HCPCS Code |
Description |
HCPCS Code Dosage |
Payment Limit |
90371 |
Hep b ig, m |
1ml |
$122.595 |
90385 |
Rh ig, minidose, im |
50 mcg |
$27.136 |
J2788 |
Rho d immune globulin 50 mcg |
50 mcg |
$26.732 |
J2790 |
Rho d immune globulin inj |
300 mcg |
$83.262 |
J2792 |
Rho(D) immune globulin h, sd |
100iu |
$16.833 |
J1756 |
Venofer |
|
|
J2916 |
Ferrlecit |
|
|
J7189 |
Factor VIIa recombinant |
1 mcg |
$1.256 |
J7190 |
Factor VIII |
1iu |
$0.851 |
J7191 |
Factor VIII (porcine) |
1iu |
$1.860 |
J7192 |
Factor VIII recombinant |
1iu |
$1.082 |
J7193 |
Factor IX non-recombinant |
1iu |
$0.905 |
J7194 |
Factor IX complex |
1iu |
$0.817 |
J7195 |
Factor IX recombinant |
1iu |
$1.073 |
J7197 |
Antithrombin III injection |
1iu |
$2.284 |
J7187 |
Inj von Willebrand Factor Complex |
1iu |
$0.881 |
J7198 |
Anti-Inhibitor |
1iu |
$1.481 |
P9041 |
Albumin (human), 5% |
50mL |
$27.322 |
P9043 |
Plasma Protein Fraction, 5% |
50mL |
$22.344 |
P9045 |
Albumin (human), 5% |
250mL |
$54.682 |
P9046 |
Albumin (human) 25% |
20mL |
$25.593 |
P9047 |
Albumin (human) 25% |
50mL |
$52.196 |
P9048 |
Plasma Protein Fraction 5% |
250mL |
$41.211 |
J1568 |
Octagam Injection |
500mg |
$36.786 |
J1569 |
Gammagard Liquid Injection |
500mg |
$35.079 |
J2791 |
Rhophylac Injection |
100 iu |
$5.237 |
J1571 |
Hepagam B IM Injection |
0.5mL |
$44.085 |
J1572 |
Flebogamma Injection |
500mg |
$35.617 |
J1459 |
Privigen Injection |
500mg |
$35.189 |
J1561 |
Gamunex Injection |
500mg |
$36.203 |
J1566 |
IVIG lyophiized |
500mg |
$31.018 |
J1460 |
IVIG lyophiizedGamma globulin 1CC inj |
1CC |
$12.814 |
J1470 |
IVIG lyophiizedGamma globulin 2CC inj |
2CC |
$25.629 |
J1480 |
IVIG lyophiizedGamma globulin 3CC inj |
3CC |
$38.422 |
J1490 |
IVIG lyophiizedGamma globulin 4CC inj |
4CC |
$51.255 |
J1500 |
IVIG lyophiizedGamma globulin 5CC inj |
5CC |
$64.069 |
J1510 |
IVIG lyophiizedGamma globulin 6CC inj |
6CC |
$76.959 |
J1520 |
IVIG lyophiizedGamma globulin 7CC inj |
7CC |
$89.607 |
J1530 |
IVIG lyophiizedGamma globulin 8CC inj |
8CC |
$102.510 |
J1540 |
IVIG lyophiizedGamma globulin 9CC inj |
9CC |
$115.439 |
J1550 |
IVIG lyophiizedGamma globulin 10CC inj |
10CC |
$128.137 |
J1560 |
IVIG lyophiizedGamma globulin >10CC inj |
>10CC |
$128.137 |
J1562 |
Vivaglobulin, injection |
100mg |
$7.002 |
J1566 |
immune globulin. powder |
500mg |
$31.018 |
J1640 |
Hemin, 1mg |
1mg |
$7.876 |
90375 |
Rabies ig, im / sc |
150iu |
$147.265 |
90376 |
Rabies ig, heat treated |
150iu |
$112.053 |
90675 |
Rabies Vaccine, im |
1mL |
$168.902 |
J0850 |
Cytomegalovirus imm IV / vial |
per vial |
$878.825 |
J9045 |
Cytomegalovirus imm IV / vial |
50mg |
$5.167 |
J9100 |
Cytarabine hcl 100MG inj |
100mg |
$0.772 |
J9110 |
Cytarabine hcl 500MG inj |
500mg |
$3.859 |
J9130 |
Dacarbazine 100 MG inj |
100mg |
$4.109 |
J9140 |
Dacarbazine 200 MG inj |
200mg |
$8.107 |
J9206 |
Irinotecan injection |
20mg |
$18.296 |
J9250 |
Methotrexate sodium inj |
5mg |
$0.220 |
J9260 |
Methotrexate sodium inj |
50mg |
$2.201 |
J9264 |
Paclitaxel protein bound |
1mg |
$9.107 |
J9265 |
Paclitaxel injection |
30mg |
$8.718 |
J9293 |
Mitoxantron hydrochl / 5 MG |
5mg |
$81.178 |
