N.J. Admin. Code § 10:58A-4.3 - HCPCS procedure codes and maximum fee allowance schedule for Level II codes and narratives

IND	HCPCS CODES		MOD	MAXIMUM FEE
		ALLOWANCE $
(a) APN Administered Drugs:
J0120		Injection, tetracycline, up to 250 mg			0.73
J0128		Injection, abarelix, 10 mg			70.81
J0129		Injection, abatacept, 10 mg			19.69
J0130		Injection, abciximab, 10 mg			601.69
J0132		Injection, acetylcysteine, 100 mg			2.16
J0133		Injection, acyclovir, 5 mg			0.16
J0135		Injection, adalimumab, 20 mg			335.64
J0150		Injection, adenosine, 6 mg			33.11
J0152		Injection, adenosine, 30 mg			76.50
J0170		Injection, adrenalin, epinephrine, up to 1 ml ampul			2.88
J0180		Injection, agalsidase beta, 1 mg			131.25
J0190		Injection, biperiden lactate, 5 mg			2.91
J0200		Injection, alatrofloxacin mesylate 100 mg			17.15
J0205		Injection, alglucerase, per 10 units			37.52
J0207		Injection, amifostine, 500 mg			536.14
J0210		Injection, methyldopate HCl, (Aldomet), up to 250 mg			1.74
J0215		Injection, alefacept, 0.5 mg			29.02
J0220		Injection, aglucosidase alfa, 10 mg			131.25
J0256		Injection, alpha 1-proteinase inhibitor-human, per 500			0.01
J0278		Injection, amikacin sulfate, 100 mg			2.29
J0280		Injection, aminophylline, up to 250 mg			0.75
J0282		Injection, amiodarone hydrochloride, 30 mg			0.80
J0285		Injection, amphotericin B, 50 mg			17.06
J0287		Injection, amphotericin B lipid complex, 10 mg			21.00
J0288		Injection, amphotericin B cholesteryl sulfate complex, 10 mg			15.17
J0289		Injection, amphotericin B liposome, 10 mg			34.34
J0290		Injection, ampicillin sodium, up to 500 mg			3.86
J0295		Injection, ampicillin sodium/sulbactam sodium, 1.5 mg			7.25
J0300		Injection, amobarbital, up to 125 mg			2.66
J0330		Injection, succinylcholine chloride, (Anectine), up to 20 mg			0.26
J0350		Injection, anistreplase, per 30 units			2,481.13
J0360		Hydralazine HCl, (Apresoline), up to 20 mg			14.77
J0364		Apomorphine hydrochloride, 1 mg			3.39
J0365		Aprotonin, 10,000 KIU			2.85
J0380		Injection, metaraminol bitartrate, per 10 mg			1.21
J0390		Injection, chloroquine HCl, (Araten HCl), up to 250 mg			17.44
J0395		Injection, arbutamine HCl, 1 mg			168.00
J0400		Injection, aripiprazole			0.31
J0456		Injection, azithromycin, 500 mg			27.09
J0461		Injection, atropine sulfate			0.24
J0470		Injection, dimercaprol, per 100 mg			28.84
J0475		Injection, baclofen, 10 mg			223.13
J0476		Injection, baclofen, 50 mcg for intrathecal trial			73.50
J0480		Basiliximab, 20 mg			2,215.72
J0500		Injection, dicyclomine HCl, (Bentyl, Spasmoject), 10 mg			18.52
J0515		Injection, benztropine mesylate, (Cogentin), 1 mg			12.21
J0520		Injection, bethanechol chloride, myotonachol or urecholine,			4.91
		up to 5 mg
J0559		Injection, penicillin G benzathine/procaine			0.08
J0560		Injection, penicillin G benzathine, (Bicillin long acting),			25.71
		up to 600,000 units
J0570		Injection, penicillin G benzathine, (Bicillin long acting),			19.76
		up to 1,200,000 units
J0580		Injection, penicillin G benzathine, (Bicillin long acting),			22.51
		up to 2,400,000 units
J0583		Bivalirudin, 1 mg			2.08
J0585		Botulinum toxin type A per unit			5.52
J0586		Botulinum toxin type A			7.16
J0587		Botulinum toxin type B, per 100 units			8.99
J0592		Injection, buprenorphine hydrochloride, 0.1 mg			1.02
J0594		Injection, busulfan, 1 mg			10.09
J0595		Butorphanol; tartrate, 1 mg			3.91
J0598		Injection, C1 Esterase inhibitor			37.71
J0600		Injection, edetate calcium disodium, 200 mg			52.89
J0610		Injection, calcium gluconate, per 10 ml			2.03
J0620		Injection calcium glycerophosphate and calcium lactate, per			12.58
		10 ml (Calphosan)
J0630		Injection, calcitonin salmon, up to 400 units			48.09
J0636		Injection, calcitriol, 0.1 mcg			1.34
J0637		Injection, caspofungin acetate, 5 mg			30.89
J0640		Injection, leucovorine calcium, 50 mg			3.28
J0641		Injection, levoleucovorin, 0.5 mg			1.05
J0670		Injection, mepivacaine HCl, (Carbocaine), per 10 ml			2.45
