NDC 2010

00002-0501-01
00002-1444-25
00002-1498-25
00002-1499-25
J3260
J3370
J0690
J3260
1/1/2002
1/1/2002
1/1/2002
1/1/2002
3/13/2002 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG

3/28/2003 INJECTION, VANCOMYCIN HCL, 500 MG
8/12/2003 INJECTION, CEFAZOLIN SODIUM, 500 MG
00002-5357-25
J0697
1/1/2002
3/28/2003 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG
00002-5358-10
00002-5363-10
00002-7014-01
J0697
J0697
J0690
1/1/2002
1/1/2002
1/1/2002
00002-7040-01
J7682
1/1/2002
00002-7040-01 KO J7682
00002-7040-16
KO
J7682
00002-7040-16 KO J7682
00002-7090-01
J3260
00002-7090-16
J3260
00002-7140-01
J0130
00002-7175-10
J1250
00002-7217-01
J1644
00002-7231-01
J0713
00002-7231-25
J0713
00002-7234-01
J0713
00002-7234-10
J0713
00002-7241-01
J0713
00002-7241-16
J0713
00002-7266-01
J0690
00002-7266-25
J0690
00002-7271-01
J0697
00002-7271-25
J0697
00002-7272-01
J0697
00002-7272-10
J0697
00002-7273-01
J0697
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONCOMPOUNDED, UNIT DOSE FORM, ADMINISTERED THROUGH DME, PER 300
9/30/2003 MILLIGRAMS
99/99/9999 INJECTION ABCIXIMAB, 10 MG
6/5/2003 INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG
1/18/2002 INJECTION, HEPARIN SODIUM, PER 1000 UNITS
8/12/2003 INJECTION, CEFTAZIDIME, PER 500 MG
00002-7275-01
00002-7278-01
00002-7278-25
00002-7279-01
00002-7279-10
00002-7290-01
00002-7290-25
00002-7291-01
00002-7291-10
00002-7298-01
00002-7298-10
00002-7321-01
00002-7321-25
00002-7335-01
J0697
J0697
J0697
J0697
J0697
J0713
J0713
J0713
J0713
J3370
J3370
J3370
J3370
J2941
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00002-7335-11
00002-7335-16
00002-7355-01
J2941
J2941
J3370
00002-7381-25
J7682
3/1/2006 99/99/9999 INJECTION, SOMATROPIN, 1 MG

1/1/2002 3/14/2003 INJECTION, VANCOMYCIN HCL, 500 MG
1/1/2002 3/13/2002 MILLIGRAMS
1/1/2002 3/13/2002 MILLIGRAMS
00002-7381-25 KO J7682
J3260
00002-7382-16
00002-7501-01
J9201
00002-7501-01 QR J9201
00002-7502-01
J9201
00002-7502-01 QR J9201
00002-7510-01
J1820
00002-7510-01
J1817
00002-7511-01
J1820
00002-7511-01
00002-7512-01
00002-7515-59
00002-7515-59
J1815
J1815
J1820
J1815
Published by PDAC 01/05/2010
KO
QR
QR
1/1/2002
1/1/2002
1/28/2005
1/1/2002
1/28/2005
1/1/2002

2/28/2006 INJECTION, SOMATROPIN, 1 MG

99/99/9999 INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG
12/31/2002 INJECTION, INSULIN, UP TO 100 UNITS
NEBCIN PEDIATRIC (M.D.V.) 10 MG/ML

VANCOCIN HCL (TRAYPAK) 500 MG
KEFZOL (TRAYPACK) 1 GM
NEBCIN (M.D.V.) 40 MG/ML
CEFUROXIME SODIUM NOVATION 750
MG
CEFUROXIME SODIUM NOVATION 1.5
GM
CEFUROXIME SODIUM 1.5 GM
KEFZOL 10 GM
2 ML
1 EA
1 EA
2 ML
VL
VL
VL
VL
IJ
IV
IJ
IJ
ML
EA
EA
ML
80 MG
500 MG
500 MG
80 MG
0.125
1
2
0.5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/13/2002
03/28/2003
08/12/2003
05/20/2004
1 EA VL
IJ
EA
750 MG
01/01/2002
03/28/2003
1 EA VL
1 EA VL
1 EA VL
IJ
IJ
IJ
EA
EA
EA
750 MG
750 MG
500 MG
2
2
20
01/01/2002
01/01/2002
01/01/2002
03/28/2003
03/28/2003
03/28/2003
NEBCIN (BULK VIAL) 1.2 GM
1 EA VL
IV
EA
300 MG
01/01/2002
09/30/2003
1 EA VL
IV
EA
300 MG
01/01/2002
09/30/2003
1 EA VL
IV
EA
300 MG
01/01/2002
09/30/2003

REOPRO (VIAL) 2 MG/ML
DOBUTREX (TRAYPACK) 12.5 MG/ML
HEPARIN SODIUM (VIAL) 10000 U/ML
TAZIDIME 1 GM
TAZIDIME 1 GM
TAZIDIME 2 GM
TAZIDIME 2 GM
TAZIDIME 6 GM
TAZIDIME 6 GM
KEFZOL 1 GM
KEFZOL (ADD-VANTAGE) 1 GM
KEFUROX (10 ML VIAL) 750 MG
KEFUROX (20 ML VIAL) 1.5 GM
KEFUROX (20 ML VIAL) 1.5 GM
KEFUROX (TRAYPACK,100 ML VIAL) 7.5
GM
KEFUROX (ADD-TAGE) 750 MG
KEFUROX (ADD-VANTAGE) 750 MG
KEFUROX 1.5 GM
KEFUROX (ADD-VANTAGE) 1.5 GM
TAZIDIME (ADD-VANTAGE) 1 GM
VANCOCIN HCL (ADD-TAGE) 1 GM
VANCOCIN HCL (ADD-VANTAGE) 1 GM
VANCOCIN HCL (TRAYPAK) 1 GM
VANCOCIN HCL (TRAYPAK) 1 GM
HUMATROPE (W/DILUENT) 5 MG
HUMATROPE (WITH STERILE DILUENT)
5 MG
HUMATROPE (W/DILUENT) 5 MG
VANCOCIN HCL (BULK VIAL) 10 GM
TOBRAMYCIN SULFATE NOVATION
(BULK VIAL) 1.2 GM
TOBRAMYCIN SULFATE NOVATION
(BULK VIAL) 1.2 GM
TOBRAMYCIN SULFATE NOVATION 40
MG/ML
GEMZAR (VIAL) 200 MG
GEMZAR (VIAL) 200 MG
GEMZAR (VIAL) 1 GM
GEMZAR (VIAL) 1 GM
HUMALOG (VIAL) 100 U/ML
1/1/2003 99/99/9999 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS HUMALOG (VIAL) 100 U/ML
HUMALOG MIX 75/25 (VIAL) 75 U/ML-25
1/1/2002 12/31/2002 INJECTION, INSULIN, UP TO 100 UNITS
U/ML
1/1/2003 99/99/9999 INJECTION, INSULIN, PER 5 UNITS
U/ML
HUMALOG MIX 50/50 50 U/ML-50 U/ML
HUMALOG (CARTRIDGE) 100 U/ML
1/1/2003
6/3/2005 INJECTION, INSULIN, PER 5 UNITS
Page 1 of 374
1 EA
30 ML
30 ML
5 ML
20 ML
5 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IV
IJ
IJ
IV
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
ML
ML
ML
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
300 MG
80 MG
80 MG
10 MG
250 MG
1000 U
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
750 MG
750 MG
750 MG
750 MG
750 MG
4
0.5
0.5
0.2
0.05
10
2
2
4
4
12
12
2
2
1
1
2
2
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/30/2003
03/14/2003
03/14/2003
99/99/9999
06/05/2003
01/18/2002
08/12/2003
08/12/2003
08/12/2003
08/12/2003
08/12/2003
08/12/2003
06/05/2003
06/05/2003
03/28/2003
03/28/2003
03/28/2003
03/28/2003
01/10/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IV
IV
IV
IV
SC
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
750 MG
750 MG
750 MG
750 MG
750 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
1 MG
10
1
1
2
2
2
2
4
4
2
2
2
2
5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/28/2003
03/28/2003
03/28/2003
03/28/2003
03/28/2003
08/12/2003
08/12/2003
08/12/2003
08/12/2003
03/13/2002
03/13/2002
05/20/2004
05/20/2004
02/28/2006
1 EA VL
1 EA VL
1 EA VL
SC
SC
IV
EA
EA
GM
1 MG
1 MG
500 MG
5
5
2
03/01/2006
01/01/2002
01/01/2002
99/99/9999
99/99/9999
03/14/2003
1 EA VL
IV
EA
300 MG
01/01/2002
03/13/2002
1 EA VL
IV
EA
300 MG
01/01/2002
03/13/2002
VL
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
SC
ML
EA
EA
EA
EA
ML
80 MG
200 MG
200 MG
200 MG
200 MG
100 U
0.5
1
1
5
5
1
01/01/2002
01/01/2002
01/28/2005
01/01/2002
01/28/2005
01/01/2002
03/14/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2002
10 ML VL
SC
ML
50 U
01/01/2003
99/99/9999
10 ML VL
SC
ML
100 U
01/01/2002
12/31/2002
10 ML
10 ML
1.5 ML
1.5 ML
SC
SC
SC
SC
ML
ML
ML
ML
5U
5U
100 U
5U
20
2
1
20
01/01/2003
11/01/2006
01/01/2002
01/01/2003
99/99/9999
99/99/9999
12/31/2002
06/03/2005
30 ML
1 EA
1 EA
1 EA
1 EA
10 ML
VL
VL
CT
CT
Prior Conversion Factor #3
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
Route of Administration
NDC Package Type
NDC Package Measure
Number of Items in NDC

Package
NDC Label
HCPCS Description
Relationship End Date
Relationship Start Date
HCPCS Mod
HCPCS
NDC Mod
NDC
01-05-2010 NDC-HCPCS XWalk
Noridian Administrative Services
1/1/2002
1/1/2003
2/5/2004
1/1/2005
1/7/2008
00002-8031-01
J1610
1/1/2002 99/99/9999 INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG
00002-8085-01
J1610
1/1/2002
00002-8089-01
J2941
1/1/2002
00002-8090-01
J2941
00002-8091-01
J2941
00002-8147-01
J2941
00002-8148-01
J2941
00002-8149-01
J2941
00002-8211-01
J1820
00002-8211-01
00002-8215-01
00002-8215-01
00002-8311-01
00002-8311-01
00002-8315-01
00002-8315-01
00002-8411-01
00002-8411-01
00002-8415-01
00002-8415-01
J1815
J1820
J1815
J1820
J1815
J1820
J1815
J1820
J1815
J1820
J1815
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
00002-8501-01
J1820
00002-8501-01
00002-8615-01
00002-8615-01
00002-8715-01
00002-8715-01
J1815
J1820
J1815
J1820
J1815
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002

12/31/2004 UNCLASSIFIED DRUGS
99/99/9999 INJECTION, PEMETREXED, 10 MG
99/99/9999 INJECTION, PEMETREXED, 10 MG
6/3/2005 INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG



00002-8725-59
J1820
00002-8725-59
J1815
00002-8730-59
J1820
00002-8730-59
J1815
00002-8770-59
J1820
00002-8770-59
J1815
00002-8793-59
J1815
00002-8794-59
J1820
00002-8794-59
J1815
00002-8797-59
J1815
00002-8798-59
00002-8799-59
00002-8971-01
00002-8971-01
J1815
J1815
J3590
J3110
12/10/2007
12/10/2007
1/1/2003
1/1/2005
00002-8988-01
J3260
1/1/2002
00002-8989-25
J3260
1/1/2002
00002-8994-25
J0697
1/1/2002
00002-8995-19
J0697
1/1/2002
00002-9500-01
J0697
1/1/2002
00002-9504-25
J0690
1/1/2002

12/31/2004 UNCLASSIFIED BIOLOGICS
10/15/2008 INJECTION, TERIPARATIDE, 10 MCG

ALIMTA 500 MG
ALIMTA 500 MG
ALIMTA (SINGLE-USE) 100 MG
GLUCAGON EMERGENCY KIT
(HYPORET DISPOSABLE SRN) 1 MG
GLUCAGON DIAGNOSTIC KIT (HYPORET
SRN W/DILUENT) 1 MG
HUMATROPE (CARTRIDGE
W/DILUENT/PEN) 6 MG
W/DILUENT/PEN) 12 MG
W/DILUENT/PEN) 24 MG
HUMATROPE (CARTRIDGE W/DILUENT)
6 MG
12 MG
24 MG
ILETIN II REGULAR PORK (VIAL) 100
U/ML
ILETIN II REGULAR PORK (VIAL) 100
U/ML
HUMULIN R (VIAL) 100 U/ML
ILETIN II NPH PORK (VIAL) 100 U/ML
ILETIN II NPH PORK (VIAL) 100 U/ML
HUMULIN N (VIAL) 100 U/ML
ILETIN II LENTE PORK (VIAL) 100 U/ML
ILETIN II LENTE PORK (VIAL) 100 U/ML
HUMULIN L (VIAL) 100 U/ML
HUMULIN R U-500 (VIAL,
CONCENTRATED) 500 U/ML
HUMULIN R U-500 (VIAL,
CONCENTRATED) 500 U/ML
HUMULIN U (VIAL) 100 U/ML
HUMULIN U (VIAL) 100 U/ML
HUMULIN 70/30 (VIAL) 70 U/ML-30 U/ML
HUMALOG PEN (PREFILLED
DISPOSABLE) 100 U/ML
HUMALOG PEN (PREFILLED
HUMULIN N PEN (PREFILLED
HUMULIN N PEN (PREFILLED
HUMULIN 70/30 PEN (PREFILLED
DISPOSABLE) 70 U/ML-30 U/ML
HUMULIN 70/30 PEN (PREFILLED
HUMALOG MIX 50/50 (PEN,5X3ML) 50
U/ML-50 U/ML
HUMALOG MIX 75/25 PEN (PREFILLED
HUMALOG MIX 75/25 PEN (PREFILLED
HUMALOG MIX75/25 (KWIKPEN,5X3ML)
75 U/ML-25 U/ML
HUMALOG MIX 50/50 (KWIKPEN,5X3ML)
50 U/ML-50 U/ML
HUMALOG (KWIKPEN,5X3ML) 100 U/ML
FORTEO 250 MCG/ML
FORTEO 250 MCG/ML
TOBRAMYCIN PEDIATRIC AMERINET
CHOICE (M.D.V.) 10 MG/ML
TOBRAMYCIN AMERINET CHOICE
(M.D.V.) 40 MG/ML
CEFUROXIME AMERINET CHOICE 750
MG
CEFUROXIME AMERINET CHOICE 1.5
GM
CEFUROXIME AMERINET CHOICE 7.5
GM
CEFAZOLIN SODIUM AMERINET CHOICE
(VIAL) 1 GM
Page 2 of 374
SC
SC
IV
IV
IV
ML
ML
EA
EA
EA
100 U
5U
1 EA
10 MG
10 MG
1
20
1
50
10
01/01/2002
01/01/2003
02/05/2004
01/01/2005
01/07/2008
1 EA BX
IJ
EA
1 MG
01/01/2002
99/99/9999
IJ
EA
1 MG
01/01/2002
06/03/2005
1 EA CT
SC
EA
1 MG
01/01/2002
11/07/2005
1 EA CT
SC
EA
1 MG
12
01/01/2002
11/11/2005
1 EA CT
SC
EA
1 MG
24
01/01/2002
11/07/2005
1 EA CT
IJ
EA
1 MG
08/30/2005
99/99/9999
1 EA CT
IJ
EA
1 MG
12
08/30/2005
99/99/9999
1 MG
1 EA CT
IJ
EA
24
08/30/2005
99/99/9999
10 ML VL
IJ
ML
100 U
01/01/2002
12/31/2002
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
IJ
IJ
IJ
SC
SC
SC
SC
SC
SC
SC
SC
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
5U
100 U
5U
100 U
5U
100 U
5U
100 U
5U
100 U
5U
20
1
20
1
20
1
20
1
20
1
20
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
04/01/2006
12/31/2002
99/99/9999
12/31/2002
04/01/2006
12/31/2002
99/99/9999
12/31/2002
02/01/2005
12/31/2002
09/19/2006
20 ML VL
IJ
ML
100 U
01/01/2002
12/31/2002
20 ML
10 ML
10 ML
10 ML
10 ML
VL
VL
VL
VL
VL
IJ
SC
SC
SC
SC
ML
ML
ML
ML
ML
5U
100 U
5U
100 U
5U
100
1
20
1
20
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
99/99/9999
12/31/2002
07/01/2007
12/31/2002
99/99/9999
3 ML SR
SC
ML
100 U
01/01/2002
12/31/2002
3 ML SR
SC
ML
5U
20
01/01/2003
99/99/9999
3 ML CT
SC
ML
100 U
01/01/2002
12/31/2002
3 ML CT
SC
ML
5U
20
01/01/2003
99/99/9999
3 ML CT
SC
ML
100 U
01/01/2002
12/31/2002
99/99/9999
3 ML CT
SC
ML
5U
20
01/01/2003
3 ML SR
SC
ML
5U
01/20/2006
99/99/9999
3 ML SR
SC
ML
100 U
01/01/2002
12/31/2002
3 ML SR
SC
ML
5U
20
01/01/2003
99/99/9999
3 ML SR
SC
ML
5U
20
12/10/2007
99/99/9999
3 ML
3 ML
3 ML
3 ML
SC
SC
SC
SC
ML
ML
ML
ML
2
20
1
25
12/10/2007 99/99/9999
12/10/2007 99/99/9999
01/01/2003 12/31/2004
01/01/2005 10/15/2008
SR
SR
SR
SR
5U
5U
1 EA
10 MCG
Prior End Date #3
Prior Start Date #3
Prior End Date #2
12/31/2002
99/99/9999
12/31/2004
99/99/9999
99/99/9999
1 EA VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
CT
CT
VL
VL
VL
Billing Units
3 ML
3 ML
1 EA
1 EA
1 EA

Package
NDC Package Type
J1820
J1815
J3490
J9305
J9305
NDC Package Measure
00002-7516-59
00002-7516-59
00002-7623-01
00002-7623-01
00002-7640-01
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
2 ML VL
IJ
ML
80 MG
0.125
01/01/2002
2 ML VL
IJ
ML
80 MG
0.5
01/01/2002
03/13/2002
08/12/2003
1 EA VL
IJ
EA
750 MG
01/01/2002
06/05/2003
1 EA VL
IJ
EA
750 MG
01/01/2002
03/28/2003
1 EA VL
IJ
EA
750 MG
10
01/01/2002
03/28/2003
1 EA VL
IJ
EA
500 MG
01/01/2002
03/28/2003
00002-9505-01
J0690
1/1/2002
00002-9509-01
00002-9515-01
00002-9515-01
00003-0251-50
00003-0330-50
00003-0343-50
00003-0437-30
00003-0437-32
J3370
J1820
J1815
J0970
J1380
J1390
J0285
J0285
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00003-0437-60
00003-0494-20
J0285
J3301
1/1/2002
9/3/2004 INJECTION, AMPHOTERICIN B, 50 MG
1/1/2002 99/99/9999 INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG
00003-0569-02
J2680
1/1/2002
00003-0569-15
00003-0759-20
00003-0830-50
00003-2187-10
00003-2187-10
J2680
J2690
J8999
J3490
J0129
1/1/2002
1/1/2002
1/1/2002
1/3/2006
1/1/2007
00003-2725-10
J3260
1/1/2002
00003-2725-30
00003-6335-17
00003-6336-17
00003-6337-17
00003-7731-99
00004-0038-22
00004-0188-09
00004-0188-09
J3260
J8999
J8999
J8999
J0692
J3490
J3490
J1740
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
2/24/2006
1/1/2007
00004-0237-09
00004-0239-09
00004-0240-09
Q0166
J1626
J1626
1/1/2002
1/3/2002
1/1/2002
00004-0241-26
Q0166
1/1/2002
00004-0241-33
00004-0242-08
00004-0259-01
00004-0259-05
00004-0259-43
00004-0260-01
00004-0260-43
00004-0261-29
00004-0267-06
00004-0268-06
00004-0350-09
00004-0350-39
Q0166
J1626
J7517
J7517
J7517
J7517
J7517
J7517
J3265
J3265
J3490
J3490
1/1/2002
11/8/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
10/16/2002
1/10/2003
00004-0352-39
00004-0380-39
00004-0380-39
00004-0501-09
J3490
J3490
J1324
J7513
1/19/2004
3/12/2003
1/1/2007
1/1/2002
00004-0800-85
G9035
12/1/2004
00004-0810-95
00004-1100-13
00004-1100-20
00004-1100-20
00004-1100-22
00004-1100-51
00004-1100-51
00004-1101-13
00004-1101-16
00004-1101-16
00004-1101-50
00004-1101-50
00004-1101-51
00004-1911-06
00004-1946-01
G9035
None
None
J8520
None
None
J8520
None
None
J8521
None
J8521
None
J1960
J2250
12/1/2004
1/1/1999
10/1/2003
1/28/2005
1/1/1999
1/1/1999
1/28/2005
1/1/1999
1/1/1999
1/28/2005
10/1/2003
1/28/2005
1/1/1999
1/1/2002
1/1/2002
QR
QR
QR
QR
QR
QR
QR
QR

10/23/2002 INJECTION, ESTRADIOL VALERATE, UP TO 40 MG
1/26/2002 INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG

7/30/2002 INJECTION, PROCAINAMIDE HCL, UP TO 1 GM
99/99/9999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS
99/99/9999 INJECTION, ABATACEPT, 10 MG
CEFAZOLIN SODIUM AMERINET CHOICE

10 GM
VANCOMYCIN AMERINET CHOICE 10
GM
DELESTROGEN (VIAL) 40 MG/ML
FUNGIZONE INTRAVENOUS 50 MG
AMPHOTERICIN B VHA PLUS 50 MG
FUNGIZONE FOR TISSUE CULTURE 50
MG
KENALOG-10 (VIAL) 10 MG/ML
PROLIXIN DECANOATE (SRN,UNIMATIC)
25 MG/ML
PROLIXIN DECANOATE (VIAL) 25 MG/ML
PRONESTYL (VIAL) 100 MG/ML
HYDREA 500 MG
ORENCIA (W/SYRINGE,PF) 250 MG
ORENCIA (W/SYRINGE,PF) 250 MG
1 EA VL
EA
500 MG
20
01/01/2002
03/28/2003
IV
SC
SC
IM
IM
IM
IV
IV
GM
ML
ML
ML
ML
ML
EA
EA
500 MG
100 U
5U
40 MG
10 MG
20 MG
50 MG
50 MG
2
1
20
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/14/2003
12/31/2002
99/99/9999
10/23/2002
11/23/2002
08/29/2002
09/03/2004
09/03/2004
1 EA VL
5 ML VL
NA
IJ
EA
ML
50 MG
10 MG
1
1
01/01/2002
01/01/2002
09/03/2004
99/99/9999
1 ML SR
5 ML
10 ML
100 EA
1 EA
1 EA
VL
VL
BO
VL
VL
IJ
ML
25 MG
01/01/2002
01/26/2002
IJ
IV
PO
IV
IV
ML
ML
EA
EA
EA
25 MG
1 GM
1 EA
1 EA
10 MG
1
0.1
1
1
25
01/01/2002
01/01/2002
01/01/2002
01/03/2006
01/01/2007
12/31/2004
07/30/2002
99/99/9999
12/31/2006
99/99/9999
IJ
ML
80 MG
0.5
01/01/2002
01/31/2005
IJ
PO
PO
PO
IJ
PO
IV
IV
ML
EA
EA
EA
EA
EA
EA
EA
80 MG
1 EA
1 EA
1 EA
500 MG
1 EA
1 EA
1 MG
0.5
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/24/2006
01/01/2007
01/31/2005
99/99/9999
99/99/9999
99/99/9999
10/17/2003
99/99/9999
12/31/2006
99/99/9999
PO
IV
IV
ML
ML
ML
1 MG
100 MCG
100 MCG
0.2
10
10
01/01/2002
01/03/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
PO
EA
1 MG
01/01/2002
99/99/9999
PO
IV
PO
PO
PO
PO
PO
PO
IV
IV
MR
MR
EA
ML
EA
EA
EA
EA
EA
ML
ML
ML
EA
EA
1 MG
100 MCG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
10 MG
10 MG
1 EA
1 EA
1
1
1
1
1
2
2
0.8
1
1
1
1
01/01/2002
11/08/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10/16/2002
01/10/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
4/30/2008
5/30/2008
99/99/9999
08/31/2005
MR
SC
SC
IV
EA
EA
EA
ML
1 EA
1 EA
1 MG
25 MG
1
1
90
0.2
01/19/2004
03/12/2003
01/01/2007
01/01/2002
99/99/9999
12/31/2006
99/99/9999
99/99/9999
PO
EA
75 MG
12/01/2004
05/31/2005
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
IJ
IJ
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
75 MG
150 MG
150 MG
150 MG
150 MG
150 MG
150 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
2 MG
1 MG
0.16
1
1
1
1
1
1
1
1
1
1
1
1
1
5
12/01/2004
01/01/1999
10/01/2003
01/28/2005
01/01/1999
01/01/1999
01/28/2005
01/01/1999
01/01/1999
01/28/2005
10/01/2003
01/28/2005
01/01/1999
01/01/2002
01/01/2002
05/31/2005
10/01/2000
99/99/9999
99/99/9999
10/01/2000
04/01/2007
04/01/2007
10/01/2000
04/01/2007
04/01/2007
99/99/9999
99/99/9999
10/01/2000
99/99/9999
05/22/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
IJ
VL
VL
VL
VL
VL
VL
VL
VL
1 EA
10 ML
10 ML
5 ML
5 ML
5 ML
1 EA
1 EA
TOBRAMYCIN SULFATE (VIAL) 40 MG/ML

2 ML VL
TOBRAMYCIN SULFATE (M.D.V.) 40
MG/ML
30 ML VL
DROXIA 200 MG
60 EA BO
DROXIA 300 MG
60 EA BO
DROXIA 400 MG
60 EA BO
10/17/2003 INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG
MAXIPIME (VIAL) 500 MG
1 EA VL
99/99/9999 IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED
VALCYTE 450 MG
60 EA BO
BONIVA 1 MG/ML
3 ML BX
99/99/9999 INJECTION, IBANDRONATE SODIUM, 1 MG
BONIVA 1 MG/ML
3 ML BX
GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24
KYTRIL (ORANGE) 2 MG/10 ML
30 ML BO
99/99/9999 HOUR DOSAGE REGIMEN
99/99/9999 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG
KYTRIL (S.D.V.) 1 MG/ML
1 ML VL
KYTRIL (M.D.V.) 1 MG/ML
4 ML VL
KYTRIL 1 MG
20 EA BX
KYTRIL (UNIT OF USE) 1 MG
2 EA BX
KYTRIL (PF) 0.1 MG/ML
1 ML VL
99/99/9999 MYCOPHENOLATE MOFETIL, ORAL, 250 MG
CELLCEPT 250 MG
100 EA BO
CELLCEPT 250 MG
120 EA BO
CELLCEPT 250 MG
500 EA BO
CELLCEPT (CAPLET) 500 MG
100 EA BO
CELLCEPT (CAPLET) 500 MG
500 EA BO
CELLCEPT (FRUIT) 200 MG/ML
175 ML BO
4/30/2008 INJECTION, TORSEMIDE, 10 MG/ML
DEMADEX (AMP) 10 MG/ML
2 ML AM
5/30/2008 INJECTION, TORSEMIDE, 10 MG/ML
DEMADEX (AMP) 10 MG/ML
5 ML AM
PEGASYS (S.D.V.) 180 MCG/ML
1 ML VL
PEGASYS 180 MCG/ML
1 EA BX
PEGASYS (MONTHLY CONVENIENCE
PK) 180 MCG/0.5 ML
2 ML BX
FUZEON (PF) 90 MG
1 EA PG
99/99/9999 INJECTION, ENFUVIRTIDE, 1 MG
FUZEON (PF) 90 MG
1 EA PG
99/99/9999 DACLIZUMAB, PARENTERAL, 25 MG
ZENAPAX (S.D.V.) 5 MG/ML
5 ML VL
OSELTAMIVIR PHOSPHATE, ORAL, BRAND, PER 75 MG (FOR USE IN A MEDICARE
5/31/2005 APPROVED DEMONSTRATION PROJECT)
TAMIFLU (BLISTER PACK) 75 MG
10 EA DP
TAMIFLU (TUTTI FRUTTI) 12 MG/ML
25 ML BO
10/1/2000 CAPECITABINE, 150 MG, ORAL
XELODA 150 MG
1000 EA BO
XELODA 150 MG
60 EA BO
99/99/9999 CAPECITABINE, ORAL, 150 MG
XELODA 150 MG
60 EA BO
XELODA 150 MG
60 EA BO
XELODA 150 MG
120 EA BO
XELODA 150 MG
120 EA BO
XELODA 500 MG
1000 EA BO
XELODA 500 MG
240 EA BO
XELODA 500 MG
240 EA BO
XELODA 500 MG
120 EA BO
XELODA 500 MG
120 EA BO
XELODA 500 MG
120 EA BO
99/99/9999 INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG
LEVO-DROMORAN (M.D.V.) 2 MG/ML
10 ML VL
5/22/2002 INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG
VERSED (M.D.V.,TEL-E-JECT) 5 MG/ML
10 ML VL
Page 3 of 374
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00004-1962-01
00004-1962-02
00004-1963-01
00004-1963-02
00004-1964-01
00004-1964-02
00004-1964-04
00004-1964-05
00004-1965-01
00004-1965-02
00004-1965-05
00004-1971-01
00004-1973-01
00004-1974-01
00004-1975-01
00004-1998-06
00004-1999-01
00004-2000-06
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J2250
J2250
J2250
J2250
J2250
J2250
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00004-2002-78
J0696
1/1/2002
7/16/2005 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG
00004-2003-78
00004-2011-09
00004-2012-09
J0696
J9213
J9213
1/1/2002
1/1/2002
1/1/2002

4/1/2003 INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
ML
ML
ML
ML
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1
1
2
2
4
4
4
4
8
8
8
40
5
5
5
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
11/12/2004
11/12/2004
99/99/9999
99/99/9999
99/99/9999
04/05/2005
99/99/9999
03/15/2002
9/2/2008
04/05/2005
3/30/2007
99/99/9999
05/22/2002
05/22/2002
05/22/2002
05/22/2002
05/22/2002
05/22/2002
50 ML PC
IV
ML
250 MG
0.08
01/01/2002
7/16/2005
50 ML PC
3 ML VL
1 ML VL
IV
IJ
IJ
ML
ML
ML
250 MG
3 MU
3 MU
0.16
2
12
01/01/2002
01/01/2002
01/01/2002
7/16/2005
04/01/2003
04/01/2003
1/1/2002
J9213
1/1/2002
6 SR BX
MR
EA
3 MU
01/01/2002
02/28/2008
1 SR BX
MR
EA
3 MU
01/01/2002
00004-2016-07
J9213
1/1/2002
02/28/2007
6 SR BX
MR
EA
3 MU
12
01/01/2002
02/28/2008
00004-2016-09
J9213
1/1/2002
00004-2017-07
J9213
1/1/2002
1 SR BX
MR
EA
3 MU
01/01/2002
02/28/2007
6 SR BX
MR
EA
3 MU
18
01/01/2002
02/28/2008
00004-2017-09
00004-6925-06
00004-6926-06
00004-6927-09
00004-6940-03
00005-0104-32
J9213
J1885
J1885
J1885
J1570
J3490
1/1/2002 2/28/2007 INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS

1/1/2002 8/13/2002 INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG
1/1/2002 99/99/9999 INJECTION, GANCICLOVIR SODIUM, 500 MG
1/1/2002
1 SR
1 ML
1 ML
2 ML
1 EA
1 EA
MR
IJ
IJ
IM
IV
IM
EA
ML
ML
ML
EA
EA
3 MU
15 MG
15 MG
15 MG
500 MG
1 EA
3
1
2
2
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/28/2007
08/13/2002
08/13/2002
08/13/2002
99/99/9999
04/03/2007
00005-4507-04
None
1/1/1994
6/30/2003 METHOTREXATE, 2.5 MG, ORAL
RHEUMATREX DOSE PACK (4X2) 2.5 MG
8 EA DP
PO
EA
2.5 MG
01/01/1994
06/30/2003
00005-4507-05
None
1/1/1994
12 EA DP
PO
EA
2.5 MG
01/01/1994
06/30/2003
00005-4507-07
None
1/1/1994
16 EA DP
PO
EA
2.5 MG
01/01/1994
06/30/2003
00005-4507-09
00005-4507-23
None
None
1/1/1994
1/1/1994


METHOTREXATE SODIUM 2.5 MG
20 EA DP
100 EA BO
PO
PO
EA
EA
2.5 MG
2.5 MG
1
1
01/01/1994
07/08/2002
06/30/2003
09/01/2006
00005-4507-91
None
1/1/1994
24 EA DP
PO
EA
2.5 MG
01/01/1994
06/30/2003
00006-0041-68
Q0181
1/1/2002
100 EA BO
PO
EA
1 EA
01/01/2002
03/30/2005
00006-0063-12
Q0181
1/1/2002
12 EA DP
PO
EA
1 EA
01/01/2002
11/22/2004
00006-0063-68
00006-0063-68
Q0181
J8540
1/1/2002
1/1/2006
100 EA BO
100 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
11/05/2007
00006-0097-50
00006-0461-02
Q0181
J8501
1/1/2002
1/29/2008
50 EA BO
2 EA DP
PO
PO
EA
EA
1 EA
5 MG
1
16
01/01/2002
01/29/2008
01/17/2003
99/99/9999
00006-0461-05
00006-0461-05
00006-0461-06
K0415
J8501
J8501
4/11/2003
1/1/2005
7/1/2006
5 EA BX
5 EA BX
6 EA BX
PO
PO
PO
EA
EA
EA
1 MG
5 MG
5 MG
80
16
16
04/11/2003
01/01/2005
07/01/2006
12/31/2004
11/05/2007
99/99/9999
00006-0461-30
00006-0461-30
K0415
J8501
4/11/2003
1/1/2005
30 EA BO
30 EA BO
PO
PO
EA
EA
1 MG
5 MG
80
16
04/11/2003
01/01/2005
12/31/2004
08/01/2007
00006-0462-05
00006-0462-05
00006-0462-06
K0415
J8501
J8501
4/11/2003
1/1/2005
7/1/2006

UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI-EMETIC,
FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR A IV ANTI-EMETIC AT
THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE
DECADRON 0.5 MG
3/30/2005 REGIMEN
DECADRON (5-12 PAK) 0.75 MG
11/22/2004 REGIMEN
DECADRON 0.75 MG
12/31/2005 REGIMEN
11/5/2007 DEXAMETHASONE, ORAL, 0.25 MG
DECADRON 0.75 MG
DECADRON 4 MG
1/17/2003 REGIMEN
99/99/9999 APREPITANT, ORAL, 5 MG
EMEND (BI-PACK) 80 MG
PRESCRIPTION ANTIEMETIC DRUG, ORAL, PER 1 MG, FOR USE IN CONJUNCTION
12/31/2004 WITH ORAL ANTI-CANCER DRUG, NOT OTHERWISE SPECIFIED
EMEND 80 MG
EMEND 80 MG
EMEND 80 MG
EMEND 80 MG
EMEND 80 MG
EMEND 125 MG
EMEND 125 MG
EMEND 125 MG
5 EA BX
5 EA BX
6 EA BX
PO
PO
PO
EA
EA
EA
1 MG
5 MG
5 MG
125
25
25
04/11/2003
01/01/2005
07/01/2006
12/31/2004
08/01/2007
99/99/9999
BX
VL
VL
VL
VL
VL
1/1/1994
7/7/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
J9213
Page 4 of 374
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
2 ML
1 ML
5 ML
2 ML
5 ML
10 ML
NDC Package Type
NDC Package Measure

Package
00004-2015-07
00004-2015-09
ROCEPHIN (S.D.V.) 250 MG

ROCEPHIN (S.D.V.) 1 GM
ROCEPHIN (P.B.) 1 GM
ROCEPHIN (ADD-VANTAGE) 1 GM
ROCEPHIN (P.B.) 2 GM
ROCEPHIN (ADD-VANTAGE) 2 GM
ROCEPHIN (VIAL, BULK) 10 GM
VERSED (S.D.V.,TEL-E-JECT) 5 MG/ML
VERSED (S.D.V.,TEL-E-JECT) 5 MG/ML
VERSED (M.D.V.,TEL-E-JECT) 5 MG/ML
VERSED (S.D.V.) 1 MG/ML
VERSED (M.D.V.) 1 MG/ML
ROCEPHIN (GALAXY,PREMIX) 1 GM/50
ML
ROCEPHIN (GALAXY,PREMIX) 2 GM/50
ML
ROFERON-A (VIAL) 6 Million U/ML
ROFERON-A (VIAL) 36 Million U/ML
ROFERON-A (SRN,PREFILLED) 3 Million
IU/0.5 ML
IU/0.5 ML
IU/0.5 ML
IU/0.5 ML
IU/0.5 ML
IU/0.5 ML
TORADOL IV/IM (VIAL) 15 MG/ML
TORADOL IV/IM (VIAL) 30 MG/ML
TORADOL IM (S.D.V.) 30 MG/ML
CYTOVENE IV (VIAL) 500 MG
HIBTITER (S.D.V.,TAX INCL) 10 MCG

NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
4/11/2003
1/1/2005
7/24/2006
7/24/2006
1/1/2002
1/1/2002
3/5/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00006-3545-24
J0694
1/1/2002
11/5/2007 INJECTION, CEFOXITIN SODIUM, 1 GM
00006-3547-25
00006-3548-45
00006-3549-53
J0694
J0694
J0694
1/1/2002
1/1/2002
1/1/2002

00006-3551-58
J0743
1/1/2002 99/99/9999 INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG
00006-3552-59
00006-3582-75
00006-3619-32
J0743
J0743
J1205

1/1/2002 1/20/2006 INJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MG
00006-3666-59
00006-3713-25
00006-3713-50
J0743
J3245
J3245

1/1/2002
9/1/2002 INJECTION, TIROFIBAN HYDROCHLORIDE, 12.5 MG
1/1/2002 4/30/2004 INJECTION, TIROFIBAN HYDROCHLORIDE, 12.5 MG
00006-3739-55
J3245
00006-3739-55
J3246
1/1/2005
00006-3739-96
J3245
00006-3739-96
00006-3822-10
00006-3823-10
00006-3843-71
00006-3843-71
00006-3845-71
J3246
J0637
J0637
J3490
J1335
J1335

9/30/2005 INJECTION, TIROFIBAN HCL, 0.25MG
00006-3862-03
K0415

99/99/9999 INJECTION, CASPOFUNGIN ACETATE, 5 MG
99/99/9999 INJECTION, CASPOFUNGIN ACETATE, 5 MG
99/99/9999 INJECTION, ERTAPENEM SODIUM, 500 MG
99/99/9999 INJECTION, ERTAPENEM SODIUM, 500 MG
4/11/2003 12/31/2004 WITH ORAL ANTI-CANCER DRUG, NOT OTHERWISE SPECIFIED
00006-3862-03
00006-3884-32
J8501
J1453
1/1/2005 99/99/9999 APREPITANT, ORAL, 5 MG

1/30/2008 99/99/9999 INJECTION, FOSAPREPITANT, 1 MG
00006-4094-06
J3490
6/19/2007
00006-4094-31
00006-4612-00
J3490
J9020
6/19/2007 99/99/9999 UNCLASSIFIED DRUGS

1/1/2002 11/15/2006 INJECTION, ASPARAGINASE, 10,000 UNITS
00006-4769-00
J3490
1/1/2002
00006-4773-00
J3490
1/1/2002
00006-4775-00
J3490
1/1/2002
00006-4776-00
J3490
1/1/2002
00006-4848-00
J3490
1/1/2002
00006-4849-00
J3490
1/1/2002
00006-4872-00
J3490
1/1/2002
00006-4873-00
J3490
1/1/2002
00006-4876-00
J3490
1/1/2002
1/1/2005
1/1/2003
1/1/2003
2/4/2002
1/1/2004
4/16/2007
EMEND 125 MG
EMEND 125 MG
EMEND 40 MG
EMEND 40 MG
ARAMINE 10 MG/ML
COGENTIN (AMP) 1 MG/ML
COSMEGEN 0.5 MG
MEFOXIN (VIAL) 1 GM
MEFOXIN (VIAL) 2 GM
MEFOXIN (BULK PACKAGE) 10 GM
PRIMAXIN IV (VIAL) 250 MG-250 MG
PRIMAXIN IV (VIAL) 500 MG-500 MG
PRIMAXIN IV (P.B.) 500 MG-500 MG
PEPCID (GALAXY PC,PF) 0.4 MG/ML
PEPCID (S.D.V.) 10 MG/ML
PEPCID (M.D.V.) 10 MG/ML
MEFOXIN (PREMIXED IN GALAXY) 1
GM/50 ML
MEFOXIN (PREMIXED IN GALAXY) 2
GM/50 ML
MEFOXIN (ADD-VANTAGE) 1 GM
MEFOXIN (ADD-VANTAGE) 2 GM
PRIMAXIN IV (ADD-VANTAGE) 250 MG250 MG
PRIMAXIN IV (ADD-VANTAGE) 500 MG500 MG
PRIMAXIN IM (VIAL) 500 MG-500 MG
DIURIL SODIUM (VIAL) 0.5 GM
PRIMAXIN IV (MONOVIAL) 500 MG-500
MG
AGGRASTAT (VIAL,PF) 0.25 MG/ML
AGGRASTAT (VIAL,PF) 0.25 MG/ML
AGGRASTAT (S.D. INTRA VIA,P.C.) 0.05
MG/ML
MG/ML
AGGRASTAT (S.D. INTRA VIA P.C.) 0.05
MG/ML
AGGRASTAT (S.D. INTRA VIA P.C.) 0.05
MG/ML
CANCIDAS (VIAL) 50 MG
CANCIDAS (VIAL) 70 MG
INVANZ (S.D.V.) 1 GM
INVANZ (S.D.V.) 1 GM
INVANZ (SD,ADD-VANTAGE) 1 GM
PO
PO
PO
PO
IJ
IJ
IJ
IV
IJ
IJ
IJ
IV
IV
IV
IV
IV
IV
IV
IV
EA
EA
EA
EA
ML
ML
ML
EA
EA
EA
EA
EA
EA
EA
ML
ML
ML
ML
ML
1 MG
5 MG
5 MG
5 MG
10 MG
1 MG
1 MG
0.5 MG
1 GM
1 GM
1 GM
250 MG
250 MG
250 MG
1 EA
1 EA
1 EA
1 EA
1 EA
125
25
8
8
1
1
1
1
1
2
10
1
2
2
1
1
1
1
1
04/11/2003
01/01/2005
07/24/2006
07/24/2006
01/01/2002
01/01/2002
03/05/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/31/2004
08/01/2007
99/99/9999
99/99/9999
01/31/2003
06/30/2004
01/20/2006
01/20/2006
07/30/2003
07/30/2003
07/30/2003
99/99/9999
99/99/9999
99/99/9999
11/05/2007
11/05/2007
05/31/2004
04/30/2003
01/31/2003
50 ML FC
IV
ML
1 GM
0.02
01/01/2002
11/05/2007
50 ML FC
1 EA VL
1 EA VL
IV
IJ
IJ
ML
EA
EA
1 GM
1 GM
1 GM
0.04
1
2
01/01/2002
01/01/2002
01/01/2002
11/05/2007
07/30/2003
07/30/2003
1 EA VL
IV
EA
250 MG
01/01/2002
99/99/9999
1 EA VL
1 EA VL
1 EA VL
IV
IM
IV
EA
EA
EA
250 MG
250 MG
500 MG
2
2
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
01/20/2006
1 EA VL
25 ML VL
50 ML VL
IV
IV
IV
EA
ML
ML
250 MG
12.5 MG
12.5 MG
2
0.02
0.02
01/01/2002
01/01/2002
01/01/2002
99/99/9999
09/01/2002
04/30/2004
100 ML BG
IV
ML
12.5 MG
0.004
05/01/2004
12/31/2004
100 ML BG
IV
ML
0.25 MG
0.2
01/01/2005
09/30/2005
250 ML PC
IV
ML
12.5 MG
0.004
05/01/2004
12/31/2004
250 ML
1 EA
1 EA
1 EA
1 EA
1 EA
IV
IV
IV
IJ
IJ
IJ
ML
EA
EA
EA
EA
EA
0.25 MG
5 MG
5 MG
1 EA
500 MG
500 MG
0.2
10
14
1
2
2
01/01/2005
01/01/2003
01/01/2003
02/04/2002
01/01/2004
04/16/2007
10/31/2005
99/99/9999
99/99/9999
12/31/2003
99/99/9999
99/99/9999
PC
VL
VL
VL
VL
VL
EMEND (COMBO PACK) 1 125mg/ 2 80mg
3 EA PG
PO
EA
1 MG
95
04/11/2003
12/31/2004
EMEND (COMBO PACK) 1 125mg/ 2 80mg

EMEND (115 MG, EA)
RECOMBIVAX HB (SD,6X1ML,TAX
INCL,PF) 10 MCG/ML
RECOMBIVAX HB (TAX INCL,PF) 10
MCG/ML
ELSPAR 10000 IU
RECOMBIVAX HB
PEDIATRIC/ADOLESCENT (S.D.V.,TAX
INCL) 5 MCG/0.5 ML
RECOMBIVAX HB (3 DOSE VIAL,TAX
INCL) 10 MCG/ML
RECOMBIVAX HB (S.D.V.,TAX INCL) 10
MCG/ML
RECOMBIVAX HB (DIALYSIS,SDV,TAX
INCL) 40 MCG/ML
3 EA PG
1 EA VL
PO
IV
EA
MG
5 MG
1 MG
19
115
01/01/2005
1/30/2008
99/99/9999
99/99/9999
RECOMBIVAX HB (SRN,PREFILLED,TAX
INCL) 10 MCG/ML
RECOMBIVAX HB
PEDIATRIC/ADOLESCENT
(SRN,1"X23G,TAX INCL) 5 MCG/0.5 ML
MCG/ML
INCL) 10 MCG/ML
RECOMBIVAX HB
INCL) 5 MCG/0.5 ML
Page 5 of 374
1 ML SR
IM
ML
1 EA
06/19/2007
8/29/2009
1 ML SR
1 EA VL
IM
IJ
ML
EA
1 EA
10000 U
1
1
06/19/2007
01/01/2002
99/99/9999
11/15/2006
0.5 ML VL
IM
ML
1 EA
01/01/2002
09/01/2002
3 ML VL
IM
ML
1 EA
01/01/2002
05/01/2003
1 ML VL
IM
ML
1 EA
01/01/2002
05/01/2003
1 ML VL
IM
ML
1 EA
01/01/2002
05/01/2003
1 ML SR
IM
ML
1 EA
01/01/2002
09/01/2002
0.5 ML SR
IM
ML
1 EA
01/01/2002
09/01/2002
1 ML VL
IM
ML
1 EA
01/01/2002
05/01/2003
3 ML VL
IM
ML
1 EA
01/01/2002
05/01/2003
0.5 ML VL
IM
ML
1 EA
01/01/2002
05/01/2003
8/16/2002
4/30/2004
0.004
1/1/2002
4/30/2004
0.004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
BO
BX
BX
VL
AM
AM
VL
VL
VL
VL
VL
VL
GC
PC
VL
VL
VL
VL
Billing Units
30 EA
30 EA
5 EA
1 EA
10 ML
2 ML
2 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
50 ML
2 ML
4 ML
20 ML
20 ML

Package
NDC Package Type
K0415
J8501
J8501
J8501
J0380
J0515
J0515
J9120
J0694
J0694
J0694
J0743
J0743
J0743
J3490
J3490
J3490
J3490
J3490
NDC Package Measure

1/31/2003 INJECTION, METARAMINOL BITARTRATE, PER 10 MG
6/30/2004 INJECTION, BENZTROPINE MESYLATE, PER 1 MG
1/20/2006 INJECTION, DACTINOMYCIN, 0.5 MG
99/99/9999 INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG
00006-0462-30
00006-0462-30
00006-0464-05
00006-0464-10
00006-3222-10
00006-3275-16
00006-3275-38
00006-3298-22
00006-3356-45
00006-3357-53
00006-3388-67
00006-3514-58
00006-3516-59
00006-3517-75
00006-3537-50
00006-3539-04
00006-3541-14
00006-3541-20
00006-3541-49
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00006-4969-00
J3490
1/1/2002
00006-4980-00
J3490
1/1/2002
00006-4981-00
J3490
00006-4992-00
J3490
00006-4995-00
J3490
00006-4995-41
00006-7628-03
00006-7628-25
J3490
J1100
J1100
00006-7633-04
00006-7646-03
J1710
J1100
1/1/2002
1/1/2002
00006-7753-31
00007-3130-16
00007-3130-76
00007-3135-05
00007-3135-76
00007-3137-05
J9230
J0690
J0690
J0690
J0690
J0690
1/1/2002
1/1/2002
5/17/2002
1/1/2002
5/17/2002
1/1/2002
00007-3230-02
J1652
2/6/2006 99/99/9999 INJECTION, FONDAPARINUX SODIUM, 0.5 MG
00007-3230-11
J1652
00007-3232-02
J1652
00007-3232-11
J1652
00007-3234-02
J1652
00007-3234-11
J1652
00007-3236-02
J1652
00007-3236-11
00007-3343-01
J1652
J0780
00007-3344-15
Q0165
00007-3346-15
00007-3352-16
Q0165
J0780
00007-3360-03
K0416
00007-3361-03
K0416
00007-3362-03
K0416
00007-3366-20
Q0164
00007-3366-21
Q0164
00007-3367-20
Q0165
00007-3367-21
00007-4201-01
00007-4201-05
00007-4401-01
Q0165
J9350
J9350
J9261
00007-4401-06
J3490

1/1/2002
9/1/2002 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG
1/1/2002
9/1/2002 INJECTION, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 MG
1/20/2006 INJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG
RECOMBIVAX HB
PEDIATRIC/ADOLESCENT
(SRN,5/8"X25G,TAX INCL) 5 MCG/0.5 ML
RECOMBIVAX HB
INCL,PF) 5 MCG/0.5 ML
RECOMBIVAX HB
RECOMBIVAX HB (S.D.V., TAX INCL.) 40
MCG/ML
RECOMBIVAX HB (S.D.V.,TAX INCL.) 10
MCG/ML
RECOMBIVAX HB (S.D.V.,TAX INCL.) 10
MCG/ML
DECADRON (VIAL) 4 MG/ML
HYDROCORTONE PHOSPHATE (VIAL) 50
MG/ML
MUSTARGEN (VIAL) 10 MG
ANCEF (VIAL) 1 GM
ANCEF NOVATION (VIAL) 1 GM
ANCEF (VIAL, BULK) 10 GM
ANCEF NOVATION (VIAL,BULK) 10 GM
ANCEF (P.B.) 1 GM
ARIXTRA (PREFL,27GX1/2",PF) 2.5
MG/0.5 ML
ARIXTRA (SRN,PREFL,27GX1/2",PF) 2.5
MG/0.5 ML
ARIXTRA (PREFL,27GX1/2",PF) 5 MG/0.4
ML
ML
MG/0.6 ML
MG/0.6 ML
ML
ML
COMPAZINE (VIAL) 5 MG/ML

1/1/2002
5/2/2002 INJECTION, PROCHLORPERAZINE, UP TO 10 MG
PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION
COMPAZINE SPANSULE 10 MG
1/1/2002
COMPAZINE SPANSULE 15 MG
1/1/2002
1/1/2002
PRESCRIPTION ANTIEMETIC DRUG, RECTAL, PER 1 MG, FOR USE IN CONJUCTION
COMPAZINE 2.5 MG
COMPAZINE 5 MG
COMPAZINE 25 MG
PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANT
EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTIEMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48
COMPAZINE 5 MG
1/1/2002
COMPAZINE 5 MG
1/1/2002
COMPAZINE 10 MG
1/1/2002 2/26/2004 HOUR DOSAGE REGIMEN
COMPAZINE 10 MG
1/1/2002 99/99/9999 INJECTION, TOPOTECAN, 4 MG
HYCAMTIN (S.D.V.) 4 MG
1/1/2002 99/99/9999 INJECTION, TOPOTECAN, 4 MG
HYCAMTIN (S.D.V.) 4 MG
4/2/2008 99/99/9999 INJECTION, NELARABINE, 50 MG
ARRANON (LATEX-FREE) 5 MG/ML
ARRANON (6X50ML,LATEX-FREE) 5
MG/ML
Page 6 of 374
0.5 ML SR
IM
ML
1 EA
01/01/2002
09/01/2002
0.5 ML VL
IM
ML
1 EA
01/01/2002
11/05/2007
0.5 ML VL
IM
ML
1 EA
01/01/2002
99/99/9999
1 ML VL
IM
ML
1 EA
07/09/2002
99/99/9999
1 ML VL
IM
ML
1 EA
07/09/2002
99/99/9999
1 ML VL
5 ML VL
25 ML VL
IM
IJ
IJ
ML
ML
ML
1 EA
1 MG
1 MG
1
4
4
07/16/2002
01/01/2002
01/01/2002
99/99/9999
09/01/2002
09/01/2002
2 ML VL
5 ML VL
IJ
IJ
ML
ML
50 MG
1 MG
1
24
01/01/2002
01/01/2002
09/01/2002
09/01/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
IV
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
10 MG
500 MG
500 MG
500 MG
500 MG
500 MG
1
2
2
20
20
2
01/01/2002
01/01/2002
05/17/2002
01/01/2002
05/17/2002
01/01/2002
01/20/2006
01/07/2005
01/07/2005
05/16/2005
05/16/2005
05/16/2005
0.5 ML SR
SC
ML
0.5 MG
10
02/06/2006
99/99/9999
0.5 ML SR
SC
ML
0.5 MG
10
06/03/2005
99/99/9999
0.4 ML SR
SC
ML
0.5 MG
25
02/06/2006
99/99/9999
0.4 ML SR
SC
ML
0.5 MG
25
11/16/2004
99/99/9999
0.6 ML SR
SC
ML
0.5 MG
25
02/06/2006
99/99/9999
0.6 ML SR
SC
ML
0.5 MG
25
11/16/2004
99/99/9999
0.8 ML SR
SC
ML
0.5 MG
25
02/06/2006
99/99/9999
0.8 ML SR
10 ML VL
SC
IJ
ML
ML
0.5 MG
10 MG
25
0.5
11/16/2004
01/01/2002
99/99/9999
05/02/2002
50 EA BO
PO
EA
10 MG
01/01/2002
05/01/2002
50 EA BO
2 ML VL
PO
IJ
EA
ML
10 MG
10 MG
1.5
0.5
01/01/2002
01/01/2002
05/01/2002
05/02/2002
12 EA BX
RC
EA
1 MG
2.5
01/01/2002
02/26/2004
12 EA BX
RC
EA
1 MG
01/01/2002
02/26/2004
12 EA BX
RC
EA
1 MG
25
01/01/2002
02/26/2004
100 EA BO
PO
EA
5 MG
01/01/2002
05/02/2002
100 EA BX
PO
EA
5 MG
01/01/2002
05/02/2002
100 EA BO
PO
EA
10 MG
01/01/2002
02/26/2004
100 EA
1 EA
1 EA
50 ML
PO
IV
IV
IV
EA
EA
EA
ML
10 MG
4 MG
4 MG
50 MG
1
1
1
0.1
01/01/2002
01/01/2002
01/01/2002
04/02/2008
02/26/2004
99/99/9999
99/99/9999
99/99/9999
IV
ML
1 EA
01/27/2006
12/31/2006
VL
VL
VL
VL
VL
VL
BX
VL
VL
VL
50 ML VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00007-5070-03
K0416
00007-5071-03
00007-5071-03
K0416
J8498
00007-5072-44
00007-5085-11
00007-5088-04
00007-5089-04
Q0171
J0713
J0713
J0713
00008-0018-34
J2510
1/1/2002
00008-0018-35
J2510
1/1/2002
00008-0019-01
00008-0021-12
Q0169
J0560
1/1/2002
1/1/2002
00008-0026-22
J0530
1/1/2002
00008-0026-36
J0530
1/1/2002
00008-0026-37
00008-0063-01
J0530
J2550
1/1/2002
1/1/2002
00008-0212-01
00008-0258-01
00008-0259-01
K0416
J2175
J2175
1/1/2002
1/1/2002
1/1/2002
00008-0304-01
J2560
1/1/2002
00008-0498-01
00008-0570-05
00008-0570-13
00008-0570-15
K0416
J2060
J2060
J2060
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00008-0581-05
00008-0581-07
00008-0581-13
00008-0581-15
J2060
J2060
J2060
J2060
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00008-0613-02
00008-0746-01
00008-0814-01
J2175
J2550
J0282
1/1/2002
1/1/2002
1/1/2002
00008-0923-03
00008-0923-51
00008-0923-55
00008-1030-06
00008-1031-05
00008-1031-10
00008-1032-05
00008-1041-05
00008-1041-10
00008-1042-05
00008-1179-01
00008-2564-01
00008-4510-01
00008-4990-02
00008-5360-02
00008-5360-02
00008-9149-01
J3490
J3490
J3490
J7520
J7520
J7520
J7520
J7520
J7520
J7520
J9330
J3590
J9300
J3243
J3490
J3243
J7320
1/1/2002
5/20/2004
5/18/2004
1/1/2002
1/1/2002
1/1/2002
3/12/2003
2/1/2006
5/26/2006
2/1/2006
6/27/2007
1/1/2003
1/1/2002
7/27/2007
6/17/2005
1/1/2007
1/1/2002
00008-9149-02
00009-0022-01
00009-0032-01
00009-0045-01
J7320
J7509
J7506
J7506
1/1/2002
1/1/2002
1/1/2002
1/1/2002
ARRANON (6X50ML,LATEX-FREE) 5
MG/ML
TOPOTECAN HYDROCHLORIDE
HYCAMTIN 0.25 MG
TOPOTECAN HYDROCHLORIDE
HYCAMTIN 1 MG
THORAZINE 25 MG/ML
THORAZINE 25 MG/ML
THORAZINE 25 MG/ML
IV
PO
PO
PO
PO
IJ
IJ
IJ
ML
EA
EA
EA
EA
ML
ML
ML
50 MG
1 EA
0.25 MG
1 EA
0.25 MG
50 MG
50 MG
50 MG
0.1
1
1
1
4
0.5
0.5
0.5
01/01/2007
09/16/2008
07/01/2009
09/16/2008
07/01/2009
01/01/2002
01/01/2002
01/01/2002
12 EA BX
RC
EA
1 MG
25
01/01/2002
06/10/2002
THORAZINE 100 MG
THORAZINE 100 MG
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
100
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
PO
IJ
IJ
IJ
ML
EA
EA
EA
10 MG
500 MG
500 MG
500 MG
0.2
4
2
4
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/14/2003
12/12/2002
4/1/2001
4/1/2001
1 ML SR
IM
ML
600000 U
01/01/2002
04/24/2002
2 ML SR
IM
ML
600000 U
01/01/2002
07/18/2002
PO
IM
EA
ML
12.5 MG
600000 U
1
1
01/01/2002
01/01/2002
07/07/2004
03/11/2002
4 ML SR
IM
ML
600000 U
01/01/2002
06/19/2002
2 ML SR
IM
ML
600000 U
01/01/2002
05/27/2002
1 ML SR IM
1 ML AM IJ
ML
ML
600000 U
50 MG
1
0.5
01/01/2002
01/01/2002
01/18/2002
06/01/2002
RC
IJ
IJ
EA
ML
ML
1 MG
100 MG
100 MG
25
0.5
1
01/01/2002
01/01/2002
01/01/2002
12/01/2005
09/30/2002
06/01/2002
120 MG
Page 7 of 374
120 ML
1 EA
1 EA
1 EA
BO
VL
PC
PC
100 EA BO
4 ML SR
12 EA BX
30 ML VL
20 ML VL
1 ML SR
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
6/30/2009
99/99/9999
6/30/2009
99/99/9999
06/10/2002
05/14/2003
11/01/2003
THORAZINE 25 MG
THORAZINE (AF) 10 MG/5 ML

TAZICEF (P.B.) 2 GM
TAZICEF (PREMIX) 1 GM
TAZICEF (PREMIX) 2 GM
WYCILLIN (TUBEX, 21GX1 1/4) 600000
4/24/2002 INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS
U/ML
U/ML
PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION
PHENERGAN 12.5 MG
3/11/2002 INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS
BICILLIN L-A (SRN) 600000 U/ML
INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO
BICILLIN C-R (SRN) 300000 U/ML-300000
6/19/2002 600,000 UNITS
U/ML
BICILLIN C-R PEDIATRIC
(TUBEX,21GX1") 300000 U/ML-300000
U/ML
5/27/2002 600,000 UNITS
BICILLIN C-R (TUBEX,20GX1 1/4) 300000
1/18/2002 600,000 UNITS
U/ML-300000 U/ML
6/1/2002 INJECTION, PROMETHAZINE HCL, UP TO 50 MG
PHENERGAN (AMP) 25 MG/ML
PHENERGAN 25 MG
9/30/2002 INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG
MEPERIDINE HCL 50 MG/ML
PHENOBARBITAL SODIUM
6/1/2002 INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG
(TUBEX,22GX1 1/4") 130 MG/ML
PHENERGAN 12.5 MG
1/31/2002 INJECTION, LORAZEPAM, 2 MG
ATIVAN (TAMP-R-TEL,TUBEX) 4 MG/ML
ATIVAN (M.D.V.) 4 MG/ML
ATIVAN (S.D.V.) 4 MG/ML
ATIVAN (TBX,22GX1 1/4",TAMPRTEL) 2
MG/ML
ATIVAN (TUBEX, 22GX1-1/4") 2 MG/ML
MEPERIDINE HCL (TUBEX, 22GX1 1/4")
100 MG/ML
4/26/2006 INJECTION, AMIODARONE HYDROCHLORIDE, 30 MG
CORDARONE IV (AMP) 50 MG/ML
PROTONIX (VIAL,W/INLINE FILTERS) 40
MG
PROTONIX 40 MG
PROTONIX 40 MG
99/99/9999 SIROLIMUS, ORAL, 1 MG
RAPAMUNE (M.D. BOTTLE) 1 MG/ML
RAPAMUNE 1 MG
RAPAMUNE (REDIPAK,10X10) 1 MG
RAPAMUNE 2 MG
RAPAMUNE 1 MG
RAPAMUNE (REDIPAK,10X10) 1 MG
RAPAMUNE 2 MG
99/99/9999 INJECTION, TEMSIROLIMUS, 1 MG
TORISEL (WITH DILUENT) 25MG/ML
NORPLANT SYSTEM 36 MG
99/99/9999 INJECTION, GEMTUZUMAB OZOGAMICIN, 5 MG
MYLOTARG (VIAL,PF) 5 MG
99/99/9999 INJECTION, TIGECYCLINE, 1 MG
TYGACIL (SDV,PF) 50 MG
TYGACIL (S.D.V.,PF) 50 MG
7/26/2007 INJECTION, TIGECYCLINE, 1 MG
TYGACIL (S.D.V.,PF) 50 MG
1/6/2005 HYLAN G-F 20, 16 MG, FOR INTRA ARTICULAR INJECTION
SYNVISC (SRN,PREFILLED) 8 MG/ML
SYNVISC (3X2 ML SRN,PREFILLED) 8
MG/ML
99/99/9999 METHYLPREDNISOLONE ORAL, PER 4 MG
MEDROL 8 MG
10/11/2002 PREDNISONE, ORAL, PER 5MG
DELTASONE 2.5 MG
DELTASONE 5 MG
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
VL
PG
BO
PG
BO
AM
AM
VL
Billing Units
50 ML
10 EA
10 EA
10 EA
10 EA
1 ML
2 ML
10 ML

Package
NDC Label
HCPCS Description
1/1/2007 99/99/9999 INJECTION, NELARABINE, 50 MG

