG

4592.8

4592.8

J0717

Certolizumab pegol inj 1mg

1 MG

8.135

7.889

J0725

Chorionic gonadotropin/1000u

1000 UNITS

N/A

N/A

22.6

J0740

Cidofovir injection

375 MG

478.071

522.744

J0775

Collagenase, clost hist inj

0.01 MG

45.05

45.063

J0795

Corticorelin ovine triflutal

1 MCG

8.593

8.928

J0800

Corticotropin injection

40 UNITS

3984.76

N/A

N/A

J0840

Crotalidae poly immune fab

UP TO 1 GM

3250.521

3291.265

J0841

Inj crotalidae im f(ab')2 eq

120 MG

N/A

N/A

1256.6

J0850

Cytomegalovirus imm iv /vial

PER VIAL

1129.154

1129.154

J0875

Injection, dalbavancin

5 MG

14.35

13.553

J0878

Daptomycin injection

1 MG

0.323

0.414

J0881

Darbepoetin alfa, non-esrd

1 MCG

3.773

3.832

J0882

Darbepoetin alfa, esrd use

1 MCG

3.773

3.832

J0883

Argatroban nonesrd use 1mg

1 MG

1.228

1.023

J0884

Argatroban esrd dialysis 1mg

1 MG

1.228

1.023

J0885

Epoetin alfa, non-esrd

1000 UNITS

12.271

11.951

J0888

Epoetin beta non esrd

1 MCG

1.739

N/A

N/A

J0894

Decitabine injection

1 MG

14.065

12.631

J0897

Denosumab injection

1 MG

18.58

18.611

J1095

Injection, dexamethasone 9%

1 MCG

N/A

N/A

1.1072

J1110

Inj dihydroergotamine mesylt

1 MG

73.467

N/A

N/A

J1130

Inj diclofenac sodium 0.5mg

0.5 MG

0.223

N/A

N/A

J1162

Digoxin immune fab (ovine)