J0690		Injection, cefazolin sodium, (Ancef, Kefzol), up to 500 mg			2.83
J0692		Injection, cefepime HCl, 500 mg (Maxipime)			9.13
J0694		Injection, cefoxitin sodium, (Mefoxin), 1 gm			10.23
J0696		Injection, ceftriaxone sodium, (Rocephin), per 250 mg			12.97
J0697		Injection, sterile cefuroxime sodium, 750 mg			5.92
J0698		Cefotaxime sodium, (Claforan), per gm			7.10
J0702		Injection, betamethasone acetate and betamethasone sodium			2.88
		phosphate, per 3 mg
J0704		Injection, betamethasone sodium phosphate, per 4 mg			1.09
J0706		Injection, caffeine citrate, 5 mg (Cafcit)			3.53
J0710		Injection, cephapirin sodium (Cefadyl), up to 1 gram			1.44
J0713		Injection, ceftazidime, per 500 mg			6.48
J0715		Injection, ceftazoxime sodium, per 500 mg			5.89
J0718		Injection, certolizumab pegol			7.37
J0720		Injection, chloramphenicol sodium succinate, (Chloromycetin			14.62
		Sodium Succinate), up to 1 gram
J0735		Injection, clonidine hydrochloride, 1 mg			70.58
J0740		Injection, cidofovir, 375 mg			818.27
J0743		Injection, cilastatin sodium/imipenem (Primaxin), 250 mg			18.77
J0744		Injection, ciprofloxacin for IV infusion 200 mg (Cipro)			14.22
J0745		Injection, codeine phosphate, 30 mg			1.07
J0760		Injection, colchicine, per 1 mg			6.78
J0770		Injection, colistimethate sodium, (Coly-Mycin), up to 150mg			49.88
J0780		Injection, prochlorperazine, (Compazine), up to 10 mg			8.37
J0795		Corticorelin ovine triflutal, 1 mcg			4.75
J0800		Injection, corticotropin, up to 40 units			180.49
J0833		Injection, cosyntropin, nos			98.70
J0834		Injection, cosyntropin cortrosyn			107.44
J0850		Injection, cytomegalovirus immune globulin intravenous			925.32
		(human), per vial
J0878		Injection, dapromycin			0.35
J0881		Darbepoetin alpha, non-ESRD use, 1 mcg			5.01
J0882		Darbepoetin alpha, ESRD use, 1 mcg			5.01
J0885		Epoetin alfa, non-ESRD, 1,000 units			13.69
J0886		Injection, epoetin alfa, ESRD use, 1,000 units			13.31
J0886		Injection, epoetin alfa, non-ESRD use, 1,000 units			13.31
J0894		Injection, decitabine, 1 mg			26.25
J0895		Injection, deferoxamine mesylate, (Desferal), 100 mg			16.92
J0945		Injection, brompheniramine maleate, per 10 mg			0.62
J0970		Injection, estradiol valerate, up to 40 mg			34.60
J1000		Injection, depo-estradiol cypionate, 5 mg			6.59
J1020		Injection, methylprednisolone acetate, 20 mg			3.13
J1030		Injection, methylprednisolone acetate, 40 mg			6.34
J1040		Injection, methylprednisolone acetate, 80 mg			10.45
J1051		Injection, medroxyprogesterone acetate, 50 mg			15.47
J1055		Injection, medroxprogesterone acetate, for contraceptive use,			53.97
		150 mg
J1056		Injection, medroxyprogesterone acetate/estradial cypionate, 5			22.60
		mg/25 mg (Lunelle monthly contraceptive)
J1060		Injection, testosterone cypionate and estradiol cypionate, up			3.41
		to 1 ml
J1070		Injection, testosterone cypionate, up to 100 mg			6.04
J1080		Injection, testosterone cypionate, 1 cc/200 mg			12.03
J1094		Injection, dexamethasone acetate, 1 mg			0.53
J1100		Injection, dexamethasone sodium phosphate, 1 mg			0.13
J1110		Dihydroergotamine Mesylate, 1 mg			31.94
J1120		Injection, acetazolamide sodium, (Diamox Sodium), up to 500			22.97
		mg
J1160		Injection, digoxin, up to 0.5 mg			2.49
J1162		Digoxin immune fab (ovine), per vial			594.23
J1165		Injection, phenytoin sodium, (Dilantin), per 50 mg			0.70
J1170		Injection, hydromorphone, 2 mg			1.01
J1180		Injection, dyphylline, (Dilor, Lufyllin), up to 500 mg			8.30
J1190		Injection, dexrazoxane hydrochloride, per 250 mg			224.47
J1200		Injection, diphenhydramine HCl, (Benadryl), up to 50 mg			1.16
J1205		Injection, chlorothiazide sodium, (Diuril), per 500 mg			149.94
J1212		Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml			52.50
J1230		Injection, methadone HCl, (Dolophine HCl), up to 10 mg			2.14
J1240		Injection, demenhydrinate, (Dramamine), up to 50 mg			2.74
J1245		Injection, dipyridamole, per 10 mg			7.66