9/16/2008 6/30/2009 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS
7/1/2009 99/99/9999 TOPOTECAN, ORAL, 0.25 MG
7/1/2009 99/99/9999 TOPOTECAN, ORAL, 0.25 MG
1/1/2002 6/10/2002 INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG
1/1/2006 99/99/9999 ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED
CHLORPROMAZINE HYDROCHLORIDE, 10 MG, ORAL, FDA APPROVED
PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC
SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY
1/1/2002 5/14/2003 TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
1/1/2002 12/12/2002 INJECTION, CEFTAZIDIME, PER 500 MG
1/1/2002
1/1/2002
NDC Package Type
J9261
J8999
None
J8999
None
J3230
J3230
J3230
NDC Package Measure
00007-4401-06
00007-4205-11
00007-4205-11
00007-4207-11
00007-4207-11
00007-5060-11
00007-5061-11
00007-5062-01
HCPCS Mod
HCPCS
NDC Mod
NDC
IJ
ML
1.08333
01/01/2002
06/01/2002
12 EA
1 ML
10 ML
1 ML
BX
SR
VL
VL
RC
IJ
IJ
IJ
EA
ML
ML
ML
1
2
2
2
MG
MG
MG
MG
12.5
2
2
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/01/2005
01/31/2002
06/01/2002
06/01/2002
0.5 ML
0.5 ML
10 ML
1 ML
SR
SR
VL
VL
IJ
IJ
IJ
IJ
ML
ML
ML
ML
2
2
2
2
MG
MG
MG
MG
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/01/2002
06/01/2002
06/01/2002
06/01/2002
1 ML SR IJ
1 ML AM IJ
3 ML AM IV
ML
ML
ML
100 MG
50 MG
30 MG
1
1
1.66666
01/01/2002
01/01/2002
01/01/2002
04/25/2002
06/01/2002
04/26/2006
1 EA
1 EA
1 EA
60 ML
100 EA
100 EA
100 EA
100 EA
100 EA
100 EA
1 ML
1 EA
1 EA
1 EA
1 EA
1 EA
2 ML
VL
VL
VL
BO
BO
DP
BO
BO
BX
BO
VL
BX
VL
VL
VL
VL
SR
IV
IV
IV
PO
PO
PO
PO
PO
PO
PO
IV
ID
IV
IV
IV
IV
IJ
EA
EA
EA
ML
EA
EA
EA
EA
EA
EA
MG
EA
EA
EA
EA
EA
ML
1 EA
1 EA
1 EA
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 EA
5 MG
1 MG
1 EA
1 MG
16 MG
1
1
1
1
1
1
2
1
1
2
25.0
1
1
50
1
50
0.5
01/01/2002
05/20/2004
05/18/2004
01/01/2002
01/01/2002
01/01/2002
03/12/2003
02/01/2006
05/26/2006
02/01/2006
6/27/2007
01/01/2003
01/01/2002
07/27/2007
06/17/2005
01/01/2007
01/01/2002
06/16/2004
05/21/2004
99/99/9999
99/99/9999
01/31/2006
05/25/2006
01/31/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
05/12/2003
99/99/9999
99/99/9999
12/31/2006
07/26/2007
01/06/2005
2 ML
25 EA
100 EA
100 EA
SR
BO
BO
BO
IJ
PO
PO
PO
ML
EA
EA
EA
16 MG
4 MG
5 MG
5 MG
0.5
2
0.5
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/06/2005
99/99/9999
10/11/2002
03/26/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00009-0113-19
00009-0155-01
00009-0165-01
00009-0165-02
00009-0176-01
00009-0190-16
00009-0193-01
00009-0193-02
00009-0233-01
J2920
J7509
J7506
J7506
J7509
J2930
J7506
J7506
J3490
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00009-0253-02
00009-0268-01
00009-0268-02
00009-0268-12
00009-0271-01
00009-0280-02
00009-0280-03
J1060
J1644
J1644
J1644
J1000
J1030
J1030
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00009-0280-51
00009-0280-52
00009-0291-01
00009-0317-02
00009-0317-10
00009-0317-11
J1030
J1030
J1644
J1644
J1644
J1644
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00009-0347-02
00009-0373-01
00009-0388-01
J1070
J9100
J7506
1/1/2002
1/1/2002
1/1/2002
00009-0417-01
J1080
1/1/2002
00009-0417-02
00009-0473-01
00009-0555-01
00009-0555-02
00009-0566-01
00009-0626-01
00009-0626-01
00009-0698-01
00009-0728-09
J1080
J9110
J2010
J2010
J3320
J1050
J1051
J2930
J3490
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2002
00009-0746-30
J1055
1/1/2002
00009-0746-35
00009-0758-01
00009-0765-02
00009-0775-26
00009-0796-01
00009-0825-01
00009-0844-01
00009-0870-26
00009-0900-13
J1055
J2930
J2930
J3490
J2930
J1720
J9320
J3490
J1720
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00009-0900-20
00009-0902-11
00009-0902-18
00009-0909-08
J1720
J3490
J3490
J1720
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00009-0909-16
00009-0912-05
00009-0920-03
00009-3073-01
J1720
J1720
J1720
J1030
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00009-3073-03
J1030
1/1/2002
00009-3124-03
J3490
1/1/2002
00009-3169-06
00009-3295-01
00009-3296-01
J0270
J9110
J9110
1/1/2002
1/1/2002
1/1/2002
DELTASONE 5 MG
DELTASONE 5 MG
MEDROL 2 MG
MEDROL 4 MG
MEDROL 4 MG
MEDROL (UNIT OF USE) 4 MG
MEDROL 4 MG
MEDROL 16 MG
SOLU-MEDROL (ACT-O-VIAL, 25 PACK)
99/99/9999 INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG
40 MG
MEDROL 24 MG
DELTASONE 20 MG
DELTASONE 20 MG
MEDROL 32 MG
SOLU-MEDROL (ACT-O-VIAL) 125 MG
DELTASONE 10 MG
DELTASONE 10 MG
BACITRACIN 50000 U
DEPO-TESTADIOL (VIAL) 2 MG/ML-50
2/25/2003 INJECTION, TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE, UP TO 1 ML MG/ML
99/99/9999 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG
DEPO-ESTRADIOL (VIAL) 5 MG/ML
99/99/9999 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG
DEPO-MEDROL (M.D.V.) 40 MG/ML
DEPO-MEDROL (M.D.V.,5X25ML) 40
MG/ML
HEPARIN SODIUM 10000 U/ML
DEPO-TESTOSTERONE (VIAL) 100
99/99/9999 INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG
MG/ML
6/4/2003 INJECTION, CYTARABINE, 100 MG
CYTOSAR-U (M.D.V.) 100 MG
DELTASONE 50 MG
99/99/9999 INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG
MG/ML
MG/ML
CYTOSAR-U (M.D.V.) 500 MG
99/99/9999 INJECTION, LINCOMYCIN HCL, UP TO 300 MG
LINCOCIN (VIAL) 300 MG/ML
11/10/2005 INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GM
TROBICIN (W/DILUENT) 2 GM
12/31/2002 INJECTION, MEDROXYPROGESTERONE ACETATE, 100 MG
DEPO-PROVERA (VIAL) 400 MG/ML
SOLU-MEDROL (VIAL) 1 GM
CLEOCIN PHOSPHATE 150 MG/ML
INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150 DEPO-PROVERA CONTRACEPTIVE
99/99/9999 MG
(VIAL) 150 MG/ML
99/99/9999 MG
(VIAL,25X1ML) 150 MG/ML
SOLU-MEDROL (VIAL) 500 MG
SOLU-MEDROL (W/DILUENT) 2 GM
99/99/9999 INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG
SOLU-CORTEF 100 MG
4/13/2003 INJECTION, STREPTOZOCIN, 1 GRAM
ZANOSAR (STERILE) 1 GM
SOLU-CORTEF (ACT-O-VIAL) 100 MG
SOLU-CORTEF (ACT-O-VIAL, 25 PACK)
100 MG
SOLU-CORTEF (ACT-O-VIAL, 25 PACK)
250 MG
SOLU-CORTEF (ACT-O-VIAL) 1 GM
DEPO-MEDROL (S.D.V.) 40 MG/ML
DEPO-MEDROL (S.D.V.,25X1ML) 40
MG/ML
CLEOCIN PHOSPHATE (ADD99/99/9999 UNCLASSIFIED DRUGS
VANTAGE,25X4ML) 150 MG/ML
INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN
PROSTIN VR PEDIATRIC (AMP,5X1ML)
DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT
0.5 MG/ML
99/99/9999 FOR USE WHEN DRUG IS SELF ADMINISTERED)
CYTOSAR-U (30 ML VIAL) 1 GM
CYTOSAR-U 2 GM
Page 8 of 374
10 ML VL
1 EA VL
100 EA BO
1 ML VL
10 ML
1 EA
2 ML
10 ML
1 EA
2.5 ML
2.5 ML
1 EA
60 ML
VL
VL
VL
VL
VL
VL
VL
VL
VL
40 MG
4 MG
5 MG
5 MG
4 MG
125 MG
5 MG
5 MG
1 EA
1
6
4
4
8
1
2
2
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
01/02/2004
06/07/2002
12/20/2002
99/99/9999
99/99/9999
01/02/2004
04/26/2004
99/99/9999
IM
IJ
IJ
IJ
IM
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
1 ML
1000 U
1000 U
1000 U
5 MG
40 MG
40 MG
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/25/2003
11/20/2002
08/08/2002
09/21/2004
99/99/9999
99/99/9999
99/99/9999
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
40 MG
40 MG
1000 U
1000 U
1000 U
1000 U
1
1
5
10
10
10
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
12/12/2002
12/13/2002
10/14/2002
01/02/2004
IM
IJ
PO
ML
EA
EA
100 MG
100 MG
5 MG
1
1
10
01/01/2002
01/01/2002
01/01/2002
99/99/9999
06/04/2003
05/01/2003
IM
ML
200 MG
01/01/2002
99/99/9999
IM
IJ
IJ
IJ
IM
IM
IM
IJ
IJ
ML
EA
ML
ML
EA
ML
ML
EA
ML
200 MG
500 MG
300 MG
300 MG
2 GM
100 MG
50 MG
125 MG
1 EA
1
1
1
1
1
4
8
8
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2002
01/01/2002
99/99/9999
06/04/2003
99/99/9999
99/99/9999
11/10/2005
12/31/2002
99/99/9999
99/99/9999
99/99/9999
1 ML VL
IM
ML
150 MG
01/01/2002
99/99/9999
1 ML
1 EA
1 EA
4 ML
1 EA
1 EA
1 EA
2 ML
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
IM
IJ
IJ
IJ
IJ
IJ
IV
IJ
IJ
ML
EA
EA
ML
EA
EA
EA
ML
EA
150 MG
125 MG
125 MG
1 EA
125 MG
100 MG
1 GM
1 EA
100 MG
1
4
4
1
16
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
04/13/2003
99/99/9999
99/99/9999
1 EA
6 ML
6 ML
1 EA
VL
VL
VL
VL
IJ
IJ
IJ
IJ
EA
ML
ML
EA
100 MG
1 EA
1 EA
100 MG
1
1
1
2.5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
05/24/2002
99/99/9999
99/99/9999
1
1
1
1
VL
VL
VL
VL
IJ
IJ
IJ
IJ
EA
EA
EA
ML
100 MG
100 MG
100 MG
40 MG
2.5
5
10
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
EA
EA
EA
ML
1 ML VL
IJ
ML
40 MG
01/01/2002
99/99/9999
4 ML VL
IJ
ML
1 EA
01/01/2002
99/99/9999
1 ML AM IV
1 EA VL IJ
1 EA VL IJ
ML
EA
EA
1.25 MCG
500 MG
500 MG
400
2
4
01/01/2002
01/01/2002
01/01/2002
99/99/9999
06/04/2003
04/13/2003
VL
VL
VL
VL
VL
VL
EA
EA
EA
EA
EA
EA
EA
EA
EA
Prior End Date #3
5 ML
10 ML
10 ML
4 ML
1 ML
4 ML
09/20/2002
06/21/2002
99/99/9999
99/99/9999
08/06/2007
99/99/9999
06/19/2007
99/99/9999
Prior Start Date #3
VL
VL
VL
VL
VL
VL
VL
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10 ML
10 ML
30 ML
10 ML
5 ML
5 ML
10 ML
1
1
0.5
1
1
1
1
4
Prior End Date #2
IJ
PO
PO
PO
PO
IJ
PO
PO
IM
MG
MG
MG
MG
MG
MG
MG
MG
Prior Start Date #2
VL
BO
BO
BO
BO
VL
BO
BO
VL
End Date #1
1 EA
25 EA
100 EA
500 EA
25 EA
1 EA
100 EA
500 EA
1 EA
5
5
4
4
4
4
4
4
Start Date #1
EA
EA
EA
EA
EA
EA
EA
EA
CF
PO
PO
PO
PO
PO
PO
PO
PO
HCPCS Measure #1
BO
BO
BO
BO
BO
DP
BX
BO
Billing Units
500 EA
1000 EA
100 EA
100 EA
500 EA
21 EA
100 EA
50 EA
HCPCS Amount #1

Package
NDC Label
HCPCS Description

NDC Package Type
J7506
J7506
J7509
J7509
J7509
J7509
J7509
J7509
NDC Package Measure
00009-0045-02
00009-0045-16
00009-0049-02
00009-0056-02
00009-0056-03
00009-0056-04
00009-0056-05
00009-0073-01
HCPCS Mod
HCPCS
NDC Mod
NDC
00009-3375-02
J3490
00009-3381-02
J3490
00009-3382-02
00009-3389-01
J3490
J2930

1/1/2002 99/99/9999 INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG
INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG /
1/1/2002 10/16/2003 25MG
1/1/2002 10/16/2003 25MG
00009-3447-03
J3490
00009-3484-04
J1056
00009-3484-05
J1056
00009-3484-06
J1056
1/7/2002
00009-3484-10
J1056
1/1/2002
00009-3701-01
J0270
1/1/2002
00009-3701-05
J0270
1/1/2002
00009-3778-05
J0270
1/1/2002
00009-3778-08
00009-3794-01
J0270
J1742
1/1/2002
1/1/2002
00009-4709-01
00009-5091-01
00009-5091-01
00009-5093-01
00009-5093-01
00009-5137-01
00009-5140-01
J1051
J9180
J9178
J9180
J9178
J2020
J2020
4/6/2005
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
00009-5181-01
J0270
6/25/2002
00009-5182-01
00009-5215-01
00009-5215-01
J0270
J9999
J3315
6/25/2002
1/10/2002
1/1/2003
00009-5216-01
J9999
1/10/2002
00009-5219-01
J9999
1/10/2002
00009-7212-03
J0270
1/1/2002
00009-7224-02
J7504
1/1/2002
00009-7376-01
J1055
1/1/2002
00009-7376-02
J1055
1/1/2002
00009-7376-03
J1055
1/1/2002
00009-7376-04
J1055
00009-7529-01
J9206
00009-7529-01 QR J9206
00009-7529-02
J9206
00009-7529-02 QR J9206
QR
QR
4/21/2003
1/1/2002
1/28/2005
1/1/2002
1/28/2005
00009-7650-02
00009-7663-04
00009-7664-01
00009-7664-01
J0270
J8999
J9999
J3315
1/1/2002
1/1/2002
1/10/2002
1/1/2003
00009-7686-04
00013-1036-91
00013-1046-94
00013-1056-94
J0270
J9190
J9190
J9190
1/1/2002
1/1/2002
1/1/2002
1/1/2002

10/16/2003 25MG
4/26/2002 25MG
99/99/9999 INJECTION, IBUTILIDE FUMARATE, 1 MG
12/31/2003 EPIRUBICIN HYDROCHLORIDE, 50 MG
99/99/9999 INJECTION, EPIRUBICIN HCL, 2 MG
12/31/2003 EPIRUBICIN HYDROCHLORIDE, 50 MG
99/99/9999 INJECTION, LINEZOLID, 200MG
99/99/9999 INJECTION, LINEZOLID, 200MG
12/31/2002 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS
12/31/2004 INJECTION, TRIPTORELIN PAMOATE, 3.75 MG
LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE,
99/99/9999 PARENTERAL, 250 MG
INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150
4/20/2003 MG
4/20/2003 MG
4/20/2003 MG
99/99/9999 MG
99/99/9999 INJECTION, IRINOTECAN, 20 MG
4/13/2003 INJECTION, FLUOROURACIL, 500 MG
CLEOCIN PHOSPHATE (PREMIX) 600

MG/50 ML
MG/50 ML
MG/50 ML
SOLU-MEDROL (ACT-O-VIAL) 1 GM
CLEOCIN PHOSPHATE (ADDVANTAGE,25X6ML) 150 MG/ML
LUNELLE MONTHLY CONTRACEPTIVE
(S.D.V.) 5 MG/0.5 ML-25 MG/0.5 ML
(S.D.V.) 5 MG/0.5 ML-25 MG/0.5 ML
(PREFILLED SRN) 5 MG/0.5 ML-25
MG/0.5 ML
(S.D.V.) 5 MG/0.5 ML-25 MG/0.5 ML
50 ML PC
IV
ML
1 EA
01/01/2002
99/99/9999
50 ML PC
IV
ML
1 EA
01/01/2002
99/99/9999
50 ML PC
1 EA VL
IV
IJ
ML
EA
1 EA
125 MG
1
8
01/01/2002
01/01/2002
99/99/9999
99/99/9999
6 ML VL
IJ
ML
1 EA
01/01/2002
99/99/9999
0.5 ML VL
IM
ML
5 MG
01/01/2002
10/16/2003
0.5 ML VL
IM
ML
5 MG
01/01/2002
10/16/2003
0.5 ML SR
IM
ML
5 MG
01/07/2002
10/16/2003
0.5 ML VL
IM
ML
5 MG
01/01/2002
04/26/2002
CAVERJECT (SYSTEM) 20 MCG
1 EA VL
IC
EA
1.25 MCG
16
01/01/2002
11/01/2002
CAVERJECT (VIAL) 20 MCG
1 EA VL
IC
EA
1.25 MCG
16
01/01/2002
99/99/9999
1 EA VL
IC
EA
1.25 MCG
01/01/2002
99/99/9999
1 EA VL
10 ML VL
IC
IV
EA
ML
1.25 MCG
1 MG
8
0.1
01/01/2002
01/01/2002
11/01/2002
99/99/9999
SC
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
50 MG
50 MG
2 MG
50 MG
2 MG
200 MG
200 MG
3.2
0.04
1
0.04
1
0.01
0.01
04/06/2005
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
1 EA BX
IC
EA
1.25 MCG
06/25/2002
99/99/9999
1 EA BX
1 EA VL
1 EA VL
IC
IM
IM
EA
EA
EA
1.25 MCG
1 EA
3.75 MG
16
1
3
06/25/2002
01/10/2002
01/01/2003
99/99/9999
12/31/2002
12/31/2004
1 EA VL
IM
EA
1 EA
01/10/2002
03/07/2002
1 EA VL
IM
EA
1 EA
01/10/2002
03/07/2002
1 EA VL
IC
EA
1.25 MCG
24
01/01/2002
11/01/2002
ATGAM (AMP,5X5ML) 50 MG/ML

DEPO-PROVERA CONTRACEPTIVE
(SRN, PREFILLED) 150 MG/ML
5 ML AM IV
ML
250 MG
0.2
01/01/2002
99/99/9999
1 ML SR
IM
ML
150 MG
01/01/2002
04/20/2003
1 ML SR
IM
ML
150 MG
01/01/2002
04/20/2003
1 ML SR
IM
ML
150 MG
01/01/2002
04/20/2003
1
5
5
2
2

CORVERT (FLIP-TOP VIAL) 0.1 MG/ML
DEPO-SUBQ PROVERA 104 (PRE-FILLED
W/NEEDLE) 104 MG/0.65 ML
ELLENCE (S.D.V.,PF) 2 MG/ML
ZYVOX (P.C.) 2 MG/ML
ZYVOX (P.C.) 2 MG/ML
CAVERJECT IMPULSE (SYSTEM) 10
MCG
CAVERJECT IMPULSE (SYSTEM) 20
MCG
TRELSTAR LA (S.D.V.) 11.25 MG
TRELSTAR LA (S.D.V.) 11.25 MG
TRELSTAR LA (S.D.V.,W/DEBIO CLIP)
11.25 MG
TRELSTAR DEPOT (S.D.V.,W/DEBIO
CLIP) 3.75 MG
DEPO-PROVERA CONTRACEPTIVE (W/

SAFETY GLIDE NEEDLE) 150 MG/ML
CAMPTOSAR (S.D.V.) 20 MG/ML
CAVERJECT (SYSTEM) 0.02 MG/ML

AROMASIN 25 MG
TRELSTAR DEPOT (S.D.V.) 3.75 MG
TRELSTAR DEPOT (S.D.V.) 3.75 MG

ADRUCIL (VIAL) 50 MG/ML
Page 9 of 374
0.65 ML
25 ML
25 ML
100 ML
100 ML
100 ML
300 ML
SR
VL
VL
VL
VL
FC
FC
ML
ML
ML
ML
ML
SR
VL
VL
VL
VL
IM
IV
IV
IV
IV
ML
ML
ML
ML
ML
150 MG
20 MG
20 MG
20 MG
20 MG
1
1
1
1
1
04/21/2003
01/01/2002
01/28/2005
01/01/2002
01/28/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML
30 EA
1 EA
1 EA
AM
BO
VL
VL
IC
PO
IM
IM
ML
EA
EA
EA
1.25 MCG
1 EA
1 EA
3.75 MG
16
1
1
1
05/03/2002
01/01/2002
01/10/2002
01/01/2003
99/99/9999
99/99/9999
12/31/2002
12/31/2004
1 EA
10 ML
50 ML
100 ML
VL
VL
VL
VL
IC
IV
IV
IV
EA
ML
ML
ML
1.25 MCG
500 MG
500 MG
500 MG
32
0.1
0.1
0.1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
04/13/2003
04/13/2003
04/13/2003
1/1/2002
3/26/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
16
00013-1086-91
00013-1096-91
00013-1106-79
00013-1116-83
J9000
J9000
J9000
J9000
1/1/2002
1/1/2002
1/1/2002
1/1/2002
12/15/2002 INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG

00013-1136-91
J9000
1/1/2002
00013-1146-91
J9000
1/1/2002
00013-1156-79
J9000
1/1/2002
00013-1166-83
00013-1176-87
J9000
J9000
1/1/2002 2/22/2002 INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG

00013-1236-91
J9000
00013-1246-91
J9000
00013-1256-79
J9000
00013-1266-83
J9000
00013-1286-83
00013-1405-44
J9000
J0285
2/26/2002
1/1/2002
00013-2200-01
J9211
1/7/2003
9/28/2004 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG
00013-2201-01
J9211
1/7/2003
00013-2202-01
00013-2406-91
J9211
J1645
1/7/2003
1/1/2002

6/25/2007 INJECTION, DALTEPARIN SODIUM, PER 2500 IU
00013-2426-01
00013-2426-91
00013-2436-06
J1645
J1645
J1645
6/14/2002
1/1/2002
1/1/2002
00013-2576-91
J9211
1/1/2002 99/99/9999 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG
00013-2586-91
J9211
00013-2596-91
00013-2606-94
00013-2616-81
00013-2616-94
00013-2626-81
00013-2626-94
00013-2646-81
00013-2646-94
J9211
J2941
J2941
J2941
J2941
J2941
J2941
J2941

1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00013-2649-02
J2941
00013-2650-02
J2941
00013-2651-02
J2941
00013-2652-02
J2941
00013-2653-02
J2941
00013-2654-02
J2941
00013-2655-02
J2941
00013-2656-02
J2941
00013-2657-02
J2941
00013-2658-02
J2941
00013-5190-01
00013-5191-01
00013-5606-93
00013-5616-93
00013-5626-93
00013-5636-70
00013-5646-70
00013-7001-12
00013-7001-12
00013-7336-91
00013-7346-94
00013-7356-88
J1645
J1645
J9093
J9094
J9095
J9096
J9097
Q2001
J8515
J9181
J9181
J9181


6/13/2002 11/19/2006 INJECTION, DALTEPARIN SODIUM, PER 2500 IU

1/1/2002 4/13/2004 CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MG
1/1/2002 4/13/2003 CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM
1/1/2002 12/31/2005 ORAL, CABERGOLINE, 0.5 MG
1/1/2006
4/5/2006 CABERGOLINE, ORAL, 0.25 MG
1/1/2002 4/13/2003 INJECTION, ETOPOSIDE, 10 MG
ADRIAMYCIN RDF 10 MG
ADRIAMYCIN RDF (M.D.V.) 150 MG
ADRIAMYCIN PFS (SDV,CYTOSAFE VIAL)
2 MG/ML
2 MG/ML
2 MG/ML
2 MG/ML
ADRIAMYCIN PFS (SDV,PF) 2 MG/ML
2 MG/ML
2 MG/ML
2 MG/ML
2 MG/ML
ADRIAMYCIN PFS (MDV, CYTOSAFE
VIAL,PF) 2 MG/ML
AMPHOCIN 50 MG
IDAMYCIN PFS (S.D. GLASS VIAL,PF) 1
MG/ML
IDAMYCIN PFS (S.D. GLASS VIALS,PF) 1
MG/ML
IDAMYCIN PFS (S.D. GLASS VIAL,PF) 1
MG/ML
FRAGMIN (SRN) 2500 IU/0.2 ML
FRAGMIN (SRN, PREFILLED,27GX1/2")
7500 IU/0.3 ML
FRAGMIN (SRN) 5000 IU/0.2 ML
FRAGMIN (M.D.V.) 10000 IU/ML
IDAMYCIN PFS (SDV,PF,CYTOSAFE
VIAL,PF) 1 MG/ML
IDAMYCIN PFS (SDV.PF,CYTOSAFE
VIAL,PF) 1 MG/ML
IDAMYCIN PFS (SDV,PF,CYTOSAFE
VIAL,PF) 1 MG/ML
GENOTROPIN (INTRA-MIX,PF) 1.5 MG
GENOTROPIN (INTRA-MIX) 5.8 MG
GENOTROPIN (INTRA-MIX) 5.8 MG
GENOTROPIN 5.8 MG
GENOTROPIN 5.8 MG
GENOTROPIN 13.8 MG
GENOTROPIN 13.8 MG
GENOTROPIN MINIQUICK
(SRN,PREFILLED,PF) 0.2 MG
(SRN,PREFILLED,PF) 1 MG
GENOTROPIN MINIQUICK (SRN,PF) 1.2
MG
MG
MG
MG
GENOTROPIN MINIQUICK (SRN,PF) 2
MG
FRAGMIN (SRN, PREFILLED,27GX1/2")
10000 IU/ML
FRAGMIN (M.D.V.) 25000 IU/ML
NEOSAR (S.D.V.) 100 MG
NEOSAR (S.D.V.) 1 GM
NEOSAR (S.D.V.) 2 GM
DOSTINEX 0.5 MG
DOSTINEX 0.5 MG
TOPOSAR (M.D.V.) 20 MG/ML
Page 10 of 374
1
1
1
1
EA
EA
EA
EA
VL
VL
VL
VL
IV
IV
IV
IV
EA
EA
EA
EA
10 MG
10 MG
10 MG
10 MG
1
2
5
15
01/01/2002
01/01/2002
01/01/2002
01/01/2002
5 ML VL
IV
ML
10 MG
0.2
01/01/2002
02/22/2002
IV
ML
10 MG
0.2
01/01/2002
02/22/2002
25 ML VL
IV
ML
10 MG
0.2
01/01/2002
02/22/2002
100 ML VL
37.5 ML VL
IV
IV
ML
ML
10 MG
10 MG
0.2
0.2
01/01/2002
03/27/2002
02/22/2002
12/15/2002
5 ML VL
IV
ML
10 MG
0.2
01/01/2002
12/15/2002
10 ML VL
IV
ML
10 MG
0.2
01/01/2002
12/15/2002
25 ML VL
IV
ML
10 MG
0.2
01/01/2002
12/15/2002
100 ML VL
IV
ML
10 MG
0.2
01/01/2002
12/15/2002
75 ML VL
1 EA VL
IV
IV
ML
EA
10 MG
50 MG
0.2
1
02/26/2002
01/01/2002
05/06/2002
04/06/2007
5 ML VL
IV
ML
5 MG
0.2
01/07/2003
09/28/2004
10 ML VL
IV
ML
5 MG
0.2
01/07/2003
01/02/2004
20 ML VL
0.2 ML SR
IV
SC
ML
ML
5 MG
2500 IU
0.2
5
01/07/2003
01/01/2002
01/02/2004
06/25/2007
0.3 ML SR
0.2 ML SR
9.5 ML VL
SC
SC
SC
ML
ML
ML
2500 IU
2500 IU
2500 IU
10
10
4
06/14/2002
01/01/2002
01/01/2002
02/05/2007
10/09/2006
07/09/2006
5 ML VL
IV
ML
5 MG
0.2
01/01/2002
99/99/9999
10 ML VL
IV
ML
5 MG
0.2
01/01/2002
99/99/9999
20 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
CT
CT
CT
CT
CT
CT
CT
IV
SC
SC
SC
SC
SC
SC
SC
ML
EA
EA
EA
EA
EA
EA
EA
5 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
0.2
1.5
5.8
5.8
5.8
5.8
13.8
13.8
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
06/01/2005
06/01/2005
06/01/2005
99/99/9999
6/9/2008
99/99/9999
01/07/2008
1 EA CT
SC
EA
1 MG
0.2
01/01/2002
99/99/9999
1 EA CT
SC
EA
1 MG
0.4
01/01/2002
99/99/9999
1 EA CT
SC
EA
1 MG
0.6
01/01/2002
99/99/9999
1 EA CT
SC
EA
1 MG
0.8
01/01/2002
99/99/9999
1 EA CT
SC
EA
1 MG
01/01/2002
99/99/9999
1 EA CT
SC
EA
1 MG
1.2
01/01/2002
99/99/9999
1 EA CT
SC
EA
1 MG
1.4
01/01/2002
99/99/9999
1 EA CT
SC
EA
1 MG
1.6
01/01/2002
99/99/9999
1 EA CT
SC
EA
1 MG
1.8
01/01/2002
99/99/9999
1 EA CT
SC
EA
1 MG
01/01/2002
99/99/9999
SC
SC
IV
IV
IV
IV
IV
PO
PO
IV
IV
IV
ML
ML
EA
EA
EA
EA
EA
EA
EA
ML
ML
ML
2500 IU
2500 IU
100 MG
200 MG
500 MG
1 GM
2 GM
0.5 MG
0.25 MG
10 MG
10 MG
10 MG
4
10
1
1
1
1
1
1
2
2
2
2
06/13/2002
06/17/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2006
01/01/2002
01/01/2002
01/01/2002
11/19/2006
11/19/2006
04/13/2004
04/13/2003
04/13/2003
04/13/2003
04/13/2003
12/31/2005
04/05/2006
04/13/2003
04/13/2003
04/13/2003
SR
VL
VL
VL
VL
VL
VL
BO
BO
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
12/15/2002
12/15/2002
12/15/2002
12/15/2002
10 ML VL
1 ML
3.8 ML
1 EA
1 EA
1 EA
1 EA
1 EA
8 EA
8 EA
5 ML
10 ML
25 ML
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00015-0547-12
00015-0547-41
J9095
J9095

00015-0548-12
00015-0548-41
J9096
J9096

1/1/2002
9/2/2004 CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM
00015-0549-12
00015-0549-41
00015-0556-05
00015-0556-11
00015-0557-11
00015-0557-41
00015-0595-01
00015-0596-41
00015-1179-80
00015-1180-78
00015-1180-79
00015-1180-80
00015-1181-78
00015-1181-79
00015-1181-80
00015-3001-20
00015-3002-20
00015-3010-20
00015-3010-26
00015-3012-38
00015-3012-60
00015-3015-20
00015-3015-20
00015-3015-97
00015-3020-20
00015-3020-97
00015-3023-20
00015-3023-20
00015-3023-97
00015-3030-20
00015-3031-20
00015-3032-20
J9097
J9097
J9208
J9208
J9208
J9208
J8999
J8999
J1590
J1590
J1590
J1590
J1590
J1590
J1590
J9280
J9290
J9040
J9040
J9050
J9050
J3490
J0278
J3490
J3490
J3490
J3490
J0278
J3490
J8999
J8999
J8999
1/1/2002
1/1/2002
1/1/2002
1/9/2002
1/9/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/23/2006
9/4/2003
1/1/2002
1/23/2006
12/16/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
4/7/2008
1/1/2002
1/1/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002

3/3/2009 INJECTION, IFOSFAMIDE, 1 GRAM
6/2/2006 INJECTION, GATIFLOXACIN, 10MG
5/3/2007 MITOMYCIN, 5 MG
10/31/2007 INJECTION, BLEOMYCIN SULFATE, 15 UNITS
4/7/2008 INJECTION, CARMUSTINE, 100 MG
99/99/9999 INJECTION, CARMUSTINE, 100 MG
99/99/9999 INJECTION, AMIKACIN SULFATE, 100 MG
00015-3034-10
00015-3059-20
00015-3061-20
00015-3062-20
00015-3063-01
00015-3063-26
00015-3075-19
00015-3075-97
00015-3084-20
00015-3091-45
00015-3095-20
00015-3210-30
J8999
J9291
J9181
J9181
J9040
J9040
Q2017
Q2017
J9181
None
J9181
J9045
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/1994
1/1/2002
8/21/2003

2/2/2005 INJECTION, ETOPOSIDE, 10 MG
99/99/9999 INJECTION, TENIPOSIDE, 50 MG
12/31/2006 INJECTION, TENIPOSIDE, 50 MG
11/15/2007 ETOPOSIDE, 50 MG, ORAL
9/30/2007 INJECTION, CARBOPLATIN, 50 MG
00015-3210-76
00015-3211-30
00015-3211-76
00015-3212-30
J9045
J9045
J9045
J9045
4/2/2004
8/21/2003
4/2/2004
8/21/2003
00015-3212-76
00015-3213-30
00015-3214-30
00015-3215-30
00015-3216-30
J9045
J9045
J9045
J9045
J9045
4/2/2004
1/1/2002 3/31/2008 INJECTION, CARBOPLATIN, 50 MG
00015-3220-22
J9060
1/1/2002 11/30/2005 CISPLATIN, POWDER OR S0LUTION, PER 10 MG
00015-3221-22
J9060

VINCASAR PFS (VIAL) 1 MG/ML

VINCASAR PFS (VIAL) 1 MG/ML
ZINECARD (S.D.V.) 250 MG
ZINECARD (S.D.V.) 500 MG
CYTOXAN (VIAL) 500 MG
CYTOXAN 50 MG
CYTOXAN 50 MG
CYTOXAN 50 MG
CYTOXAN 25 MG
CYTOXAN (VIAL) 1 GM
CYTOXAN (VIAL) 2 GM
MEGACE 40 MG/ML
CYTOXAN LYOPHILIZED (VIAL) 100 MG
CYTOXAN LYOPHILIZED NOVAPLUS
(S.D.V.) 500 MG
(S.D.V.) 1 GM
CYTOXAN LYOPHILIZED (VIAL) 1 GM
(S.D.V.) 2 GM
CYTOXAN LYOPHILIZED (VIAL) 2 GM
IFEX (S.D.V.) 1 GM
IFEX NOVAPLUS (S.D.V.) 1 GM
IFEX NOVAPLUS (S.D.V.) 3 GM
IFEX (S.D.V.) 3 GM
MEGACE 20 MG
MEGACE 40 MG
TEQUIN (VIAL) 10 MG/ML
TEQUIN (PREMIX BAG) 2 MG/ML
MUTAMYCIN (VIAL) 5 MG
BLENOXANE (VIAL) 15 U
BLENOXANE NOVAPLUS (VIAL) 15 U
BICNU (VIAL, W/DILUENT) 100 MG
BICNU (W/DILUENT) 100 MG
AMIKIN PEDIATRIC (VIAL) 50 MG/ML
AMIKIN (VIAL) 250 MG/ML
CEENU 10 MG
CEENU 40 MG
CEENU 100 MG
CEENU (DOSE PACK,2X10,40,100MG) 10
MG
VEPESID (M.D.V.) 20 MG/ML
BLENOXANE (VIAL) 30 U
BLENOXANE NOVAPLUS (VIAL) 30 U
VUMON (AMP) 10 MG/ML
VUMON (AMP) 10 MG/ML
VEPESID (BLISTER PACK) 50 MG
PARAPLATIN (M.D.V.) 10 MG/ML
PARAPLATIN NOVAPLUS (SDV) 10
MG/ML
PARAPLATIN (SDV) 10 MG/ML
PARAPLATIN NOVAPLUS (SDV) 10
MG/ML
PARAPLATIN (VIAL) 50 MG
PLATINOL-AQ (M.D.V.,CYTOSHIELD,PF)
1 MG/ML
PLATINOL-AQ (M.D.V.,CYTOSHIELD,PF)
1 MG/ML
Page 11 of 374
IV
IV
IV
IV
IV
PO
PO
PO
PO
IV
IV
PO
IV
IV
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
EA
EA
1 MG
1 MG
250 MG
250 MG
500 MG
50 MG
50 MG
50 MG
25 MG
1 GM
2 GM
1 EA
100 MG
200 MG
1
1
1
2
1
1
1
1
1
1
1
1
1
1
01/01/2002 04/13/2003
01/01/2002 04/13/2003
01/01/2002 09/01/2009
01/01/2002 09/01/2009
05/15/2004
8/6/2008
01/01/1994 10/31/2007
01/01/1994 09/01/2006
01/01/1994 07/05/1994
01/01/1994 10/31/2007
05/15/2004
8/14/2008
05/15/2004
8/6/2008
01/01/2002 99/99/9999
01/01/2002 06/06/2002
05/08/2003 12/31/2004
1 EA VL
1 EA VL
IV
IV
EA
EA
500 MG
500 MG
1
1
01/01/2002
01/01/2002
11/14/2002
05/27/2004
1 EA VL
1 EA VL
IV
IV
EA
EA
1 GM
1 GM
1
1
01/01/2002
01/01/2002
11/14/2002
09/02/2004
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
100 EA
100 EA
40 ML
100 ML
100 ML
100 ML
200 ML
200 ML
200 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
2 ML
2 ML
2 ML
2 ML
2 ML
4 ML
4 ML
4 ML
20 EA
20 EA
20 EA
VL
VL
VL
VL
VL
VL
BO
BO
VL
FC
BG
BG
FC
BG
BG
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
BO
BO
BO
IV
IV
IV
IV
IV
IV
PO
PO
IV
IV
IV
IV
IV
IV
IV
IV
IV
IJ
IJ
IV
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
ML
ML
ML
ML
ML
EA
EA
EA
EA
EA
EA
ML
ML
ML
ML
ML
ML
ML
ML
EA
EA
EA
2 GM
2 GM
1 GM
1 GM
1 GM
1 GM
1 EA
1 EA
10 MG
10 MG
10 MG
10 MG
10 MG
10 MG
10 MG
5 MG
20 MG
15 U
15 U
100 MG
100 MG
1 EA
100 MG
1 EA
1 EA
1 EA
1 EA
100 MG
1 EA
1 EA
1 EA
1 EA
1
1
1
1
3
3
1
1
1
0.2
0.2
0.2
0.2
0.2
0.2
1
1
1
1
1
1
1
0.5
1
1
1
1
2.5
1
1
1
1
01/01/2002 11/14/2002
01/01/2002 12/20/2004
01/01/2002
3/3/2009
01/09/2002 09/01/2002
01/09/2002 09/01/2002
01/01/2002
3/3/2009
01/01/2002 09/30/2002
01/01/2002 09/30/2002
01/01/2002 06/02/2006
01/23/2006 06/02/2006
09/04/2003 01/22/2006
01/01/2002 09/03/2003
01/23/2006 06/02/2006
12/16/2003 01/22/2006
01/01/2002 12/31/2003
01/01/2002 05/03/2007
01/01/2002 05/03/2007
01/01/2002 10/31/2007
01/01/2002 11/14/2002
01/01/2002
4/7/2008
04/07/2008 99/99/9999
01/01/2002 12/31/2005
01/01/2006 99/99/9999
01/01/2002 09/03/2004
01/01/2002 01/31/2005
01/01/2002 09/03/2004
01/01/2002 12/31/2005
01/01/2006 99/99/9999
01/01/2002 09/03/2004
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 99/99/9999
6 EA
1 EA
25 ML
50 ML
1 EA
1 EA
5 ML
5 ML
7.5 ML
20 EA
5 ML
5 ML
DP
VL
VL
VL
VL
VL
AM
AM
VL
BX
VL
VL
PO
IV
IV
IV
IJ
IJ
IV
IV
IV
PO
IV
IV
EA
EA
ML
ML
EA
EA
ML
ML
ML
EA
ML
ML
1 EA
40 MG
10 MG
10 MG
15 U
15 U
50 MG
50 MG
10 MG
50 MG
10 MG
50 MG
1
1
2
2
2
2
0.2
0.2
2
1
2
0.2
01/01/2002 10/19/2008
01/01/2002 05/03/2007
01/01/2002 02/02/2005
01/01/2002 02/16/2005
01/01/2002 05/03/2007
01/01/2002 11/14/2002
01/01/2002 99/99/9999
01/01/2002 12/31/2006
01/01/2002 02/17/2005
01/01/1994 11/15/2007
01/01/2002 04/07/2005
08/21/2003 09/30/2007
5 ML
15 ML
15 ML
45 ML
VL
VL
VL
VL
IV
IV
IV
IV
ML
ML
ML
ML
50 MG
50 MG
50 MG
50 MG
0.2
0.2
0.2
0.2
04/02/2004
08/21/2003
04/02/2004
08/21/2003
09/01/2006
09/30/2007
09/01/2006
09/30/2007
45 ML
1 EA
1 EA
1 EA
60 ML
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
ML
EA
EA
EA
ML
50 MG
50 MG
50 MG
50 MG
50 MG
0.2
1
3
9
0.2
04/02/2004
01/01/2002
01/01/2002
01/01/2002
02/25/2004
09/01/2006
03/31/2008
5/19/2008
04/30/2008
12/31/2006
50 ML VL
IV
ML
10 MG
0.1
01/01/2002 11/30/2005
100 ML VL
IV
ML
10 MG
0.1
01/01/2002 11/30/2005
1/1/2002 10/15/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
VL
VL
VL
VL
VL
BO
BO
NA
BO
VL
VL
BO
VL
VL
Billing Units
1 ML
2 ML
1 EA
1 EA
1 EA
100 EA
1000 EA
100 EA
100 EA
1 EA
1 EA
240 ML
1 EA
1 EA

Package
NDC Package Type
4/13/2003 VINCRISTINE SULFATE, 1 MG

9/1/2009 INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG
8/6/2008 CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MG
10/31/2007 CYCLOPHOSPHAMIDE, 50 MG, ORAL
NDC Package Measure
J9370
J9370
J1190
J1190
J9095
None
None
None
None
J9096
J9097
J8999
J9093
J9094
NDC Label
HCPCS Description
00013-7456-86
00013-7466-86
00013-8715-62
00013-8725-89
00015-0502-41
00015-0503-01
00015-0503-02
00015-0503-03
00015-0504-01
00015-0505-41
00015-0506-41
00015-0508-42
00015-0539-41
00015-0546-41
1/1/2002
1/1/2002
1/1/2002
1/1/2002
5/15/2004
1/1/1994
1/1/1994
1/1/1994
1/1/1994
5/15/2004
5/15/2004
1/1/2002
1/1/2002
1/1/2002
HCPCS Mod
HCPCS
NDC Mod
NDC
00015-3230-11
J9045
10/11/2004
00015-3231-11
J9045
10/11/2004
00015-3232-11
J9045
10/11/2004
00015-3233-11
00015-3352-22
00015-3353-22
00015-3404-20
00015-3475-30
00015-3476-30
00015-3479-11
00015-3503-20
00015-3503-99
J9045
J9000
J9000
J9181
J9265
J9265
J9265
J1840
J1840

1/1/2002
7/9/2008 INJECTION, PACLITAXEL, 30 MG
1/1/2002
1/1/2002
1/1/2002
2/1/2005 INJECTION, KANAMYCIN SULFATE, UP TO 500 MG
1/1/2002
00015-3554-10
J9999
1/1/2002 11/14/2002 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS
00015-3554-27
J9999
00015-3556-10
J9999
1/1/2002
00015-3556-26
00015-3563-02
00015-3563-03
J9999
J9209
J9209

1/1/2002
6/8/2009 INJECTION, MESNA, 200 MG
1/1/2002 5/13/2009 INJECTION, MESNA, 200 MG
00015-3563-10
J9209
1/1/2002
00015-3564-10
J9999
1/1/2002
00015-3564-15
00015-5644-15
00015-5644-15
00015-5644-20
00015-5644-20
00015-5644-33
00015-5645-15
00015-5645-15
00015-5645-20
00015-5645-20
00015-5645-33
00015-5646-15
00015-5646-15
00015-5646-20
00015-5646-20
00015-5646-33
00015-5648-20
00015-5648-20
00015-5648-97
00015-5648-97
J9999
J3490
J0595
J3490
J0595
J3490
J3490
J0595
J3490
J0595
J3490
J3490
J0595
J3490
J0595
J3490
J3490
J0595
J3490
J0595
1/1/2002
4/16/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
4/16/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
4/16/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004

9/1/2004 INJECTION, BUTORPHANOL TARTRATE, 1 MG
00015-7100-28
J0290
1/1/2002
7/1/2005 INJECTION, AMPICILLIN SODIUM, 500 MG
00015-7100-98
J0290
1/1/2002
00015-7101-28
J3490
00015-7101-98
J3490
1/1/2002
00015-7103-28
J2700
1/1/2002
10/1/2004 INJECTION, OXACILLIN SODIUM, UP TO 250 MG
00015-7103-98
J2700
1/1/2002
00015-7225-18
00015-7225-20
J3490
J3490

1/1/2002
00015-7225-89
00015-7225-99
J3490
J3490
1/1/2002
1/1/2002
00015-7226-18
00015-7226-20
J3490
J3490

1/1/2002
00015-7226-89
00015-7226-99
00015-7338-12
00015-7338-99
00015-7339-12
00015-7339-99
00015-7346-39
00015-7346-97
J3490
J3490
J0690
J0690
J0690
J0690
J0690
J0690

1/1/2002
1/1/2002 99/99/9999 INJECTION, CEFAZOLIN SODIUM, 500 MG
1/1/2002
1/1/2002
1/1/2002

CARBOPLATIN OTN (MDV,

50MG/5ML,PF) 10 MG/ML
CARBOPLATIN OTN
(MDV,150MG/15ML,PF) 10 MG/ML
CARBOPLATIN OTN
CARBOPLATIN OTN
RUBEX (VIAL) 50 MG
RUBEX (VIAL) 100 MG
ETOPOPHOS (S.D.V.) 100 MG
TAXOL (M.D.V.) 6 MG/ML
KANTREX (VIAL) 1 GM/3 ML
KANTREX (VIAL) 1 GM/3 ML
IFEX/MESNEX NOVAPLUS (COMBOPACK) 10 GM-10 GM
IFEX/MESNEX (COMBO-PACK) 10 GM-10
GM
GM
MESNEX (M.D.V.) 100 MG/ML
MESNEX (M.D.V.) 100 MG/ML
MESNEX NOVAPLUS (M.D.V.) 100 MG/ML
GM
STADOL (VIAL) 2 MG/ML
STADOL (M.D.V.) 2 MG/ML
AMPICILLIN SODIUM (BULK PACKAGE)
10 GM
AMPICILLIN SODIUM (BULK PACKAGE)
10 GM
NAFCILLIN SODIUM (VIAL,PHARMACY
BULK) 10 GM
BULK) 10 GM
OXACILLIN SODIUM (VIAL,PHARMACY
BULK) 10 GM
OXACILLIN SODIUM (VIAL,PHARMACY
BULK) 10 GM
NAFCILLIN SODIUM (ADD-VANTAGE) 1
GM
NAFCILLIN SODIUM (VIAL) 1 GM
GM
GM
GM
CEFAZOLIN SODIUM (VIAL) 500 MG
CEFAZOLIN SODIUM (VIAL) 1 GM
Page 12 of 374
5 ML VL
IV
ML
50 MG
0.2
10/11/2004
4/30/2006
15 ML VL
IV
ML
50 MG
0.2
10/11/2004
9/30/2005
45 ML VL
IV
ML
50 MG
0.2
10/11/2004
4/30/2006
VL
VL
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
IV
IJ
IJ
ML
EA
EA
EA
ML
ML
ML
ML
ML
50 MG
10 MG
10 MG
10 MG
30 MG
30 MG
30 MG
500 MG
500 MG
0.2
5
10
10
0.2
0.2
0.2
0.666
0.666
10/11/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
5/31/2006
11/06/2002
06/17/2002
99/99/9999
7/9/2008
6/8/2009
2/3/2009
02/01/2005
02/01/2005
1 EA BX
IV
EA
1 EA
01/01/2002
11/14/2002
1 EA BX
IV
EA
1 EA
01/01/2002 10/31/2007
60 ML
1 EA
1 EA
1 EA
5 ML
16.7 ML
50 ML
3 ML
3 ML
1 EA BX
IV
EA
1 EA
1 EA BX
10 ML VL
10 ML VL
IV
IV
IV
EA
ML
ML
1 EA
200 MG
200 MG
1
0.5
0.5
01/01/2002 10/31/2007
01/01/2002
6/8/2009
01/01/2002
5/13/2009
10 ML VL
IV
ML
200 MG
0.5
01/01/2002
1 EA BX
IV
EA
1 EA
01/01/2002
03/29/2002
BX
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 EA
1 EA
1 MG
1 EA
1 MG
1 EA
1 EA
1 MG
1 EA
1 MG
1 EA
1 EA
1 MG
1 EA
1 MG
1 EA
1 EA
1 MG
1 EA
1 MG
1
1
2
1
2
1
1
1
1
1
1
1
2
1
2
1
1
2
1
2
01/01/2002
04/16/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
04/16/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
04/16/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
05/03/2007
12/31/2003
09/01/2004
12/31/2003
10/04/2004
11/24/2003
12/31/2003
09/01/2004
12/31/2003
99/99/9999
08/08/2002
12/31/2003
07/01/2004
12/31/2003
99/99/9999
08/08/2002
12/31/2003
12/01/2004
12/31/2003
12/01/2004
1 EA VL
IJ
EA
500 MG
20
01/01/2002
07/01/2005
1 EA VL
IJ
EA
500 MG
20
01/01/2002
05/11/2004
1 EA VL
IJ
EA
1 EA
01/01/2002
99/99/9999
1 EA VL
IJ
EA
1 EA
01/01/2002
06/28/2006
1 EA VL
IJ
EA
250 MG
40
01/01/2002
10/01/2004
1 EA VL
IJ
EA
250 MG
40
01/01/2002
08/30/2004
1 EA VL
1 EA VL
IJ
IJ
EA
EA
1 EA
1 EA
1
1
01/01/2002
01/01/2002
99/99/9999
05/01/2004
1 EA VL
1 EA VL
IJ
IJ
EA
EA
1 EA
1 EA
1
1
01/01/2002
01/01/2002
02/22/2005
05/01/2004
1 EA VL
1 EA VL
IJ
IJ
EA
EA
1 EA
1 EA
1
1
01/01/2002
01/01/2002
99/99/9999
06/01/2004
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
1 EA
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
1
1
1
1
2
2
20
20
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/22/2005
06/01/2004
99/99/9999
09/03/2004
01/01/2005
01/01/2005
06/17/2004
06/17/2004
1 EA
2 ML
2 ML
2 ML
2 ML
2 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
10 ML
10 ML
10 ML
10 ML
VL
VL
VL
VL
VL
VL
VL
VL
01/01/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
03/29/2002
01/23/2002
00015-7401-20
00015-7401-99
00015-7402-20
00015-7402-99
00015-7403-20
00015-7403-99
J0290
J0290
J0290
J0290
J0290
J0290
1/1/2002
6/1/2004 INJECTION, AMPICILLIN SODIUM,
1/1/2002 5/11/2004 INJECTION, AMPICILLIN SODIUM,
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
00015-7404-18
00015-7404-20
J0290
J0290
1/1/2002 99/99/9999 INJECTION, AMPICILLIN SODIUM, 500 MG

00015-7404-89
00015-7404-99
J0290
J0290

00015-7405-18
J0290
00015-7405-20
J0290
00015-7405-89
00015-7405-99
J0290
J0290

00015-7970-18
00015-7970-20
J2700
J2700
1/1/2002 99/99/9999 INJECTION, OXACILLIN SODIUM, UP TO 250 MG

1/1/2002
00015-7970-89
J2700
00015-7970-99
J2700
1/1/2002
00015-7981-18
00015-7981-20
J2700
J2700

00015-7981-89
00015-7981-99
00023-1145-01
00023-9232-01
J2700
J2700
J0585
J0585

1/1/2002 99/99/9999 INJECTION, ONABOTULINUMTOXINA, 1 UNIT
6/7/2002 99/99/9999 INJECTION, ONABOTULINUMTOXINA, 1 UNIT
00024-0222-05
00024-0590-10
00024-0590-10
00024-0591-20
00024-0591-20
00024-0592-40
00024-0592-40
00024-0596-02
00024-0596-02
00024-0596-02
00024-0597-04
00024-0597-04
00024-0597-04
J9217
J9263
QR J9263
J9263
QR J9263
J9263
QR J9263
J9999
J9263
QR J9263
J9999
J9263
QR J9263
00024-0597-07
11/1/2003
6/8/2005
6/8/2005
6/8/2005
6/8/2005
8/20/2007
8/20/2007
8/16/2002
1/1/2004
1/28/2005
8/16/2002
1/1/2004
1/28/2005
99/99/9999 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG

99/99/9999 INJECTION, OXALIPLATIN, 0.5 MG
J9217
5/20/2002
00024-0597-22
00024-0605-45
00024-0610-30
J9217
J9217
J9217
9/13/2002 10/31/2003 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG

QR
QR
QR
QR
QR
AMPICILLIN SODIUM (VIAL) 125 MG

AMPICILLIN SODIUM (ADD-VANTAGE) 1
GM
AMPICILLIN SODIUM (VIAL) 1 GM
GM
GM
AMPICILLIN SODIUM (VIAL,PIGGYBACK)
2 GM
AMPICILLIN SODIUM (ADDVANTAGE,ADD-VANTAGE) 2 GM
OXACILLIN SODIUM (ADD-VANTAGE) 2
GM
OXACILLIN SODIUM (VIAL) 2 GM
GM
OXACILLIN SODIUM (VIAL,PIGGYBACK) 2
GM
GM
GM
BOTOX 100 U
BOTOX COSMETIC 100 U
ELIGARD (SRN,PREFILLED,W/NDL) 22.5
MG
ELOXATIN (S.D.V.,PF) 5 MG/ML
ELOXATIN (SDV,PF) 5 MG/ML
ELOXATIN (SDV,PF) 5 MG/ML
ELOXATIN (S.D.V.,PF) 50 MG
MG
MG
ELIGARD (SINGLE-USE KIT) 45 MG
ELIGARD (SINGLE-USE) 30 MG
MG
PRIMACOR (22GX1-1/4",CARPUJECT) 1
MG/ML
PRIMACOR (INTERLINK
SYS,CARPUJECT) 1 MG/ML
PRIMACOR (S.D.V.,CARPUJECT) 1
MG/ML
PRIMACOR (S.D.V.,CARPUJECT) 1
MG/ML
PRIMACOR (S.D.V.,VALUE PACK) 1
MG/ML
PRIMACOR (S.D.V.) 1 MG/ML
PRIMACOR (S.D. FLEXIBLE CONTAINER)
5%-20 MG/100 ML
PRIMACOR (S.D. FLEXIBLE CONTAINER)
5%-20 MG/100 ML
PRIMACOR
(BAG,PREFILLED,VALUEPACK) 5%-20
MG/100 ML
PRIMACOR
(BAG,PREFILLED,VALUEPACK) 5%-20
MG/100 ML
1
1
1
1
1
1
EA
EA
EA
EA
EA
EA
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
0.25
0.25
0.5
0.5
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/01/2004
05/11/2004
99/99/9999
07/20/2006
99/99/9999
08/14/2006
1 EA VL
1 EA VL
IJ
IJ
EA
EA
500 MG
500 MG
2
2
01/01/2002
01/01/2002
99/99/9999
08/14/2006
1 EA VL
1 EA VL
IJ
IJ
EA
EA
500 MG
500 MG
2
2
01/01/2002
01/01/2002
99/99/9999
07/20/2006
1 EA VL
IJ
EA
500 MG
01/01/2002
99/99/9999
1 EA VL
IJ
EA
500 MG
01/01/2002
99/99/9999
1 EA VL
1 EA VL
IJ
IJ
EA
EA
500 MG
500 MG
4
4
01/01/2002
01/01/2002
99/99/9999
07/20/2006
1 EA VL
1 EA VL
IJ
IJ
EA
EA
250 MG
250 MG
8
8
01/01/2002
01/01/2002
99/99/9999
07/01/2004
1 EA VL
IJ
EA
250 MG
01/01/2002
99/99/9999
1 EA VL
IJ
EA
250 MG
01/01/2002
07/01/2004
1 EA VL
1 EA VL
IJ
IJ
EA
EA
250 MG
250 MG
4
4
01/01/2002
01/01/2002
99/99/9999
12/02/2004
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
IJ
IJ
IM
IM
EA
EA
EA
EA
250 MG
250 MG
1U
1U
4
4
100
100
01/01/2002
01/01/2002
01/01/2002
06/07/2002
99/99/9999
12/02/2004
99/99/9999
99/99/9999
1 EA
10 ML
10 ML
20 ML
20 ML
40 ML
40 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
SR
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
SC
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
EA
ML
ML
ML
ML
ML
ML
EA
EA
EA
EA
EA
EA
7.5 MG
0.5 MG
0.5 MG
0.5 MG
0.5 MG
0.5 MG
0.5 MG
1 EA
0.5 MG
0.5 MG
1 EA
0.5 MG
0.5 MG
3
10
10
10
10
10
10
1
100
100
1
200
200
11/01/2003
06/08/2005
06/08/2005
06/08/2005
06/08/2005
08/20/2007
08/20/2007
08/16/2002
01/01/2004
01/28/2005
08/16/2002
01/01/2004
01/28/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2003
06/30/2006
06/30/2006
12/31/2003
06/30/2006
06/30/2006
1 EA SR
SC
EA
7.5 MG
05/20/2002
07/24/2003
1 EA SR
1 EA BX
1 EA BX
SC
SC
SC
EA
EA
EA
7.5 MG
7.5 MG
7.5 MG
3
6
4
09/13/2002
02/18/2005
03/04/2003
10/31/2003
99/99/9999
99/99/9999
1 EA SR
SC
EA
7.5 MG
07/25/2003
99/99/9999
5 ML SR
IV
ML
5 MG
0.2
01/01/2002
12/23/2003
5 ML SR
IV
ML
5 MG
0.2
01/01/2002
03/29/2004
10 ML VL
IV
ML
5 MG
0.2
01/01/2002
05/12/2006
20 ML VL
IV
ML
5 MG
0.2
01/01/2002
05/12/2006
20 ML VL
50 ML VL
IV
IV
ML
ML
5 MG
5 MG
0.2
0.2
01/01/2002
01/01/2002
05/01/2006
05/18/2005
100 ML FC
IV
ML
5 MG
0.04
01/01/2002
04/03/2008
200 ML FC
IV
ML
5 MG
0.04
01/01/2002
9/16/2008
100 ML FC
IV
ML
5 MG
0.04
01/01/2002
01/24/2007
00024-0793-75
J9217
00024-1200-05
J2260
1/1/2002 12/23/2003 INJECTION, MILRINONE LACTATE, 5 MG
00024-1200-06
J2260
1/1/2002
3/29/2004 INJECTION, MILRINONE LACTATE, 5 MG
00024-1200-10
J2260
1/1/2002
00024-1200-20
J2260
1/1/2002
00024-1200-25
00024-1200-50
J2260
J2260
1/1/2002
1/1/2002

00024-1203-01
J2260
1/1/2002
00024-1203-02
J2260
1/1/2002
00024-1203-15
J2260
1/1/2002
00024-1203-25
J2260
1/1/2002
200 ML FC
IV
ML
5 MG
0.04
01/01/2002
09/30/2005
00024-5150-10
J3490
ELITEK (3 S.D.V. W/DILUENT,PF) 1.5 MG
1 EA VL
IV
EA
1 EA
09/04/2002
12/31/2003
00024-5150-10
J2783
1/1/2004 99/99/9999 INJECTION, RASBURICASE, 0.5 MG
ELITEK (3 S.D.V. W/DILUENT,PF) 1.5 MG
1 EA VL
IV
EA
0.5 MG
01/01/2004
99/99/9999
Page 13 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
6/27/2006 99/99/9999 INJECTION, RASBURICASE, 0.5 MG
00024-5151-75
J2783
00026-0372-20
J7192
1/1/2002
6/30/2008 FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.
00026-0372-30
J7192
1/1/2002
00026-0372-50
J7192
1/1/2002
00026-0379-20
J7192
1/1/2006
00026-0379-30
J7192
1/1/2006
00026-0379-50
J7192
1/1/2006
00026-0601-30
J0256
1/1/2002 10/13/2006 INJECTION, ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MG
PROLASTIN (APPRX 500 MG VIAL) 1 MG
00026-0601-35
J0256
VL
00026-0603-20
J7197
1/1/2002 10/13/2006 ANTITHROMBIN III (HUMAN), PER I.U.
00026-0603-30
J7197
00026-0631-02
J2790
1/1/2002 10/13/2006 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MCG (1500 I.U.)
PROLASTIN (APPRX 1000 MG VIAL) 1 MG 1000 MG

THROMBATE III (W/DILUENT,~ 500
IU/VIAL) 1 IU
500 IU
THROMBATE III (W/DILUENT,~1000
IU/VIAL) 1 IU
1000 IU
BAYRHO-D FULL DOSE (SRN,PREFILLED
ULTRASE)
1 ML
00026-0631-05
00026-0631-06
00026-0631-06
J2790
J2790
J2788
1/1/2003 10/13/2006 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MCG (250 I.U.)
00026-0634-02
00026-0635-04
00026-0635-12
00026-0636-01
00026-0636-02
00026-0636-02
00026-0636-03
00026-0636-03
00026-0636-05
00026-0636-05
00026-0645-12
00026-0645-12
00026-0645-15
00026-0645-15
00026-0645-20
00026-0645-20
00026-0645-24
00026-0645-24
00026-0645-71
00026-0645-71
J1670
J1460
J1460
J3590
J3490
J3590
J3490
J3590
J3490
J3590
J1563
Q9943
J1563
Q9943
J1563
Q9943
J1563
Q9943
J1563
Q9943
1/1/2002
1/1/2002
1/1/2002
6/18/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
10/9/2003
4/1/2005
10/9/2003
4/1/2005
10/9/2003
4/1/2005
10/9/2003
4/1/2005
10/9/2003
4/1/2005
BAYRHO-D (SRN, PREFILLED, ~50 MCG)

