-
ProcCode NDC Description Facility Non-Facility
J0129 Abatacept 10 mg, injection (Orencia) $18.73 $18.73J0586
AbobotulinumtoxinA, 5 units (Dysport) $7.57 $7.57J0178 Aflibercept,
1 mg, injection (Eylea) $982.43 $982.43J0202 Alemtuzumab, 1 mg
(Lemtrada) $1,831.01 $1,831.01J0221 Alglucosidase alfa, 10 mg,
injection (Lumizyme) $148.61 $148.61J7308 Aminolevulinic acid HCI
for topical admin. 20% single unit dosage form (354 mg)
(Levulan) (Kerastick)$109.98 $109.98
J7196 Antithrombin (recombinant), 50 IU (ATryn) $105.51
$105.51J3590 Asfotase alfa 1 mg (Strensiq) $75.60 $75.60J9999
Avelumab injection, 1 mg (Bavencio) $8.12 $8.12J0485 Belatacept, 1
mg, injection (Nulojix) $3.81 $3.81J0490 Belimumab, 10 mg,
injection (Benlysta) $38.49 $38.49J0179 Brolucizumab-dbll injection
1 mg (Beovu) $333.46 $333.46J0597 C1 Esterase Inhibitor (human), 10
units (Berinert) $27.59 $27.59J0598 C1 esterase inhibitor (human),
10 units, injection (Cinryze) $43.64 $43.64J0638 Canakinumab, 1 mg
vial (Ilaris) $89.35 $89.35J0716 Centruriodes Immune F(ab), 120 mg
(Anascorp) $3,945.28 $3,945.28J3590 Cerliponase alfa injection 1
kit (Brineura) $29,160.00 $29,160.00J0717 Certolizumab pegol, 1 mg,
injection (Cimzia) $5.45 $5.45J0775 Collagenase clostridium
histolyticum, 0.01 mg (Xiaflex) $37.59 $37.59J0791
Crizanlizumab-tmca injection 5 mg (Adakveo) $122.44 $122.44J0897
Denosumab, 1 mg (Xgeva) (Prolia) $14.46 $14.46J1300 Eculizumab, 10
mg, injection (Soliris) $176.76 $176.76J9358 fam-trastuzumab
deruxtecan-nxki for injection 1 mg (Enhertu) $24.19 $24.19J1458
Galsulfase injection for intravenous use 1 mg (Naglazyme) $399.53
$399.53J1602 Golimumab Hydrochloride 1 mg (Simponi) $25.82
$25.82J7178 Human fibrinogen concentrate, 1 mg, injection (RiaSTAP)
$0.98 $0.98J3590 Human Topical Protein, 1 IU (Recothrom) $0.02
$0.02J1744 Icatibant acetate, 1 mg (Firazyr) $152.40 $152.40J3590
Idarucizumab injection 2.5 g/50 ml (Praxbind) $1,890.00
$1,890.00J3590 Immune Globulin Subcutaneous, 20% solution 100 mg
(Cuvitru) $18.14 $18.14J0588 IncobotulinumtoxinA, 1 unit (Xeomin)
$5.54 $5.54J9999 isatuximab-irfc injection 1 mg (Sarclisa) $7.02
$7.02J3590 Peanut (Arachis hypogaea) allergen powder-dnfp 1 daily
dose (Palforzia) $32.04 $32.04Q5108 Pegfilgrastim-jmdb injection
0.5 mg (Fulphila) $387.23 $387.23S0145 Peginterferon Alfa-2a, 180
mcg/ml (Pegasys) $337.13 $337.13J3590 Peginterferon Alfa-2b, 1 mcg
(Sylatron) $3.10 $3.10J2507 Pegloticase, 1 mg (Krystexxa) $302.72
$302.72S0148 Pegylated interferon alfa-2b, 10 mcg (Peg-Intron)
$105.30 $105.30J9306 Pertuzumab, 1 mg, injection (Perjeta) $10.84
$10.84J2724 Protein C concentrate, intravenous, human, 1 IU,
injection (Ceprotin) $12.21 $12.21J3590 Prothrombin complex
concentrate (Human) 1 IU (Kcentra) $2.04 $2.04J2778 Ranibizumab,
0.1 mg, injection (Lucentis) $406.05 $406.05J2786 Reslizumab
injection 1 mL(Cinqair) $94.69 $94.69J2793 Rilonacept, 1 mg
injection (Arcalyst) $24.59 $24.59J3590 Secukinumab injection 150
mg (Cosentyx) $3,656.66 $3,656.66J3262 Tocilizumab, 1 mg (Actemra)
$3.48 $3.48J3357 Ustekinumab Injection for subcutaneous use, 1 mg
(Stelara) $112.10 $112.10J3358 Ustekinumab injection for
intravenous use, 1 mg (Stelara IV) $13.49 $13.49J3385 Velaglucerase
Alfa, 100 units (VPRIV) $351.28 $351.28J9400 Ziv-aflibercept, 1 ml
or 25 mg, injection (Zaltrap) $9.96 $9.96
J3490 17 Alpha Hydroxprogesterone Caporoate, Bulk powder, 250 mg
(17P) $19.80 $19.80J0130 Abciximab, 10mg, injection (ReoPro)
$423.96 $423.96J1120 Acetazolamide sodium, up to 500 mg, injection
(Diamox) $16.71 $16.71J0133 Acyclovir, 5 mg, injection (Zovirax)
$0.02 $0.02J0153 Adenosine injection 1 mg (Adenoscan, Adenocard)
$0.93 $0.93J9354 Ado-trastuzumab Emtansine, 1 mg, injection
(Kadcyla) $32.11 $32.11J0180 Agalsidase Beta, 1 mg, injection
(Fabrazyme) $129.86 $129.86P9047 Albumin (human), 25%, 50 ml,
infusion (Albuminar, Albutein, Bluminate), Plasbumin $40.22
$40.22
P9041 Albumin (human), 5%, 50 ml, infusion (Albiminar, Albutein,
Buminate, Plasbumin) $20.10 $20.10
J9015 Aldesleukin, per single use vial (Proleukin, etc) $769.05
$769.05J0215 Alefacept, 0.5 mg, injection (Amevive) $26.71
$26.71J0205 Alglucerase, per 10 units, injection (Ceredase) $39.75
$39.75J0220 Alglucosidase alfa, 10 mg, injection (Myozyme) $127.47
$127.47
DRUGS
BIOLOGICALS
Physician Drug Program Procedure Codes And RatesEffective March
1, 2020
The inclusion of a rate on this table does not guarantee that a
service is covered. Please refer to the Medicaid Billing Guide and
the Medicaid and Health Choice Clinical Policies on the DMA Web
Site.
Providers should always bill their usual and customary charges.
Please use the monthly NC Medicaid Bulletins for additions,
changes, and deletion to this schedule.
****Please note: LARCs, Vaccines, and Clotting Factor rates are
priced off of the NDC.****
-
J0257 Alpha 1 proteinase inhibitor (human), 10 mg (Glassia)
$3.86 $3.86J0256 Alpha 1-proteinase inhibitor-human, 10mg,
injection (Prolastin) (Aralast, Zemaira) $3.67 $3.67J2997 Alteplase
recombinant, 1 mg, injection (Activase) $32.24 $32.24J0207
Amifostine, 500mg, injection (Ethyol) $512.32 $512.32J0278 Amikacin
sulfate, 100 mg, injection (Amikin) $0.73 $0.73J0280 Aminophylline,
up to 250mg, injection $0.37 $0.37J0300 Amobarbital, up to 125mg,
injection (Amytal) $11.98 $11.98J0285 Amphotericin B, 50 mg,
injection (Amphocin) (Fungizone) $12.00 $12.00J0288 Amphotericin B
cholesteryl sulfate complex, 10 mg, injection (Amphotec) $12.02
$12.02J0287 Amphotericin B lipid complex, 10 mg, injection
(Abelcet) $10.48 $10.48J0289 Amphotericin B liposome, 10 mg,
injection (Ambisome) $17.19 $17.19J0290 Ampicillin sodium, 500mg,
injection $2.25 $2.25J0295 Ampicillin sodium/sulbactam sodium, per
1.5g, injection (Unasyn) $4.41 $4.41J7188 Antihemophilic factor
(recombinant) porcine sequence 1 IU (Orbizur) $5.85 $5.85J7199
Antihempohilic factor VIII (recombinant) 1 IU (Nuwiq) $1.92
$1.92J7197 Antithrombin III (human), per IU (Throbate III) $1.91
$1.91J3490 Aprepitant injectable emulsion, for intravenous use 1 mg
(Cinvanti) $2.45 $2.45J0400 Aripiprazole, intramuscular, 0.25 mg,
injection (Abilify) $0.29 $0.29J0401 Aripiprazole, extended
release, 1 mg, injection $4.04 $4.04J1943 Aripiprazole, lauroxil
extended-release injectable suspension 1 mg (Aristada Initio) $3.00
$3.00
J9017 Arsenic trioxide, 1 mg (Trisenox) $34.55 $34.55J9020
Asparaginase, 10,000 units (Elspar) $57.14 $57.14J9019 Asparaginase
Erwinia Chrysanthemi, 1,000 IUs, injection (Erwinaze) $334.98
$334.98J0461 Atropine sulfate, 0.01 mg, injection $0.04 $0.04J9025
Azacitidine 1 mg (Vidaza) $4.49 $4.49J0456 Azithromycin, 500mg,
injection (Zithromax) $18.02 $18.02Q0144 Azithromycin dihydrate,
oral, capsules/powder, 1 gm (Zithromax, Zithromax Z-Pak) $21.78
$21.78J0475 Baclofen, 10mg, injection (Lioresal) $191.26
$191.26J0476 Baclofen, 50 mcg for intrathecal trial, injection
(Lioresal) $69.91 $69.91J9031 BCG live (intravesical), per
installation (Tice BCG, Theracys) $113.99 $113.99J9032 Belinostat
10 mg (Beleodaq) $34.13 $34.13J9033 Bendamustine HCl, 1 mg,
injection (Treanda) $18.65 $18.65J0702 Betamethasone acetate and
betamethasone sodium phosphate, per 3mg, injection
(Celestone) (Soluspan)$5.76 $5.76
J9035 Bevacizumab, 10 mg, injection (Avastin) $57.57 $57.57Q5118
Bevacizumab-bzr injection 10 mg (Zirabev) $69.56 $69.56J3490
Bimatoprost implant, for intracameral administration, 1 implant -10
mcg (Durysta) $2,106.00 $2,106.00
J9040 Bleomycin sulfate, 15 units (Blenoxane) $29.09 $29.09J9039
Blinatumomab (Blincyto), 1 mcg $102.98 $102.98J9041 Bortezomib, 0.1
mg, inj. (Velcade) $34.50 $34.50J0585 Botulinum toxin type A, per
unit (Botox) $5.96 $5.96J0587 Botulinum toxin type B, per 100 units
(Myobloc) $8.73 $8.73J9042 Brentuximab vedotin, 1 mg (Adcetris)
$99.19 $99.19Q9991 Buprenorphine extended-release injection (<
or = 100 mg) (Sublocade) $1,758.54 $1,758.54Q9992 Buprenorphine
extended-release injection (> 100 mg) (Sublocade) $1,758.54
$1,758.54J0570 Buprenorphine implant, 74.2 mg (Probuphine)
$1,344.55 $1,344.55J0595 Butorphinol tartrate, 1 mg, injection
(Stadol) $0.50 $0.50J9043 Cabazitaxel, 1 mg (Jevtana) $135.47
$135.47J9118 Calaspargase pegol-mknl injection 10 Units (Asparlas)
$72.58 $72.58J0636 Calcitriol, 0.1 mcg, injection (Calcijex) $0.43
$0.43J0610 Calcium gluconate, per 10ml, injection $0.36 $0.36J0620
Calcium glycerophosphate and calcium lactate, per 10ml, injection
(Calphosan) $12.60 $12.60J3590 caplacizumab-yhdp for injection 11
mg (Cablivi) $7,884.00 $7,884.00J7336 Capsaicin 8% patch, per 1
square cm (Qutenza) $3.00 $3.00J9045 Carboplatin, 50 mg
(Paraplatin) $6.32 $6.32J9047 Carfilzomib, 1 mg injection
(Kyprolis) $31.11 $31.11J9050 Carmustine, 100 mg (BiCNU) $157.16
$157.16J0690 Cefazolin Sodium, 500 mg, Injection $0.66 $0.66J0692
Cefepime HCL, 500 mg, injection (Maxipime) $6.76 $6.76J0698
Cefotaxime Sodium, per 1 g (Claforan) $4.30 $4.30J0694 Cefoxitin
Sodium, 1g, injection (Mefoxin) $8.21 $8.21J0712 Ceftaroline
Fosamil Acetate, 10 mg (Teflaro) $0.74 $0.74J0714 Ceftazidime;
avibactam injection 0.625 g (Avycaz) $80.80 $80.80J0713
Ceftazidime, per 500 mg, injection (Fortaz, Tazidime) $3.48
$3.48J0715 Ceftizoxime sodium, per 500mg, injection (Cefizox) $5.25
$5.25J0695 Ceftolozane/Tazobactam 75 mg, 1-0.5 gm vial (Zerbaxa)
$4.70 $4.70J0696 Ceftriaxone Sodium, per 250mg, injection
(Rocephin) $1.48 $1.48J0697 Cefuroxime sodium, per 750mg, injection
(Zinacef) $3.45 $3.45J9119 cemiplimab-rwlc injection, 1 mg
(Libtayo) $27.45 $27.45J1201 Cetrizine hydrochloride injection .5
mg (Quzyttir) $16.20 $16.20J9055 Cetuximab, 10 mg, injection
(Erbitux) $49.92 $49.92J0720 Chloramphenicol sodium succinate, up
to 1g, injection (Chloromycetin) $18.42 $18.42J1990
Chlordiazepoxide HCl, up to 100 mg, injection (Librium) $21.09
$21.09J2400 Chloroprocaine HCl, per 30 ml, injection (Nesacaine)
$12.75 $12.75J1205 Chlorothiazide sodium, per 500 mg, injection
(Diuril Sodium) $165.48 $165.48J3230 Chlorpromazine HCl, up to 50
mg, injection (Thorazine) $3.23 $3.23J0725 Chorionic Gonadotropin,
per 1,000 USP units, injection (Novarel, Pregnyl, Profasil HP)
$3.38 $3.38
J0740 Cidofovir, 375 mg, injection (Vistide) $764.08
$764.08J0743 Cilastatin sodium imipenem, per 250mg, injection
(Primaxin IM or IV) $14.31 $14.31
-
S0023 Cimetidine hydrochloride, 300 mg, injection (Tagamet)
$0.61 $0.61J0744 Ciprofloxacin for IV infusion, 200 mg, injection
(Cipro) $5.35 $5.35J9060 Cisplatin, powder or solution, per 10 mg
$2.27 $2.27J9065 Cladribine, per 1 mg, injection (Leustatin) $30.70
$30.70J3490 Clevidipine injectable emulsion (Cleviprex) $2.89
$2.89J0735 Clonidine hydrochloride, 1mg, 1 IU injection (Duracion)
$56.12 $56.12J7199 Coagulation factor IX (recombinant) vials
(Ixinity) $1.92 $1.92J7169 Coagulation factor Xa (recombinant) 10
mg (Andexxa) $297.00 $297.00J0745 Codeine phosphate, per 30mg,
injection $1.27 $1.27J0770 Colistimethate Sodium,150 mg, injection