J1250		Injection, dobutamine hydrochloride, per 250 mg			43.51
J1260		Injection, dolasetron mesylate, 1 mg			4.27
J1265		Injection, dopamine, 40 mg			0.32
J1267		Injection, doripenem, 10 mg			0.81
J1270		Injection, doxercalciferol, 1 mcg (Hectorol)			6.31
J1300		Injection, eculizumab			182.00
J1320		Injection, amitriptyline HCl, (Elavil HCl), up to 20 mg			2.05
J1324		Injection, enfuvirtide, 1 mg			19.70
J1325		Injection, epoprostenol, 0.5 mg			19.47
J1327		Injection, eptifibatide, 5 mg			21.13
J1330		Injection, ergonovine maleate, up to 0.2 mg			5.08
J1335		Injection, ertapenem, 500 mg			27.27
J1364		Injection, erythromycin lactobionate, 500 mg			9.09
J1380		Injection, estradiol valerate, up to 10 mg			14.81
J1390		Injection, estradiol valerate, up to 20 mg			20.88
J1410		Injection, estrogen conjugated, per 25 mg			70.83
J1430		Ethanolamine oleate, 100 mg			84.99
J1435		Injection, estrone, per 1 mg			0.25
J1436		Injection, etidronate disodium, per 300 mg			70.88
J1438		Injection, etanercept, 25 mg			180.50
J1440		Injection, filgrastim, (G-CSF), 300 mcg			216.68
J1441		Injection, filagrastim, (G-CSF), 480 mcg			345.19
J1450		Injection, fluconazole, 200 mg			20.81
J1451		Fomepizole, 15 mg			12.11
J1452		Injection, fomivirsen sodium, intraocular, 1.65 mg			875.00
J1453		Injection, fosaprepitant, 1 mg			1.62
J1455		Injection, foscarnet sodium, (Foscavir), per 1000 mg			12.00
J1457		Injection, gallium nitrate, 1 mg			1.71
J1458		Injection, galsulfase, 1 mg			327.91
J1459		Injection, ivig privigen, 500 mg			45.94
J1460		Injection, gamma globulin I.M., 1 cc			15.45
J1470		Injection, gamma globulin I.M., 2 cc			30.89
J1480		Injection, gamma globulin I.M., 3 cc			46.34
J1490		Injection, gamma globulin I.M., 4 cc			61.78
J1500		Injection, gamma globulin I.M., 5 cc			77.23
J1510		Injection, gamma globulin I.M., 6 cc			92.67
J1520		Injection, gamma globulin I.M., 7 cc			108.12
J1530		Injection, gamma globulin I.M., 8 cc			123.56
J1540		Injection, gamma globulin I.M., 9 cc			139.01
J1550		Injection, gamma globulin I.M., 10 cc			118.00
J1561		Injection, immune globulin (Gamunex)			47.28
J1562		Injection, globulin sc, 100 mg			13.13
J1566		Immune globulin, powder, 500 mg			43.89
J1568		Injection, octagam			55.61
J1569		Injection, gammagard liquid			59.17
J1570		Injection, ganciclovir sodium, (Cytovene), 500 mg			54.38
J1571		Injection, hepagam B IM, 0.5 ml			75.00
J1572		Injection, flebogamma, 500 mg			44.10
J1573		Injection, hepagam B intravenous, 0.5 ml			75.00
J1580		Injection, garamycin, gentamicin, up to 80 mg			2.12
J1590		Injection, gatifloxacin, 10 mg (Tequin)			0.83
J1600		Injection, gold sodium thiomalate, 50 mg			13.69
J1610		Injection, glucagon hydrochloride, 1 mg			76.56
J1620		Injection, gonadorelin hydrochloride, per 100 mcg			186.03
J1626		Injection, granisetron hydrochloride, 100 mcg			17.08
J1630		Injection, haloperidol, up to 5 mg			6.55
J1631		Injection, haloperidol decanoate, 50 mg			2.97
J1640		Injection, hemin, 1 mg			7.52
J1642		Injection, heparin sodium, (Heparin Lock Flush), 10 units			0.07
J1644		Injection, heparin sodium, 1,000 units			0.14
J1645		Injection, dalteparin sodium, per 2,500 IU			17.47
J1650		Injection, enoxaparin sodium, 10 mg			7.10
J1652		Injection, fondaparinux sodium, 0.5 mg			8.79
J1655		Injection, tinzaparin sodium, 1,000 IU (Innohep)			3.97
J1670		Injection, tetanus immune globulin, human, up to 250 units			124.26
J1675		Injection, histrelin acetate, 10 mcg			8.24
J1680		Injection, human fibrinogen concentrate			91.56
J1700		Injection, hydrocortisone acetate, (Analpram HC, Hydrocortone			0.61
		Acetate), up to 25 mg
J1710		Injection, hydrocortisone sodium phosphate, (Hydrocortone			5.13
		Phosphate), up to 50 mg
J1720		Injection, hydrocortisone sodium succinate, (Solu-Cortef), up			1.74
		to 100 mg
J1730		Injection, diazoxide, (Hyperstat), up to 300 mg			117.96
J1740		Injection, ibandronate sodium, 1 mg			147.20
J1742		Injection, ibutilide fumarate, 1 mg			309.71