0.17 ML
BAYRHO-D (MINI-DOSE,SRN)
0.17 ML
BAYRHO-D (MINI-DOSE,SRN)
0.17 ML
BAYTET (SRN,PREFILLED ULTRASE) 250
10/13/2006 INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS
U
1 ML
10/13/2006 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC
BAYGAM (S.D.V.,PF)
2 ML
BAYGAM (S.D.V.,PF)
10 ML
BAYHEP B (S.D.V.,200 IU/ML)
1 ML
BAYHEP B
1 ML
BAYHEP B
1 ML
BAYHEP B (S.D.SRN)
0.5 ML
BAYHEP B (S.D.SRN)
0.5 ML
5 ML
5 ML
3/31/2005 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 1G
GAMUNEX (PF) 100 MG/ML
10 ML
7/14/2005 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED, 1 G
10 ML
25 ML
25 ML
50 ML
50 ML
200 ML
200 ML
100 ML
100 ML
GAMIMUNE N 5 % (0.5 GM/VIAL,S/D
TREATED) 50 MG/ML
10 ML
GAMIMUNE N 5 % (2.5 GM/VIAL,S/D
TREATED) 50 MG/ML
50 ML
GAMIMUNE N 5 % (10 GM/VIAL,S/D
TREATED) 50 MG/ML
200 ML
GAMIMUNE N 5 % (12.5 GM/VL,S/D
TREATED) 50 MG/ML
250 ML
GAMIMUNE N 5 % (5 GM/VIAL,S/D
TREATED) 50 MG/ML
100 ML
GAMIMUNE N 10 % (1 GM/VIAL) 100
MG/ML
10 ML
GAMIMUNE N 10 % (2.5 GM/VIAL) 100
MG/ML
25 ML
MG/ML
50 ML
MG/ML
200 ML
MG/ML
100 ML
11/1/2007 FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.
KOATE-DVI (APPROX 250 IU/VIAL) 1 IU
250 IU
500 IU
1000 IU
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISE
99/99/9999 SPECIFIED
KOGENATE FS (2000IU,PF) 1 IU
2000 IU
KOGENATE FS (2000IU,PF) 1 IU
2000 IU
99/99/9999 DACARBAZINE, 200 MG
DTIC-DOME (VIAL) 200 MG
1 EA
12/31/2005 INJECTION, APROTININ, 10,000 KIU
TRASYLOL 10000 KIU/ML
100 ML
99/99/9999 INJECTION, APROTONIN, 10,000 KIU
100 ML
12/31/2005 INJECTION, APROTININ, 10,000 KIU
200 ML
99/99/9999 INJECTION, APROTONIN, 10,000 KIU
200 ML
00026-0646-12
J1563
1/1/2002
00026-0646-20
J1563
1/1/2002
00026-0646-24
J1563
1/1/2002
00026-0646-25
J1563
1/1/2002
00026-0646-71
J1563
1/1/2002
00026-0648-12
J1563
1/1/2002
00026-0648-15
J1563
1/1/2002
00026-0648-20
J1563
1/1/2002
00026-0648-24
J1563
1/1/2002
00026-0648-71
00026-0665-20
00026-0665-30
00026-0665-50
J1563
J7190
J7190
J7190
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00026-3786-60
J7192
7/2/2007
00026-3796-60
00026-8151-20
00026-8196-36
00026-8196-36
00026-8197-63
00026-8197-63
J7192
J9140
Q2003
J0365
Q2003
J0365
7/2/2007
1/1/2002
1/1/2002
1/1/2006
1/1/2002
1/1/2006
ELITEK (SDV,W/DILUENT) 7.5 MG

1 EA
KOGENATE FS (APPROX. 250 IU/VIAL) 1
IU
250 IU
IU
500 IU
IU
1000 IU
KOGENATE FS W/BIO-SET (250IU,VIAL
W/DILUENT,PF) 1 IU
250 IU
W/DILUENT,PF) 1 IU
500 IU
W/DILUENT) 1 IU
1000 IU
Page 14 of 374
VL
IV
EA
0.5 MG
15
06/27/2006
99/99/9999
VL
IV
EA
1 IU
01/01/2002
6/30/2008
VL
IV
EA
1 IU
01/01/2002
6/30/2008
VL
IV
EA
1 IU
01/01/2002
6/30/2008
VL
IV
EA
1 IU
01/01/2006
6/30/2008
VL
IV
EA
1 IU
01/01/2006
6/30/2008
VL
IV
EA
1 IU
01/01/2006
6/30/2008
500 MG VL
IV
EA
10 MG
0.1
01/01/2002
10/13/2006
IV
EA
10 MG
0.1
01/01/2002
10/13/2006
VL
IV
EA
1 IU
01/01/2002
10/13/2006
VL
IV
EA
1 IU
01/01/2002
10/13/2006
SR
IM
ML
300 MCG
01/01/2002
10/13/2006
SR
SR
SR
IM
IM
IM
ML
ML
ML
300 MCG
300 MCG
50 MCG
1
1
6
01/01/2002
03/21/2002
01/01/2003
03/20/2002
12/31/2002
10/13/2006
SR
VL
VL
VL
SR
SR
SR
SR
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
250 U
1 ML
1 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1
1
1
1
1
1
1
1
1
1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
01/01/2002
01/01/2002
01/01/2002
06/18/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
10/09/2003
04/01/2005
10/09/2003
04/01/2005
10/09/2003
04/01/2005
10/09/2003
04/01/2005
10/09/2003
04/01/2005
10/13/2006
10/13/2006
10/13/2006
10/13/2006
12/31/2002
10/13/2006
12/31/2002
10/13/2006
12/31/2002
10/13/2006
03/31/2005
07/14/2005
03/31/2005
07/14/2005
03/31/2005
07/14/2005
03/31/2005
07/14/2005
03/31/2005
07/14/2005
VL
IV
ML
1 GM
0.05
01/01/2002
07/31/2002
VL
IV
ML
1 GM
0.05
01/01/2002
07/31/2002
VL
IV
ML
1 GM
0.05
01/01/2002
07/31/2002
VL
IV
ML
1 GM
0.05
01/01/2002
07/31/2002
VL
IV
ML
1 GM
0.05
01/01/2002
07/31/2002
VL
IV
ML
1 GM
0.1
01/01/2002
12/31/2004
VL
IV
ML
1 GM
0.1
01/01/2002
12/31/2004
VL
IV
ML
1 GM
0.1
01/01/2002
12/31/2004
VL
IV
ML
1 GM
0.1
01/01/2002
12/31/2004
VL
VL
VL
VL
IV
IV
IV
IV
ML
EA
EA
EA
1
1
1
1
0.1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/31/2004
11/01/2007
11/01/2007
11/01/2007
VL
IV
EA
1 IU
07/02/2007
99/99/9999
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
EA
EA
ML
ML
ML
ML
1
1
1
1
1
1
07/02/2007
01/01/2002
01/01/2002
01/01/2006
01/01/2002
01/01/2006
99/99/9999
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
GM
IU
IU
IU
1 IU
200 MG
10000 KIU
10000 KIU
10000 KIU
10000 KIU
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
CIPRO IV (BAXTER DELIVERY SYSTEM)

200 MG/100 ML
CIPRO IV (BAXTER DELIVERY SYSTEM)
400 MG/200 ML
CIPRO IV (PREMIX,LATEX-FREE) 200
MG/100 ML
CIPRO IV (PREMIX,LATEX-FREE) 400
MG/200 ML
CIPRO IV (VIAL) 10 MG/ML
CIPRO IV (BULK VIAL) 10 MG/ML
AVELOX I.V. (FLEXIBAG,PF) 400 MG/250
ML
ML
VIADUR 65 MG
BRETHINE (AMP) 1 MG/ML
KYTRIL (S.D.V.) 1 MG/ML
00026-8527-36
J0744
1/1/2002
8/16/2005 INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, 200 MG
00026-8527-63
J0744
1/1/2002
00026-8552-36
J0744
1/1/2002
00026-8554-63
00026-8562-20
00026-8564-64
00026-8566-65
J0744
J0744
J0744
J0744
1/1/2002
1/1/2002
1/1/2002
1/1/2002

00026-8582-31
J3490
00026-8582-31
00026-9711-01
00028-7507-01
00028-7507-23
00029-4149-01
J2280
J9219
J3105
J3105
J1626
00029-4151-05
Q0166
00029-4151-39
00029-6571-26
Q0166
J3490
00029-6571-31
J3490
1/1/2004 8/16/2005 INJECTION, MOXIFLOXACIN, 100 MG

1/1/2002 99/99/9999 LEUPROLIDE ACETATE IMPLANT, 65 MG
1/1/2002 7/15/2004 INJECTION, TERBUTALINE SULFATE, UP TO 1 MG
1/1/2002
KYTRIL 1 MG
1/1/2002
KYTRIL (UNIT OF USE) 1 MG
1/1/2002
TIMENTIN (VIAL) 100 MG-3 GM
TIMENTIN (PREMIX) 100 MG/100 ML-3
GM/100 ML
00029-6571-40
J3490
00029-6571-56
J3490
1/1/2002
00029-6571-57
00029-6579-21
J3490
J3490

00029-6579-76
00031-7409-87
J3490
J2800
1/1/2002
1/1/2002
00031-7890-06
J7643
00031-7890-06 KO J7643
00031-7890-11
KO
1/1/2002
1/1/2002
KO
J7643
00031-7890-95 KO J7643
00039-0017-10
J0698
00039-0018-10
J0698
00039-0018-11
J0698
00039-0018-25
J0698
00039-0018-49
J0698
00039-0018-50
J0698
00039-0019-10
J0698
00039-0019-11
J0698
J0698
00039-0019-25
00039-0019-49
J0698
00039-0019-50
J0698
00039-0020-01
J0698
1/1/2002
1/1/2002
J7643
00031-7890-83 KO J7643
00031-7890-95
1/1/2002
KO
J7643
00031-7890-11 KO J7643
00031-7890-83
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
4/1/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
6/1/2005
1/1/2002
1/1/2002

5/21/2003 INJECTION, METHOCARBAMOL, UP TO 10 ML
GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
2/12/2004 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
99/99/9999 INJECTION, CEFOTAXIME SODIUM, PER GM
00039-0020-49
00039-0023-25
J0698
J0698
6/1/2005 99/99/9999 INJECTION, CEFOTAXIME SODIUM, PER GM

00039-0023-49
00039-0023-50
00039-0023-61
00039-0024-25
J0698
J0698
J0698
J0698
6/1/2005
1/1/2002
4/3/2006
1/1/2002

00039-0024-49
00039-0024-50
00039-0037-05
00039-0038-05
J0698
J0698
J0698
J0698
6/1/2005
1/1/2002
1/1/2002
1/1/2002

TIMENTIN (ADD-VANTAGE) 100 MG-3 GM

TIMENTIN NOVAPLUS (VIAL) 100 MG-3
GM
TIMENTIN NOVAPLUS (ADD-VANTAGE)
100 MG-3 GM
TIMENTIN (BULK VIAL) 1 GM-30 GM
TIMENTIN NOVAPLUS (BULK VIAL) 1 GM30 GM
ROBAXIN (S.D.V.) 100 MG/ML
100 ML FC
IV
ML
200 MG
0.01
01/01/2002
08/16/2005
400 ML FC
IV
ML
200 MG
0.01
01/01/2002
08/16/2005
100 ML FC
IV
ML
200 MG
0.01
01/01/2002
08/16/2005
200 ML
20 ML
40 ML
120 ML
FC
VL
VL
VL
IV
IV
IV
IV
ML
ML
ML
ML
200 MG
200 MG
200 MG
200 MG
0.01
0.05
0.05
0.05
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/16/2005
08/16/2005
08/16/2005
08/17/2005
250 ML FC
IV
ML
1 EA
250 ML
65 mg
1 ML
1 ML
1 ML
FC
BX
AM
AM
VL
IV
ID
SC
SC
IV
ML
EA
ML
ML
ML
100 MG
65 MG
1 MG
1 MG
100 MCG
20 EA BX
PO
EA
2 EA BX
1 EA VL
PO
IV
EA
EA
01/10/2002
12/31/2003
0.016
1
1
1
10
01/01/2004
01/01/2002
01/24/2002
01/24/2002
01/01/2002
08/16/2005
99/99/9999
07/15/2004
05/22/2003
01/02/2002
1 MG
01/01/2002
02/08/2002
1 MG
1 EA
1
1
01/01/2002
01/01/2002
02/08/2002
99/99/9999
100 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
1 EA VL
IV
EA
1 EA
01/01/2002
99/99/9999
1 EA VL
IV
EA
1 EA
01/01/2002
07/11/2006
1 EA VL
1 EA VL
IV
IV
EA
EA
1 EA
1 EA
1
1
01/01/2002
01/01/2002
07/11/2006
99/99/9999
1 EA VL
10 ML VL
IV
IJ
EA
ML
1 EA
10 ML
1
0.1
01/01/2002
01/01/2002
07/11/2006
05/21/2003
ROBINUL (VIAL) 0.2 MG/ML
5 ML VL
IJ
ML
1 MG
0.2
01/01/2002
02/12/2004
5 ML VL
IJ
ML
1 MG
0.2
01/01/2002
02/12/2004
1 ML VL
IJ
ML
1 MG
0.2
01/01/2002
02/12/2004
1 ML VL
IJ
ML
1 MG
0.2
01/01/2002
02/12/2004
20 ML VL
IJ
ML
1 MG
0.2
01/01/2002
02/12/2004
20 ML VL
IJ
ML
1 MG
0.2
01/01/2002
02/12/2004
2 ML VL
IJ
ML
1 MG
0.2
01/01/2002
02/12/2004

CLAFORAN (VIAL) 500 MG
CLAFORAN (VIAL) 1 GM
CLAFORAN (P.B.) 1 GM
NOVAPLUS CLAFORAN 1 GM
CLAFORAN (P.B.) 2 GM
NOVAPLUS CLAFORAN 2 GM
CLAFORAN (BULK VIAL) 10 GM
NOVAPLUS CLAFORAN (PHARMACY
BULK PACKAGE) 10 GM
CLAFORAN (ADD-VANTAGE) 1 GM
NOVAPLUS CLAFORAN (ADD-VANTAGE
SYSTEM) 1 GM
AMERINET CLAFORAN 1 GM
NOVAPLUS CLAFORAN (ADD-VANTAGE
SYSTEM) 2 GM
CLAFORAN (GALAXY) 1 GM/50 ML
CLAFORAN (GALAXY) 2 GM/50 ML
2 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 MG
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
0.2
0.5
1
1
1
1
1
2
2
2
2
2
10
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/01/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/01/2005
01/01/2002
01/01/2002
02/12/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA GC IJ
1 EA VL IJ
EA
EA
1 GM
1 GM
10
1
06/01/2005
01/01/2002
99/99/9999
99/99/9999
1
1
1
1
Page 15 of 374
VL
VL
VL
GC
VL
VL
VL
VL
GC
VL
VL
VL
GC
EA
EA
EA
EA
VL
VL
VL
VL
IJ
IJ
IJ
IJ
EA
EA
EA
EA
1
1
1
1
GM
GM
GM
GM
1
1
1
2
06/01/2005
01/01/2002
04/03/2006
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA
1 EA
50 ML
50 ML
VL
VL
FC
FC
IJ
IJ
IV
IV
EA
EA
ML
ML
1
1
1
1
GM
GM
GM
GM
2
2
0.02
0.04
06/01/2005
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01-Jan-02
1/1/2002
23-Jan-02
1/23/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1
1
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
11/4/2002 INJECTION, HYDROMORPHONE, UP TO 4 MG

9/13/2009 INJECTION, LEVOFLOXACIN, 250 MG
00045-0066-01
J1956
1/1/2002 99/99/9999 INJECTION, LEVOFLOXACIN, 250 MG
00045-0067-01
J1956
00045-0068-01
00045-0069-51
00045-0253-01
00045-0253-03
J1956
J1956
J1631
J1631

1/1/2002 99/99/9999 INJECTION, HALOPERIDOL DECANOATE, PER 50 MG
00045-0253-46
J1631
1/1/2002
00045-0254-14
J1631
00045-0254-46
00045-0255-01
00045-0255-49
00045-1515-01
00046-0374-06
00046-0507-05
J1631
J1630
J1630
J1956
J2730
J1620
00046-0749-05
00046-3265-10
00049-0013-83
00049-0014-83
J1410
J1800
J0295
J0295
1/1/2002 99/99/9999 INJECTION, ESTROGEN CONJUGATED, PER 25 MG

1/1/2002
6/1/2002 INJECTION, PROPRANOLOL HCL, UP TO 1 MG
1/1/2002 99/99/9999 INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM
6/21/2006 INJECTION, HALOPERIDOL DECANOATE, PER 50 MG

1/1/2002 99/99/9999 INJECTION, HALOPERIDOL, UP TO 5 MG
1/1/2002 3/13/2003 INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM
1/1/2002
6/1/2002 INJECTION, GONADORELIN HYDROCHLORIDE, PER 100 MCG
00049-0022-83
J0295
00049-0023-83
J0295
00049-0024-28
J0295
00049-0031-83
J0295
00049-0032-83
00049-0210-35
J0295
J0560

1/1/2002
1/1/2002 99/99/9999 INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS
00049-0520-83
J2540
00049-0530-28
00049-1010-28
00049-1010-28
00049-1201-83
00049-1202-83
00049-1219-28
00049-3190-28
J2540
J3490
J0348
J3490
J3490
J3490
J3465
00049-3371-26
J1450
1/1/2002 99/99/9999 INJECTION FLUCONAZOLE, 200 MG
00049-3372-26
J1450
00049-3382-25
J3490
00049-3435-26
J1450
00049-3436-26
J1450
00049-3437-26
J1450
00049-3438-26
00049-3890-28
00049-3900-28
00049-3920-83
00049-3920-83
00049-5460-74
J1450
J0200
J0200
J3490
J3486
J3410
00051-0021-21
Q0167
1/1/2002
4/25/2006
1/1/2007
1/1/2002
1/1/2002
1/1/2002
1/1/2004
99/99/9999 INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS

99/99/9999 INJECTION, ANADULAFUNGIN, 1 MG
99/99/9999 INJECTION, VORICONAZOLE, 10 MG
DILAUDID (AMP) 1 MG/ML

DILAUDID-HP (S.D.V.) 10 MG/ML
DILAUDID-HP (AMP) 10 MG/ML
DILAUDID
DILAUDID (M.D.V.) 2 MG/ML
DILAUDID-HP (S.D.V.) 250 MG
LEVAQUIN (S.D.V.) 25 MG/ML
LEVAQUIN (PREMIXED W/DEXTROSE) 5
MG/ML
MG/ML
MG/ML
HALDOL DECANOATE (AMP) 50 MG/ML
IJ
IJ
IJ
IJ
IJ
IJ
IJ
NA
IJ
IJ
IV
ML
ML
ML
ML
ML
ML
ML
GM
ML
EA
ML
4 MG
4 MG
4 MG
4 MG
4 MG
4 MG
4 MG
4 MG
4 MG
4 MG
250 MG
0.25
0.5
0.5
1
2.5
2.5
2.5
250
0.5
62.5
0.1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
11/04/2002
11/13/2002
12/10/2002
12/18/2002
11/25/2002
12/18/2002
11/13/2002
02/09/2003
12/18/2002
12/10/2002
9/13/2009
150 ML PC
IV
ML
250 MG
0.02
01/01/2002
99/99/9999
50 ML FC
IV
ML
250 MG
0.02
01/01/2002
99/99/9999
FC
VL
AM
AM
IV
IV
IM
IM
ML
ML
ML
ML
250 MG
250 MG
50 MG
50 MG
0.02
0.1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
8/23/2009
99/99/9999
99/99/9999
HALDOL DECANOATE (M.D.V.) 50 MG/ML
5 ML VL
IM
ML
50 MG
01/01/2002
06/21/2006

HALDOL DECANOATE (M.D.V.) 100
MG/ML
HALDOL (AMP) 5 MG/ML
HALDOL (M.D.V.) 5 MG/ML
LEVAQUIN 25 MG/ML
PROTOPAM CHLORIDE (S.D.V.) 1 GM
FACTREL 0.1 MG
PREMARIN INTRAVENOUS (W/SECULE
VIAL) 25 MG
INDERAL (AMP) 1 MG/ML
UNASYN (VIAL) 1 GM-0.5 GM
UNASYN (VIAL) 2 GM-1 GM
UNASYN (P.B.,ADD-VANTAGE) 1 GM-0.5
GM
UNASYN (P.B.,ADD-VANTAGE) 2 GM-1
GM
1 ML AM IM
ML
50 MG
01/01/2002
99/99/9999
2
1
1
0.1
1
1
01/01/2002
01/01/2002
01/01/2002
11/05/2004
01/01/2002
01/01/2002
06/21/2006
99/99/9999
05/16/2005
8/23/2009
03/13/2003
06/01/2002
UNASYN (BULK PACKAGE) 10 GM-5 GM

UNASYN (ADD-VANTAGE,ADDVANTAGE) 1 GM-0.5 GM
UNASYN (ADD-VANTAGE,ADDVANTAGE) 2 GM-1 GM
PERMAPEN ISOJECT 600000 U/ML
PFIZERPEN (VIAL, PHARMACY BOTTLE)
5 Million U
PFIZERPEN (VIAL, PHARMACY BOTTLE)
20 Million U
ERAXIS (W/ DILUENT,PF) 50 MG
ERAXIS (W/ DILUENT,PF) 50 MG
CEFOBID (VIAL) 1 GM
CEFOBID (VIAL) 2 GM
CEFOBID (BULK VIAL) 10 GM
VFEND I.V. (S.D.V.) 200 MG
DIFLUCAN IV (SODIUM CHLORIDE
DILUENT) 200 MG/100 ML
DIFLUCAN IV (SODIUM CHLORIDE
DILUENT) 400 MG/200 ML
SUFENTANIL CITRATE (FTV,LATEXFREE) 50 MCG/ML
DIFLUCAN IV (VIAFLEX,SODIUM
CHLORIDE) 200 MG/100 ML
DIFLUCAN IV (VIAFLEX,SODIUM
DIFLUCAN IV (VIAFLEX, DEXTROSE,AF)
200 MG/100 ML
DIFLUCAN IV (VIAFLEX, DEXTROSE,AF)
400 MG/200 ML
TROVAN IV 5 MG/ML
TROVAN IV 5 MG/ML
GEODON 20 MG
GEODON 20 MG
VISTARIL IM (VIAL) 50 MG/ML

1/1/2002 7/10/2003 INJECTION, ALATROFLOXACIN MESYLATE, 100 MG
1/1/2002 7/10/2003 INJECTION, ALATROFLOXACIN MESYLATE, 100 MG
1/1/2004 99/99/9999 INJECTION, ZIPRASIDONE MESYLATE, 10 MG
1/1/2002 7/10/2003 INJECTION, HYDROXYZINE HCL, UP TO 25 MG
DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR
USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE
TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE
1/1/2002 99/99/9999 REGIMEN
MARINOL 2.5 MG
Page 16 of 374
100 ML
20 ML
1 ML
1 ML
5 ML
1 ML
10 ML
480 ML
1 EA
1 EA
VL
AM
VL
BO
VL
VL
IM
IM
IM
PO
IJ
IJ
ML
ML
ML
ML
EA
EA
50 MG
5 MG
5 MG
250 MG
1 GM
100 MCG
VL
AM
VL
VL
IV
IV
IJ
IJ
EA
ML
EA
EA
25 MG
1 MG
1.5 GM
1.5 GM
1
1
1
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
06/01/2002
99/99/9999
99/99/9999
1 EA VL
IV
EA
1.5 GM
01/01/2002
99/99/9999
1 EA VL
IV
EA
1.5 GM
01/01/2002
99/99/9999
1 EA VL
IV
EA
1.5 GM
10
01/01/2002
99/99/9999
1 EA VL
IV
EA
1.5 GM
01/01/2002
99/99/9999
1 EA VL
2 ML NA
IV
IM
EA
ML
1.5 GM
600000 U
2
1
01/01/2002
01/01/2002
99/99/9999
01/02/2003
1
1
1
1
EA
ML
EA
EA
1 EA VL
IV
EA
600000 U
8.33333
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
IV
IV
IV
IJ
IJ
IJ
IV
EA
EA
EA
EA
EA
EA
EA
600000 U
1 EA
1 MG
1 EA
1 EA
1 EA
10 MG
33.33333
1
50
1
1
1
20
01/01/2002
04/25/2006
01/01/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2004
99/99/9999
12/31/2006
99/99/9999
07/01/2002
07/01/2002
01/02/2003
99/99/9999
100 ML GC IV
ML
200 MG
0.01
01/01/2002
99/99/9999
200 ML GC IV
ML
200 MG
0.01
01/01/2002
99/99/9999
VL
VL
VL
VL
VL
VL
VL
5 ML VL
IJ
ML
1 EA
10/19/2005
99/99/9999
100 ML PC
IV
ML
200 MG
0.01
01/01/2002
99/99/9999
200 ML PC
IV
ML
200 MG
0.01
01/01/2002
99/99/9999
100 ML PC
IV
ML
200 MG
0.01
01/01/2002
99/99/9999
200 ML
40 ML
60 ML
1 EA
1 EA
10 ML
IV
IV
IV
IM
IM
IM
ML
ML
ML
EA
EA
ML
200 MG
100 MG
100 MG
1 EA
10 MG
25 MG
0.01
0.05
0.05
1
2
2
01/01/2002
01/01/2002
01/01/2002
08/26/2002
01/01/2004
01/01/2002
99/99/9999
07/10/2003
07/10/2003
12/31/2003
99/99/9999
07/10/2003
PO
EA
2.5 MG
01/01/2002
99/99/9999
PC
VL
VL
VL
VL
VL
60 EA BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
AM
AM
AM
AM
VL
AM
AM
BO
VL
VL
VL
Billing Units
1 ML
1 ML
1 ML
1 ML
50 ML
1 ML
5 ML
1 EA
20 ML
1 EA
30 ML

Package
NDC Package Type
J1170
J1170
J1170
J1170
J1170
J1170
J1170
J1170
J1170
J1170
J1956
NDC Package Measure
00044-1011-01
00044-1012-01
00044-1012-09
00044-1014-01
00044-1017-06
00044-1017-10
00044-1017-25
00044-1040-01
00044-1062-05
00044-1911-01
00045-0065-55
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00051-0022-11
00051-0022-21
Q0168
Q0168
1/1/2002
00051-0023-21
Q0168
1/1/2002
J3490
8/10/2006
00052-0272-01
00052-0301-51
00052-0301-61
00052-0315-10
J7307
J3490
J3490
J0725
1/1/2008
5/1/2003
6/1/2003
1/1/2002
00052-0445-10
00052-0602-02
00052-0603-02
00052-0697-02
00052-0698-01
00052-0731-10
J0330
J9031
J9031
J2321
J2322
J0835
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00052-0731-12
00053-1770-01
00053-1771-01
00053-1773-01
J0835
J2995
J2995
J2995
1/13/2003
9/17/2002
9/17/2002
9/17/2002
00053-7201-02
00053-7486-01
00053-7486-02
00053-7486-05
J0256
J1563
J1563
Q9941
8/18/2003
1/1/2002
1/1/2002
4/1/2005
1/1/2006
00053-7486-05
J1566
J1563
Q9941
00053-7486-10
00053-7596-03
00053-7596-03
00053-7596-10
00053-7596-10
00053-7596-15
00053-7596-15
00053-7596-20
00053-7596-20
00053-7596-25
00053-7596-25
00053-7615-05
J1566
J7799
J1562
J7799
J1562
J7799
J1562
J7799
J1562
J7799
J1562
J7188
00053-7615-05
00053-7615-10
J7187
J7188
00053-7615-10
00053-7615-20
J7187
J7188
00053-7615-20
J7187
00053-7620-05
J7188
00053-7620-05
J7187
00053-7620-10
J7188
00053-7620-10
J7187
00053-7620-20
J7188
00053-7620-20
00053-7656-01
00053-7656-02
00053-7656-04
00053-7656-05
00053-7668-01
00053-7668-02
00053-7668-04
J7187
J7190
J7190
J7190
J7190
J7193
J7193
J7193
DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE

AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME
99/99/9999 OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN MARINOL (SOFTGEL) 10 MG
IMPLANON (HOSPITAL USE ONLY) 68
MG
ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND IMPLANON (HOSPITAL USE ONLY) 68
99/99/9999 SUPPLIES
MG
GANIRELIX ACETATE 250 MCG/0.5 ML
ANTAGON 250 MCG/0.5 ML
99/99/9999 INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS
PREGNYL (W/DILUENT) 10000 U
SUCCINYLCHOLINE CHLORIDE (VIAL) 20
8/23/2004 INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG
MG/ML
99/99/9999 BCG (INTRAVESICAL) PER INSTILLATION
TICE BCG (VIAL) 800 Million CFU
99/99/9999 BCG (INTRAVESICAL) PER INSTILLATION
BCG VACCINE (VIAL)
5/21/2002 INJECTION, NANDROLONE DECANOATE, UP TO 100 MG
DECA-DURABOLIN (VIAL) 100 MG/ML
1/13/2003 INJECTION, COSYNTROPIN, PER 0.25 MG
CORTROSYN (W/DILUENT) 0.25 MG
CORTROSYN (WITHOUT DILUENT) 0.25
MG
99/99/9999 INJECTION, STREPTOKINASE, PER 250,000 IU
STREPTASE (6ML VIAL) 250000 IU
STREPTASE (6ML VIAL) 750000 IU
STREPTASE (6ML VIAL) 1.5 Million IU
ZEMAIRA (APPRX 1000 MG VIAL,PF) 1
99/99/9999 INJECTION, ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MG
MG
GAMMAR-P I.V. (W/DILUENT) 1 GM
GAMMAR-P I.V. (W/DILUENT) 2.5 GM
12/31/2005 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED, 1 G
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT
99/99/9999 OTHERWISE SPECIFIED, 500 MG
1/1/2002 1/19/2004 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, 1G

4/1/2005 12/31/2005 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED, 1 G
1/1/2006 99/99/9999 OTHERWISE SPECIFIED, 500 MG
3/1/2006 12/31/2006 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME
1/1/2007 99/99/9999 INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG
2/15/2006 12/31/2006 INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, IU
INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN
1/1/2007 99/99/9999 COFACTOR, PER IU VWF:RCO
1/1/2002 99/99/9999 FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.
1/1/2002 99/99/9999 FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.
GAMMAR-P I.V. (BULK PACKAGE) 5 GM

VIVAGLOBIN (PF) 160 MG/ML
HUMATE-P (600IU) 1 IU-1 IU
25 EA BO
PO
EA
5 MG
01/01/2002
8/14/2006
60 EA BO
PO
EA
5 MG
08/14/2006
99/99/9999
60 EA BO
PO
EA
5 MG
01/01/2002
99/99/9999
1 EA PG
ID
EA
1 EA
08/10/2006
12/31/2007
1
1
1
10
01/01/2008
05/01/2003
06/01/2003
01/01/2002
99/99/9999
99/99/9999
06/02/2003
99/99/9999
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/23/2004
99/99/9999
99/99/9999
05/21/2002
05/21/2002
01/13/2003
1 EA
0.5 ML
0.5 ML
1 EA
PG
SR
SR
VL
ID
SC
SC
IM
EA
ML
ML
EA
1 IMPLANT
1 EA
1 EA
1000 USP Units
10 ML
1 EA
1 EA
2 ML
1 ML
1 EA
VL
VL
VL
VL
VL
VL
IV
IL
ID
IM
IM
IJ
ML
EA
EA
ML
ML
EA
20 MG
1 INSTILLATION
1 INSTILLATION
100 MG
200 MG
0.25 MG
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
IJ
IV
IV
IV
EA
EA
EA
EA
0.25 MG
250000 IU
250000 IU
250000 IU
1
1
3
6
01/13/2003
09/17/2002
09/17/2002
09/17/2002
06/26/2003
99/99/9999
99/99/9999
99/99/9999
1000 MG
1 EA
1 EA
1 EA
VL
VL
VL
VL
IV
IV
IV
IV
EA
EA
EA
EA
10 MG
1 GM
1 GM
1 GM
0.1
1
2.5
5
08/18/2003
01/01/2002
01/01/2002
04/01/2005
99/99/9999
01/19/2004
01/19/2004
12/31/2005
1 EA VL
IV
EA
500 MG
10
01/01/2006
99/99/9999
1 EA VL
1 EA VL
IV
IV
EA
EA
1 GM
1 GM
5
10
01/01/2002
04/01/2005
01/19/2004
12/31/2005
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IV
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
IV
EA
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
EA
500 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
1 IU
20
1
1.6
1
1.6
1
1.6
1
1.6
1
1.6
1
01/01/2006
03/01/2006
01/01/2007
03/01/2006
01/01/2007
03/01/2006
01/01/2007
03/01/2006
01/01/2007
03/01/2006
01/01/2007
02/15/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
1 EA
3 ML
3 ML
10 ML
10 ML
10 ML
10 ML
20 ML
20 ML
20 ML
20 ML
600 IU

600 IU
1200 IU
VL
VL
IV
IV
EA
EA
1 IU
1 IU
1
1
01/01/2007
02/15/2006
99/99/9999
12/31/2006

1200 IU
2400 IU
VL
VL
IV
IV
EA
EA
1 IU
1 IU
1
1
01/01/2007
02/15/2006
99/99/9999
12/31/2006

HUMATE-P (10 ML SDV, PASTEURIZED)
1 IU-1 IU
1 IU-1 IU
1 IU-1 IU
1 IU-1 IU
1 IU-1 IU
1 IU-1 IU
MONOCLATE-P (250 IU) 1 IU
MONONINE (250 IU) 1 IU
2400 IU
VL
IV
EA
1 IU
01/01/2007
99/99/9999
500 IU
VL
IV
EA
1 IU
01/01/2006
12/31/2006
Page 17 of 374
500 IU
VL
IV
EA
1 IU
01/01/2007
11/9/2009
1000 IU
VL
IV
EA
1 IU
01/01/2006
12/31/2006
1000 IU
VL
IV
EA
1 IU
01/01/2007
11/9/2009
2000 IU
VL
IV
EA
1 IU
01/01/2006
12/31/2006
2000 IU
250 IU
500 IU
1000 IU
1500 IU
250 IU
500 IU
1000 IU
VL
BX
BX
BX
BX
VL
VL
VL
IV
IV
IV
IV
IV
IV
IV
IV
EA
EA
EA
EA
EA
EA
EA
EA
1 IU
1 IU
1 IU
1 IU
1 IU
1 IU
1 IU
1 IU
1
1
1
1
1
1
1
1
01/01/2007
01/01/2002
01/01/2002
01/01/2002
05/26/2004
01/01/2002
01/01/2002
01/01/2002
11/9/2009
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description


8/14/2006 99/99/9999 OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN MARINOL (SOFT GELATIN) 5 MG
00052-0272-01
00053-7486-06
00053-7486-10
HCPCS Mod
HCPCS
NDC Mod
NDC
00053-8130-01
J7192
00053-8130-02
J7192
00053-8130-04
00054-0017-20
00054-0017-25
00054-0017-29
00054-0018-20
00054-0018-25
00054-0018-29
00054-0019-20
00054-0019-25
00054-1218-42
00054-1701-07
00054-1701-25
00054-2247-25
J7192
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J1230
J3280
J3280
J8999
00054-3025-02
J7608
00054-3025-02 KO J7608
00054-3026-02
KO
J7608
00054-3027-02 KO J7608
00054-3028-02
KO
J7608
00054-3026-02 KO J7608
00054-3027-02
KO
J7608
00054-3028-02 KO J7608
00054-3144-50
Q0172
00054-3146-58
Q0172
00054-3176-44
00054-3176-44
00054-3177-57
Q0181
J8540
J8540
00054-3408-40
J7649
00054-3408-40 KO J7649
KO
1/1/2002
00054-3542-58
00054-3721-44
J8999
J7506
4/11/2002
1/1/2002
00054-3722-50
J7506
1/1/2002
00054-3722-63
00054-4084-25
00054-4129-25
00054-4130-25
J7506
J7500
None
None
1/1/2002
1/1/2002
3/28/2000
3/28/2000
00054-4179-25
00054-4179-25
Q0181
J8540
1/1/2002
1/1/2006
00054-4180-25
00054-4180-25
Q0181
J8540
1/1/2002
1/1/2006
00054-4181-25
00054-4181-25
Q0181
J8540
1/1/2002
1/1/2006
ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON5/16/2002 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMISOETHARINE HCL 1%
ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON5/16/2002 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMISOETHARINE HCL 1%
MEGESTROL ACETATE (LEMON,LIME)
40 MG/ML
PREDNISONE INTENSOL 5 MG/ML
PREDNISONE (PEPPERMINT-VANILLA) 5
MG/5 ML
MG/5 ML
99/99/9999 AZATHIOPRINE, ORAL, 50 MG
AZATHIOPRINE 50 MG
CYCLOPHOSPHAMIDE 25 MG
DEXAMETHASONE 0.5 MG
12/31/2005 REGIMEN
12/31/2005 REGIMEN
DEXAMETHASONE 1 MG
12/31/2005 REGIMEN
DEXAMETHASONE 1 MG
Page 18 of 374
10 ML BO
IV
EA
1 IU
01/01/2002
IV
EA
1 IU
01/01/2002
99/99/9999
IV
PO
PO
PO
PO
PO
PO
PO
PO
IJ
IM
IM
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
ML
EA
1 IU
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
10 MG
10 MG
10 MG
1 EA
1
2
2
2
4
4
4
10
10
1
0.5
0.5
1
01/01/2002
12/01/2004
01/01/2005
12/01/2004
09/07/2004
10/14/2004
10/08/2004
09/24/2004
08/10/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
06/01/2003
05/14/2002
08/08/2002
05/05/2004
IH
ML
1 GM
0.1
01/01/2002
99/99/9999
IH
ML
1 GM
0.1
01/01/2002
99/99/9999
IH
ML
1 GM
0.2
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISEHELIXATE FS (APPROX. 25O IU/VIAL) 1
1/1/2002 99/99/9999 SPECIFIED
IU
250 IU VL
1/1/2002 99/99/9999 SPECIFIED
HELIXATE FS (APPROX. 500 IU/VIAL) 1 IU 500 IU VL
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISEHELIXATE FS (APPROX. 1000 IU/VIAL) 1
1/1/2002 99/99/9999 SPECIFIED
IU
1000 IU VL
12/1/2004 99/99/9999 PREDNISONE, ORAL, PER 5MG
PREDNISONE (10X10) 10 MG
100 EA BX
PREDNISONE 10 MG
100 EA BO
PREDNISONE 10 MG
500 EA BO
100 EA BX
PREDNISONE 20 MG
100 EA BO
PREDNISONE 20 MG
500 EA BO
100 EA BX
PREDNISONE 50 MG
100 EA BO
1/1/2002
6/1/2003 INJECTION, METHADONE HCL, UP TO 10 MG
DOLOPHINE HCL (VIAL) 10 MG/ML
20 ML VL
1/1/2002 5/14/2002 INJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MG
TORECAN (AMP) 5 MG/ML
2 ML AM
1/1/2002
8/8/2002 INJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MG
2 ML AM
1/1/2002
HYDROXYUREA 500 MG
100 EA BO
ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT
1/1/2002 99/99/9999 DOSE FORM, PER GRAM
ACETYLCYSTEINE 10%
30 ML VL
ACETYLCYSTEINE 10%
30 ML VL
ACETYLCYSTEINE 20%
30 ML VL
ACETYLCYSTEINE 20%
30 ML VL
ACETYLCYSTEINE 10%
10 ML VL
ACETYLCYSTEINE 10%
10 ML VL
ACETYLCYSTEINE 20%
10 ML VL
ACETYLCYSTEINE 20%
10 ML VL
CHLORPROMAZINE HCL INTENSOL 30
MG/ML
120 ML BO
CHLORPROMAZINE HCL INTENSOL 100
MG/ML
240 ML BO
DEXAMETHASONE INTENSOL 1 MG/ML
30 ML BO
1/1/2002 12/31/2005 REGIMEN
1/1/2006 99/99/9999 DEXAMETHASONE, ORAL, 0.25 MG
DEXAMETHASONE INTENSOL 1 MG/ML
30 ML BO
DEXAMETHASONE (1X240ML)
240 ML BO
1/1/2002
KO
HCPCS Mod
HCPCS
NDC Mod
NDC
99/99/9999
IH
ML
1 GM
0.2
01/01/2002
99/99/9999
IH
ML
1 GM
0.1
01/01/2002
99/99/9999
IH
ML
1 GM
0.1
01/01/2002
99/99/9999
IH
ML
1 GM
0.2
01/01/2002
99/99/9999
IH
ML
1 GM
0.2
01/01/2002
99/99/9999
PO
ML
25 MG
1.2
01/01/2002
10/10/2002
PO
ML
25 MG
01/01/2002
01/21/2003
PO
PO
PO
ML
ML
ML
1 EA
0.25 MG
0.25 MG
1
4
2
01/01/2002
01/01/2006
07/31/2008
12/31/2005
99/99/9999
99/99/9999
IH
ML
1 MG
10
01/01/2002
05/16/2002
10 ML BO
IH
ML
1 MG
10
01/01/2002
05/16/2002
240 ML BO
30 ML BO
PO
PO
ML
ML
1 EA
5 MG
1
1
04/11/2002
01/01/2002
99/99/9999
99/99/9999
120 ML BO
PO
ML
5 MG
0.2
01/01/2002
99/99/9999
500 ML
100 EA
100 EA
100 EA
BO
BO
BO
BO
PO
PO
PO
PO
ML
EA
EA
EA
5 MG
50 MG
25 MG
50 MG
0.2
1
1
1
01/01/2002
01/01/2002
03/28/2000
03/28/2000
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BO
100 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA BO
100 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA BO
100 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
4
01/01/2002
01/01/2006
12/31/2005
99/99/9999
00054-4182-25
00054-4182-25
Q0181
J8540
1/1/2002
1/1/2006
00054-4183-25
00054-4183-25
Q0181
J8540
1/1/2002
1/1/2006
00054-4184-25
00054-4184-25
00054-4550-15
00054-4550-25
00054-4581-11
00054-4581-27
00054-4603-25
00054-4604-25
00054-4728-25
00054-4728-31
00054-4729-25
00054-4729-29
00054-4730-25
00054-4730-29
00054-4733-25
00054-4741-25
00054-4741-31
00054-4742-25
Q0181
J8540
None
None
J8999
J8999
J8999
J8999
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
1/1/2002
1/1/2006
9/27/1994
9/27/1994
2/19/2004
2/19/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00054-4748-25
00054-4831-21
00054-4831-26
00054-4834-13
00054-4834-22
Q0174
J8999
J8999
J8999
J8999
1/1/2002
2/21/2003
2/21/2003
2/21/2003
2/21/2003
00054-8063-11
J7619
1/1/2002
00054-8063-11 KO J7619
00054-8063-13
J7619
00054-8063-13 KO J7619
00054-8063-21
00054-8167-23
KO
KO
1/1/2002
1/1/2002
3/28/2000
3/28/2000
1/1/2002
KO
J7631
00054-8167-23 KO J7631
1/1/2002
1/1/2002
J7631
00054-8167-21 KO J7631
1/1/2002
1/1/2002
J7619
00054-8063-21 KO J7619
00054-8084-25
J7500
00054-8089-25
None
00054-8130-25
None
00054-8167-21
KO
1/1/2002
1/1/2002
KO
1/1/2002
00054-8174-25
00054-8174-25
Q0181
J8540
1/1/2002
1/1/2006
00054-8175-25
00054-8175-25
Q0181
J8540
1/1/2002
1/1/2006

12/31/2005 REGIMEN
DEXAMETHASONE 2 MG
12/31/2005 REGIMEN
DEXAMETHASONE 2 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
MERCAPTOPURINE (USP) 50 MG
MEGESTROL ACETATE 20 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 50 MG
PREDNISONE 1 MG
PREDNISONE 1 MG
PREDNISONE 2.5 MG
THIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTIEMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTIEMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48
TORECAN 10 MG
TAMOXIFEN CITRATE 10 MG
ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION
SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE, PER 1 MG (ALBUTEROL) ORALBUTEROL SULFATE
9/25/2003 PER 0.5 MG (LEVALBUTEROL)
(VIAL,PROTECTPAK) 0.083%
AZATHIOPRINE (10X10) 50 MG
CYCLOPHOSPHAMIDE (10X10) 25 MG
CYCLOPHOSPHAMIDE (10X10) 50 MG
CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT
2/1/2005 DOSE FORM, PER 10 MILLIGRAMS
CROMOLYN SODIUM (VIAL) 10 MG/ML
DEXAMETHASONE (10X10) 1 MG
12/31/2005 REGIMEN
12/31/2005 REGIMEN
Page 19 of 374
100 EA BO
100 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
6
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA BO
100 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
8
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA
100 EA
36 EA
100 EA
25 EA
250 EA
100 EA
100 EA
100 EA
1000 EA
100 EA
500 EA
100 EA
500 EA
100 EA
100 EA
1000 EA
100 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
0.25 MG
2.5 MG
2.5 MG
1 EA
1 EA
1 EA
1 EA
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
16
1
1
1
1
1
1
1
1
4
4
2
2
10
0.2
0.2
0.5
01/01/2002
01/01/2006
09/27/1994
09/27/1994
02/19/2004
02/19/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/13/2004
10/07/2004
12/31/2004
11/30/2004
08/09/2004
99/99/9999
99/99/9999
99/99/9999
100 EA
60 EA
180 EA
30 EA
90 EA
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
10 MG
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
08/09/2002
02/21/2003
02/21/2003
02/21/2003
02/21/2003
12/18/2003
4/17/2007
4/17/2007
6/20/2007
4/17/2007
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
09/25/2003
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
09/25/2003
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
03/28/2003
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
03/28/2003
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
09/25/2003
IH
PO
PO
PO
ML
EA
EA
EA
1 MG
50 MG
25 MG
50 MG
0.83
1
1
1
01/01/2002
01/01/2002
03/28/2000
03/28/2000
09/25/2003
99/99/9999
6/1/2005
3/23/2005
2 ML VL
IH
ML
10 MG
01/01/2002
02/01/2005
2 ML VL
IH
ML
10 MG
01/01/2002
02/01/2005
2 ML VL
IH
ML
10 MG
01/01/2002
10/19/2004
2 ML VL
IH
ML
10 MG
01/01/2002
10/19/2004
100 EA BX
100 EA BX
PO
PO
EA
EA
1 EA
0.25 MG
1
4
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA BX
100 EA BX
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
3 ML
100 EA
100 EA
100 EA
VL
BX
BX
BX
1/1/2002
8/8/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00054-8176-25
00054-8176-25
Q0181
J8540
1/1/2002
1/1/2006
00054-8179-25
00054-8179-25
Q0181
J8540
1/1/2002
1/1/2006
00054-8180-25
00054-8180-25
Q0181
J8540
1/1/2002
1/1/2006
00054-8181-25
00054-8181-25
00054-8233-01
00054-8234-01
00054-8247-25
Q0181
J8540
J0735
J0735
J8999
1/1/2002
1/1/2006
1/1/2002
1/1/2002
1/1/2002
00054-8402-11
J7644
1/1/2002
00054-8402-11 KO J7644
00054-8402-13
J7644
00054-8402-13 KO J7644
00054-8402-21
00054-8404-13
KO
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
KO
J7644
00054-8404-21 KO J7644
1/1/2002
1/1/2002
J7644
00054-8404-13 KO J7644
00054-8404-21
KO
J7644
00054-8404-11 KO J7644
1/1/2002
1/1/2002
J7644
00054-8402-21 KO J7644
00054-8404-11
KO
1/1/2002
1/1/2002
KO
1/1/2002
00054-8550-03
None
9/27/1994
00054-8550-05
None
9/27/1994
00054-8550-06
None
9/27/1994
00054-8550-07
None
9/27/1994
00054-8550-10
None
9/27/1994
00054-8550-25
00054-8603-25
00054-8604-25
None
J8999
J8999
9/27/1994
1/1/2002
1/1/2002
00054-8722-16
00054-8724-25
00054-8725-25
00054-8726-25
00054-8729-25
00054-8739-25
00054-8740-25
J7506
J7506
J7506
J7506
J7506
J7506
J7506
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

12/31/2005 REGIMEN
DEXAMETHASONE (10X10) 0.5 MG
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
7/25/2005 INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG
DURACLON (S.D.V.) 0.1 MG/ML
DURACLON (S.D.V.,PF) 0.5 MG/ML
HYDROXYUREA (10X10) 500 MG
IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER
IPRATROPIUM BROMIDE
(S.D.V.,5X5,PROTECTAPAK) 0.02%
12/11/2003 MILLIGRAM
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
4/7/2004 MILLIGRAM
IPRATROPIUM BROMIDE
4/7/2004 MILLIGRAM
IPRATROPIUM BROMIDE
11/5/2004 MILLIGRAM
IPRATROPIUM BROMIDE
11/5/2004 MILLIGRAM
IPRATROPIUM BROMIDE NOVAPLUS
4/8/2004 MILLIGRAM
(S.D.V.,5X5, PROTECTAPAK) 0.02%
4/8/2004 MILLIGRAM
(S.D.V.,5X5, PROTECTAPAK) 0.02%
(S.D.V.,6X5 PROTECTAPAK) 0.02%
5/3/2004 MILLIGRAM
(S.D.V.,6X5 PROTECTAPAK) 0.02%
5/3/2004 MILLIGRAM
3/22/2004 MILLIGRAM
3/22/2004 MILLIGRAM
METHOTREXATE SODIUM (4X2 DOSE
PACK) 2.5 MG
PACK) 2.5 MG
PACK) 2.5 MG
PACK) 2.5 MG
PACK) 2.5 MG
METHOTREXATE SODIUM (10X10) 2.5
MG
MEGESTROL ACETATE (10X10) 20 MG
MG/5 ML
PREDNISONE (10X10) 2.5 MG
Page 20 of 374
100 EA BX
100 EA BX
PO
PO
EA
EA
1 EA
0.25 MG
1
8
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA BX
100 EA BX
PO
PO
EA
EA
1 EA
0.25 MG
1
2
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA BX
100 EA BX
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA
100 EA
10 ML
10 ML
100 EA
PO
PO
EP
EP
PO
EA
EA
ML
ML
EA
1 EA
0.25 MG
1 MG
1 MG
1 EA
1
6
0.1
0.5
1
01/01/2002
01/01/2006
01/01/2002
01/01/2002
01/01/2002
12/31/2005
99/99/9999
07/25/2005
09/22/2005
01/13/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
12/11/2003
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
12/11/2003
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
04/07/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
04/07/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
11/05/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
11/05/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
04/08/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
04/08/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
05/03/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
05/03/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
03/22/2004
2.5 ML PC
03/22/2004
BX
BX
VL
VL
BX
IH
ML
1 MG
0.2
01/01/2002
8 EA DP
PO
EA
2.5 MG
09/27/1994
04/29/2002
12 EA DP
PO
EA
2.5 MG
09/27/1994
01/02/2002
16 EA DP
PO
EA
2.5 MG
09/27/1994
02/28/2002
20 EA DP
PO
EA
2.5 MG
09/27/1994
02/28/2002
24 EA DP
PO
EA
2.5 MG
09/27/1994
02/28/2002
100 EA BX
100 EA BX
100 EA BX
PO
PO
PO
EA
EA
EA
2.5 MG
1 EA
1 EA
1
1
1
09/27/1994
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
5 ML
100 EA
100 EA
100 EA
100 EA
100 EA
100 EA
PO
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
0.2
1
2
4
10
0.2
0.5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
11/30/2004
09/06/2004
09/23/2004
99/99/9999
99/99/9999
CP
BX
BX
BX
BX
BX
BX
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00054-8809-25
00054-8810-25
J7051
J7051
1/1/2002
1/1/2002
00054-8831-25
J8999
2/21/2003
00054-8834-25
00056-0342-08
00056-0342-53
00065-0543-01
00068-0597-01
00068-0809-23
J8999
J1655
J1655
J3301
J3490
J0500
00069-3051-07
Q0144
00069-3051-75
00069-3060-30
00069-3060-75
00069-3060-86
00069-3070-30
00069-3070-75
00069-3070-86
00069-3080-30
00069-3110-19
00069-3120-19
00069-3130-19
00069-3140-19
00069-3150-14
00069-3150-83
00069-4170-21
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
J0456
J0456
Q0144
1/1/2002
1/1/2002
1/1/2002
1/1/2002
8/6/2002
8/6/2002
10/21/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
2/25/2002
1/1/2002
7/11/2005
00069-5410-66
Q0177
1/1/2002
00069-5420-66
Q0178
1/1/2002
00069-5430-66
Q0178
1/1/2002
00069-5440-93
Q0177
1/1/2002
00069-5440-97
Q0177
1/1/2002
00071-0840-13
Q0163
1/1/2002
00071-0840-18
Q0163
1/1/2002
00071-2195-17
Q0163
11/18/2003
00071-2333-17
00071-4007-05
00071-4008-10
00071-4259-03
00071-4259-13
Q0163
Q2009
Q2009
J1200
J1200
11/17/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00071-4259-45
00071-4402-10
00074-1036-30
00074-1038-50
00074-1041-30
00074-1067-20
00074-1067-20
J1200
J1200
J0670
J0670
J0670
J0670
J0670
1/1/2002 99/99/9999 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG

1/1/2002 3/20/2006 INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML
00074-1081-01
A4216
4/25/2005 12/26/2006 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML
00074-1097-02
J0745
9/16/2002 STERILE SALINE OR WATER, UP TO 5 CC

2/21/2003
1/1/2002 7/16/2002 INJECTION, TINZAPARIN SODIUM, 1000 IU
1/1/2002 3/22/2007 INJECTION, DICYCLOMINE HCL, UP TO 20 MG
1/1/2002 99/99/9999 AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM
1/1/2002
99/99/9999 AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM

99/99/9999 INJECTION, AZITHROMYCIN, 500 MG
HYDROXYZINE PAMOATE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTIEMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTIEMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48
DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED
SUBSTITUTE FOR AN IV ANTI-EMETIC AT TIME OF CHEMOTHERAPY TREATMENT
99/99/9999 NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
99/99/9999 INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT
99/99/9999 INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT
2/3/2005 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG
6/6/2003 INJECTION, CODEINE PHOSPHATE, PER 30 MG
SODIUM CHLORIDE (5X20) 0.9%

SODIUM CHLORIDE (5X20) 0.9%
TAMOXIFEN CITRATE (BLISTER PACK
10X10) 10 MG
TAMOXIFEN CITRATE (BLISTER PACK
10X10) 20 MG
INNOHEP (M.D.V.) 20000 IU/ML
TRIESENCE 40 MG/ML
RIFADIN IV (VIAL) 600 MG
BENTYL (AMP) 10 MG/ML
ZITHROMAX (SINGLE DOSE PACKETS) 1
GM/Packet
GM/Packet
ZITHROMAX 250 MG
ZITHROMAX Z-PAK (3X6) 250 MG
ZITHROMAX 250 MG
ZITHROMAX 500 MG
ZITHROMAX TRI-PAK (3X3) 500 MG
ZITHROMAX (5 X 10) 500 MG
ZITHROMAX 600 MG
ZITHROMAX 100 MG/5 ML
ZITHROMAX (W/VIAL MATE) 500 MG
ZITHROMAX (VIAL) 500 MG
ZMAX (CHERRY-BANANA) 2 GM/60 ML
3 PK
30 EA
18 EA
50 EA
30 EA
9 EA
50 EA
30 EA
15 ML
15 ML
22.5 ML
30 ML
1 EA
1 EA
1 EA
ML
ML
5 ML
5 ML
0.2
0.2
01/01/2002
01/01/2002
09/16/2002
09/13/2002
100 EA BX
PO
EA
1 EA
02/21/2003
4/17/2007
100 EA
2 ML
2 ML
1 ML
1 EA
2 ML
BX
VL
VL
VL
VL
AM
PO
SC
SC
IJ
IV
IM
EA
ML
ML
ML
EA
ML
1 EA
1000 IU
1000 IU
10 MG
1 EA
20 MG
1
20
20
4
1
0.5
02/21/2003
01/01/2002
01/01/2002
11/29/2007
01/01/2002
11/15/2004
2/5/2007
07/16/2002
07/16/2002
99/99/9999
99/99/9999
03/22/2007
10 EA BX
PO
EA
1 GM
01/01/2002
99/99/9999
BX
BO
DP
BX
BO
DP
BX
BO
BO
BO
BO
BO
VL
VL
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
IV
IV
PO
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
ML
ML
EA
EA
EA
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
500 MG
500 MG
1 GM
1
0.25
0.25
0.25
0.5
0.5
0.5
0.6
0.02
0.04
0.04
0.04
1
1
2
VISTARIL 25 MG
100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
VISTARIL 50 MG
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
VISTARIL 100 MG
100 EA BO
PO
EA
50 MG
01/01/2002
01/02/2004
VISTARIL 25 MG/5 ML
480 ML BO
PO
ML
25 MG
0.2
01/01/2002
03/07/2007
VISTARIL 25 MG/5 ML
120 ML BO
PO
ML
25 MG
0.2
01/01/2002
12/11/2006
BENADRYL 25 MG
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
BENADRYL 25 MG
48 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
118 ML BO
PO
ML
50 MG
0.05
11/18/2003 12/20/2006
118 ML
2 ML
10 ML
1 ML
1 ML
BO
VL
VL
AM
VL
PO
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
50 MG
50 MG
50 MG
50 MG
50 MG
0.05
1
1
1
1
11/17/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
02/03/2005
10/06/2006
1 ML
10 ML
30 ML
50 ML
30 ML
20 ML
20 ML
SR
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
50 MG
50 MG
10 ML
10 ML
10 ML
10 ML
10 ML
1
1
0.1
0.1
0.1
0.1
0.1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10/1/2009
99/99/9999
11/16/2006
3/20/2006
10/07/2007
4/25/2006
01/14/2007
99/99/9999
BENADRYL ALLERGY (AF,CHERRY) 12.5

MG/5 ML
CEREBYX (VIAL) 50 MG/ML
CEREBYX (VIAL) 50 MG/ML
BENADRYL (AMP) 50 MG/ML
BENADRYL (STERI-VIAL) 50 MG/ML
BENADRYL (SRN, STERI-DOSE) 50
MG/ML
CARBOCAINE HCL (S.D.V.) 1%
CARBOCAINE HCL (M.D.V.) 1%
CARBOCAINE HCL (S.D.V.) 1.5%
SODIUM CHLORIDE (THERMOJECT
KIT,PF) 0.9%
CODEINE PHOSPHATE (22GX1-1/4") 15
MG/ML
Page 21 of 374
1/1/2002
6/21/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
IH
IH
BENYLIN DECONGESTANT COUGH 12.5

MG/5 ML
3 ML PC
5 ML PC
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.5
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 99/99/9999
08/06/2002 99/99/9999
08/06/2002 99/99/9999
10/21/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 99/99/9999
02/25/2002 99/99/9999
01/01/2002 99/99/9999
07/11/2005 10/12/2009
10 ML VL
IV
EA
10 ML
04/25/2005
12/26/2006
2 ML SR
IJ
ML
30 MG
0.5
01/01/2002
06/06/2003
00074-1097-32
J0745
1/1/2002 11/14/2005 INJECTION, CODEINE PHOSPHATE, PER 30 MG
00074-1102-02
J0745
1/1/2002
00074-1102-32
00074-1130-02
J0745
J7799
1/1/2002
1/1/2002

5/12/2005 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME
00074-1133-03
J2270
1/1/2002
9/5/2003 INJECTION, MORPHINE SULFATE, UP TO 10 MG
00074-1133-04
J2270
1/1/2002
00074-1133-21
J2270
1/1/2002 10/24/2003 INJECTION, MORPHINE SULFATE, UP TO 10 MG
00074-1133-22
J2270
1/1/2002
00074-1134-03
J2271
1/1/2002
9/14/2005 INJECTION, MORPHINE SULFATE, 100MG
00074-1134-05
J2271
1/1/2002
00074-1134-22
J2271
1/1/2002
00074-1135-01
J2275
1/1/2002
00074-1135-02
J2275
1/1/2002
00074-1135-03
J2275
1/1/2002
00074-1135-04
J2275
1/1/2002
00074-1141-01
J7799

INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER
10/24/2003 10 MG
7/20/2005 10 MG
10/24/2003 10 MG
10/24/2003 10 MG
00074-1141-02
J7799
1/1/2002
00074-1151-12
J1642
1/1/2002
7/13/2005 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS
00074-1151-14
J1642
1/1/2002
00074-1151-70
J1642
1/1/2002
00074-1151-78
J1642
1/1/2002
00074-1152-12
J1642
1/1/2002
00074-1152-14
J1642
1/1/2002
00074-1152-70
J1642
1/1/2002
00074-1152-78
J1642
1/1/2002
00074-1158-01
J3490
1/1/2002
00074-1158-02
J3490
00074-1159-01
J3490
1/1/2002
00074-1159-02
J3490
1/1/2002
00074-1160-01
J3490
1/1/2002
00074-1161-01
J3490
00074-1162-01
J3490
00074-1162-02
J3490
00074-1163-01
J3490
1/1/2002
00074-1164-01
J3490
1/1/2002
00074-1165-01
J3490
1/1/2002
00074-1165-02
J3490
1/1/2002
00074-1176-01
J2175
1/1/2002
00074-1176-02
J2175
1/1/2002 10/24/2003 INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG
00074-1176-11
J2175
00074-1176-21
J2175
CODEINE PHOSPHATE (LUER

LOCK,CARPUJECT) 15 MG/ML
CODEINE PHOSPHATE (22GX1-1/4") 30
MG/ML
SODIUM CHLORIDE 23.4%
MORPHINE SULFATE (VIAL, FLIPTOP) 25
MG/ML
MORPHINE SULFATE (VIAL, 50 ML
FLIPTOP) 25 MG/ML
FLIPTOP) 25 MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
FLIPTOP,PF) 25 MG/ML
MORPHINE SULFATE (VIAL, FLIPTOP,PF)
25 MG/ML
25 MG/ML
25 MG/ML
SODIUM CHLORIDE (VIAL, FLIPTOP,
BULK PKG) 23.4%
BULK PKG) 23.4%
HEPARIN LOCK FLUSH
(VIAL,FLIPTOP,LIFESHIELD) 10 U/ML
HEPARIN LOCK FLUSH
HEPARIN LOCK FLUSH (VIAL, FLIPTOP)
10 U/ML
10 U/ML
HEPARIN LOCK FLUSH
HEPARIN LOCK FLUSH
HEPARIN LOCK FLUSH
(VIAL,FLIPTOP,LATEX-FREE) 100 U/ML
100 U/ML
BUPIVACAINE HCL (AMP,5X30ML,LATEXFREE) 0.25%
BUPIVACAINE HCL (AMP,LATEX-FREE)
0.25%
BUPIVACAINE HCL (VIAL,LATEX-FREE)
0.25%
0.25%
BUPIVACAINE HCL (VIAL, FLIPTOP)
0.25%
0.5%
0.5%
0.5%
BUPIVACAINE HCL (VIAL, FLIPTOP) 0.5%
0.75%
0.75%
0.75%
DEMEROL HYDROCHLORIDE (22GX11/4") 25 MG/ML
DEMEROL HYDROCHLORIDE (SLIM
PK,LATEX-FREE) 25 MG/ML
DEMEROL HYDROCHLORIDE (BLUNT
CANNULA) 25 MG/ML
DEMEROL HYDROCHLORIDE
(INTERLINK,LATEX-FREE) 25 MG/ML
Page 22 of 374
2 ML SR
IJ
ML
30 MG
0.5
01/01/2002
2 ML SR
IJ
ML
30 MG
01/01/2002
06/06/2003
2 ML SR
250 ML VL
IJ
IV
ML
ML
30 MG
1 EA
1
1
01/01/2002
01/01/2002
10/04/2005
05/12/2005
20 ML VL
IJ
ML
10 MG
2.5
01/01/2002
09/05/2003
40 ML VL
IJ
ML
10 MG
2.5
01/01/2002
09/05/2003
4 ML VL
IJ
ML
10 MG
2.5
01/01/2002
10/24/2003
10 ML VL
IJ
ML
10 MG
2.5
01/01/2002
09/05/2003
20 ML VL
IJ
ML
100 MG
0.5
01/01/2002
09/14/2005
50 ML VL
IJ
ML
100 MG
0.5
01/01/2002
08/07/2005
10 ML VL
IJ
ML
100 MG
0.5
01/01/2002
09/05/2003
4 ML VL
IJ
ML
10 MG
2.5
01/01/2002
10/24/2003
10 ML VL
IJ
ML
10 MG
2.5
01/01/2002
07/20/2005
20 ML VL
IJ
ML
10 MG
2.5
01/01/2002
10/24/2003
50 ML VL
IJ
ML
10 MG
2.5
01/01/2002
10/24/2003
50 ML VL
IV
ML
1 EA
01/01/2002
10/24/2003
100 ML VL
IV
ML
1 EA
01/01/2002
04/12/2005
10 ML VL
IV
ML
10 U
01/01/2002
07/13/2005
30 ML VL
IV
ML
10 U
01/01/2002
02/19/2003
10 ML VL
IV
ML
10 U
01/01/2002
07/19/2005
30 ML VL
IV
ML
10 U
01/01/2002
09/18/2005
10 ML VL
IV
ML
10 U
10
01/01/2002
03/14/2005
30 ML VL
IV
ML
10 U
10
01/01/2002
05/16/2005
10 ML VL
IV
ML
10 U
10
01/01/2002
09/06/2005
30 ML VL
IV
ML
10 U
10
01/01/2002
02/24/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
11/14/2005
30 ML AM IJ
ML
1 EA
01/01/2002
07/26/2005
50 ML AM IJ
ML
1 EA
01/01/2002
10/27/2005
10 ML VL
IJ
ML
1 EA
01/01/2002
06/28/2005
30 ML VL
IJ
ML
1 EA
01/01/2002
08/09/2005
50 ML VL
IJ
ML
1 EA
01/01/2002
04/11/2005
30 ML AM IJ
ML
1 EA
01/01/2002
10/17/2004
10 ML VL
IJ
ML
1 EA
3/1/2009
30 ML VL
IJ
ML
1 EA
01/01/2002
11/21/2005
50 ML VL
03/29/2005
99/99/9999 01/01/2002 03/07/2006
IJ
ML
1 EA
01/01/2002
30 ML AM IJ
ML
1 EA
01/01/2002
3/23/2006
10 ML VL
IJ
ML
1 EA
01/01/2002
12/07/2005
30 ML VL
IJ
ML
1 EA
01/01/2002
05/23/2005
1 ML SR
IJ
ML
100 MG
0.25
01/01/2002
06/06/2003
1 ML SR
IJ
ML
100 MG
0.25
01/01/2002
10/24/2003
1 ML SR
IJ
ML
100 MG
0.25
01/01/2002
10/24/2003
1 ML SR
IJ
ML
100 MG
0.25
01/01/2002
10/24/2003
00074-1176-30
J2175
1/1/2002
00074-1176-31
J2175
1/1/2002
00074-1178-01
J2175
00074-1178-02
J2175
1/1/2002
00074-1178-11
J2175
1/1/2002
00074-1178-21
J2175
00074-1178-30
J2175
1/1/2002
00074-1178-31
J2175
1/1/2002
00074-1179-01
J2175
00074-1179-02
J2175
00074-1179-11
J2175
1/1/2002
00074-1179-21
J2175
00074-1179-30
J2175
00074-1179-31
J2175
1/1/2002
00074-1180-01
J2175
00074-1180-02
J2175
1/1/2002
00074-1180-11
J2175
00074-1180-21
J2175
1/1/2002
00074-1180-31
J2175
1/1/2002
00074-1180-69
J2175
3/8/2002
00074-1181-30
J2175
00074-1184-01
J0610
1/1/2002
7/28/2006 INJECTION, CALCIUM GLUCONATE, PER 10 ML
00074-1187-01
J1790
1/1/2002
8/22/2005 INJECTION, DROPERIDOL, UP TO 5 MG
00074-1201-20
00074-1202-03
J2175
J7799
1/1/2002
1/1/2002