(Coly-Mycin M) $19.93 $19.93S4993 Contraceptive pills for birth
control, 1 tablet $3.15 $3.15J9999 Copanlisib injection, 1 mg
(Aliqopa) $75.60 $75.60J0800 Corticotropin, up to 40 units,
injection (Acthar, ACTH) $2,360.58 $2,360.58J0834 Cosyntropin, 0.25
injection (Cortrosyn) $91.38 $91.38J3590 Crotalidae immune f(ab')2
(equine), lyophilized powder for solution 1 vial (Anavip) $1,317.60
$1,317.60J0840 Crotalidae polyvalent immune fab (ovine) powder for
solution for intravenous injection,
up to 1 gram (1 vial) (CroFab)$2,194.76 $2,194.76
J9070 Cyclophosphamide, 100 mg (Cytoxan, Neosar) $1.87
$1.87J9100 Cytarabine, 100 mg (Cytosar-U) $1.20 $1.20J9098
Cytarabine Liposome, 10 MG (Depocyt) $415.84 $415.84J7070 D-5-W,
1,000 cc, infusion $2.18 $2.18J9130 Dacarbazine, 100 mg (DTIC-
Dome) $4.61 $4.61J7513 Daclizumab, parenteral, 25 mg (Zenapax)
$316.36 $316.36J9120 Dactinomycin, 0.5 mg (Cosmegen) $494.49
$494.49J0875 Dalbavancin hydrochloride 5 mg (Dalvance) $15.31
$15.31J1645 Dalteparin sodium, per 2500 IU, injection (Fragmin)
$10.81 $10.81J0878 Daptomycin, 1 mg (Cubicin) $0.35 $0.35J0881
Darbepoetin alfa, 1 mcg, (for non-ESRD use), injection (Aranesp)
$2.78 $2.78J0882 Darbepoetin alfa for ESRD on dialysis, 1 mcg
(Aranesp) $2.78 $2.78J9151 Daunorubicin citrate, liposomal
formulation, 10 mg (Daunoxome) $56.18 $56.18J9150 Daunorubicin HCl,
10 mg (Cerubidine) $17.17 $17.17J0894 Decitabine, 1 mg, injection
(Dacogen) $27.17 $27.17J0895 Deferoxamine Mesylate, 500mg,
injection (Desferal) $12.33 $12.33J9155 Degarelix, 1 mg, injection
(Firmagon) $2.88 $2.88J3490 Delafloxacin for injection 300 mg
(Baxdela) $0.48 $0.48J9160 Denileukin Diftitox, 300 mcg (Ontak)
$1,413.07 $1,413.07J1000 Depo-estradiol cypionate, up to 5mg,
injection (Depo-Estradiol) $6.19 $6.19J2597 Desmopressin acetate,
per 1 mcg, injection (DDAVP) $1.87 $1.87J1094 Dexamethasone
acetate, 1 mg, injection (Dalalone DP, Dexasone LA, Dexone LA,
Cortastat LA)$0.23 $0.23
J1095 Dexamethasone Intraocular suspension 9% 1 mcg (Dexycu)
$1.30 $1.30J7312 Dexamethasone, Intravitreal implant, 0.1 mg
(Ozurdex) $196.37 $196.37J1096 Dexamethasone ophthalmic insert 0.4
mg, 1 mg (Dextenza) $152.75 $152.75J1100 Dexamethasone sodium
phosphate, 1mg, injection (Cortastat, Dalalone) (Hexadrol) $0.08
$0.08
J1190 Dexrazoxane hydrochloride, per 250 mg, injection
(Zinecard) (Totect) $181.33 $181.33J7042 Dextrose 5% / normal
saline (500 ml = 1 unit) $0.28 $0.28J7060 Dextrose 5% / water (500
ml = 1 unit) $1.09 $1.09J7121 Dextrose 5% in lactated ringers
infusion, up to 1000 cc (Dextrose) $2.22 $2.22J3360 Diazepam, up to
5 mg, injection (Valium, Zetran) $0.79 $0.79J1730 Diazoxide, up to
300 mg, injection (Hyperstat IV) (Proglycern) $112.09 $112.09J0500
Dicyclomine HCl, up to 20mg, injection (Bentyl, Dilomine) $11.94
$11.94J3490 Defibrotide sodium injection, for intravenous use 1 ml
(Defitelio) $356.40 $356.40J1160 Digoxin, up to 0.5 mg injection
(Lanoxin) $1.18 $1.18J1110 Dihydroergotamine mesylate, per 1mg,
injection (DHE 45) $24.55 $24.55J1240 Dimenhydrinate, up to 50 mg,
injection $3.13 $3.13J0470 Dimercaprol, per 100mg, injection (BAL
in oil) $26.72 $26.72J9999 Dinutuximab Vial 1 ml (Unituxin)
$1,603.80 $1,603.80J1200 Diphenhydramine HCl, up to 50 mg,
injection (Benadryl) $0.75 $0.75J1245 Dipyridamole, per 10 mg,
injection (Persantine IV) $0.73 $0.73J1212 DMSO, dimethyl
sulfoxide, 50%, 50 ml, injection $50.60 $50.60J1250 Dobutamine HCl,
per 250 mg, injection (Dobutrex) $5.16 $5.16J9171 Docetaxel, 1 mg,
injection (Taxotere) $17.65 $17.65J1260 Dolasetron mesylate, 10 mg,
injection (Anzemet) $4.20 $4.20J1265 Dopamine HCI, 40 mg, injection
$0.51 $0.51J1267 Doripenem, 10 mg, injection (Doribax) $0.65
$0.65J1270 Doxercalciferol, 1 mcg, injection (Hectorol) $2.81
$2.81J9000 Doxorubicin HCl, 10 mg (Adriamycin) $4.76 $4.76Q2049
Doxorubicin HCL Liposomal, Imported Lipodox. 10 mg (Doxil) $499.24
$499.24Q2050 Doxorubicin Hydrochloride, Injection, Liposomal, Not
otherwise specified, 10 mg $579.32 $579.32J1790 Droperidol, up to 5
mg, injection (Inapsine) $1.32 $1.32J1290 Ecallantide, 1 mg
(Kalbitor) $275.82 $275.82J3490 Edaravone injection (Radicava) 1 mg
$19.55 $19.55J0600 Edetate calcium disodium, up to 1000mg,
injection (Calcium EDTA) $50.34 $50.34J3590 Elapegademase-lvir
injection 1 mg (Revcovi) $4,435.20 $4,435.20J1322 Elosulfase alfa,
injection 1mg (Vimizim) $239.80 $239.80J9210 Emapalumab-lzsg
injection (1 mg) (Gamifant) Manual Pricing Manual PricingJ9177
Enfortumab vedotin-ejfv for injection .25 mg (Padcev) $27.96
$27.96J1650 Enoxaparin sodium, 10 mg, injection (Lovenox) $5.91
$5.91J0122 Ervacucline for injection 1 mg (Xerava) $1.00 $1.00J0171
Adrenalin, epinephrine, 0.1 mg ampule, injection (Adrenalin) $0.04
$0.04J9178 Epirubicin HCl, 2 mg, inj. (Ellence) $6.26 $6.26
-
Q4081 Epoetin Alfa, 100 units (for ESRD on dialysis), injection
(Epogen, Procrit) $0.91 $0.91Q5105 Epoetin Alfa, biosimilar
injection (for ESRD on dialysis), 100 units (Retacrit) $1.23
$1.23Q5106 Epoetin Alfa-epbx injection (for non-ESRD use), 1000
units (Retacrit) $12.27 $12.27J0885 Epoetin alfa (for non-ESRD
use), 1000 units, injection (Epogen, Procrit) $9.09 $9.09J0887
Epoetin beta ESRD use, 1 microgram injection $2.02 $2.02J0888
Epoetin beta non ESRD use, 1 microgram injection $2.02 $2.02J1325
Epoprostenol, 0.5 mg, injection (Flolan) $14.39 $14.39J3590
eptinezumab-jjmr injection 100 mg/mL solution (Vyepti) $16.15
$16.15J9179 Eribulin Mesylate, 0.1 mg (Halaven) $90.23 $90.23J1335
Ertapenem, 500 mg, injection (Invanz) $25.56 $25.56J1364
Erythromycin lactobionate, per 500 mg, injection (Erthrocin) $6.77
$6.77J3490 Esketamine nasal spray 1 device (28 mg) (Spravato)
$318.60 $318.60J1380 Estradiol valerate, up to 10 mg, injection
(Delestrogen) $8.63 $8.63J1410 Estrogen conjugated, per 25 mg,
injection (Premarin IV) $71.40 $71.40J0606 Etelcalcetide injection
0.1 mg (Parsabiv) $3.71 $3.71J1436 Etidronate disodium, per 300 mg,
injection (Didronel) $71.56 $71.56J9181 Etoposide, 10 mg (VePesid)
$0.40 $0.40J7191 Factor VIII (antihemophilic factor (porcine)), per
IU (Hyate C) $1.86 $1.86J3010 Fentanyl Citrate, 0.1 mg, injection
(Sublimaze) $0.28 $0.28J1439 Ferric Carboxymaltos injection, 1 mg
$1.17 $1.17Q0138 Ferumoxytol, for treatment of iron deficiency
anemia, 1 mg (non-ESRD use), injection
(Feraheme)$0.83 $0.83
Q0139 Ferumoxytol, for treatment of iron deficiency anemia, 1 mg
(for ESRD on dialysis), injection (Feraheme)
$0.83 $0.83
J3590 Fibrinogen concentrate (human) lyophilized powder 1 mg
(Fibryga) $1.19 $1.19J1442 Filgrastim (G-CSF), 1 mcg, injection
(Neupogen) $1.06 $1.06Q5110 Filgrastim-aafi injection 1 mcg
(Nivestym) $0.83 $0.83J9200 Floxuridine, 500 mg (FUDR) $51.23
$51.23J7311 Fluocinolone acetonide intravitreal 1 implant
(Retisert) $21,907.52 $21,907.52J7313 Fluocinolone acetonide
intravitreal implant 0.01 mg (Iluvien) $515.49 $515.49J7314
Fluocinolone acetonide intravitreal implant 0.18 mg (Yutiq) $525.42
$525.42J9185 Fludarabine phosphate, 50 mg, injection (Fludara)
$201.18 $201.18J9190 Fluorouracil, 500 mg (Adrucil) $1.87
$1.87J2680 Fluphenazine decanoate, up to 25 mg, injection
(Prolixin) $2.37 $2.37J1652 Fondaparinux sodium, 0.5 mg, injection
(Arixtra) $6.25 $6.25J1453 Fosaprepitant, 1 mg, injection (Emend)
$1.57 $1.57J1455 Foscarnet sodium, per 1,000 mg, injection
(Foscavir) $10.40 $10.40J9395 Fulvestrant, 25 mg, injection
(Faslodex) $81.54 $81.54J1940 Furosemide, up 20 mg, injection
(Lasix) $0.19 $0.19J1570 Ganciclovir sodium, 500 mg, injection
(Cytovene) $43.94 $43.94J1580 Gentamicin, up to 80 mg, injection
$1.04 $1.04J9201 Gemcitabine HCl, 200 mg (Gemzar) $132.06
$132.06J9199 Gemcitabine in sodium chloride injection 200 mg
(Infugem) $86.18 $86.18J9203 Gemtuzumab Ozogamicin, 0.1 mg,
injection (Mylotarg) $202.81 $202.81J0223 Givosiran injection, for
subcutaneous use .5 mg (Givlaari) $107.18 $107.18J1610 Glucagon
hydrochloride, per 1 mg, injection (GlucaGen) $68.80 $68.80J1600
Gold sodium thiomalate, up to 50 mg, injection (Myochrysine,
Aurolate) $7.86 $7.86J9202 Goserelin acetate implant, per 3.6 mg
(Zoladex) $190.13 $190.13J1626 Granisetron hydrochloride, 100 mcg,
injection (Kytril) $4.97 $4.97J1631 Haloperidol decanoate, per 50
mg, injection (Haldol Decanoate-50) $2.41 $2.41J1630 Haloperidol,
up to 5 mg, injection (Haldol) $1.73 $1.73J1640 Hemin, 1 mg,
injection (Panhematin) $7.32 $7.32J1642 Heparin sodium, per 10
units, injection (Heparin Lock Flush) $0.04 $0.04J1644 Heparin
sodium, per 1,000 units, injection (Heparin) $0.07 $0.07J9225
Histrelin implant (Vantas), 50 mg $1,511.33 $1,511.33J9226
Histrelin implant (Supprelin LA), 50 mg $14,687.27 $14,687.27J3470
Hyaluronidase injection up to 150 units (Hydase, Amphadase,
Vitrase) $17.31 $17.31J3473 Hyaluronidase, recombinant, 1 USP unit
(Hylenex) $0.41 $0.41J0360 Hydralazine HCl, up to 20mg, injection
(Apresoline) $6.08 $6.08J1720 Hydrocortisone sodium succinate, up
to 100 mg, injection (A-Hydrocort, Solu-Cortef) $2.23 $2.23
J1170 Hydromorphone, up to 4 mg, injection (Dilaudid) $1.28
$1.28J1729 Hydroxyprogesterone caproate injection, 10 mg $17.47
$17.47J1726 Hydroxyprogestorone caproate, 10 mg, injection (Makena)
$34.67 $34.67J3410 Hydroxyzine HCl, up to 25 mg, injection
(Vistaril) $0.14 $0.14J1980 Hyoscyamine sulfate, up to 0.25 mg,
injection (Levsin) $9.31 $9.31J3590 Ibalizumab-uiyk injection 1 mg
(Trogarzo) $6.13 $6.13J1740 Ibandronate sodium, 1 mg (Boniva)
$139.27 $139.27J1742 Ibutilide fumarate, 1 mg, injection (Corvert)
$323.99 $323.99J9211 Idarubicin HCl, 5 mg (Idamycin) $276.66
$276.66J1743 Idursulfase, 1 mg, injection (Elaprase) $456.01
$456.01J9208 Ifosfamide, per 1 g (Ifex) $38.00 $38.00J1786
Imiglucerase, 10 units, injection (Cerezyme) $42.07 $42.07J0742
Imipenem, cilastatin, and relebactam for injection 10 mg
(Recarbrio) $2.31 $2.31J1575 Immune Globulin Infusion 10% (Human)
with recombinant human hyaluronidase 100 mg
(Hyqvia)$11.37 $11.37
J1599 Immune Globulin intravenous, human-ifas 500 mg (Panzyga)
$94.12 $94.12J1599 Immune Globulin intravenous, human-slra 10%
liquid 500 mg (Asceniv) $490.86 $490.86J1558 Immune Globulin
subcutaneous, human - klhw 20% solution 100 mg (Xembify) $16.84
$16.84J1745 Infliximab, 10 mg, injection (Remicade) $55.16
$55.16J0185 Injection, aprepitant, 1 mg (Cinvanti) $2.21 $2.21J1944
Injection, aripiprazole lauroxil, 1 mg (Aristada) $2.92 $2.92
-
J9022 Injecton, atezolizumab, 10 mg (Tecentriq) $79.58
$79.58J9023 Injection, avelumab, 10 mg (Bavencio) $83.34
$83.34J9034 Injection, bendamustine hcl (Bendeka), 1 mg $24.87
$24.87Q5107 Inection, bevacizumab, (Mvasi) 10 mg $76.82 $76.82J0565
Injection, bezlotoxumab, 10 mg (Zinplava) $43.09 $43.09J9044
Injection, bortezomib, 0.1 mg $37.45 $37.45J0584 Injection,
burosumab-twza 1 mg (Crysvita) $385.56 $385.56J0567 Injection,
cerliponase alfa, 1 mg (Brineura) $102.06 $102.06J9057 Injection,
copanlisib, 1 mg (Aliqopa) $79.38 $79.38J0841 Injection, crotalidae
