Medicare maximum payment for J1956,J1980 J2001 J2020 J2175 J2180

Drugs & Biologicals: Maximum Allowed Units (MAUs) - Palmetto GBA Medicare

Maximum Allowed Units List - 2

KEY	HCPCS Code	Code Description	MAU	Release Date	Reassesment Date
	J1956	Injection, levofloxacin, 250 mg	3	11/14/2008
	J1980	Injection, hyoscyamine sulfate, up to 0.25 mg	6	12/16/2008
	J2001	Injection, lidocaine HCl for intravenous infusion, 10 mg	210	12/16/2008
	J2010	Injection, lincomycin HCl, up to 300 mg	7	12/3/2008
	J2020	Injection, linezolid, 200 mg	3	7/17/2009
	J2060	Injection, lorazepam, 2 mg	4	12/16/2008
	J2150	Injection, mannitol, 25% in 50 ml	8	12/16/2008	7/1/2010
	J2175	Injection, meperidine HCl, per 100 mg	3	12/3/2008
4	J2180	Injection, meperidine and promethazine HCl, up to 50 mg	0	11/21/2008
	J2185	Injection, meropenem, 100 mg	88	12/16/2008
	J2210	Injection, methylergonovine maleate, up to 0.2 mg	3	12/16/2008	7/1/2010
	J2250	Injection, midazolam hydrochloride, per 1 mg	22	12/16/2008
	J2270	Injection, morphine sulfate, up to 10 mg	3	11/14/2008	7/1/2010
	J2271	Injection, morphine sulfate, 100 mg	1	11/14/2008
5	J2275	Injection, morphine sulfate (preservative-free sterile solution), per 10 mg	15	12/3/2008
	J2280	Injection, moxifloxacin, 100 mg	4	7/17/2009
	J2300	Injection, nalbuphine HCl, per 10 mg	16	11/14/2008
	J2310	Injection, naloxone hydrochloride, per 1 mg	10	12/16/2008
	J2320	Injection, nandrolone deconoate, up to 50 mg	4	12/16/2008
	J2321	Injection, nandrolone deconoate, up to 100 mg	2	7/17/2009
	J2322	Injection, nandrolone decanoate, up to 200 mg	1	4/1/2010
	J2323	Injection, natalizumab, 1 mg	300	11/14/2008
	J2353	Injection, octreotide, depot form for intramuscular injection, 1 mg	30	12/16/2008	Denied
3	J2354	Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg	0	12/16/2008
	J2355	Injection, oprelvekin, 5 mg	1	11/14/2008
5	J2357	Injection, omalizumab, 5 mg	75	12/16/2008
	J2360	Injection, orphenadrine citrate, up to 60 mg	1	12/3/2008
	J2405	Injection, ondansetron hydrochloride, per 1 mg	50	12/16/2008
	J2410	Injection, oxymorphone HCl, up to 1 mg	5	12/16/2008
	J2430	Injection, pamidronate disodium, per 30 mg	3	11/14/2008
	J2440	Injection, papaverine HCl, up to 60 mg	2	11/14/2008
	J2460	Injection, oxytetracycline HCl, up to 50 mg	5	7/17/2009
	J2469	Injection, palonosetron HCl, 25 mcg	10	11/14/2008
	J2503	Injection, pegaptanib sodium, 0.3 mg	2	11/14/2008
	J2505	Injection, pegfilgrastim, 6 mg	1	11/7/2008
	J2510	Injection, penicillin G procaine, aqueous, up to 600,000 units	4	11/14/2008	7/1/2010
	J2543	Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams)	12	12/16/2008	6/1/2010
	J2550	Injection, promethazine HCl, up to 50 mg	3	12/3/2008
	J2562	Injection, plerixafor, 1 mg	40	1/1/2010
	J2597	Injection, desmopressin acetate, per 1 mcg	32	12/16/2008
4	J2650	Injection, prednisolone acetate, up to 1 ml	0	11/21/2008
3	J2675	Injection, progesterone, per 50 mg	0	11/21/2008
	J2680	Injection, fluphenazine decanoate, up to 25 mg	4	11/14/2008
	J2690	Injection, procainamide HCl, up to 1 gram	1	11/14/2008
	J2720	Injection, protamine sulfate, per 10 mg	5	11/14/2008
	J2760	Injection, phentolamine mesylate, up to 5 mg	1	11/14/2008
	J2765	Injection, metoclopramide HCl, up to 10 mg	132	12/16/2008
	J2778	Injection, ranibizumab, 0.1 mg	10	12/16/2008
	J2780	Injection, ranitidine hydrochloride, 25 mg	4	12/16/2008
8	J2785	Injection, regadenoson, 0.1 mg	4	12/16/2008