00074-1203-01
J2175
00074-1207-03
00074-1211-01
J1580
J2310
1/1/2002
1/1/2002
8/29/2005 INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG

5/6/2004 INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG
00074-1212-01
00074-1213-01
J2310
J2310
1/1/2002
1/1/2002

00074-1215-01
J2310
1/1/2002
00074-1216-01
J2310
1/1/2002
00074-1219-01
J2310
9/7/2005 99/99/9999 INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG
00074-1253-01
J2175
1/1/2002
00074-1254-01
J2175
1/1/2002
00074-1255-02
J2175
00074-1256-01
J2175
1/1/2002
00074-1258-01
J2270
00074-1258-02
J2270
1/1/2002
00074-1258-11
J2270
00074-1258-21
J2270
00074-1258-30
J2270
1/1/2002
DEMEROL HYDROCHLORIDE (LLK,SLIM

DEMEROL HYDROCHLORIDE (LUER
LOCK,LATEX-FREE) 25 MG/ML
DEMEROL HYDROCHLORIDE (22GX11/4",LATEX-FREE) 50 MG/ML
CANNULA) 50 MG/ML
DEMEROL HYDROCHLORIDE (22GX11/4") 75 MG/ML
CANNULA) 75 MG/ML
DEMEROL HYDROCHLORIDE (22GX11/4",LATEX-FREE) 100 MG/ML
PK,CARPUJECT) 100 MG/ML
CANNULA,CARPUJECT) 100 MG/ML
(INTERLINK,CARPUJECT) 100 MG/ML
DEMEROL HYDROCHLORIDE 100 MG/ML
(M.D.V.,LATEX-FREE) 50 MG/ML
CALCIUM GLUCONATE (AMP,LATEXFREE) 100 MG/ML
DROPERIDOL (S.D.AMP,LATEX-FREE)
2.5 MG/ML
(M.D.V.,LATEX-FREE) 100 MG/ML
DEXTROSE (AMP,LATEX-FREE) 10%
DEMEROL HYDROCHLORIDE (UNIAMP,5X5,LATEX-FREE) 50 MG/ML
GENTAMICIN SULFATE (VIAL, FLIPTOP)
40 MG/ML
NALOXONE HCL (AMP) 0.02 MG/ML
NALOXONE HCL (AMP,LATEX-FREE) 0.4
MG/ML
NALOXONE HCL (HYPAK) 0.4 MG/ML
NALOXONE HCL (VIAL, FLIPTOP) 0.4
MG/ML
MG/ML
MG/ML
MORPHINE SULFATE (25GX5/8") 4
MG/ML
MORPHINE SULFATE (25G,SLIM
MORPHINE SULFATE (BLUNT CANNULA)
4 MG/ML
MORPHINE SULFATE (INTERLINK,LATEX
FREE) 4 MG/ML
MORPHINE SULFATE (LLK,SLIM
Page 23 of 374
1 ML SR
IJ
ML
100 MG
0.25
01/01/2002
08/24/2005
1 ML SR
IJ
ML
100 MG
0.25
01/01/2002
06/06/2003
1 ML SR
IJ
ML
100 MG
0.5
01/01/2002
10/24/2003
1 ML SR
IJ
ML
100 MG
0.5
01/01/2002
03/18/2004
1 ML SR
IJ
ML
100 MG
0.5
01/01/2002
08/16/2004
1 ML SR
IJ
ML
100 MG
0.5
01/01/2002
10/24/2003
1 ML SR
IJ
ML
100 MG
0.5
01/01/2002
09/13/2005
1 ML SR
IJ
ML
100 MG
0.5
01/01/2002
03/18/2004
1 ML SR
IJ
ML
100 MG
0.75
01/01/2002
12/10/2003
1 ML SR
IJ
ML
100 MG
0.75
01/01/2002
12/10/2003
1 ML SR
IJ
ML
100 MG
0.75
01/01/2002
03/18/2004
1 ML SR
IJ
ML
100 MG
0.75
01/01/2002
99/99/9999
1 ML SR
IJ
ML
100 MG
0.75
3/1/2009
1 ML SR
IJ
ML
100 MG
0.75
01/01/2002
99/99/9999 01/01/2002 12/07/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.75
03/18/2004
1 ML SR
IJ
ML
100 MG
01/01/2002
10/24/2003
1 ML SR
IJ
ML
100 MG
01/01/2002
05/06/2004
1 ML SR
IJ
ML
100 MG
01/01/2002
10/24/2003
1 ML SR
IJ
ML
100 MG
01/01/2002
03/18/2004
1 ML SR
IJ
ML
100 MG
01/01/2002
03/18/2004
1 ML SR
IJ
ML
100 MG
03/08/2002
09/13/2005
30 ML VL
IJ
ML
100 MG
0.5
3/1/2009
1 ML AM IV
ML
10 ML
0.1
01/01/2002
99/99/9999 01/01/2002 01/30/2006
2 ML AM IJ
ML
5 MG
0.5
01/01/2002
08/22/2005
20 ML VL IJ
3 ML AM IV
ML
ML
100 MG
1 EA
1
1
01/01/2002
01/01/2002
03/08/2006
05/07/2002
0.5 ML AM IJ
ML
100 MG
0.5
10/01/2008
99/99/9999 01/01/2002 12/15/2005
2 ML VL IJ
2 ML AM IJ
ML
ML
80 MG
1 MG
0.5
0.02
01/01/2002
01/01/2002
08/29/2005
05/06/2004
1 ML AM IJ
1 ML VL IJ
ML
ML
1 MG
1 MG
0.4
0.4
01/01/2002
01/01/2002
06/15/2005
05/07/2002
1 ML VL
IJ
ML
1 MG
0.4
01/01/2002
07/07/2005
2 ML VL
IJ
ML
1 MG
0.02
01/01/2002
05/07/2002
10 ML VL
0.5
07/28/2006
IJ
ML
1 MG
0.4
09/07/2005
99/99/9999
1 ML AM IJ
ML
100 MG
0.5
01/01/2002
01/03/2006
1.5 ML AM IJ
ML
100 MG
0.5
01/01/2002
2 ML AM IJ
ML
100 MG
0.5
3/1/2009
1 ML AM IJ
ML
100 MG
01/01/2002
01/25/2006
1 ML SR
IJ
ML
10 MG
0.4
01/01/2002
12/10/2003
1 ML SR
IJ
ML
10 MG
0.4
01/01/2002
03/18/2004
1 ML SR
IJ
ML
10 MG
0.4
01/01/2002
10/24/2003
1 ML SR
IJ
ML
10 MG
0.4
01/01/2002
10/24/2003
1 ML SR
IJ
ML
10 MG
0.4
01/01/2002
05/09/2005
0.5
3/19/2006
99/99/9999 01/01/2002 11/22/2005
0.5
00074-1258-31
J2270
1/1/2002
00074-1259-01
J2270
1/1/2002
00074-1259-60
J2270
00074-1260-01
J2270
1/1/2002
00074-1260-11
J2270
1/1/2002
00074-1260-21
J2270
1/1/2002
00074-1260-31
J2270
1/1/2002
00074-1260-69
J2270
3/8/2002
00074-1261-01
J2270
00074-1261-02
J2270
1/1/2002
00074-1261-30
J2270
1/1/2002
00074-1261-31
J2270
00074-1262-01
J2271
1/1/2002
00074-1263-01
J2270
1/1/2002
00074-1263-11
J2270
1/1/2002
00074-1263-21
J2270
1/1/2002
00074-1264-01
J2271
1/1/2002
00074-1264-11
J2271
1/1/2002
00074-1264-21
J2271
1/1/2002
00074-1264-31
00074-1273-02
J2271
J3360
1/1/2002 12/15/2005 INJECTION, MORPHINE SULFATE, 100MG

1/1/2002
6/6/2003 INJECTION, DIAZEPAM, UP TO 5 MG
00074-1273-12
J3360
1/1/2002
00074-1273-22
J3360
1/1/2002
00074-1273-32
J3360
1/1/2002
00074-1275-02
J1940
1/1/2002
3/18/2004 INJECTION, FUROSEMIDE, UP TO 20 MG
00074-1275-22
00074-1275-32
J1940
J1940
1/1/2002
4/14/2004

00074-1276-02
J3010
1/1/2002
5/7/2002 INJECTION, FENTANYL CITRATE, 0.1 MG
00074-1276-05
J3010
1/1/2002
00074-1276-32
J3010
1/1/2002
00074-1276-35
J3010
1/1/2002 12/10/2003 INJECTION, FENTANYL CITRATE, 0.1 MG
00074-1277-01
J3410
1/1/2002
00074-1280-01
J1642
1/1/2002
00074-1280-02
J1642
1/1/2002
00074-1280-03
J1642
1/1/2002
00074-1280-05
J1642
1/1/2002
00074-1280-11
J1642
1/1/2002
00074-1280-12
J1642
1/1/2002 12/10/2003 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS
00074-1280-13
J1642
00074-1280-15
J1642
1/1/2002
00074-1280-21
J1642
2/15/2002 INJECTION, HYDROXYZINE HCL, UP TO 25 MG
MORPHINE SULFATE (LUER

MORPHINE SULFATE (22GX5/8",LATEXFREE) 8 MG/ML
MORPHINE SULFATE (BLUNT
MORPHINE SULFATE
MORPHINE SULFATE (CARPUJECT
LUER LOCK) 8 MG/ML
MG/ML
MG/ML
MG/ML
10 MG/ML
FREE) 10 MG/ML
MG/ML
15 MG/ML
FREE) 15 MG/ML
DIAZEPAM (22GX1-1/4") 5 MG/ML
DIAZEPAM (U-BLUNT CANN,LATEXFREE) 5 MG/ML
DIAZEPAM (INTERLINK,LATEX-FREE) 5
MG/ML
DIAZEPAM (LUER LOCK,LATEX-FREE) 5
MG/ML
FUROSEMIDE (22GX1-1/4",LATEX-FREE)
10 MG/ML
FUROSEMIDE (INTERLINK,CARPUJECT)
10 MG/ML
FUROSEMIDE 10 MG/ML
FENTANYL CITRATE (22GX11/4",PF,CARPUJECT) 0.05 MG/ML
FENTANYL CITRATE (22GX11/4",PF,CARPUJECT) 0.05 MG/ML
FENTANYL CITRATE (LUER
LOCK,PF,CARPUJECT) 0.05 MG/ML
LOCK,PF,CARPUJECT) 0.05 MG/ML
HYDROXYZINE HCL (CARPUJECT) 25
MG/ML
HEPARIN LOCK FLUSH (25GX5/8",LATEXFREE) 10 U/ML
HEPARIN LOCK FLUSH (BLUNT
CANNULA) 10 U/ML
CANNULA) 10 U/ML
CANNULA) 10 U/ML
CANNULA) 10 U/ML
HEPARIN LOCK FLUSH
(INTERLINK,LATEX-FREE) 10 U/ML
Page 24 of 374
1 ML CR
IJ
ML
10 MG
0.4
01/01/2002
1 ML SR
IJ
ML
10 MG
0.8
01/01/2002
06/06/2003
1 ML SR
IJ
ML
10 MG
0.8
03/08/2002
12/10/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
06/06/2003
1 ML SR
IJ
ML
10 MG
0.8
01/01/2002
03/18/2004
1 ML SR
IJ
ML
10 MG
0.8
01/01/2002
05/07/2002
1 ML SR
IJ
ML
10 MG
0.8
01/01/2002
05/07/2002
1 ML CR
IJ
ML
10 MG
0.8
01/01/2002
06/06/2003
1 ML SR
IJ
ML
10 MG
0.8
03/08/2002
3/21/2006
1 ML SR
IJ
ML
10 MG
01/01/2002
12/10/2003
1 ML SR
IJ
ML
10 MG
01/01/2002
03/18/2004
1 ML SR
IJ
ML
10 MG
01/01/2002
07/20/2005
1 ML CR
IJ
ML
10 MG
01/01/2002
12/10/2003
1 ML SR
IJ
ML
100 MG
0.15
01/01/2002
03/18/2004
1 ML SR
IJ
ML
10 MG
01/01/2002
03/18/2004
1 ML SR
IJ
ML
10 MG
01/01/2002
06/06/2003
1 ML SR
IJ
ML
10 MG
01/01/2002
05/06/2004
1 ML SR
IJ
ML
100 MG
0.15
01/01/2002
09/20/2002
1 ML SR
IJ
ML
100 MG
0.15
01/01/2002
09/20/2002
1 ML SR
IJ
ML
100 MG
0.15
01/01/2002
05/07/2002
1 ML CR
2 ML SR
IJ
IJ
ML
ML
100 MG
5 MG
0.15
1
01/01/2002
01/01/2002
12/15/2005
06/06/2003
2 ML SR
IJ
ML
5 MG
01/01/2002
05/07/2002
2 ML SR
IJ
ML
5 MG
01/01/2002
05/07/2002
2 ML CR
IJ
ML
5 MG
01/01/2002
08/22/2005
2 ML SR
IJ
ML
20 MG
0.5
01/01/2002
03/18/2004
2 ML SR
2 ML SR
IJ
IJ
ML
ML
20 MG
20 MG
0.5
0.5
01/01/2002
04/14/2004
03/18/2004
08/30/2005
2 ML SR
IJ
ML
0.1 MG
0.5
01/01/2002
05/07/2002
5 ML SR
IJ
ML
0.1 MG
0.5
01/01/2002
05/07/2002
2 ML CR
IJ
ML
0.1 MG
0.5
01/01/2002
07/26/2005
5 ML CR
IJ
ML
0.1 MG
0.5
01/01/2002
12/10/2003
1 ML SR
IM
ML
25 MG
01/01/2002
02/15/2002
1 ML SR
IV
ML
10 U
01/01/2002
09/05/2003
2 ML SR
IV
ML
10 U
01/01/2002
06/21/2002
3 ML CR
IV
ML
10 U
01/01/2002
06/06/2003
5 ML CR
IV
ML
10 U
01/01/2002
05/07/2002
1 ML SR
IV
ML
10 U
01/01/2002
10/01/2004
2 ML SR
IV
ML
10 U
01/01/2002
12/10/2003
3 ML SR
IV
ML
10 U
01/01/2002
10/24/2003
5 ML SR
IV
ML
10 U
01/01/2002
06/06/2003
1 ML SR
IV
ML
10 U
01/01/2002
12/10/2003
00074-1280-22
J1642
00074-1280-23
J1642
1/1/2002
00074-1280-25
J1642
00074-1280-31
J1642
1/1/2002
00074-1280-32
J1642
1/1/2002
00074-1280-33
J1642
1/1/2002
00074-1280-35
J1642
1/1/2002
00074-1281-01
J1642
00074-1281-02
J1642
1/1/2002
00074-1281-03
J1642
1/1/2002
00074-1281-05
J1642
00074-1281-11
J1642
00074-1281-12
J1642
1/1/2002
00074-1281-13
J1642
1/1/2002
00074-1281-15
J1642
1/1/2002
00074-1281-21
J1642
00074-1281-22
J1642
1/1/2002
00074-1281-23
J1642
1/1/2002
00074-1281-25
J1642
00074-1281-31
J1642
1/1/2002
00074-1281-32
J1642
1/1/2002
00074-1281-33
J1642
1/1/2002
00074-1281-35
J1642
1/1/2002
00074-1282-02
J1642
1/1/2002
00074-1283-01
J1170
1/1/2002 99/99/9999 INJECTION, HYDROMORPHONE, UP TO 4 MG
00074-1283-31
J1170
1/1/2002
00074-1304-01
J1170
00074-1304-12
J1170
1/1/2002
00074-1304-31
J1170
1/1/2002
00074-1312-01
J1170
00074-1312-02
J1170
00074-1312-12
J1170
1/1/2002
00074-1312-30
J1170
1/1/2002
00074-1312-31
J1170
1/1/2002
00074-1316-01
J1644
1/1/2002
00074-1316-02
J1644
1/1/2002
00074-1316-11
J1644
1/1/2002
00074-1316-12
J1644
1/1/2002
00074-1316-13
J1644
1/1/2002
00074-1316-14
J1644
1/1/2002 12/10/2003 INJECTION, HEPARIN SODIUM, PER 1000 UNITS
HEPARIN LOCK FLUSH

HEPARIN LOCK FLUSH
HEPARIN LOCK FLUSH
HEPARIN LOCK FLUSH (LUER
LOCK,LATEX-FREE) 10 U/ML
HEPARIN LOCK FLUSH
(25GX5/8",CARPUJECT) 100 U/ML
HEPARIN LOCK FLUSH
CANNULA,CARPUJECT) 100 U/ML
HEPARIN LOCK FLUSH
HEPARIN LOCK FLUSH
HEPARIN LOCK FLUSH
(INTERLINK,CARPUJECT) 100 U/ML
HEPARIN LOCK FLUSH
(INTERLINK,CARPUJECT) 100 U/ML
LOCK,CARPUJECT) 100 U/ML
HEP-PAK CONVENIENCE PACKAGE
(CARPUJECT) 10 U/ML
HYDROMORPHONE HCL (22GX1-1/4") 1
MG/ML
HYDROMORPHONE HCL (LUER
MG/ML
HYDROMORPHONE HCL (U-BLUNT
CANN,LATEX-FREE) 4 MG/ML
MG/ML
HYDROMORPHONE HCL (SLIM
HYDROMORPHONE HCL (U-BLUNT
CANN,LATEX-FREE) 2 MG/ML
HYDROMORPHONE HCL (10X1ML,
LLK,SLIM PK) 2 MG/ML
HEPARIN SODIUM (25GX5/8") 10000
U/ML
2 ML SR
IV
ML
10 U
01/01/2002
12/10/2003
3 ML SR
IV
ML
10 U
01/01/2002
09/20/2002
5 ML SR
IV
ML
10 U
01/01/2002
12/12/2002
1 ML CR
IV
ML
10 U
01/01/2002
03/27/2005
2 ML CR
IV
ML
10 U
01/01/2002
04/07/2005
3 ML CR
IV
ML
10 U
01/01/2002
04/04/2005
5 ML CR
IV
ML
10 U
01/01/2002
03/31/2005
1 ML SR
IV
ML
10 U
10
01/01/2002
12/12/2002
2 ML SR
IV
ML
10 U
10
01/01/2002
02/19/2003
3 ML CR
IV
ML
10 U
10
01/01/2002
06/06/2003
5 ML CR
IV
ML
10 U
10
01/01/2002
12/12/2002
1 ML SR
IV
ML
10 U
10
01/01/2002
10/24/2003
2 ML SR
IV
ML
10 U
10
01/01/2002
02/15/2002
3 ML SR
IV
ML
10 U
10
01/01/2002
06/06/2003
5 ML SR
IV
ML
10 U
10
01/01/2002
07/12/2004
1 ML SR
IV
ML
10 U
10
01/01/2002
12/10/2003
2 ML SR
IV
ML
10 U
10
01/01/2002
06/06/2003
3 ML SR
IV
ML
10 U
10
01/01/2002
06/06/2003
5 ML SR
IV
ML
10 U
10
01/01/2002
12/10/2003
1 ML CR
IV
ML
10 U
10
01/01/2002
07/21/2005
2 ML CR
IV
ML
10 U
10
01/01/2002
04/24/2005
3 ML CR
IV
ML
10 U
10
01/01/2002
07/14/2005
5 ML CR
IV
ML
10 U
10
01/01/2002
04/24/2005
50 EA BX
IV
EA
10 U
50
01/01/2002
06/06/2003
1 ML SR
IJ
ML
4 MG
0.25
01/01/2002
99/99/9999
1 ML CR
IJ
ML
4 MG
0.25
01/01/2002
06/13/2005
1 ML SR
IJ
ML
4 MG
01/01/2002
12/10/2003
1 ML SR
IJ
ML
4 MG
01/01/2002
02/15/2002
1 ML CR
IJ
ML
4 MG
01/01/2002
07/12/2005
1 ML SR
IJ
ML
4 MG
0.5
01/01/2002
12/10/2003
1 ML SR
IJ
ML
4 MG
0.5
01/01/2002
10/24/2003
1 ML SR
IJ
ML
4 MG
0.5
01/01/2002
11/01/2004
1 ML SR
IJ
ML
4 MG
0.5
01/01/2002
07/06/2005
1 ML CR
IJ
ML
4 MG
0.5
01/01/2002
06/06/2003
06/06/2003
1 ML SR
IJ
ML
1000 U
10
01/01/2002
HEPARIN SODIUM (25GX5/8") 2500 U/ML

U/ML
0.25 ML SR
IJ
ML
1000 U
2.5
01/01/2002
06/06/2003
1 ML SR
IJ
ML
1000 U
10
01/01/2002
06/06/2003
HEPARIN SODIUM (25GX5/8") 7500 U/ML

U/ML
U/ML
0.75 ML SR
IJ
ML
1000 U
7.5
01/01/2002
06/06/2003
0.5 ML SR
IJ
ML
1000 U
10
01/01/2002
06/06/2003
0.5 ML SR
IJ
ML
1000 U
10
01/01/2002
12/10/2003
Page 25 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00074-1316-31
00074-1316-32
J1644
J1644
1/1/2002
10/30/2003

00074-1316-66
J1644
6/23/2003
00074-1317-01
J1165
1/1/2002
2/7/2005 INJECTION, PHENYTOIN SODIUM, PER 50 MG
00074-1317-02
00074-1323-05
00074-1323-05
J1165
J2000
J2001
1/1/2002 3/29/2005 INJECTION, PHENYTOIN SODIUM, PER 50 MG

1/1/2002 12/31/2003 INJECTION, LIDOCAINE HCL, 50 CC
1/1/2004 99/99/9999 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG
00074-1389-01
J1644
1/1/2002
00074-1389-02
J1644
1/1/2002
00074-1389-32
J1644
1/1/2002
00074-1402-01
J1644
00074-1402-11
J1644
1/1/2002
00074-1402-31
J1644
1/1/2002
00074-1410-01
J7659
00074-1410-01 KO J7659
00074-1410-05
2/22/2002
KO
J7659
00074-1410-05 KO J7659
00074-1412-04
J3490
2/22/2002
2/22/2002
KO
2/22/2002
1/1/2002

ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
00074-1412-10
J3490
00074-1412-14
J3490
1/1/2002
00074-1463-01
00074-1464-01
J2300
J2300
1/1/2002
1/1/2002
3/8/2005 INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG

00074-1465-01
J2300
1/1/2002 11/17/2004 INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG
00074-1467-01
J2300
1/1/2002
00074-1489-01
J7799
1/1/2002
00074-1493-01
J2912
1/1/2002
9/20/2002 INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML
00074-1494-01
J7060
1/1/2002
9/20/2002 5% DEXTROSE/WATER (500 ML = 1 UNIT)
00074-1495-01
J7060
1/1/2002
00074-1497-01
J3480
1/1/2002
6/6/2003 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ
00074-1498-01
J3480
1/1/2002
00074-1499-01
J3480
1/1/2002
00074-1505-03
J7110
1/1/2002 12/28/2005 INFUSION, DEXTRAN 75, 500 ML
00074-1507-03
00074-1508-05
J7110
J7799

00074-1513-02
00074-1518-05
00074-1519-05
J3480
J7799
J7799
1/1/2002
1/1/2002
1/1/2002

00074-1521-05
00074-1522-01
00074-1522-02
00074-1522-03
00074-1523-01
00074-1523-11
J7120
J7060
J7060
J7060
J7060
J7060
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
4/30/2003 RINGERS LACTATE INFUSION, UP TO 1000 CC

00074-1534-05
00074-1535-03
J7799
J7799
1/1/2002
1/1/2002
HEPARIN SODIUM (LUER

LOCK,PF,CARPUJECT) 10000 U/ML
HEPARIN SODIUM (PF,CARPUJECT)
10000 U/ML
PHENYTOIN SODIUM (AMP,LATEXFREE) 50 MG/ML
LIDOCAINE HCL (10X5ML, ANSYR) 2%
HEP-PAK CONVENIENCE PACKAGE
(CARPUJECT) 100 U/ML
HEP-PAK CVC CONVENIENCE PACKAGE
100 U/ML
1 ML SR
0.5 ML SR
IJ
IJ
ML
ML
1000 U
1000 U
10
10
01/01/2002
10/30/2003
02/15/2002
03/22/2005
0.5 ML SR
1000 U
IJ
ML
10
06/23/2003
02/10/2005
2 ML AM IV
ML
50 MG
01/01/2002
02/07/2005
5 ML AM IV
5 ML SR IJ
5 ML SR IJ
ML
ML
ML
50 MG
50 ML
10 MG
1
0.02
2
01/01/2002
01/01/2002
3/1/2009
03/29/2005
12/31/2003
99/99/9999 01/01/2004 12/07/2005
01/01/2002
02/15/2002
50 EA BX
IV
EA
1000 U
30 EA BX
IV
EA
1000 U
01/01/2002
06/21/2002
IV
EA
1000 U
01/01/2002
06/21/2002
1 ML SR
IJ
ML
1000 U
01/01/2002
12/10/2003
1 ML SR
IJ
ML
1000 U
01/01/2002
06/06/2003
1 ML AM IJ
ML
1000 U
01/01/2002
03/20/2005
ISUPREL (25X1ML, AMP,LATEX-FREE)

0.2 MG/ML
1 ML AM IV
ML
1 MG
0.2
10/01/2008
99/99/9999 02/22/2002 07/27/2005
0.2

0.2 MG/ML
1 ML AM IV
ML
1 MG
0.2
10/01/2008
99/99/9999 02/22/2002 07/27/2005
0.2

0.2 MG/ML
5 ML AM IV
ML
1 MG
0.2
02/22/2002
10/25/2005
5 ML AM IV
4 ML VL IJ
ML
ML
1 MG
1 EA
0.2
1
02/22/2002
3/1/2009
10/25/2005
99/99/9999 01/01/2002 06/13/2006
99/99/9999 01/01/2002 06/28/2006

0.2 MG/ML
BUMETANIDE (10X4ML) 0.25 MG/ML
BUMETANIDE (10X10ML, M.D.V.) 0.25
MG/ML
BUMETANIDE (CARPUJECT) 0.25 MG/ML
NALBUPHINE HCL (AMP,LATEX-FREE)
10 MG/ML
NALBUPHINE HCL (25X10ML) 10 MG/ML
20 MG/ML
NALBUPHINE HCL (VIAL, FLIPTOP) 20
MG/ML
DEXTROSE (VIAL,100 ML PRESS. PNTP)
70%
SODIUM CHLORIDE (100 ML
PRESS.PNTOP VIAL) 0.9%
5%
5%
POTASSIUM CHLORIDE (VIAL,
PINTOP,LATEX-FREE) 2 MEQ/ML
DEXTRAN-70 W/SODIUM CHLORIDE 6%0.9%
DEXTRAN-70/DEXTROSE (12X500ML) 6%
5%
DEXTROSE (6X1000ML) 2.5%
BULK,LATEX-FREE) 2 MEQ/ML
DEXTROSE (LATEX-FREE) 50%
DEXTROSE 2.5% IN RINGERS (1/2
STRENGTH LACT RING)
DEXTROSE 5%
DEXTROSE 5%
DEXTROSE (12X500ML) 5%
DEXTROSE (50/150 ML PART FILL) 5%
DEXTROSE (100/150 ML PART FILL) 5%
DEXTROSE/SODIUM CHLORIDE
(6X1000ML) 10%-0.9%
Page 26 of 374
10 ML VL
IJ
ML
1 EA
3/1/2009
4 ML SR
IJ
ML
1 EA
01/01/2002
02/15/2002
1 ML AM IJ
10 ML VL IJ
ML
ML
10 MG
10 MG
1
1
01/01/2002
01/01/2002
03/08/2005
07/12/2005
ML
10 MG
01/01/2002
11/17/2004
10 ML VL
1 ML AM IJ
IJ
ML
10 MG
01/01/2002
05/11/2005
70 ML VL
IV
ML
02/19/2003
50 ML VL
IV
ML
0.9 %
100 ML VL
IV
ML
50 ML VL
IV
ML
10 ML VL
IV
ML
2 MEQ
15 ML VL
IV
ML
20 ML VL
IV
ML
500 ML FC
IV
ML
500 ML GC IV
1000 ML GC IV
ML
ML
250 ML VL IV
1000 ML GC IV
1000 ML GC IV
ML
ML
ML
1000 ML
150 ML
250 ML
500 ML
50 ML
100 ML
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
1000 ML GC IV
500 ML GC IV
ML
ML
NA
GC
GC
GC
GC
GC
1 EA
01/01/2002
0.5
01/01/2002
09/20/2002
500 ML
0.002
01/01/2002
09/20/2002
500 ML
0.002
01/01/2002
05/07/2002
01/01/2002
06/06/2003
2 MEQ
01/01/2002
09/20/2002
2 MEQ
01/01/2002
06/21/2002
500 ML
0.002
01/01/2002
12/28/2005
500 ML
1 EA
0.002
1
01/01/2002
01/01/2002
99/99/9999
08/30/2005
1
1
1
01/01/2002
01/01/2002
01/01/2002
06/15/2005
03/18/2004
03/18/2004
1000 ML
500 ML
500 ML
500 ML
500 ML
500 ML
0.0005
0.002
0.002
0.002
0.002
0.002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/30/2003
04/10/2005
03/08/2005
06/15/2005
09/15/2005
07/26/2005
1 EA
1 EA
1
1
01/01/2002
01/01/2002
02/23/2006
09/07/2005
2 MEQ
1 EA
1 EA
30 EA BX
HEP-PAK CVC CONVENIENCE PACKAGE

(W/LUER LOCK,CARPUJECT) 100 U/ML
HEPARIN SODIUM
HEPARIN SODIUM
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00074-1536-03
J7799
1/1/2002
00074-1539-11
J2060
1/1/2002
00074-1539-12
J2060
1/1/2002
00074-1539-21
J2060
1/1/2002
00074-1539-31
00074-1540-01
J2060
J2560
1/1/2002 12/22/2005 INJECTION, LORAZEPAM, 2 MG

1/1/2002 3/18/2004 INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG

LORAZEPAM (22GX1-1/4",LATEX-FREE) 4
MG/ML
LORAZEPAM (U-BLUNT CANN,LATEXFREE) 4 MG/ML
LORAZEPAM (INTERLINK,LATEX-FREE) 4
MG/ML
LORAZEPAM (10X1ML, LUER LOCK) 4
MG/ML
LUMINAL SODIUM (AMP) 130 MG/ML
MARCAINE HCL (S.D.V.,LATEX-FREE)
0.25%
0.25%
MARCAINE HCL (AMP,LATEX-FREE)
0.25%
MARCAINE HCL (S.D.V.) 0.5%
MARCAINE HCL (AMP) 0.5%
00074-1559-10
J3490
1/1/2002
00074-1559-30
J3490
1/1/2002
00074-1559-50
00074-1560-10
00074-1560-29
00074-1560-30
J3490
J3490
J3490
J3490

1/1/2002
00074-1582-10
J3490
1/1/2002
00074-1582-29
J3490
1/1/2002
00074-1582-30
J3490
1/1/2002
MARCAINE HCL (10X10ML, S.D.V.) 0.75%

MARCAINE HCL (10X30ML,LATEX-FREE)
0.75%
MARCAINE HCL (AMP,LATEX-FREE)
0.75%
00074-1583-01
J7050
1/1/2002
7/19/2005 INFUSION, NORMAL SALINE SOLUTION , 250 CC
00074-1583-02
J7050
1/1/2002
00074-1584-01
J2912
1/1/2002 12/31/2003 INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML
00074-1584-01
A4216
00074-1584-11
00074-1586-03
J7050
J7799
1/1/2002
1/1/2002

00074-1587-50
J3490
1/1/2002
00074-1590-02
A4712
1/1/2002 12/31/2003 WATER, STERILE, FOR INJECTION, PER 10 ML
00074-1590-02
A4217
1/1/2004
00074-1590-05
A4712
00074-1590-05
00074-1592-02
00074-1610-50
A4217
J3350
J3490
1/1/2004 6/27/2005 STERILE WATER/SALINE, 500 ML

1/1/2002
5/7/2002 INJECTION, UREA, UP TO 40 GM
00074-1623-01
J3490
00074-1623-01
J0595
1/1/2004
00074-1623-49
J3490
00074-1623-49
J0595
1/1/2004 10/18/2005 INJECTION, BUTORPHANOL TARTRATE, 1 MG
00074-1624-49
J3490
1/1/2002
00074-1626-01
J3490
00074-1626-01
J0595
1/1/2004
00074-1626-02
J3490
00074-1626-02
J0595
00074-1626-49
J3490
00074-1626-49
J0595
1/1/2004
00074-1626-51
J3490
00074-1626-51
J0595
1/1/2004
00074-1627-49
J3490
1/1/2002
00074-1630-10
J0460
7/17/2003
00074-1639-10
J1940
1/1/2002
8/4/2005 STERILE WATER/SALINE, 500 ML

1/10/2006 INJECTION, ATROPINE SULFATE, UP TO 0.3 MG
500 ML GC IV
1 ML SR
IJ
ML
1 EA
01/01/2002
03/18/2004
ML
2 MG
01/01/2002
04/30/2003
1 ML SR
IJ
ML
2 MG
01/01/2002
09/20/2002
1 ML SR
IJ
ML
2 MG
01/01/2002
06/21/2002
1 ML CR IJ
1 ML AM IJ
ML
ML
2 MG
120 MG
2
1.08333
01/01/2002
01/01/2002
12/22/2005
03/18/2004
10 ML VL
IJ
ML
1 EA
01/01/2002
08/21/2005
30 ML VL
IJ
ML
1 EA
01/01/2002
09/06/2005
50 ML
10 ML
30 ML
30 ML
AM
VL
VL
AM
IJ
IJ
IJ
IJ
ML
ML
ML
ML
1 EA
1 EA
1 EA
1 EA
1
1
1
1
01/01/2002
3/1/2009
01/01/2002
01/01/2002
08/16/2004
99/99/9999 01/01/2002 08/30/2005
08/04/2005
03/18/2004
10 ML VL
IJ
ML
1 EA
01/01/2002
07/21/2005
30 ML VL
IJ
ML
1 EA
01/01/2002
08/03/2005
30 ML AM IJ
ML
1 EA
01/01/2002
05/16/2005
SODIUM CHLORIDE (12X150ML,PF) 0.9%
150 ML GC IV
ML
250 ML
0.004
01/01/2002
07/19/2005

CONTAINER,PF) 0.9%
CONTAINER,PF) 0.9%
250 ML GC IV
ML
250 ML
0.004
01/01/2002
09/13/2005
50 ML GC IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
50 ML GC IV
ML
10 ML
0.1
01/01/2004
99/99/9999

SODIUM CHLORIDE (12X500ML) 5%
MARCAINE HCL (M.D.V.,LATEX-FREE)
0.25%
WATER FOR INJECTION
(12X250ML,PF,LATEX-FREE)
WATER FOR INJECTION
WATER FOR INJECTION (PF,LATEXFREE)
WATER FOR INJECTION (PF,LATEXFREE)
UREAPHIL 40 GM
MARCAINE HCL (M.D.V.) 0.5%
BUTORPHANOL TARTRATE (10X1ML) 1
MG/ML
MG/ML
BUTORPHANOL TARTRATE NOVATION
(10X1ML) 1 MG/ML
(10X1ML) 1 MG/ML
(HYPAK) 1 MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
(10X1ML) 2 MG/ML
(10X1ML) 2 MG/ML
(10X2ML) 2 MG/ML
(10X2ML) 2 MG/ML
(HYPAK) 2 MG/ML
ATROPINE SULFATE (ANSYR, 10X10ML)
0.1 MG/ML
FUROSEMIDE (10X10ML, ANSYR) 10
MG/ML
100 ML GC IV
500 ML GC IV
ML
ML
250 ML
1 EA
0.004
1
01/01/2002
01/01/2002
09/15/2005
3/23/2006
Page 27 of 374
IJ
ML
1 EA
01/01/2002
01/09/2006
250 ML GC IV
50 ML VL
ML
10 ML
0.1
01/01/2002
12/31/2003
08/04/2005
250 ML GC IV
ML
500 ML
0.002
01/01/2004
1000 ML GC IV
ML
10 ML
0.1
01/01/2002
12/31/2003
1000 ML GC IV
1 EA GC IV
50 ML VL IJ
ML
EA
ML
500 ML
40 GM
1 EA
0.002
1
1
01/01/2004
01/01/2002
3/1/2009
06/27/2005
05/07/2002
99/99/9999 01/01/2002 11/21/2005
1 ML VL
ML
1 EA
01/01/2002
12/31/2003
IJ
1 ML VL
IJ
ML
1 MG
01/01/2004
09/19/2005
1 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
1 ML VL
IJ
ML
1 MG
01/01/2004
10/18/2005
1 ML SR
IJ
ML
1 EA
01/01/2002
05/07/2002
1 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
1 ML VL
IJ
ML
1 MG
01/01/2004
3/20/2006
2 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
2 ML VL
IJ
ML
1 MG
01/01/2004
12/20/2005
1 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
1 ML VL
IJ
ML
1 MG
01/01/2004
05/23/2006
2 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
2 ML VL
IJ
ML
1 MG
01/01/2004
12/07/2005
1 ML SR
IJ
ML
1 EA
01/01/2002
05/07/2002
10 ML SR
IJ
ML
0.3 MG
0.33333
07/17/2003
01/10/2006
10 ML SR
IJ
ML
20 MG
0.5
01/01/2002
01/22/2006
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00074-1658-01
J2500
1/1/2002 12/31/2002 INJECTION, PARICALCITOL, 5 MCG
ZEMPLAR (S.D.V.,FLIPTOP) 0.005 MG/ML
1 ML VL
IV
ML
5 MCG
01/01/2002
00074-1658-01
J2501
1 ML VL
IV
ML
1 MCG
01/01/2003
99/99/9999
00074-1658-02
J2500
2 ML VL
IV
ML
5 MCG
01/01/2002
12/31/2002
00074-1658-02
J2501
J3490
1/1/2002
00074-1754-10
J3475
1/1/2002 11/26/2006 INJECTION, MAGNESIUM SULFATE, PER 500 MG
00074-1761-02
J3490
1/1/2002
00074-1762-01
J2270
1/1/2002
00074-1762-02
J2270
00074-1762-11
J2270
00074-1762-21
J2270
1/1/2002
00074-1762-30
J2270
1/1/2002
00074-1762-31
00074-1775-10
J2270
J7799
1/1/2002
00074-1782-01
J2310
1/1/2002

BRETYLIUM TOSYLATE (ANSYR) 50
MG/ML
MAGNESIUM SULFATE (ANSYR,LATEXFREE) 500 MG/ML
MARCAINE SPINAL
(AMP,W/DEXTROSE,PF) 0.75%
MG/ML
MORPHINE SULFATE (BLUNT
MORPHINE SULFATE
DEXTROSE (10X10ML,ANSYR) 25%
NALOXONE HCL (22GX1-1/4",LATEXFREE) 0.4 MG/ML
NALOXONE HCL
(INTERLINK,CARPUJECT) 0.4 MG/ML
NALOXONE HCL (10X1ML, CARPUJECT)
0.4 MG/ML
NEO-SYNEPHRINE HCL (AMP,LATEXFREE) 10 MG/ML
SODIUM CHLORIDE (22GX1-1/4",PF)
0.9%
SODIUM CHLORIDE (22GX1-1/4",PF)
0.9%
SODIUM CHLORIDE (BLUNTCANNULA,PF) 0.9%
SODIUM CHLORIDE
(INTERLINK,50X2ML,PF) 0.9%
SODIUM CHLORIDE
(INTERLINK,50X2ML,PF) 0.9%
SODIUM CHLORIDE
(INTERLINK,PF,LATEX-FREE) 0.9%
SODIUM CHLORIDE
(INTERLINK,PF,LATEX-FREE) 0.9%
PROCAINAMIDE HCL (22G X 1
1/4",CARPUJECT) 500 MG/ML
PHENYTOIN SODIUM (22GX1-1/4",LATEXFREE) 50 MG/ML
PHENYTOIN SODIUM (22GX1-1/4",LATEXFREE) 50 MG/ML
PROCHLORPERAZINE EDISYLATE
(22GX1-1/4") 5 MG/ML
(LUER LOCK,CARPUJECT) 5 MG/ML
SODIUM CHLORIDE (25GX5/8",PF,LATEXFREE) 0.9%
PROCAINAMIDE HCL (VIAL, FLIPTOP)
100 MG/ML
PROCAINAMIDE HCL (VIAL, FLIPTOP)
500 MG/ML
SODIUM CHLORIDE (50X2ML, LUER
LOCK,PF) 0.9%
SODIUM CHLORIDE (LUER
LOCK,PF,LATEX-FREE) 0.9%
99/99/9999
00074-1698-10

00074-1782-21
J2310
00074-1782-69
J2310
00074-1800-01
J2370
1/1/2002 99/99/9999 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML
00074-1811-02
J2912
1/1/2002
00074-1811-05
J2912
1/1/2002
00074-1812-02
J2912
1/1/2002
00074-1812-03
J2912
00074-1812-05
J2912
1/1/2002
00074-1812-22
J2912
00074-1812-22
A4216
00074-1812-23
J2912
1/1/2002
00074-1812-25
J2912
1/1/2002
00074-1826-02
J2690
1/1/2002
00074-1844-02
J1165
1/1/2002
00074-1844-15
J1165
00074-1880-02
J0780
1/1/2002 12/12/2002 INJECTION, PROCHLORPERAZINE, UP TO 10 MG
00074-1880-22
J0780
00074-1880-32
J0780
1/1/2002
00074-1885-02
J2912
1/1/2002
00074-1885-03
J2912
00074-1885-05
J2912
00074-1902-01
J2690
1/1/2002
00074-1903-01
J2690
1/1/2002
00074-1918-32
J2912
00074-1918-33
J2912
1/1/2002
00074-1918-35
J2912
1/1/2002

3/10/2004
Page 28 of 374
2 ML VL
IV
ML
1 MCG
01/01/2003
IV
ML
1 EA
01/01/2002
03/18/2004
10 ML VL
IJ
ML
500 MG
01/01/2002
11/26/2006
2 ML AM IJ
ML
1 EA
01/01/2002
06/05/2005
1 ML SR
ML
10 MG
0.2
01/01/2002
03/18/2004
1 ML SR
IJ
ML
10 MG
0.2
01/01/2002
12/10/2003
1 ML SR
IJ
ML
10 MG
0.2
01/01/2002
10/24/2003
1 ML SR
IJ
ML
10 MG
0.2
01/01/2002
09/05/2003
1 ML SR
IJ
ML
10 MG
0.2
01/01/2002
05/26/2005
1 ML CR
10 ML SR
IJ
IV
ML
ML
10 MG
1 EA
0.2
1
01/01/2002
3/1/2009
06/06/2003
99/99/9999 01/01/2002 02/19/2006
1 ML SR
IJ
ML
1 MG
0.4
01/01/2002
03/18/2004
1 ML SR
IJ
ML
1 MG
0.4
01/01/2002
99/99/9999
1 ML SR
IJ
ML
1 MG
0.4
03/10/2004
09/28/2005
1 ML AM IJ
ML
1 ML
3/1/2009
2 ML NA
ML
0.5
01/01/2002
IV
0.9 %
Prior End Date #3
Prior Start Date #3
Prior End Date #2
12/31/2002
10 ML SR
IJ
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
99/99/9999 01/01/2002 04/13/2005
06/06/2003
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
06/06/2003
2 ML SR
IV
ML
0.9 %
0.5
01/01/2002
09/05/2003
3 ML NA
IV
ML
0.9 %
0.5
01/01/2002
10/24/2003
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
03/18/2004
2 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
2 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML NA
IV
ML
0.9 %
0.5
01/01/2002
06/06/2003
5 ML NA
IV
ML
0.9 %
0.5
01/01/2002
06/06/2003
2 ML SR
IV
ML
1 GM
0.5
01/01/2002
02/15/2002
2 ML SR
IV
ML
50 MG
01/01/2002
01/07/2005
5 ML SR
IV
ML
50 MG
01/01/2002
10/24/2003
2 ML SR
IJ
ML
10 MG
0.5
01/01/2002
12/12/2002
2 ML SR
IJ
ML
10 MG
0.5
01/01/2002
12/12/2002
2 ML SR
IJ
ML
10 MG
0.5
01/01/2002
03/18/2004
2 ML SR
IV
ML
0.9 %
0.5
01/01/2002
09/05/2003
3 ML NA
IV
ML
0.9 %
0.5
01/01/2002
12/12/2002
5 ML NA
IV
ML
0.9 %
0.5
01/01/2002
12/12/2002
10 ML VL
IV
ML
1 GM
0.1
01/01/2002
03/09/2006
2 ML VL
IV
ML
1 GM
0.5
01/01/2002
08/23/2005
2 ML CR
IV
ML
0.9 %
0.5
01/01/2002
11/22/2005
5 ML CR
IV
ML
0.9 %
0.5
01/01/2002
02/16/2005
5 ML CR
IV
ML
0.9 %
0.5
01/01/2002
04/07/2005
TALWIN LACTATE (VIAL,LATEX-FREE) 30

MG/ML
TALWIN LACTATE (LATEX-FREE) 30
4/30/2003 INJECTION, PENTAZOCINE, 30 MG
MG/ML
TALWIN LACTATE (LUER
TALWIN LACTATE (22GX1-1/4",LATEX9/5/2003 INJECTION, PENTAZOCINE, 30 MG
FREE) 30 MG/ML
TALWIN LACTATE (UNI-AMP,LATEX11/17/2005 INJECTION, PENTAZOCINE, 30 MG
FREE) 30 MG/ML
TRIMETHOBENZAMIDE HCL
10/1/2004 INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG
(CARPUJECT) 100 MG/ML
TRIMETHOBENZAMIDE HCL (LUER
AMIKACIN SULFATE (VIAL, FLIPTOP) 50
MG/ML
AMIKACIN SULFATE (10X2ML) 250
MG/ML
MG/ML
SODIUM CHLORIDE BACTERIOSTATIC
(25X10ML,LATEX-FREE) 0.9%
8/29/2005 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML
(VIAL, FLIPTOP) 0.9%
(VIAL, FLIPTOP) 0.9%
(VIAL, FLIPTOP PLASTIC) 0.9%
(VIAL, FLIPTOP PLASTIC) 0.9%
(25X10ML,LS-PLASTIC) 0.9%
(25X10ML,LS-PLASTIC) 0.9%
(FLIPTOP,LS-PLASTIC) 0.9%
LORAZEPAM (VIAL) 2 MG/ML
LORAZEPAM (22GX1-1/4",CARPUJECT) 2
MG/ML
LORAZEPAM (U-BLUNT
CANN,CARPUJECT) 2 MG/ML
LORAZEPAM (INTERLINK,CARPUJECT) 2
MG/ML
LORAZEPAM (LLK,SLIM PK,CARPUJECT)
2 MG/ML
LORAZEPAM (LUER LOCK,CARPUJECT)
2 MG/ML
3/17/2005 INJECTION, HEMIN, PER 1 MG
PANHEMATIN 313 MG
BUPRENORPHINE HYDROCHLORIDE
(CARPUJECT) 0.3 MG/ML
3/1/2005 INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG
(CARPUJECT) 0.3 MG/ML
DOBUTAMINE HCL (10X20ML) 12.5
MG/ML
MG/ML
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER MORPHINE SULFATE (PF,LATEX-FREE)
8/16/2004 10 MG
0.5 MG/ML
MORPHINE SULFATE (10X30ML,LATEX11/23/2006 INJECTION, MORPHINE SULFATE, UP TO 10 MG
FREE) 1 MG/ML
KETOROLAC TROMETHAMINE
5/7/2002 INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG
NOVATION (ABBOJECT-PA) 30 MG/ML
NOVATION (ABBOJECT-PA) 30 MG/ML
DIPYRIDAMOLE (AMP,UNI-NEST,LATEX3/30/2005 INJECTION, DIPYRIDAMOLE, PER 10 MG
FREE) 5 MG/ML
DIPYRIDAMOLE (AMP,UNI-NEST,LATEX5/16/2005 INJECTION, DIPYRIDAMOLE, PER 10 MG
FREE) 5 MG/ML
DEMEROL HYDROCHLORIDE (AMP,UNI9/5/2003 INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG
NEST,LATEX-FREE) 100 MG/ML
99/99/9999 INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML
CARBOCAINE HCL (M.D.V.) 2%
J3070
1/1/2002
00074-1937-01
J3070
1/1/2002
00074-1937-31
J3070
1/1/2002
00074-1938-02
J3070
1/1/2002
00074-1941-01
J3070
1/1/2002
00074-1952-02
J3250
1/1/2002
00074-1952-32
J3250
6/8/2004
00074-1955-01
J3490
1/1/2002
00074-1956-01
J3490
1/1/2002
00074-1957-01
J3490
1/1/2002
00074-1966-04
J2912
1/1/2002
00074-1966-04
A4216
1/1/2004
00074-1966-05
J2912
1/1/2002
00074-1966-05
A4216
1/1/2004
00074-1966-07
J2912
1/1/2002
00074-1966-07
A4216
1/1/2004
00074-1966-12
J2912
1/1/2002
00074-1966-12
A4216
1/1/2004
00074-1966-14
J2912
1/1/2002
00074-1966-14
00074-1985-01
00074-1985-10
A4216
J2060
J2060
1/1/2004
1/1/2002
1/1/2002
00074-1985-11
J2060
1/1/2002
00074-1985-12
J2060
1/1/2002
00074-1985-21
J2060
1/1/2002
00074-1985-30
J2060
1/1/2002
00074-1985-31
00074-2000-43
J2060
Q2011
1/1/2002
1/1/2002
00074-2012-01
J3490
1/1/2002
00074-2012-01
J0592
1/1/2003
00074-2025-20
J1250
1/1/2002
00074-2025-54
J1250
1/1/2002
00074-2028-02
J2275
1/1/2002
00074-2029-02
J2270
1/1/2002
00074-2036-49
J1885
1/1/2002
00074-2039-49
J1885
1/1/2002
00074-2043-02
J1245
1/1/2002
00074-2043-10
J1245
1/1/2002
00074-2046-01
00074-2047-50
J2175
J0670
1/1/2002
1/1/2002
00074-2066-05
J2000
LIDOCAINE HCL (VIAL,LATEX-FREE) 2%
5 ML VL
00074-2066-05
00074-2102-02
J2001
J2912
1/1/2004
1/1/2002

SODIUM CHLORIDE (VIAL,PF) 0.9%
5 ML VL
2 ML VL
9/5/2005 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG

Page 29 of 374
10 ML VL
IJ
ML
30 MG
01/01/2002
1 ML SR
IJ
ML
30 MG
01/01/2002
04/30/2003
1 ML SR
IJ
ML
30 MG
01/01/2002
02/19/2003
2 ML SR
09/05/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure
00074-1920-10

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
09/28/2005
IJ
ML
30 MG
01/01/2002
1 ML AM IJ
ML
30 MG
01/01/2002
11/17/2005
2 ML SR
IM
ML
200 MG
0.5
01/01/2002
10/01/2004
2 ML SR
IM
ML
200 MG
0.5
06/08/2004
01/08/2006
2 ML VL
IJ
ML
1 EA
01/01/2002
03/10/2005
2 ML VL
IJ
ML
1 EA
01/01/2002
09/05/2005
4 ML VL
IJ
ML
1 EA
01/01/2002
09/25/2005
10 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
10 ML VL
IV
ML
10 ML
0.1
01/01/2004
08/29/2005
20 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
20 ML VL
IV
ML
10 ML
0.1
01/01/2004
05/01/2005
30 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
30 ML VL
IV
ML
10 ML
0.1
01/01/2004
04/04/2005
10 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
10 ML VL
IV
ML
10 ML
0.1
01/01/2004
10/05/2005
30 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
30 ML VL
1 ML VL
10 ML VL
IV
IJ
IJ
ML
ML
ML
10 ML
2 MG
2 MG
0.1
1
1
01/01/2004
01/01/2002
01/01/2002
05/31/2005
04/24/2005
11/15/2005
1 ML SR
IJ
ML
2 MG
01/01/2002
06/06/2003
1 ML SR
IJ
ML
2 MG
01/01/2002
06/06/2003
02/15/2002
1 ML SR
IJ
ML
2 MG
01/01/2002
1 ML SR
IJ
ML
2 MG
01/01/2002
05/31/2005
1 ML CR
1 EA VL
IJ
IV
ML
EA
2 MG
1 MG
1
313
01/01/2002
01/01/2002
10/24/2003
03/17/2005
1 ML SR
IJ
ML
1 EA
01/01/2002
12/31/2002
1 ML SR
IJ
ML
0.1 MG
3.24
01/01/2003
03/01/2005
20 ML VL
IV
ML
250 MG
0.05
01/01/2002
02/19/2006
40 ML VL
IV
ML
250 MG
0.05
01/01/2002
11/09/2005
30 ML VL
IJ
ML
10 MG
0.05
01/01/2002
08/16/2004
30 ML VL
IJ
ML
10 MG
0.1
01/01/2002
11/23/2006
1 ML SR
IJ
ML
15 MG
01/01/2002
05/07/2002
2 ML SR
IM
ML
15 MG
01/01/2002
05/07/2002
2 ML AM IV
ML
10 MG
0.5
01/01/2002
03/30/2005
10 ML AM IV
ML
10 MG
0.5
01/01/2002
05/16/2005
1 ML AM IJ
50 ML VL IJ
ML
ML
100 MG
10 ML
1
0.1
01/01/2002
3/1/2009
09/05/2003
99/99/9999 01/01/2002 09/21/2006
IJ
ML
50 ML
0.02
01/01/2002
12/31/2003
IJ
IV
ML
ML
10 MG
0.9 %
2
0.5
01/01/2004
01/01/2002
09/05/2005
08/15/2005
0.1
00074-2102-05
00074-2102-05
J2912
A4216

00074-2102-32
J2912
00074-2167-01
J1160
1/1/2002
2/19/2003 INJECTION, DIGOXIN, UP TO 0.5 MG
00074-2168-01
J3475
1/1/2002
3/18/2004 INJECTION, MAGNESIUM SULFATE, PER 500 MG
00074-2168-02
J3475
1/1/2002
00074-2168-03
J3475
00074-2169-01
J1160
1/1/2002
00074-2169-02
J1160
1/1/2002
00074-2169-31
J1160
1/1/2002
00074-2169-32
J1160
1/1/2002
00074-2172-01
J1170
1/1/2002
00074-2173-02
J2765
1/1/2002
00074-2173-32
J2765
1/1/2002 12/10/2003 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG
00074-2174-01
J3490
1/1/2002
00074-2265-01
J2597
1/1/2002
00074-2269-11
J1790
1/1/2002
00074-2269-32
J1790
1/1/2002 12/10/2003 INJECTION, DROPERIDOL, UP TO 5 MG
00074-2287-01
J1885
6/6/2003 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG

2/3/2005 INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG
00074-2287-02
J1885
00074-2287-11
J1885
00074-2287-31
J1885
1/1/2002
00074-2287-49
J1885
00074-2287-51
J1885
00074-2287-53
J1885
1/1/2002
00074-2287-54
J1885
00074-2287-55
J1885
00074-2287-61
J1885
1/1/2002
00074-2288-01
J1885
00074-2288-11
J1885
00074-2288-31
J1885
1/1/2002
00074-2288-49
J1885
00074-2288-53
J1885
1/1/2002
00074-2288-54
J1885
00074-2290-01
J1200
1/1/2002
00074-2290-31
J1200
1/1/2002
00074-2295-02
J2250
1/1/2002

SODIUM CHLORIDE (VIAL,ALUER,PF)
0.9%
DIGOXIN PEDIATRIC (AMP,UNI-NEST) 0.1
MG/ML
MAGNESIUM SULFATE (VIAL, FLIPTOP)
500 MG/ML
500 MG/ML
500 MG/ML
DIGOXIN (LATEX-FREE,CARPUJECT)
0.25 MG/ML
DIGOXIN (LATEX-FREE,CARPUJECT)
0.25 MG/ML
DIGOXIN (LUER LOCK,LATEX-FREE) 0.25
MG/ML
DIGOXIN (LUER LOCK,LATEX-FREE) 0.25
MG/ML
HYDROMORPHONE HCL (AMP,UNINEST) 10 MG/ML
METOCLOPRAMIDE (CARPUJECT) 5
MG/ML
METOCLOPRAMIDE (LUER
THIAMINE HCL (22GX1-1/4",CARPUJECT)
100 MG/ML
DESMOPRESSIN ACETATE (UNI-AMP) 4
MCG/ML
DROPERIDOL (BLUNT
CANNULA,CARPUJECT) 2.5 MG/ML
DROPERIDOL (LUER LOCK,CARPUJECT)
2.5 MG/ML
KETOROLAC TROMETHAMINE (LATEXFREE,CARPUJECT) 30 MG/ML
KETOROLAC TROMETHAMINE (BLUNT
KETOROLAC TROMETHAMINE (LUER
NOVATION (LATEX-FREE,CARPUJECT)
30 MG/ML
30 MG/ML
NOVATION (BLCN,LATEX-FREE) 30
MG/ML
NOVATION (LL,LATEXFREE,CARPUJECT) 30 MG/ML
KETOROLAC TROMETHAMINE (LATEXFREE,CARPUJECT) 15 MG/ML
KETOROLAC TROMETHAMINE (BLUNT
CANNULA) 15 MG/ML
15 MG/ML
NOVATION (BLCN,LATEX-FREE) 15
MG/ML
DIPHENHYDRAMINE HCL (CARPUJECT)
50 MG/ML
DIPHENHYDRAMINE HCL (LUER
MIDAZOLAM HCL (CARPUJECT) 1
MG/ML
Page 30 of 374
5 ML VL
5 ML VL
IV
IV
ML
ML
0.9 %
10 ML
0.5
0.1
09/13/2005
01/01/2007
12/31/2006
99/99/9999
10 ML VL
IV
ML
0.9 %
0.5
01/01/2002
10/24/2003
1 ML AM IV
ML
0.5 MG
0.2
01/01/2002
02/19/2003
10 ML VL
IJ
ML
500 MG
01/01/2002
03/18/2004
20 ML VL
IJ
ML
500 MG
01/01/2002
01/30/2005
50 ML VL
IJ
ML
500 MG
01/01/2002
10/21/2004
1 ML SR
IV
ML
0.5 MG
0.5
01/01/2002
06/06/2003
2 ML SR
IV
ML
0.5 MG
0.5
01/01/2002
06/06/2003
1 ML SR
IV
ML
0.5 MG
0.5
01/01/2002
06/15/2005
2 ML SR
IV
ML
0.5 MG
0.5
01/01/2002
10/08/2004
1 ML AM IJ
ML
4 MG
2.5
01/01/2002
02/15/2002
2 ML SR
IV
ML
10 MG
0.5
01/01/2002
06/06/2003
2 ML SR
IV
ML
10 MG
0.5
01/01/2002
12/10/2003
1 ML SR
IJ
ML
1 EA
01/01/2002
02/15/2002
1 ML AM IJ
ML
1 MCG
01/01/2002
02/03/2005
2 ML SR
ML
5 MG
0.5
01/01/2002
02/15/2002
IJ
2 ML SR
IJ
ML
5 MG
0.5
01/01/2002
12/10/2003
1 ML SR
IJ
ML
15 MG
01/01/2002
12/10/2003
2 ML SR
IM
ML
15 MG
01/01/2002
12/10/2003
1 ML SR
IJ
ML
15 MG
01/01/2002
12/10/2003
1 ML SR
IJ
ML
15 MG
01/01/2002
04/24/2005
1 ML SR
IJ
ML
15 MG
01/01/2002
12/10/2003
2 ML SR
IM
ML
15 MG
01/01/2002
12/10/2003
1 ML SR
IJ
ML
15 MG
01/01/2002
05/07/2002
1 ML SR
IJ
ML
15 MG
01/01/2002
99/99/9999
2 ML CT
IM
ML
15 MG
01/01/2002
12/10/2003
2 ML SR
IM
ML
15 MG
01/01/2002
06/19/2005
1 ML SR
IJ
ML
15 MG
01/01/2002
12/10/2003
1 ML SR
IJ
ML
15 MG
01/01/2002
12/10/2003
1 ML SR
IJ
ML
15 MG
01/01/2002
08/28/2005
1 ML SR
IJ
ML
15 MG
01/01/2002
12/12/2002
1 ML SR
IJ
ML
15 MG
01/01/2002
05/07/2002
1 ML SR
IJ
ML
15 MG
01/01/2002
12/12/2002
1 ML SR
IJ
ML
50 MG
01/01/2002
02/15/2002
1 ML SR
IJ
ML
50 MG
01/01/2002
04/24/2005
2 ML SR
IJ
ML
1 MG
01/01/2002
02/19/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00074-2295-05
J2250
1/1/2002
00074-2295-32
J2250
1/1/2002
00074-2295-35
J2250
1/1/2002 12/10/2003 INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG
00074-2295-36
J2250
00074-2295-39
J2250
1/1/2002
00074-2295-51
J2250
00074-2295-52
J2250
00074-2296-01
J2250
1/1/2002
00074-2296-02
J2250
1/1/2002
00074-2296-30
J2250
00074-2296-31
J2250
00074-2296-32
J2250
1/1/2002
00074-2296-36
J2250
1/1/2002
00074-2296-49
J2250
00074-2296-51
J2250
00074-2301-01
J3490
00074-2301-01
J0595
00074-2301-31
J3490
1/1/2002
00074-2302-01
J3490
00074-2302-01
J0595
00074-2302-31
J3490
1/1/2002
00074-2305-02
J2250
5/1/2003
00074-2305-05
J2250
00074-2305-49
J2250
5/1/2003
00074-2305-50
J2250
5/1/2003
00074-2306-62
J2250
5/1/2003
00074-2307-60
J2250
5/1/2003
00074-2307-62
J2250
5/1/2003
00074-2308-01
J2250
5/1/2003
00074-2308-02
J2250
5/1/2003
00074-2308-49
J2250
00074-2308-50
J2250
00074-2312-01
J2550
1/1/2002
00074-2312-11
J2550
1/1/2002
00074-2312-31
00074-2332-11
00074-2333-11
00074-2333-26
00074-2334-11
J2550
J1170
J1170
J1170
J1170
1/1/2002
11/5/2002
11/14/2002
12/11/2002
12/19/2002

00074-2335-01
J2550
1/1/2002
00074-2335-31
J2550
1/1/2002
00074-2336-10
J0895
2/26/2004
4/24/2005 INJECTION, DEFEROXAMINE MESYLATE, 500 MG