immune f(ab')2 (equine), 120 mg (Anavip) $1,383.48 $1,383.48J9145
Injection, daratumumab, 10 mg (Darzalex) $49.27 $49.27J9999
Injection, daratumumab and hyaluronidase-fihj 10 mg (Darzalex
Faspro) $45.44 $45.44J1130 Injection, diclofenac sodium, 0.5 mg
(Dyloject) $0.23 $0.23J9173 Injection, durvalumab, 10 mg (Imfinizi)
$78.90 $78.90J1301 Injection, edaravone, 1 mg (Radicava) $20.53
$20.53J9176 Injection, elotuzumab, 1 mg (Empliciti) $6.54
$6.54J7170 Injection, emicizumab-kxwh, 0.5 mg (Hemlibra) $48.70
$48.70J7175 Injection, factor X, (human), 1 IU (Coagadex) $8.78
$8.78J1443 Injection, ferric pyrophosphate citrate solution, 0.1mg
of iron (Triferic) $0.02 $0.02J9198 Injection, gemcitabine
hydrochloride 100 mg (Infugem) $41.04 $41.04J1444 ferric
pyrophosphate citrate solution, for hemodialysis use, 0.1 mg
(Triferic) $0.03 $0.03Q5101 Injection, Filgrastim (G-CSC),
Biosimilar, 1 microgram (Zarxio) $1.07 $1.07J1454 Injection,
fosnetupitant 235 mg and palonosetron 0.25 mg (Akynzeo) $556.00
$556.00J1627 Injection, granisetron, extended-release, 0.1 mg
(Sustol) $4.83 $4.83J7177 Injection, human fibrinogen concentrate
(Fibryga), 1 mg $1.25 $1.25J1746 Injection, ibalizumab-uiyk, 10 mg
(Trogarzo) $64.35 $64.35J1555 Injection, immune globuline, 100 mg
(Cuvitru) $14.48 $14.48Q5103 Injection, infliximab, biosimilar, 10
mg (Inflectra) $73.20 $73.20J9229 Injection, inotuzumab ozogamicin,
0.1 mg (Besponsa) $2,356.20 $2,356.20J0594 Injection, busulfan, 60
mg/10 ml (Busulfex) $34.84 $34.84J9205 Injection, irinotecan
liposome, 1 mg (Onivyde) $41.49 $41.49J9153 injection, liposomal, 1
mg daunorubicin and 2.27 mg cytarabine (Vyxeos) $199.83
$199.83J9295 Injection, necitumumab, 1 mg (Portrazza) $5.52
$5.52J9285 Injection, olaratumab 10 mg (Lartruvo) $52.45
$52.45J9311 Injection, rifuximab,10 mg and hyaluronidase (Rituxan
Hycela) $48.97 $48.97J9312 Injection, rituximab, 10 mg (Rituxan)
$100.17 $100.17Q5115 Injection, rituximab-abbs, biosimilar, 10 mg
(Truxima) $95.89 $95.89J2797 Injection, rolapitant, 0.5 mg (Varubi)
$1.00 $1.00Q5111 Injection, pegfilgrastim-cbqv, biosimilar, 0.5 mg
(Udenyca) $394.54 $394.54J2840 Injection, sebelipase alfa, 1 mg
(Kanuma) $567.00 $567.00J9325 Injection, talimogene laherparepvec,
per 1 million plaque forming units (Imlygic) $48.44 $48.44J9352
Injection, trabectedin, 0.1 mg (Yondelis) $297.56 $297.56Q5114
Injection, trastuzumab-dkst 10 mg, (Ogivri) $99.82 $99.82J3304
Injection, triamcinolone acetonide, preservative-free,
extended-release, microsphere
formulation, 1 mg (Zilretta)$19.83 $19.83
J3316 Injection, triptorelin, extended-release, 3.75 mg
(Triptodur) $3,024.00 $3,024.00J3397 Injection, vestronidase
alfa-vjbk, 1 mg (Mepsevii) $239.84 $239.84J7342 Installation,
ciprofloxacin otic suspension, 6 mg (Otiprio) $32.12 $32.12J1815
Insulin, per 5 units, injection $0.28 $0.28J9212 Interferon
Alfacon-1, recombinant, 1 mcg, injection (Infergen) $4.81
$4.81J9215 Interferon alfa-N3, (human leukocyte derived), 250,000
IU (Alferon N) $19.39 $19.39J9213 Interferon alfa-2A, recombinant,
3 million units (Roferon-A) $41.01 $41.01J9214 Interferon alfa-2B,
recombinant, 1 million units (Intron-A) $14.19 $14.19Q3027
Interferon beta-1a, 1 mcg for intramuscular use, injection $34.86
$34.86Q3028 Interferon beta-1a, 1 mcg for subcutaneous use,
injection $19.82 $19.82J1826 Interferon beta-1a, 30 mcg for
intramuscular use, injection (Avonex) $781.30 $781.30J1830
Interferon beta-1b, 0.25 mg, injection (Extavia) $177.43
$177.43J9216 Interferon gamma-1B, 3 million units (Actimmune)
$310.25 $310.25J9228 Ipilimumab, 1 mg, (Yervoy) $125.30
$125.30J9206 Irinotecan, 20 mg (Camptosar) $126.51 $126.51J1750
Iron dextran, 50 mg, injection (InFeD, Dexferrum) $11.81
$11.81J1756 Iron sucrose, 1 mg, injection (Venofer) $0.35
$0.35J1833 Isavuconazonium sulfate injection 1 mg (Cresemba) $0.72
$0.72J9207 Ixabepilone, 1 mg, injection (Ixempra) $63.88
$63.88J1850 Kanamycin sulfate, up to 75 mg, injection (Kantrex)
$0.76 $0.76J1840 Kanamycin sulfate, up to 500 mg, injection
(Kantrex) $5.10 $5.10J1885 Ketorolac tromethamine, per 15 mg,
injection (Toradol) $0.34 $0.34J3490 Lacosamide, per ml/10mg
(Vimpat) $1.95 $1.95J1930 Lanreotide, 1 mg, injection (Somatuline
Depot) $26.91 $26.91J1931 Laronidase, 0.1 mg, inj. (Aldurazyme)
$24.41 $24.41J0691 Lefamulin injection, 1 mg (Xenleta) $0.72
$0.72J3490 Letermovir injection, for intravenous use 1 vial
(Prevymis) $291.60 $291.60J0640 Leucovorin Calcium, per 50 mg,
injection (Wellcovorin) $0.78 $0.78J9218 Leuprolide acetate, per 1
mg (Lupron) $7.48 $7.48J9217 Leuprolide acetate (for depot
suspension), 7.5 mg (Lupron Depot) (Eligard) $221.33 $221.33J1950
Leuprolide acetate (for depot suspension), per 3.75 mg, injection
(Lupron Depot)
(Eligard)$442.60 $442.60
J9219 Leuprolide Acetate Implant 65mg (Viadur) $1,611.63
$1,611.63J1953 Levetiracetam, 10 mg, injection (Keppra) $0.43
$0.43J1955 Levocarnitine, per 1 g, injection (Carnitor) $5.89
$5.89J1956 Levofloxacin, 250 mg, injection (Levaquin) $5.88
$5.88
-
J0641 Levoleucovorin calcium, 0.5 mg, injection (Fusilev) $1.05
$1.05J0642 Levoleucovorin for injection, 0.5 mg (Khapzory) $2.14
$2.14J1960 Levorphanol tartrate, up to 2 mg, injection
(Levo-Dromoran) $3.18 $3.18J3490 Lidocaine , for topical use 1 mg
invoice required ***See Rate Table belowJ2001 Lidocaine HCL for IV
infusion, Injection 10 mg $0.02 $0.02J2010 Lincomycin HCl, up to
300 mg, injection (Lincocin) $4.27 $4.27J2020 Linezolid, 200 mg,
injection (Zyvox) $28.15 $28.15J2060 Lorazepam, 2 mg, injection
(Ativan) $0.64 $0.64J9999 lurvinectedin for injection, 1 mg
(Zepzelca) $1,790.91 $1,790.91J0896 Luspatercept-aamt for injection
.25 mg (Reblozyl) $37.16 $37.16J3475 Magnesium sulfate, per 500 mg,
injection $0.05 $0.05J2150 Mannitol, 25% in 50 ml, injection,
(Osmitrol, Resectisol) $0.86 $0.86J9230 Mechlorethamine HCl, 10 mg
(Nitrogen Mustard) $144.75 $144.75J3490 Meloxica injection (30 mg)
(Anjeso) $101.52 $101.52J9246 Melphalan for injection 1 mg
(Evomela) $43.20 $43.20J9245 Melphalan HCl, 50 mg, injection
(Alkeran) $1,566.99 $1,566.99J2175 Meperidine HCl, per 100 mg,
injection (Demerol) $1.52 $1.52J0670 Mepivacaine HCl, per 10ml,
injection (Carbocaine) (Polocaine) $1.15 $1.15J2186 Meropenem and
vaborbactem for injection 10 mg/10 mg (20 mg) (Vabomere) $1.87
$1.87J9209 Mesna, 200 mg (Mesnex) $7.89 $7.89J0380 Metaraminol
bitartrate, per 10mg, injection (Aramine) $1.15 $1.15J7674
Methacholine chloride (Provocholine) $0.55 $0.55J1230 Methadone
HCl, up to 10 mg, injection (Dolophine) $2.96 $2.96J2800
Methocarbamol up to 10 ml, injection (Robaxin) $10.24 $10.24J9250
Methotrexate sodium, 5 mg $0.21 $0.21J9260 Methotrexate sodium, 50
mg $2.26 $2.26J7309 Methly aminolevulinate (MAL) for topical
administration, 16.8%, 1 gram (Metvixia) $77.54 $77.54J0210
Methyldopate HCl, up to 250mg, injection IV $15.22 $15.22J3490
Methylene blue injection 1 mL (Provayblue) $20.14 $20.14J2210
Methylergonovine maleate, up to 0.2 mg, injection (Methergine)
$5.05 $5.05J1020 Methylprednisolone acetate, 20mg, injection
(Depo-Medrol) $2.41 $2.41J1030 Methylprednisolone acetate, 40mg,
injection (Depo-Medrol) $4.48 $4.48J1040 Methylprednisolone
acetate, 80mg, injection (Depo-Medrol) $9.43 $9.43J2920
Methylprednisolone sodium succinate, up to 40 mg, injection
(Solu-Medrol) $2.07 $2.07J2930 Methylprednisolone sodium succinate,
up to 125 mg, injection (Solu-Medrol) $3.03 $3.03J2765
Metoclopramide HCl, up to 10 mg, injection (Reglan) $0.34
$0.34J2250 Midazolam HCl, per 1 mg, injection (Versed) $0.15
$0.15S0190 mifepristone tablets, for oral use 200 mcg (Mifeprex)
$77.49 $77.49J2260 Milrinone lactate, per 5 mg, injection
(Primacor) $4.56 $4.56S0191 misoprostol tablets, for oral use 200
mcg (Cytotec) $1.03 $1.03J9280 Mitomycin, 5 mg (Mutamycin) $13.08
$13.08J9999 mitomycin for pyelocalyceal solution, 1 mg (Jelmyto)
$288.58 $288.58J9293 Mitoxantrone HCl, per 5 mg, injection
(Novantrone) $88.89 $88.89J9204 Mogamuliumab-kpke injection 1 mg
(Poteligeo) $210.91 $210.91J7401 Mometasone furoate sinus implant
10 mcg (Sinuva) $10.71 $10.71J2274 Morphine preservative free,
Injection 10 mg $10.22 $10.22J2270 Morphine sulfate, up to 10 mg,
injection $1.79 $1.79J9313 Moxetumomab pasudotox-tdfk for injection
0.01 mg (Lumoxiti) $23.63 $23.63J2300 Nalbuphine HCl, per 10 mg,
injection (Nubain) $0.96 $0.96J2310 Naloxone HCl, per 1 mg,
injection (Narcan) $3.17 $3.17J2315 Naltrexone, depot form, 1 mg,
injection (Vivitrol) $1.88 $1.88J2320 Nandrolone decanoate, up to
50 mg, injection (Deca-Durabolin) $4.77 $4.77J2323 Natalizumab, 1
mg, injection (Tysabri) $7.54 $7.54J9261 Nelarabine, 50 mg,
injection (Arranon) $91.88 $91.88J2710 Neostigmine methylsulfate,
up to 0.5 mg, injection (Prostigmin) $0.10 $0.10J9299 Nivolumab, 1
mg, injection (Opdivo) $26.64 $26.64J7050 Normal saline solution,
250 cc infusion $0.26 $0.26J7040 Normal saline solution, sterile
(500 ml = 1 unit), infusion $0.52 $0.52J7030 Normal saline
solution, 1,000 cc, infusion $1.03 $1.03J2326 Nusinersen injection
for intrathecal use 0.1 mg (Spinraza) $1,181.25 $1,181.25J9301
Obinutuzumab Inj 10 mg (Gazyva) $59.77 $59.77J7316 Ocriplasmin,
0.125 mg, injection (Jetrea) $1,111.75 $1,111.75J2353 Octreotide,
depot form for IM injection, 1 mg (Sandostatin LAR Depot) $90.32
$90.32J2354 Octreotide non-depot form for SC or IV injection, 25
mcg (Sandostatin) $2.21 $2.21J9302 Ofatumumab, per 10 mg (Arzerra)
$45.47 $45.47S0166 Olanzapine, 2.5 mg (Zyprexa) $8.05 $8.05J2358
Olanzapine long-acting, 1 mg (Zyprexa Relprevv) $2.75 $2.75J9262
Omacetaxine mepesuccinate, 0.01 mg, injection (Synbrio) $2.58
$2.58J0121 Omadacucline for injection, 1 mg (Nuzyra) $3.92
$3.92J2405 Ondansetron HCl, per 1 mg, injection (Zofran) $0.22
$0.22J2407 Oritavancin diphosphate 10 mg (Orbactiv) $26.90
$26.90J2360 Orphenadrine citrate, up to 60 mg, injection (Norflex)
$9.04 $9.04J2700 Oxacillin sodium, up to 250 mg, injection
(Bactocile, Prostaphlin) $1.58 $1.58J9263 Oxaliplatin, 0.5 mg,
injection (Eloxatin) $9.51 $9.51J2410 Oxymorphone HCl, up to 1 mg,
injection (Numorphan) $2.51 $2.51J2460 Oxytetracycline HCl, up to
50 mg, injection (Terramycin IM) $0.94 $0.94J2590 Oxytocin, up to
10 units, injection (Pitocin) $2.05 $2.05J9267 Paclitaxel, 1 mg
injection (Taxol) $0.18 $0.18J9264 Paclitaxel protein-bound
particles, 1 mg, (Abraxane) $8.87 $8.87J2425 Palifermin injection
50 mcg (Kepivance) $11.92 $11.92
-
J3490 Paliperidone palmitate extended-release injectable
suspension 1 mg (Invega Trinza) $8.82 $8.82
J2426 Paliperidone palmitate extended-release injectable
suspension 1 mg (Invega Sustenna) $6.52 $6.52
J2469 Palonosetron HCl, 25 mcg, injection (Aloxi) $17.25
$17.25J2430 Pamidronate disodium, per 30 mg, injection (Aredia)
$28.39 $28.39J9303 Panitumumab, 10 mg, injection (Vectibix) $82.43
$82.43J2440 Papaverine HCl, up to 60 mg, injection $0.57 $0.57J2501
Paricalcitol, 1 mcg, injection (Zemplar) $3.93 $3.93J2502