J1743		Injection, idursulfase			479.10
J1745		Injection, infliximab, 10 mg			61.15
J1750		Injection, iron dextran, 50 mg			13.41
J1756		Injection, iron sucrose, 1 mg			0.60
J1785		Injection, imiglucerase, per unit			4.05
J1790		Injection, droperidol, (Inapsine), up to 5 mg			3.72
J1800		Injection, propranolol HCl, (Inderal), up to 1 mg			8.62
J1810		Injection, droperidol and fentanyl citrate, (Innovar), up to			14.67
		2 ml ampule
J1815		Injection, insulin, per 5 units			0.34
J1817		Insulin for insulin pump use, per 50 units			4.50
J1825		Injection, interferon beta-1a, 33 mcg administered under			400.18
		direct supervision of a physician, excludes self administration
J1830		Injection, interferon beta-1B, 0.25 mg			96.08
J1835		Injection, itraconazole, 50 mg (Sporanox)			43.63
J1840		Injection, kanamycin sulfate, (Kantrex), up to 500 mg			7.70
J1850		Injection, kanamycin sulfate, (Kantrex), up to 75 mg			2.66
J1885		Injection, ketorolac tromethamine, (Toradol I.M.), per 15 mg			3.05
J1890		Injection, cephalothin sodium, (Keflin), up to 1 gram			9.45
J1930		Injection, lanreotide, 1 mg			27.81
J1931		Injection, laronidase (aldurazyme), 0.1 mg			24.63
J1940		Injection, furosemide, (Lasix), up to 20 mg			0.63
J1945		Lepirudin, 50 mg			174.13
J1950		Injection, leuprolide acetate, (Depot Suspension), 3.75 mg			544.60
J1953		Injection, levetiracetam, 10 mg			0.69
J1955		Injection, levocarnitine, per 1 gram			34.30
J1956		Injection, levofloxacin, 250 mg			18.82
J1960		Injection, levorphanal tartrate, up to 2 mg			3.72
J1980		Injection, hyoscyamine sulfate, (Levsin), up to 0.25 mg			10.35
J1990		Injection, chlordiazepoxide HCl, (Librium), up to 100mg			23.02
J2001		Injection, lidocaine, per 10 mg			0.31
J2010		Injection, lincomycin HCl, up to 300 mg			2.76
J2020		Injection, linezolid, 200 mg (Zyvox)			36.13
J2060		Injection, lorazepam (Atvian), 2 mg			2.82
J2150		Injection, mannitol, 25% in 50 ml			2.49
J2170		Injection, mecasermin, 1 mg			14.15
J2175		Injection, meperidine HCl, 100 mg			1.19
J2180		Injection, meperidine/ promethazine HCl, (Mepergan), up to 50			8.00
		mg
J2185		Meropenem, 100 mg			6.21
J2210		Injection, methylergonovine maleate, (Metherqine Maleate), up			5.37
		to 0.2 mg
J2248		Injection, micafungin sodium, 1 mg			2.05
J2250		Injection, midazolam hydrochloride, per 1 mg			0.56
J2260		Injection, milrinone lactate, per 5 ml			6.56
J2270		Injection, morphine sulfate, up to 10 mg			1.62
J2271		Injection, morphine sulfate, 100 mg			4.22
J2275		Injection, morphine sulfate, 10 mg (Preservative Free)			6.25
J2278		Injection, ziconotide, 1 mcg			6.99
J2280		Injection, moxifloxacin, 100 mg			9.57
J2300		Injection, nalbuphine HCl, per 10 mg			1.76
J2310		Injection, naloxone hydrochloride, per 1 mg			5.12
J2315		Naltrexone, depot form, 1 mg			2.00
J2320		Injection, nandrolone deconate, up to 50 mg			6.15
J2321		Injection, nandrolone deconoate, up to 100 mg			8.17
J2322		Injection, nandrolone deconoate, up to 200 mg			20.66
J2323		Injection, natalizumab			8.12
J2325		Injection, nesiritide, 0.1 mg			34.99
J2353		Injection, octreotide depot, 1 mg			104.36
J2354		Injection, octreotide, non-depot, 25 mcg			4.89
J2355		Injection, oprelvekin, 5 mg			267.75
J2357		Injection, omalizumab, 5 mg			18.11
J2360		Injection, orphenadrine citrate, (Norflex, Norgesic), up to			17.94
		60 mg
J2370		Injection, phenylephrine HCl, (Neo-Synephrine), up to 1 ml			2.73
J2400		Injection, chloroprocaine HCl, (Nesacaine and Nesacaine MPF),			17.17
		per 30 ml
J2405		Injection, ondansetron HCl, 1 mg			1.23
J2410		Injection, oxymorphone HCl, (Numorphan), up to 1 mg			2.85
J2425		Injection, paliferim, 50 mcg			12.03
J2430		Injection, pamidronate disodium, per 30 mg			92.70
J2440		Injection, papaverine HCl, up to 60 mg			4.77
J2460		Injection, oxytetracycline HCl, up to 50 mg			0.97
J2469		Palonosetron HCL, 25 mcg			34.86
J2501		Injection, paricalcitol, 1 mcg			5.11
J2503		Injection, pegaptanib sodium, .03 mg			1,088.28