MG/ML
MIDAZOLAM HCL (LUER
MIDAZOLAM HCL (LUER
MIDAZOLAM HCL NOVATION (LUER
MIDAZOLAM HCL NOVATION
(CARPUJECT) 1 MG/ML
(CARPUJECT) 1 MG/ML
MG/ML
MG/ML
MIDAZOLAM HCL (LUER
MIDAZOLAM HCL (LUER
(LL,CARPUJECT) 5 MG/ML
(CARPUJECT) 5 MG/ML
(CARPUJECT) 5 MG/ML
BUTORPHANOL TARTRATE
(CARPUJECT) 1 MG/ML
(CARPUJECT) 1 MG/ML
BUTORPHANOL TARTRATE (LUER
(CARPUJECT) 2 MG/ML
(CARPUJECT) 2 MG/ML
BUTORPHANOL TARTRATE (LUER
MIDAZOLAM HCL (VIAL, FLIPTOP,PF) 1
MG/ML
MIDAZOLAM HCL (VIAL,FLIPTOP,PF) 1
MG/ML
(VIAL,FLIPTOP,PF) 1 MG/ML
MIDAZOLAM HCL (LUER
LOCK,STERILE,PF) 1 MG/ML
MIDAZOLAM HCL (PF,CARPUJECT) 5
MG/ML
MIDAZOLAM HCL (PF,CARPUJECT) 5
MG/ML
MIDAZOLAM HCL (FLIPTOP VIAL,PF) 5
MG/ML
MIDAZOLAM HCL (FLIPTOP VIAL,PF) 5
MG/ML
MIDAZOLAM HCL NOVATION (FLIPTOP
VIAL,PF) 5 MG/ML
VIAL,PF) 5 MG/ML
PROMETHAZINE HCL (CARPUJECT) 25
MG/ML
PROMETHAZINE HCL (BLUNT
PROMETHAZINE HCL (LUER
PROMETHAZINE HCL (CARPUJECT) 50
MG/ML
DEFEROXAMINE MESYLATE (LATEXFREE) 500 MG
Page 31 of 374
5 ML SR
IJ
ML
1 MG
01/01/2002
02/19/2003
2 ML SR
IJ
ML
1 MG
01/01/2002
05/06/2004
5 ML SR
IJ
ML
1 MG
01/01/2002
12/10/2003
2 ML SR
IJ
ML
1 MG
01/01/2002
12/10/2003
5 ML CT
IJ
ML
1 MG
01/01/2002
02/19/2003
2 ML SR
IJ
ML
1 MG
01/01/2002
12/12/2002
5 ML SR
IJ
ML
1 MG
01/01/2002
12/12/2002
1 ML SR
IJ
ML
1 MG
01/01/2002
02/19/2003
2 ML SR
IJ
ML
1 MG
01/01/2002
02/19/2003
1 ML SR
IJ
ML
1 MG
01/01/2002
12/12/2002
1 ML SR
IJ
ML
1 MG
01/01/2002
12/10/2003
2 ML SR
IJ
ML
1 MG
01/01/2002
05/06/2004
2 ML CT
IJ
ML
1 MG
01/01/2002
02/19/2003
1 ML SR
IJ
ML
1 MG
01/01/2002
12/12/2002
2 ML SR
IJ
ML
1 MG
01/01/2002
12/12/2002
1 ML SR
IJ
ML
1 EA
01/01/2002
12/31/2003
1 ML SR
IJ
ML
1 MG
01/01/2004
99/99/9999
1 ML SR
IJ
ML
1 EA
01/01/2002
09/20/2002
1 ML SR
IJ
ML
1 EA
01/01/2002
12/31/2003
1 ML SR
IJ
ML
1 MG
01/01/2004
99/99/9999
1 ML SR
IJ
ML
1 EA
01/01/2002
09/20/2002
2 ML VL
IJ
ML
1 MG
05/01/2003
08/14/2005
5 ML VL
IJ
ML
1 MG
05/01/2003
12/20/2005
2 ML VL
IJ
ML
1 MG
05/01/2003
08/01/2005
5 ML VL
IJ
ML
1 MG
05/01/2003
09/12/2005
2 ML SR
IJ
ML
1 MG
05/01/2003
03/09/2005
1 ML SR
IJ
ML
1 MG
05/01/2003
04/24/2005
2 ML SR
IJ
ML
1 MG
05/01/2003
01/07/2005
1 ML VL
IJ
ML
1 MG
05/01/2003
06/06/2005
2 ML VL
IJ
ML
1 MG
05/01/2003
10/09/2005
1 ML VL
IJ
ML
1 MG
05/01/2003
12/29/2005
2 ML VL
IJ
ML
1 MG
05/01/2003
11/17/2005
1 ML SR
IJ
ML
50 MG
0.5
01/01/2002
06/06/2003
1 ML SR
IJ
ML
50 MG
0.5
01/01/2002
06/06/2003
1
1
1
1
1
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
50 MG
4 MG
4 MG
4 MG
4 MG
0.5
0.25
0.5
0.5
1
01/01/2002
11/05/2002
11/14/2002
12/11/2002
12/19/2002
04/04/2005
9/14/2008
09/14/2008
9/14/2008
11/2/2008
ML
ML
ML
ML
ML
SR
AM
AM
AM
AM
1 ML SR
IJ
ML
50 MG
01/01/2002
06/06/2003
1 ML SR
IJ
ML
50 MG
01/01/2002
06/06/2003
1 EA VL
IJ
EA
500 MG
02/26/2004
04/24/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00074-2337-25
J0895
2/26/2004
00074-2343-01
J2560
1/1/2002
00074-2343-31
J2560
1/1/2002
00074-2344-01
J1250
1/1/2002
00074-2344-02
J1250
1/1/2002
00074-2346-32
J1250
1/1/2002
00074-2346-34
J1250
1/1/2002
00074-2347-32
J1250
1/1/2002
00074-2349-01
J2560
1/1/2002
00074-2349-31
00074-2414-21
00074-2428-16
J2560
J1170
J1170
1/1/2002
12/19/2002
2/10/2003

00074-2434-03
00074-2453-11
00074-2453-27
00074-2453-51
00074-2455-31
J3490
J1170
J1170
J1170
J1170
1/1/2002
12/19/2002
11/14/2002
11/26/2002
12/11/2002

00074-2581-02
J1644
1/1/2002
00074-2584-02
J1644
1/1/2002
00074-2587-02
J2250
1/1/2002
00074-2587-03
J2250
1/1/2002
00074-2587-05
J2250
1/1/2002
00074-2587-51
J2250
1/1/2002
00074-2587-52
J2250
1/1/2002
00074-2587-53
J2250
1/1/2002
00074-2596-01
J2250
1/1/2002
00074-2596-02
J2250
1/1/2002
00074-2596-03
J2250
00074-2596-05
J2250
1/1/2002
00074-2596-49
J2250
1/1/2002
00074-2596-51
J2250
1/1/2002
00074-2596-52
J2250
1/1/2002
00074-2596-53
J2250
1/1/2002
00074-2775-01
J2260
00074-2775-02
J2260
00074-2776-02
J2260
5/1/2003
00074-2776-23
00074-3210-32
00074-3213-02
J2260
J3360
J3360

1/1/2002 10/24/2003 INJECTION, DIAZEPAM, UP TO 5 MG
1/1/2002
00074-3254-03
J3260
1/1/2002
00074-3255-03
J3260
1/1/2002
00074-3307-03
J7608
1/1/2002
00074-3307-03 KO J7608
00074-3308-03
J7608
KO
1/1/2002
1/1/2002

4/10/2005 DOSE FORM, PER GRAM
DEFEROXAMINE MESYLATE
(VIAL,LATEX-FREE) 2 GM
LUMINAL SODIUM (CARPUJECT) 60
MG/ML
LUMINAL SODIUM (LUER
DOBUTAMINE HCL (VIAL, FLIPTOP) 12.5
MG/ML
DOBUTAMINE HCL (VIAL, FLIPTOP) 12.5
MG/ML
DEXTROSE/DOBUTAMINE (LATEX-FREE)
5%-100 MG/100 ML
5%-100 MG/100 ML
5%-200 MG/100 ML
LUMINAL SODIUM (CARPUJECT) 130
MG/ML
DILAUDID (M.D.V.) 2 MG/ML
DILAUDID
AMIKACIN SULFATE (ADDVANTAGE,LATEX-FREE) 62.5 MG/ML
DILAUDID-HP (S.D.V.) 10 MG/ML
DILAUDID-HP (S.D.V.) 250 MG
HEPARIN SODIUM (VIAL, ADDVANTAGE,PF) 2000 U/ML
HEPARIN SODIUM (VIAL, ADDVANTAGE,PF) 2500 U/ML
MIDAZOLAM HCL (VIAL,FLIPTOP,LATEXFREE) 1 MG/ML
(VIAL,FLIPTOP,LATEX-FREE) 1 MG/ML
MILRINONE LACTATE
MILRINONE LACTATE
DEXTROSE/MILRINONE LACTATE 5%-20
MG/100 ML
MG/100 ML
DIAZEPAM (AMP) 5 MG/ML
DIAZEPAM (M.D.V.,FLIPTOP) 5 MG/ML
TOBRAMYCIN SULFATE (VIAL, ADDVANTAGE) 10 MG/ML
TOBRAMYCIN SULFATE (VIAL, ADDVANTAGE) 10 MG/ML
1 EA VL
IJ
EA
500 MG
02/26/2004
03/20/2005
1 ML SR
IJ
ML
120 MG
0.5
01/01/2002
06/06/2003
1 ML SR
IJ
ML
120 MG
0.5
01/01/2002
09/18/2005
20 ML VL
IV
ML
250 MG
0.05
01/01/2002
07/26/2005
20 ML VL
IV
ML
250 MG
0.05
01/01/2002
06/28/2005
250 ML FC
IV
ML
250 MG
0.004
01/01/2002
08/10/2005
500 ML FC
IV
ML
250 MG
0.004
01/01/2002
02/06/2006
250 ML FC
IV
ML
250 MG
0.008
01/01/2002
01/10/2006
1 ML SR
IJ
ML
120 MG
1.08333
01/01/2002
06/06/2003
1 ML SR
20 ML VL
1 EA BO
IJ
IJ
NA
ML
ML
GM
120 MG
4 MG
4 MG
1.08333
0.5
250
01/01/2002
12/19/2002
02/10/2003
09/06/2005
6/30/2008
6/30/2008
8 ML
1 ML
5 ML
50 ML
1 EA
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
EA
1 EA
4 MG
4 MG
4 MG
4 MG
1
2.5
2.5
2.5
62.5
01/01/2002
12/19/2002
11/14/2002
11/26/2002
12/11/2002
02/15/2002
11/2/2008
11/2/2008
11/2/2008
11/2/2008
VL
AM
AM
VL
VL
5 ML VL
IV
ML
1000 U
01/01/2002
3/23/2006
10 ML VL
IJ
ML
1000 U
2.5
01/01/2002
06/30/2005
2 ML VL
IJ
ML
1 MG
01/01/2002
03/18/2004
5 ML VL
IJ
ML
1 MG
01/01/2002
03/18/2004
10 ML VL
IJ
ML
1 MG
01/01/2002
01/26/2006
2 ML VL
IJ
ML
1 MG
01/01/2002
03/18/2004
5 ML VL
IJ
ML
1 MG
01/01/2002
03/18/2004
10 ML VL
IJ
ML
1 MG
01/01/2002
03/06/2006
1 ML VL
IJ
ML
1 MG
01/01/2002
03/18/2004
2 ML VL
IJ
ML
1 MG
01/01/2002
03/18/2004
5 ML VL
IJ
ML
1 MG
3/1/2009
10 ML VL
IJ
ML
1 MG
01/01/2002
01/10/2006
1 ML VL
IJ
ML
1 MG
01/01/2002
03/18/2004
2 ML VL
IJ
ML
1 MG
01/01/2002
03/18/2004
5 ML VL
IJ
ML
1 MG
01/01/2002
01/22/2006
10 ML VL
IJ
ML
1 MG
01/01/2002
09/26/2005
10 ML VL
IV
ML
5 MG
0.2
06/05/2002
99/99/9999
20 ML VL
IV
ML
5 MG
0.2
06/05/2002
12/30/2004
200 ML FC
IV
ML
5 MG
0.04
05/01/2003
03/07/2006
100 ML FC IV
2 ML AM IJ
10 ML VL IJ
ML
ML
ML
5 MG
5 MG
5 MG
0.04
1
1
05/01/2003
01/01/2002
01/01/2002
06/14/2005
10/24/2003
05/08/2005
IJ
ML
80 MG
0.125
01/01/2002
05/07/2002
8 ML VL
IJ
ML
80 MG
0.125
01/01/2002
03/30/2005
ACETYLCYSTEINE 10%
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
04/10/2005
ACETYLCYSTEINE 10%
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
04/10/2005
ACETYLCYSTEINE 20%
30 ML VL
IH
ML
1 GM
0.2
01/01/2002
05/24/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999 01/01/2002 10/27/2005
6 ML VL
Page 32 of 374
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002

00074-3380-31
J3490
1/1/2002
00074-3380-32
J3490
1/1/2002
00074-3380-35
J3490
00074-3380-49
J3490
00074-3380-50
J3490
8/27/2003
00074-3380-51
J3490
00074-3382-21
J3490
1/1/2002
00074-3382-22
J3490
1/1/2002
00074-3382-25
J3490
00074-3400-01
J1580
1/1/2002
00074-3401-01
J1580
1/1/2002
00074-3402-01
00074-3413-01
J1580
J2765
1/1/2002
1/1/2002

00074-3414-01
J2765
1/1/2002
00074-3454-05
J1642
00074-3454-25
J1642
00074-3469-13
J3260
1/1/2002
00074-3470-23
J3260
1/1/2002
00074-3577-01
J3260
1/1/2002
00074-3578-01
J3260
1/1/2002 99/99/9999 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG
00074-3590-02
J3260
1/1/2002
00074-3613-01
J3490
1/1/2002
00074-3722-01
J2710
1/1/2002
3/18/2004 INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG
00074-3723-01
J2710
1/1/2002
00074-3724-32
J1250
1/1/2002
00074-3778-04
00074-3778-05
J2515
J2515
1/1/2002
1/1/2002
6/10/2003 INJECTION, PENTOBARBITAL SODIUM, PER 50 MG

00074-3793-01
J1885
1/1/2002
00074-3793-49
J1885
1/1/2002
00074-3795-01
J1885
1/1/2002
00074-3795-49
J1885
1/1/2002
00074-3795-61
J1885
00074-3796-01
J1885
00074-3796-49
J1885
1/1/2002
00074-3796-61
J1885
1/1/2002
00074-3799-01
J3590
9/12/2003
00074-3799-02
J3590


1/2/2003 12/31/2004 UNCLASSIFIED BIOLOGICS
ACETYLCYSTEINE 20%
SUFENTANIL CITRATE (AMP,LATEXFREE) 50 MCG/ML
SUFENTANIL CITRATE NOVAPLUS
(AMP,PF,LATEX-FREE) 50 MCG/ML
SUFENTANIL CITRATE (VIAL, FLIPTOP)
50 MCG/ML
50 MCG/ML
50 MCG/ML
GENTAMICIN SULFATE (VIAL, ADDVANTAGE) 10 MG/ML
METOCLOPRAMIDE (AMP) 5 MG/ML
METOCLOPRAMIDE (VIAL, FLIPTOP) 5
MG/ML
HEPARIN LOCK FLUSH (ANSYR,LATEXFREE) 100 U/ML
HEPARIN LOCK FLUSH (ANSYR,LATEXFREE) 100 U/ML
SODIUM CHLORIDE/TOBRAMYCIN
SULFATE (PREMIX,LATEX-FREE) 0.9%60 MG/50 ML
TOBRAMYCIN SULFATE (VIAL, FLIPTOP)
10 MG/ML
TOBRAMYCIN SULFATE (VIAL, FLIPTOP)
40 MG/ML
TOBRAMYCIN SULFATE (BULK VIAL) 40
MG/ML
BUPIVACAINE SPINAL AMPUL
(AMP,LATEX-FREE) 0.25%
NEOSTIGMINE METHYLSULFATE (VIAL,
FLIPTOP) 0.5 MG/ML
NEOSTIGMINE METHYLSULFATE (VIAL,
FLIPTOP) 1 MG/ML
5%-400 MG/100 ML
NEMBUTAL SODIUM (DO NOT
REFRIGERATE) 50 MG/ML
NEMBUTAL SODIUM (VIAL) 50 MG/ML
(VIAL,FLIPTOP) 15 MG/ML
NOVATION (VIAL,FLIPTOP,LATEX-FREE)
15 MG/ML
30 MG/ML
AMERINET (VIAL,FLIPTOP,LATEX-FREE)
30 MG/ML
30 MG/ML
30 MG/ML
HUMIRA (PF,PREFILLED SYRINGE) 40
MG/0.8 ML
MG/0.8 ML
Page 33 of 374
30 ML VL
IH
ML
1 GM
0.2
01/01/2002
1 ML AM IJ
ML
1 EA
01/01/2002
08/31/2005
2 ML AM IJ
ML
1 EA
01/01/2002
11/02/2005
5 ML AM IJ
ML
1 EA
01/01/2002
12/27/2005
1 ML AM IJ
ML
1 EA
08/27/2003
11/28/2005
2 ML AM IJ
ML
1 EA
08/27/2003
11/06/2005
5 ML AM IJ
ML
1 EA
08/27/2003
10/11/2005
1 ML VL
IJ
ML
1 EA
01/01/2002
07/14/2005
2 ML VL
IJ
ML
1 EA
01/01/2002
07/17/2005
5 ML VL
IJ
ML
1 EA
3/1/2009
6 ML VL
IJ
ML
80 MG
0.125
01/01/2002
8 ML VL
IJ
ML
80 MG
0.125
01/01/2002
01/08/2006
10 ML VL IJ
2 ML AM IV
ML
ML
80 MG
10 MG
0.125
0.5
01/01/2002
01/01/2002
06/04/2006
04/20/2005
Prior End Date #3
Prior Start Date #3
05/24/2005
99/99/9999 01/01/2002 10/18/2005
3/23/2006
2 ML VL
IV
ML
10 MG
0.5
01/01/2002
01/31/2006
5 ML SR
IV
ML
10 U
10
01/01/2002
12/12/2002
5 ML SR
IV
ML
10 U
10
02/20/2002
99/99/9999
50 ML FC
IV
ML
80 MG
0.02
01/01/2002
05/29/2005
100 ML FC
IV
ML
80 MG
0.01
01/01/2002
09/25/2005
2 ML VL
IJ
ML
80 MG
0.125
01/01/2002
03/30/2005
2 ML VL
IJ
ML
80 MG
0.5
3/1/2009
50 ML VL
IJ
ML
80 MG
0.5
01/01/2002
02/14/2006
2 ML AM IJ
99/99/9999 01/01/2002 11/01/2004
ML
1 EA
01/01/2002
01/06/2005
10 ML VL
IJ
ML
0.5 MG
01/01/2002
03/18/2004
10 ML VL
IJ
ML
0.5 MG
01/01/2002
03/18/2004
250 ML FC
IV
ML
250 MG
0.016
01/01/2002
10/06/2005
20 ML VL
50 ML VL
IJ
IJ
ML
ML
50 MG
50 MG
1
1
01/01/2002
01/01/2002
06/10/2003
06/10/2003
1 ML VL
IJ
ML
15 MG
01/01/2002
05/30/2005
1 ML VL
IJ
ML
15 MG
01/01/2002
04/18/2005
1 ML VL
IJ
ML
15 MG
01/01/2002
01/05/2006
1 ML VL
IJ
ML
15 MG
01/01/2002
09/20/2005
1 ML VL
IJ
ML
15 MG
01/01/2002
10/30/2005
2 ML VL
IM
ML
15 MG
10/01/2008
99/99/9999 01/01/2002 12/20/2005
2 ML VL
IM
ML
15 MG
01/01/2002
11/06/2005
2 ML VL
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
00074-3308-03 KO J7608
NDC
HCPCS
IM
ML
15 MG
01/01/2002
08/04/2005
0.8 ML CR
MR
EA
1 EA
09/12/2003
09/13/2003
0.8 ML BX
MR
EA
1 EA
01/02/2003
12/31/2004
0.5
00074-3814-12
J2275
00074-3815-12
J2270
00074-3817-12
J2270
00074-3819-12
J2271
00074-3907-03
J3480
00074-3934-02
J3480
00074-3977-03
A4712
00074-3977-03
A4216
00074-4027-02
A4712
00074-4027-02
A4216
00074-4029-03
A4712
00074-4029-03
00074-4031-01
A4216
J2150
00074-4044-02
A4712
00074-4044-02
A4216
00074-4050-01
J3490
00074-4051-01
J3490
00074-4052-01
J3490
00074-4053-03
J3490
00074-4054-03
J3490
00074-4055-03
J3490
00074-4056-01
J2000
00074-4056-01
J2001
00074-4057-12
J2275
00074-4058-12
J2270
00074-4075-32
00074-4089-02
J3475
J7799
00074-4141-03
Q4076
00074-4141-03
J1265
00074-4142-02
Q4076
00074-4142-03
Q4076
00074-4142-03
J1265
00074-4155-02
00074-4169-01
00074-4170-01
Q4076
J2400
J2400
00074-4197-01
J3490
00074-4219-02
J7799
00074-4265-01
J3490
00074-4265-01
00074-4270-01
00074-4270-01
Q4076
J2000
J2001
Page 34 of 374
ML
10 MG
0.1
01/01/2002
06/27/2005
IJ
ML
10 MG
01/01/2002
03/18/2004
20 ML VL
IJ
ML
100 MG
0.15
01/01/2002
06/06/2003
10 ML AM IV
ML
2 MEQ
01/01/2002
11/23/2004
20 ML AM IV
ML
2 MEQ
01/01/2002
99/99/9999
30 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
30 ML VL
CF
HCPCS Amount #1
IV
ML
10 ML
0.1
01/01/2004
04/06/2005
5 ML AM IV
ML
10 ML
0.1
01/01/2002
12/31/2003
5 ML AM IV
ML
10 ML
0.1
3/1/2009
20 ML AM IV
ML
10 ML
0.1
01/01/2002
12/31/2003
20 ML AM IV
50 ML VL IV
ML
ML
10 ML
50 ML
0.1
0.02
01/01/2004
01/01/2002
02/28/2005
10/18/2004
10 ML AM IV
ML
10 ML
0.1
01/01/2002
12/31/2003
10 ML AM IV
ML
10 ML
0.1
01/01/2004
02/08/2006
99/99/9999 01/01/2004 05/25/2006
2 ML VL
IJ
ML
1 EA
01/01/2002
05/12/2005
4 ML VL
IJ
ML
1 EA
01/01/2002
05/30/2005
6 ML VL
IJ
ML
1 EA
3/1/2009
2 ML VL
IJ
ML
1 EA
01/01/2002
05/10/2005
4 ML VL
IJ
ML
1 EA
01/01/2002
02/17/2005
6 ML VL
IJ
ML
1 EA
01/01/2002
02/23/2005
20 ML AM IJ
ML
50 ML
0.02
01/01/2002
12/31/2003
20 ML AM IJ
ML
10 MG
1.5
01/01/2004
10/30/2005
10 ML AM IJ
ML
10 MG
0.05
01/01/2002
12/12/2005
10 ML AM IJ
ML
10 MG
0.1
01/01/2002
10/06/2005
2 ML AM IJ
5 ML AM IV
ML
ML
500 MG
1 EA
1
1
01/01/2002
01/01/2002
03/18/2004
05/17/2005
500 ML GC IV
ML
40 MG
0.02
10/01/2003
12/31/2005
500 ML GC IV
ML
40 MG
0.02
01/01/2006
99/99/9999
250 ML GC IV
ML
40 MG
0.04
10/01/2003
01/31/2005
500 ML GC IV
ML
40 MG
0.04
10/01/2003
12/31/2005
500 ML GC IV
ML
40 MG
0.04
01/01/2006
99/99/9999
250 ML GC IV
30 ML VL IJ
30 ML VL IJ
ML
ML
ML
40 MG
30 ML
30 ML
0.08
0.03333
0.03333
10/01/2003
01/01/2002
01/01/2002
11/01/2004
06/19/2005
04/19/2005
99/99/9999 01/01/2002 07/04/2005
60 ML VL
IJ
ML
1 EA
01/01/2002
03/30/2005
250 ML VL
IV
ML
1 EA
01/01/2002
03/29/2005
10 ML VL
IV
ML
1 EA
01/01/2002
09/30/2003
ML
ML
ML
40 MG
50 ML
10 MG
2
0.02
1
10/01/2003
01/01/2002
01/01/2004
07/10/2005
12/31/2003
02/26/2006
10 ML VL IV
30 ML AM EP
30 ML AM EP
IJ
10 ML VL
Prior End Date #3
10 ML VL
Prior Start Date #3
07/18/2005
99/99/9999
01/01/2002
Prior End Date #2
01/01/2005
0.05
End Date #1
10 MG
Start Date #1
20 MG
ML
HCPCS Measure #1
EA
IJ
NDC Package Type
MR
10 ML VL
NDC Package Measure
0.8 ML BX
Prior Start Date #2

Package
NDC Label
HCPCS Description

1/1/2005 99/99/9999 INJECTION, ADALIMUMAB, 20 MG
MG/0.8 ML
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER MORPHINE SULFATE (VIAL, FLIPTOP,PF)
1/1/2002 7/18/2005 10 MG
0.5 MG/ML
MG/ML
MG/ML
1/1/2002
MG/ML
POTASSIUM CHLORIDE (AMP,LATEX1/1/2002 11/23/2004 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ
FREE) 2 MEQ/ML
POTASSIUM CHLORIDE (AMP,LATEX1/1/2002 99/99/9999 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ
FREE) 2 MEQ/ML
WATER FOR INJECTION
BACTERIOSTATIC (VIAL,FLIPTOP,LATEXFREE)
WATER FOR INJECTION
1/1/2004
WATER FOR INJECTION (AMP,PF,LATEX1/1/2002 12/31/2003 WATER, STERILE, FOR INJECTION, PER 10 ML
FREE)
WATER FOR INJECTION (AMP,PF,LATEX1/1/2004 99/99/9999 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML
FREE)
FREE)
WATER FOR INJECTION (AMP,PF,LATEX1/1/2004 2/28/2005 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML
FREE)
1/1/2002 10/18/2004 INJECTION, MANNITOL, 25% IN 50 ML
MANNITOL (VIAL, FLIPTOP) 25%
FREE)
WATER FOR INJECTION (AMP,PF,LATEX1/1/2004
FREE)
CLINDAMYCIN PHOSPHATE (VIAL,
FLIPTOP) 150 MG/ML
FLIPTOP) 150 MG/ML
FLIPTOP) 150 MG/ML
CLINDAMYCIN PHOSPHATE (VIAL, ADD1/1/2002 5/10/2005 UNCLASSIFIED DRUGS
VANTAGE) 150 MG/ML
VANTAGE) 150 MG/ML
VANTAGE) 150 MG/ML
LIDOCAINE HCL (AMP,LATEX-FREE)
1.5%
1.5%
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER MORPHINE SULFATE (AMP,PF,LATEX1/1/2002 12/12/2005 10 MG
FREE) 0.5 MG/ML
MORPHINE SULFATE (AMP,LATEX1/1/2002 10/6/2005 INJECTION, MORPHINE SULFATE, UP TO 10 MG
FREE) 1 MG/ML
MAGNESIUM SULFATE (AMP,LATEX1/1/2002 3/18/2004 INJECTION, MAGNESIUM SULFATE, PER 500 MG
FREE) 500 MG/ML
DEXTROSE/DOPAMINE HCL 5%-80
10/1/2003 12/31/2005 INJECTION, DOPAMINE HCL, 40 MG
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
DEXTROSE/DOPAMINE HCL (LATEX10/1/2003 11/1/2004 INJECTION, DOPAMINE HCL, 40 MG
FREE) 5%-320 MG/100 ML
1/1/2002 6/19/2005 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML
CHLOROPROCAINE HCL (VIAL) 2%
CHLOROPROCAINE HCL (VIAL) 3%
BULK,LATEX-FREE) 150 MG/ML
SODIUM CHLORIDE (BULK ADDITIVE
SOLUTION) 2.5%
DOPAMINE HCL
(VIAL,FLIPTOP,10ML/20ML) 80 MG/ML
DOPAMINE HCL
LIDOCAINE HCL (STERILE PACK) 1%
LIDOCAINE HCL (STERILE PACK) 1%
Billing Units
J0135
00074-3799-02
HCPCS Mod
HCPCS
NDC Mod
NDC
0.1
00074-4272-01
J3490
1/1/2002
00074-4273-01
J3490
1/1/2002
00074-4274-01
00074-4275-01
00074-4275-01
00074-4276-01
00074-4276-01
00074-4276-02
00074-4276-02
00074-4277-01
00074-4277-01
00074-4277-02
00074-4277-02
J3490
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
00074-4278-01
J2000
00074-4278-01
J2001
1/1/2004
00074-4279-02
J2000
00074-4279-02
J2001
1/1/2004
00074-4282-01
J2000
00074-4282-01
J2001
1/1/2004
00074-4282-02
J2000

12/31/2003 INJECTION, LIDOCAINE HCL, 50 CC
BUPIVACAINE HCL (AMP,

STERILE,LATEX-FREE) 0.25%
BUPIVACAINE HCL (AMP, STERILE
PACK) 0.5%
BUPIVACAINE HCL (AMP,
STERILE,LATEX-FREE) 0.75%
LIDOCAINE HCL (VIAL, FLIPTOP) 0.5%
LIDOCAINE HCL (VIAL, FLIPTOP) 1%
LIDOCAINE HCL (TEARDROP BOTTLE)
0.5%
0.5%
1%
1%
LIDOCAINE HCL (AMP,LATEX-FREE) 2%
20 ML AM IJ
ML
1 EA
01/01/2002
4/5/2006
20 ML AM IJ
ML
1 EA
01/01/2002
06/27/2006
20 ML
50 ML
50 ML
20 ML
20 ML
50 ML
50 ML
20 ML
20 ML
50 ML
50 ML
IJ
IJ
IJ
EP
EP
EP
EP
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 EA
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
1
0.02
0.5
0.02
1
0.02
1
0.02
2
0.02
2
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
3/30/2006
12/31/2003
12/29/2005
12/31/2003
08/11/2005
12/31/2003
07/06/2005
12/31/2003
06/12/2005
12/31/2003
08/11/2005
50 ML VL
IJ
ML
50 ML
0.02
01/01/2002
12/31/2003
50 ML VL
IJ
ML
10 MG
0.5
01/01/2004
06/28/2005
30 ML VL
EP
ML
50 ML
0.02
01/01/2002
12/31/2003
30 ML VL
EP
AM
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
2 ML AM IJ
ML
10 MG
01/01/2004
08/30/2005
ML
50 ML
0.02
01/01/2002
12/31/2003
2 ML AM IJ
ML
10 MG
01/01/2004
09/08/2005
10 ML AM IJ
ML
50 ML
0.02
01/01/2002
12/31/2003
00074-4282-02
J2001
1/1/2004
10 ML AM IJ
ML
10 MG
01/01/2004
02/07/2006
00074-4283-01
J2000
5 ML AM IJ
ML
50 ML
0.02
01/01/2002
12/31/2003
00074-4283-01
J2001
1/1/2004
ML
10 MG
01/01/2004
J3370
1 EA VL
IV
EA
500 MG
3/1/2009
00074-4332-49
00074-4335-01
00074-4335-02
00074-4335-04
00074-4339-02
J3370
J9265
J9265
J9265
J0135
1/1/2002
5/9/2002 4/20/2004 INJECTION, PACLITAXEL, 30 MG
VL
VL
VL
VL
BX
IV
IV
IV
IV
MR
EA
ML
ML
ML
EA
500 MG
30 MG
30 MG
30 MG
20 MG
1
0.2
0.2
0.2
4
01/01/2002
05/09/2002
05/10/2002
05/10/2002
07/17/2006
00074-4339-06
J0135
1 ML BX
MR
00074-4346-73
00074-4348-35
J3490
J0282

VANCOMYCIN HCL (VIAL, FLIPTOP) 500
MG
VANCOMYCIN HCL NOVATION
(VIAL,FLIPTOP,LATEX-FREE) 500 MG
PACLITAXEL 6 MG/ML
PACLITAXEL 6 MG/ML
PACLITAXEL 6 MG/ML
HUMIRA 40 MG/0.8 ML
HUMIRA (SINGLE-USE,6X1ML,,PF) 40
MG/0.8 ML
AMINOCAPROIC ACID (VIAL, FLIPTOP)
250 MG/ML
AMIODARONE HCL 50 MG/ML
ACYCLOVIR SODIUM (VIAL,FLIPTOP) 500
MG
ACYCLOVIR SODIUM VHA
(VIAL,FLIPTOP) 500 MG
ACYCLOVIR SODIUM (VIAL, FLIPTOP)
1000 MG
ACYCLOVIR SODIUM NOVATION
ACYCLOVIR SODIUM NOVATION
LEUCOVORIN CALCIUM (VIAL, FLIPTOP)
10 MG/ML
LEUCOVORIN CALCIUM (VIAL, FLIPTOP
30 ML) 10 MG/ML
PENTAMIDINE ISETHIONATE 300 MG
5 ML AM IJ
00074-4332-01

5/1/2004 99/99/9999 INJECTION, AMIODARONE HYDROCHLORIDE, 30 MG
00074-4427-01
J3490
1/1/2002
00074-4427-49
J3490
1/1/2002
00074-4452-01
J3490
1/1/2002
00074-4452-49
J3490
1/1/2002
00074-4452-49
Q4075
00074-4541-02
J0640
00074-4541-04
00074-4548-01
J0640
J7699
00074-4548-01
J7676
00074-4548-01 KO J7676
00074-4548-49
00074-4637-01
00074-4637-01
J2545
J2500
J2501
00074-4684-02
J1450
00074-4688-02
00074-4688-23
J1450
J1450
00074-4688-28
J1450
10/1/2003 10/24/2003 INJECTION, ACYCLOVIR, 5 MG

1/1/2002
KO
5/7/2002 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG
1/1/2002
1/1/2007 12/31/2007 NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME
PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
1/1/2008 99/99/9999 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG
PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA-APPROVED FINAL
PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM PENTAMIDINE ISETHIONATE NOVATION
300 MG
1/1/2002 3/18/2004 PER 300 MG
ZEMPLAR (VIAL,FLIPTOP) 0.002 MG/ML
ZEMPLAR (VIAL,FLIPTOP) 0.002 MG/ML
FLUCONAZOLE (6X200ML) 200 MG/100
4/1/2006
3/5/2007 INJECTION FLUCONAZOLE, 200 MG
ML
ML
FLUCONAZOLE 200 MG/100 ML
FLUCONAZOLE NOVAPLUS 200 MG/100
ML
Page 35 of 374
1 EA
5 ML
16.7 ML
50 ML
0.8 ML
20 ML VL IV
3 ML AM IV
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
05/15/2005
99/99/9999 01/01/2002 04/24/2005
08/03/2005
04/20/2004
04/20/2004
04/20/2004
99/99/9999
EA
20 MG
15
02/27/2007
99/99/9999
ML
ML
1 EA
30 MG
1
1.66666
01/01/2002
3/1/2009
04/12/2005
99/99/9999 05/01/2004 09/26/2006 1.66666
09/05/2003
1 EA VL
IV
EA
1 EA
01/01/2002
1 EA VL
IV
EA
1 EA
01/01/2002
09/05/2003
1 EA VL
IV
EA
1 EA
01/01/2002
09/05/2003
1 EA VL
IV
EA
1 EA
01/01/2002
09/30/2003
1 EA VL
IV
EA
5 MG
200
10/01/2003
10/24/2003
10 ML VL
IJ
ML
50 MG
0.2
01/01/2002
05/07/2002
25 ML VL
1 EA VL
IJ
IJ
ML
EA
50 MG
1 EA
0.2
1
01/01/2002
01/01/2007
05/07/2002
12/31/2007
1 EA VL
IJ
EA
300 MG
01/01/2008
99/99/9999
1 EA VL
IJ
EA
300 MG
01/01/2008
99/99/9999
1 EA VL
1 ML VL
1 ML VL
IJ
IV
IV
EA
ML
ML
300 MG
5 MCG
1 MCG
1
0.4
2
01/01/2002
01/01/2002
01/01/2003
03/18/2004
12/31/2002
99/99/9999
200 ML PC
IV
ML
200 MG
0.01
04/01/2006
03/05/2007
200 ML PC
600 ML PC
IV
IV
ML
ML
200 MG
200 MG
0.01
0.01
06/01/2005
06/01/2005
07/26/2006
06/15/2006
100 ML PC
IV
ML
200 MG
0.01
05/30/2005
05/31/2005
00074-4688-33
J1450
00074-4688-34
J1450
6/1/2005
AMERINET CHOICE FLUCONAZOLE

(6X200ML,LATEX-FREE) 200 MG/100 ML
FLUCONAZOLE NOVAPLUS (6X200ML)
200 MG/100 ML
00074-4713-02
J2000
00074-4713-02
J2001
5 ML AM EP
ML
10 MG
01/01/2004
11/20/2005
00074-4713-32
J2000
2 ML AM EP
ML
50 ML
0.02
01/01/2002
12/31/2003
00074-4713-32
00074-4729-01
J2001
J1250
1/1/2004
1/1/2002 99/99/9999 INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG

DOBUTAMINE HCL (VIAL) 12.5 MG/ML
CEFAZOLIN SODIUM (ADDVANTAGE,LATEX-FREE) 1 GM
CEFAZOLIN SODIUM (ADDVANTAGE,LATEX-FREE) 1 GM
1.5%
1.5%
DEXTROSE/SODIUM CHLORIDE 10%0.225%
WATER FOR INJECTION (VIAL,
FLIPTOP,PF)
FLIPTOP,PF)
WATER FOR INJECTION (VIAL,FLIPTOP
LIFESHIELD)
FLIPTOP,PF)
FLIPTOP,PF)
FLIPTOP,PF)
FLIPTOP,PF)
FLIPTOP,PF)
FLIPTOP,PF)
ADDITIVE) 0.9%
ADDITIVE) 0.9%
SODIUM CHLORIDE
(VIAL,FLIPTOP,LIFESHIELD) 0.9%
SODIUM CHLORIDE
(VIAL,FLIPTOP,LIFESHIELD) 0.9%
ADDITIVE) 0.9%
ADDITIVE) 0.9%
ADDITIVE) 0.9%
ADDITIVE) 0.9%
SODIUM CHLORIDE (VIAL,PLASTIC
ALUER,PF) 0.9%
ADDITIVE) 0.9%
EPINEPHRINE HCL (18GX3-1/2,LATEXFREE) 0.1 MG/ML
DEXTROSE (LIFESHIELD, 18GX1-1/2)
50%
LIDOCAINE HCL (21GX1-1/2",LATEXFREE) 2%
LIDOCAINE HCL (LIFESHIELD,LATEXFREE) 1%
LIDOCAINE HCL (LIFESHIELD,LATEXFREE) 1%
2 ML AM EP
100 ML VL IV
ML
ML
10 MG
250 MG
1
0.05
01/01/2004
01/01/2002
09/05/2005
99/99/9999
08/23/2007
00074-4732-03
J0690
00074-4732-03
J0690
00074-4776-01
J2000
00074-4776-01
J2001
1/1/2004
00074-4862-02
J7799
1/1/2002
00074-4862-03
J7799
1/1/2002
00074-4887-10
A4712
00074-4887-10
A4216
1/1/2004
00074-4887-12
A4712
1/1/2002
9/20/2002 WATER, STERILE, FOR INJECTION, PER 10 ML
00074-4887-20
A4712
00074-4887-20
A4216
1/1/2004
00074-4887-50
A4712
00074-4887-50
A4216
00074-4887-99
A4712
00074-4887-99
A4216
1/1/2004
00074-4888-10
J2912
00074-4888-10
A4216
1/1/2004
00074-4888-12
J2912
00074-4888-12
A4216
1/1/2004
00074-4888-20
J2912
00074-4888-20
A4216
00074-4888-50
J2912
00074-4888-50
A4216
1/1/2004
00074-4888-70
J2912
00074-4888-99
J7050
1/1/2002
00074-4901-18
J0170
1/1/2002
9/22/2005 INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE
00074-4902-34
J7799
00074-4903-34
J2000
00074-4903-34
J2001
00074-4904-34
J2000
00074-4904-34
J2001
1/1/2004
00074-4905-18
1/1/2002
J7659
00074-4905-18 KO J7659
KO

1/1/2002 12/12/2002 MILLIGRAM
1/1/2002 12/12/2002 MILLIGRAM
200 ML PC
IV
ML
200 MG
0.01
04/01/2006
200 ML PC
IV
ML
200 MG
0.01
06/01/2005
03/01/2006
ML
50 ML
0.02
01/01/2002
12/31/2003
5 ML AM EP
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
1 EA VL
IJ
EA
500 MG
01/01/2002
1 EA VL
IJ
EA
500 MG
10/01/2009
99/99/9999
20 ML AM IJ
ML
50 ML
0.02
01/01/2002
12/31/2003
20 ML AM IJ
ML
10 MG
1.5
01/01/2004
02/05/2006
250 ML GC IV
ML
1 EA
01/01/2002
03/08/2005
500 ML GC IV
ML
1 EA
01/01/2002
04/03/2005
10 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
10 ML VL
IV
ML
10 ML
0.1
01/01/2004
08/17/2005
10 ML VL
IV
ML
10 ML
0.1
01/01/2002
09/20/2002
20 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
20 ML VL
IV
ML
10 ML
0.1
01/01/2004
06/15/2005
50 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
50 ML VL
IV
ML
10 ML
0.1
3/1/2009
100 ML VL
IV
ML
10 ML
0.1
01/01/2002
99/99/9999 01/01/2004 08/04/2005
0.1
12/31/2003
100 ML VL
IV
ML
10 ML
0.1
01/01/2004
08/02/2005
10 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
10 ML VL
IV
ML
10 ML
0.1
01/01/2004
04/21/2005
10 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
10 ML VL
IV
ML
10 ML
0.1
01/01/2004
07/14/2005
20 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
20 ML VL
IV
ML
10 ML
0.1
3/1/2009
50 ML VL
IV
ML
0.9 %
0.5
01/01/2002
99/99/9999 01/01/2004 02/22/2005
0.1
12/31/2003
50 ML VL
IV
ML
10 ML
0.1
01/01/2004
02/13/2005
10 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/10/2003
100 ML VL
IV
ML
250 ML
0.004
01/01/2002
03/18/2004
10 ML SR
IJ
ML
1 ML
01/01/2002
50 ML SR
IV
ML
1 EA
3/1/2009
5 ML SR
IJ
ML
50 ML
0.02
01/01/2002
5 ML SR
IJ
ML
10 MG
3/1/2009
5 ML SR
EP
ML
50 ML
0.02
01/01/2002
12/31/2003
09/22/2005
99/99/9999 01/01/2002 12/07/2005
12/31/2003
99/99/9999 01/01/2004 11/30/2005
5 ML SR
EP
ML
10 MG
01/01/2004
08/22/2005
ISOPROTERENOL HCL (21GX11/2,ABBOJECT) 0.02 MG/ML
10 ML SR
IV
ML
1 MG
0.02
01/01/2002
12/12/2002
ISOPROTERENOL HCL (21GX11/2,ABBOJECT) 0.02 MG/ML
10 ML SR
IV
ML
1 MG
0.02
01/01/2002
12/12/2002
Page 36 of 374
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00074-4906-19
J0280
1/1/2002
00074-4909-18
J0280
1/1/2002 99/99/9999 INJECTION, AMINOPHYLLIN, UP TO 250 MG
1/7/2005 INJECTION, AMINOPHYLLIN, UP TO 250 MG
00074-4910-15
J0460
1/1/2002
00074-4910-34
J0460
1/1/2002
00074-4911-18
J0460
1/1/2002
00074-4911-34
J0460
1/1/2002 12/31/2009 INJECTION, ATROPINE SULFATE, UP TO 0.3 MG
00074-4913-15
J3475
1/1/2002
00074-4914-18
J3475
1/1/2002
00074-4921-18
J0170
1/1/2002
00074-4921-34
J0170
1/1/2002 99/99/9999 INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE
00074-4931-01
J3480
1/1/2002
00074-4932-01
J3480
1/1/2002
00074-4939-01
J3480
1/1/2002
00074-4943-01
J3475
1/1/2002
00074-4991-15
J3480
1/1/2002
00074-4993-19
00074-5082-16
00074-5083-11
00074-5084-11
00074-5086-11
J3480
J0713
J0713
J0713
J0713
1/1/2002 2/15/2002 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ

00074-5092-16
J0713
00074-5093-11
J0713
1/1/2002
00074-5365-05
J2912
00074-5365-05
A4216
00074-5365-10
00074-5630-04
J2912
J2930
1/1/2002
1/1/2002
00074-5631-08
00074-5641-25
00074-5642-25
00074-5644-25
00074-5645-25
00074-5646-25
00074-5647-25
J2930
J7799
J7799
J7799
J7799
J7799
J7799

1/1/2002
00074-5671-02
00074-5672-02
00074-5673-04
00074-5674-08
J1720
J1720
J1720
J1720
1/1/2002
1/1/2002
1/1/2002
1/1/2002


00074-5684-01
J2920
1/1/2002
00074-5685-02
J2930
1/1/2002
00074-5748-21
J3490
1/1/2002
00074-5749-22
00074-5820-01
00074-5820-01
J3490
J3490
Q4076
00074-5820-10
J3490
1/1/2002
00074-5820-10
Q4076
10/1/2003
00074-5823-25
J7799
1/1/2002
00074-5921-01
J0280
1/1/2002
00074-5922-01
J0280

5/6/2004 INJECTION, DOPAMINE HCL, 40 MG
AMINOPHYLLINE (ABBOJECT) 25 MG/ML

AMINOPHYLLINE (10X10ML,ABBOJECT)
25 MG/ML
ATROPINE SULFATE (21GX1-1/2,LATEXFREE) 0.1 MG/ML
ATROPINE SULFATE (LIFESHIELD,LATEX
FREE) 0.1 MG/ML
ATROPINE SULFATE (21GX1-1/2,LATEXFREE) 0.1 MG/ML
ATROPINE SULFATE (LIFESHIELD,
21GX1-1/2) 0.1 MG/ML
MAGNESIUM SULFATE (20GX21/2,LATEX-FREE) 500 MG/ML
MAGNESIUM SULFATE (20GX21/2,LATEX-FREE) 500 MG/ML
EPINEPHRINE HCL (21GX1-1/2,LATEXFREE) 0.1 MG/ML
EPINEPHRINE HCL (LIFE,21GX1-1/2) 0.1
MG/ML
MAGNESIUM SULFATE (VIAL, PINTOP)
125 MG/ML
POTASSIUM CHLORIDE (SRN,LATEXFREE) 2 MEQ/ML
POTASSIUM CHLORIDE (SRN, UNIV
ADDITIVE) 1.5 MEQ/ML
TAZICEF (VIAL,LATEX-FREE) 1 GM
TAZICEF (P.B.,LATEX-FREE) 1 GM
TAZICEF (VIAL) 2 GM
TAZICEF (VIAL, BULK) 6 GM
TAZICEF (ADD-VANTAGE,LATEX-FREE)
1 GM
TAZICEF (ADD-VANTAGE,LATEX-FREE)
2 GM
SODIUM CHLORIDE (ANSYR,FOR IV
,50X5ML,PF) 0.9%
SODIUM CHLORIDE (ANSYR,FOR IV
,50X5ML,PF) 0.9%
SODIUM CHLORIDE (SRN,FOR IV
FLUSH,PF) 0.9%
A-METHAPRED (UNIVIAL) 500 MG
A-METHAPRED (UNIVIAL,LATEX-FREE) 1
GM
DEXTROSE (1000 ML CONTAINER) 10%
A-HYDROCORT (UNIVIAL,LATEX-FREE)
100 MG
A-HYDROCORT (UNIVIAL) 250 MG
A-HYDROCORT (UNIVIAL) 500 MG
A-HYDROCORT (UNIVIAL) 1 GM
A-METHAPRED (UNIVIAL,LATEX-FREE)
40 MG
125 MG
BUPIVACAINE HCL (W/MALE
ADAPTER,ABBOJECT) 0.5%
BUPIVACAINE HCL (W/MALE ADAPTER)
0.25%
DOPAMINE HCL (FLIPTOP) 40 MG/ML
DOPAMINE HCL (VIAL, FLIPTOP) 40
MG/ML
DOPAMINE HCL (VIAL, FLIPTOP) 40
MG/ML
DEXTROSE (VIAL, 1000 ML CONTAINER)
30%
AMINOPHYLLINE (VIAL,
FLIPTOP,ABBOJECT) 25 MG/ML
Page 37 of 374
20 ML SR
IV
ML
250 MG
0.1
01/01/2002
01/07/2005
10 ML SR
IV
ML
250 MG
0.1
01/01/2002
99/99/9999
5 ML SR
IJ
ML
0.3 MG
0.33333
01/01/2002
01/07/2005
5 ML SR
IJ
ML
0.3 MG
0.33333
01/01/2002
08/17/2005
10 ML SR
IJ
ML
0.3 MG
0.33333
01/01/2002
10/08/2004
10 ML SR
IJ
ML
0.3 MG
0.33333
3/1/2009
5 ML SR
IJ
ML
500 MG
01/01/2002
05/07/2002
10 ML SR
IJ
ML
500 MG
01/01/2002
05/07/2002
01/07/2005
10 ML SR
IJ
ML
1 ML
01/01/2002
IJ
ML
1 ML
3/1/2009
5 ML VL
IV
ML
2 MEQ
01/01/2002
05/07/2002
10 ML VL
IV
ML
2 MEQ
01/01/2002
05/07/2002
20 ML VL
IV
ML
2 MEQ
01/01/2002
02/19/2003
8 ML VL
IJ
ML
0.25
01/01/2002
04/30/2003
5 ML SR
99/99/9999 01/01/2002 12/22/2005
IV
ML
2 MEQ
01/01/2002
02/19/2003
SR
VL
VL
VL
VL
IV
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
2 MEQ
500 MG
500 MG
500 MG
500 MG
0.75
2
2
4
12
01/01/2002
10/01/2008
01/01/2002
10/01/2008
01/01/2002
02/15/2002
99/99/9999
05/16/2005
99/99/9999
99/99/9999
1 EA VL
IJ
EA
500 MG
3/1/2009
1 EA VL
IJ
EA
500 MG
01/01/2002
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
10 ML SR
1 EA VL
IV
IJ
ML
EA
0.9 %
125 MG
0.5
4
01/01/2002
01/01/2002
03/18/2004
03/18/2004
20 ML
1 EA
1 EA
1 EA
1 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
12/31/2009 01/01/2002 11/13/2005 0.33333
10 ML SR
500 MG
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002 12/12/2002
2 12/13/2002 10/23/2005
1/1/2002 12/12/2002
4 12/13/2002 12/04/2005
99/99/9999 01/01/2002
5/1/2006
4/2/2006
1 EA
500 ML
500 ML
500 ML
500 ML
500 ML
500 ML
VL
GC
GC
GC
GC
GC
GC
IJ
IV
IV
IV
IV
IV
IV
EA
ML
ML
ML
ML
ML
ML
125 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
8
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/18/2004
99/99/9999
05/06/2004
99/99/9999
03/18/2004
02/19/2003
03/18/2004
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
IJ
IJ
IJ
IJ
EA
EA
EA
EA
100 MG
100 MG
100 MG
100 MG
1
2.5
5
10
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/18/2004
03/18/2004
12/01/2004
09/20/2002
1 EA VL
IJ
EA
40 MG
01/01/2002
03/18/2004
1 EA VL
IJ
EA
125 MG
01/01/2002
03/18/2004
30 ML SR
IJ
ML
1 EA
01/01/2002
02/19/2003
50 ML SR
5 ML VL
5 ML VL
IJ
IV
IV
ML
ML
ML
1 EA
1 EA
40 MG
1
1
1
01/01/2002
09/08/2003
10/01/2003
99/99/9999
09/30/2003
08/22/2005
5 ML VL
IV
ML
1 EA
01/01/2002
09/30/2003
5 ML VL
IV
ML
40 MG
10/01/2003
05/06/2004
500 ML GC IV
ML
1 EA
01/01/2002
03/18/2004
10 ML VL
IV
ML
250 MG
0.1
01/01/2002
04/24/2005
20 ML VL
IV
ML
250 MG
0.1
01/01/2002
12/23/2004
00074-6022-02
J2270
1/1/2002
00074-6023-04
J2270
1/1/2002
00074-6028-04
J2270
1/1/2002
00074-6030-04
00074-6054-02
00074-6056-17
J2175
J1940
J1940
1/1/2002
1/1/2002
1/1/2002
00074-6062-02
J2270
1/1/2002
00074-6062-03
J2270
1/1/2002
00074-6062-11
J2270
1/1/2002
00074-6063-02
J2270
1/1/2002
00074-6063-03
J2270
00074-6101-02
J1940
1/1/2002
00074-6101-04
J1940
1/1/2002
00074-6101-10
J1940
1/1/2002
00074-6102-02
J1940
1/1/2002
00074-6102-04
J1940
1/1/2002
00074-6102-10
00074-6109-05
00074-6111-01
J1940
J3365
J3364
1/1/2002
1/1/2002
1/1/2002

2/14/2005 INJECTION, IV, UROKINASE, 250,000 I.U. VIAL
7/9/2002 INJECTION, UROKINASE, 5000 IU VIAL
00074-6138-03
A4323
1/1/2002 12/31/2003 STERILE SALINE IRRIGATION SOLUTION, 1000 ML.
00074-6138-03
A4217
1/1/2004
00074-6138-22
A4323
00074-6138-22
A4217
1/1/2004
00074-6139-03
A4319
1/1/2002 12/31/2003 STERILE WATER IRRIGATION SOLUTION, 1000 ML
00074-6139-03
A4217
1/1/2004
00074-6139-22
A4319
00074-6139-22
00074-6145-02
A4217
J3364
1/1/2004
1/1/2002
00074-6147-36
A4323
00074-6147-36
A4217
00074-6177-14
J2270
1/1/2002
00074-6179-14
00074-6217-02
00074-6217-02
00074-6248-01
00074-6254-01
J2270
J2000
J2001
J2000
J2000

1/1/2002
1/1/2002


7/9/2002 INJECTION, UROKINASE, 5000 IU VIAL
00074-6342-05
J1364
1/1/2002
00074-6365-02
00074-6463-32
J1364
J7515
1/1/2002 7/18/2003 INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG

1/1/2002 99/99/9999 CYCLOSPORINE, ORAL, 25 MG
00074-6476-44
J1364
00074-6478-44
00074-6479-32
J1364
J7502

00074-6481-01
J1364
1/1/2002
7/18/2003 INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG
00074-6482-01
J1364
1/1/2002
00074-6509-01
J3370
1/1/2002
00074-6509-49
J3370
1/1/2002
MORPHINE SULFATE (S.D.V.,PCA) 2

MG/ML
MG/ML
MG/ML
MEPERIDINE HCL (VIAL, PCA,LATEXFREE) 10 MG/ML
FUROSEMIDE (ABBOJECT) 10 MG/ML
DEXTROSE/MORPHINE SULFATE
(PREMIX) 5%-100 MG/100 ML
FUROSEMIDE (AMP,LATEX-FREE) 10
MG/ML
MG/ML
MG/ML
FUROSEMIDE
(VIAL,FLIPTOP,ABBOJECT) 10 MG/ML
FUROSEMIDE (VIAL,
FUROSEMIDE (VIAL, FLIPTOP) 10 MG/ML
ABBOKINASE 250000 IU
ABBOKINASE OPEN-CATH 5000 IU
SODIUM CHLORIDE
(AQUALITE,PF,LATEX-FREE) 0.9%
SODIUM CHLORIDE
SODIUM CHLORIDE
(AQUALITE,24X250ML,PF) 0.9%
SODIUM CHLORIDE
WATER FOR IRRIGATION
(AQUALITE,PF,LATEX-FREE)
ABBOKINASE OPEN-CATH 9000 IU
SODIUM CHLORIDE
SODIUM CHLORIDE
MORPHINE SULFATE (ADDVANTAGE,LATEX-FREE) 25 MG/ML
LIDOCAINE HCL (VIAL, PINTOP) 20%
ERYTHROCIN LACTOBIONATE (LATEXFREE) 1 GM
ERYTHROCIN LACTOBIONATE (LATEXFREE) 500 MG
GENGRAF (BLISTER PACK) 25 MG
ERYTHROCIN LACTOBIONATE (ADDVANTAGE,LATEX-FREE) 500 MG
ERYTHROCIN LACTOBIONATE (ADDVANTAGE,LATEX-FREE) 1 GM
GENGRAF (BLISTER PACK) 100 MG
ERYTHROCIN LACTOBIONATE (LATEXFREE) 1 GM
VANCOMYCIN HCL (BULK VIAL,LATEXFREE) 5 GM
(VIAL,BULK PKG) 5 GM
Page 38 of 374
30 ML VL
IV
ML
10 MG
0.2
01/01/2002
10/08/2004
30 ML VL
IJ
ML
10 MG
0.1
01/01/2002
05/16/2005
30 ML VL
IJ
ML
10 MG
0.5
01/01/2002
03/22/2007
30 ML VL
2 ML SR
8 ML SR
IJ
IJ
IJ
ML
ML
ML
100 MG
20 MG
20 MG
0.1
0.5
0.5
01/01/2002
01/01/2002
01/01/2002
01/01/2007
05/07/2002
05/06/2004
250 ML GC IV
ML
10 MG
0.1
01/01/2002
01/09/2006
500 ML GC IV
ML
10 MG
0.1
01/01/2002
03/18/2004
100 ML GC IV
ML
10 MG
0.1
01/01/2002
07/21/2005
250 ML GC IV
ML
10 MG
0.02
01/01/2002
09/05/2003
500 ML GC IV
ML
10 MG
0.02
01/01/2002
12/10/2003
2 ML AM IJ
ML
20 MG
0.5
01/01/2002
03/18/2004
4 ML AM IJ
ML
20 MG
0.5
01/01/2002
03/18/2004
10 ML AM IJ
ML
20 MG
0.5
01/01/2002
03/18/2004
2 ML VL
IJ
ML
20 MG
0.5
01/01/2002
02/17/2005
4 ML VL
IJ
ML
20 MG
0.5
01/01/2002
02/20/2005
10 ML VL
1 EA VL
1 EA VL
IJ
IV
IV
ML
EA
EA
20 MG
250000 IU
5000 IU
0.5
1
1
01/01/2002
01/01/2002
01/01/2002
03/23/2005
02/14/2005
07/09/2002
500 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
500 ML PC
IR
ML
500 ML
0.002
01/01/2004
05/31/2005
250 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
250 ML PC
IR
ML
500 ML
0.002
01/01/2004
08/31/2005
500 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
500 ML PC
IR
ML
500 ML
0.002
01/01/2004
05/08/2005
250 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
250 ML PC
1 EA VL
IR
IV
ML
EA
500 ML
5000 IU
0.002
1.8
01/01/2004
01/01/2002
05/03/2005
07/09/2002
1500 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
1500 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
4 ML VL
IJ
ML
10 MG
2.5
01/01/2002
07/13/2005
IJ
IV
IV
IV
IV
ML
ML
ML
ML
ML
10 MG
50 ML
10 MG
50 ML
50 ML
2.5
0.02
20
0.02
0.02
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2002
08/31/2005
12/31/2003
99/99/9999
05/07/2002
05/07/2002
10 ML
10 ML
10 ML
10 ML
10 ML
VL
VL
VL
VL
VL
1 EA VL
IV
EA
500 MG
01/01/2002
07/18/2003
1 EA VL
30 EA BX
IV
PO
EA
EA
500 MG
25 MG
1
1
01/01/2002
01/01/2002
07/18/2003
99/99/9999
1 EA VL
IV
EA
500 MG
3/1/2009
99/99/9999 01/01/2002 03/09/2006
1 EA VL
30 EA BX
IV
PO
EA
EA
500 MG
100 MG
2
1
3/1/2009
01/01/2002
99/99/9999 01/01/2002 01/09/2007

99/99/9999
1 EA VL
IV
EA
500 MG
01/01/2002
07/18/2003
1 EA VL
IV
EA
500 MG
01/01/2002
05/22/2005
1 EA VL
IV
GM
500 MG
01/01/2002
06/05/2005
1 EA VL
IV
GM
500 MG
01/01/2002
06/02/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00074-6533-01
J3370
1/1/2002
00074-6533-49
J3370
1/1/2002
00074-6534-01
J3370
1/1/2002
00074-6534-49
J3370
1/1/2002
00074-6535-01
J3370
1/1/2002
00074-6535-49
00074-6629-02
J3370
J0330
1/1/2002
1/1/2002 99/99/9999 INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG
00074-6635-01
J3480
1/1/2002
00074-6636-01
J3480
1/1/2002
00074-6642-02
J0330
1/1/2002
00074-6648-02
J7799
1/1/2002
00074-6651-06
J3480
00074-6653-05
J3480
1/1/2002
00074-6657-73
J7799
00074-6660-75
J7799
1/1/2002
00074-6727-23
00074-6728-03
J3475
J3475
1/1/2002
1/1/2002

VANCOMYCIN HCL (VIAL, FLIPTOP) 1

GM
(VIAL,FLIPTOP,LATEX-FREE) 1 GM
VANCOMYCIN HCL (ADDVANTAGE,LATEX-FREE) 500 MG
VANCOMYCIN HCL NOVATION (ADDVANTAGE,LATEX-FREE) 500 MG
VANCOMYCIN HCL (ADDVANTAGE,LATEX-FREE) 1 GM
VANCOMYCIN HCL NOVATION (ADDVANTAGE,LATEX-FREE) 1 GM
QUELICIN (VIAL, FLIPTOP) 20 MG/ML
POTASSIUM CHLORIDE (VIAL, FLIPTOP,
10 ML) 2 MEQ/ML
30 ML) 2 MEQ/ML
EA
500 MG
01/01/2002
IV
EA
500 MG
01/01/2002
04/05/2005
1 EA VL
IV
EA
500 MG
01/01/2002
06/07/2005
1 EA VL
IV
EA
500 MG
01/01/2002
06/09/2005
1 EA VL
IV
EA
500 MG
01/01/2002
03/28/2005
1 EA VL
10 ML VL
IV
IV
EA
ML
500 MG
20 MG
2
1
01/01/2002
3/1/2009
04/05/2005
99/99/9999 01/01/2002 04/24/2004
5 ML VL
IV
ML
01/01/2002
09/20/2005
15 ML VL
08/08/2005
2 MEQ
2 MEQ
IV
ML
01/01/2002
10 ML AM IV
ML
20 MG
2.5
01/01/2002
09/20/2002
50 ML VL
IV
ML
1 EA
01/01/2002
03/28/2005
10 ML VL
IV
ML
2 MEQ
3/1/2009
20 ML VL
IV
ML
2 MEQ
01/01/2002
08/08/2005
20 ML VL
IV
ML
1 EA
01/01/2002
10/13/2005
40 ML VL
IV
ML
1 EA
01/01/2002
07/25/2005
100 ML FC
IV
ML
500 MG
0.02
01/01/2002
09/19/2005
DEXTROSE/MAGNESIUM SULFATE
(PLASTIC CONTAINER) 5%-2 GM/100 ML
500 ML FC
IV
ML
500 MG
0.04
01/01/2002
05/07/2002
1000 ML FC
IV
ML
500 MG
0.04
01/01/2002
03/18/2004
500 ML PC
IV
ML
500 MG
0.08
01/01/2002
08/15/2005
1000 ML PC
IV
ML
500 MG
0.08
01/01/2002
09/21/2005
10/06/2005
J3475
1/1/2002
00074-6729-03
J3475
1/1/2002
00074-6729-09
J3475
1/1/2002
00074-6729-23
J3475
10/6/2005
00074-6730-13
J3475
1/1/2002
00074-6776-01
00074-6778-01
00074-6778-02
J2060
J2060
J2060
00074-6778-61
J2060
1/1/2002
00074-6778-62
00074-6779-01
J2060
J2060