	J2788	Injection, RHo D immune globulin, human, minidose, 50 micrograms	1	7/1/2010
	J2790	Injection, RHo D immune globulin, human, full dose, 300 micrograms (1500 IU)	1	11/14/2008
	J2791	Injection, RHo D immune globulin, human, IM or IV, 100 IU	275	7/1/2010
	J2792	Injection, RHo D immune globulin, intravenous, human, solvent detergent, 100 IU	300	11/14/2008	7/1/2010
5	J2793	Injection, rilonacept, 1 mg	440	1/1/2010
	J2794	Injection, risperidone, long acting, 0.5 mg	100	11/14/2008
5	J2795	Injection, ropivacaine hydrochloride, 1 mg	300	12/16/2008
5	J2796	Injection, romiplostim, 10 micrograms	150	1/1/2010
	J2800	Injection, methocarbamol, up to 10 ml	2	12/3/2008
	J2805	Injection, sincalide, 5 micrograms	1	11/14/2008
5	J2820	Injection, sargramostim (GM-CSF), 50 mcg	15	11/14/2008	2/17/2009
	J2910	Injection, aurothioglucose, up to 50 mg	1	11/14/2008
4	J2912	Injection, sodium chloride, 0.9%, per 2 ml	0	11/14/2008
	J2916	Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg	10	12/16/2008
	J2920	Injection, methylprednisolone sodium succinate, up to 40 mg	83	12/16/2008
	J2930	Injection, methylprednisolone sodium succinate, up to 125 mg	27	12/16/2008
3	J2941	Injection, somatropin, 1 mg	0	11/21/2008
	J2950	Injection, promazine HCl, up to 25 mg	8	12/16/2008
	J2997	Injection, alteplase recombinant, 1 mg	100	12/16/2008
	J3000	Injection, streptomycin, up to 1 gram	2	12/3/2008
5	J3010	Injection, fentanyl citrate, 0.1 mg	3	12/3/2008
3	J3030	Injection, sumatriptan succinate, 6 mg (only for direct physician supervision administration)	0	11/21/2008
	J3070	Injection, pentazocine, 30 mg	4	12/16/2008
1	J3100	Injection, tenecteplase, 50 mg	1	7/17/2009
8	J3101	Injection, tenecteplase, 1 mg	50	12/16/2008
	J3105	Injection, terbutaline sulfate, up to 1 mg	1	11/14/2008
	J3120	Injection, testosterone enanthate, up to 100 mg	4	12/3/2008
	J3130	Injection, testosterone enanthate, up to 200 mg	2	11/14/2008
4	J3140	Injection, testosterone suspension, up to 50 mg	0	11/21/2008
4	J3150	Injection, testosterone propionate, up to 100 mg	0	11/21/2008
	J3230	Injection, chlorpromazine HCl, up to 50 mg	4	12/16/2008
	J3240	Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial	1	11/14/2008
	J3243	Injection, tigecycline, 1 mg	100	11/14/2008
	J3250	Injection, trimethobenzamide HCl, up to 200 mg	2	11/14/2008
	J3260	Injection, tobramycin sulfate, up to 80 mg	5	12/16/2008
	J3265	Injection, torsemide, 10 mg/ml	2	11/14/2008
8	J3300	Injection, triamcinolone acetonide, preservative free, 1 mg	40	12/16/2008
	J3301	Injection, triamcinolone acetonide, not otherwise specified, per 10 mg	16	12/16/2008
4	J3302	Injection, triamcinolone diacetate, per 5 mg	0	11/21/2008
	J3303	Injection, triamcinolone hexacetonide, per 5 mg	12	12/16/2008	4/10/2009
	J3315	Injection, triptorelin pamoate, 3.75 mg	6	11/14/2008	7/1/2010
	J3360	Injection, diazepam, up to 5 mg	6	12/16/2008
	J3370	Injection, vancomycin HCl, 500 mg	8	12/16/2008	9/18/2009
	J3396	Injection, verteporfin, 0.1 mg	150	12/16/2008
	J3410	Injection, hydroxyzine HCl, up to 25 mg	12	12/16/2008
	J3411	Injection, thiamine HCl, 100 mg	1	11/21/2008
	J3420	Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg	1	11/21/2008
	J3430	Injection, phytonadione (vitamin K), per 1 mg	100	12/16/2008
	J3470	Injection, hyaluronidase, up to 150 units	2	11/21/2008
	J3471	Injection hyaluronidase, ovine, preservative free, per 1 usp unit (up to 999 USP units)	400	12/16/2008
	J3473	Injection, hyaluronidase, recombinant, 1 USP unit	300	7/17/2009