PER VIAL

3688.292

3687.74

J1190

Dexrazoxane hcl injection

250 MG

229.926

220.967

J1212

Dimethyl sulfoxide 50% 50 ml

50 ML

535.987

541.606

J1290

Ecallantide injection

1 MG

477.96

478.642

J1300

Eculizumab injection

10 MG

230.479

230.479

J1301

Injection, edaravone, 1 mg

1 MG

N/A

N/A

19.161

J1322

Elosulfase alfa, injection

1 MG

236.628

236.955

J1327

Eptifibatide injection

5 MG

16.281

15.266

J1364

Erythro lactobionate /500 mg

500 MG

78.867

78.8672

J1410

Inj estrogen conjugate 25 mg

25 MG

308.631

308.907

J1428

Inj, eteplirsen, 10 mg

10 MG

168.121

168.007

J1430

Ethanolamine oleate 100 mg

100 MG

444.099

444.099

J1438

Etanercept injection

25 MG

645.54

645.54

J1439

Inj ferric carboxymaltos 1mg

1 MG

1.06

1.084

J1442

Inj filgrastim excl biosimil

1 MCG

1.016

1.004

J1447

Inj tbo filgrastim 1 microg

1 MCG

0.579

0.582

J1451

Fomepizole, 15 mg

15 MG

7.407

8.555

J1453

Fosaprepitant injection

1 MG

2.188

2.104

J1454

Inj fosnetupitant, palonoset

0.25 MG

N/A

N/A

529.523

J1455

Foscarnet sodium injection

1000 MG

82.268

82.2678

J1458

Galsulfase injection

1 MG

389.951

390.464

J1459

Inj ivig privigen 500 mg

500 MG

39.633

40.318

J1460

Gamma globulin 1 cc inj

1 CC

38.048

39.972

J1555

Inj cuvitru, 100 mg

100 MG

13.397

13.605

J1556

Inj, imm glob bivigam, 500mg

500 MG

70.516

70.516

J1557

Gammaplex injection

500 MG

52.063

45.89

J1559

Hizentra injection

100 MG

9.86

10.112

J1560

Gamma globulin > 10 cc inj

10 CC

380.48

399.717

J1561

Gamunex-c/gammaked

500 MG

39.492

40.114

J1566

Immune globulin, powder

500 MG

37.945

43.11

J1568

Octagam injection

500 MG

36.72

35.471

J1569

Gammagard liquid injection

500 MG

43.14

42.227

J1571

Hepagam b im injection

0.5 ML

64.218

64.336

J1572

Flebogamma injection

500 MG

35.067

34.397

J1573

Hepagam b intravenous, inj

0.5 ML

64.218

64.336

J1575

Hyqvia 100mg immuneglobulin

100 MG

14.125

14.178

J1595

Injection glatiramer acetate

20 MG

201.168

194.569

J1602

Golimumab for iv use 1mg

1 MG

24.005

23.332

J1610

Glucagon hydrochloride/1 mg

1 MG

214.385

219.916

J1627

Inj, granisetron, xr, 0.1 mg

0.1 MG

3.576

3.19

J1628

Inj., guselkumab, 1 mg

1 MG

N/A

N/A

97.917

J1640

Hemin, 1 mg

1 MG

23.028

22.978

J1670

Tetanus immune globulin inj

250 UNITS

255.699

418.609

J1726

Makena, 10 mg

10 MG

27.928

24.56

J1740

Ibandronate sodium injection

1 MG

56.238

55.441

J1742

Ibutilide fumarate injection

1 MG

240.758

235.477

J1743

Idursulfase injection

1 MG

536.557

542.917

J1744

Icatibant injection

1 MG

359.004

363.391

J1745

Infliximab not biosimil 10mg

10 MG

78.833

76.649

J1746

Inj., ibalizumab-uiyk, 10 mg

10 MG

N/A

N/A

58.642

J1750

Inj iron dextran

50 MG

14.056

13.623

J1786

Imuglucerase injection

10 UNITS

41.451

42.121

J1826

Interferon beta-1a inj

30 MCG

604.4

2785.97

J1830

Interferon beta-1b / .25 mg

0.25 MG

379.627

370.819

J1833

Injection, isavuconazonium

1 MG

0.848

0.745

J1930

Lanreotide injection

1 MG

58.843

58.771

J1931

Laronidase injection

0.1 MG

30.784

31.217

J1942

Aripiprazole lauroxil 1mg

1 MG

2.439

2.567

J1950

Leuprolide acetate /3.75 mg

3.75 MG

1193.665

1188.987

J2062

Loxapine for inhalation 1 mg

1 MG

N/A

N/A

14.708

J2182

Injection, mepolizumab, 1mg

1 MG

29.584

29.502

J2186

Inj., meropenem, vaborbactam

10 MG/10MG (20MG)

N/A

N/A

1.66

J2265

Minocycline hydrochloride

1 MG

1.571

1.647

J2278

Ziconotide injection

1 MCG

7.587

7.729

J2315

Naltrexone, depot form

1 MG

3.255

3.248

J2320

Nandrolone decanoate 50 mg

UP TO 50 MG

72.58

21.69

J2323

Natalizumab injection

1 MG

19.828

19.731

J2325

Nesiritide injection

0.1 MG

73.338

74.8014

J2326

Inj, nusinersen, 0.1mg

0.1 MG

1101.873

1101.724

J2350

Injection, ocrelizumab, 1 mg

1 MG

57.344

57.371

J2353

Octreotide injection, depot

1 MG

198.51

197.883

J2355

Oprelvekin injection

5 MG

426.915

163.98

J2357

Omalizumab injection

5 MG

37.065

37.049

J2407

Injection, oritavancin

10 MG

23.081

23.657

J2425

Palifermin injection

50 MCG

20.29

20.22

J2426

Paliperidone palmitate inj

1 MG

10.939

10.942

J2469

Palonosetron hcl

25 MCG

17.141

14.946

J2502

Inj, pasireotide long acting

1 MG

289.623