00074-6779-02
00074-6780-01
00074-6780-02
00074-6781-01
J2060
J2060
J2060
J2060
2/20/2002
00074-6781-02
J2060
2/20/2002
00074-6940-03
J3520
1/1/2002 10/16/2007 EDETATE DISODIUM, PER 150 MG
00074-6970-10
J0330
00074-7067-30
J2912
1/1/2002
00074-7074-26
J3480
1/1/2002
00074-7075-14
J3480
1/1/2002
00074-7075-26
J3480
1/1/2002
00074-7076-26
J3480
1/1/2002
00074-7077-14
J3480
1/1/2002
00074-7077-26
J3480
1/1/2002
1/1/2002
Page 39 of 374
99/99/9999 01/01/2002 11/09/2005
100 ML PC
IV
ML
500 MG
0.08
10/06/2005
50 ML PC
IV
ML
500 MG
0.16
01/01/2002
4/2/2006
1 ML SR
1 ML VL
1 ML VL
IJ
IJ
IJ
ML
ML
ML
2 MG
2 MG
2 MG
1
1
1
01/01/2002
01/01/2002
02/20/2002
05/07/2002
10/24/2003
01/26/2006
1 ML VL
IJ
ML
2 MG
01/01/2002
02/20/2002
1 ML VL
1 ML VL
IJ
IJ
ML
ML
2 MG
2 MG
1
2
01/01/2002
01/01/2002
10/24/2003
10/24/2003
VL
VL
VL
VL
IJ
IJ
IJ
IJ
ML
ML
ML
ML
2
2
2
2
2
1
1
2
02/20/2002
01/01/2002
02/20/2002
01/01/2002
01/04/2006
10/24/2003
12/28/2005
10/24/2003
10 ML VL
1 ML
10 ML
10 ML
10 ML
MG
MG
MG
MG
Prior End Date #3
Prior Start Date #3
03/14/2005
MAGNESIUM SULFATE (PLASTIC
CONTAINER) 40 MG/ML
CONTAINER) 40 MG/ML
MAGNESIUM SULFATE (LATEX-FREE) 40
MG/ML
CONTAINER) 80 MG/ML
LORAZEPAM (HYPAK SYRINGE) 2
MG/ML
LORAZEPAM (VIAL, FLIPTOP) 2 MG/ML
LORAZEPAM (VIAL,FLIPTOP) 2 MG/ML
LORAZEPAM AMERINET (VIAL,FLIPTOP)
2 MG/ML
LORAZEPAM AMERINET
LORAZEPAM (VIAL,FLIPTOP,LATEXFREE) 4 MG/ML
LORAZEPAM (VIAL,FLIPTOP,LATEXFREE) 4 MG/ML
ENDRATE (AMP,LATEX-FREE) 150
MG/ML
QUELICIN (VIAL, FLIPTOP, 20 ML) 100
MG/ML
(FLIPTOP,LS-GLASS) 0.9%
POTASSIUM CHLORIDE (P.C.,LATEXFREE) 10 MEQ/100 ML
Prior End Date #2
IV
1 EA VL
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
1 EA VL
QUELICIN (AMP,LATEX-FREE) 50 MG/ML

DEXTROSE (VIAL, FLIPTOP, ADDITIVE)
50%
20 ML) 2 MEQ/ML
30 ML) 2 MEQ/ML
50MEQ) 14.6%
ADDITIVE) 14.6%
00074-6728-09
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
IJ
ML
2 MG
02/20/2002
01/22/2006
20 ML AM IV
ML
150 MG
01/01/2002
10/16/2007
10 ML VL
IV
ML
20 MG
30 ML VL
IV
ML
0.9 %
100 ML PC
IV
ML
50 ML PC
IV
ML
100 ML PC
IV
100 ML FC
50 ML FC
100 ML FC
3/1/2009
0.5
01/01/2002
02/15/2002
99/99/9999 01/01/2002 09/29/2005
2 MEQ
0.05
01/01/2002
04/24/2005
2 MEQ
0.1
01/01/2002
06/07/2005
ML
2 MEQ
0.1
01/01/2002
04/10/2005
IV
ML
2 MEQ
0.15
01/01/2002
02/07/2006
IV
ML
2 MEQ
0.2
01/01/2002
06/27/2005
IV
ML
2 MEQ
0.2
01/01/2002
05/03/2005
00074-7100-02
J7060
1/1/2002
00074-7100-66
J7060
1/1/2002
00074-7100-67
J7060
1/1/2002
00074-7101-02
J7050
1/1/2002
00074-7101-66
J2912
00074-7101-66
A4216
1/1/2004
00074-7101-67
J7050
1/1/2002
00074-7111-09
J7120
1/1/2002
00074-7113-09
J7120
1/1/2002
00074-7115-09
J3480
1/1/2002
00074-7116-09
J3480
1/1/2002
00074-7118-07
A4319
00074-7118-07
A4217
1/1/2004
00074-7119-07
J7799
1/1/2002
00074-7120-07
J7799
1/1/2002
00074-7132-02
J7799
1/1/2002
00074-7132-66
J7799
1/1/2002
00074-7132-67
J7799
00074-7138-09
A4323
00074-7138-09
A4217
1/1/2004
00074-7138-36
A4323
00074-7138-36
A4217
1/1/2004
00074-7139-09
A4319
1/1/2002
5/7/2002 STERILE WATER IRRIGATION SOLUTION, 1000 ML
00074-7139-36
A4319
00074-7139-36
00074-7241-01
00074-7269-50
A4217
J0170
J7502
00074-7385-01
J0280
00074-7386-01
J0280
00074-7418-03
J7100
1/1/2002
2/13/2006 INFUSION, DEXTRAN 40, 500 ML
00074-7419-03
J7100
1/1/2002
00074-7444-01
J3490
00074-7445-01
J3490
1/1/2002
00074-7446-02
00074-7447-16
00074-7517-15
J3490
J3490
J7799
1/1/2002
1/1/2002
1/1/2002

1/1/2004
00074-7517-16
J7799
00074-7620-03
J1644
1/1/2002
00074-7620-59
J1644
1/1/2002
00074-7638-62
J3490
1/1/2002
00074-7639-62
J3490
1/1/2002
DEXTROSE (ADD-VANTAGE,24X250ML)
5%
DEXTROSE (ADD-VANTAGE,LATEXFREE) 5%
SODIUM CHLORIDE (ADD-VANTAGE,
LIFECARE) 0.9%
SODIUM CHLORIDE (ADDVANT,LIFECARE,PF) 0.9%
DEX/LACT. RINGERS/POTASSIUM CHL
(5% DEXTROSE,LATEX-FREE)
(5% DEXTROSE,LATEX-FREE)
POTASSIUM CHLORIDE/SODIUM
CHLORIDE (LATEX-FREE) 2 MEQ/100 ML0.9%
CHLORIDE (LATEX-FREE) 4 MEQ/100 ML0.9%
WATER FOR IRRIGATION (BULK
PACKAGE,PF)
PACKAGE,PF)
DEXTROSE (BULK PACKAGE,LATEXFREE) 50%
DEXTROSE (BULK PACKAGE,LATEXFREE) 70%
SODIUM CHLORIDE (ADDVANTAGE,LATEX-FREE) 0.45%
SODIUM CHLORIDE
SODIUM CHLORIDE
SODIUM CHLORIDE
SODIUM CHLORIDE
WATER FOR IRRIGATION (AQUALITE
W/HANGER,PF)
W/HANGER,PF)
W/HANGER,PF)
EPINEPHRINE HCL (AMP) 1 MG/ML
GENGRAF 100 MG/ML
AMINOPHYLLINE (AMP,LATEX-FREE) 25
MG/ML
MG/ML
LMD W/5% DEXTROSE (LATEX-FREE)
10%-5%
LMD W/0.9% SODIUM CHLORIDE (LATEXFREE) 10%-0.9%
CIMETIDINE HCL (VIAL, FLIPTOP) 150
MG/ML
CIMETIDINE HCL (VIAL, FLIPTOP) 150
MG/ML
CIMETIDINE HCL (ADD-VANTAGE,LATEXFREE) 150 MG/ML
CIMETIDINE HCL 300 MG/50 ML
DEXTROSE (ANSYR,LATEX-FREE) 50%
DEXTROSE (ANSYR II,LATEX-FREE) 50%
HEPARIN SODIUM/SODIUM CHLORIDE
(LATEX-FREE) 200 U/100 ML-0.9%
BRETYLIUM TOSYLATE/DEXTROSE 200
MG/100 ML-5%
BRETYLIUM TOSYLATE/DEXTROSE 400
MG/100 ML-5%
Page 40 of 374
250 ML VL
IV
ML
500 ML
0.002
01/01/2002
50 ML PC
IV
ML
500 ML
0.002
01/01/2002
08/16/2005
100 ML PC
IV
ML
500 ML
0.002
01/01/2002
09/13/2005
250 ML FC
IV
ML
250 ML
0.004
01/01/2002
07/07/2005
50 ML PC
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
50 ML PC
IV
ML
10 ML
0.1
01/01/2004
07/27/2005
100 ML PC
IV
ML
250 ML
0.004
01/01/2002
08/23/2005
IV
ML
1000 ML
0.0005
01/01/2002
08/04/2005
1000 ML FC
IV
ML
1000 ML
0.0005
01/01/2002
02/20/2005
1000 ML FC
IV
ML
0.01
01/01/2002
04/05/2005
1000 ML FC
IV
ML
0.02
01/01/2002
06/21/2005
2000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
2 MEQ
2000 ML PC
IR
ML
500 ML
0.002
01/01/2004
08/15/2005
2000 ML PC
IV
ML
1 EA
01/01/2002
05/26/2006
2000 ML GC IV
ML
1 EA
01/01/2002
07/05/2005
05/25/2006
250 ML FC
IV
ML
1 EA
01/01/2002
50 ML PC
IV
ML
1 EA
01/01/2002
09/11/2005
100 ML PC
IV
ML
1 EA
01/01/2002
11/13/2005
1000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
1000 ML PC
IR
ML
500 ML
0.002
01/01/2004
05/10/2005
1500 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
1500 ML PC
IR
ML
500 ML
0.002
01/01/2004
06/08/2005
1000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
05/07/2002
1500 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
1500 ML PC IR
1 ML AM IJ
50 ML BO PO
ML
ML
ML
500 ML
1 ML
100 MG
0.002
1
1
01/01/2004
3/1/2009
01/18/2002
05/03/2005
99/99/9999 04/09/2002 09/12/2005
99/99/9999
10 ML AM IV
ML
250 MG
0.1
01/01/2002
12/28/2005
20 ML AM IV
ML
250 MG
0.1
01/01/2002
11/28/2005
500 ML GC IV
ML
500 ML
0.002
01/01/2002
02/13/2006
500 ML GC IV
ML
500 ML
0.002
01/01/2002
08/08/2005
2 ML VL
IJ
ML
1 EA
01/01/2002
99/99/9999
8 ML VL
IJ
ML
1 EA
01/01/2002
11/09/2005
2 ML VL
50 ML PC
50 ML SR
IV
IV
IV
ML
ML
ML
1 EA
1 EA
1 EA
1
1
1
01/01/2002
01/01/2002
01/01/2002
05/07/2002
01/08/2006
03/18/2004
1 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
07/21/2005
1000 ML FC
2 MEQ
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
50 ML SR
IV
ML
3/1/2009
500 ML FC
IV
ML
1000 U
0.002
01/01/2002
04/04/2005
99/99/9999 01/01/2002 12/06/2005
1000 ML FC
IV
ML
1000 U
0.002
01/01/2002
04/12/2005
250 ML FC
IV
ML
1 EA
01/01/2002
03/18/2004
250 ML GC IV
ML
1 EA
01/01/2002
03/18/2004
00074-7650-62
J1644
1/1/2002
00074-7651-03
J1644
1/1/2002
00074-7651-62
J1644
1/1/2002
00074-7665-03
J2810
1/1/2002 12/28/2005 INJECTION, THEOPHYLLINE, PER 40 MG
00074-7665-09
J2810
1/1/2002
4/24/2005 INJECTION, THEOPHYLLINE, PER 40 MG
00074-7666-03
J2810
1/1/2002
00074-7666-62
J2810
1/1/2002
00074-7668-23
J2810
1/1/2002
00074-7677-13
J2810
1/1/2002
00074-7677-23
J2810
1/1/2002
00074-7705-62
00074-7712-09
00074-7713-09
00074-7714-03
00074-7715-02
00074-7715-03
J2810
J7799
J7799
J7799
J7799
J7799

1/1/2002
00074-7730-20
J7799
1/1/2002
00074-7730-36
J7799
1/1/2002
00074-7730-37
00074-7745-01
J7799
J3490
1/1/2002
1/1/2002
00074-7760-03
J1644
1/1/2002
00074-7761-03
J1644
1/1/2002
00074-7793-23
J1644
1/1/2002
00074-7793-62
J1644
00074-7794-62
J1644
1/1/2002
00074-7808-22
Q4076
10/1/2003
00074-7808-24
Q4076
10/1/2003
00074-7809-22
Q4076
10/1/2003
00074-7809-24
Q4076
10/1/2003
00074-7810-22
Q4076
10/1/2003
00074-7811-24
J3490
1/1/2002
00074-7811-37
J3490
1/1/2002
00074-7879-13
J1580
1/1/2002
00074-7881-13
J1580
1/1/2002
00074-7883-13
J1580
1/1/2002
00074-7884-23
J1580
1/1/2002
00074-7886-23
J1580
1/1/2002
00074-7889-23
J1580
1/1/2002

(LATEX-FREE) 10000 U/100 ML-0.45%
250 ML FC
(LATEX-FREE) 5000 U/100 ML-0.45%
500 ML FC
(LATEX-FREE) 5000 U/100 ML-0.45%
250 ML FC
DEXTROSE/THEOPHYLLINE (LATEXFREE) 5%-80 MG/100 ML
500 ML GC
1000 ML GC
500 ML GC
250 ML FC
100 ML GC
50 ML FC
100 ML FC
250 ML FC
MANNITOL (LATEX-FREE) 5%
1000 ML VL
1000 ML VL
500 ML GC
250 ML FC
500 ML GC
SODIUM CHLORIDE (QUAD-PK,48X25ML)
0.45%
25 ML VL
SODIUM CHLORIDE (80X50ML,LATEXFREE) 0.45%
50 ML FC
100 ML FC
INAMRINONE LACTATE (AMP) 5 MG/ML
20 ML AM
DEXTROSE/HEPARIN SODIUM (LATEXFREE) 5%-4000 U/100 ML
500 ML FC
500 ML FC
100 ML FC
250 ML FC
250 ML FC
DEXTROSE/DOPAMINE HCL
(LIFECARE,LATEX-FREE) 5%-80 MG/100
ML
250 ML FC
ML
500 ML FC
ML
250 ML FC
ML
500 ML FC
ML
250 ML FC
METRONIDAZOLE (S.D.V.,LATEX-FREE)
500 MG/100 ML
100 ML VL
METRONIDAZOLE (LIFECARE,LATEXFREE) 500 MG/100 ML
100 ML FC
GENTAMICIN SULFATE/SODIUM
CHLORIDE (LIFECARE,LATEX-FREE) 1.2
MG/ML-0.9%
50 ML FC
MG/ML-0.9%
50 ML FC
MG/ML-0.9%
50 ML FC
CHLORIDE (LIFECARE,LATEX-FREE) 80
MG/100 ML-0.9%
100 ML FC
MG/100 ML-0.9%
100 ML FC
MG/100 ML-0.9%
100 ML FC
Page 41 of 374
IV
ML
1000 U
0.1
01/01/2002
07/05/2005
IV
ML
1000 U
0.05
01/01/2002
06/27/2005
IV
ML
1000 U
0.05
01/01/2002
07/27/2005
IV
ML
40 MG
0.02
01/01/2002
12/28/2005
IV
ML
40 MG
0.02
01/01/2002
04/24/2005
IV
ML
40 MG
0.04
01/01/2002
05/26/2006
IV
ML
40 MG
0.04
01/01/2002
01/26/2006
IV
ML
40 MG
0.05
01/01/2002
02/05/2007
IV
ML
40 MG
0.1
01/01/2002
08/09/2006
IV
ML
40 MG
0.1
01/01/2002
05/16/2005
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
40 MG
1 EA
1 EA
1 EA
1 EA
1 EA
0.08
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/26/2006
08/18/2005
4/6/2006
08/29/2005
11/13/2005
09/15/2005
IV
ML
1 EA
01/01/2002
07/26/2005
IV
ML
1 EA
01/01/2002
07/10/2005
IV
IV
ML
ML
1 EA
1 EA
1
1
01/01/2002
01/01/2002
09/15/2005
03/18/2004
IV
ML
1000 U
0.04
01/01/2002
08/29/2005
IV
ML
1000 U
0.05
01/01/2002
07/21/2005
IV
ML
1000 U
0.1
01/01/2002
01/24/2006
IV
ML
1000 U
0.1
01/01/2002
10/13/2005
IV
ML
1000 U
0.05
01/01/2002
06/11/2006
IV
ML
40 MG
0.02
10/01/2003
06/16/2005
IV
ML
40 MG
0.02
10/01/2003
08/29/2005
IV
ML
40 MG
0.04
10/01/2003
04/24/2005
IV
ML
40 MG
0.025
10/01/2003
10/09/2005
IV
ML
40 MG
0.08
10/01/2003
08/03/2005
IV
ML
1 EA
01/01/2002
08/30/2005
IV
ML
1 EA
01/01/2002
09/21/2005
IV
ML
80 MG
0.015
01/01/2002
3/30/2006
IV
ML
80 MG
0.0175
01/01/2002
01/22/2006
IV
ML
80 MG
0.02
01/01/2002
01/08/2006
IV
ML
80 MG
0.01
01/01/2002
07/05/2005
IV
ML
80 MG
0.01125
01/01/2002
01/26/2006
IV
ML
80 MG
0.0125
01/01/2002
09/19/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00074-7897-15
J0460
1/1/2002
00074-7907-07
00074-7918-19
00074-7922-02
00074-7922-03
00074-7922-09
00074-7922-53
A7020
J7799
J7060
J7060
J7060
J7060
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00074-7922-55
00074-7922-61
00074-7923-13
J7060
J7060
J7060
1/1/2002 10/30/2006 5% DEXTROSE/WATER (500 ML = 1 UNIT)

1/1/2002
12/18/2002

STERILE WATER OR STERILE SALINE, 1000 ML, USED WITH LARGE VOLUME
9/20/2002 NEBULIZER
00074-7923-20
00074-7923-23
J7060
J7060
1/1/2002
12/18/2002

00074-7923-36
J7060
1/1/2002
00074-7923-37
J7060
1/1/2002
00074-7924-02
J7799
1/1/2002
00074-7924-03
J7799
1/1/2002
00074-7924-09
J7799
00074-7925-02
J7799
1/1/2002
00074-7925-03
J7799
1/1/2002
00074-7925-09
J7799
1/1/2002
00074-7926-02
J7799
1/1/2002
00074-7926-03
J7799
1/1/2002
00074-7926-09
J7799
1/1/2002
00074-7929-03
J7120
1/1/2002
00074-7929-09
J7120
1/1/2002
00074-7930-02
J7799
1/1/2002
00074-7930-03
J7799
1/1/2002
00074-7930-09
J7799
1/1/2002
00074-7931-24
J2000
00074-7931-24
J2001
1/1/2004
00074-7931-32
J2000
00074-7931-32
00074-7935-19
00074-7936-17
00074-7936-19
J2001
J7799
J7799
J7799
1/1/2004
1/1/2002
1/1/2002
1/1/2002
00074-7936-29
00074-7937-19
00074-7938-19
J7799
J7799
J7799

00074-7939-32
J2000
00074-7939-32
J2001
1/1/2004
00074-7940-03
J7799
1/1/2002
00074-7940-09
J7799
1/1/2002
00074-7941-02
J7042
1/1/2002
5/26/2006 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT)
00074-7941-03
J7042
1/1/2002
00074-7941-09
J7042
1/1/2002
00074-7953-02
J7120
1/1/2002
00074-7953-03
J7120
1/1/2002
ATROPINE SULFATE (21GX1

1/2",ABBOJECT) 0.05 MG/ML
WATER FOR INHALATION (FLEXIBLE
PLASTIC)
DEXTROSE (LIFECARE/PLASTIC) 5%
DEXTROSE (LIFECARE,24X250ML) 5%
DEXTROSE (LIFECARE,LATEX-FREE) 5%
DEXTROSE 5%
DEXTROSE (LIFECARE,QUAD PACK,LF)
5%
DEXTROSE (PARTIAL-FILL, FLEX C) 5%
5%
5%
(LIFECARE/PLASTIC) 5%-0.225%
DEXTROSE 5% IN RINGERS (LATEXFREE)
DEXTROSE 5% IN RINGERS
(LIFECARE,LATEX-FREE)
DEXTROSE (LIFECARE,LATEX-FREE)
10%
10%
10%
DEXTROSE/LIDOCAINE HCL
(LIFECARE,LATEX-FREE) 5%-0.4%
DEXTROSE (BARCODED,LATEX-FREE)
50%
(LIFECARE,LATEX-FREE) 2.5%-0.45%
(LIFECARE,LATEX-FREE) 2.5%-0.45%
LACTATED RINGER'S (LIFECARE,LATEXFREE)
Page 42 of 374
5 ML SR
IJ
ML
0.3 MG
0.16666
01/01/2002
10/08/2004
FC
PC
FC
FC
FC
FC
IH
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
1000 ML
1 EA
500 ML
500 ML
500 ML
500 ML
0.001
1
0.002
0.002
0.002
0.002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/20/2002
07/07/2005
04/04/2005
02/24/2005
02/20/2005
08/31/2005
500 ML FC
150 ML FC
50 ML FC
IV
IV
IV
ML
ML
ML
500 ML
500 ML
500 ML
0.002
0.002
0.002
01/01/2002
01/01/2002
12/18/2002
10/30/2006
08/04/2005
06/08/2005
25 ML FC
100 ML FC
IV
IV
ML
ML
500 ML
500 ML
0.002
0.002
01/01/2002
12/18/2002
06/16/2005
07/14/2005
50 ML FC
IV
ML
500 ML
0.002
03/19/2004
04/04/2005
100 ML FC
IV
ML
500 ML
0.002
01/01/2002
03/15/2005
250 ML FC
IV
ML
1 EA
01/01/2002
07/27/2005
500 ML FC
IV
ML
1 EA
01/01/2002
07/27/2005
1000 ML FC
IV
ML
1 EA
01/01/2002
12/20/2005
250 ML FC
IV
ML
1 EA
01/01/2002
06/28/2005
500 ML FC
IV
ML
1 EA
01/01/2002
09/15/2005
1000 ML FC
IV
ML
1 EA
01/01/2002
3/16/2006
250 ML FC
IV
ML
1 EA
01/01/2002
08/29/2005
2000 ML
500 ML
250 ML
500 ML
1000 ML
250 ML
500 ML FC
IV
ML
1 EA
01/01/2002
06/06/2005
1000 ML FC
IV
ML
1 EA
01/01/2002
08/24/2005
500 ML FC
IV
ML
1000 ML
0.0005
01/01/2002
06/08/2005
1000 ML FC
IV
ML
1000 ML
0.0005
01/01/2002
02/06/2005
250 ML FC
IV
ML
1 EA
01/01/2002
07/04/2005
500 ML FC
IV
ML
1 EA
01/01/2002
01/11/2005
1000 ML FC
IV
ML
1 EA
01/01/2002
03/15/2005
500 ML FC
IV
ML
50 ML
0.02
01/01/2002
12/31/2003
500 ML FC
IV
ML
10 MG
0.4
01/01/2004
05/17/2005
250 ML FC
IV
ML
50 ML
0.02
01/01/2002
12/31/2003
FC
PC
FC
PC
IV
IV
IV
IV
ML
ML
ML
ML
10 MG
1 EA
1 EA
1 EA
0.4
1
1
1
01/01/2004
01/01/2002
01/01/2002
01/01/2002
09/15/2005
09/11/2005
05/06/2004
06/23/2005
1000 ML FC
500 ML PC
500 ML PC
IV
IV
IV
ML
ML
ML
1 EA
1 EA
1 EA
1
1
1
08/21/2003
01/01/2002
01/01/2002
10/27/2005
08/23/2005
09/28/2005
250 ML FC
IV
ML
50 ML
0.02
01/01/2002
12/31/2003
250 ML FC
IV
ML
10 MG
0.8
01/01/2004
01/10/2006
500 ML FC
IV
ML
1 EA
01/01/2002
06/01/2005
1000 ML FC
IV
ML
1 EA
01/01/2002
10/08/2004
250 ML FC
IV
ML
5%
0.002
01/01/2002
05/26/2006
500 ML FC
IV
ML
5%
0.002
01/01/2002
09/19/2005
1000 ML FC
IV
ML
5%
0.002
01/01/2002
08/07/2005
250 ML FC
IV
ML
1000 ML
0.001
01/01/2002
03/08/2005
500 ML FC
IV
ML
1000 ML
0.001
01/01/2002
05/19/2005
250 ML
500 ML
1000 ML
500 ML
1/1/2002
3/18/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.002
00074-7953-09
J7120
1/1/2002
00074-7972-05
A4323
1/1/2002
00074-7972-07
A4323
00074-7972-07
A4217
1/1/2004
00074-7972-08
A4323
00074-7972-08
A4217
1/1/2004
00074-7973-05
A4319
1/1/2002
00074-7973-07
A4319
00074-7973-07
A4217
1/1/2004
00074-7973-08
A4319
00074-7973-08
A4217
1/1/2004
00074-7975-07
A4323
00074-7975-07
A4217
1/1/2004
00074-7983-02
J7050
1/1/2002
00074-7983-03
J7040
1/1/2002
1/4/2005 INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT)
00074-7983-09
J7030
1/1/2002
00074-7983-53
J7050
1/1/2002
00074-7983-55
J7040
1/1/2002
00074-7983-61
J7050
1/1/2002
00074-7984-13
J2912
00074-7984-13
A4216
1/1/2004
00074-7984-20
J2912
00074-7984-20
A4216
1/1/2004
00074-7984-23
J7050
2/23/2003
00074-7984-36
J2912
00074-7984-36
A4216
1/1/2004
00074-7984-37
J7050
1/1/2002
00074-7985-02
J7799
1/1/2002
00074-7985-03
J7799
1/1/2002
00074-7985-09
J7799
00074-7990-09
A4712
00074-7990-09
00074-8004-15
00074-8005-15
00074-8026-01
00074-8026-01
00074-8027-01
00074-8027-01
00074-8065-15
A4217
J7799
J7799
J2000
J2001
J2000
J2001
J0330
1/1/2004
1/1/2004
00074-8110-31
J0635
1/1/2002 12/31/2002 INJECTION, CALCITRIOL, 1 MCG AMP.
00074-8110-31
J0636
1/1/2003 99/99/9999 INJECTION, CALCITRIOL, 0.1 MCG
00074-9093-32
J3010
00074-9093-35
J3010
00074-9093-36
J3010

5/7/2002 STERILE SALINE IRRIGATION SOLUTION, 1000 ML.




SODIUM CHLORIDE (FLEXIBLE
CONTAINER,PF) 0.9%
CONTAINER,PF) 0.9%
CONTAINER,PF) 0.9%
SODIUM CHLORIDE (FLEX
CONTAINER,4X3000ML) 0.9%
WATER FOR IRRIGATION (FLEXIBLE
CONTAINER,PF)
CONTAINER,PF)
CONTAINER,PF)
CONTAINER,PF)
CONTAINER,PF)
SODIUM CHLORIDE (PF,LATEX-FREE)
0.45%
0.45%
SODIUM CHLORIDE
(LIFECARE,P.C.,24X250ML) 0.9%
SODIUM CHLORIDE (LIFECARE,P.C.,PF)
0.9%
SODIUM CHLORIDE (LIFECARE,P.C.,PF)
0.9%
SODIUM CHLORIDE (LIFECARE,2
PORTS,PC,LF) 0.9%
PORTS,PC,LF) 0.9%
SODIUM CHLORIDE
SODIUM CHLORIDE (LIFECARE SINGLEP/F) 0.9%
SODIUM CHLORIDE (LIFECARE,QUAD
PACK,LF) 0.9%
PACK,LF) 0.9%
PACK,LF) 0.9%
PACK,LF) 0.9%
PACK,LF) 0.9%
SODIUM CHLORIDE (LATEX-FREE)
0.45%
SODIUM CHLORIDE (LIFECARE,LATEXFREE) 0.45%
SODIUM CHLORIDE (LIFECARE,LATEXFREE) 0.45%
WATER FOR INJECTION
(LIFECARE,PF,LATEX-FREE)
WATER FOR INJECTION
LIDOCAINE HCL 1%
LIDOCAINE HCL 1%
LIDOCAINE HCL (LATEX-FREE) 2%
QUELICIN 20 MG/ML
CALCIJEX (AMP,LOW-ALUMINUM) 1
MCG/ML
CALCIJEX (AMP,LOW-ALUMINUM) 1
MCG/ML
FENTANYL CITRATE (AMP,LATEX-FREE)
0.05 MG/ML
0.05 MG/ML
0.05 MG/ML
Page 43 of 374
1000 ML FC
IV
ML
1000 ML
0.001
01/01/2002
05/17/2005
1000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
05/07/2002
2000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
2000 ML FC
IR
ML
500 ML
0.002
01/01/2004
04/04/2005
3000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
3000 ML FC
IR
ML
500 ML
0.002
01/01/2004
05/17/2005
1000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
05/07/2002
2000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
2000 ML FC
IR
ML
500 ML
0.002
01/01/2004
08/08/2005
3000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
3000 ML FC
IR
ML
500 ML
0.002
01/01/2004
07/13/2005
2000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
2000 ML FC
IR
ML
500 ML
0.002
01/01/2004
4/25/2006
250 ML FC
IV
ML
250 ML
0.004
01/01/2002
06/30/2005
500 ML FC
IV
ML
500 ML
0.002
01/01/2002
01/04/2005
1000 ML FC
IV
ML
1000 ML
0.001
01/01/2002
02/06/2005
250 ML FC
IV
ML
250 ML
0.004
01/01/2002
09/29/2005
500 ML FC
IV
ML
500 ML
0.002
01/01/2002
04/10/2005
150 ML FC
IV
ML
250 ML
0.004
01/01/2002
06/16/2005
50 ML FC
IV
ML
0.9 %
0.5
02/23/2003
12/31/2003
50 ML FC
IV
ML
10 ML
0.1
01/01/2004
06/19/2005
25 ML FC
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
25 ML FC
IV
ML
10 ML
0.1
01/01/2004
06/16/2005
05/17/2005
100 ML FC
IV
ML
250 ML
0.004
02/23/2003
50 ML FC
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
50 ML FC
IV
ML
10 ML
0.1
01/01/2004
07/13/2005
100 ML FC
IV
ML
250 ML
0.004
01/01/2002
07/14/2005
250 ML FC
IV
ML
1 EA
01/01/2002
04/05/2005
500 ML FC
IV
ML
1 EA
01/01/2002
04/05/2005
1000 ML FC
IV
ML
1 EA
01/01/2002
11/23/2004
1000 ML FC
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
1000 ML
500 ML
500 ML
5 ML
5 ML
5 ML
5 ML
5 ML
IV
IV
IV
EP
EP
IJ
IJ
IV
ML
ML
ML
ML
ML
ML
ML
ML
500 ML
1 EA
1 EA
50 ML
10 MG
50 ML
10 MG
20 MG
0.002
1
1
0.02
1
0.02
2
1
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
09/01/2005
07/31/2005
05/16/2005
12/31/2003
05/06/2004
12/31/2003
10/08/2004
99/99/9999
FC
GC
GC
SR
SR
SR
SR
SR
1 ML AM IV
ML
1 MCG
01/01/2002
12/31/2002
1 ML AM IV
ML
0.1 MCG
10
01/01/2003
99/99/9999
2 ML AM IJ
ML
0.1 MG
0.5
3/1/2009
99/99/9999 01/01/2002 11/13/2005
5 ML AM IJ
ML
0.1 MG
0.5
3/1/2009
99/99/9999 01/01/2002 12/12/2005
0.5
10 ML AM IJ
ML
0.1 MG
0.5
3/1/2009
99/99/9999 01/01/2002 07/11/2006
0.5
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.5
00074-9093-38
00074-9094-22
00074-9094-25
00074-9094-28
00074-9094-31
J3010
J3010
J3010
J3010
J3010

0.05 MG/ML
FENTANYL CITRATE
(VIAL,FLIPTOP,LATEX-FREE) 0.05 MG/ML
2 ML VL
1/1/2002
FENTANYL CITRATE
FENTANYL CITRATE
FENTANYL CITRATE
J3010
00074-9104-20
J3490
1/1/2002
00074-9104-20
Q4076
10/1/2003
00074-9137-05
J2000
00074-9137-05
J2001
1/1/2004
00074-9267-18
J3490
1/1/2002
00074-9374-02
J0135
00074-9628-05
J3475
1/1/2002
00074-9629-05
J0460
7/17/2003
00074-9630-05
J0460
00074-9631-04
00075-0620-40
J1940
J1650
1/1/2002 99/99/9999 INJECTION, FUROSEMIDE, UP TO 20 MG

1/1/2002 99/99/9999 INJECTION, ENOXAPARIN SODIUM, 10 MG
00075-0620-41
J1650
00075-0621-60
J1650
00075-0621-61
J1650
00075-0622-80
J1650
00075-0622-81
J1650
00075-0623-00
J1650
00075-0623-01
00075-0624-03
00075-0624-30
J1650
J1650
J1650

00075-0624-31
J1650
00075-0626-03
J1650
00075-0626-04
00075-2451-01
00075-2451-53
00075-2912-01
J1650
J2597
J2597
J1650
00075-2915-01
J1650
00075-8001-20
J9170
1/1/2002 12/31/2009 INJECTION, DOCETAXEL, 20 MG
00075-8001-80
00075-9051-10
00078-0041-01
00078-0053-03
00078-0109-01
00078-0110-22
00078-0120-94
00078-0122-95
00078-0124-96
J9170
J2770
J1110
J2210
J7516
J7502
J1563
J1563
J1563
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002


3/11/2008
1/1/2002
1/1/2002
1/1/2002

99/99/9999 INJECTION, ENOXAPARIN SODIUM, 10 MG

12/31/2009 INJECTION, DOCETAXEL, 20 MG

6/26/2003 INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350)
12/30/2002 INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG
99/99/9999 INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG
99/99/9999 CYCLOSPORIN, PARENTERAL, 250 MG
99/99/9999 CYCLOSPORINE, ORAL, 100 MG
FENTANYL CITRATE
DOPAMINE HCL
DOPAMINE HCL
LIDOCAINE HCL (ANSYR,LATEX-FREE)
1%
LIDOCAINE HCL (ANSYR,LATEX-FREE)
1%
BRETYLIUM TOSYLATE (ABBOJECT) 50
MG/ML
HUMIRA (SINGLE-DOSE,PF) 40 MG/0.8
ML
MAGNESIUM SULFATE (ANSYR,PLASTIC
SRN) 500 MG/ML
ATROPINE SULFATE (ANSYR PLASTIC
SYRINGE) 0.1 MG/ML
SYRINGE) 0.05 MG/ML
FUROSEMIDE (ANSYR,LATEX-FREE) 10
MG/ML
LOVENOX 40 MG/0.4 ML
NOVAPLUS LOVENOX
(10X0.4ML,SINGLE-DOSE,PF) 40 MG/0.4
ML
LOVENOX (SRN,PREFILLED) 60 MG/0.6
ML
NOVAPLUS LOVENOX
ML
ML
NOVAPLUS LOVENOX
ML
LOVENOX (SRN,PREFILLED) 100 MG/ML
NOVAPLUS LOVENOX (10X1ML,SINGLEDOSE,PF) 100 MG/ML
LOVENOX (AMP) 30 MG/0.3 ML
LOVENOX (SRN) 30 MG/0.3 ML
NOVAPLUS LOVENOX
ML
LOVENOX (VIAL,MULTIPLE DOSE VIAL)
100 MG/ML
NOVAPLUS LOVENOX (1X3ML,MULTIPLE
DOSE) 100 MG/ML
DDAVP (AMP) 4 MCG/ML
DDAVP (VIAL) 4 MCG/ML
LOVENOX (W/AUTO SAFETY DEVICE)
150 MG/ML
TAXOTERE (S.D.V. W/DILUENT) 20
MG/0.5 ML
TAXOTERE (S.D.V. W/DILUENT) 20
MG/0.5 ML
SYNERCID (PF) 350 MG-150 MG
D.H.E. 45 (AMP) 1 MG/ML
METHERGINE (AMP) 0.2 MG/ML
SANDIMMUNE (AMP) 50 MG/ML
SANDIMMUNE 100 MG/ML
SANDOGLOBULIN (S.D.V.) 1 GM
SANDOGLOBULIN 3 GM
SANDOGLOBULIN 6 GM
Page 44 of 374
20 ML AM IJ
99/99/9999 01/01/2002 03/02/2006
ML
0.1 MG
0.5
3/1/2009
IJ
ML
0.1 MG
0.5
01/01/2002
10/11/2005
5 ML VL
IJ
ML
0.1 MG
0.5
01/01/2002
11/06/2005
10 ML VL
IJ
ML
0.1 MG
0.5
3/1/2009
99/99/9999 01/01/2002 02/13/2006
0.5
20 ML VL
IJ
ML
0.1 MG
0.5
3/1/2009
99/99/9999 01/01/2002 09/22/2005
0.5
50 ML VL
IJ
ML
0.1 MG
0.5
01/01/2002
12/29/2005
10 ML VL
IV
ML
1 EA
01/01/2002
09/30/2003
10 ML VL
IV
ML
40 MG
10/01/2003
06/30/2005
5 ML SR
EP
ML
50 ML
0.02
01/01/2002
12/31/2003
06/29/2005
5 ML SR
EP
ML
10 MG
01/01/2004
10 ML SR
IV
ML
1 EA
01/01/2002
05/07/2002
2 EA BX
SC
EA
20 MG
02/22/2008
99/99/9999
04/01/2006
5 ML SR
IJ
ML
500 MG
01/01/2002
10 ML SR
IJ
ML
0.3 MG
0.33333
07/17/2003
4/25/2006
5 ML SR
IJ
ML
0.3 MG
0.16666
07/17/2003
10/18/2004
4 ML SR
0.4 ML SR
IJ
IJ
ML
ML
20 MG
10 MG
0.5
10
3/1/2009 99/99/9999 01/01/2002

01/01/2002 99/99/9999
0.4 ML SR
SC
ML
10 MG
10
03/17/2008
99/99/9999
0.6 ML SR
IJ
ML
10 MG
10
01/01/2002
99/99/9999
0.6 ML SR
SC
ML
10 MG
10
03/11/2008
99/99/9999
0.8 ML SR
IJ
ML
10 MG
10
01/01/2002
99/99/9999
0.8 ML SR
1 ML SR
SC
ML
10 MG
10
03/11/2008
99/99/9999
IJ
ML
10 MG
10
01/01/2002
99/99/9999
ML
ML
ML
10 MG
10 MG
10 MG
10
10
10
03/11/2008
01/01/2002
01/01/2002
99/99/9999
04/30/2003
99/99/9999
1 ML SR SC
0.3 ML AM SC
0.3 ML SR IJ
0.3 ML SR
SC
ML
10 MG
10
03/17/2008
99/99/9999
3 ML VL
SC
ML
10 MG
10
03/07/2003
99/99/9999
VL
AM
VL
SR
IJ
IJ
IJ
IJ
ML
ML
ML
ML
10 MG
1 MCG
1 MCG
10 MG
10
4
4
15
03/11/2008
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
3 ML
1 ML
10 ML
0.8 ML
1 ML SR
IJ
ML
10 MG
15
01/01/2002
99/99/9999
0.5 ML VL
IV
ML
20 MG
01/01/2002
12/31/2009
2 ML
1 EA
1 ML
1 ML
5 ML
50 ML
1 EA
1 EA
1 EA
IV
IV
IJ
IJ
IV
PO
IV
IV
IV
ML
EA
ML
ML
ML
ML
EA
EA
EA
20 MG
500 MG
1 MG
0.2 MG
250 MG
100 MG
1 GM
1 GM
1 GM
2
1
1
1
0.2
1
1
3
6
01/01/2002
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/31/2009
06/26/2003
12/30/2002
99/99/9999
99/99/9999
99/99/9999
05/25/2004
05/25/2004
05/25/2004
VL
VL
AM
AM
AM
BO
VL
GC
GC
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
00074-9094-61
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.5
4/20/2006
0.5
1/1/2002 12/31/2002
00078-0149-23
00078-0180-01
J0630
J2352
00078-0180-01
00078-0180-03
00078-0181-01
J2354
J2352
J2352
00078-0181-01
00078-0181-03
00078-0182-01
J2354
J2352
J2352
00078-0182-01
00078-0182-03
00078-0183-25
J2354
J2352
J2352
00078-0183-25
00078-0184-25
J2354
J2352
1/1/2002 99/99/9999 INJECTION, CALCITONIN SALMON, UP TO 400 UNITS

3/28/2003 12/31/2003 INJECTION, OCTREOTIDE ACETATE, 1 MG
INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR
1/1/2004 99/99/9999 INTRAVENOUS INJECTION, 25 MCG
MIACALCIN (VIAL) 200 IU/ML

SANDOSTATIN (AMP) 50 MCG/ML
2 ML VL IJ
1 ML AM IJ
ML
ML

1 ML AM IJ
1 ML AM IJ
1 ML AM IJ
ML
ML
ML

1 ML AM IJ
1 ML AM IJ
1 ML AM IJ

SANDOSTATIN (M.D.V.) 200 MCG/ML
01/01/2002
03/28/2003
99/99/9999
12/31/2003
25 MCG
1 MG
1 MG
2
0.05
0.1
01/01/2004
01/01/2002
03/28/2003
99/99/9999
03/28/2003
12/31/2003
ML
ML
ML
25 MCG
1 MG
1 MG
4
0.1
0.5
01/01/2004
01/01/2002
03/28/2003
99/99/9999
03/28/2003
12/31/2003
1 ML AM IJ
1 ML AM IJ
5 ML VL IJ
ML
ML
ML
25 MCG
1 MG
1 MG
20
0.5
0.2
01/01/2004
01/01/2002
01/01/2002
99/99/9999
03/28/2003
12/31/2003
5 ML VL
5 ML VL
ML
ML
25 MCG
1 MG
8
1
01/01/2004
01/01/2002
99/99/9999
12/31/2003
25 MCG
00078-0184-25
J2354
J7515
J7502
J1563
J7515
J7502
J7502
Q2019
J0480
00078-0340-61
J2353
00078-0340-84
J2352
00078-0340-84
J2353
1/1/2004
00078-0341-61
J2353
00078-0341-84
J2352
00078-0341-84
J2353
1/1/2004
00078-0342-61
J2353
00078-0342-84
J2352
00078-0342-84
00078-0347-51
00078-0350-84
00078-0373-66
J2353
J0895
J3487
J8999
1/1/2004 10/1/2004 INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG

1/1/2002 99/99/9999 INJECTION, DEFEROXAMINE MESYLATE, 500 MG
1/1/2003 5/23/2003 INJECTION, ZOLEDRONIC ACID (ZOMETA), 1 MG
1/1/2002
00078-0385-66
J7599
3/1/2004 12/31/2004 IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED
MYFORTIC (K-30,FILM-COATED) 180 MG
120 EA BO
PO
EA
1 EA
03/01/2004
12/31/2004
00078-0385-66
J7518
1/1/2005 99/99/9999 MYCOPHENOLIC ACID, ORAL, 180 MG
120 EA BO
PO
EA
180 MG
01/01/2005
99/99/9999
00078-0386-66
J7599
3/1/2004 12/31/2004 IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED
00078-0386-66
00078-0387-25
00078-0393-61
00078-0393-61
00078-0435-61
00078-0435-61
00078-0437-61
00078-0463-91
00078-0464-61
00078-0467-91
J7518
J3487
Q2019
J0480
Q4095
J3488
J3396
J2430
J2430
J0895
00078-0494-71
J7682
00078-0494-71 KO J7682
00078-0495-61
00081-0045-35
00083-0167-02
J9015
None
J7699
00083-0167-74
00083-2601-04
00083-2609-01
00083-3801-04
J7699
J2430
J2430
J0895

12/31/2005 INJECTION, BASILIXIMAB, 20 MG
10/1/2004 INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG
10/1/2004 INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG
1/1/2005
5/1/2003
1/2/2003
1/1/2006
7/1/2007
1/1/2008
10/18/2005
7/13/2006
7/13/2006
5/1/2007
KO
99/99/9999 MYCOPHENOLIC ACID, ORAL, 180 MG

99/99/9999 INJECTION, ZOLEDRONIC ACID (ZOMETA), 1 MG
12/31/2007 INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG
99/99/9999 INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG
99/99/9999 INJECTION, VERTEPORFIN, 0.1 MG
99/99/9999 INJECTION, PAMIDRONATE DISODIUM, PER 30 MG
4/1/2008 99/99/9999 MILLIGRAMS
4/1/2008 99/99/9999 MILLIGRAMS
12/12/2007 99/99/9999 INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL

1/1/1994 7/26/1996 MELPHALAN, 2 MG, ORAL
1/1/2002
1/1/2002
1/1/2002
1/1/2002
5/7/2003 NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME

5 ML VL
IJ
ML
40
01/01/2004
99/99/9999
PO
PO
IV
PO
PO
PO
IV
IV
EA
EA
EA
EA
EA
ML
EA
EA
25 MG
100 MG
1 GM
25 MG
100 MG
100 MG
20 MG
20 MG
1
1
12
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2006
99/99/9999
99/99/9999
05/25/2004
99/99/9999
99/99/9999
99/99/9999
12/31/2005
99/99/9999
1 EA BX
IM
EA
1 MG
10
07/26/2004
99/99/9999
1 EA BX
IJ
EA
1 MG
10
01/01/2002
12/31/2003
1 EA BX
IJ
EA
1 MG
10
01/01/2004
10/01/2004
1 EA BX
IM
EA
1 MG
20
08/18/2004
99/99/9999
1 EA BX
IJ
EA
1 MG
20
01/01/2002
12/31/2003
1 EA BX
IJ
EA
1 MG
20
01/01/2004
10/01/2004
1 EA BX
IM
EA
1 MG
30
07/14/2004
99/99/9999
1 EA BX
IJ
EA
1 MG
30
01/01/2002
12/31/2003
IJ
IJ
IV
PO
EA
EA
EA
EA
1 MG
500 MG
1 MG
1 EA
30
4
4
1
01/01/2004
01/01/2002
01/01/2003
01/01/2002
10/01/2004
99/99/9999
05/23/2003
09/02/2003
30 EA
30 EA
1 EA
30 EA
30 EA
50 ML
1 EA
1 EA
1 EA
1 EA
1 EA
120 EA
BX
BX
BO
BX
BX
BO
VL
VL
BX
VL
VL
BO
120 EA BO
PO
EA
1 EA
03/01/2004
12/31/2004

ZOMETA (CONCENTRATE) 4 MG/5 ML
SIMULECT (S.D.V.,PF) 10 MG
RECLAST
RECLAST
VISUDYNE 15 MG
AREDIA 30 MG
AREDIA 90 MG
DESFERAL (USP) 500 MG
120 EA
5 ML
1 EA
1 EA
100 ML
100 ML
1 EA
1 EA
1 EA
1 EA
PO
IV
IV
IV
IV
IV
IV
IV
IV
IJ
EA
ML
EA
EA
ML
ML
EA
EA
EA
EA
180 MG
1 MG
20 MG
20 MG
1 MG
1 MG
0.1 MG
30 MG
30 MG
500 MG
2
0.8
0.5
0.5
0.05
0.05
150
1
3
1
01/01/2005
05/01/2003
01/02/2003
01/01/2006
07/01/2007
01/01/2008
10/18/2005
07/13/2006
07/13/2006
05/01/2007
99/99/9999
99/99/9999
12/31/2005
99/99/9999
12/31/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
IH
ML
300 MG
0.2
04/01/2008
99/99/9999
300 MG
0.2
04/01/2008
99/99/9999
1
1
1
12/12/2007
01/01/1994
01/01/2002
99/99/9999
07/26/1996
07/20/2003
1
1
3
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/07/2003
07/12/2006
07/12/2006
04/30/2007
TOBI (56X5ML,SDA,PF)
TOBI (56X5ML,SDA,PF)
PROLEUKIN (PF,LYOPHILOZED) 22
Million IU
ALKERAN 2 MG
FORADIL AEROLIZER (2X6) 0.012 MG
FORADIL AEROLIZER (BLISTER
PACK,10X6) 0.012 MG
AREDIA (VIAL) 30 MG
AREDIA (VIAL) 90 MG
DESFERAL 500 MG
Page 45 of 374
BO
VL
VL
VL
PC
PC
VL
VL
VL
VL
5 ML PC
5 ML PC
IH
ML
1 EA VL
50 EA BO
12 EA BX
IV
PO
IH
EA
EA
EA
60 EA
1 EA
1 EA
1 EA
IH
IV
IV
IJ
EA
EA
EA
EA
BX
VL
VL
VL
1 VIAL
2 MG
1 EA
1 EA
30 MG
30 MG
500 MG
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
0.5
0.05
IJ
IJ
400 U
1 MG
00078-0240-15
00078-0241-15
00078-0244-93
00078-0246-15
00078-0248-15
00078-0274-22
00078-0331-84
00078-0331-84
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2006

SANDIMMUNE (SANDOPAK,SOFTGEL)
25 MG
SANDIMMUNE (SOFTGEL) 100 MG
SANDOGLOBULIN 12 GM
NEORAL (SOFTGEL) 25 MG
NEORAL (SOFTGEL) 100 MG
NEORAL 100 MG/ML
SANDOSTATIN LAR DEPOT
(1&1/2"X19G,PFS) 10 MG
SANDOSTATIN LAR DEPOT (VIAL
W/DILUENT) 10 MG
W/DILUENT) 10 MG
(1&1/2"X19G,PFS) 20 MG
W/DILUENT) 20 MG
W/DILUENT) 20 MG
(1&1/2"X19G,PFS) 30 MG
W/DILUENT) 30 MG
W/DILUENT) 30 MG
DESFERAL (VIAL) 2 GM
ZOMETA (STERILE) 4 MG
GLEEVEC 100 MG
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
PRISCOLINE HYDROCHLORIDE (AMP) 25

MG/ML
TRILAFON (AMP) 5 MG/ML
GARAMYCIN (VIAL) 40 MG/ML
00083-6733-04
00085-0012-04
00085-0069-04
J2670
J3310
J1580
1/1/2002
1/1/2002
1/1/2002
TRILAFON 16 MG
1/1/2002
INTRON A (W/DILUENT IN VIAL) 5 Million
1/1/2002
8/5/2002 INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS
IU
1/1/2002 99/99/9999 INJECTION, DIAZOXIDE, UP TO 300 MG
HYPERSTAT (AMP) 15 MG/ML
SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 1 MG
PROVENTIL 0.5%
1/1/2002 5/24/2002 (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)
SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE, PER 1 MG (ALBUTEROL) OR
1/1/2002 5/27/2002 PER 0.5 MG (LEVALBUTEROL)
PROVENTIL 0.083%
PROVENTIL 0.083%
1/1/2002
IU
PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR
TRILAFON 8 MG
1/1/2002 5/17/2002 REGIMEN
1/1/2002 5/17/2002 INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG
SOLGANAL (VIAL) 50 MG/ML
EULEXIN 125 MG
EULEXIN 125 MG
EULEXIN 125 MG
1/1/2002 99/99/9999 INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS
IU
INJECTION, BETAMETHASONE ACETATE 3MG AND BETAMETHASONE SODIUM
CELESTONE SOLUSPAN (M.D.V.) 3
1/1/2002 99/99/9999 PHOSPHATE 3MG
MG/ML-3 MG/ML
IU
INTRON A (PAK-3, W/DILUENT IN SRN) 3
1/1/2002
Million IU
PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR
TRILAFON 2 MG
1/1/2002 5/17/2002 REGIMEN
METICORTEN 1 MG
BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
CELESTONE PHOSPHATE (M.D.V.) 3
1/1/2002 5/16/2002 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
MG/ML
CELESTONE PHOSPHATE (M.D.V.) 3
MG/ML
TRILAFON 4 MG
1/1/2002 5/17/2002 REGIMEN
IU
INTRON A (M.D.V.,AF) 10 Million IU/ML
1/1/2002 99/99/9999 INJECTION, EPTIFIBATIDE, 5 MG
INTEGRILIN (VIAL) 0.75 MG/ML
INTRON A (M.D.V.,AF) 6 Million IU/ML
INTEGRILIN (VIAL) 2 MG/ML
INTEGRILIN (VIAL) 2 MG/ML
INTRON A (VIAL/SRN,PAK10,AF) 10
Million IU/ML
INTRON A (VIAL/SRN,PAK-3,AF) 3 Million
1/1/2002
IU/0.5 ML
INTRON A (VIAL/SRN,PAK-5,AF) 5 Million
1/1/2002
IU/0.5 ML
INTRON A (M.D. PEN,6 DOSE UNIT) 5
Million IU/0.2 ML
REBETRON 1200 (M.D.V.)
1/1/2002
REBETRON 1200 (PAK-3)
Million IU/0.2 ML
1/1/2000
1/5/2009 TEMODAR, 20 MG, ORAL
TEMODAR 20 MG
1/1/2000
TEMODAR 20 MG
1/1/2000
TEMODAR 5 MG
1/1/2000
TEMODAR 5 MG
4/9/2007 99/99/9999 TEMODAR, 5 MG, ORAL
TEMODAR 5 MG
1/1/2000
TEMODAR 250 MG
1/1/2000
TEMODAR 250 MG
00085-0077-05
Q0176
00085-0120-02
00085-0201-05
J9214
J1730
00085-0208-02
J7618
00085-0209-01
J7619
00085-0209-01 KO J7619
00085-0285-02
J9214
00085-0313-05
00085-0460-03
00085-0525-03
00085-0525-05
00085-0525-06
Q0176
J2910
J8999
J8999
J8999
00085-0539-01
J9214
00085-0566-05
J0702
00085-0571-02
J9214
00085-0647-05
J9214
00085-0705-04
00085-0843-03
Q0175
J7506
00085-0879-05
J7624
00085-0879-05 KO J7624
00085-0940-05
Q0175
00085-1110-01
00085-1133-01
00085-1136-01
00085-1168-01
00085-1177-01
00085-1177-02
J9214
J9214
J1327
J9214
J1327
J1327
00085-1179-02
J9214
00085-1184-02
J9214
00085-1191-02
J9214
00085-1235-01
00085-1236-01
00085-1236-02
00085-1236-03
00085-1241-01
00085-1241-02
00085-1241-03
J9214
J3490
J3490
J3490
J3490
J3490
J3490
00085-1242-01
00085-1244-01
00085-1244-02
00085-1248-01
00085-1248-02
00085-1248-03
00085-1252-01
00085-1252-02
J9214
None
None
None
None
None
None
None
KO
KO
11/6/2002 INJECTION, TOLAZOLINE HCL, UP TO 25 MG

5/17/2002 INJECTION, PERPHENAZINE, UP TO 5 MG
5/17/2002 REGIMEN
Page 46 of 374
4 ML AM IJ
1 ML AM IJ
2 ML VL IJ
100 EA BO
ML
ML
ML
1
1
0.5
01/01/2002
01/01/2002
01/01/2002
EA
8 MG
01/01/2002
05/17/2002
1 MU
300 MG
5
0.05
01/01/2002
01/01/2002
08/05/2002
99/99/9999
20 ML BO
IH
ML
1 MG
01/01/2002
05/24/2002
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
05/27/2002
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
05/27/2002
1 EA VL
IJ
EA
1 MU
25
01/01/2002
08/05/2002
PO
IM
PO
PO
PO
EA
ML
EA
EA
EA
8 MG
50 MG
1 EA
1 EA
1 EA
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/17/2002
05/17/2002
09/30/2004
09/30/2005
09/30/2005
1 EA VL
IJ
EA
1 MU
50
01/01/2002
99/99/9999
5 ML VL
IJ
ML
3 MG
01/01/2002
99/99/9999
1 EA VL
IJ
EA
1 MU
10
01/01/2002
99/99/9999
1 EA SR
IJ
EA
1 MU
01/01/2002
08/05/2002
PO
PO
EA
EA
4 MG
5 MG
0.5
0.2
01/01/2002
01/01/2002
05/17/2002
05/17/2002
5 ML VL
IJ
ML
1 MG
01/01/2002
05/16/2002
5 ML VL
IJ
ML
1 MG
01/01/2002
05/16/2002
100 EA BO
100 EA BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
11/06/2002
05/17/2002
11/01/2003
EA
ML
BO
VL
BX
BO
BO
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
25 MG
5 MG
80 MG
1 EA VL IJ
20 ML AM IV
100 EA
10 ML
100 EA
500 EA
180 EA
PO
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
100 EA BO
PO
EA
4 MG
01/01/2002
05/17/2002
1 EA
2.5 ML
100 ML
3 ML
10 ML
100 ML
VL
VL
VL
VL
VL
VL
IJ
IJ
IV
IJ
IV
IV
EA
ML
ML
ML
ML
ML
1
1
5
1
5
5
MU
MU
MG
MU
MG
MG
18
10
0.15
6
0.4
0.4
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
6 EA BX
IJ
EA
1 MU
60
01/01/2002
10/03/2006
6 EA BX
IJ
EA
1 MU
18
01/01/2002
08/05/2002
6 EA BX
IJ
EA
1 MU
30
01/01/2002
08/05/2002
1.5 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BX
VL
VL
VL
BX
BX
BX
IJ
MR
MR
MR
MR
MR
MR
ML
EA
EA
EA
EA
EA
EA
1 MU
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
25
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
11/30/2004
11/30/2004
11/30/2004
09/07/2003
12/11/2005
12/07/2003
1.5 ML
5 EA
20 EA
5 EA
20 EA
14 EA
5 EA
20 EA
BX
BO
BO
BO
BO
BO
BO
BO
IJ
PO
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
EA
1 MU
20 MG
20 MG
5 MG
5 MG
5 MG
250 MG
250 MG
15
1
1
1
1
1
1
1
01/01/2002
01/01/2000
01/01/2000
01/01/2000
01/01/2000
04/09/2007
01/01/2000
01/01/2000
99/99/9999
1/5/2009
1/5/2009
1/5/2009
1/5/2009
99/99/9999
1/5/2009
1/5/2009
J3490
00085-1291-01
00085-1297-01
00085-1297-02
J3490
J3490
J3490

00085-1304-01
00085-1316-01
00085-1316-02
00085-1323-01
00085-1323-02
J3490
J3490
J3490
J3490
J3490
1/1/2002
2/2/2004
3/7/2005
2/2/2004
3/7/2005
00085-1336-01
J7602
1/1/2008
J7611
None
None
4/1/2008
4/9/2007
4/9/2007
00085-1368-01
00085-1370-01
00085-1370-02
00085-1401-01
00085-1402-01
00085-1417-01
00085-1425-01
00085-1425-02
00085-1430-01
00085-1430-02
00085-1519-01
00085-1519-02
00085-1731-01
J3490
J3490
J3490
J7699
J7699
None
None
None
None
None
None
None
J0744
1/1/2002
2/2/2004
3/7/2005
8/20/2003
7/21/2003
4/9/2007
4/9/2007
4/9/2007
4/9/2007
4/9/2007
4/9/2007
4/9/2007
8/17/2005

SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED
THROUGH DME, CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG
3/31/2008 (LEVALBUTEROL)
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MG
00085-1737-01
J2280
8/17/2005 99/99/9999 INJECTION, MOXIFLOXACIN, 100 MG
00085-1741-02
J0744
8/17/2005 99/99/9999 INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, 200 MG
00085-1755-02
J0744
00085-1762-01
00085-1763-03
J0744
J0744

00085-1781-01
J0744
00085-1806-01
Q4094

THROUGH DME, UNIT DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG
7/1/2007 12/31/2007 (LEVALBUTEROL)
7/1/2007 12/31/2007 (LEVALBUTEROL)
1/1/2008
1/1/2008
1/30/2008 99/99/9999 TEMODAR, 5 MG, ORAL
1/30/2008 99/99/9999 TEMODAR, 5 MG, ORAL
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00085-1806-01 KO Q4094
00085-1806-01
J7603
00085-1806-01 KO J7603
00085-3004-01
None
00085-3004-02
None
00087-0570-03
KO
J7608
00087-0570-07 KO J7608
00087-0570-09
KO
J7608
00087-0570-03 KO J7608
00087-0570-07
KO
J7608
KO
1 EA BX
MR
EA
1 EA
01/01/2002
99/99/9999
1 EA BX
1 EA BX
1 EA BX
MR
MR
MR
EA
EA
EA
1 EA
1 EA
1 EA
1
1
1
01/01/2002
02/02/2004
03/07/2005
99/99/9999
99/99/9999
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
MR
MR
MR
MR
MR
EA
EA
EA
EA
EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
01/01/2002
02/02/2004
03/07/2005
02/02/2004
03/07/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
BX
BX
BX
BX
BX
CF
HCPCS Amount #1
PROVENTIL 0.5%
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
PROVENTIL 0.5%
TEMODAR 100 MG
TEMODAR 100 MG
PEG-INTRON (VIAL/SRN/DILUENT,PF) 50
MCG
PEG-INTRON (PF,REDIPEN) 150 MCG
TEMODAR 250 MG
TEMODAR 140 MG
TEMODAR 140 MG
TEMODAR 180 MG
TEMODAR 180 MG
TEMODAR 20 MG
TEMODAR 20 MG
ML
CIPRO IV (PRE-MIXED W/DEX) 400
MG/200 ML
CIPRO IV (PRE-MIXED W/DEX) 200
MG/100 ML
CIPRO IV (PRE-MIXED W/DEX,BAXTER)
400 MG/200 ML
CIPRO IV (PRE-MIXED W/DEX,BAXTER)
200 MG/100 ML
20 ML BO
14 EA BO
5 EA BO
IH
PO
PO
ML
EA
EA
1 MG
100 MG
100 MG
5
1
1
04/01/2008
04/09/2007
04/09/2007
99/99/9999
99/99/9999
99/99/9999
1 EA
1 EA
1 EA
60 EA
12 EA
5 EA
5 EA
14 EA
5 EA
14 EA
14 EA
5 EA
40 ML
MR
MR
MR
IH
IH
PO
PO
PO
PO
PO
PO
PO
IV
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
1 EA
1 EA
1 EA
1 EA
1 EA
250 MG
20 MG
20 MG
20 MG
20 MG
20 MG
20 MG
200 MG
1
1
1
1
1
1
7
7
9
9
1
1
0.05
01/01/2002
02/02/2004
03/07/2005
08/20/2003
07/21/2003
04/09/2007
04/09/2007
04/09/2007
04/09/2007
04/09/2007
04/09/2007
04/09/2007
08/17/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
4/1/2009
BX
BX
BX
BX
BX
BO
BO
BO
BO
BO
BO
BO
VL
250 ML FC
IV
ML
100 MG
0.016
08/17/2005
99/99/9999
200 ML FC
IV
ML
200 MG
0.01
08/17/2005
99/99/9999
100 ML FC
IV
ML
200 MG
0.01
08/17/2005
99/99/9999
400 ML FC
20 ML VL
IV
IV
ML
ML
200 MG
200 MG
0.01
0.05
08/17/2005
08/17/2005
99/99/9999
99/99/9999
100 ML FC
IV
ML
200 MG
0.01
08/17/2005
99/99/9999
PROVENTIL 0.083%
3 ML PC
IH
ML
1 MG
0.83
07/01/2007
12/31/2007
PROVENTIL 0.083%
3 ML PC
IH
ML
1 MG
0.83
07/01/2007
12/31/2007
PROVENTIL 0.083%
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/03/2008
PROVENTIL 0.083%
TEMODAR 5 MG
TEMODAR 5 MG
3 ML PC
14 EA BO
5 EA BO
IH
PO
PO
ML
EA
EA
1 MG
5 MG
5 MG
0.83
1
1
01/01/2008
01/30/2008
01/30/2008
03/03/2008
99/99/9999
99/99/9999
MUCOMYST 20%
10 ML VL
IH
ML
1 GM
0.2
01/01/2002
04/01/2004
MUCOMYST 20%
10 ML VL
IH
ML
1 GM
0.2
01/01/2002
04/01/2004
MUCOMYST 20%
4 ML VL
IH
ML
1 GM
0.2
01/01/2002
08/01/2004
MUCOMYST 20%
4 ML VL
IH
ML
1 GM
0.2
01/01/2002
08/01/2004
MUCOMYST 20%
30 ML VL
IH
ML
1 GM
0.2
01/01/2002
08/01/2005
Page 47 of 374
99/99/9999
11/30/2004
11/30/2004
11/30/2004
1/5/2009
1/5/2009
Prior End Date #3
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2000
01/01/2000
Prior Start Date #3
50
1
1
1
1
1
1 MU
1 EA
1 EA
1 EA
100 MG
100 MG
Prior End Date #2
ML
EA
EA
EA
EA
EA
End Date #1
IJ
MR
MR
MR
PO
PO
Start Date #1
BX
BX
BX
BX
BO
BO
HCPCS Measure #1
1.5 ML
1 EA
1 EA
1 EA
5 EA
20 EA
Prior Start Date #2