J2504		Pedademase bovine, 25 IU			204.17
J2505		Injection, pegfilgrastim, 6 mg			3,080.01
J2510		Injection, penicillin G procaine, aqueous, up to 600,000			10.50
		units
J2513		Pentastarch 10% solution, 100 ml			13.16
J2515		Injection, pentobarbital sodium, per 50 mg			5.61
J2540		Injection, penicillen G potassium, up to 600,000 units			0.43
		(Pfizerpen)
J2543		Injection, piperacillin sodium/tazobactam sodium, 1 gram			5.81
		0.125 grams (1.125 g)
J2545		Pentamadine isethionate, 300 mg, solution for inhalation			86.41
J2550		Injection, promethazine HCl, (Phenergan), up to 50 mg			3.79
J2560		Phenobarbital Sodium, up to 120 mg			2.96
J2562		Injection, plerixafor			262.50
J2590		Injection, oxytocin, (Pitocin), up to 10 units			2.56
J2597		Injection, desmopressin acetate, per 1 mcg			5.01
J2650		Injection, prednisolone acetate, up to 1 ml			0.68
J2670		Injection, tolazoline HCl, (Priscoline HCl), up to 25 mg			3.61
J2680		Injection, fluphenazine deconoate, (Prolixin DeConoate), up			4.38
		to 25 mg
J2690		Injection, procainamide HCl, (Proenstyl), up to 1 gram			3.45
J2700		Injection, oxacillin sodium, (Prostaphlin), up to 250 mg			1.02
J2710		Injection, neostigmine methylsulfate, (Prostigmin			0.44
		Methylsulfate), up to 0.5 mg
J2720		Injection, protamine sulfate, 10 mg			0.93
J2724		Protein C concentrate, 10 I.U.			1.26
J2725		Injection, protirelin, per 250 mcg			22.47
J2730		Injection, pralidoxime chloride, (Protopam Chloride), up to 1			94.83
		gm
J2760		Injection, phentolamine mesylate, (Regitine), up to 5 mg			33.91
J2765		Injection, metoclopramide HCl, (Reglan), up to 10 mg			0.77
J2770		Injection, quinupristin/dalfopri stin, 500 mg (150/350)			137.00
J2778		Injection, ranibizumab			426.56
J2780		Injection, ranitidine hydrochloride, 25 mg			1.38
J2783		Rasburicase, 0.5 mg			152.18
J2785		Injection, regadenoson, 0.1 mg			107.50
J2788 UD		Injection, Rho D immune globulin, human, minidose, 50 mcg			49.55
J2788		Injection, Rho D immune globulin, human, minidose, 50 mcg			49.55
J2790		Injection, Rho (D) Immune Globulin, (Human), (Rhogam), Human,			115.94
		Full dose, 300 mcg
J2790 UD		Injection, RHO (D) Immune Globulin Human, Full dose, 300 mcg			115.94
J2791		Injection, rhophylac			1.12
J2792		Injection, Rho(D) immune globulin, intravenous, human,			20.71
		solvent detergent, 100 IU
J2793		Injection, rilonacept			22.91
J2794		Risperidone, long acting, 0.5 mg			5.10
J2795		Injection, ropivacaine hydrochloride, 1 mg			0.08
J2796		Injection, romiplostim			43.70
J2800		Injection, methocarbamol, (Robaxin), up to 10 ml			17.27
J2805		Injection, sincalide, 5 mcg			60.03
J2820		Injection, sarqramostim, (GM-CSF), 50 mcg			33.30
J2850		Injection, secretin synthetic, human, 1 mcg			22.22
J2910		Injection, aurothioglucose, (Solqanal), up to 50 mg			25.73
J2916		Injection, sodium ferric gluconate complex in sucrose			7.53
		Injection, 12.5 mg
J2920		Injection, methylprednisolone sodium succinate, (Solu			2.25
		Medrol), up to 40 mg
J2930		Injection, methylprednisolone sodium succinate, (Solu			3.79
		Medrol), up to 125 mg
J2941		Injection, somatropin, 1 mg			48.21
J2950		Injection, promazine HCl, (Prozine, Sparine), up to 25 mg			0.22
J2993		Injection, reteplase, 18.8 mg			1,319.55
J2995		Injection, streptokinase, per 250,000 IU			82.03
J2997		Injection, alteplase recombinant, 1 mg			33.47
J3000		Injection, streptomycin, up to 1 gram			7.96
J3010		Injection, fentanyl citrate, (Sublimaze), up to 2 ml			0.63
J3030		Injection, sumatriptan succinate, 6 mg			137.25
J3070		Injection, pentazocine HCl, (Talwin), up to 30 mg			4.43
J3101		Injection, tenecteplase, 1 mg			51.09
J3105		Terbutaline sulfate, up to 1 mg			15.86
J3120		Injection, testosterone enanthate, up to 100 mg			0.39
J3130		Injection, testosterone enanthate, up to 200 mg			17.88
J3150		Injection, testosterone propionate, up to 100 mg			0.87
J3230		Injection, chlorpromazine HCl, (Thorazine), up to 50 mg			5.70
J3240		Injection, thyrotropin, alpha 1.1 mg			869.53