Pasireotide suspension 1 mg (Signifor LAR) $305.31 $305.31J0222
Patisiran lipid complex injection 0.1 mg (Onpattro) $107.73
$107.73J2503 Pegaptanib sodium, 0.3 mg, (Macugen) $1,033.23
$1,033.23J9266 Pegaspargase, per single dose vial (Oncaspar)
$2,098.12 $2,098.12J2505 Pegfilgastrim, 6 mg, injection (Neulasta)
$2,204.83 $2,204.83Q5120 Pegfilgrastim-bmez injection 0.5 mg
(Ziextenzo) $317.28 $317.28J0890 Peginesatide, 0.1 mg (Omontys)
$9.09 $9.09J9271 Pembrolizumab Powder 1 mg (Keytruda) $47.98
$47.98J9305 Pemetrexed, 10 mg, injection (Alimta) $46.30
$46.30J0561 Penicillin G benzathine, per 100,000 units, injection
(Bicillin L-A) $4.07 $4.07J0558 Injection, penicillin G benzathine
and penicillin G procaine, per 100,000 units (Bicillin C-
R)$3.22 $3.22
J2540 Penicillin G potassium, up to 600,000 units, injection
(Pfizerpen) $0.94 $0.94J2510 Penicillin G procaine, aqueous, up to
600,000 units, injection (Wycillin) $10.31 $10.31J2545 Pentamidine
isethionate, inhalation solution, per 300 mg, administered through
a DME
(Pentam 300, NebuPent)$54.43 $54.43
S0080 Pentamidine isethionate, 300 mg, injection (NebuPent)
$42.56 $42.56J3070 Pentazocine HCl, up to 30 mg, injection (Talwin)
$6.12 $6.12J2515 Pentobarbital sodium, per 50 mg, injection
(Nembutal Sodium) $7.63 $7.63J9268 Pentostatin, per 10 mg (Nipent)
$1,832.85 $1,832.85J2547 Peramivir (Rapivab) 1 mg 200 mg/20 ml vial
$1.80 $1.80J9999 Pertuzumab, trastuzumab, and hyaluronidase-zzxf
injection, 1 mL (Phesgo) $914.87 $914.87J2560 Phenobarbital sodium,
up to 120 mg, injection $3.01 $3.01J2760 Phentolamine mesylate, up
to 5 mg, injection (Regitine) $21.12 $21.12J1097 Phenylephrine and
ketorolac injection1 mL (Omidria) $130.52 $130.52J2370
Phenylephrine HCl, up to 1 ml, injection (Neosynephrine) $0.70
$0.70J1165 Phenytoin sodium, per 50 mg, injection (Dilantin) $0.45
$0.45J3430 Phytonadione (vitamin K), per 1 mg, injection (Mephyton)
$3.63 $3.63J2543 Piperacillin sodium/tazobactam sodium, injection,
1g/0.125g (1.125 g) (Zosyn) $5.16 $5.16J0291 Plazomicin injection,
for intravenous use 5 mg (Zemdri) $3.57 $3.57J2562 Plerixafor, 1
mg, injection (Mozobil) $269.25 $269.25J9309 Polatuzumab
vedotin-piiq for injection 1 mg (Polivy) $119.05 $119.05J9600
Porfimer sodium, 75 mg (Photofin) $2,508.93 $2,508.93J3480
Potassium Chloride, per 2 mEq, injection $0.01 $0.01J9307
Pralatrezate, 1 mg (Folotyn) $165.96 $165.96J2730 Pralidoxime
chloride, up to 1 g, injection (Protopam) $88.27 $88.27J2650
Prednisolone acetate, up to 1 ml, injection (Predcor-50) $0.17
$0.17J2690 Procainamide HCl, up to 1 g, injection (Pronestyl) $2.66
$2.66J0780 Prochlorperazine, up to 10 mg, injection, (Compazine)
$1.16 $1.16J2675 Progesterone, per 50 mg, injection $1.51
$1.51J2550 Promethazine HCl, up to 50 mg, injection (Phenergan)
$1.37 $1.37J1800 Propranolol HCl, up to 1 mg, injection (Inderal)
$3.19 $3.19J2720 Protamine sulfate, per 10 mg, injection $0.59
$0.5990399 Rabies immune globulin (human) solution 150 IU (Kedrab)
$385.95 $385.95J2780 Ranitidine hydrochloride, 25 mg, injection
(Zantac) $0.74 $0.74J2783 Rasburicase, 0.5 mg, injection (Elitek)
$155.52 $155.52J1303 Ravulizumab-cwvz injection, 10 mg (Ultomiris)
$237.59 $237.59J0596 Recombinant human C1 esterase inhibitor 10
units (rhC1INH) (Ruconest) $29.49 $29.49J2993 Reteplase, 18.1 mg,
injection (Retavase) $835.53 $835.53J7120 Ringer's lactate
infusion, up to 1,000 cc $0.91 $0.91J2798 Risperidone for
extended-release injectable suspension 0.5 mg (Perseris) $10.36
$10.36J2794 Risperidone, long acting 0.5 mg, injection (Risperdal
Consta) $4.94 $4.94Q5119 Rituximab-pvvr injection 10 mg (Ruxience)
$73.83 $73.83J9308 Ramucirumab 5 mg (Cyramza) $56.72 $56.72J3490
rolapitant injectable emulsion 1 vial (Varubi) $318.60 $318.60J9315
Romidepsin, 1 mg (Istodax) $219.73 $219.73J2796 Romiplostim, 10
mcg, injection (Nplate) $43.69 $43.69J3590 Romosozumab-aqqg
injection 1 mg (Evenity) $8.95 $8.95J2795 Ropivacaine HCI injection
1 mg (Naropine) $0.07 $0.07J9999 sacituzumab govitecan-hziy for
injection 1 mg (Trodelvy) $12.08 $12.08J2820 Sargramostim (GM-CSF),
50 mcg, injection (Leukine) $25.16 $25.16J3490 Sildenafil, per vial
(Revatio) $96.19 $96.19Q2043 Sipuleucel-T, 3 units, injection 250
ml (Provenge) $32,876.62 $32,876.62J2860 Slituxumab Injection 10 mg
(Sylvant) $9.73 $9.73J3490 Sodium bicarbonate7.5%, up to 50 ml
$3.26 $3.26J2916 Sodium ferric gluconate complex in sucrose, 12.5
mg, injection (Ferrlecit) $4.79 $4.79J2995 Streptokinase, per
250,000 IU, injection (Streptase) $79.67 $79.67J3000 Streptomycin,
up to 1 g, injection $6.99 $6.99J9320 Streptozocin, 1 g (Zanosar)
$191.05 $191.05J0330 Succinylcholine chloride, up to 20 mg,
injection (Anectine) (Quelicin) $0.17 $0.17J3490 sugammadex
injection 1 mg (Bridion) $0.39 $0.39J3030 Sumatriptan succinate, 6
mg, injection (Imitrex) (Alsuma) $66.76 $66.76J9269
tagraxofusp-erzs injection 10 mcg (Elzonris) $277.03 $277.03
-
J3060 Taliglucerace alfa, 10 units, injection (Elelyso) $32.83
$32.83J1447 TBO-filgrastim, 1 mcg, injection (Granix) $0.81
$0.81J3090 Tedizolid phosphate injection 1 mg (Sivextro) $0.13
$0.13J3095 Telavancin , per 10 mg (Vibativ) $1.93 $1.93J9328
Temozolomide, 1 mg, injection (Temodar) $5.10 $5.10J9330
Temsirolimus, 1 mg, injection (Torisel) $48.01 $48.01J3590
Teprotumumab-trbw for injection 1 mg (Tepezza) $32.18 $32.18J3105
Terbutaline sulfate, up to 1 mg, injection (Brethine) $2.42
$2.42J1071 Depo-Testosterone Cypionate, 1 mg injection
(Delatrstryl) $0.04 $0.04J3121 Testosterone enanthate, 1 mg
injection $0.06 $0.06S0189 Testosterone pellet, 75 mg (Testopel)
$67.64 $67.64J3145 Testosterone undecanoate 1 mg (Aveed) strength:
3 ml vial $1.24 $1.24J9340 Thiotepa, 15 mg (Thioplex) $40.49
$40.49J3240 Thyrotropin alpha, 0.9 mg provided in 1.1 mg vial,
injection (Thyrogen) $840.76 $840.76J3243 Tigecycline, 1 mg
(Tygacil) $1.25 $1.25J3260 Tobramycin sulfate, up to 80 mg,
injection (Nebcin) $2.32 $2.32J9351 Topotecan, 0.1 mg (Hycamtin)
$27.40 $27.40J3265 Torsemide, 10 mg/ml, injection (Demadex) $2.18
$2.18J3285 Treprostinil njection 1 mg (Remodulin) $67.05
$67.05J9355 Trastuzumab, 10 mg (Herceptin) $60.21 $60.21J9999
trastuzumab and hyaluronidase-oysk injection 1 mg (Herceptin
Hylecta) $8.42 $8.42Q5117 trastuzumab-anns for injection, 10 mg
(Kanjinti) $95.20 $95.20Q5113 trasuzumab-pkrb for injection 10 mg
(Herzuma) $100.98 $100.98Q5112 trastuzumab-dttb for injection 10 mg
(Ontruzant) $95.38 $95.38Q5116 trastuzumab-qyyp for injection 10 mg
(Trazimera) $91.56 $91.56J3301 Triamcinolone acetonide, per 10 mg,
injection (Kenalog-10, Kenalog-40) $1.38 $1.38J3300 Triamcinolone
acetonide, preservative free, 1 mg, injection (Trivaris) $3.26
$3.26J3303 Triamcinolone hexacetonide, per 5mg injection
(Aristospan) $1.34 $1.34J3250 Trimethobenzamide HCl, up to 200 mg,
injection (Tigan) $4.47 $4.47J3305 Trimetrexate glucuronate, per 25
mg, injection (Neutrexin) $150.03 $150.03J3315 Triptorelin pamoate
(Trelstar Depot, Trelstar LA), 3.75 mg $149.49 $149.49J3365
Urokinase, 250,000 IU, injection IV (Abbokinase) $458.71
$458.71J3490 valproate sodium 1 mg (Depacon) $0.00 $0.00J9357
Valrubicin, 200 mg, injection (Valstar) $966.32 $966.32J3370
Vancomycin HCl, 500 mg, injection (Vancoled) (Vancocin) $3.15
$3.15J3380 Vendolizumab Injection 1 mg (Entyvio) $17.88 $17.88J3396
Verteporfin, 0.1 mg, inj. (Visudyne) $9.17 $9.17J9360 Vinblastine
sulfate, 1 mg (Velban) $1.07 $1.07J9370 Vincristine sulfate, 1 mg
(Vincasar PFS) $7.03 $7.03J9371 Vincristine sulfate liposome, 1 mg
(Marqibo) $2,110.15 $2,110.15J9390 Vinorelbine tartrate, per 10 mg
(Navelbine) $16.26 $16.26J3420 Vitamin B-12 cyanocobalamin, up to
1,000 mcg, injection $0.25 $0.25J2278 Ziconotide 1 mcg, (Prialt)
$6.53 $6.53J3489 Zoledronic acid, 1 mg, injection $111.96
$111.96
90291 Cytomegalovirus Immune Globulin (CMV-IgIV), Human, 1 ml
(CytoGam) $23.84 $23.84J1460 Gamma globulin, intramuscular, 1 cc,
injection (Gamastan S/D) $11.57 $11.57J1560 Gamma globulin,
intramuscular, over 10 cc, injection (Gamastan S/D) $115.78
$115.78J1571 Injection, hepatitis B immune globulin, intramuscular,
0.5 ml, (Hepagam B) $48.45 $48.4590371 Hepatitis B Immune globulin
(HBIg), human, 1 ml (BayHep B HepaGam B Nabi-HB ) $120.23
$120.23
J1573 Hepatitis B immune globulin, intravenous, 0.5 ml,
injection (Hepagam B) $48.45 $48.45J1559 Immune Globulin
subcutaneous, 20% 100 mg (Hizentra) $7.30 $7.30J1556 Immune
Globulin intravenous, 10% 500 mg, injection (Bivigam) $41.04
$41.04J1557 Immune Globulin (Gammaplex) intravenous,
non-lyophilized (e.g., liquid) 500 mg $37.36 $37.36J1566 Immune
Globulin, intravenous, lyophilized, (e.g. powder) 500 mg, injection
(Gammagard
S-D)$28.13 $28.13
J1568 Immune globulin, intravenous, nonlyophilized (e.g.,
liquid), 500 mg, injection (Octagma) $35.15 $35.15
J1572 Immune globulin, intravenous, nonlyophilized (e.g.,
liquid), 500 mg, injection (Flebogamma)
$32.59 $32.59
J1459 Immune globulin, intravenous, nonlyophilized (e.g.,
liquid), 500 mg, injection (Privigen) $34.23 $34.23
J1561 Immune Globulin, Intravenous, 500 mg, injection (Gamunex)
$33.52 $33.52J1569 Immune globulin, intravenous, nonlyophilized,
(e.g., liquid), 500 mg, injection
(Gammagard liquid)$31.86 $31.86
J1562 Immune globulin, subcutaneous, 100 mg (Vivaglobin) $7.10
$7.10J7504 Lymphocyte Immune Globulin, anit-thymocyte globulin
equine, parenteral, 250 mg
(Atgam)$384.62 $384.62
90375Rabies Immune Globulin (RIg), human, for intramuscular
and/or subcutaneous use 150 IU (HyperRab-HyperRab-B)
$67.97 $67.97
90376 Rabies Immune Globulin, Heat-treated (Rig-HT), human, 2 ml
(Imogam Rabies-HT) $78.24 $78.24
J2790 Rho D immune globulin, human, full dose, 300 mcg $89.91
$89.91J2788 Rho(D) Immune Globulin, 50 mcg $28.49 $28.49J2792
Rho(D) Immune Globulin (RhIgIV), Intravenous, Human, Solvent
Detergent, 100 IU,
injection$15.65 $15.65
J2791 Rho( D) immune globulin (human), intramuscular or
intravenous, 100 IU, injection $5.34 $5.3490389 Tetanus Immune
Globulin (Tlg), Human, for Intramuscular use,
250 U/1 ml (BayTet)$140.25 $140.25
90396 Varicella-Zoster Immune Globulin, human, 125 units $110.64
$110.64
J1050 00009074630 DEPO-PROVERA 150 MG/ML VIAL - INJECTION,
MEDROXYPROGESTERONE ACETA $1.55 $1.55
IMMUNE GLOBULINS
LARCs and Depo-Provera
-
J1050 00009074635 DEPO-PROVERA 150 MG/ML VIAL - INJECTION,
MEDROXYPROGESTERONE ACETA $1.48 $1.48J1050 00009074635 DEPO-PROVERA
150 MG/ML VIAL - INJECTION, MEDROXYPROGESTERONE ACETA $1.55
$1.55J1050 00009470913 DEPO-SUBQ PROVERA 104 SYRINGE - INJECTION,
MEDROXYPROGESTERONE AC $2.38 $2.38J1050 00009470913 DEPO-SUBQ
PROVERA 104 SYRINGE - INJECTION, MEDROXYPROGESTERONE AC $2.50
$2.50J1050 00009737611 DEPO-PROVERA 150 MG/ML SYRINGE - INJECTION,
MEDROXYPROGESTERONE AC $1.41 $1.41J1050 00009737611 DEPO-PROVERA
150 MG/ML SYRINGE - INJECTION, MEDROXYPROGESTERONE AC $1.48
$1.48J1050 00548540000 MEDROXYPROGESTERONE 150 MG/ML - INJECTION,
MEDROXYPROGESTERONE A $0.32 $0.32J1050 00548540000