	J3475	Injection, magnesium sulfate, per 500 mg	48	12/16/2008
	J3480	Injection, potassium chloride, per 2 mEq	60	12/16/2008
	J3486	Injection, ziprasidone mesylate, 10 mg	4	11/21/2008
	J3487	Injection, zoledronic acid, 1 mg	4	12/3/2008
	J3488	Injection, zoledronic acid, 1 mg	5	11/21/2008
2	J3520	Edetate disodium, per 150 mg	0	11/21/2008
2	J3535	Drug administered through a metered dose inhaler	0	11/21/2008
	J7030	Infusion, normal saline solution, 1000 cc	2	12/16/2008
	J7040	Infusion, normal saline solution, sterile (500 ml = 1 unit)	4	12/3/2008
	J7042	5% dextrose/normal saline solution (500 ml = 1 unit)	4	12/3/2008
	J7050	Infusion, normal saline solution , 250 cc	8	12/16/2008
	J7060	5% dextrose/water (500 ml = 1 unit)	4	12/3/2008
	J7070	Infusion, D5W, 1000 cc	2	11/21/2008
	J7100	Infusion, dextran 40, 500 ml	2	7/1/2010
	J7110	Infusion, dextran 75, 500 ml	2	7/1/2010
	J7120	Ringers lactate infusion, up to 1000 cc	4	12/3/2008	7/1/2010
2	J7130	Hypertonic saline solution, 50 or 100 mEq, 20 cc vial	0	11/21/2008
5	J7185	Injection, factor VII (antihemophilic factor, recombinant) (Xyntha), per I.U.	5500	1/1/2010
8	J7186	Injection, antihemophilic factor VIII/Von Willebrand factor complex (human), per factor VIII IU	5500	12/16/2008
5	J7192	Factor VIII (antihemophilic factor, recombinant) per IU	5500	12/16/2008
2	J7300	Intrauterine copper contraceptive	0	11/21/2008
2	J7302	Levonorgestrel-releasing intrauterine contraceptive system, 52 mg	0	11/21/2008
	J7308	Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form	2	11/21/2008
	J7311	Fluocinolone acetonide, intravitreal implant (Retisert)	1	11/21/2008	4/1/2010
2	J7317	Sodium hyaluronate, per 20 to 25 mg dose for intra-articular injection	0	11/21/2008
	J7321	Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose	2	11/21/2008
9	J7322	Hyaluronan or derivative, Synvisc, for intra-articular injection, per dose	2	11/21/2008
	J7323	Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose	2	11/21/2008
	J7324	Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose	2	11/21/2008
	J7325	Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg	96	1/1/2010
2	J7502	Cyclosporine, oral 100 mg	0	12/16/2008
2	J7506	Prednisone, oral, per 5 mg	0	12/16/2008
2	J7510	Prednisolone, oral, per 5 mg	0	12/16/2008
	J7513	Daclizumab, parenteral, 25 mg	5	11/21/2008
2	J7515	Cyclosporine, oral, 25 mg	0	12/16/2008
7	J7602	Albuterol, all formulations including separated isomers, inhalation, solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 1 mg (albuterol) or per 0.5 mg (levalbuterol)	3	12/16/2008
7	J7603	Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, per 1 mg (albuterol) or per 0.5 mg (levalbuterol)	3	12/16/2008
8	J7606	Formoterol fumarate, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, 20 micrograms	1	12/16/2008
	J7607	Levalbuterol, inhalation solution, compounded product, administered through DME, concentrated form, 0.5 mg	3	12/16/2008
	J7615	Levalbuterol inhalation solution, compounded product, administered through DME, unit dose, 0.5 mg	3	12/16/2008
	J7620	Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME	1	12/16/2008
	J7626	Budesonide, inhalation solution, FDA-approved final product, non-compounded, administered trough DME, unit dose form, up to 0.5 mg	2	12/16/2008
4	J7628	Bitolterol mesylate, inhalation solution, compounded product, administered through DME, concentrated form, per mg	0	11/21/2008