Package
NDC Label
Million IU/0.2 ML
REBETRON 1200 (M.D. PEN)
TEMODAR 100 MG
TEMODAR 100 MG
PEG-INTRON (VIAL/SRN/DILUENT,PF)
150 MCG
PEG-INTRON (VIAL/SRN/DILUENT,PF) 80
MCG
PEG-INTRON (VIAL/SRN/DILUENT,PF)
120 MCG
Billing Units
00085-1279-01
00085-1336-01
00085-1366-01
00085-1366-02

1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2000
1/1/2000
NDC Package Type
J9214
J3490
J3490
J3490
None
None
NDC Package Measure
00085-1254-01
00085-1258-01
00085-1258-02
00085-1258-03
00085-1259-01
00085-1259-02
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00087-0572-01
J7608
00087-0572-01 KO J7608
00087-0572-02
00087-0572-03
KO
1/1/2002
1/1/2002
KO
J7608
00087-0572-03 KO J7608
00087-6011-42
J0706
1/1/2002
1/1/2002
J7608
00087-0572-02 KO J7608
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2004
00088-1150-03
Q2010
00088-1153-30
Q2010
1/1/2002
00088-1153-30
J1595
1/1/2004
00088-1202-05
Q0180
1/1/2002
00088-1202-29
Q0180
1/1/2002
00088-1202-43
Q0180
1/1/2002
00088-1203-05
Q0180
1/1/2002
00088-1203-29
Q0180
1/1/2002
00088-1203-43
00088-1206-32
00088-1208-06
00088-1208-65
00088-1208-69
00088-1208-76
00088-1209-26
00088-2150-57
00088-2220-33
00088-2220-33
00088-2220-52
00088-2220-60
Q0180
J1260
J1260
J1260
J1260
J1260
J1260
Q2021
J1820
J1815
J1815
J1815
1/1/2002
1/1/2002
12/15/2003
1/1/2002
1/1/2002
2/20/2002
7/21/2003
1/1/2002
1/1/2002
1/1/2003
1/10/2005
7/9/2007

11/4/2008 INJECTION, CAFFEINE CITRATE, 5MG
5/2/2002 INJECTION, GLATIRAMER ACETATE, PER DOSE
4/18/2002 12/31/2003 INJECTION, GLATIRAMER ACETATE, PER DOSE

4/27/2008 INJECTION, GLATIRAMER ACETATE, 20 MG
DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTION ANTIEMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTIEMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24
99/99/9999 INJECTION, DOLASETRON MESYLATE, 10 MG
2/26/2002 INJECTION, LEPIRUDIN, 50 MG
30 ML VL
IH
ML
1 GM
0.2
01/01/2002
08/01/2005
MUCOMYST 10%
10 ML VL
IH
ML
1 GM
0.1
01/01/2002
02/01/2005
MUCOMYST 10%
10 ML VL
IH
ML
1 GM
0.1
01/01/2002
02/01/2005
MUCOMYST 10%
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
04/26/2006
MUCOMYST 10%
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
04/26/2006
MUCOMYST 10%
4 ML VL
IH
ML
1 GM
0.1
01/01/2002
08/01/2004
MUCOMYST 10%
CAFCIT (S.D.V.) 20 MG/ML
COPAXONE (SDV,DILUENT,SRN,NDL,PF)
20 MG
COPAXONE (30 SRN,PREFILLED,PF) 20
MG/ML
MG/ML
4 ML VL
3 ML VL
IH
IJ
ML
ML
1 GM
5 MG
0.1
4
01/01/2002
01/01/2004
08/01/2004
11/4/2008
32 VL BX
SC
EA
1 DOSE
01/01/2002
05/02/2002
1 ML DP
MR
EA
1 DOSE
30
04/18/2002
12/31/2003
1 ML DP
MR
EA
20 MG
30
01/01/2004
04/27/2008
ANZEMET 50 MG
5 EA BO
PO
EA
100 MG
0.5
01/01/2002
99/99/9999
ANZEMET (BLISTER PACK,1X5) 50 MG
5 EA BX
PO
EA
100 MG
0.5
01/01/2002
08/04/2004
10 EA BX
PO
EA
100 MG
0.5
01/01/2002
99/99/9999
ANZEMET 100 MG
5 EA BO
PO
EA
100 MG
01/01/2002
99/99/9999
ANZEMET (BLISTER PACK,1X5) 100 MG
5 EA BX
PO
EA
100 MG
01/01/2002
10/15/2004
PO
IV
IV
IV
IV
IV
IV
IV
SC
SC
SC
SC
EA
ML
ML
ML
ML
ML
ML
EA
ML
ML
ML
ML
100 MG
10 MG
10 MG
10 MG
10 MG
10 MG
10 MG
50 MG
100 U
5U
5U
5U
1
2
2
2
2
2
2
1
1
20
20
20
01/01/2002
01/01/2002
12/15/2003
01/01/2002
01/01/2002
02/20/2002
07/21/2003
01/01/2002
01/01/2002
01/01/2003
01/10/2005
07/09/2007
99/99/9999
99/99/9999
99/99/9999
02/09/2004
04/04/2002
99/99/9999
99/99/9999
02/26/2002
12/31/2002
99/99/9999
99/99/9999
99/99/9999
ANZEMET 50 MG
ANZEMET 100 MG
ANZEMET (S.D.V.) 20 MG/ML
ANZEMET (S.D.V.) 20 MG/ML
ANZEMET (AMP) 20 MG/ML
ANZEMET (CARPUJECT) 20 MG/ML
ANZEMET 20 MG/ML
ANZEMET (M.D.V.) 20 MG/ML
REFLUDAN (VIAL) 50 MG
LANTUS 100 U/ML
LANTUS 100 U/ML
LANTUS (U-100,5X3ML) 100 U/ML
LANTUS SOLOSTAR 100 U/ML
00088-2500-33
J1817
1/24/2006 99/99/9999 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS APIDRA 100 U/ML
J1815
00088-2502-05
J1817
00089-0510-06
00089-0540-06
J0600
J2360
00091-1010-06
J0270
00091-1020-06
J0270
00091-1027-22
J0270
00091-1029-22
J0270
00091-1032-22
J0270
APIDRA (5X3ML,OPTICLIK PEN) 100 U/ML
3/4/2009 99/99/9999 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS APIDRA SOLOSTAR (5X3ML) 100U/ML
CALCIUM DISODIUM VERSENATE (AMP)
1/1/2002 99/99/9999 INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG
200 MG/ML
1/1/2002 99/99/9999 INJECTION, ORPHENADRINE CITRATE, UP TO 60 MG
NORFLEX (AMP) 30 MG/ML
EDEX (6 S.D.V. PER CARTON) 10 MCG
1/1/2002
1/1/2002
EDEX CARTRIDGE REFILL PACK (2 S.D.
CARTRIDGES/NDLS) 10 MCG
1/1/2002
1/1/2002
1/1/2002
Page 48 of 374
10 EA
5 ML
0.625 ML
0.625 ML
0.625 ML
0.625 ML
25 ML
1 EA
10 ML
10 ML
3 ML
3 ML
BX
VL
VL
AM
CT
CT
VL
VL
VL
VL
CT
SR
10 ML VL
SC
ML
50 U
01/24/2006
99/99/9999
3 ML CT
SC
ML
5U
20
01/24/2006
99/99/9999
3 ML EA
IJ
ML
50 U
5 ML AM IJ
2 ML AM IJ
ML
ML
1000 MG
60 MG
3/4/2009
99/99/9999
0.2
0.5
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1 EA VL
IC
EA
1.25 MCG
01/01/2002
09/01/2004
1 EA VL
IC
EA
1.25 MCG
16
01/01/2002
09/01/2004
2 EA BX
IC
EA
1.25 MCG
16
01/01/2002
09/01/2004
2 EA BX
IC
EA
1.25 MCG
32
01/01/2002
09/01/2004
2 EA BX
IC
EA
1.25 MCG
64
01/01/2002
09/01/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure
MUCOMYST 20%
00088-2500-52

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
00087-0570-09 KO J7608
NDC
HCPCS
00091-1040-06
J0270
1/1/2002
00091-1110-11
J0270
1/1/2002
00091-1110-16
J0270
9/2/2004
00091-1110-20
J0270
9/2/2004
00091-1120-11
J0270
1/1/2002
00091-1120-16
J0270
9/2/2004
00091-1120-20
J0270
9/2/2004
12/3/2003 INJECTION, KUTAPRESSIN, UP TO 2 ML
4/15/2009 INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG
1 EA VL
IC
EA
1.25 MCG
32
01/01/2002
09/01/2004
EDEX CARTRIDGE STARTER PACK 10

MCG
2 EA BX
IC
EA
1.25 MCG
16
01/01/2002
09/01/2004
EDEX (29GX1/2",KIT) 10 MCG
1 EA BX
MR
EA
1.25 MCG
09/02/2004
99/99/9999
1 EA BX
MR
EA
1.25 MCG
09/02/2004
99/99/9999

MCG
2 EA BX
IC
EA
1.25 MCG
32
01/01/2002
09/01/2004
1 EA BX
MR
EA
1.25 MCG
16
09/02/2004
99/99/9999
1 EA BX
MR
EA
1.25 MCG
16
09/02/2004
99/99/9999

MCG
2 EA BX
IC
EA
1.25 MCG
64
01/01/2002
09/01/2004
1 EA BX
MR
EA
1.25 MCG
32
09/02/2004
99/99/9999
1 EA BX
MR
EA
1.25 MCG
32
09/02/2004
99/99/9999
EDEX (VIAL,SRN,NDLS,SWABS) 10 MCG
4 EA BX
IC
EA
1.25 MCG
32
01/01/2002
09/01/2004
4 EA BX
IC
EA
1.25 MCG
64
01/01/2002
09/01/2004
4 EA BX IC
20 ML VL IJ
1 ML AM IJ
EA
ML
ML
1.25 MCG
2 ML
0.25 MG
128
0.5
2
01/01/2002
01/01/2002
01/01/2002
09/01/2004
12/03/2003
4/15/2009
99/99/9999
00091-1140-11
J0270
1/1/2002
00091-1140-16
J0270
9/2/2004
00091-1140-20
J0270
9/2/2004
00091-1410-44
J0270
1/1/2002
00091-1420-44
J0270
1/1/2002
00091-1440-44
00091-1510-21
00091-1536-05
J0270
J1910
J1980
1/1/2002
1/1/2002
1/1/2002
00093-0782-01
J8999
2/20/2003
00093-0782-05
J8999
1/9/2008
00093-0782-10
J8999
1/9/2008
00093-0782-56
J8999
2/20/2003
00093-0784-05
J8999
1/9/2008
00093-0784-06
J8999
2/20/2003
00093-0784-10
J8999
1/9/2008
00093-0784-86
00093-5420-88
00093-5510-06
00093-6118-16
00093-6118-87
J8999
J8515
J8999
J7510
J7510
2/20/2003
3/7/2007
4/27/2005
1/1/2002
1/1/2002
00093-6723-73
J7620
1/3/2008
00093-6723-74
00093-7120-05
00093-7120-86
J7620
J8999
J8999
1/3/2008
1/1/2002
1/1/2002
00093-7146-09
Q0144
18 EA DP
PO
EA
00093-7146-18
Q0144
AZITHROMYCIN (FILM-COATED) 250 MG
6 EA DP
PO
EA
00093-7146-56
Q0144
30 EA BO
PO
EA
1 GM
00093-7147-56
Q0144
30 EA BO
PO
EA
1 GM
00093-7169-33
Q0144
3 EA DP
PO
EA
1 GM
00093-7169-56
Q0144
30 EA BO
PO
EA
1 GM
0.5
12/6/2005

KUTAPRESSIN (VIAL) 25.5 MG/ML
LEVSIN (AMP) 0.5 MG/ML
TAMOXIFEN CITRATE (FILM COATED) 20
MG
MG
MG
MG
MG
MG
MG
MG
CABERGOLINE 0.5 MG
99/99/9999 PREDNISOLONE ORAL, PER 5 MG
PREDNISOLONE 15 MG/5 ML
IPRATROPIUM BROMIDE AND
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDAALBUTEROL SULFATE (30X3ML) 3 MG/3
99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME ML-0.5 MG/3 ML
ALBUTEROL SULFATE (60X3ML) 3 MG/3
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME ML-0.5 MG/3 ML
FLUTAMIDE 125 MG
FLUTAMIDE 125 MG
AZITHROMYCIN (3X6,FILM-COATED) 250
MG
Page 49 of 374
100 EA BO
PO
EA
1 EA
02/20/2003
500 EA BO
PO
EA
1 EA
01/09/2008
99/99/9999
1000 EA BO
PO
EA
1 EA
01/09/2008
99/99/9999
30 EA BO
PO
EA
1 EA
02/20/2003
99/99/9999
500 EA BO
PO
EA
1 EA
01/09/2008
99/99/9999
60 EA BO
PO
EA
1 EA
02/20/2003
99/99/9999
1000 EA BO
PO
EA
1 EA
01/09/2008
99/99/9999
PO
PO
PO
PO
PO
EA
EA
EA
ML
ML
1 EA
0.25 MG
1 EA
5 MG
5 MG
1
2
1
0.6
0.6
02/20/2003
03/07/2007
04/27/2005
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
IH
ML
2.5 MG
0.33333
01/03/2008
99/99/9999
IH
PO
PO
ML
EA
EA
2.5 MG
1 EA
1 EA
0.33333
1
1
01/03/2008
01/01/2002
01/01/2002
99/99/9999
01/26/2006
01/26/2006
1 GM
0.25
12/06/2005
99/99/9999
1 GM
0.25
11/14/2005
99/99/9999
0.25
11/14/2005
99/99/9999
0.6
11/14/2005
99/99/9999
0.5
11/14/2005
99/99/9999
11/14/2005
99/99/9999
180 EA
8 EA
60 EA
480 ML
240 ML
BO
BO
BO
BO
BO
3 ML VL
3 ML VL
500 EA BO
180 EA BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00093-7236-56
Q0179
8/1/2007
00093-7301-65
Q0179
7/3/2007
00093-7302-03
Q0179
7/3/2007
00093-7302-65
Q0179
00093-7477-05
J7517
00093-7485-12
Q0166
00093-7485-20
00093-8940-01
00093-8940-05
Q0166
J8499
J8499
00093-8940-93
00093-8943-01
00093-8943-05
00093-8947-01
00093-8947-05
J8499
J8499
J8499
J8499
J8499
00093-9634-87
J8999
00093-9643-01
Q0164
00093-9652-01
00095-0086-35
Q0165
J8540
00095-0086-51
00095-0086-51
Q0181
J8540
00113-0024-05
Q0163
00113-0024-73
Q0163
00113-0379-26
Q0163
00113-0406-73
Q0163
00113-0431-62
Q0163
00113-0462-62
Q0163
00113-0479-62
Q0163
00113-0479-78
Q0163
7/3/2007
ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIPTION

ONDANSETRON HCL
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 ONDANSETRON (USP,STRAWBERRY) 4
MG
MG
MG
30 EA BO
PO
EA
8 MG
08/01/2007
99/99/9999
30 EA BX
PO
EA
8 MG
0.5
07/03/2007
99/99/9999
10 EA BX
PO
EA
8 MG
07/03/2007
99/99/9999
30 EA BX
PO
EA
8 MG
07/03/2007
99/99/9999
500 EA BO
PO
EA
250 MG
5/5/2009
99/99/9999
2 EA BX
PO
EA
1 MG
01/02/2008
99/99/9999
20 EA BX
100 EA BO
500 EA BO
PO
PO
PO
EA
EA
EA
1 MG
1 EA
1 EA
1
1
1
01/02/2008
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
100 EA
100 EA
500 EA
100 EA
500 EA
BX
BO
BO
BO
BO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
11/30/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
240 ML BO
PO
ML
1 EA
08/13/2003
99/99/9999
100 EA BO
PO
EA
5 MG
01/01/2002
99/99/9999
100 EA BO
35 EA DP
PO
PO
EA
EA
10 MG
0.25 MG
1
6
01/01/2002
09/01/2006
99/99/9999
9/30/2009
51 EA DP
51 EA DP
PO
PO
EA
EA
1 EA
0.25 MG
1
6
01/01/2002
01/01/2006
12/31/2005
8/31/2009
32 EA BO
PO
EA
50 MG
01/14/2004
09/01/2004
16 EA BO
PO
EA
50 MG
01/14/2004
09/01/2004
118 ML BO
PO
ML
50 MG
0.05
01/14/2004
99/99/9999
16 EA BX
PO
EA
50 MG
0.5
01/14/2004
01/01/2006
24 EA NA
PO
EA
50 MG
0.5
01/14/2004
99/99/9999
24 EA BX
PO
EA
50 MG
0.5
01/14/2004
99/99/9999
24 EA BX
PO
EA
50 MG
0.5
01/14/2004
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/14/2004
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
MYCOPHENOLATE MOFETIL (FILM-
COATED) 500 MG
5/5/2009 99/99/9999 MYCOPHENOLATE MOFETIL , ORAL, 250 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 GRANISTERON HYDROCHLORIDE
(2X1,FILM COATED) 1 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 GRANISTERON HYDROCHLORIDE
1/1/2002 99/99/9999 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR (USP,HARD GELATIN) 200
MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
MEGESTROL ACETATE (APRICOT) 40
MG/ML
PROCHLORPERAZINE MALEATE 5 MG
DEXPAK JR TAPERPAK 1.5 MG
DEXPAK (TAPERPAK) 1.5 MG
1/1/2002 12/31/2005 REGIMEN
DEXPAK (TAPERPAK) 1.5 MG
GOOD SENSE SLEEP AID SOFTGELS
(MAXIMUM STRENGTH) 50 MG
1/14/2004
GOOD SENSE SLEEP AID SOFTGELS
1/14/2004
GOOD SENSE ANTIHISTAMINE ALLERGY
RELIEF (ALCOHOL FREE,CHERRY) 12.5
MG/5 ML
1/14/2004 99/99/9999 NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
GOOD SENSE SLEEP (ORIGINAL
FORMULA) 25 MG
1/14/2004
GOOD SENSE NIGHTTIME SLEEP AID
(MINI-CAPLETS) 25 MG
RELIEF (EASY TO SWALLOW) 25 MG
Page 50 of 374
00115-1042-01
Q0170
5/20/2008
00115-1911-01
G9020
12/1/2004
00121-0489-05
Q0163
1/1/2002
00121-0489-10
Q0163
1/1/2002
00121-0489-20
Q0163
1/1/2002
00121-0646-10
G9017
12/1/2004
00121-0646-16
00121-0687-05
00121-0687-08
00121-0687-16
G9017
J7510
J7510
J7510
12/1/2004
4/1/2003
4/17/2003
4/17/2003
00121-0711-04
J7510
2/25/2003
00121-0711-05
J7510
2/25/2003
00121-0711-10
J7510
2/25/2003
00121-0711-20
J7510
2/25/2003
00121-0759-08
J7510
5/2/2005
00121-4776-10
00143-1425-01
00143-1473-01
00143-1473-10
00143-1475-01
00143-1475-10
00143-1477-01
00143-1477-05
00143-1477-10
J8999
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
7/7/2006
12/9/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE HYDROCHLORIDE
(USP) 12.5 MG
PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION
(USP) 25 MG
(USP) 25 MG
(USP) 50 MG
RIMANTADINE HYDROCHLORIDE, ORAL, PER 100 MG (FOR USE IN A MEDICARE
RIMANTADINE HCL 100 MG
DIPHENHYDRAMINE HCL 12.5 MG/5 ML
AMANTADINE HYDROCHLORIDE, ORAL, PER 100 MG (FOR USE IN A MEDICARE
AMANTADINE HCL (AF,SF,DYE-FREE) 50
MG/5 ML
AMANTADINE HCL (AF,SF,DYE-FREE) 50
MG/5 ML
PREDNISOLONE (BERRY) 15 MG/5 ML
PREDNISOLONE SODIUM PHOSPHATE
(AF,SF,DYE-FREE) 6.7 MG/5 ML
(AF,DYE-FREE,GRAPE) 15 MG/5 ML
MEGESTROL ACETATE (40X10ML
CUPS,APRICOT) 40 MG/ML
PREDNISONE 2.5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
00143-9771-06
00143-9856-25
00143-9857-25
00143-9858-25
00143-9859-25
J2405
J0696
J0696
J0696
J0696
2/5/2009
4/21/2008
4/21/2008
4/21/2008
4/21/2008
99/99/9999 INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG

00143-9868-22
J2550
8/4/2008 99/99/9999 INJECTION, PROMETHAZINE HCL, UP TO 50 MG
00143-9869-22
J2550
00143-9872-01
J1800
4/21/2008 99/99/9999 INJECTION, PROPRANOLOL HCL, UP TO 1 MG
00143-9875-10
J0282
00143-9881-25
J1165
00143-9882-25
J1165
00143-9890-01
J2405
4/3/2007 99/99/9999 INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG
00143-9891-05
J2405
00143-9899-06
J1450
00115-1040-01
Q0169
2/12/2008
00115-1041-01
Q0170
2/12/2008
00115-1041-03
Q0170
4/1/2008
ONDANSETRON (48X50ML) 32 MG/50ML

CEFTRIAXONE (USP) 2 GM
CEFTRIAXONE (USP) 500 MG
PROMETHAZINE HCL (25X1ML,USP) 50
MG/ML
PROMETHAZINE HCL (25X1ML,USP) 25
MG/ML
PROPRANOLOL HYDROCHLORIDE
(10X1ML) 1 MG/ML
AMIODARONE HYDROCHLORIDE
(10X3ML) 50 MG/ML
PHENYTOIN SODIUM (USP,25X5ML) 50
MG/ML
PHENYTOIN SODIUM (USP,25X2ML) 50
MG/ML
ONDANSETRON (USP,MULTIDOSE) 2
MG/ML
ONDANSETRON (USP,SINGLE DOSE) 2
MG/ML
ML
Page 51 of 374
100 EA BO
PO
EA
12.5 MG
02/12/2008
99/99/9999
100 EA BO
PO
EA
25 MG
02/12/2008
99/99/9999
1000 EA BO
PO
EA
25 MG
04/01/2008
99/99/9999
100 EA BO
PO
EA
25 MG
05/20/2008
99/99/9999
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
5 ML CP
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
10 ML CP
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
20 ML CP
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
10 ML CP
PO
ML
100 MG
0.1
12/01/2004
05/31/2005
BO
CP
BO
BO
PO
PO
PO
PO
ML
ML
ML
ML
100 MG
5 MG
5 MG
5 MG
0.1
0.6
0.6
0.6
12/01/2004
04/01/2003
04/17/2003
04/17/2003
05/31/2005
7/22/2008
7/22/2008
7/22/2008
120 ML BO
PO
ML
5 MG
0.268
02/25/2003
09/15/2005
5 ML CP
PO
ML
5 MG
0.268
02/25/2003
10/07/2005
10 ML CP
PO
ML
5 MG
0.268
02/25/2003
05/11/2004
06/22/2004
473 ML
5 ML
237 ML
473 ML
20 ML CP
PO
ML
5 MG
0.268
02/25/2003
237 ML BO
PO
ML
5 MG
0.6
05/02/2005
99/99/9999
10 ML
100 EA
100 EA
1000 EA
100 EA
1000 EA
100 EA
500 EA
1000 EA
CP
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
0.5
2
2
1
1
4
4
4
07/07/2006
12/09/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
50 ML
1 EA
1 EA
1 EA
1 EA
EA
VL
VL
VL
VL
IV
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
1 MG
250 MG
250 MG
250 MG
250 MG
0.64
8
4
2
1
2/5/2009
04/21/2008
04/21/2008
04/21/2008
04/21/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
IJ
EA
50 MG
08/04/2008
99/99/9999
1 ML VL
IJ
EA
50 MG
0.5
08/04/2008
99/99/9999
1 ML VL
IV
ML
1 MG
04/21/2008
99/99/9999
3 ML VL
IV
ML
30 MG
1.66666
05/26/2008
99/99/9999
5 ML VL
IV
ML
50 MG
04/03/2007
99/99/9999
2 ML VL
IV
ML
50 MG
04/03/2007
99/99/9999
20 ML VL
IJ
ML
1 MG
04/03/2007
99/99/9999
2 ML VL
IJ
ML
1 MG
04/03/2007
99/99/9999
100 ML GC IV
ML
200 MG
0.01
04/03/2007
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/13/2003
1/13/2003
4/3/2007
4/3/2007
4/3/2007
00143-9923-90
00143-9924-90
00143-9930-03
00143-9931-22
00143-9933-22
J0690
J0690
J0698
J0698
J0698
00143-9935-91
J0698
00143-9976-03
J0697
4/3/2007 99/99/9999 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG
00143-9976-91
00143-9977-22
00143-9977-90
00143-9979-22
00143-9979-90
J0697
J0697
J0697
J0697
J0697
3/10/2005
4/3/2007
3/11/2005
4/3/2007
3/10/2005


CEFAZOLIN SODIUM (U.S.P.) 500 MG

CEFAZOLIN SODIUM (U.S.P.) 1 GM
CEFOTAXIME (USP) 500 MG
CEFOTAXIME (USP) 1 GM
CEFOTAXIME (USP,PHARMACY BULK)
10 GM
CEFUROXIME SODIUM (USP,BULK
PACKAGE) 7.5 GM
CEFUROXIME SODIUM (BULK
PACKAGE) 7.5 GM
CEFUROXIME SODIUM (USP) 1.5 GM
CEFUROXIME SODIUM (USP) 750 MG
CEFUROXIME SODIUM 750 MG
CEFAZOLIN SODIUM (BULK PACKAGE)
10 GM
10 GM
EPINEPHRINE HCL (10X30ML,M.D.V.) 1
MG/ML
HALOPERIDOL DECANOATE (VIAL) 50
MG/ML
MG/ML
MG/ML
MG/ML
FLUPHENAZINE DECANOATE (VIAL) 25
MG/ML
NOVOLIN 70/30 (SRN,PREFILLED) 70
U/ML-30 U/ML
NOVOLIN 70/30 (SRN,PREFILLED) 70
U/ML-30 U/ML
1
1
1
1
1
EA
EA
EA
EA
EA
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
1 EA VL
IJ
1 EA VL
IV
VL
VL
VL
VL
VL
1 GM
10
04/03/2007
99/99/9999
EA
750 MG
10
04/03/2007
99/99/9999
IV
IV
IV
IJ
IJ
EA
EA
EA
EA
EA
750 MG
750 MG
750 MG
750 MG
750 MG
10
2
2
1
1
03/10/2005
04/03/2007
03/11/2005
04/03/2007
03/10/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
500 MG
20
04/03/2007
99/99/9999
1 EA VL
IJ
EA
500 MG
20
01/13/2003
99/99/9999
30 ML VL
IJ
ML
1 ML
07/20/2005
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
06/22/2005
5 ML VL
IM
ML
50 MG
01/01/2002
06/22/2005
1 ML VL
IM
ML
50 MG
01/01/2002
06/22/2005
5 ML VL
IM
ML
50 MG
01/01/2002
06/22/2005
5 ML VL
IJ
ML
25 MG
01/01/2002
06/22/2005
SC
ML
100 U
01/01/2002
12/31/2002
1 EA
1 EA
1 EA
25 EA
1 EA
00143-9984-90
J0170
00144-0444-51
J1631
1/1/2002
00144-0444-56
J1631
1/1/2002
00144-0544-51
J1631
1/1/2002
00144-0544-56
J1631
1/1/2002
00144-0644-56
J2680
1/1/2002
00169-0017-71
J1820
00169-0017-71
J1815
1/1/2003
00169-0044-71
J1820
00169-0044-71
J1815
1/1/2003
NOVOLIN R (SRN,PREFILLED) 100 U/ML
1.5 ML SR
IJ
00169-0045-71
J1820
NOVOLIN N (SRN,PREFILLED) 100 U/ML
1.5 ML SR
SC
00169-0045-71
J1815
1/1/2003
SC
J1820
10 ML VL
IJ
00169-0070-11
00169-1833-11
00169-1833-11
00169-1833-17
00169-1833-17
00169-1833-18
00169-1833-18
00169-1834-11
00169-1834-11
00169-1834-17
00169-1834-17
00169-1834-18
00169-1834-18
00169-1835-11
00169-1835-11
00169-1837-11
00169-1837-11
J1815
J1820
J1815
J1820
J1815
J1820
J1815
J1820
J1815
J1820
J1815
J1820
J1815
J1820
J1815
J1820
J1815
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
NOVOLIN N (SRN,PREFILLED) 100 U/ML

VELOSULIN BR (VIAL, RECOMBINANT
DNA) 100 U/ML
VELOSULIN BR (VIAL, RECOMBINANT
DNA) 100 U/ML
NOVOLIN R (VIAL) 100 U/ML
NOVOLIN R PENFILL (SRN) 100 U/ML
RELION/NOVOLIN R (VIAL) 100 U/ML
RELION/NOVOLIN R (VIAL) 100 U/ML
NOVOLIN N (VIAL) 100 U/ML
NOVOLIN N PENFILL (SRN) 100 U/ML
RELION/NOVOLIN N (VIAL) 100 U/ML
RELION/NOVOLIN N (VIAL) 100 U/ML
NOVOLIN L (VIAL) 100 U/ML
NOVOLIN 70/30 (VIAL) 70 U/ML-30 U/ML
NOVOLIN 70/30 PENFILL (SRN) 70 U/ML30 U/ML
RELION/NOVOLIN 70/30 (VIAL) 70 U/ML30 U/ML
RELION/NOVOLIN 70/30 (VIAL) 70 U/ML30 U/ML
NOVOLIN R INNOLET (SRN,PREFILLED)
100 U/ML
NOVOLIN R INNOLET (SRN,PREFILLED)
100 U/ML
NOVOLIN N INNOLET (SRN, PREFILLED)
100 U/ML
NOVOLIN N INNOLET (SRN, PREFILLED)
100 U/ML
NOVOLIN 70/30 INNOLET (SRN,
PREFILLED) 70 U/ML-30 U/ML
1.5 ML SR
00169-0070-11
10 ML
10 ML
10 ML
1.5 ML
1.5 ML
10 ML
10 ML
10 ML
10 ML
1.5 ML
1.5 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
VL
VL
VL
CT
CT
EA
EA
VL
VL
CT
CT
EA
EA
VL
VL
VL
VL
00169-1837-17
J1820
00169-1837-17
J1815
1/1/2003
00169-1837-18
J1820
00169-1837-18
J1815
1/1/2003
00169-2313-21
J1820
00169-2313-21
J1815
00169-2314-21
J1820
00169-2314-21
J1815
00169-2317-21
J1820
Page 52 of 374
1.5 ML SR
1.5 ML SR
SC
ML
5U
20
01/01/2003
09/30/2003
1.5 ML SR
IJ
ML
100 U
01/01/2002
12/31/2002
ML
5U
20
01/01/2003
09/30/2003
ML
100 U
01/01/2002
12/31/2002
ML
5U
20
01/01/2003
02/26/2004
ML
100 U
01/01/2002
12/31/2002
IJ
IJ
IJ
IJ
IJ
IJ
IJ
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
5U
100 U
5U
100 U
5U
100 U
5U
100 U
5U
100 U
5U
100 U
5U
100 U
5U
100 U
5U
20
1
20
1
20
1
20
1
20
1
20
1
20
1
20
1
20
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
2/28/2006
12/31/2002
99/99/9999
12/31/2002
04/30/2003
12/31/2002
07/12/2005
12/31/2002
99/99/9999
12/31/2002
03/31/2004
12/31/2002
07/12/2005
12/31/2002
06/30/2004
12/31/2002
99/99/9999
1.5 ML CT
SC
ML
100 U
01/01/2002
12/31/2002
1.5 ML CT
SC
ML
5U
20
01/01/2003
06/06/2004
10 ML EA
SC
ML
100 U
01/01/2002
12/31/2002
10 ML EA
SC
ML
5U
20
01/01/2003
07/12/2005
3 ML CT
IJ
ML
100 U
08/01/2002
12/31/2002
3 ML CT
IJ
ML
5U
20
01/01/2003
99/99/9999
3 ML CT
SC
ML
100 U
05/03/2002
12/31/2002
3 ML CT
SC
ML
5U
20
01/01/2003
99/99/9999
3 ML CT
SC
ML
100 U
05/03/2002
12/31/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
EA

Start Date #1
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
J0690
CF
01/13/2003
01/13/2003
04/03/2007
04/03/2007
04/03/2007
J0690
HCPCS Measure #1
1
2
0.5
1
2
00143-9983-03
NOVOLIN R (SRN,PREFILLED) 100 U/ML
HCPCS Amount #1
500 MG
500 MG
1 GM
1 GM
1 GM
00143-9983-91
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00169-2317-21
J1815
00169-3303-12
J1820
00169-3303-12
00169-3473-18
00169-3473-18
00169-3474-18
00169-3474-18
J1815
J1820
J1815
J1820
J1815
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
00169-3477-18
J1820
00169-3477-18
J1815
00169-3682-13
J1820
00169-3682-13
J1815
00169-3685-12
J1815
00169-3696-19
J1820
00169-3696-19
J1815
00169-6339-10
00169-7060-01
00169-7060-01
00169-7061-01
00169-7061-01
00169-7062-01
00169-7062-01
00169-7065-15
00169-7501-11
J1815
Q0187
J7189
Q0187
J7189
Q0187
J7189
J1610
J1820
00169-7501-11
J1817
00169-7704-11
J2941
00169-7705-11
J2941
00169-7708-11
J2941
00169-7768-11
J2941
00169-7770-11
00169-7774-11
00169-7778-12
J2941
J2941
J2941
00172-2909-60
Q0178
00172-2911-60
Q0177
00172-2911-70
Q0177
00172-3667-60
Q0175
00172-3668-60
Q0175
00172-3669-60
Q0176
00172-3670-60
Q0176
00172-3690-60
Q0164


1/1/2003

2/10/2003
1/1/2002
1/1/2006
6/5/2002
1/1/2006
1/1/2002
1/1/2006
6/1/2005
1/1/2002

12/31/2005 FACTOR VIIA (COAGULATION FACTOR, RECOMBINANT) PER 1.2 MG
99/99/9999 FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAM
NOVOLIN 70/30 INNOLET (SRN,

NOVOLOG (PENFILL CARTRIDGE) 100
U/ML
NOVOLOG (PENFILL CARTRIDGE) 100
U/ML
NOVOLOG MIX 70/30 (PENFILL
CARTRIDGE) 70 U/ML-30 U/ML
NOVOLOG MIX 70/30 (PENFILL
CARTRIDGE) 70 U/ML-30 U/ML
NOVOLOG MIX 70/30 (VIAL) 70 U/ML-30
U/ML
NOVOLOG MIX 70/30 (FLEXPEN,SRN
NOVOLOG MIX 70/30 (FLEXPEN,SRN
NOVOLOG FLEXPEN (PREFILLED
SYRINGE) 100 U/ML
NOVOSEVEN (1200MCG/VIAL) 1.2 MG
GLUCAGEN HYPOKIT 1 MG
NOVOLOG (VIAL) 100 U/ML
1/1/2003 99/99/9999 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS NOVOLOG (VIAL) 100 U/ML
NORDITROPIN NORDIFLEX (PEN,
ORANGE) 5 MG/1.5 ML
NORDITROPIN NORDIFLEX (PEN,BLUE)
10 MG/1.5 ML
NORDITROPIN NORDIFLEX
(PEN,GREEN) 15 MG/1.5 ML
NORDITROPIN (CARTRIDGE) 5 MG/1.5
ML
NORDITROPIN (CARTRIDGE,GREEN) 15
MG/1.5 ML
NORDITROPIN (VIAL) 4 MG
NORDITROPIN (VIAL) 8 MG
HYDROXYZINE PAMOATE 50 MG
PERPHENAZINE 2 MG
1/1/2002
5/3/2007 REGIMEN
PERPHENAZINE 4 MG
1/1/2002 3/14/2007 REGIMEN
PERPHENAZINE 8 MG
1/1/2002 9/14/2007 REGIMEN
PERPHENAZINE 16 MG
1/1/2002
2/1/2007 REGIMEN
PROCHLORPERAZINE MALEATE (FILMCOATED) 5 MG
Page 53 of 374
3 ML CT
SC
ML
5U
20
01/01/2003
99/99/9999
3 ML CT
SC
ML
100 U
01/01/2002
12/31/2002
3 ML
3 ML
3 ML
3 ML
3 ML
CT
CT
CT
CT
CT
SC
IJ
IJ
SC
SC
ML
ML
ML
ML
ML
5U
100 U
5U
100 U
5U
20
1
20
1
20
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
99/99/9999
12/31/2002
99/99/9999
12/31/2002
99/99/9999
3 ML CT
SC
ML
100 U
01/01/2002
12/31/2002
3 ML CT
SC
ML
5U
20
01/01/2003
99/99/9999
3 ML CT
SC
ML
100 U
09/11/2002
12/31/2002
3 ML CT
SC
ML
5U
20
01/01/2003
5/16/2008
10 ML VL
SC
ML
5U
20
02/10/2003
99/99/9999
3 ML SR
SC
ML
100 U
09/11/2002
12/31/2002
3 ML SR
SC
ML
5U
20
01/01/2003
99/99/9999
SR
VL
VL
VL
VL
VL
VL
BX
VL
SC
IV
IV
IV
IV
IV
IV
IJ
SC
ML
EA
EA
EA
EA
EA
EA
EA
ML
5U
1.2 MG
1 MCG
1.2 MG
1 MCG
1.2 MG
1 MCG
1 MG
100 U
20
1
1200
2
2400
4
4800
1
1
02/10/2003
01/01/2002
01/01/2006
06/05/2002
01/01/2006
01/01/2002
01/01/2006
06/01/2005
01/01/2002
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
99/99/9999
12/31/2002
3 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
10 ML
50 U
10 ML VL
SC
ML
01/01/2003
99/99/9999
1.5 ML SR
SC
ML
1 MG
3.33333
01/24/2005
99/99/9999
1.5 ML SR
SC
ML
1 MG
6.66666
01/02/2006
99/99/9999
1.5 ML SR
SC
ML
1 MG
10
01/24/2005
99/99/9999
1.5 ML CT
SC
ML
1 MG
3.33333
01/01/2002
99/99/9999
1.5 ML CT
1 EA VL
1 EA VL
SC
SC
SC
ML
EA
EA
1 MG
1 MG
1 MG
10
4
8
01/01/2002
01/01/2002
01/01/2002
99/99/9999
06/30/2003
06/30/2003
100 EA BO
PO
EA
50 MG
01/01/2002
4/10/2006
100 EA BO
PO
EA
25 MG
01/01/2002
4/10/2006
500 EA BO
PO
EA
25 MG
01/01/2002
4/10/2006
100 EA BO
PO
EA
4 MG
0.5
05/13/2003
05/03/2007
1/1/2002
3/12/2002
0.5
100 EA BO
PO
EA
4 MG
05/13/2003
03/14/2007
1/1/2002
3/12/2002
100 EA BO
PO
EA
8 MG
05/13/2003
09/14/2007
1/1/2002
3/12/2002
100 EA BO
PO
EA
8 MG
05/13/2003
02/01/2007
1/1/2002
3/12/2002
100 EA BO
PO
EA
5 MG
01/01/2002
01/16/2006
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002
1/1/2002
1/24/2002
1/1/2002
1/24/2002
10/16/2003
1/1/2002
1/24/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
2/20/2003
2/20/2003
2/20/2003
2/20/2003
2/11/2004
2/20/2003
2/20/2003
4/28/2003
00172-6405-44
Q4094
7/1/2007
00172-6405-44 KO Q4094
00172-6405-44
J7603
00172-6405-44 KO J7603
00172-6405-49
00172-6406-49
00172-6407-44
00172-7310-46
KO
J7515
1/1/2008
1/1/2002
KO
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
KO
J7644
00172-6407-49 KO J7644
7/1/2007
1/1/2008
J7644
00172-6407-44 KO J7644
00172-6407-49
KO
J7631
00172-6406-59 KO J7631
1/1/2008
7/1/2007
J7631
00172-6406-49 KO J7631
00172-6406-59
KO
J7603
00172-6405-49 KO J7603
7/1/2007
1/1/2008
Q4094
00172-6405-49 KO Q4094
00172-6405-49
KO
1/1/2002
1/1/2002
KO
1/1/2002
4/14/2005
PO
IV
IV
IV
IV
IV
IV
IV
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
ML
ML
ML
ML
ML
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
10 MG
30 MG
30 MG
30 MG
30 MG
30 MG
30 MG
30 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
0.2
0.2
0.2
0.2
0.2
0.2
0.2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
01/01/2002 99/99/9999
01/01/2002
9/15/2009
01/24/2002 99/99/9999
01/01/2002
11/2/2009
01/24/2002 99/99/9999
10/16/2003 10/09/2006
01/01/2002 10/22/2008
01/24/2002 99/99/9999
01/01/2002 05/31/2006
01/01/2002 05/31/2006
01/01/2002 08/28/2007
01/01/2002 07/23/2007
01/01/2002 07/10/2007
07/18/2003 10/15/2007
01/01/2002 99/99/9999
01/01/2002 99/99/9999
02/20/2003 01/08/2008
02/20/2003 01/08/2008
02/20/2003 01/08/2008
02/20/2003 01/08/2008
02/11/2004 99/99/9999
02/20/2003 10/10/2007
02/20/2003 01/08/2008
04/28/2003 01/08/2008
3 ML PC
IH
ML
1 MG
0.83
07/01/2007
12/31/2007
3 ML PC
IH
ML
1 MG
0.83
07/01/2007
12/31/2007
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/25/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/25/2008
3 ML PC
IH
ML
1 MG
0.83
07/01/2007
12/31/2007
3 ML PC
IH
ML
1 MG
0.83
07/01/2007
12/31/2007
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/25/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/25/2008
2 ML PC
IH
ML
10 MG
01/01/2002
99/99/9999
2 ML PC
IH
ML
10 MG
01/01/2002
99/99/9999
2 ML PC
IH
ML
10 MG
01/01/2002
99/99/9999
2 ML PC
IH
ML
10 MG
01/01/2002
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
01/23/2008
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
01/23/2008
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
01/23/2008
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
01/23/2008
30 EA BX
PO
EA
25 MG
04/14/2005
99/99/9999
1/1/2002
3/12/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
VL
VL
VL
VL
VL
VL
VL
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
100 EA
50 ML
50 ML
5 ML
5 ML
16.7 ML
25 ML
25 ML
100 EA
500 EA
100 EA
500 EA
100 EA
500 EA
180 EA
500 EA
60 EA
180 EA
500 EA
1000 EA
30 EA
100 EA
500 EA
1000 EA

Package
HCPCS Description
NDC Label
Page 54 of 374
NDC Package Type
Q0165
J9265
J9265
J9265
J9265
J9265
J9265
J9265
J8499
J8499
J8499
J8499
J8499
J8499
J8999
J8999
J8999
J8999
J8999
J8999
J8999
J8999
J8999
J8999

ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROCHLORPERAZINE MALEATE (FILMCOATED) 10 MG
ONXOL (M.D.V.) 6 MG/ML
NOV-ONXOL (M.D.V.) 6 MG/ML
PACLITAXEL NOVAPLUS 6 MG/ML
5/31/2006 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
FLUTAMIDE 125 MG
FLUTAMIDE 125 MG
TAMOXIFEN CITRATE (USP) 20 MG
ALBUTEROL SULFATE (VIAL,PF) 0.083%
IPRATROPIUM BROMIDE (VIAL,PF)
0.02%
1/23/2008 MILLIGRAM
0.02%
1/23/2008 MILLIGRAM
0.02%
1/23/2008 MILLIGRAM
0.02%
1/23/2008 MILLIGRAM
CYCLOSPORINE
(USP,MODIFIED,SOFTGEL) 25 MG
NDC Package Measure
00172-3691-60
00172-3753-77
00172-3753-96
00172-3754-73
00172-3754-94
00172-3755-31
00172-3756-75
00172-3756-95
00172-4266-60
00172-4266-70
00172-4267-60
00172-4267-70
00172-4268-60
00172-4268-70
00172-4960-58
00172-4960-70
00172-5656-49
00172-5656-58
00172-5656-70
00172-5656-80
00172-5657-46
00172-5657-60
00172-5657-70
00172-5657-80
HCPCS Mod
HCPCS
NDC Mod
NDC
00172-7311-46
J7515
00172-7312-46
J7502
00172-7313-20
00173-0045-35
00173-0045-35
00173-0071-95
00173-0107-93
00173-0130-93
00173-0230-44
00173-0230-44
00173-0260-10
00173-0260-35
00173-0262-10
00173-0352-10
00173-0352-31
00173-0353-32
00173-0354-10
00173-0354-35
00173-0356-32
00173-0362-38
00173-0363-00
00173-0363-01
00173-0377-10
00173-0377-31
00173-0378-10
00173-0378-35
00173-0379-34
00173-0380-32
00173-0381-32
00173-0382-37
00173-0400-00
00173-0414-00
00173-0415-00
00173-0416-00
00173-0417-00
00173-0418-00
00173-0424-00
00173-0425-00
00173-0434-00
00173-0435-00
00173-0436-00
00173-0437-00
00173-0441-00
00173-0442-00
00173-0442-02
J7502
None
None
J0330
J3485
J9245
Q2006
J1162
J1160
J1160
J1160
J0697
J0697
J0697
J0697
J0697
J0697
J2780
J2780
J2780
J0713
J0713
J0713
J0713
J0713
J0713
J0713
J0713
J0697
J0713
J0713
J0713
J0713
J0713
J0697
J0697
J0713
J0713
J0697
J0697
J2780
J2405
J2405
4/14/2005
1/1/1994
4/1/2009
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2006
1/1/2002
1/1/2002
1/1/2002
2/1/2005
1/1/2002
1/1/2002
2/1/2005
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
2/1/2005
1/1/2002
2/1/2005
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00173-0446-00
Q0179
1/1/2002
00173-0446-02
Q0179
1/1/2002
00173-0446-04
Q0179
1/1/2002
00173-0447-00
Q0179
1/1/2002
00173-0447-02
Q0179
1/1/2002
00173-0447-04
Q0179
1/1/2002
00173-0449-01
J3030
1/1/2002
00173-0449-02
J3030
1/1/2002
00173-0461-00
J2405
CYCLOSPORINE
CYCLOSPORINE
CYCLOSPORINE (USP,MODIFIED) 100
MG/ML
ALKERAN (FILM-COATED) 2 MG
ANECTINE (M.D.V.) 20 MG/ML
RETROVIR (S.D.V.) 10 MG/ML
ALKERAN IV 50 MG
DIGIBIND (VIAL) 38 MG
DIGIBIND (VIAL) 38 MG
LANOXIN (AMP) 0.25 MG/ML
LANOXIN PEDIATRIC (AMP) 0.1 MG/ML
ZINACEF 750 MG
ZINACEF 750 MG
ZINACEF (P.B.) 750 MG
ZINACEF 1.5 GM
ZINACEF 1.5 GM
ZINACEF (P.B.) 1.5 GM
ZANTAC (VIAL) 25 MG/ML
ZANTAC (VIAL) 25 MG/ML
ZANTAC (M.D.V.) 25 MG/ML
FORTAZ 500 MG
FORTAZ (VIAL) 500 MG
FORTAZ 1 GM
FORTAZ (VIAL) 1 GM
FORTAZ (VIAL) 2 GM
FORTAZ (P.B.) 1 GM
FORTAZ (P.B.) 2 GM
FORTAZ (BULK VIAL) 6 GM
ZINACEF 7.5 GM
CEPTAZ (VIAL) 1 GM
CEPTAZ (VIAL) 2 GM
CEPTAZ (P.B.) 1 GM
CEPTAZ (P.B.) 2 GM
CEPTAZ (BULK VIAL) 10 GM
ZINACEF (PREMIX) 750 MG/50 ML
ZINACEF (PREMIX) 1.5 GM/50 ML
FORTAZ (ADD-VANTAGE) 1 GM
FORTAZ (ADD-VANTAGE) 2 GM
ZINACEF (ADD-VANTAGE) 750 MG
ZINACEF (ADD-VANTAGE) 1.5 GM
ZANTAC (PREMIX) 1 MG/ML
ZOFRAN (M.D.V.) 2 MG/ML
ZOFRAN (S.D.V.) 2 MG/ML

10/07/2005 MELPHALAN, 2 MG, ORAL
99/99/9999 INJECTION, ZIDOVUDINE, 10 MG
99/99/9999 INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG
12/31/2005 INJECTION, DIGOXIN IMMUNE FAB (OVINE), PER VIAL
99/99/9999 INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG
ZOFRAN 4 MG
ZOFRAN 4 MG
ZOFRAN (1X3 DAILY PACK) 4 MG
ZOFRAN 8 MG
ZOFRAN 8 MG
INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE
WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, IMITREX (SRN,PREFILLED,UNIT/USE) 6
MG/0.5 ML
10/24/2002 NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)
WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN,
IMITREX (S.D.V.) 6 MG/0.5 ML
ZOFRAN (PREMIXED BAG) 32 MG/50 ML
Page 55 of 374
30 EA BX
PO
EA
25 MG
04/14/2005
99/99/9999
30 EA BX
PO
EA
100 MG
04/14/2005
99/99/9999
50 ML
50 EA
50 EA
10 ML
20 ML
1 EA
1 EA
1 EA
2 ML
2 ML
1 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
2 ML
40 ML
6 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
50 ML
50 ML
1 EA
1 EA
1 EA
1 EA
50 ML
20 ML
2 ML
BO
BO
BO
VL
VL
VL
VL
VL
AM
AM
AM
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
PC
PC
VL
VL
VL
VL
FC
VL
VL
PO
PO
PO
IV
IV
IV
IV
IV
IV
IV
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IV
IV
IJ
IJ
IJ
IJ
IV
IJ
IJ
ML
EA
EA
ML
ML
EA
EA
EA
ML
ML
ML
EA
EA
EA
EA
EA
EA
ML
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
EA
EA
EA
EA
ML
ML
ML
100 MG
2 MG
2 MG
20 MG
10 MG
50 MG
1 VIAL
1 VIAL
0.5 MG
0.5 MG
0.5 MG
750 MG
750 MG
750 MG
750 MG
750 MG
750 MG
25 MG
25 MG
25 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
750 MG
500 MG
500 MG
500 MG
500 MG
500 MG
750 MG
750 MG
500 MG
500 MG
750 MG
750 MG
25 MG
1 MG
1 MG
1
1
1
1
1
1
1
1
0.5
0.5
0.2
1
1
1
2
2
2
1
1
1
1
1
2
2
4
2
4
12
10
2
4
2
4
20
0.02
0.04
2
4
1
2
0.04
2
2
04/14/2005
01/01/1994
4/1/2009
01/01/2002
01/01/2002
4/1/2009
01/01/2002
01/01/2006
01/01/2002
01/01/2002
01/01/2002
02/01/2005
01/01/2002
01/01/2002
02/01/2005
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/01/2005
01/01/2002
02/01/2005
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
10/07/2005
99/99/9999
01/13/2003
99/99/9999
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
02/01/2005
05/09/2007
99/99/9999
02/01/2005
03/30/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
02/01/2005
99/99/9999
02/01/2005
99/99/9999
04/27/2007
11/06/2006
99/99/9999
99/99/9999
01/09/2002
01/09/2002
01/09/2002
01/09/2002
08/05/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 EA BO
PO
EA
8 MG
0.5
01/01/2002
99/99/9999
100 EA BX
PO
EA
8 MG
0.5
01/01/2002
99/99/9999
3 EA BX
PO
EA
8 MG
0.5
01/01/2002
99/99/9999
30 EA BO
PO
EA
8 MG
01/01/2002
99/99/9999
100 EA BX
PO
EA
8 MG
01/01/2002
99/99/9999
3 EA BX
PO
EA
8 MG
01/01/2002
99/99/9999
0.5 ML SR
SC
ML
6 MG
01/01/2002
10/24/2002
01/01/2002
99/99/9999
0.5 ML VL
SC
ML
6 MG
50 ML FC
IV
ML
1 MG
0.64
1/1/2002
3/31/2003
1 06/01/2003 03/14/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
01/01/2002 11/18/2008
00173-0489-00
00173-0517-00
00173-0519-00
Q0179
J1325
J1325
1/1/2002
1/1/2002
1/1/2002
00173-0569-00
Q0179
1/1/2002
00173-0570-00
Q0179
1/1/2002
00173-0570-04
00173-0635-35
00173-0656-01
00173-0656-44
Q0179
J8999
J9390
J9390
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00173-0680-00
Q0179
1/1/2002
00173-0681-01
00173-0713-25
G9034
None
12/1/2004
1/1/2000
00173-0739-00
J3030
3/17/2006
00173-0739-02
00173-0807-25
00173-0807-65
00173-0945-55
00173-0949-55
00173-0952-01
00173-0952-01
00173-0953-96
00173-0991-55
00173-0991-56
00173-0995-01
00173-0995-01
00182-0201-89
J3030
J8999
J8999
J8499
J8499
J3490
Q4075
J8499
J8499
J8499
Q4075
J0133
J7506
3/17/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
10/1/2003
1/1/2002
1/1/2002
1/1/2002
10/1/2003
1/1/2006
1/1/2002
00182-0492-10
Q0163
1/1/2002
00182-1050-03
00182-1086-89
J7509
J7506
1/1/2002
1/1/2002
00182-1098-89
Q0177
1/1/2002
00182-1099-89
Q0178
1/1/2002
00182-1131-93
00182-1334-89
Q0163
J7506
5/3/2002
1/1/2002
00182-1396-01
00182-1539-01
00182-1539-95
00182-1864-89
Q0173
None
None
J8999
1/1/2002
1/1/1994
3/30/1995
1/1/2002
00182-2001-37
Q0163
1/1/2002
00182-2091-16
Q0163
1/1/2002

ZOFRAN (BERRY) 4 MG/5 ML
50 ML BO
4/1/2009 INJECTION, EPOPROSTENOL, 0.5 MG
FLOLAN 0.5 MG
1 EA VL
FLOLAN 1.5 MG
1 EA VL
ZOFRAN ODT 4 MG
30 EA BX
ZOFRAN ODT 8 MG
30 EA BX
ZOFRAN ODT (5X2) 8 MG
10 EA BX
LEUKERAN 2 MG
50 EA BO
12/19/2005 INJECTION, VINORELBINE TARTRATE, 10 MG
NAVELBINE (S.D.V.) 10 MG/ML
1 ML VL
NAVELBINE (S.D.V.) 10 MG/ML
5 ML VL
ZOFRAN 24 MG
1 EA BX
ZANAMIVIR, INHALATION POWDER ADMINISTERED THROUGH INHALER, BRAND,
RELENZA (5X4,W/DISKHALER) 5
5/31/2005 PER 10 MG (FOR USE IN A MEDICARE APPROVED DEMONSTRATION PROJECT)
MG/Actuation
20 EA IH
99/99/9999 BUSULFAN, 2 MG, ORAL
MYLERAN 2 MG
25 EA BO
IMITREX STATDOSE 4 MG/0.5 ML
1 EA BX
WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, IMITREX STATDOSE (REFILL W/2
SYRINGES) 4 MG/0.5 ML
1 EA BX
PURINETHOL 50 MG
25 EA BO
PURINETHOL 50 MG
250 EA BO
ZOVIRAX 800 MG
100 EA BO
ZOVIRAX 400 MG
100 EA BO
ZOVIRAX 1000 MG
1 EA VL
1/14/2005 INJECTION, ACYCLOVIR, 5 MG
ZOVIRAX 1000 MG
1 EA VL
ZOVIRAX 200 MG/5 ML
473 ML BO
ZOVIRAX 200 MG
100 EA BO
ZOVIRAX (2X5X10) 200 MG
100 EA BX
ZOVIRAX 500 MG
1 EA VL
ZOVIRAX 500 MG
1 EA VL
100 EA BX
DIPHENHYDRAMINE HCL 25 MG
1000 EA BO
METHYLPREDNISOLONE (DOSE PACK)
4 MG
21 EA DP
100 EA BX
HYDROXYZINE PAMOATE (10X10) 25 MG 100 EA BX
HYDROXYZINE PAMOATE (10X10) 50 MG 100 EA BX
NIGHT-TIME SLEEP AID (MAX.
STR.,SOFTGEL) 50 MG
32 EA BO
100 EA BX
TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED
TRIMETHOBENZAMIDE HCL 250 MG
100 EA BO
7/7/2004 TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
100 EA NA
36 EA NA
100 EA BX
GENAHIST 12.5 MG/5 ML
120 ML BO
GENAHIST 25 MG
24 EA BO
Page 56 of 374
PO
IV
IV
ML
EA
EA
8 MG
0.5 MG
0.5 MG
0.1
1
3
01/01/2002
11/11/2006
11/11/2006
99/99/9999
4/1/2009
4/1/2009
PO
EA
8 MG
0.5
01/01/2002
99/99/9999
PO
EA
8 MG
01/01/2002
99/99/9999
PO
PO
IV
IV
EA
EA
ML
ML
8 MG
1 EA
10 MG
10 MG
1
1
1
1
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 12/19/2005
01/01/2002 12/19/2005
PO
EA
8 MG
01/01/2002
02/21/2006
IH
PO
EA
EA
10 MG
2 MG
0.5
1
12/01/2004
01/01/2000
05/31/2005
99/99/9999
SC
EA
6 MG
0.666667
03/17/2006
99/99/9999
SC
PO
PO
PO
PO
IV
IV
PO
PO
PO
IV
IV
PO
EA
EA
EA
EA
EA
EA
EA
ML
EA
EA
EA
EA
EA
6 MG
1 EA
1 EA
1 EA
1 EA
1 EA
5 MG
1 EA
1 EA
1 EA
5 MG
5 MG
5 MG
0.666667
1
1
1
1
1
200
1
1
1
100
100
1
03/17/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10/01/2003
01/01/2002
01/01/2002
01/01/2002
10/01/2003
01/01/2006
01/01/2002
99/99/9999
09/09/2003
09/12/2003
99/99/9999
99/99/9999
09/30/2003
01/14/2005
99/99/9999
99/99/9999
09/07/2007
12/31/2005
04/18/2006
2/5/2009
PO
EA
50 MG
0.5
PO
PO
EA
EA
4 MG
5 MG
1
4
01/01/2002
01/01/2002
03/01/2002
2/5/2009
PO
EA
25 MG
01/01/2002
4/10/2006
PO
EA
50 MG
01/01/2002
4/10/2006
PO
PO
EA
EA
50 MG
5 MG
1
2
05/03/2002
01/01/2002
99/99/9999
2/5/2009
PO
PO
PO
PO
EA
EA
EA
EA
250 MG
2.5 MG
2.5 MG
1 EA
1
1
1
1
01/01/2002
01/01/1994
03/30/1995
01/01/2002
07/07/2004
10/18/1998
10/18/1998
7/16/2009
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
PO
EA
50 MG
0.5
1/1/2002
1/1/2002
9/30/2006
9/30/2006
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1
3
01/01/2002 10/23/2009
01/01/2002 10/30/2009
00182-2092-01
Q0163
1/1/2002
00182-2092-16
00182-2666-89
00182-2667-89
Q0163
J8499
J8499
1/1/2002
1/1/2002
1/1/2002
00182-3154-99
J9218
1/25/2002
00182-6014-65
J7602
1/1/2008
00182-6014-65
J7611
4/1/2008
00182-6168-37
Q0163
1/1/2002
00182-6168-40
Q0163
1/1/2002
00182-7096-11
00182-7096-11
K0416
J8498
3/3/2003
1/1/2006
00182-7099-11
00182-7099-11
K0416
J8498
10/8/2004
1/1/2006
00182-7100-11
00182-7100-11
K0416
J8498
10/8/2004
1/1/2006
00182-7101-11
00182-7101-11
00182-8200-89
K0416
J8498
J8499
10/8/2004
1/1/2006
1/1/2002
00182-8210-89
Q0164
1/1/2002
00182-8211-89
Q0165
1/1/2002
00185-0613-01
Q0177
1/1/2002
00185-0613-05
Q0177
1/1/2002
00185-0615-01
Q0178
1/1/2002
00185-0615-05
Q0178
1/1/2002
00185-0648-01
Q0163
1/1/2002
00185-0648-10
Q0163
1/1/2002
00185-0649-01
Q0163
1/1/2002
00185-0649-10
00185-0932-30
00185-0933-30
Q0163
J7515
J7502
1/1/2002
1/1/2002
1/1/2002

GENAHIST 25 MG
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
GENAHIST 25 MG
ACYCLOVIR (10X10) 200 MG
LEUPROLIDE ACETATE (2 WEEK
ADMINISTRATION) 5 MG/ML
24 EA BX
100 EA BX
100 EA BX
PO
PO
PO
EA
EA
EA
50 MG
1 EA
1 EA
0.5
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
11/29/2007
9/14/2008
2.8 ML VL
SC
EA
1 MG
14
01/25/2002
4/26/2006
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML BO
IH
ML
1 MG
04/01/2008
99/99/9999
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
4/26/2006 LEUPROLIDE ACETATE, PER 1 MG