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.33 $0.33J1050 00548540025 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.32 $0.32J1050 00548540025
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.33 $0.33J1050 00548541000 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.32 $0.32J1050 00548541000
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.33 $0.33J1050 00548541025 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.32 $0.32J1050 00548541025
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.33 $0.33J1050 00548570100 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.39 $0.39J1050 00548570100
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.41 $0.41J1050 00548571100 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.39 $0.39J1050 00548571100
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.41 $0.41J1050 00703680101 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.58 $0.58J1050 00703680101
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.61 $0.61J1050 00703680104 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.58 $0.58J1050 00703680104
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.60 $0.60J1050 16714099901 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.59 $0.59J1050 16714099901
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.62 $0.62J1050 59762453701 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.58 $0.58J1050 59762453701
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.61 $0.61J1050 59762453702 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.58 $0.58J1050 59762453702
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.60 $0.60J1050 59762453802 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.68 $0.68J1050 59762453802
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.71 $0.71J1050 62756009040 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.58 $0.58J1050 62756009040
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.61 $0.61J1050 62756009045 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.58 $0.58J1050 62756009045
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.60 $0.60J1050 67457088701 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.58 $0.58J1050 67457088701
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.32 $0.32J1050 67457088701 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.33 $0.33J1050 67457088799
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.58 $0.58J1050 67457088799 MEDROXYPROGESTERONE 150 MG/ML -
INJECTION, MEDROXYPROGESTERONE A $0.32 $0.32J1050 67457088799
MEDROXYPROGESTERONE 150 MG/ML - INJECTION, MEDROXYPROGESTERONE A
$0.33 $0.33J7296 50419042401 KYLEENA 19.5 MG SYSTEM -
LEVONORGESTREL-RELEASING INTRAUTERINE CON $1,010.72 $1,010.72J7296
50419042401 KYLEENA 19.5 MG SYSTEM - LEVONORGESTREL-RELEASING
INTRAUTERINE CON $1,061.26 $1,061.26J7297 00023585801 LILETTA 52 MG
SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRA $794.36
$794.36J7297 00023585801 LILETTA 52 MG SYSTEM -
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRA $834.08 $834.08J7297
00023585801 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING
INTRAUTERINE CONTRA $875.79 $875.79J7297 52544003554 LILETTA 52 MG
SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRA $794.36
$794.36J7297 52544003554 LILETTA 52 MG SYSTEM -
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRA $834.08 $834.08J7297
52544003554 LILETTA 52 MG SYSTEM - LEVONORGESTREL-RELEASING
INTRAUTERINE CONTRA $834.08 $834.08J7298 50419042101 MIRENA SYSTEM
- LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPT $963.51
$963.51J7298 50419042101 MIRENA SYSTEM - LEVONORGESTREL-RELEASING
INTRAUTERINE CONTRACEPT $1,011.68 $1,011.68J7298 50419042301 MIRENA
SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPT $1,010.72
$1,010.72J7298 50419042301 MIRENA SYSTEM - LEVONORGESTREL-RELEASING
INTRAUTERINE CONTRACEPT $1,061.26 $1,061.26J7300 51285020401
PARAGARD T 380-A IUD - INTRAUTERINE COPPER CONTRACEPTIVE $857.01
$857.01J7300 51285020401 PARAGARD T 380-A IUD - INTRAUTERINE COPPER
CONTRACEPTIVE $937.57 $937.57J7300 51285020401 PARAGARD T 380-A IUD
- INTRAUTERINE COPPER CONTRACEPTIVE $984.45 $984.45J7300
51285020402 PARAGARD T 380-A IUD - INTRAUTERINE COPPER
CONTRACEPTIVE $783.34 $783.34J7300 59365512801 PARAGARD T 380-A IUD
- INTRAUTERINE COPPER CONTRACEPTIVE $857.01 $857.01J7300
59365512801 PARAGARD T 380-A IUD - INTRAUTERINE COPPER
CONTRACEPTIVE $937.57 $937.57J7300 59365512801 PARAGARD T 380-A IUD
- INTRAUTERINE COPPER CONTRACEPTIVE $984.45 $984.45J7301
50419042201 SKYLA SYSTEM - LEVONORGESTREL-RELEASING INTRAUTERINE
CONTRACEPTIV $841.60 $841.60J7301 50419042201 SKYLA SYSTEM -
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIV $883.68
$883.68J7307 00052027401 NEXPLANON 68 MG IMPLANT - ETONOGESTREL
(CONTRACEPTIVE) IMPLANT SYST $817.81 $817.81J7307 00052433001
NEXPLANON 68 MG IMPLANT - ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYST
$943.72 $943.72J7307 00052433001 NEXPLANON 68 MG IMPLANT -
ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYST $1,040.45 $1,040.45
A9552 Fluorodeoxyglucose F-18 FDG, diagnostic per study dose, up
to 45mCi $650.35 $650.35A9515 Choline C-11, diagnostic, per study
dose up to 20 millicuries Invoice required invoice requiredA9578
Gadobenate dimeglumine (MultiHance multipack), per ml, injection
$5.65 $5.65A9577 Gadobenate dimeglumine (MultiHance), per ml,
injection $5.65 $5.65A9585 Gadobutrol, 0.1 ml (Gadavist) $0.89
$0.89A9579 Gadolinium-based magnetic resonance contrast agent, not
otherwise specified, per ml $2.56 $2.56
A9576 Gadoteridol, (ProHance multipack), per ml, injection $5.65
$5.65A9581 Gadoxetate Disodium, 1ml injection $13.52 $13.52A9556
Gallium GA-67 citrate, diagnostic, per mCi $46.59 $46.59A9571
Indium IN-111 oxyquinolone Labeled autologous platelets,
diagnostic, per study dose $2,709.81 $2,709.81
A9570 Indium IN-111 oxyquinolone Labeled autologous white blood
cells, diagnostic, per study dose
$1,840.16 $1,840.16
A9547 Indium IN-111 oxyquinoline, diagnostic, per 0.5mCi $292.23
$292.23A9548 Indium IN-111 pentetate, diagnostic, per 0.5mCi
$272.80 $272.80
RADIOPHARMACEUTICALSDiagnostic
-
Q9968 Injection, nonradioactive, noncontrast, visualization
adjunct (e.g., methylene blue, isosulfan blue) 1 mg
invoice required invoice required
A9582 Iodine I-123 Iobenguane, Diagnostic, per study dose, up to
15 millicuries $3,749.59 $3,749.59A9516 Iodine I-123 sodium iodide
capsule(s), diagnostic, per 100 µCi $72.95 $72.95A9584 Iodine 1-123
ioflupane, diagnostic, per study dose, up to 5 mCi (DaTscan)
$2,142.62 $2,142.62A9554 Iodine I-125 sodium iothalamate,
diagnostic per study dose, up to 10µCi $2,074.45 $2,074.45A9590
Iodine i-131, iobenguane, 1 millicurie (Azeda) $342.47 $342.47A9524
Iodine I-131 iodinated serum albumin, diagnostic, per 5 μCi $49.60
$49.60A9529 Iodine I-131 sodium iodide solution, diagnostic, per
mCi $149.82 $149.82A9531 Iodine I-131 Sodium Iodide, Diagnostic,
Per Microcurie (Up To 100 Microcuries) $55.24 $55.24A9528 Iodine
I-131 sodium iodide capsules, diagnostic, per mCi $55.24
$55.24Q9965 Low osmolar contrast material, 100-199 mg/ml iodine
concentration, per ml $1.39 $1.39Q9966 Low osmolar contrast
material, 200-299 mg/ml iodine concentration, per ml $0.41
$0.41Q9967 Low osmolar contrast material, 300-399 mg/ml iodine
concentration, per ml $0.21 $0.21Q9951 Low Osmolar Contrast
Material, 400 or greater Mg/Ml Iodine Concentration, Per Ml invoice
required invoice required
A9513 Lutetium lu 177, dotatate, therapeutic, 1 millicurie
(Lutathera) $269.33 $269.33A9526 Nitrogen N-13 ammonia, diagnostic,
per study dose, up to 40 mCi invoice required invoice requiredQ9957
Injection, perflutren lipid microspheres, per ml $62.74 $62.74A4641
Radiopharmaceutical, diagnostic, not otherwise classified
(dosimetric use) 1ml (Azedra) invoice required invoice required
A9699 Radiopharmaceutical, therapeutic, not otherwise
classified, (therapeutic use) 1 ml (Azedra)
invoice required invoice required
J2785 Regadenoson, 0.1 mg injection (Lexiscan) $47.51
$47.51A9555 Rubidium RB-82, diagnostic per study, up to 60mCi
$30,941.35 $30,941.35A9604 Samarium Sm-153 lexidronamm,
therapeutic, 1 mg (Quadramet) $1,607.34 $1,607.34J2805 Injection,
Sincalide, per mcg (Kinevac) $55.49 $55.49A9580 Sodium fluoride
F-18, diagnostic, per study dose, up to 30 millicuries invoice
required invoice requiredQ9950 Sulfur Hexafluoride Lipid-type A
Microspheres 1 mL (Lumason) $25.37 $25.37A9700 Supply of injectable
contrast material for use in echocardiography, per study invoice
required invoice requiredA9503 Technetium Tc-99 medronate,
diagnostic, per study dose, up to 30 mCi $40.33 $40.33A9500
Technetium Tc-99 sestamibi, diagnostic, per study dose, up to 40
mCi $121.95 $121.95A9502 Technetium Tc-99 tetrofosmin, diagnostic,
per study dose, up to 40 mCi $121.31 $121.31A9557 Technetium TC-99m
bicisate, diagnostic per study dose, up to 25mCi $921.97
$921.97A9510 Technetium Tc-99m disofenin, diagnostic, per study
dose, up to 15 mCi $28.24 $28.24A9569 Technetium TC-99M Exametazime
Labeled Autologous white blood cells, diagnostic, per
study dose$1,840.16 $1,840.16
A9521 Technetium T-99m exametazime, diagnostic, per study dose,
up to 25 mCi $723.40 $723.40A9560 Technetium TC-99m labeled red
blood cells, diagnostic per study dose, up to 30mCi $95.45
$95.45
A9540 Technetium TC99m macroaggregated albumin, diagnostic per
study dose, up to 10mCi $40.33 $40.33
A9537 Technetium TC99m mebrofenin, diagnostic per study, up to
15mCi $68.17 $68.17A9562 Technetium TC-99m meriatide, diagnostic
per study dose, up to 15mCi $259.50 $259.50A9561 Technetium TC-99m
oxidronate, diagnostic per study dose, up to 30mCi $42.36
$42.36A9567 Technetium Tc-99m pentetate, diagnostic, aerosol, per
study dose, up to 75 mCi $69.59 $69.59A9512 Technetium Tc-99m
pertechnetate, diagnostic, per mCi $12.54 $12.54A9538 Technetium
TC99m pyrophosphate, diagnostic, per study dose, up to 25mCi $52.44
$52.44A9541 Technetium TC99m sulphur colloid, diagnostic per study
dose, up to 20mCi $54.02 $54.02A9505 Thallium TI-201 thallous
chloride, diagnostic, per mCi $63.14 $63.14A9558 Xenon Xe-133 gas,
diagnostic, per 10 mCi $43.65 $43.65A9543 Yttrium Y-90 ibritumomab
tiuxetan, therapeutic, per treatment dose, up to 40 millicuries
$22,763.78 $22,763.78
A9564 Chromic phosphate P-32 suspension, therapeutic, per mCi
$323.12 $323.12A9530 Iodine I-131 Sodium Iodide Solution,
Therapeutic, Per Millicurie invoice required invoice requiredA9606
Radium ra-223 dichloride, therapeutic,per microcurle $127.77
$127.77A9563 Sodium Phosphate P-32, therapeutic, per mCi $317.05
$317.05A9600 Strontium Sr-89 chloride, therapeutic, per mCi $895.67
$895.67
90585 00052060301 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS
CALMETTE-GUERIN VACCINE (BCG $152.49 $152.4990585 00052060301 BCG
VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG
$161.78 $161.7890585 00052060301 BCG VACCINE (TICE STRAIN) VIAL -
BACILLUS CALMETTE-GUERIN VACCINE (BCG $169.87 $169.8790585
00052060302 BCG VACCINE (TICE STRAIN) VIAL - BACILLUS
CALMETTE-GUERIN VACCINE (BCG $161.78 $161.7890585 00052060302 BCG
VACCINE (TICE STRAIN) VIAL - BACILLUS CALMETTE-GUERIN VACCINE (BCG
$169.87 $169.8790620 46028011401 BEXSERO PREFILLED SYRINGE -
MENINGOCOCCAL RECOMBINANT PROTEIN AND $164.80 $164.8090620
46028011402 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT
PROTEIN AND $164.80 $164.8090620 46028011411 BEXSERO PREFILLED
SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND $164.80
$164.8090620 58160097602 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL
RECOMBINANT PROTEIN AND $175.10 $175.1090620 58160097602 BEXSERO
PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND $183.86
$183.8690620 58160097602 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL
RECOMBINANT PROTEIN AND $183.86 $183.8690620 58160097602 BEXSERO
PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND $193.05
$193.0590620 58160097606 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL
RECOMBINANT PROTEIN AND $175.10 $175.1090620 58160097606 BEXSERO
PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND $183.86
$183.8690620 58160097606 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL
RECOMBINANT PROTEIN AND $183.86 $183.8690620 58160097606 BEXSERO
PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND $193.05
$193.0590620 58160097620 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL
RECOMBINANT PROTEIN AND $175.10 $175.1090620 58160097620 BEXSERO
PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND $183.86
$183.8690620 58160097620 BEXSERO PREFILLED SYRINGE - MENINGOCOCCAL
RECOMBINANT PROTEIN AND $183.86 $183.8690620 58160097620 BEXSERO
PREFILLED SYRINGE - MENINGOCOCCAL RECOMBINANT PROTEIN AND $193.05
$193.0590621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN -
MENINGOCOCCAL RECOMBINANT LIPOPRO $136.86 $136.86
THERAPEUTIC
VACCINES
-
90621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL
RECOMBINANT LIPOPRO $136.86 $136.8690621 00005010001 TRUMENBA 120
MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPRO $143.70
$143.7090621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN -
MENINGOCOCCAL RECOMBINANT LIPOPRO $153.62 $153.6290621 00005010001
TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPRO
$153.62 $153.6290621 00005010001 TRUMENBA 120 MCG/0.5 ML VACCIN -
MENINGOCOCCAL RECOMBINANT LIPOPRO $161.30 $161.3090621 00005010005
TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPRO
$136.86 $136.8690621 00005010005 TRUMENBA 120 MCG/0.5 ML VACCIN -
MENINGOCOCCAL RECOMBINANT LIPOPRO $136.86 $136.8690621 00005010005
TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPRO
$143.70 $143.7090621 00005010005 TRUMENBA 120 MCG/0.5 ML VACCIN -
MENINGOCOCCAL RECOMBINANT LIPOPRO $153.62 $153.6290621 00005010005
TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPRO
$153.62 $153.6290621 00005010005 TRUMENBA 120 MCG/0.5 ML VACCIN -
MENINGOCOCCAL RECOMBINANT LIPOPRO $161.30 $161.3090621 00005010010
TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPRO
$136.86 $136.8690621 00005010010 TRUMENBA 120 MCG/0.5 ML VACCIN -
MENINGOCOCCAL RECOMBINANT LIPOPRO $136.86 $136.8690621 00005010010
TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPRO
$143.70 $143.7090621 00005010010 TRUMENBA 120 MCG/0.5 ML VACCIN -
MENINGOCOCCAL RECOMBINANT LIPOPRO $153.62 $153.6290621 00005010010
TRUMENBA 120 MCG/0.5 ML VACCIN - MENINGOCOCCAL RECOMBINANT LIPOPRO
$153.62 $153.6290621 00005010010 TRUMENBA 120 MCG/0.5 ML VACCIN -
MENINGOCOCCAL RECOMBINANT LIPOPRO $161.30 $161.3090632 00006409602
VAQTA 50 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT
DOSAGE, FO $69.50 $69.5090632 00006409602 VAQTA 50 UNITS/ML SYRINGE
- HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FO $70.89 $70.8990632
00006409602 VAQTA 50 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA),
ADULT DOSAGE, FO $74.44 $74.4490632 00006409609 VAQTA 50 UNITS/ML
SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FO $68.14
$68.1490632 00006484100 VAQTA 50 UNITS/ML VIAL - HEPATITIS A
VACCINE (HEPA), ADULT DOSAGE, FOR IN $70.63 $70.6390632 00006484100
VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE,
FOR IN $72.04 $72.0490632 00006484100 VAQTA 50 UNITS/ML VIAL -
HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN $75.64 $75.6490632
00006484101 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA),
ADULT DOSAGE, FOR IN $69.25 $69.2590632 00006484101 VAQTA 50
UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN
$70.63 $70.6390632 00006484101 VAQTA 50 UNITS/ML VIAL - HEPATITIS A
VACCINE (HEPA), ADULT DOSAGE, FOR IN $72.04 $72.0490632 00006484101
VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE,
FOR IN $75.64 $75.6490632 00006484141 VAQTA 50 UNITS/ML VIAL -
HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN $68.14 $68.1490632
00006484141 VAQTA 50 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA),
ADULT DOSAGE, FOR IN $69.50 $69.5090632 00006484141 VAQTA 50
UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR IN
$70.89 $70.8990632 00006484141 VAQTA 50 UNITS/ML VIAL - HEPATITIS A
VACCINE (HEPA), ADULT DOSAGE, FOR IN $74.44 $74.4490632 58160082601
HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT
DOSAGE, FO $70.87 $70.8790632 58160082601 HAVRIX 1,440 UNITS/ML
VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FO $73.00
$73.0090632 58160082601 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A
VACCINE (HEPA), ADULT DOSAGE, FO $73.00 $73.0090632 58160082601
HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT
DOSAGE, FO $76.65 $76.6590632 58160082611 HAVRIX 1,440 UNITS/ML
VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FO $70.87
$70.8790632 58160082611 HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A
VACCINE (HEPA), ADULT DOSAGE, FO $73.00 $73.0090632 58160082611
HAVRIX 1,440 UNITS/ML VIAL - HEPATITIS A VACCINE (HEPA), ADULT
DOSAGE, FO $73.00 $73.0090632 58160082611 HAVRIX 1,440 UNITS/ML
VIAL - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FO $76.65
$76.6590632 58160082643 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A
VACCINE (HEPA), ADULT DOSAGE $70.87 $70.8790632 58160082643 HAVRIX
1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE
$73.00 $73.0090632 58160082643 HAVRIX 1,440 UNITS/ML SYRINGE -
HEPATITIS A VACCINE (HEPA), ADULT DOSAGE $73.00 $73.0090632
58160082643 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE
(HEPA), ADULT DOSAGE $76.65 $76.6590632 58160082652 HAVRIX 1,440
UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE $70.87
$70.8790632 58160082652 HAVRIX 1,440 UNITS/ML SYRINGE - HEPATITIS A
VACCINE (HEPA), ADULT DOSAGE $73.00 $73.0090632 58160082652 HAVRIX
1,440 UNITS/ML SYRINGE - HEPATITIS A VACCINE (HEPA), ADULT DOSAGE
$73.00 $73.0090632 58160082652 HAVRIX 1,440 UNITS/ML SYRINGE -
HEPATITIS A VACCINE (HEPA), ADULT DOSAGE $76.65 $76.6590633
00006409502 VAQTA 25 UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE
(HEPA), PEDIATRIC/ADO $32.86 $32.8690633 00006409502 VAQTA 25
UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADO
$33.52 $33.5290633 00006409502 VAQTA 25 UNITS/0.5 ML SYRINGE -
HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADO $35.20 $35.2090633
00006409509 VAQTA 25 UNITS/0.5 ML SYRINGE - HEPATITIS A VACCINE
(HEPA), PEDIATRIC/ADO $31.28 $31.2890633 00006483101 VAQTA 25
UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESC
$32.86 $32.8690633 00006483101 VAQTA 25 UNITS/0.5 ML VIAL -
HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESC $33.52 $33.5290633
00006483101 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE
(HEPA), PEDIATRIC/ADOLESC $35.20 $35.2090633 00006483141 VAQTA 25
UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESC
$32.86 $32.8690633 00006483141 VAQTA 25 UNITS/0.5 ML VIAL -
HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESC $33.52 $33.5290633
00006483141 VAQTA 25 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE
(HEPA), PEDIATRIC/ADOLESC $35.20 $35.2090633 58160082501 HAVRIX 720
UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLE
$33.10 $33.1090633 58160082501 HAVRIX 720 UNITS/0.5 ML VIAL -
HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLE $34.10 $34.1090633
58160082501 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE
(HEPA), PEDIATRIC/ADOLE $34.10 $34.1090633 58160082501 HAVRIX 720
UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLE
$35.80 $35.8090633 58160082511 HAVRIX 720 UNITS/0.5 ML VIAL -
HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLE $33.10 $33.1090633
58160082511 HAVRIX 720 UNITS/0.5 ML VIAL - HEPATITIS A VACCINE
(HEPA), PEDIATRIC/ADOLE $34.10 $34.1090633 58160082511 HAVRIX 720
UNITS/0.5 ML VIAL - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLE
$34.10 $34.1090633 58160082511 HAVRIX 720 UNITS/0.5 ML VIAL -
HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLE $35.80 $35.8090633
58160082543 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE
(HEPA), PEDIATRIC/ADO $33.10 $33.1090633 58160082543 HAVRIX 720
UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADO
$34.10 $34.1090633 58160082543 HAVRIX 720 UNIT/0.5 ML SYRINGE -
HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADO $34.10 $34.1090633
58160082543 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE
(HEPA), PEDIATRIC/ADO $35.80 $35.8090633 58160082552 HAVRIX 720
UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADO
$33.10 $33.1090633 58160082552 HAVRIX 720 UNIT/0.5 ML SYRINGE -
HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADO $34.10 $34.1090633
58160082552 HAVRIX 720 UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE
(HEPA), PEDIATRIC/ADO $34.10 $34.1090633 58160082552 HAVRIX 720
UNIT/0.5 ML SYRINGE - HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADO
$35.80 $35.8090636 58160081501 TWINRIX VACCINE VIAL - HEPATITIS A
AND HEPATITIS B VACCINE (HEPA-HEPB), A $99.50 $99.5090636
58160081501 TWINRIX VACCINE VIAL - HEPATITIS A AND HEPATITIS B
VACCINE (HEPA-HEPB), A $104.47 $104.4790636 58160081511 TWINRIX
VACCINE VIAL - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), A
$99.50 $99.5090636 58160081511 TWINRIX VACCINE VIAL - HEPATITIS A
AND HEPATITIS B VACCINE (HEPA-HEPB), A $104.47 $104.4790636
58160081543 TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B
VACCINE (HEPA-HEP $105.58 $105.5890636 58160081543 TWINRIX VACCINE
SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEP $110.85
$110.8590636 58160081543 TWINRIX VACCINE SYRINGE - HEPATITIS A AND
HEPATITIS B VACCINE (HEPA-HEP $110.85 $110.85
-
90636 58160081543 TWINRIX VACCINE SYRINGE - HEPATITIS A AND
HEPATITIS B VACCINE (HEPA-HEP $116.40 $116.4090636 58160081552
TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE
(HEPA-HEP $105.58 $105.5890636 58160081552 TWINRIX VACCINE SYRINGE
- HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEP $110.85