4	J7636	Atropine, inhalation solution, compounded product, administered through DME, unit dose form, per mg	0	11/21/2008
	J7638	Dexamethasone, inhalation solution, compounded product, administered through DME,  unit dose form, per mg	10	12/16/2008
3	J7639	Dornase alpha, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per mg	0	12/16/2008
3	J7641	Flunisolide,  inhalation solution, compounded product, administered through DME, unit dose, per milligram	0	12/16/2008
3	J7643	Glycopyrrolate, inhalation solution, compounded product, administered through DME, unit dose, per mg	0	12/16/2008
	J7644	Ipratropium bromide, inhalation solution, FDA-aapproved final product, non-compounded, administered through DME, unit dose form, per mg	1	12/16/2008
	J7645	Ipratropium bromide, inhalation solution, compounded product, administered through DME, unit dose, per mg	1	12/16/2008
	J7668	Metaproterenol sulfate, inhalation solution, FDA-approved final product, non-compounded, administesred through DME, concentrated form, per 10mg	2	12/16/2008
	J7681	Terbutaline sulfate, inhalant solution, compounded product, administered through DME, unit dose form, per mg	3	12/16/2008
3	J7685	Tobramycin, inhalation solution, compounded product, administered through DME, unit dose form, per 300mg	0	12/16/2008
2	J8501	Aprepitant, oral, 5 mg	0	11/21/2008
2	J8521	Capecitabine, oral, 500 mg	0	12/16/2008
2	J8530	Cyclophosphamide, oral, 25 mg	0	12/16/2008
2	J8600	Melphalan, oral, 2mg	0	12/16/2008
2	J8700	Temozolmide, oral 5 mg	0	11/21/2008
2, 8	J8705	Topotecan, oral, 0.25 mg	0	12/16/2008
	J9000	Injection, doxorubicin hydrochoride, 10 mg	18	12/16/2008
	J9001	Injection, doxorubicin hydrochloride, all lipid formulations, 10 mg	14	11/7/2008	7/1/2010
	J9010	Injection, alemtuzumab, 10 mg	3	11/7/2008
	J9015	Aldesleukin, per single use vial	6	12/16/2008
	J9017	Injection, arsenic trioxide, 1 mg	20	12/3/2008	1/12/2009
	J9020	Injection, asparaginase, 10,000 units	2	11/21/2008
	J9025	Injection, azacitidine, 1 mg	300	12/3/2008
	J9031	BCG (intravesical), per instillation	1	11/21/2008
8	J9033	Injection, bendamustine HCl, 1 mg	300	12/16/2008
	J9035	Injection, bevacizumab, 10 mg	170	12/3/2008	Denied
	J9040	Injection, bleomycin sulfate, 15 units	4	11/21/2008
	J9041	Injection, bortezomib, 0.1 mg	35	11/7/2008
	J9045	Injection, carboplatin, 50 mg	20	11/21/2008	Denied
	J9050	Injection, carmustine, 100 mg	5	12/3/2008
	J9055	Injection, cetuximab, 10 mg	120	11/7/2008	2/27/2009
	J9060	Cisplatin, powder or solution, per 10 mg	24	12/3/2008
	J9062	Cisplatin, 50 mg	5	11/21/2008
	J9065	Injection, cladribine, per 1 mg	11	11/21/2008	6/1/2010
	J9070	Cyclophosphamide, 100 mg	55	12/3/2008
	J9080	Cyclophosphamide, 200 mg	19	12/16/2008	7/1/2010
	J9090	Cyclophosphamide, 500 mg	11	12/3/2008
	J9091	Cyclophosphamide, 1.0 gram	6	12/3/2008
	J9092	Cyclophosphamide, 2.0 gram	3	11/21/2008
	J9093	Cyclophosphamide, lyophilized, 100 mg	24	12/3/2008	7/1/2010
	J9094	Cyclophosphamide, lyophilized, 200 mg	19	12/16/2008	7/1/2010
	J9095	Cyclophosphamide, lyophilized, 500 mg	6	12/3/2008	7/1/2010
	J9096	Cyclophosphamide, lyophilized, 1.0 gram	4	12/3/2008	7/1/2010
	J9097	Cyclophosphamide, lyophilized, 2.0 gram	2	11/21/2008	7/1/2010
	J9098	Injection, cytarabine liposome, 10 mg	5	11/21/2008
	J9100	Injection, cytarabine, 100 mg	3	11/21/2008
	J9110	Injection, cytarabine, 500 mg	10	11/21/2008	3/12/2009
	J9120	Injection, dactinomycin, 0.5 mg	4	11/21/2008
	J9130	Dacarbazine, 100 mg	10	12/3/2008	6/12/2009