290.276

J2503

Pegaptanib sodium injection

0.3 MG

713.858

N/A

N/A

J2504

Pegademase bovine, 25 iu

25 IU

367.961

367.961

J2505

Injection, pegfilgrastim 6mg

6 MG

4687.714

4681.806

J2507

Pegloticase injection

1 MG

2334.59

2361.045

J2515

Pentobarbital sodium inj

50 MG

47.076

48.29

J2547

Injection, peramivir

1 MG

1.622

1.614

J2562

Plerixafor injection

1 MG

330.412

330.475

J2597

Inj desmopressin acetate

1 MCG

12.604

12.46

J2724

Protein c concentrate

10 UNITS

15.151

15.133

J2760

Phentolaine mesylate inj

UP TO 5 MG

392.842

379.639

J2770

Quinupristin/dalfopristin

500 MG

418.374

417.761

J2778

Ranibizumab injection

0.1 MG

373.364

363.979

J2783

Rasburicase

0.5 MG

278.147

279.818

J2786

Injection, reslizumab, 1mg

1 MG

9.297

9.338

J2792

Rho(d) immune globulin h, sd

100 IU

27.018

27.779

J2793

Rilonacept injection

1 MG

24.091

N/A

N/A

J2794

Risperidone, long acting

0.5 MG

9.409

9.41

J2796

Romiplostim injection

10 MCG

71.399

71.605

J2797

Inj., rolapitant, 0.5 mg

0.5 MG

N/A

N/A

0.939

J2820

Sargramostim injection

50 MCG

37.606

38.961

J2840

Inj sebelipase alfa 1 mg

1 MG

541.13

541.13

J2850

Inj secretin synthetic human

1 MCG

34.781

34.7812

J2860

Injection, siltuximab

10 MG

95.351

95.378

J2941

Somatropin injection

1 MG

74.65

N/A

N/A

J2993

Reteplase injection

18.1 MG

2301.91

504.98

J2997

Alteplase recombinant

1 MG

87.777

87.749

J3060

Inj, taliglucerase alfa 10 u

10 units

40.386

40.335

J3070

Pentazocine injection

30 MG

108.385

N/A

N/A

J3090

Inj tedizolid phosphate

1 MG

1.426

1.423

J3095

Telavancin injection

10 MG

5.468

5.554

J3101

Tenecteplase injection

1 MG

121.756

121.813

J3145

Testosterone undecanoate 1mg

1 MG

1.363

1.361

J3240

Thyrotropin injection

0.9 MG

1624.454

1653.589

J3243

Tigecycline injection

1 MG

2.059

1.874

J3246

Tirofiban hcl

0.25 MG

8.259

7.721

J3262

Tocilizumab injection

1 MG

4.734

4.93

J3285

Treprostinil injection

1 MG

66.136

66.125

J3300

Triamcinolone a inj prs-free

1 MG

3.857

3.855

J3304

Inj triamcinolone ace xr 1mg

1 MG

N/A

N/A

18.881

J3315

Triptorelin pamoate

3.75 MG

267.382

244.495

J3316

Inj., triptorelin xr 3.75 mg

3.75 MG

N/A

N/A

2875.187

J3357

Ustekinumab sub cu inj, 1 mg

1 MG

191.028

184.046

J3358

Ustekinumab, iv inject, 1 mg

1 MG

12.28

12.19

J3380

Injection, vedolizumab

1 MG

19.581

20.04

J3385

Velaglucerase alfa

100 UNITS

345.394

345.622

J3396

Verteporfin injection

0.1 MG

10.949

10.982

J3397

Inj., vestronidase alfa-vjbk

1 MG

N/A

N/A

218.767

J3398

Inj luxturna 1 billion vec g

1 BILLION VECTOR GENOMES

N/A

N/A

2941.5

J3465

Injection, voriconazole

10 MG

1.902

N/A

N/A

J7170

Inj., emicizumab-kxwh 0.5 mg

0.5 MG

N/A

N/A

48.598

J7175

Inj, factor x, (human), 1iu

1 IU

7.169

7.174

J7177

Inj., fibryga, 1 mg

1 MG

N/A

N/A

1.067

J7178

Human fibrinogen conc inj

1 MG

1.164

1.167

J7179

Vonvendi inj 1 iu vwf:rco

1 I.U. VWF:RCO

2.015

1.955

J7180

Factor xiii anti-hem factor

1 IU

8.228

8.213

J7181

Factor xiii recomb a-subunit

1 IU

14.909

14.82

J7182

Factor viii recomb novoeight

1 IU

1.34

1.331

J7183

Wilate injection

1 I.U. VWF:RCO

1.009

1.024

J7185

Xyntha inj

1 IU

1.222

1.218

J7186

Antihemophilic viii/vwf comp

PER FACTOR VIII IU

0.992

0.997

J7187

Humate-p, inj

1 IU

1.123

1.129

J7188

Factor viii recomb obizur

1 IU

2.848

3.051

J7189

Factor viia

1 MCG

2.062

2.08

J7190

Factor viii

1 IU

1.07

1.08

J7192

Factor viii recombinant nos

1 IU

1.326

1.301

J7193

Factor ix non-recombinant

1 IU

1.119

1.142

J7194

Factor ix complex

1 IU

1.415

1.426

J7195

Factor ix recombinant nos

1 IU

1.505

1.503

J7196

Antithrombin recombinant

50 IU

N/A

N/A

103.35

J7197

Antithrombin iii injection

1 IU

3.493

3.497

J7198

Anti-inhibitor

1 IU

2.082

1.998

J7200

Factor ix recombinan rixubis

1 IU

1.304

1.309

J7201

Factor ix alprolix recomb

1 IU

2.985

3.002

J7202

Factor ix idelvion inj

1 IU

4.28

4.312

J7203

Factor ix recomb gly rebinyn

1 IU

N/A

N/A

3.65

J7205

Factor viii fc fusion recomb

1 IU

2.012

2.012

J7207

Factor viii pegylated recomb

1 IU

1.717

1.691

J7209

Factor viii nuwiq recomb 1iu

1 IU

1.416

1.342

J7210

Inj, afstyla, 1 i.u.