J3243		Injection, tigecycline, 1 mg			1.04
J3246		Tirofiban HCL (Aggrastat), 0.25 mg			9.29
J3250		Injection, trimethobenzamide HCl, up to 200 mg			2.88
J3260		Injection, tobramycin sulfate, (Nebcin), up to 80 mg			3.71
J3265		Injection, torsemide, 10 mg/ml			2.74
J3280		Injection, thiethylperazine maleate, up to 10 mg			4.24
J3285		Injection, treprostinil, 1 mg			58.84
J3300		Injection, triamcinolone A, prs-free, 1 mg			0.06
J3301		Injection, triamcinolone acetonide, (Kenalog), 10 mg			1.45
J3302		Injection, triamcinolole diacetate, (Aristocort), per 5 mg			0.57
J3303		Injection, triamcinolone hexacetonide, (Aristospan), per 5 mg			2.97
J3305		Injection, trimetrexate glucoronate, per 25 mg			154.48
J3310		Injection, perphenazine, (Trilafon), up to 5 mg			6.38
J3315		Injection, triptorelin pamoate, 3.75 mg			530.47
J3320		Injection, spectinomycin hydrochloride, (Trobicin), up to 2			31.05
		mg
J3350		Injection, urea, (Ureaphil), up to 40 mg			77.77
J3360		Injection, diazepam, (Valium), up to 5 mg			1.25
J3364		Injection, urokinase, 5,000 IU vial			49.53
J3365		Injection, IV, urokinase, 250,000 IU vial			472.31
J3370		Injection, vancomycin HCl, up to 500 mg			4.01
J3396		Injection, verteporfin, .01 mg			10.14
J3400		Injection, triflupromazine HCl, (Vesprin), up to 20 mg			11.38
J3410		Injection, hydroxyzine HCl, (Vistaril), 25 mg			0.39
J3411		Thiamine HCL, 100 mg			1.89
J3415		Pyridoxine HCL, 100 mg			2.49
J3420		Injection, vitamin B-12 cyanocobalamin, up to 1,000 mg			0.42
J3430		Injection, phytonadione, (Vitamin K), 1 mg			2.26
J3465		Injection, voriconazole, 10 mg			5.54
J3470		Injection, hyaluronidase, (Wydase), up to 150 units			21.88
J3471		Ovine, up to 999 USP units			0.12
J3472		Ovine, 1000 USP units			142.19
J3475		Injection, magnesium sulfate, per 500 mg			3.13
J3480		Injection, potassium chloride, per 2 mEq			0.09
J3485		Injection, zidovudine, 10 mg			1.19
J3486		Ziprasidone mesylate, 10 mg			5.36
J3487		Injection, zoledronic acid, 1 mg			223.00
J3488		Injection, reclast			227.84
J7030		Infusion, normal saline solution, 1,000 ml = 1 unit			7.14
J7040		Infusion, normal saline solution, sterile, 500 ml = 1 unit			6.98
J7042		5% dextrose/normal saline solution, 500 ml = 1 unit			5.65
J7050		Infusion, normal saline solution. 250 ml = 1 unit			6.03
J7060		5% dextrose/water solution, 500 ml = 1 unit			8.09
J7070		Infusion, D5W, 1,000 cc			7.10
J7100		Infusion, dextran 40, 500 ml			54.49
J7110		Infusion, dextran 75, 500 ml			64.28
J7120		Ringer's Lactate Infusion, up to 1,000 ml = 1 unit			10.39
J7185		Injection, xyntha			1.39
J7186		Antihemophilic VIII/VWF composition			1.06
J7189		Factor VIIA (antihemophilic factor, recombinant), per IU			1.44
J7190		Factor VIII (antihemophilic factor, human) per IU			0.90
J7191		Factor VIII (antihemophilic factor, porcine) per IU			1.93
J7192		Factor VIII (antihemophilic factor, recombinant), per IU			1.48
J7193		Factor IX (antihemophilic factor, purified non-recombinant)			1.09
		per IU (Alphanine SD)
J7194		Factor IX complex, per IU			0.59
J7195		Factor IX (antihemophilic factor, recombinant) per IU			0.91
		(Benefix)
J7198		Anti-inhibitor, per IU			1.31
J7300		Intrauterine copper contraceptive (Paragard)			396.64
J7302		Levonorgestrel-releasing intrauterine contraceptive system,			450.88
		52 mg (Mirena)
J7303		Contraceptive vaginal ring			40.02
J7304		Contraceptive hormone patch			15.72
J7307		Estrogestrel implant system			620.08
J7310		Ganciclovir, 4.5 mg, long-acting implant			4,725.00
J7311		Fluocinolone acetonide implant			1,662.50
J7321		Injection, hyalgan/supartz, per dose			126.88
J7323		Injection, euflexxa, per dose			133.96
J7324		Injection, orthovisc, per dose			228.69
J7325		Injection, synvisc or synvisc-one			405.72
J7500		Azathioprine, oral, 50 mg			1.15
J7501		Azathioprine; parenteral, vial, 100 mg, 20 ml each			74.38
J7502		Cyclosporin, oral, 100 mg			5.34
J7503		Cyclosporin, parenteral, 50 mg			5.50