	J9140	Dacarbazine, 200 mg	5	12/3/2008	2/27/2009
	J9150	Injection, daunorubicin, 10 mg	11	12/3/2008
	J9155	Injection, degarelix, 1 mg	240	1/1/2010
	J9160	Injection, denileukin diftitox, 300 micrograms	7	11/21/2008
9	J9170	Injection, docetaxel, 20 mg	12	11/21/2008
	J9171	Injection, docetaxel, 1 mg	240	1/1/2010	1/8/2010
	J9178	Injection, epirubicin HCl, 2 mg	150	12/16/2008
	J9181	Injection, etoposide, 10 mg	30	12/3/2008	6/23/2009
	J9182	Etoposide, 100 mg	3	11/21/2008
	J9185	Injection, fludarabine phosphate, 50 mg	2	11/21/2008
	J9190	Injection, fluorouracil, 500 mg	21	11/21/2008	1/12/2009
	J9200	Floxuridine, 500 mg	4	12/16/2008
	J9201	Injection, gemcitabine hydrochloride, 200 mg	14	11/7/2008
	J9202	Goserelin acetate implant, per 3.6 mg	3	11/7/2008
	J9206	Injection, irinotecan, 20 mg	42	11/7/2008
8	J9207	Injection, ixabepilone, 1 mg	105	12/16/2008
	J9208	Injection, ifosfamide, 1 gram	6	12/3/2008	2/27/2009
	J9209	Injection, mesna, 200 mg	30	12/3/2008	2/27/2009
	J9211	Injection, idarubicin hydrochloride, 5 mg	8	12/16/2008
	J9213	Injection, interferon, alfa-2A, recombinant, 3 million units	3	11/21/2008
	J9214	Injection, interferon, alfa-2B, recombinant, 1 million units	100	11/21/2008
3	J9216	Injection, interferon, gamma 1-B, 3 million units	0	11/21/2008
	J9217	Leuprolide acetate (for depot suspension), 7.5 mg	6	12/16/2008	4/24/2009
	J9218	Leuprolide acetate, per 1 mg	1	7/1/2010
	J9219	Leuprolide acetate implant, 65 mg	1	12/16/2008
	J9225	Histrelin implant, 50 mg	1	12/16/2008
	J9226	Histrelin implant, 50 mg	1	12/16/2008
	J9230	Mechlorethamine HCl, (nitrogen mustard), 10 mg	5	12/16/2008
	J9245	Injection, melphalan HCl, 50 mg	1	11/21/2008
	J9250	Methotrexate sodium, 5 mg	7200	12/16/2008
	J9260	Methotrexate sodium, 50 mg	720	12/16/2008
	J9263	Injection, oxaliplatin, 0.5 mg	624	12/16/2008	2/27/2009
	J9264	Injection, paclitaxel protein-bound particles, 1 mg	624	12/16/2008
	J9265	Paclitaxel, 30 mg	18	12/16/2008	2/27/2009
	J9268	Injection, pentostatin, per 10 mg	1	11/21/2008
	J9280	Mitomycin, 5 mg	10	12/16/2008
	J9290	Mitomycin, 20 mg	3	11/21/2008
	J9291	Mitomycin, 40 mg	2	11/21/2008
	J9293	Injection, mitoxantrone hydrochloride, per 5 mg	10	12/16/2008
	J9300	Injection, gemtuzumab ozogamicin, 5 mg	5	12/3/2008
	J9303	Injection, panitumumab, 10 mg	70	12/16/2008	4/20/2010
	J9305	Injection, pemetrexed, 10 mg	120	12/3/2008
	J9310	Injection, rituximab, 100 mg	11	11/7/2008
	J9320	Injection, streptozocin, 1 gram	4	12/16/2008
	J9328	Injection, temozolomide, 1 mg	500	1/1/2010
8	J9330	Injection, temsirolimus, 1 mg	25	12/16/2008
	J9340	Injection, thiotepa, 15 mg	6	12/3/2008
	J9350	Injection, topotecan, 4 mg	10	12/3/2008	1/12/2009
	J9355	Injection, trastuzumab, 10 mg	88	11/7/2008	Denied
	J9360	Vinblastine sulfate, 1 mg	45	12/16/2008
	J9370	Vincristine sulfate, 1 mg	4	12/16/2008
	J9375	Vincristine sulfate, 2 mg	2	12/3/2008
	J9380	Vincristine sulfate, 5 mg	1	4/1/2010
	J9390	Injection, vinorelbine tartrate, per 10 mg	8	12/3/2008
	J9395	Injection, fulvestrant, 25 mg	20	11/21/2008	6/1/2010
	Q0138	Injection ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)	510	1/1/2010
	Q0139	Injection ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD use)	510	1/1/2010
9	Q2024	Injection, bevacizumab, 0.25 mg	510	10/1/2009
6	Q4083	Hyalgan-supartz, per dose	2	11/21/2008
6	Q4084	Synvisc, per dose	2	11/21/2008
6	Q4085	Euflexxa, per dose	2	11/21/2008
6	Q4086	Orthovisc, per dose	2	11/21/2008