$110.8590636 58160081552 TWINRIX VACCINE SYRINGE - HEPATITIS A AND
HEPATITIS B VACCINE (HEPA-HEP $110.85 $110.8590636 58160081552
TWINRIX VACCINE SYRINGE - HEPATITIS A AND HEPATITIS B VACCINE
(HEPA-HEP $116.40 $116.4090647 00006489700 PEDVAXHIB VACCINE VIAL -
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), P $26.25 $26.2590647
00006489700 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B
VACCINE (HIB), P $27.56 $27.5690647 00006489701 PEDVAXHIB VACCINE
VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), P $26.25
$26.2590647 00006489701 PEDVAXHIB VACCINE VIAL - HAEMOPHILUS
INFLUENZAE TYPE B VACCINE (HIB), P $27.56 $27.5690648 49281054503
ACTHIB VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE
( $15.76 $15.7690648 49281054503 ACTHIB VACCINE WITH DILUENT -
HAEMOPHILUS INFLUENZAE TYPE B VACCINE ( $16.88 $16.8890648
49281054503 ACTHIB VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE
TYPE B VACCINE ( $17.73 $17.7390648 49281054505 ACTHIB VACCINE WITH
DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE ( $15.45
$15.4590648 49281054758 ACTHIB VACCINE VIAL - HAEMOPHILUS
INFLUENZAE TYPE B VACCINE (HIB), PRP- $15.76 $15.7690648
49281054758 ACTHIB VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B
VACCINE (HIB), PRP- $16.88 $16.8890648 49281054758 ACTHIB VACCINE
VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP- $17.73
$17.7390648 58160081601 HIBERIX VACCINE VIAL - HAEMOPHILUS
INFLUENZAE TYPE B VACCINE (HIB), PRP $10.40 $10.4090648 58160081601
HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB),
PRP $10.72 $10.7290648 58160081601 HIBERIX VACCINE VIAL -
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP $10.72 $10.7290648
58160081601 HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B
VACCINE (HIB), PRP $11.25 $11.2590648 58160081605 HIBERIX VACCINE
VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP $10.40
$10.4090648 58160081605 HIBERIX VACCINE VIAL - HAEMOPHILUS
INFLUENZAE TYPE B VACCINE (HIB), PRP $10.72 $10.7290648 58160081605
HIBERIX VACCINE VIAL - HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB),
PRP $10.72 $10.7290648 58160081605 HIBERIX VACCINE VIAL -
HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP $11.25 $11.2590648
58160081811 HIBERIX VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE
TYPE B VACCINE $10.40 $10.4090648 58160081811 HIBERIX VACCINE WITH
DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE $10.72 $10.7290648
58160081811 HIBERIX VACCINE WITH DILUENT - HAEMOPHILUS INFLUENZAE
TYPE B VACCINE $10.72 $10.7290648 58160081811 HIBERIX VACCINE WITH
DILUENT - HAEMOPHILUS INFLUENZAE TYPE B VACCINE $11.25 $11.2590649
00006404500 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6,
11, 16, 18, QUADR $164.54 $164.5490649 00006404500 GARDASIL VIAL -
HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADR $172.77
$172.7790649 00006404501 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS
VACCINE, TYPES 6, 11, 16, 18, QUADR $164.54 $164.5490649
00006404501 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6,
11, 16, 18, QUADR $172.77 $172.7790649 00006404541 GARDASIL VIAL -
HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADR $164.20
$164.2090649 00006404541 GARDASIL VIAL - HUMAN PAPILLOMAVIRUS
VACCINE, TYPES 6, 11, 16, 18, QUADR $172.41 $172.4190649
00006410901 GARDASIL SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE, TYPES
6, 11, 16, 18, QU $165.77 $165.7790649 00006410902 GARDASIL SYRINGE
- HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QU $165.77
$165.7790649 00006410909 GARDASIL SYRINGE - HUMAN PAPILLOMAVIRUS
VACCINE, TYPES 6, 11, 16, 18, QU $165.77 $165.7790651 00006411901
GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18,
31, 33, $222.85 $222.8590651 00006411901 GARDASIL 9 VIAL - HUMAN
PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, $234.00
$234.0090651 00006411901 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS
VACCINE TYPES 6, 11, 16, 18, 31, 33, $245.70 $245.7090651
00006411903 GARDASIL 9 VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6,
11, 16, 18, 31, 33, $222.85 $222.8590651 00006411903 GARDASIL 9
VIAL - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33,
$234.00 $234.0090651 00006411903 GARDASIL 9 VIAL - HUMAN
PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, $245.70
$245.7090651 00006412101 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS
VACCINE TYPES 6, 11, 16, 18, 31 $222.85 $222.8590651 00006412101
GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16,
18, 3 $234.00 $234.0090651 00006412101 GARDASIL 9 SYRINGE - HUMAN
PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 3 $245.70 $245.7090651
00006412102 GARDASIL 9 SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES
6, 11, 16, 18, 3 $222.85 $222.8590651 00006412102 GARDASIL 9
SYRINGE - HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 3
$234.00 $234.0090651 00006412102 GARDASIL 9 SYRINGE - HUMAN
PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 3 $245.70 $245.7090653
70461001903 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE,
INACTIVATED (IIV), SUBUNIT, A $53.14 $53.1490653 70461001903 FLUAD
2019-2020 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT,
A $55.80 $55.8090653 70461001904 FLUAD 2019-2020 SYRINGE -
INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, A $53.14 $53.1490653
70461001904 FLUAD 2019-2020 SYRINGE - INFLUENZA VACCINE,
INACTIVATED (IIV), SUBUNIT, A $55.80 $55.8090653 70461002003 FLUAD
2020-2021 SYRINGE - INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT,
A $55.80 $55.8090653 70461002004 FLUAD 2020-2021 SYRINGE -
INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, A $55.80 $55.8090662
49281040565 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE
(IIV), SPLIT VIRU $49.96 $49.9690662 49281040565 FLUZONE HIGH-DOSE
2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRU $52.46
$52.4690662 49281040565 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA
VIRUS VACCINE (IIV), SPLIT VIRU $52.46 $52.4690662 49281040588
FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE (IIV),
SPLIT VIRU $49.96 $49.9690662 49281040588 FLUZONE HIGH-DOSE 2019-20
SYR - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRU $52.45 $52.4590662
49281040588 FLUZONE HIGH-DOSE 2019-20 SYR - INFLUENZA VIRUS VACCINE
(IIV), SPLIT VIRU $52.45 $52.4590662 49281012065 FLUZONE HIGH-DOSE
QUAD 2020-21 - INFLUENZA VIRUS VACCINE (IIV), SPLIT VIR $57.18
$57.1890662 49281012088 FLUZONE HIGH-DOSE QUAD 2020-21 - INFLUENZA
VIRUS VACCINE (IIV), SPLIT VIR $57.18 $57.1890670 00005197101
PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PC
$190.47 $190.4790670 00005197101 PREVNAR 13 SYRINGE - PNEUMOCOCCAL
CONJUGATE VACCINE, 13 VALENT (PC $200.00 $200.0090670 00005197101
PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PC
$213.80 $213.8090670 00005197101 PREVNAR 13 SYRINGE - PNEUMOCOCCAL
CONJUGATE VACCINE, 13 VALENT (PC $213.80 $213.8090670 00005197101
PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PC
$224.49 $224.4990670 00005197102 PREVNAR 13 SYRINGE - PNEUMOCOCCAL
CONJUGATE VACCINE, 13 VALENT (PC $184.68 $184.6890670 00005197102
PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PC
$193.91 $193.9190670 00005197102 PREVNAR 13 SYRINGE - PNEUMOCOCCAL
CONJUGATE VACCINE, 13 VALENT (PC $207.29 $207.2990670 00005197102
PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PC
$207.29 $207.2990670 00005197102 PREVNAR 13 SYRINGE - PNEUMOCOCCAL
CONJUGATE VACCINE, 13 VALENT (PC $217.66 $217.6690670 00005197105
PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PC
$200.00 $200.0090670 00005197105 PREVNAR 13 SYRINGE - PNEUMOCOCCAL
CONJUGATE VACCINE, 13 VALENT (PC $213.80 $213.8090670 00005197105
PREVNAR 13 SYRINGE - PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PC
$213.80 $213.8090670 00005197105 PREVNAR 13 SYRINGE - PNEUMOCOCCAL
CONJUGATE VACCINE, 13 VALENT (PC $224.49 $224.4990672 66019030601
FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE,
QUADRIVALEN $23.64 $23.6490672 66019030610 FLUMIST QUAD NASAL
2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALEN $23.64
$23.6490672 66019030601 FLUMIST QUAD NASAL 2019-20 VAC - INFLUENZA
VIRUS VACCINE, QUADRIVALEN $24.82 $24.8290672 66019030610 FLUMIST
QUAD NASAL 2019-20 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALEN
$24.82 $24.82
-
90672 66019030701 FLUMIST QUAD NASAL 2020-21 VAC - INFLUENZA
VIRUS VACCINE, QUADRIVALEN $24.82 $24.8290672 66019030710 FLUMIST
QUAD NASAL 2020-21 VAC - INFLUENZA VIRUS VACCINE, QUADRIVALEN
$24.82 $24.8290674 70461031903 FLUCELVAX QUAD 2019-2020 SYR -
INFLUENZA VIRUS VACCINE, QUADRIVALENT $24.77 $24.7790674
70461031904 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE,
QUADRIVALENT $24.77 $24.7790674 70461031903 FLUCELVAX QUAD
2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT $26.01
$26.0190674 70461031904 FLUCELVAX QUAD 2019-2020 SYR - INFLUENZA
VIRUS VACCINE, QUADRIVALENT $26.01 $26.0190674 70461032003
FLUCELVAX QUAD 2020-2021 SYR - INFLUENZA VIRUS VACCINE,
QUADRIVALENT $27.05 $27.0590674 70461032004 FLUCELVAX QUAD
2020-2021 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT $27.05
$27.0590675 49281024658 IMOVAX RABIES VACCINE VIAL - RABIES
VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.4090675 49281024858
IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE
$349.56 $349.5690675 49281024858 IMOVAX RABIES VACCINE VIAL -
RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40 $385.4090675
49281024858 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR
INTRAMUSCULAR USE $404.66 $404.6690675 49281025051 IMOVAX RABIES
VACCINE+DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR US $367.04
$367.0490675 49281025051 IMOVAX RABIES VACCINE+DILUENT - RABIES
VACCINE, FOR INTRAMUSCULAR US $385.40 $385.4090675 49281025051
IMOVAX RABIES VACCINE+DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR
US $385.40 $385.4090675 49281025051 IMOVAX RABIES VACCINE+DILUENT -
RABIES VACCINE, FOR INTRAMUSCULAR US $404.66 $404.6690675
49281025251 IMOVAX RABIES VACCINE VIAL - RABIES VACCINE, FOR
INTRAMUSCULAR USE $385.40 $385.4090675 49281025251 IMOVAX RABIES
VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $385.40
$385.4090675 58160096412 RABAVERT RABIES VACC W-DILUENT - RABIES
VACCINE, FOR INTRAMUSCULAR U $347.11 $347.1190675 58160096412
RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR
U $357.52 $357.5290675 58160096412 RABAVERT RABIES VACC W-DILUENT -
RABIES VACCINE, FOR INTRAMUSCULAR U $357.52 $357.5290675
58160096412 RABAVERT RABIES VACC W-DILUENT - RABIES VACCINE, FOR
INTRAMUSCULAR U $375.40 $375.4090675 58160096601 RABAVERT RABIES
VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR USE $347.11
$347.1190675 58160096601 RABAVERT RABIES VACCINE VIAL - RABIES
VACCINE, FOR INTRAMUSCULAR USE $357.52 $357.5290675 58160096601
RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR INTRAMUSCULAR