J7504		Lymphocyte immune globulin, antithymocyte globulin,			367.36
		parenteral, amp, 50 mg/ml, 5 ml each
J7506		Prednisone, oral, 5 mg tablet			0.14
J7507		Tacrolimus, oral, per 1 mg			3.97
J5709		Methylprednisolone, oral, 4 mg			0.58
J5710		Prednisolone, oral, 5 mg			0.12
J7511		Lymphocyte immune globulin, antithymocyte globulin, rabbit,			426.56
		parenteral, 25 mg (Thymoglobulin)
J7513		Daclizumab, parenteral, 25 mg			449.66
J7515		Cyclosporine, oral, 25 mg			1.20
J7516		Cyclosporine, parenteral, 250 mg			24.06
J7517		Mycophenolate mofetil, 250 mg			3.27
J7518		Mycophenolic acid, 180 mg			4.02
J7520		Sirolimus, oral, 1 mg			7.97
J7525		Tacrolimus, parenteral, 5 mg			149.43
J7604		Acetylcysteine, comp unit, per gram			3.57
J7605		Arformoterol, non-comp unit, 15 mcg			5.04
J7606		Formoterol fumarate, inhale			5.60
J7607		Levabuterol, comp concentrate, 0.5 mg			1.33
J7608		Acetylcysteine, inhale solution, unit dose, per gram			1.80
J7611		Albuterol, concentrate form, 1 mg			0.15
J7612		Levabuterol, concentrate, 0.5 mg			1.19
J7613		Albuterol, unit dose, 1 mg			0.54
J7614		Levalbuterol, unit dose, 0.5 mg			2.61
J7615		Levalbuterol, inhalation solution, 0.5 mg			1.89
J7620		Albuterol, 2.5 mg/Ipratrop, 0.5 mg			2.18
J7626		Budesonide, inhalation solution, up to 0.5 mg			9.35
J7627		Budesonide, powder, inhalation, up to 0.5 mg			161.35
J7628		Bitolterol mesylate, concentrate form, per mg			0.48
J7631		Cromolyn sodium, unit dose form			0.34
J7632		Cromolyn sodium, comp unit			0.31
J7634		Budesonide, comp concentrate, per 0.25 mg			4.81
J7635		Atropine, inhalation solution, concentrated, per mg			1.23
J7636		Atropine, inhalation solution, unit dose, per mg			1.09
J7637		Dexamethasone, inhalation solution, concentrated, per mg			0.43
J7638		Dexamethasone, inhalation solution, unit dose, per mg			0.20
J7639		Dornase alpha inhalation solution			21.00
J7642		Glycopyrrolate, inhalation solution, per mg			2.32
J7644		Ipratroprium bromide, inhalation solution, per mg			1.54
J7645		Ipratroprium bromide, inhalation solution, comp, per mg			1.26
J7669		Metaproterenol, inhalation solution, unit dose, per 10 mg			0.49
J7674		Methacholine chloride, nebulizers, per mg			0.42
J7676		Pentamidine comp, unit dose			93.44
J7682		Tobramycin, inhalation solution, 300 mg			66.11
J7684		Triamcinolone, inhalation solution, per mg			0.61
J8501		Oral aprepitant, 5 mg			4.71
J8510		Bulsulfan, oral, 2 mg			2.59
J8520		Capecitabine, oral, 150 mg			6.51
J8521		Capecitabine, oral, 500 mg			21.71
J8530		Cyclophosphamide, oral, 25 mg			3.15
J8560		Etoposide, oral, 50 mg			41.68
J8600		Melphalan, oral, 2 mg			5.29
J8610		Methotrexate, oral, 2.5 mg			3.19
J8700		Temozolomide, 5 mg			7.93
J9000		Doxorubicin HCl, (Adriamycin), 10 mg			12.03
J9001		Doxorubicin HCI, all lipid formulations, 10 mg			435.26
J9010		Alemtuzumab, 10 mg			585.40
J9015		Aldesleukin, per single use vial			826.40
J9017		Arsenic trioxide, 1 mg (Trisenox)			36.79
J9020		Asparaginase, 10,000 units			55.02
J9025		Injection, azacitidine, 1 mg			4.42
J9027		Injection, clofarabine, 1 mg			123.05
J9031		BCG (intravesical) per installation			172.59
J9033		Injection, bendamustine, 1 mg			19.13
J9035		Injection, bevacizumab (Avastin), 10 mg			60.16
J9040		Bleomycin sulfate, (Blenoxane) 15 units			77.11
J9041		Injection, bortezomib (Velcade), 0.1 mg			35.31
J9045		Carboplatin (Paraplatin), 50 mg			76.42
J9050		Carmustine, (BiCNU), 100 mg			163.91
J9055		Injection, cetuximab (Erbitux), 10 mg			52.50
J9060		Cisplatin, (Platinol), powder or solution, 10 mg			4.05
J9062		Cisplatin, 50 mg			20.13
J9065		Injection, cladribine, (Leustatin), per 1 mg			53.05
J9070		Cyclophosphamide, (Cytoxan), 100 mg			2.52
J9080		Cyclophosphamide, (Cytoxan), 200 mg			5.04
J9090		Cyclophosphamide, (Cytoxan), 500 mg			13.86
J9091		Cyclophosphamide, (Cytoxan), 1 gram			25.08
J9092		Cyclophosphamide, (Cytoxan), 2 grams			45.37
J9093		Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 100 mg			5.42