1 IU

1.36

1.36

J7211

Inj, kovaltry, 1 i.u.

1 IU

1.264

1.265

J7308

Aminolevulinic acid hcl top

354 MG

404.591

404.591

J7311

Fluocinolone acetonide implt

0.59 MG

20130.5

20142.37

J7312

Dexamethasone intra implant

0.1 MG

200.167

200.095

J7313

Fluocinol acet intravit imp

0.01 MG

490.329

490.661

J7316

Inj, ocriplasmin, 0.125 mg

0.125 MG

836.337

1046.927

J7318

Inj, durolane 1 mg

1 MG

N/A

N/A

17.225

J7320

Genvisc 850, inj, 1mg

1 MG

10.6

7.1953

J7321

Hyalgan supartz visco-3 dose

PER DOSE

85.304

79.912

J7322

Hymovis injection 1 mg

1 MG

19.257

19.2567

J7323

Euflexxa inj per dose

PER DOSE

141.471

141.025

J7324

Orthovisc inj per dose

PER DOSE

147.787

146.91

J7325

Synvisc or synvisc-one

1 MG

11.826

11.863

J7326

Gel-one

PER DOSE

537.361

1057.88

J7327

Monovisc inj per dose

PER DOSE

779.346

791.241

J7328

Gelsyn-3 injection 0.1 mg

0.1 MG

2.177

2.1768

J7329

Inj, trivisc 1 mg

1 MG

N/A

N/A

6.9916

J7336

Capsaicin 8% patch

1 SQ CM

3.159

3.146

J7340

Carbidopa levodopa ent 100ml

100 ML

2.142

N/A

N/A

J7342

Ciprofloxacin otic susp 6 mg

6 MG

29.976

29.966

J7345

Aminolevulinic acid, 10% gel

10 MG

1.384

1.371

J7501

Azathioprine parenteral

100 MG

229.356

238.893

J7503

Tacrol envarsus ex rel oral

0.25 MG

1.26

N/A

N/A

J7504

Lymphocyte immune globulin

250 MG

2081.222

2066.117

J7505

Monoclonal antibodies

5 MG

6.8

N/A

N/A

J7511

Antithymocyte globuln rabbit

25 MG

751.25

731.324

J7525

Tacrolimus injection

5 MG

205.624

206.014

J8501

Oral aprepitant

5 MG

6.716

N/A

N/A

J8560

Etoposide oral 50 mg

50 MG

75.56

75.761

J8562

Oral fludarabine phosphate

10 MG

N/A

N/A

81.42

J8600

Melphalan oral 2 mg

2 MG

N/A

N/A

11.9996

J8655

Netupitant palonosetron oral

0.5 MG

301.941

282.827

J8670

Rolapitant, oral, 1mg

1 MG

2.212

1.307

J8705

Topotecan oral

0.25 mg

103.648

N/A

N/A

J9015

Aldesleukin injection

1 EA

4138.145

4138.1446

J9017

Arsenic trioxide injection

1 MG

77.034

76.91

J9019

Erwinaze injection

1,000 IU

414.825

414.824

J9022

Inj, atezolizumab,10 mg

10mg

76.912

77.759

J9023

Injection, avelumab, 10 mg

10 MG

81.82

81.808

J9025

Azacitidine injection

1 MG

1.47

1.309

J9027

Clofarabine injection

1 MG

111.285

94.928

J9031

Bcg live intravesical vac

1 EA

140.618

140.257

J9032

Injection, belinostat, 10mg

10 MG

37.74

38.24

J9033

Inj., treanda 1 mg

1 MG

30.576

30.268

J9034

Inj., bendeka 1 mg

1 MG

23.84

23.831

J9035

Bevacizumab injection

10 MG

79.252

81.179

J9039

Injection, blinatumomab

1 MCG

110.366

110.153

J9041

Bortezomib injection

0.1 MG

45.554

45.614

J9042

Brentuximab vedotin inj

1 MG

150.484

156.722

J9043

Cabazitaxel injection

1 MG

167.99

168.312

J9044

Inj, bortezomib, nos, 0.1 mg

0.1 MG

N/A

N/A

35.667

J9047

Injection, carfilzomib, 1 mg

1 MG

36.317

36.3

J9050

Carmustine injection

100 MG