USE $357.52 $357.5290675 58160096601 RABAVERT RABIES VACCINE VIAL -
RABIES VACCINE, FOR INTRAMUSCULAR USE $375.40 $375.4090675
63851050101 RABAVERT RABIES VACCINE VIAL - RABIES VACCINE, FOR
INTRAMUSCULAR USE $262.40 $262.4090675 63851050102 RABAVERT RABIES
VACC W-DILUENT - RABIES VACCINE, FOR INTRAMUSCULAR U $337.12
$337.1290675 63851051111 RABAVERT RABIES VACCINE VIAL - RABIES
VACCINE, FOR INTRAMUSCULAR USE $337.12 $337.1290680 00006404701
ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE
SCHED $84.60 $84.6090680 00006404701 ROTATEQ VACCINE - ROTAVIRUS
VACCINE, PENTAVALENT (RV5), 3 DOSE SCHED $84.60 $84.6090680
00006404701 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5),
3 DOSE SCHED $86.30 $86.3090680 00006404701 ROTATEQ VACCINE -
ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHED $90.61
$90.6190680 00006404720 ROTATEQ VACCINE - ROTAVIRUS VACCINE,
PENTAVALENT (RV5), 3 DOSE SCHED $84.60 $84.6090680 00006404720
ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE
SCHED $84.60 $84.6090680 00006404720 ROTATEQ VACCINE - ROTAVIRUS
VACCINE, PENTAVALENT (RV5), 3 DOSE SCHED $86.29 $86.2990680
00006404720 ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5),
3 DOSE SCHED $90.61 $90.6190680 00006404741 ROTATEQ VACCINE -
ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHED $84.60
$84.6090680 00006404741 ROTATEQ VACCINE - ROTAVIRUS VACCINE,
PENTAVALENT (RV5), 3 DOSE SCHED $84.60 $84.6090680 00006404741
ROTATEQ VACCINE - ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE
SCHED $86.30 $86.3090680 00006404741 ROTATEQ VACCINE - ROTAVIRUS
VACCINE, PENTAVALENT (RV5), 3 DOSE SCHED $90.61 $90.6190681
58160085101 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN,
ATTENUATED (R $123.81 $123.8190681 58160085101 ROTARIX VACCINE
SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (R $127.52
$127.5290681 58160085101 ROTARIX VACCINE SUSPENSION - ROTAVIRUS
VACCINE, HUMAN, ATTENUATED (R $127.52 $127.5290681 58160085101
ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED (
$133.90 $133.9090681 58160085452 ROTARIX VACCINE SUSPENSION -
ROTAVIRUS VACCINE, HUMAN, ATTENUATED ( $123.81 $123.8190681
58160085452 ROTARIX VACCINE SUSPENSION - ROTAVIRUS VACCINE, HUMAN,
ATTENUATED ( $127.52 $127.5290681 58160085452 ROTARIX VACCINE
SUSPENSION - ROTAVIRUS VACCINE, HUMAN, ATTENUATED ( $127.52
$127.5290681 58160085452 ROTARIX VACCINE SUSPENSION - ROTAVIRUS
VACCINE, HUMAN, ATTENUATED ( $133.90 $133.9090682 49281071910
FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE,
QUADRIVALEN $49.96 $49.9690682 49281071988 FLUBLOK QUAD 2019-2020
SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALEN $49.96 $49.9690682
49281071910 FLUBLOK QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS
VACCINE, QUADRIVALEN $52.46 $52.4690682 49281071988 FLUBLOK QUAD
2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALEN $52.45
$52.4590682 49281072010 FLUBLOK QUAD 2020-2021 SYRINGE - INFLUENZA
VIRUS VACCINE, QUADRIVALEN $57.18 $57.1890682 49281072088 FLUBLOK
QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALEN
$57.18 $57.1890685 33332021920 AFLURIA QUAD 2019-20 (6-35MO) -
INFLUENZA VIRUS VACCINE, QUADRIVALENT ( $17.74 $17.7490685
33332021921 AFLURIA QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS
VACCINE, QUADRIVALENT ( $17.74 $17.7490685 49281051900 FLUZONE QUAD
PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT $19.45
$19.4590685 49281051925 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA
VIRUS VACCINE, QUADRIVALENT $19.45 $19.4590685 33332021920 AFLURIA
QUAD 2019-20 (6-35MO) - INFLUENZA VIRUS VACCINE, QUADRIVALENT (
$18.62 $18.6290685 33332021921 AFLURIA QUAD 2019-20 (6-35MO) -
INFLUENZA VIRUS VACCINE, QUADRIVALENT ( $18.62 $18.6290685
49281051900 FLUZONE QUAD PEDI 2019-20 SYR - INFLUENZA VIRUS
VACCINE, QUADRIVALENT $20.42 $20.4290685 49281051925 FLUZONE QUAD
PEDI 2019-20 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT $20.42
$20.4290685 33332022020 AFLURIA QUAD 2020-21 (6-35MO) - INFLUENZA
VIRUS VACCINE, QUADRIVALENT ( $19.37 $19.3790685 33332022021
AFLURIA QUAD 2020-21 (6-35MO) - INFLUENZA VIRUS VACCINE,
QUADRIVALENT ( $19.37 $19.3790686 33332031901 AFLURIA QUAD 2019-20
(3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT ( $17.74
$17.7490686 33332031902 AFLURIA QUAD 2019-20 (3YR UP) - INFLUENZA
VIRUS VACCINE, QUADRIVALENT ( $17.74 $17.7490686 58160089641
FLUARIX QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE,
QUADRIVALEN $16.55 $16.5590686 58160089652 FLUARIX QUAD 2019-2020
SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALEN $16.55 $16.5590686
19515090641 FLULAVAL QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE,
QUADRIVALENT (II $16.55 $16.5590686 19515090652 FLULAVAL QUAD
2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (II $16.55
$16.5590686 49281041950 FLUZONE QUAD 2019-2020 SYRINGE - INFLUENZA
VIRUS VACCINE, QUADRIVALEN $18.09 $18.0990686 49281041988 FLUZONE
QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALEN
$18.09 $18.0990686 49281041910 FLUZONE QUAD 2019-2020 VIAL -
INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV $18.09 $18.0990686
49281041958 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE,
QUADRIVALENT (IIV $18.09 $18.0990686 33332031901 AFLURIA QUAD
2019-20 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT ( $18.62
$18.6290686 33332031902 AFLURIA QUAD 2019-20 (3YR UP) - INFLUENZA
VIRUS VACCINE, QUADRIVALENT ( $18.62 $18.6290686 58160089641
FLUARIX QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE,
QUADRIVALEN $17.38 $17.3890686 58160089652 FLUARIX QUAD 2019-2020
SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALEN $17.38 $17.3890686
19515090641 FLULAVAL QUAD 2019-2020 SYR - INFLUENZA VIRUS VACCINE,
QUADRIVALENT (II $17.38 $17.3890686 19515090652 FLULAVAL QUAD
2019-2020 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (II $17.38
$17.38
-
90686 49281041950 FLUZONE QUAD 2019-2020 SYRINGE - INFLUENZA
VIRUS VACCINE, QUADRIVALEN $19.00 $19.0090686 49281041988 FLUZONE
QUAD 2019-2020 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALEN
$18.99 $18.9990686 49281041910 FLUZONE QUAD 2019-2020 VIAL -
INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV $19.00 $19.0090686
49281041958 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE,
QUADRIVALENT (IIV $18.99 $18.9990686 33332032001 AFLURIA QUAD
2020-21 (3YR UP) - INFLUENZA VIRUS VACCINE, QUADRIVALENT ( $19.37
$19.3790686 33332032002 AFLURIA QUAD 2020-21 (3YR UP) - INFLUENZA
VIRUS VACCINE, QUADRIVALENT ( $19.37 $19.3790686 58160088541
FLUARIX QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE,
QUADRIVALEN $17.90 $17.9090686 58160088552 FLUARIX QUAD 2020-2021
SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALEN $17.90 $17.9090686
19515081641 FLULAVAL QUAD 2020-2021 SYR - INFLUENZA VIRUS VACCINE,
QUADRIVALENT (II $17.90 $17.9090686 19515081652 FLULAVAL QUAD
2020-2021 SYR - INFLUENZA VIRUS VACCINE, QUADRIVALENT (II $17.90
$17.9090686 49281042050 FLUZONE QUAD 2020-2021 SYRINGE - INFLUENZA
VIRUS VACCINE, QUADRIVALEN $18.81 $18.8190686 49281042088 FLUZONE
QUAD 2020-2021 SYRINGE - INFLUENZA VIRUS VACCINE, QUADRIVALEN
$18.81 $18.8190686 49281042010 FLUZONE QUAD 2020-2021 VIAL -
INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV $18.81 $18.8190686
49281042058 FLUZONE QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE,
QUADRIVALENT (IIV $18.81 $18.8190687 49281063115 FLUZONE QUAD
2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV $8.34
$8.3490687 49281063178 FLUZONE QUAD 2019-2020 VIAL - INFLUENZA
VIRUS VACCINE, QUADRIVALENT (IIV $8.34 $8.3490687 49281063115
FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT
(IIV $8.75 $8.7590687 49281063178 FLUZONE QUAD 2019-2020 VIAL -
INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV $8.75 $8.7590687
33332042010 AFLURIA QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE,
QUADRIVALENT (IIV $8.93 $8.9390687 33332042011 AFLURIA QUAD
2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV $8.93
$8.9390687 49281063315 FLUZONE QUAD 2020-2021 VIAL - INFLUENZA
VIRUS VACCINE, QUADRIVALENT (IIV $8.75 $8.7590687 49281063378
FLUZONE QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT
(IIV $8.75 $8.7590688 33332041910 AFLURIA QUAD 2019-2020 VIAL -
INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV $17.16 $17.1690688
33332041911 AFLURIA QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE,
QUADRIVALENT (IIV $17.16 $17.1690688 19515089701 FLULAVAL QUAD
2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (I $16.24
$16.2490688 19515089711 FLULAVAL QUAD 2019-2020 VIAL - INFLUENZA
VIRUS VACCINE, QUADRIVALENT (I $16.24 $16.2490688 49281063115
FLUZONE QUAD 2019-2020 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT
(IIV $17.51 $17.5190688 49281063178 FLUZONE QUAD 2019-2020 VIAL -
INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV $17.51 $17.5190688
33332042010 AFLURIA QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE,
QUADRIVALENT (IIV $17.85 $17.8590688 33332042011 AFLURIA QUAD
2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV $17.85
$17.8590688 49281063315 FLUZONE QUAD 2020-2021 VIAL - INFLUENZA
VIRUS VACCINE, QUADRIVALENT (IIV $17.51 $17.5190688 49281063378
FLUZONE QUAD 2020-2021 VIAL - INFLUENZA VIRUS VACCINE, QUADRIVALENT
(IIV $17.51 $17.5190694 70461012003 FLUAD QUAD 2020-2021 SYRINGE
$57.19 $57.1990694 70461012004 FLUAD QUAD 2020-2021 SYRINGE $57.19
$57.1990696 49281056210 QUADRACEL DTAP-IPV VIAL - DIPHTHERIA,
TETANUS TOXOIDS, ACELLULAR PERT $50.13 $50.1390696 49281056210
QUADRACEL DTAP-IPV VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR
PERT $53.18 $53.1890696 49281056210 QUADRACEL DTAP-IPV VIAL -
DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERT $55.84 $55.8490696
49281056258 QUADRACEL DTAP-IPV VIAL - DIPHTHERIA, TETANUS TOXOIDS,
ACELLULAR PERT $50.13 $50.1390696 49281056258 QUADRACEL DTAP-IPV
VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERT $53.18
$53.1890696 49281056258 QUADRACEL DTAP-IPV VIAL - DIPHTHERIA,
TETANUS TOXOIDS, ACELLULAR PERT $55.84 $55.8490696 58160081201
KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS
VACCINE $50.61 $50.6190696 58160081201 KINRIX VIAL - DIPHTHERIA,
TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE $52.13 $52.1390696
58160081201 KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR
PERTUSSIS VACCINE $52.13 $52.1390696 58160081201 KINRIX VIAL -
DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE $54.74
$54.7490696 58160081211 KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS,
ACELLULAR PERTUSSIS VACCINE $50.61 $50.6190696 58160081211 KINRIX
VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE
$52.13 $52.1390696 58160081211 KINRIX VIAL - DIPHTHERIA, TETANUS
TOXOIDS, ACELLULAR PERTUSSIS VACCINE $52.13 $52.1390696 58160081211
KINRIX VIAL - DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS
VACCINE $54.74 $54.7490696 58160081243