J9094		Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 200 mg			10.29
J9095		Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 500 mg			21.60
J9096		Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 1 gram			43.21
J9097		Cyclophosphamide, lyophilized, (Lyophilized Cytoxan), 2 grams			86.44
J9098		Cytarabine liposome, 10 mg			437.50
J9100		Cytarabine, (Cytarabine Hydrochloride), 100 mg			3.17
J9110		Cytarabine, (Cytarabine Hydrochloride), 500 mg			8.75
J9120		Dactinomycin, 0.5 mg			519.53
J9130		Dacarbazine, 100 mg			10.34
J9140		Dacarbazine, 200 mg			20.67
J9150		Daunorubicin, 10 mg			70.57
J9151		Daunorubicin citrate, liposomal formulation, 10 mg			59.50
J9155		Injection, degarelix			3.92
J9160		Denileukin diftitox, 300 mcg			1,487.50
J9165		Injection, diethlstilbestrol diphosphate, (Stilphostrol), 250			13.27
		mg
J9171		Injection, docetaxel			19.51
J9175		Elliotts B solution, per ml			4.29
J9178		Injection, epirubicin, 2 mg			26.22
J9181		Etoposide, (VePesid), 10 mg			1.64
J9185		Fludarabine Phosphate, 50 mg			317.80
J9190		Fluorouracil, 500 mg			3.28
J9200		Floxuridine, 500 mg			130.70
J9201		Gemcitabine HCl, (Gemzar), 200 mg			135.98
J9202		Goserelin acetate implant, (Zoladex), 3.6 mg			411.24
J9206		Irinotecan, 20 mg			134.24
J9207		Injection, ixabepilione, 1 mg			65.31
J9208		Ifosfomide, 1 gram			63.49
J9209		Mesna, (Mesnex), 200 mg			30.76
J9211		Idarubicin hydrochloride, 5 mg			386.79
J9212		Injection, interferon alfacon-1, recombinant, 1 mcg			8.50
J9213		Interferon alfa-2A, Recombinant, 3 million units			40.53
J9214		Interferon alfa-2B, recombinant, 1 million units (Intron A)			14.84
J9215		Interferon alfa-N3 (human leukocyte derived) 250,000 IU			15.68
		(Alferon N)
J9216		Interferon gamma-1B, 3 million units			344.41
J9217		Leuprolide acetate, (Lupron Depot), 7.5 mg			678.73
J9218		Leuprolide acetate, (Lupron), 1 mg			271.53
J9219		Leuprolide acetate implant, 65 mg			4,973.50
J9225		Histrelin implant, 50 mg			5,250.00
J9226		Supprelin LA implant			15,312.50
J9230		Mechlorethamide HCl, (nitrogen mustard), Mustargen OE, 10 mg			152.08
J9245		Injection, melphalan HCl, 50 mg			1,267.39
J9250		Methotrexate sodium, 5 mg (Folex)			0.48
J9260		Methotrexate sodium, 50 mg			4.16
J9261		Injection, nelarabine, 50 mg			90.13
J9263		Oxaliplatin, 0.5 mg			9.32
J9264		Injection, paclitaxel, 1 mg			9.40
J9265		Paclitaxel, 30 mg			151.13
J9266		Pegaspargase, per single dose vial			2,187.50
J9268		Pentostatin, per 10 mg			2,324.00
J9270		Plicamycin, (Mithracin), 2.5 mg			86.39
J9280		Mitomycin, 5 mg			61.25
J9290		Injection, mitoxantrone HCl, per 5 mg			199.06
J9291		Mitomycin, 40 mg			273.44
J9293		Injection, mitoxantrone HCl, per 5 mg			325.23
J9300		Gemtuzumab ozogamicin, 5 mg (Gemzar)			2,563.75
J9303		Injection, panitumumab			87.50
J9305		Injection, pemetrexed (Alimta), 10 mg			47.63
J9310		Rituximab, 100 mg			571.97
J9320		Streptozocin, 1 gram			113.78
J9328		Injection, temozolomide			4.75
J9330		Injection, temsirolimus, 1 mg			48.99
J9340		Thiotepa, 15 mg			85.59
J9350		Topotecan, 4 mg			932.71
J9355		Trastuzumab, 10 mg			61.81
J9357		Valrubicin, intravesical, 200 mg			485.10
J9360		Vinblastine sulfate, (Velban), 1 mg			2.90
J9370		Vincristine sulfate, (Oncovin), 1 mg			12.60
J9375		Vincristine sulfate, (Oncovin), 2 mg			25.21
J9380		Vincristine sulfate, (Oncovin), 5 mg			142.37
J9390		Vinorelbine tartrate, per 10 mg			82.25
J9395		Injection, fulvestrant, 25 mg			86.93
J9600		Porfimer sodium, (Photofrin), 75 mg			2,637.93

Notes

N.J. Admin. Code § 10:58A-4.3

Amended by R.2000 d.144, effective 4/3/2000.
See: 31 N.J.R. 3968(a), 32 N.J.R. 1208(a).
Rewrote the section.
Amended by R.2004 d.409, effective 11/1/2004.
See: 35 N.J.R. 4977(a), 36 N.J.R. 4968(a).
Rewrote the section.
Amended by R.2005 d.406, effective 11/21/2005.
See: 37 N.J.R. 2329(a), 37 N.J.R. 4445(a).
Rewrote the section.
Amended by R.2011 d.119, effective 4/18/2011.
See: 42 N.J.R. 2890(a), 43 N.J.R. 1015(a).
Rewrote the section.