4051.503

4052.346

J9055

Cetuximab injection

10 MG

60.633

60.573

J9057

Inj., copanlisib, 1 mg

1 MG

N/A

N/A

77.463

J9065

Inj cladribine per 1 mg

1 MG

22.641

21.876

J9070

Cyclophosphamide 100 mg inj

100 MG

41.612

37.822

J9098

Cytarabine liposome inj

10 MG

628.368

628.368

J9120

Dactinomycin injection

0.5 MG

1427.666

1455.383

J9145

Injection, daratumumab 10 mg

10 MG

52.407

52.304

J9150

Daunorubicin injection

10 MG

50.659

48.173

J9151

Daunorubicin citrate inj

10 MG

N/A

N/A

0.32

J9153

Inj daunorubicin, cytarabine

1 MG/2.27 MG

N/A

N/A

190.317

J9155

Degarelix injection

1 MG

3.716

3.804

J9171

Docetaxel injection

1 MG

1.509

1.345

J9173

Inj., durvalumab, 10 mg

10 MG

N/A

N/A

73.852

J9176

Injection, elotuzumab, 1mg

1 MG

6.415

6.404

J9179

Eribulin mesylate injection

0.1 MG

114.337

115.309

J9185

Fludarabine phosphate inj

50 MG

59.936

N/A

N/A

J9202

Goserelin acetate implant

3.6 MG

509.022

501.205

J9203

Gemtuzumab ozogamicin 0.1 mg

0.1 MG

193.156

194.013

J9205

Inj irinotecan liposome 1 mg

1 MG

45.531

45.649

J9207

Ixabepilone injection

1 MG

70.988

76.895

J9211

Idarubicin hcl injection

5 MG

34.26

N/A

N/A

J9213

Interferon alfa-2a inj

3 MIL UNITS

N/A

N/A

169.33

J9214

Interferon alfa-2b inj

1 MIL UNITS

34.146

34.032

J9217

Leuprolide acetate suspnsion

7.5 MG

228.414

236.154

J9218

Leuprolide acetate injeciton

1 MG

27.169

N/A

N/A

J9225

Vantas implant

50 MG

3610.321

3659.725

J9226

Supprelin la implant

50 MG

31835.045

31864.232

J9228

Ipilimumab injection

1 MG

150.872

150.903

J9229

Inj inotuzumab ozogam 0.1 mg

0.1 MG

N/A

N/A

2208.268

J9230

Mechlorethamine hcl inj

10 MG

321.723

320.086

J9245

Inj melphalan hydrochl 50 mg

50 MG

814.804

804.634

J9261

Nelarabine injection

50 MG

152.214

152.023

J9262

Inj, omacetaxine mep, 0.01mg

0.01 MG

2.976

2.975

J9264

Paclitaxel protein bound

1 MG

11.6

11.866

J9266

Pegaspargase injection

1 EA

15028.71

15061.171

J9268

Pentostatin injection

10 MG

2096.286

2017.332

J9270

Plicamycin (mithramycin) inj

2.5 MG

N/A

N/A

6.12

J9271

Inj pembrolizumab

1 MG

49.351

48.987

J9280

Mitomycin injection

5 MG

134.247

125.073

J9285

Inj, olaratumab, 10 mg

10 MG

51.039

51.039

J9293

Mitoxantrone hydrochl / 5 mg

5 MG

27.359

27.582

J9295

Injection, necitumumab, 1 mg

1 MG

5.572

5.608

J9299

Injection, nivolumab

1 MG

27.541

27.498

J9301

Obinutuzumab inj

10 MG

62.633

64.62

J9302

Ofatumumab injection

10 MG

58.549

58.493

J9303

Panitumumab injection

10 MG

114.375

114.701

J9305

Pemetrexed injection

10 MG

68.217

68.107

J9306

Injection, pertuzumab, 1 mg

1 MG

11.865

12.2

J9307

Pralatrexate injection

1 MG

271.611

276.233

J9308

Injection, ramucirumab

5 MG

57.676

57.624

J9310

Rituximab injection

100 MG

919.854

N/A

N/A

J9311

Inj rituximab, hyaluronidase

10 MG (rituximab)

