N.J. Admin. Code § 10:58-3.4 - HCPCS Procedure Codes (Level II) and maximum fee allowance schedule for certified nurse midwifery services

Current through Register Vol. 54, No. 7, April 4, 2022

HCPCS Maximum Fee
Codes Descriptions Allowance
J2790 RhoGAM, Rho (D) Immune $ 26.00
Globulin (Human)
Single dose (Micro-Dose)
J2790 22 RhoGAM, Rho (D) Immune $ 45.00
Globulin (Human)
Single dose (Full dose)
(22--Services greater than usual)
J1050 Medroxyprogesterone acetate, 100 mg 9.05
J1055 Medroxyprogesterone acetate for 44.54
contraceptive use, 150 mg
J1056 Lunelle (25mg medroxyprogesterone and 5 mg Lower of AWP
estradiol cypionate)/0.5 ml minus 12.5
percent or the
cost +
+ Effective September 18, 2006, the Maximum Fee Allowance based on the AWP
minus 12.5 percent is $ 24.95 per 0.5 ml. Enter the lower of the AWP minus
12.5 percent or the acquisition cost in Block 24G on the CMS 1500 claim


N.J. Admin. Code § 10:58-3.4
Amended by R.2001 d.204, effective 6/18/2001.
See: 33 N.J.R. 1160(a), 33 N.J.R. 2188(a).
Rewrote the table.
Amended by R.2006 d.338, effective 9/18/2006.
See: 38 N.J.R. 2003(a), 38 N.J.R. 3900(a).
In the table, inserted reference to HCPCS code "J1056".

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