N/A

N/A

46.636

J9312

Inj., rituximab, 10 mg

10 MG

N/A

N/A

95.397

J9315

Romidepsin injection

1 MG

322.58

316.784

J9320

Streptozocin injection

1 GM

348.706

346.377

J9325

Inj talimogene laherparepvec

1 MILLION PFU

49.994

50.047

J9328

Temozolomide injection

1 MG

10.553

10.461

J9330

Temsirolimus injection

1 MG

73.753

65.555

J9340

Thiotepa injection

15 MG

741.578

761.588

J9352

Injection trabectedin 0.1mg

0.1 MG

300.674

300.63

J9354

Inj, ado-trastuzumab emt 1mg

1 MG

30.778

31.218

J9355

Trastuzumab injection

10 MG

104.123

106.995

J9357

Valrubicin injection

200 MG

1328.667

1331.12

J9371

Inj, vincristine sul lip 1mg

1 MG

2916.624

2916.624

J9395

Injection, fulvestrant

25 MG

97.936

97.492

J9400

Inj, ziv-aflibercept, 1mg

1 MG

8.321

8.084

J9600

Porfimer sodium injection

75 MG

21219.568

21219.568

P9041

Albumin (human),5%, 50ml

50 ML

10.49

10.49

P9045

Albumin (human), 5%, 250 ml

250 ML

52.45

52.45

P9046

Albumin (human), 25%, 20 ml

20 ML

20.98

20.98

P9047

Albumin (human), 25%, 50ml

50 ML

52.45

52.45

Q0138

Ferumoxytol, non-esrd

1 MG

0.98

1.006

Q0139

Ferumoxytol, esrd use

1 MG

0.98

1.006

Q2009

Fosphenytoin inj pe

50 MG PHENYTOIN EQUIVALENT

4.401

N/A

N/A

Q2017

Teniposide, 50 mg

50 MG

2575.153

2583.973

Q2026

Radiesse injection

0.1 ML

N/A

N/A

473.9

Q2028

Inj, sculptra, 0.5mg

0.1 ML

N/A

N/A

3.28

Q2040

Tisagenlecleucel car-pos t

PER INFUSION

500901.94

N/A

N/A

Q2041

Axicabtagene ciloleucel car+

PER THERAPEUTIC DOSE

395380

395380

Q2042

Tisagenlecleucel car-pos t

PER THERAPEUTIC DOSE

N/A

N/A

439388.306

Q2043

Sipuleucel-t auto cd54+

PER INFUSION

43419.425

42616.294

Q2049

Imported lipodox inj

10 MG

N/A

N/A

470.4

Q2050

Doxorubicin inj 10mg

10 MG

383.566

381.334

Q3027

Inj beta interferon im 1 mcg

1 MCG

54.113

53.625

Q4172

Puraply or puraply am

1 SQ CM

120.78

N/A

N/A

Q5101

Injection, zarxio

1 MCG

0.64

0.637

Q5103

Injection, inflectra

10 MG

61.363

57.276

Q5104

Injection, renflexis

10 MG

64.382

61.903

Q5105

Inj retacrit esrd on dialysi

100 UNITS

1.169

1.1361

Q5106

Inj retacrit non-esrd use

1000 UNITS

11.692

11.3609

Q5108

Injection, fulphila

0.5 MG

368.792

358.3542

Q5110

Nivestym

1 MCG

N/A

N/A

0.7519

Q5111

Injection, udenyca 0.5 mg

0.5 MG

N/A

N/A

358.354

Q9950

Inj sulf hexa lipid microsph

1 ML

21.25

21.246

Q9968

Visualization adjunct

1 MG

3.859

4.266

Q9969

Non-heu tc-99m add-on/dose

PER STUDY DOSE

10

10

Q9982

Flutemetamol f18 diagnostic

UP TO 5 MCI

3498

N/A

N/A

Q9983

Florbetaben f18 diagnostic

UP TO 8 MCI

2968

N/A

N/A

Q9991

Buprenorph xr 100 mg or less

LESS THAN OR EQUAL TO 100 MG

1674.8

1674.8

Q9992

Buprenorphine xr over 100 mg

GREATER THAN 100 MG

1674.8

1674.8

Q9993

Inj., triamcinolone ext rel

1 MG

18.881

N/A

N/A

Q9995

inj. emicizumab-kxwh, 0.5 mg

0.5 MG

48.86

N/A

N/A