ALBUTEROL SULFATE 0.5%
HYDRAMINE (AF) 12.5 MG/5 ML
HYDRAMINE (AF) 12.5 MG/5 ML
PROCHLORPERAZINE 25 MG
8/19/2008 ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED
PROMETHAZINE HCL 12.5 MG
PROMETHAZINE HCL 25 MG
PROCHLORPERAZINE MALEATE
(10X10,FILM-COATED) 5 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROCHLORPERAZINE MALEATE
CYCLOSPORINE (SOFTGEL) 25 MG
Page 57 of 374
480 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
03/03/2003
01/01/2006
12/31/2005
8/19/2008
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
10/08/2004
01/01/2006
12/31/2005
8/8/2008
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
10/08/2004
01/01/2006
12/31/2005
8/8/2008
12 EA BX
12 EA BX
100 EA BX
RC
RC
PO
EA
EA
EA
1 MG
1 EA
1 EA
50
1
1
10/08/2004
01/01/2006
01/01/2002
12/31/2005
8/8/2008
9/14/2008
100 EA BO
PO
EA
5 MG
01/01/2002
99/99/9999
100 EA BO
PO
EA
10 MG
01/01/2002
99/99/9999
100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
500 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
500 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
1000 EA BO
30 EA BO
30 EA BO
PO
PO
PO
EA
EA
EA
50 MG
25 MG
100 MG
1
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00185-1125-05
00185-1125-18
J8999
J8999
00185-1125-88
00185-7203-70
500 EA BO
180 EA BO
PO
PO
EA
EA
1 EA
1 EA
J8999
1/1/2002
100 EA BX
PO
EA
Q0144
9/21/2006
15 ML BO
PO
ML
00185-7206-70
Q0144
9/21/2006
15 ML BO
PO
00185-7209-69
Q0144
9/21/2006
22.5 ML BO
00185-7212-68
Q0144
9/21/2006
00185-7322-13
J7620
7/1/2007
J7620
7/1/2007
00185-7322-60
J7620
7/1/2007
00185-7400-14
J9218
1/1/2002
00185-7400-85
00186-0110-01
00186-0110-01
00186-0112-01
00186-0112-01
J9218
J2000
J2001
J2000
J2001
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
00186-0112-91
J2000
1/1/2002
00186-0112-91
00186-0120-01
00186-0120-01
00186-0135-01
00186-0135-01
00186-0137-01
00186-0137-01
00186-0145-01
00186-0145-01
00186-0155-01
00186-0155-01
00186-0170-14
00186-0170-14
00186-0210-03
00186-0210-03
00186-0215-03
00186-0215-03
00186-0230-03
00186-0230-03
00186-0232-03
00186-0232-03
00186-0235-03
00186-0235-03
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
00186-0240-44
J2000
1/1/2002
00186-0240-44
00186-0241-13
00186-0241-13
00186-0242-13
00186-0242-13
00186-0243-12
00186-0243-12
J2001
J2000
J2001
J2000
J2001
J2000
J2001
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
00186-0244-44
J2000
1/1/2002
00186-0244-44
J2001
1/1/2004
00186-0245-54
J2000
1/1/2002
00186-0245-54
00186-0255-02
00186-0255-02
00186-0275-12
00186-0275-12
00186-0276-13
00186-0276-13
00186-0277-13
00186-0277-13
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
Page 58 of 374
1
1
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1 EA
01/01/2002
99/99/9999
1 GM
0.02
09/21/2006
99/99/9999
ML
1 GM
0.04
09/21/2006
99/99/9999
PO
ML
1 GM
0.04
09/21/2006
99/99/9999
30 ML BO
PO
ML
1 GM
0.04
09/21/2006
99/99/9999
3 ML PC
IH
ML
2.5 MG
0.33333
07/01/2007
99/99/9999
3 ML PC
IH
ML
2.5 MG
0.33333
07/01/2007
99/99/9999
3 ML PC
IH
ML
2.5 MG
0.33333
07/01/2007
99/99/9999
2.8 ML VL
SC
ML
1 MG
01/01/2002
12/03/2003
2.8 ML
20 ML
20 ML
30 ML
30 ML
BX
VL
VL
VL
VL
SC
EP
EP
EP
EP
EA
ML
ML
ML
ML
1 MG
50 ML
10 MG
50 ML
10 MG
14
0.02
1
0.02
1
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
30 ML VL
EP
ML
50 ML
0.02
01/01/2002
12/31/2003
30 ML
20 ML
20 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
1.8 ML
1.8 ML
2 ML
2 ML
2 ML
2 ML
5 ML
5 ML
5 ML
5 ML
5 ML
5 ML
EP
IJ
IJ
IJ
IJ
IJ
IJ
EP
EP
IJ
IJ
IJ
IJ
EP
EP
IJ
IJ
EP
EP
IV
IV
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
1
0.02
2
0.02
0.5
0.02
0.5
0.02
1
0.02
2
0.02
2
0.02
1
0.02
2
0.02
1
0.02
2
0.02
4
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 08/14/2006
01/01/2002 12/31/2003
01/01/2004
10/8/2009
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 10/28/2009
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 99/99/9999
10 ML AM IJ
ML
50 ML
0.02
01/01/2002
12/31/2003
10 ML
2 ML
2 ML
5 ML
5 ML
10 ML
10 ML
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
2
0.02
2
0.02
2
0.02
2
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
5/10/2009
12/31/2003
99/99/9999
12/31/2003
10/8/2009
12/31/2003
99/99/9999
10 ML AM IJ
ML
50 ML
0.02
01/01/2002
12/31/2003
10 ML AM IJ
ML
10 MG
1.5
20 ML AM IJ
ML
50 ML
0.02
01/01/2002
12/31/2003
20 ML
30 ML
30 ML
10 ML
10 ML
2 ML
2 ML
5 ML
5 ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
1.5
0.02
1
0.02
1
0.02
1
0.02
1
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
3/30/2009
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
9/20/2009
12/31/2003
9/20/2009
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
EA
EA
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
VL
VL
VL
VL
VL
VL
AM
AM
AM
VL
VL
VL
VL
VL
VL
IJ
EP
EP
EP
EP
EP
EP
EP
EP
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

00185-7322-30
FLUTAMIDE 125 MG
FLUTAMIDE 125 MG
FLUTAMIDE (BLISTER PACK,10X10) 125
MG
AZITHROMYCIN (USP,CHERRY) 100
MG/5 ML
MG/5 ML
MG/5 ML
MG/5 ML
LEUPROLIDE ACETATE (M.D.V.) 5
MG/ML
XYLOCAINE (M.D.V.) 1%
XYLOCAINE-MPF (S.D.V.) 1%
XYLOCAINE-MPF (S.D.V.,STERILE-PAK)
1%
XYLOCAINE-MPF (S.D.V.,STERILE-PAK)
1%
XYLOCAINE (M.D.V.) 0.5%
XYLOCAINE-MPF (S.D.V.) 0.5%
XYLOCAINE-MPF (S.D.V.) 0.5%
XYLOCAINE (ASTRAPAK,DENTAL) 2%
XYLOCAINE (ASTRAPAK,DENTAL) 2%
XYLOCAINE-MPF (S.D. AMP) 1%
XYLOCAINE (AMP,CARDIAC) 2%
XYLOCAINE (AMP,CARDIAC) 2%
XYLOCAINE-MPF (POLYAMP,STERILE12/31/2003 INJECTION, LIDOCAINE HCL, 50 CC
PAK) 2%
XYLOCAINE-MPF (POLYAMP,STERILE5/10/2009 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG
PAK) 2%
PAK) 1.5%
PAK) 1.5%
PAK) 1.5%
PAK) 1.5%

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
01/01/2004 11/10/2009
00186-0278-44
J2000
00186-0278-44
J2001
1/1/2004
00186-0278-54
00186-0410-01
00186-0412-01
00186-0418-01
00186-0420-01
00186-0422-01
00186-0440-14
J2000
J0670
J0670
J0670
J0670
J0670
J0670
1/1/2002
1/1/2002
1/1/2002
00186-0460-14
J0670
1/1/2002
00186-0859-44
J2795
1/1/2002
4/14/2009 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG
00186-0859-54
J2795
1/1/2002
00186-0859-77
J2795
1/19/2007
00186-0859-81
J2795
1/1/2002 99/99/9999 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG
00186-0859-91
J2795
1/1/2002
00186-0863-44
J2795
1/1/2002
00186-0863-54
00186-0863-61
J2795
J2795
1/1/2002
1/1/2002

00186-0863-69
J2795
00186-0863-77
J2795
1/19/2007
00186-0867-44
J2795
1/1/2002
00186-0867-54
J2795
1/1/2002
00186-0868-44
J2795
1/1/2002
00186-0868-54
J2795
1/1/2002
00186-0868-77
00186-0971-66
00186-0972-66
00186-0991-66
00186-0992-66
J2795
J2400
J2400
J2400
J2400
00186-1026-03
00186-1030-01
00186-1030-02
J3490
J3490
J3490

1/1/2002
00186-1030-12
J3490
1/1/2002
00186-1030-91
00186-1031-01
00186-1033-01
00186-1033-02
J3490
J3490
J3490
J3490

00186-1033-12
J3490
00186-1033-91
00186-1035-01
00186-1037-01
00186-1037-02
J3490
J3490
J3490
J3490

00186-1037-12
J3490
1/1/2002
00186-1150-02
J2275
00186-1151-02
J2275
00186-1152-12
J2275
00186-1153-12
J2275
00186-1159-03
J2275
00186-1160-03
00186-1770-01
00186-1771-01
J2275
J2995
J2995


1/1/2002 11/11/2009 10 MG
1/1/2002 99/99/9999 10 MG
1/1/2002 99/99/9999 10 MG
1/1/2002 11/17/2009 10 MG
1/1/2002 9/30/2009 10 MG
1/1/2002 10/5/2009 10 MG
1/1/2002 6/26/2002 INJECTION, STREPTOKINASE, PER 250,000 IU
1/1/2002 9/18/2002 INJECTION, STREPTOKINASE, PER 250,000 IU
XYLOCAINE-MPF (POLYAMP,STERILEPAK) 1%
POLOCAINE (M.D.V.) 1%
POLOCAINE-MPF (S.D.V.) 1%
POLOCAINE-MPF (S.D.V.) 1.5%
POLOCAINE-MPF (S.D.V.) 2%
POLOCAINE (ASTRAPAK) 3%
POLOCAINE
(ASTRAPK,W/LEVONORDEFRIN) 2%
NAROPIN (POLYAMP DUOFIT,STERPAK) 2 MG/ML
NOVAPLUS NAROPIN (SINGLEDOSE,PF) 2 MG/ML
NAROPIN (S.D. INFUSION BOTTLE) 2
MG/ML
NAROPIN (S.D. INFUSION BOTTLE) 2
MG/ML
NAROPIN (POLYAMP DUOFIT,STER PAK)
5 MG/ML
NAROPIN (POLYAMP DUOFIT,STER PAK)
5 MG/ML
NAROPIN (S.D.V.) 5 MG/ML
NAROPIN (S.D.V.,STERILE-PAK) 5
MG/ML
NOVAPLUS NAROPIN (SDV,PF) 5 MG/ML
NAROPIN (POLYAMP DUOFIT,STERPAK) 7.5 MG/ML
NAROPIN (POLYAMP DUOFIT,STERPAK) 7.5 MG/ML
NOVAPLUS NAROPIN
(5X20ML,POLYAMP DUOFIT) 10 MG/ML
NESACAINE (M.D.V.) 1%
NESACAINE-MPF (S.D.V.) 2%
NESACAINE-MPF (S.D.V.) 3%
SENSORCAINE-MPF (S.D.
AMP,SPINAL,W/DEXTR) 0.75%
SENSORCAINE-MPF (S.D.V.) 0.25%
SENSORCAINE-MPF (S.D. AMP) 0.25%
SENSORCAINE-MPF (S.D.V.,E-Z O
CLOSURE) 0.25%
SENSORCAINE-MPF (S.D.V.,STERILEPAK) 0.25%
SENSORCAINE (M.D.V.) 0.25%
CLOSURE) 0.5%
SENSORCAINE-MPF (S.D.V.,STERILEPAK) 0.5%
SENSORCAINE (M.D.V.) 0.5%
CLOSURE) 0.75%
10 ML AM EP
ML
50 ML
0.02
01/01/2002
12/31/2003
10 ML AM EP
ML
10 MG
01/01/2004
4/14/2009
20 ML
50 ML
30 ML
30 ML
50 ML
20 ML
1.8 ML
EP
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
50 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
0.02
0.1
0.1
0.1
0.1
0.1
0.1
AM
VL
VL
VL
VL
VL
EA
1.8 ML EA
IJ
ML
10 ML
0.1
01/01/2002
08/14/2006
ML
1 MG
01/01/2002
4/14/2009
20 ML AM IJ
ML
1 MG
01/01/2002
7/13/2009
100 ML VL
IJ
ML
1 MG
01/19/2007
6/17/2009
100 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
200 ML VL
IJ
ML
1 MG
01/01/2002
8/9/2009
10 ML AM IJ
ML
1 MG
01/01/2002
09/05/2003
20 ML AM IJ
30 ML VL IJ
ML
ML
1 MG
1 MG
5
5
01/01/2002
01/01/2002
4/29/2009
7/19/2009
30 ML VL
IJ
ML
1 MG
01/01/2002 10/18/2009
30 ML VL
IJ
ML
1 MG
01/19/2007
8/2/2009
10 ML AM IJ
ML
1 MG
7.5
01/01/2002
09/05/2003
20 ML AM IJ
ML
1 MG
7.5
01/01/2002
9/15/2009
10 ML AM IJ
ML
1 MG
10
01/01/2002
8/4/2009
20 ML AM IJ
ML
1 MG
10
01/01/2002
6/7/2009
20 ML
30 ML
30 ML
20 ML
20 ML
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
1 MG
30 ML
30 ML
30 ML
30 ML
10
0.03333
0.03333
0.03333
0.03333
08/21/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
8/26/2009
99/99/9999
3/15/2009
11/9/2008
11/9/2008
2 ML AM IJ
30 ML VL IJ
30 ML AM IJ
ML
ML
ML
1 EA
1 EA
1 EA
1
1
1
01/01/2002
01/01/2002
01/01/2002
6/28/2009
8/3/2009
99/99/9999
10 ML VL
IJ
ML
1 EA
01/01/2002
7/26/2009
30 ML
50 ML
30 ML
30 ML
VL
VL
VL
AM
IJ
IJ
IJ
IJ
ML
ML
ML
ML
1 EA
1 EA
1 EA
1 EA
1
1
1
1
01/01/2002
9/14/2009
01/01/2002 11/11/2009
01/01/2002
9/15/2009
01/01/2002
8/31/2009
10 ML VL
IJ
ML
1 EA
01/01/2002
99/99/9999
30 ML
50 ML
30 ML
30 ML
VL
VL
VL
AM
IJ
IJ
IJ
IJ
ML
ML
ML
ML
1 EA
1 EA
1 EA
1 EA
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
8/31/2009
9/28/2009
99/99/9999
10 ML VL
01/01/2002
8/3/2009
IJ
ML
1 EA
ASTRAMORPH PF (S.D. AMP) 0.5 MG/ML
10 ML AM IJ
ML
10 MG
0.05
ASTRAMORPH PF (S.D. AMP) 1 MG/ML

ASTRAMORPH PF (S.D.V.,E-Z O
CLOSURE) 0.5 MG/ML
ASTRAMORPH PF (S.D.V., E-Z O
CLOSURE) 1 MG/ML
10 ML AM IJ
ML
10 MG
0.1
01/01/2002
99/99/9999
10 ML VL
IJ
ML
10 MG
0.05
01/01/2002
99/99/9999
10 ML VL
Prior End Date #3
Prior Start Date #3
01/01/2002 11/11/2009
IJ
ML
10 MG
0.1
ASTRAMORPH PF (S.D. AMP) 0.5 MG/ML
2 ML AM IJ
ML
10 MG
0.05
01/01/2002
9/30/2009
ASTRAMORPH PF (S.D. AMP) 1 MG/ML

STREPTASE 250000 IU
STREPTASE 750000 IU
2 ML AM IJ
1 EA VL IV
1 EA VL IV
ML
EA
EA
10 MG
250000 IU
250000 IU
0.1
1
3
01/01/2002
01/01/2002
01/01/2002
10/5/2009
06/26/2002
09/18/2002
Page 59 of 374
Prior End Date #2
01/01/2002 09/05/2003
01/01/2002 10/25/2009
01/01/2002
6/7/2009
01/01/2002 99/99/9999
01/01/2002
2/5/2009
01/01/2002 99/99/9999
01/01/2002 08/14/2006
10 ML AM IJ
AM
VL
VL
VL
VL
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
01/01/2002 11/17/2009
2 ML PC
IH
ML
0.25 MG
0.5
01/01/2002
99/99/9999
J7626
BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON1/1/2002 99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG
PULMICORT RESPULES (5X6) 0.5 MG/2

ML
2 ML PC
IH
ML
0.25 MG
0.5
01/01/2002
99/99/9999
00186-1989-04 KO J7626

ML
2 ML PC
IH
ML
0.25 MG
0.5
01/01/2002
99/99/9999
PULMICORT RESPULES (30X2ML) 1

MG/2 ML
2 ML PC
IH
ML
0.25 MG
08/27/2007
99/99/9999
2 ML PC
IH
ML
0.25 MG
08/27/2007
99/99/9999
00186-1988-04 KO J7626
00186-1989-04
00186-1990-04
KO
J7626
00186-1990-04 KO J7626
00187-0247-01
00187-0247-01
00187-2006-01
00187-2006-05
00187-2007-02
00187-2007-06
00187-3072-10
00187-3101-30
00187-3103-50
00187-3104-60
KO
KO
Q0181
J8650
J9212
J9212
J9212
J9212
J1960
J2710
J2710
J2710
J1990
00187-3755-74
00187-3953-64
J9190
00187-3953-64 QR J9190
00206-3879-16
J3490
00206-3880-25
J3490
8/27/2007
7/10/2006
1/1/2007
1/18/2008
1/18/2008
1/18/2008
1/18/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2002
QR
1/1/2002
1/1/2002
1/28/2005
1/1/2002
1/1/2002
00206-3880-29
00206-3882-28
00206-3882-55
J3490
J3490
J3490
1/1/2002
1/1/2002
1/1/2002
00206-8452-16
J2543
1/1/2002
00206-8452-17
J2543
1/1/2002
00206-8454-17
J2543
1/1/2002
00206-8454-55
J2543
1/1/2002
00206-8455-17
J2543
1/1/2002
00206-8455-25
J2543
1/1/2002
00206-8620-11
J2543
1/1/2002
00206-8820-02
J2543
1/1/2002
00206-8821-02
J2543
1/1/2002
00206-8822-02
J2543
1/1/2002
00206-8852-16
J2543
4/5/2006
00206-8852-18
J2543
4/28/2006
00206-8854-16
J2543
3/6/2006
00206-8854-18
J2543
4/5/2006
00206-8855-16
J2543
3/13/2006
00206-8855-18
J2543
4/5/2006
00206-8859-10
J2543
4/28/2006
00206-8860-02
J2543
1/9/2006
BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONPULMICORT RESPULES (30X2ML) 1

99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG MG/2 ML
CESAMET 1 MG
12/31/2006 REGIMEN
99/99/9999 NABILONE, ORAL, 1 MG
CESAMET 1 MG
3/5/2009 INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM
INFERGEN (1X0.5ML,PF) 30 MCG/ML
LEVO-DROMORAN (AMP) 2 MG/ML
PROSTIGMIN (AMP) 0.5 MG/ML
PROSTIGMIN (VIAL) 1 MG/ML
PROSTIGMIN (VIAL) 0.5 MG/ML
LIBRIUM (DUPLEX AMP W/DILUENT) 100
11/6/2008 INJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MG
MG
FLUOROURACIL (VIAL) 50 MG/ML
PIPRACIL (VIAL) 2 GM
PIPRACIL (ADD-VANTAGE,ADD9/6/2002 UNCLASSIFIED DRUGS
VANTAGE) 4 GM
PIPRACIL (ADD-VANTAGE) 3 GM
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS
12/4/2006 (1.125 GRAMS)
ZOSYN (VIAL) 2 GM-0.25 GM
12/4/2006 (1.125 GRAMS)
ZOSYN (ADD-VANTAGE) 2 GM-0.25 GM
12/4/2006 (1.125 GRAMS)
12/4/2006 (1.125 GRAMS)
12/4/2006 (1.125 GRAMS)
12/4/2006 (1.125 GRAMS)
12/4/2006 (1.125 GRAMS)
ZOSYN (BULK VIAL) 36 GM-4.5 GM
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS ZOSYN (FROZEN,S.D. GALAXY P.C.) 40
1/23/2007 (1.125 GRAMS)
MG/ML-5 MG/ML
1/23/2007 (1.125 GRAMS)
MG/ML-7.5 MG/ML
1/23/2007 (1.125 GRAMS)
GM/100 ML-0.5 GM/100 ML
99/99/9999 (1.125 GRAMS)
ZOSYN 2 GM-0.25 GM
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS ZOSYN (ADD-VANTAGE VIAL) 2 GM-0.25
8/17/2007 (1.125 GRAMS)
GM
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS ZOSYN (SDV,10X50ML) 3 GM/50 ML99/99/9999 (1.125 GRAMS)
0.375 GM/50 ML
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS ZOSYN (ADDVANTAGE VIAL) 3 GM-0.375
8/17/2007 (1.125 GRAMS)
GM
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS ZOSYN (SDV,10X100ML) 4 GM/100 ML99/99/9999 (1.125 GRAMS)
0.5 GM/100 ML
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS ZOSYN (ADDVANTAGE VIAL) 4 GM-0.5
8/17/2007 (1.125 GRAMS)
GM
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS ZOSYN (PHARMACY BULK VIAL) 36 GM99/99/9999 (1.125 GRAMS)
4.5 GM
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS ZOSYN (24 PRE-MIX BAGS OF 50ML) 2
99/99/9999 (1.125 GRAMS)
GM/50 ML-0.25 GM/50 ML
Page 60 of 374
CF
HCPCS Amount #1
20 EA
20 EA
0.5 ML
0.5 ML
0.3 ML
0.3 ML
1 ML
1 ML
10 ML
10 ML
BO
BO
VL
VL
VL
VL
AM
AM
VL
VL
PO
PO
SC
SC
SC
SC
IJ
IJ
IJ
IJ
EA
EA
ML
ML
ML
ML
ML
ML
ML
ML
1 EA
1 MG
1 MCG
1 MCG
1 MCG
1 MCG
2 MG
0.5 MG
0.5 MG
0.5 MG
1
1
30
30
30
30
1
1
2
1
07/10/2006
01/01/2007
01/18/2008
01/18/2008
01/18/2008
01/18/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/31/2006
99/99/9999
3/5/2009
3/5/2009
3/5/2009
3/5/2009
99/99/9999
06/14/2004
06/14/2004
06/14/2004
1 EA
10 ML
10 ML
1 EA
1 EA
AM
VL
VL
VL
VL
IJ
IV
IV
IJ
IJ
EA
ML
ML
EA
EA
100 MG
500 MG
500 MG
1 EA
1 EA
1
0.1
0.1
1
1
01/01/2002
01/01/2002
01/28/2005
01/01/2002
01/01/2002
11/6/2008
11/6/2008
11/6/2008
04/22/2003
04/22/2003
1 EA VL
1 EA VL
1 EA VL
IJ
IJ
IJ
EA
EA
EA
1 EA
1 EA
1 EA
1
1
1
01/01/2002
01/01/2002
01/01/2002
09/06/2002
09/06/2002
04/22/2003
1 EA VL
IV
EA
1 GM
01/01/2002
12/04/2006
1 EA VL
IV
EA
1 GM
01/01/2002
12/04/2006
1 EA VL
IV
EA
1 GM
01/01/2002
12/04/2006
1 EA VL
IV
EA
1 GM
01/01/2002
12/04/2006
1 EA VL
IV
EA
1 GM
01/01/2002
12/04/2006
1 EA VL
IV
EA
1 GM
01/01/2002
12/04/2006
1 EA VL
IV
EA
1 GM
36
01/01/2002
12/04/2006
50 ML PC
IV
ML
1 GM
0.04
01/01/2002
01/23/2007
50 ML PC
IV
ML
1 GM
0.06
01/01/2002
01/23/2007
100 ML PC
IV
ML
1 GM
0.04
01/01/2002
01/23/2007
1 EA VL
IV
EA
1 GM
04/05/2006
99/99/9999
1 EA VL
IV
EA
1 GM
04/28/2006
08/17/2007
1 EA VL
IV
EA
1 GM
03/06/2006
99/99/9999
1 EA VL
IV
EA
1 GM
04/05/2006
08/17/2007
1 EA VL
IV
EA
1 GM
03/13/2006
99/99/9999
1 EA VL
IV
EA
1 GM
04/05/2006
08/17/2007
1 EA VL
IV
EA
1 GM
36
04/28/2006
99/99/9999
50 ML PC
IV
ML
1 GM
0.04
01/09/2006
99/99/9999
99/99/9999
Prior End Date #3
01/01/2002
Prior Start Date #3
0.5
0.25 MG
Prior End Date #2
ML
J7626
End Date #1
IH

ML
00186-1988-04
STREPTASE 1.5 Million IU

STREPTASE (INFUSION) 1.5 Million IU
FOSCAVIR 24 MG/ML
FOSCAVIR 24 MG/ML
Start Date #1
2 ML PC

10/5/2005 INJECTION, FOSCARNET SODIUM, PER 1000 MG
HCPCS Measure #1

ML
1/1/2002
1/1/2002
1/1/2002
1/1/2002
Billing Units
09/18/2002
09/18/2002
10/05/2005
4/9/2009
J2995
J2995
J1455
J1455
Prior Start Date #2
NDC Package Type
01/01/2002
01/01/2002
01/01/2002
01/01/2002
00186-1773-01
00186-1774-01
00186-1905-01
00186-1906-01
NDC Label
6
6
0.024
0.024
HCPCS Description
250000 IU
250000 IU
1000 MG
1000 MG
EA
EA
ML
ML
HCPCS Mod
IV
IV
IV
IV
HCPCS
VL
VL
GC
GC
NDC Mod
1 EA
1 EA
250 ML
500 ML
NDC
NDC Package Measure

Package
00206-8861-02
J2543
00206-8862-02
J2543
00223-0671-01
Q0172
00223-0671-02
Q0172
00223-0672-01
Q0172
00223-0672-02
Q0172
00223-0673-01
Q0172
00223-0674-01
Q0172
00223-0790-01
00223-0790-01
Q0181
J8540
00223-0791-01
00223-0791-01
Q0181
J8540
00223-0791-02
00223-0791-02
Q0181
J8540
00223-0792-01
00223-0792-01
Q0181
J8540
00223-1049-01
Q0177
00223-1049-02
Q0177
00223-1050-01
Q0178
00223-1050-02
Q0178
00223-1051-01
Q0178
00223-1051-02
00223-1512-01
00223-1512-02
00223-1515-01
00223-1515-02
00223-1516-01
00223-1516-02
00223-1517-01
00223-1517-02
Q0178
J7510
J7510
J7506
J7506
J7506
J7506
J7506
J7506
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS ZOSYN (24 PRE-MIX BAGS OF 50ML) 3
1/9/2006 99/99/9999 (1.125 GRAMS)
GM/50 ML-0.375 GM/50 ML
1/9/2006 99/99/9999 (1.125 GRAMS)
ZOSYN 4 GM/100 ML-0.5 GM/100 ML
CHLORPROMAZINE HCL 25 MG
1/1/2002 12/31/2005 REGIMEN
1/1/2002 12/31/2005 REGIMEN
1/1/2002 12/31/2005 REGIMEN
1/1/2002 12/31/2005 REGIMEN
1/1/2002 8/15/2008 PREDNISOLONE ORAL, PER 5 MG
PREDNISOLONE 5 MG
PREDNISOLONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
Page 61 of 374
50 ML PC
IV
ML
1 GM
0.06
01/09/2006
99/99/9999
100 ML PC
IV
ML
1 GM
0.04
01/09/2006
99/99/9999
100 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
1000 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
100 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
1000 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
100 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
100 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
100 EA NA
100 EA NA
PO
PO
EA
EA
1 EA
0.25 MG
1
2
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA NA
100 EA NA
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
1000 EA NA
1000 EA NA
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA NA
100 EA NA
PO
PO
EA
EA
1 EA
0.25 MG
1
6
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
1000 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
100 EA NA
PO
EA
50 MG
01/01/2002
99/99/9999
1000 EA NA
PO
EA
50 MG
01/01/2002
99/99/9999
100 EA NA
PO
EA
50 MG
01/01/2002
99/99/9999
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
2
1
1
1
1
2
2
4
4
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
08/15/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1000 EA
100 EA
1000 EA
100 EA
1000 EA
100 EA
1000 EA
100 EA
1000 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00223-1521-01
Q0170
1/1/2002
00223-1521-02
Q0170
1/1/2002
00223-5346-10
J2650
1/1/2002
00223-6246-08
Q0172
1/1/2002
00223-6343-01
Q0170
1/1/2002
00223-6347-01
Q0170
1/1/2002
00223-6347-02
Q0170
1/1/2002
00223-6496-01
00223-6496-01
Q0181
J8540
1/1/2002
1/1/2006
00223-6496-02
00223-6496-02
Q0181
J8540
1/1/2002
1/1/2006
00223-7126-20
00223-7128-02
00223-7128-10
00223-7130-00
00223-7130-10
00223-7136-20
00223-7191-25
00223-7192-00
00223-7193-25
00223-7206-01
J3490
J0280
J0280
J0280
J0280
J0280
J0460
J0460
J0460
J0460
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00223-7265-05
J7624

PREDNISOLONE ACETATE (VIAL) 50
99/99/9999 INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML
MG/ML
CHLORPROMAZINE HCL 100 MG/ML
PROMETHAZINE HCL 6.25 MG/5 ML
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE PEDIATRIC 6.25 MG/5
ML
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE PEDIATRIC 6.25 MG/5
ML
DEXAMETHASONE 0.5 MG/5 ML
12/31/2005 REGIMEN
12/31/2005 REGIMEN
00223-7280-00
J0610
1/1/2002 99/99/9999 INJECTION, CALCIUM GLUCONATE, PER 10 ML
00223-7280-10
J0610
00223-7310-10
J3490
00223-7310-30
J3490
00223-7325-02
J3230
00223-7325-10
J3230
00223-7326-10
J3230
00223-7330-02
J3230
00223-7334-01
J3230
00223-7390-05
J1095
1/1/2002 12/31/2002 INJECTION, DEXAMETHASONE ACETATE, PER 8 MG
00223-7390-05
J1094
1/1/2003 99/99/9999 INJECTION, DEXAMETHASONE ACETATE, 1 MG
00223-7401-25
J1100
1/1/2002 99/99/9999 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG
00223-7402-30
J1100
AMINOCAPROIC ACID (VIAL) 250 MG/ML

AMINOPHYLLINE (VIAL) 25 MG/ML
AMINOPHYLLINE (VIAL) 25 MG/ML
AMINOPHYLLINE 25 MG/ML
AMINOPHYLLINE 25 MG/ML
AMINOPHYLLINE (S.D.V.) 25 MG/ML
ATROPINE SULFATE (VIAL) 0.4 MG/ML
ATROPINE SULFATE (VIAL) 0.4 MG/ML
ATROPINE SULFATE (AMP) 0.4 MG/ML
ATROPINE SULFATE (VIAL) 1 MG/ML
BETAMETHASONE SODIUM
PHOSPHATE (VIAL) 3 MG/ML
CALCIUM GLUCONATE (VIAL) 100
MG/ML
MG/ML
CHLORPHENIRAMINE MALEATE (VIAL)
10 MG/ML
CHLORPHENIRAMINE MALEATE (VIAL)
10 MG/ML
CHLORPROMAZINE HCL (AMPULES) 25
MG/ML
CHLORPROMAZINE HCL (VIAL) 25
MG/ML
MG/ML
MG/ML
MG/ML
DEXAMETHASONE ACETATE (VIAL) 8
MG/ML
MG/ML
DEXAMETHASONE SODIUM
PHOSPHATE (AMP) 4 MG/ML
00223-7403-01
J1100
PHOSPHATE (DOSETTE VIAL) 4 MG/ML
00223-7265-05 KO J7624
KO

Page 62 of 374
100 EA NA
PO
EA
25 MG
1000 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
IJ
ML
1 ML
01/01/2002
99/99/9999
240 ML NA
PO
ML
25 MG
01/01/2002
99/99/9999
480 ML NA
PO
ML
25 MG
0.05
01/01/2002
99/99/9999
120 ML NA
PO
ML
25 MG
0.05
01/01/2002
99/99/9999
480 ML NA
PO
ML
25 MG
0.05
01/01/2002
99/99/9999
100 ML NA
100 ML NA
PO
PO
ML
ML
1 EA
0.25 MG
1
0.4
01/01/2002
01/01/2006
12/31/2005
99/99/9999
240 ML NA
240 ML NA
PO
PO
ML
ML
1 EA
0.25 MG
1
0.4
01/01/2002
01/01/2006
12/31/2005
99/99/9999
VL
VL
VL
NA
NA
VL
VL
VL
AM
VL
IV
IV
IV
IV
IV
IV
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 EA
250 MG
250 MG
250 MG
250 MG
250 MG
0.3 MG
0.3 MG
0.3 MG
0.3 MG
1
0.1
0.1
0.1
0.1
0.1
1.33333
1.33333
1.33333
3.33333
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2009
12/31/2009
12/31/2009
12/31/2009
5 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
5 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
10 ML EA
IV
ML
10 ML
0.1
01/01/2002
99/99/9999
10 ML EA
20 ML
10 ML
10 ML
10 ML
10 ML
20 ML
1 ML
1 ML
1 ML
1 ML
01/01/2002
10 ML EA
IV
ML
10 ML
0.1
01/01/2002
99/99/9999
IJ
ML
1 EA
01/01/2002
99/99/9999
30 ML VL
IJ
ML
1 EA
01/01/2002
99/99/9999
2 ML AM IJ
ML
50 MG
0.5
01/01/2002
99/99/9999
ML
50 MG
0.5
01/01/2002
99/99/9999
IJ
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
10 ML VL
10 ML VL
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1 ML VL
IJ
ML
50 MG
0.5
01/01/2002
99/99/9999
10 ML VL
IJ
ML
50 MG
0.5
01/01/2002
99/99/9999
2 ML VL
IJ
ML
50 MG
0.5
01/01/2002
99/99/9999
5 ML VL
IJ
ML
8 MG
01/01/2002
12/31/2002
5 ML VL
IJ
ML
1 MG
01/01/2003
99/99/9999
1 ML AM IJ
ML
1 MG
01/01/2002
99/99/9999
30 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
00223-7404-05
J1100
00223-7406-25
J1100
00223-7407-01
J1100
00223-7408-10
00223-7430-10
00223-7475-10
J1100
J0500
J1240

1/1/2002 99/99/9999 INJECTION, DIMENHYDRINATE, UP TO 50 MG
00223-7484-05
Q4076
00223-7484-05
00223-7485-05
00223-7485-05
J1265
Q4076
J1265

00223-7486-05
Q4076
00223-7486-05
00223-7487-05
00223-7487-05
00223-7494-20
00223-7520-01
J1265
Q4076
J1265
J3520
J0170
1/1/2006
10/1/2003
1/1/2006
1/1/2002
1/1/2002
5 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
25 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
00223-7520-05
J0170
PHOSPHATE (DOSETTE VIAL) 4 MG/ML
DICYCLOMINE HCL (VIAL) 10 MG/ML
DIMENHYDRINATE (VIAL) 50 MG/ML
DOPAMINE HCL (AMP, DOSETTE) 40
MG/ML
MG/ML
DOPAMINE HCL (S.D.V.) 40 MG/ML
MG/ML
MG/ML
EDETATE DISODIUM (VIAL) 150 MG/ML
EPINEPHRINE HCL (VIAL) 1 MG/ML
EPINEPHRINE HCL (VIAL, AQUEOUS) 1
MG/ML
IJ
ML
1 ML
01/01/2002
00223-7602-10
J1000
1/1/2002 99/99/9999 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG
ESTRADIOL CYPIONATE (VIAL) 5 MG/ML
10 ML VL
IM
ML
5 MG
01/01/2002
99/99/9999
00223-7606-10
J1390
1/1/2002 99/99/9999 INJECTION, ESTRADIOL VALERATE, UP TO 20 MG
ESTRADIOL VALERATE (VIAL) 20 MG/ML
10 ML VL
IM
ML
20 MG
01/01/2002
99/99/9999
00223-7607-10
00223-7660-10
00223-7670-10
J0970
J1435
J1435

1/1/2002 99/99/9999 INJECTION, ESTRONE, PER 1 MG
10 ML VL
10 ML EA
10 ML EA
IM
IM
IM
ML
ML
ML
40 MG
1 MG
1 MG
1
2
5
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
00223-7700-02
00223-7701-02
J1940
J1940

2 ML AM IJ
2 ML VL IJ
ML
ML
20 MG
20 MG
0.5
0.5
01/01/2002
01/01/2002
99/99/9999
99/99/9999
00223-7704-04
00223-7705-04
J1940
J1940

4 ML AM IJ
4 ML VL IJ
ML
ML
20 MG
20 MG
0.5
0.5
01/01/2002
01/01/2002
99/99/9999
99/99/9999
00223-7707-10
00223-7708-20
J1940
J1940

ESTRADIOL VALERATE (VIAL) 40 MG/ML

ESTRONE (VIAL, AQUEOUS) 2 MG/ML
FUROSEMIDE (AMP, DOSETTE) 10
MG/ML
FUROSEMIDE (VIAL) 10 MG/ML
MG/ML
MG/ML
10 ML AM IJ
10 ML VL IJ
ML
ML
20 MG
20 MG
0.5
0.5
01/01/2002
01/01/2002
99/99/9999
99/99/9999
00223-7714-02
J1580
1/1/2002 99/99/9999 INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG
GENTAMICIN SULFATE (VIAL) 10 MG/ML
2 ML VL
IJ
ML
80 MG
0.125
01/01/2002
99/99/9999
00223-7715-02
J1580
2 ML VL
IJ
ML
80 MG
0.125
01/01/2002
99/99/9999
00223-7717-20
J1580
20 ML VL
IJ
ML
80 MG
0.5
01/01/2002
99/99/9999
00223-7719-02
J1580
2 ML VL
IJ
ML
80 MG
0.5
01/01/2002
99/99/9999
00223-7719-25
J1580
2 ML VL
IJ
ML
80 MG
0.5
01/01/2002
99/99/9999
00223-7721-02
J1580
2 ML VL
IJ
ML
80 MG
0.5
01/01/2002
99/99/9999
00223-7722-05
J7643

GLYCOPYRROLATE (VIAL) 0.2 MG/ML
5 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
5 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
20 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999

CHORIONIC GONADOTROPIN
(W/DILUENT) 5000 U
(W/DILUENT) 10000 U
HEPARIN SODIUM (VIAL, PORK) 1000
U/ML
U/ML
U/ML
U/ML
U/ML
20 ML VL
1 MG
00223-7722-05 KO J7643
00223-7723-20
KO
J7643
00223-7723-20 KO J7643
KO

99/99/9999 EDETATE DISODIUM, PER 150 MG
00223-7760-10
J0725
1/1/2002 99/99/9999 INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS
00223-7770-10
00223-7801-01
J0725
J1644

00223-7810-10
J1644
00223-7811-30
00223-7818-01
J1644
J1644

00223-7820-10
J1644
00223-7828-01
J1644
00223-7830-04
00223-7831-05
J1644
J1644

Page 63 of 374
1 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
10 ML VL
10 ML VL
10 ML VL
IJ
IM
IJ
ML
ML
ML
1 MG
20 MG
50 MG
4
0.5
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
5 ML AM IV
ML
40 MG
10/01/2003
12/31/2005
5 ML AM IV
5 ML VL IV
5 ML VL IV
ML
ML
ML
40 MG
40 MG
40 MG
1
1
1
01/01/2006
10/01/2003
01/01/2006
99/99/9999
12/31/2005
99/99/9999
5 ML AM IV
ML
40 MG
10/01/2003
12/31/2005
AM
VL
VL
VL
EA
IV
IV
IV
IV
IJ
ML
ML
ML
ML
ML
40 MG
40 MG
40 MG
150 MG
1 ML
2
2
2
1
1
01/01/2006
10/01/2003
01/01/2006
01/01/2002
01/01/2002
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
1 ML EA
99/99/9999
5 ML
5 ML
5 ML
20 ML
1 ML
IJ
ML
0.2
01/01/2002
99/99/9999
1 EA NA
IM
EA
1000 USP Units
01/01/2002
99/99/9999
1 EA NA
1 ML VL
IM
IJ
EA
ML
1000 USP Units

1000 U
10
1
01/01/2002
01/01/2002
99/99/9999
99/99/9999
10 ML VL
IJ
ML
1000 U
01/01/2002
99/99/9999
1 ML VL
1 ML VL
IJ
IJ
ML
ML
1000 U
1000 U
5
5
01/01/2002
01/01/2002
99/99/9999
99/99/9999
10 ML VL
IJ
ML
1000 U
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1000 U
10
01/01/2002
99/99/9999
4 ML VL
5 ML VL
IJ
IJ
ML
ML
1000 U
1000 U
10
10
01/01/2002
01/01/2002
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00223-7832-10
00223-7840-01
J1644
J1644

00223-7840-05
00223-7843-10
00223-7844-30
J1644
J1644
J1644

00223-7845-25
00223-7846-01
00223-7847-04
00223-7847-25
J1644
J1644
J1644
J1644
1/1/2002
1/1/2002
1/1/2002
1/1/2002

00223-7861-01
J1642
00223-7863-02
J1642
00223-7865-01
J1642
00223-7867-02
00223-7877-10
00223-7878-10
00223-7882-10
J1642
J3410
J3410
J3410
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00223-7883-01
00223-7884-02
J3410
J3410

00223-7885-01
J3410
00223-7893-02
J1720
1/1/2002 99/99/9999 INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG
00223-7894-02
J1720
00223-7896-05
J3490
00223-7898-08
J1720
00223-7899-08
J1720
00223-7912-10
J3420
1/1/2002 99/99/9999 INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG
00223-7912-30
J3420
00223-7915-05
00223-8105-50
00223-8150-10
J3490
J2150
J2800

1/1/2002 99/99/9999 INJECTION, METHOCARBAMOL, UP TO 10 ML
00223-8160-01
J2920
00223-8160-02
J2930
00223-8161-02
J2930
00223-8162-03
J2930
00223-8163-04
J2930
00223-8200-10
J2360
00223-8322-30
J3480
00223-8330-01
J3480

00223-8330-10
J3480
00223-8331-20
J3480
00223-8332-30
J3480
00223-8341-30
J2650
1/1/2002 99/99/9999 INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML
00223-8345-10
J2650
00223-8345-30
J2650
00223-8346-10
J2650
00223-8346-30
00223-8393-01
00223-8393-10
00223-8394-01
J2650
J2550
J2550
J2550
1/1/2002
1/1/2002
1/1/2002
1/1/2002


U/ML
U/ML
HEPARIN SODIUM (M.D.V.) 1000 U/ML
U/ML
HEPARIN LOCK FLUSH (VIAL, DOSETTE)
10 U/ML
10 U/ML
100 U/ML
100 U/ML
HYDROXYZINE HCL (VIAL) 25 MG/ML
HYDROXYZINE HCL (VIAL, DOSETTE) 50
MG/ML
HYDROXYZINE HCL (VIAL, DOSETTE) 25
MG/ML
HYDROCORTISONE SODIUM
SUCCINATE 100 MG
SUCCINATE 250 MG
HYDROXYPROGESTERONE CAPROATE
(VIAL) 250 MG/ML
SUCCINATE 500 MG
SUCCINATE 1 GM
HYDROXOCOBALAMIN (VIAL) 1000
MCG/ML
MCG/ML
(VIAL) 250 MG/ML
MANNITOL (VIAL) 25%
METHOCARBAMOL (VIAL) 100 MG/ML
METHYLPREDNISOLONE SODIUM
SUCCINATE (VIAL) 40 MG
SUCCINATE 500 MG
SUCCINATE 1 GM
ORPHENADRINE CITRATE (VIAL) 30
MG/ML
POTASSIUM CHLORIDE (VIALS) 2
MEQ/ML
POTASSIUM CHLORIDE (AMP) 2 MEQ/ML
POTASSIUM CHLORIDE SOLUTION
(AMP) 2 MEQ/ML
(AMP) 2 MEQ/ML
(AMP) 2 MEQ/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
PROMETHAZINE HCL (VIAL) 25 MG/ML
Page 64 of 374
10 ML VL
5 ML VL
IJ
IJ
ML
ML
1000 U
1000 U
10
20
01/01/2002
01/01/2002
99/99/9999
99/99/9999
5 ML VL
10 ML VL
30 ML VL
IJ
IJ
IJ
ML
ML
ML
1000 U
1000 U
1000 U
20
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
IJ
IJ
IJ
IJ
ML
ML
ML
ML
1000 U
1000 U
1000 U
1000 U
5
10
10
10
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
IV
ML
10 U
01/01/2002
99/99/9999
2 ML VL
IV
ML
10 U
01/01/2002
99/99/9999
1 ML VL
IV
ML
10 U
10
01/01/2002
99/99/9999
VL
VL
VL
VL
IV
IM
IM
IM
ML
ML
ML
ML
10 U
25 MG
25 MG
25 MG
10
1
2
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
2 ML VL
IM
IM
ML
ML
25 MG
25 MG
2
2
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1 ML
1 ML
4 ML
4 ML
2 ML
10 ML
10 ML
10 ML
1 ML VL
IM
ML
25 MG
01/01/2002
99/99/9999
1 EA NA
IJ
EA
100 MG
01/01/2002
99/99/9999
1 EA NA
IJ
EA
100 MG
2.5
01/01/2002
99/99/9999
5 ML VL
IM
ML
1 EA
01/01/2002
99/99/9999
1 EA NA
IJ
EA
100 MG
01/01/2002
99/99/9999
IJ
EA
100 MG
10
01/01/2002
99/99/9999
10 ML VL
1 EA NA
IM
ML
1000 MCG
01/01/2002
99/99/9999
30 ML VL
IM
ML
1000 MCG
01/01/2002
99/99/9999
5 ML VL
50 ML VL
10 ML VL
IM
IV
IJ
ML
ML
ML
1 EA
50 ML
10 ML
1
0.02
0.1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
40 MG
01/01/2002
99/99/9999
1 EA VL
IJ
EA
125 MG
01/01/2002
99/99/9999
1 EA VL
IJ
EA
125 MG
01/01/2002
99/99/9999
1 EA NA
IJ
EA
125 MG
01/01/2002
99/99/9999
1 EA NA
IJ
EA
125 MG
01/01/2002
99/99/9999
10 ML VL
IJ
ML
60 MG
0.5
01/01/2002
99/99/9999
30 ML VL
IV
ML
2 MEQ
01/01/2002
99/99/9999
10 ML AM IV
ML
2 MEQ
01/01/2002
99/99/9999
10 ML AM IV
ML
2 MEQ
01/01/2002
99/99/9999
20 ML AM IV
ML
2 MEQ
01/01/2002
99/99/9999
30 ML AM IV
ML
2 MEQ
01/01/2002
99/99/9999
30 ML EA
IJ
ML
1 ML
01/01/2002
99/99/9999
10 ML EA
IJ
ML
1 ML
01/01/2002
99/99/9999
30 ML EA
IJ
ML
1 ML
01/01/2002
99/99/9999
10 ML EA
IJ
ML
1 ML
01/01/2002
99/99/9999
30 ML
1 ML
10 ML
1 ML
IJ
IJ
IJ
IJ
ML
ML
ML
ML
1 ML
50 MG
50 MG
50 MG
1
0.5
0.5
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
EA
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
J3420
J3420
J3420

00223-8871-30
J3420
00223-8883-30
A4712
00223-8883-30
A4216
00223-8884-10
A4712
00223-8884-10
00223-8979-05
00223-8979-05
00223-8980-10
00223-8980-10
00228-2605-11
00228-2605-50
00228-2606-11
00228-2606-50
00228-2607-11
00228-2607-50
00254-4216-13
00254-4216-28
A4216
A4712
A4216
A4712
A4216
J8499
J8499
J8499
J8499
J8499
J8499
J7509
J7509
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00254-4940-28
Q0175
1/1/2002
00254-4940-35
Q0175
1/1/2002
00254-4941-28
Q0175
1/1/2002
00254-4941-35
Q0175
1/1/2002
00254-4942-28
Q0176
1/1/2002
00254-4942-35
Q0176
1/1/2002
00254-4943-28
Q0176
1/1/2002
00223-8860-30
J3420
00223-8861-01
J3420
00223-8862-25
00223-8870-00
00223-8870-30

3/26/2003 REGIMEN
3/26/2003 REGIMEN
3/26/2003 REGIMEN
3/26/2003 REGIMEN
3/26/2003 REGIMEN
3/26/2003 REGIMEN
3/26/2003 REGIMEN
CF
HCPCS Amount #1
30 ML VL
IM
ML
1000 MCG
01/01/2002
99/99/9999
1 ML VL
IM
ML
1000 MCG
01/01/2002
99/99/9999
CYANOCOBALAMIN (AMP) 1000 MCG/ML

VITABEE 12 (VIAL) 1000 MCG/ML
VITABEE 12 (VIAL) 1000 MCG/ML
1 ML AM IM
10 ML VL IM
30 ML VL IM
ML
ML
ML
1000 MCG
1000 MCG
1000 MCG
1
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
CYANOCOBALAMIN (VIAL) 100 MCG/ML

WATER FOR INJECTION
BACTERIOSTATIC (VIAL)
WATER FOR INJECTION
WATER FOR INJECTION
WATER FOR INJECTION
WATER FOR INJECTION (AMP)
WATER FOR INJECTION (AMP)
WATER FOR INJECTION (VIAL)
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
METHYLPREDNISOLONE 4 MG
30 ML VL
IM
ML
1000 MCG
0.1
01/01/2002
99/99/9999
30 ML EA
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
30 ML EA
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
10 ML EA
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
10 ML
5 ML
5 ML
10 ML
10 ML
100 EA
500 EA
100 EA
500 EA
100 EA
500 EA
21 EA
100 EA
EA
AM
AM
EA
EA
BO
BO
BO
BO
BO
BO
DP
BO
IV
IV
IV
IV
IV
PO
PO
PO
PO
PO
PO
PO
PO
ML
ML
ML
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
10 ML
10 ML
10 ML
10 ML
10 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
4 MG
4 MG
0.1
0.1
0.1
0.1
0.1
1
1
1
1
1
1
1
1
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/04/2006
12/04/2006
12/04/2006
12/04/2006
12/04/2006
12/04/2006
03/26/2003
03/26/2003
PERPHENAZINE 2 MG
100 EA BO
PO
EA
4 MG
0.5
01/01/2002
03/26/2003
PERPHENAZINE 2 MG
500 EA BO
PO
EA
4 MG
0.5
01/01/2002
03/26/2003
PERPHENAZINE 4 MG
100 EA BO
PO
EA
4 MG
01/01/2002
03/26/2003
PERPHENAZINE 4 MG
500 EA BO
PO
EA
4 MG
01/01/2002
03/26/2003
PERPHENAZINE 8 MG
100 EA BO
PO
EA
8 MG
01/01/2002
03/26/2003
PERPHENAZINE 8 MG
500 EA BO
PO
EA
8 MG
01/01/2002
03/26/2003
PERPHENAZINE 16 MG
100 EA BO
PO
EA
8 MG
01/01/2002
03/26/2003
Page 65 of 374
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
Prior End Date #3
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
Prior Start Date #3
0.5
1
1
1
1

99/99/9999 INJECTION, THIAMINE HCL, 100 MG
200 MG
1 EA
100 MG
1 EA
100 MG
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
Prior End Date #2
ML
ML
ML
ML
ML
J3250
J3490
J3411
J3490
J3411
End Date #1
IM
IJ
IJ
IJ
IJ
00223-8700-20
00223-8709-01
00223-8709-01
00223-8711-02
00223-8711-02
Start Date #1
VL
AM
AM
VL
VL

12/31/2002 INJECTION, PROMAZINE HCL, UP TO 25 MG
12/31/2002 INJECTION, PROMAZINE HCL, UP TO 25 MG
99/99/9999 INJECTION, PYRIDOXINE HCL, 100 MG
HCPCS Measure #1
20 ML
1 ML
1 ML
30 ML
30 ML
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2007
1/1/2002
1/1/2007
1/1/2002
1/1/2004
1/1/2002
1/1/2004
Billing Units
99/99/9999
12/31/2002
12/31/2002
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
J2550
J2950
J2950
J3490
J3415
J3490
J3415
J3490
J3415
J2912
A4216
J2912
A4216
J2912
A4216
J2912
A4216
Prior Start Date #2
NDC Package Type
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2007
01/01/2002
01/01/2007
01/01/2002
01/01/2004
01/01/2002
01/01/2004
00223-8394-10
00223-8397-10
00223-8398-10
00223-8403-10
00223-8403-10
00223-8404-30
00223-8404-30
00223-8410-10
00223-8410-10
00223-8496-02
00223-8496-02
00223-8496-05
00223-8496-05
00223-8497-10
00223-8497-10
00223-8500-30
00223-8500-30
NDC Label
1
1
2
1
1
1
1
1
1
0.5
0.1
0.5
0.1
0.5
0.1
0.5
0.1
HCPCS Description
50 MG
25 MG
25 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
0.9 %
10 ML
0.9 %
10 ML
0.9 %
10 ML
0.9 %
10 ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
HCPCS Mod
IJ
IM
IM
IJ
IJ
IJ
IJ
IJ
IJ
IV
IV
IV
IV
IV
IV
IV
IV
HCPCS
VL
EA
VL
VL
VL
VL
VL
VL
VL
AM
AM
AM
AM
AM
AM
VL
VL
NDC Mod
10 ML
10 ML
10 ML
10 ML
10 ML
30 ML
30 ML
10 ML
10 ML
5 ML
5 ML
5 ML
5 ML
10 ML
10 ML
30 ML
30 ML

PROMAZINE HCL (VIAL) 25 MG/ML
PROMAZINE HCL (VIAL) 50 MG/ML
PYRIDOXINE HCL (VIAL) 100 MG/ML
VITABEE 6 (VIAL) 100 MG/ML
VITABEE 6 (VIAL) 100 MG/ML
SODIUM CHLORIDE (AMP) 0.9%
SODIUM CHLORIDE (VIAL) 0.9%
TRIMETHOBENZAMIDE HCL (VIAL) 100
MG/ML
THIAMINE HCL (AMP) 100 MG/ML
THIAMINE HCL (AMP) 100 MG/ML
THIAMINE HCL (VIAL) 100 MG/ML
CYANOCOBALAMIN (M.D.V.) 1000
MCG/ML
CYANOCOBALAMIN (VIAL, DOSETTE)
1000 MCG/ML
NDC
NDC Package Measure

Package
00258-3711-01
G9020
12/1/2004
00259-0364-21
J7506
1/1/2002
00259-0389-48
00259-0390-21
00259-0391-48
00264-1101-55
00264-1102-55
J7506
J7506
J7506
J7060
J7060
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

00264-1107-55
00264-1110-00
00264-1110-23
00264-1120-00
00264-1120-01
00264-1120-10
00264-1124-01
00264-1125-01
00264-1125-10
00264-1126-01
00264-1127-00
00264-1127-01
00264-1128-00
00264-1128-10
00264-1128-50
00264-1129-00
00264-1129-01
00264-1129-20
J7060
J7060
J7060
J7799
J7799
J7799
J7799
J7799
J7799
J7799
J7799
J7799
J7799
J7799
J7799
J7799
J7799
J7799
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

00264-1129-50
00264-1178-10
J7799
J7799
00264-1200-55
J7799
00264-1201-55
J7799
00264-1207-55
J7799
00264-1217-10
J7799
00264-1222-00
J7799
00264-1240-55
J7799
00264-1250-55
J7799
00264-1251-55
J7799
00264-1260-55
J7799
00264-1270-50
J7799
00264-1270-55
J7799
00264-1280-50
J7799
00264-1280-55
J7799
00264-1281-55
J7799
00264-1285-55
J7799
00264-1290-50
J7799
00264-1290-55
J7799
00264-1292-55
J7799
00264-1441-55
Q4076
00264-1441-55
J1265
00264-1442-55
Q4076
00264-1442-55
J1265
PREDNISONE (DOSE PACK) 10 MG

STERAPRED DS (6 DAY UNI-PAK) 10 MG
STERAPRED DS (12 DAY UNI-PAK) 10
MG
STERAPRED (6 DAY UNI-PAK) 5 MG
DEXTROSE (GLASS) 5%
DEXTROSE (GLASS W/SS,250 ML) 5%
DEXTROSE (GLASS W/SOLID STOPPER)
5%
DEXTROSE (GLASS) 5%
DEXTROSE (GLASS,250 ML) 5%
DEXTROSE (GLASS) 10%
DEXTROSE (AIR TUBE,1000 ML) 10%
DEXTROSE (AIR TUBE) 20%
DEXTROSE (W/STERILE WATER) 50%
DEXTROSE HYPERTONIC (GLASS W/AIR
TUBE) 70%
MANNITOL (GLASS CONTAINER) 20%
10%
10%
DEXTROSE (GLASS W/SS,1000 ML) 10%
DEXTROSE/SODIUM CHLORIDE (GLASS)
5%-0.11%
DEXTROSE/SODIUM CHLORIDE (GLASS)
10%-0.45%
DEXTROSE HYPERTONIC (GLASS
W/SS,1000 ML) 30%
W/SS,1000 ML) 20%
W/SOLID STOPPER) 20%
W/SS,1000 ML) 40%
W/SS,1000 ML) 60%
W/SS,1000 ML) 50%
W/SS,1000 ML) 70%
DEXTROSE/DOPAMINE HCL (GLASS) 5%80 MG/100 ML
Page 66 of 374
PO
PO
PO
PO
EA
EA
EA
EA
5
5
5
5
MG
MG
MG
MG
2
2
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/26/2003
03/26/2003
03/26/2003
03/26/2003
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
21 EA DP
PO
EA
5 MG
01/01/2002
7/1/2009
48 EA
21 EA
48 EA
500 ML
150 ML
DP
DP
DP
FC
GC
PO
PO
PO
IV
IV
EA
EA
EA
ML
ML
5 MG
5 MG
5 MG
500 ML
500 ML
2
1
1
0.002
0.002
01/01/2002
8/31/2009
01/01/2002 10/31/2009
01/01/2002 10/31/2009
01/01/2002 99/99/9999
01/01/2002 99/99/9999
1000 ML
1000 ML
150 ML
1000 ML
500 ML
500 ML
500 ML
500 ML
500 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
2000 ML
1000 ML
500 ML
250 ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
500 ML
500 ML
500 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
0.002
0.002
0.002
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2000 ML GC IV
500 ML GC IV
ML
ML
1 EA
1 EA
1
1
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1000 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
500 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
500 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
99/99/9999
ML
1 EA
01/01/2002
IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
2000 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML EA
500 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
250 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
ML
40 MG
0.02
10/01/2003
12/31/2005
500 ML GC IV
ML
40 MG
0.02
01/01/2006
99/99/9999
250 ML GC IV
ML
40 MG
0.02
10/01/2003
12/31/2005
250 ML GC IV
ML
40 MG
0.02
01/01/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
DP
DP
DP
DP
Billing Units
21 EA
48 EA
21 EA
48 EA

Package
NDC Label
HCPCS Description

NDC Package Type
1/1/2002
1/1/2002
1/1/2002
1/1/2002
HCPCS Mod
HCPCS
J7506
J7506
J7506
J7506
NDC Package Measure
00254-5093-13
00254-5093-23
00254-5094-13
00254-5094-23
NDC Mod
NDC
00264-1481-55
00264-1481-55
00264-1482-55
00264-1482-55
Q4076
J1265
Q4076
J1265
ML
40 MG
0.04
10/01/2003
12/31/2005
500 ML GC IV
ML
40 MG
0.04
01/01/2006
99/99/9999
DEXTROSE/DOPAMINE HCL (GLASS

W/SOLID STOPPER) 5%-160 MG/100 ML
250 ML GC IV
ML
40 MG
0.04
10/01/2003
12/31/2005

250 ML GC IV
ML
40 MG
0.04
01/01/2006
99/99/9999

250 ML GC IV
ML
40 MG
0.08
10/01/2003
12/31/2005
250 ML
50 ML
100 ML
25 ML
50 ML
50 ML
100 ML
25 ML
25 ML
IV
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
40 MG
500 ML
500 ML
500 ML
0.9 %
10 ML
250 ML
0.9 %
10 ML
0.08
0.002
0.002
0.002
0.5
0.1
0.004
0.5
0.1
01/01/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2003
99/99/9999
99/99/9999
12/31/2003
99/99/9999
1000 ML GC IJ
ML
10 ML
0.1
01/01/2002
12/31/2003
1000 ML GC IJ
ML
500 ML
0.002
01/01/2004
99/99/9999
2000 ML GC IJ
ML
10 ML
0.1
01/01/2002
12/31/2003
2000 ML GC IJ
ML
500 ML
0.002
01/01/2004
99/99/9999
500 ML GC IV
ML
2 MEQ
01/01/2002
99/99/9999
250 ML GC IV
ML
2 MEQ
01/01/2002
99/99/9999
500 ML GC IV
ML
500 ML
0.002
01/01/2002
99/99/9999
500 ML GC IV
500 ML GC IV
500 ML BO IV
ML
ML
ML
500 ML
500 ML
10 %
0.002
0.002
0.01
01/01/2002
01/01/2002
01/01/2002
04/09/2003
04/09/2003
04/26/2004
12/31/2003
J1265
J7060
J7060
J7060
J2912
A4216
J7050
J2912
A4216
1/1/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2004
00264-1920-00
A4712
00264-1920-00
A4217
00264-1920-50
A4712
00264-1920-50
A4217
00264-1940-10
J3480
00264-1940-20
J3480
00264-1960-10
J7110
00264-1962-10
00264-1963-10
00264-1972-10
J7100
J7100
Q2013
1/1/2002
1/1/2002
1/1/2002
00264-2101-00
A4319
00264-2101-00
A4217
00264-2101-10
A4319
00264-2101-10
A4217
00264-2101-50
A4319
00264-2101-50
A4217
00264-2101-70
A4319
00264-2101-70
A4217
00264-2171-55
J7799
00264-2201-00
A4323
00264-2201-00
A4217
00264-2201-10
A4323
00264-2201-10
A4217
00264-2201-50
A4323
00264-2201-50
A4217
00264-2201-70
A4323
00264-2201-70
A4217

DEXTROSE (100 ML PAB) 5%
SODIUM CHLORIDE (100 ML PAB) 0.9%
WATER FOR INJECTION (SUPERVIAL,HYPOTONIC)
POTASSIUM CHLORIDE
(CONCENTRATE) 2 MEQ/ML
POTASSIUM CHLORIDE
(CONCENTRATE) 2 MEQ/ML
DEXTRAN-70 W/NACL (GLASS
CONTAINER) 6%-0.9%
DEXTRAN-40 W/DEXTROSE (GLASS
CONTAINER) 10%-5%
DEXTRAN-40 W/NACL 10%-0.9%
PENTASPAN 10%
WATER FOR IRRIGATION (PIC
CONTAINER)
CONTAINER)
CONTAINER)
CONTAINER)
CONTAINER)
CONTAINER)
CONTAINER)
CONTAINER)
DEXTROSE/SODIUM CHLORIDE (GLASS
W/SOLID STOPPER) 5%-0.11%
SODIUM CHLORIDE (PIC CONTAINER)
0.9%
0.9%
0.9%
0.9%
0.9%
0.9%
0.9%
0.9%
DEXTROSE/SODIUM CHLORIDE (GLASS

W/SOLID STOPPER) 10%-0.45%


4/26/2004 INJECTION, PENTASTARCH, 10% SOLUTION, PER 100 ML
Page 67 of 374
GC
FC
FC
FC
FC
FC
FC
FC
FC
1000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
1000 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
500 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
500 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
2000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
2000 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
4000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
4000 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
500 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
1000 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
500 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
500 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
2000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
2000 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
4000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
4000 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
1000 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
500 ML GC IV

Q4076
NDC Package Type

00264-1492-55
00264-1510-31
00264-1510-32
00264-1510-36
00264-1800-31
00264-1800-31
00264-1800-32
00264-1800-36
00264-1800-36
J7799
NDC Package Measure
00264-1492-55
00264-2220-55

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00264-2303-50
00264-2303-70
00264-3102-11
J7799
J7799
J0690
00264-3103-11
00264-3112-11
J0690
J0697

00264-3114-11
00264-3123-11
00264-3125-11
00264-3153-11
00264-3155-11
J0697
J0694
J0694
J0696
J0696
3/1/2004
7/1/2006
7/1/2006
7/20/2005
7/20/2005

00264-3500-55
J7120
1/1/2002 99/99/9999 RINGERS LACTATE INFUSION, UP TO 1000 CC
00264-3501-55
J7120
00264-3510-55
J7120
00264-3511-55
J7120
00264-4000-55
J7030
1/1/2002 99/99/9999 INFUSION, NORMAL SALINE SOLUTION , 1000 CC
00264-4001-55
J7040
1/1/2002 99/99/9999 INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT)
00264-4002-55
J7050
00264-4020-55
J7799
00264-4021-55
J7799
00264-5535-32
J3490
00264-5806-32
J1580
00264-5808-32
J1580
00264-5810-32
J1580
00264-5812-38
J1580
00264-5816-38
00264-7510-00
00264-7510-10
00264-7510-20
00264-7520-00
00264-7520-10
00264-7573-00
00264-7578-10
00264-7578-20
J1580
J7060
J7060
J7060
J7799
J7799
J7799
J7799
J7799
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

00264-7605-00
J7799
00264-7605-10
J7799
00264-7608-00
J7799
00264-7608-10
J7799
00264-7608-20
J7799
00264-7608-30
J7799
00264-7610-00
J7042
1/1/2002 99/99/9999 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT)
00264-7610-10
J7042
00264-7610-20
J7042
00264-7612-00
J7799
00264-7612-10
J7799
00264-7612-20
J7799
00264-7614-00
J7799
RESECTISOL 5%
RESECTISOL 5%
CEFAZOLIN 500 MG/50 ML
CEFAZOLIN SODIUM (DUPLEX) 1 GM/50
ML-4%
CEFUROXIME SODIUM 750 MG/50 ML
CEFUROXIME SODIUM (DUPLEX) 1.5
GM/50 ML
CEFOXITIN 1 GM
CEFOXITIN 2 GM
CEFTRIAXONE/DEXTROSE 1 GM/50 ML
CEFTRIAXONE/DEXTROSE 2 GM/50 ML
LACTATED RINGER'S (GLASS
CONTAINER)
LACTATED RINGER'S (GLASS
CONTAINER)
DEXTROSE 5%/LACTATED RINGERS
(GLASS)
(GLASS)
SODIUM CHLORIDE (GLASS
CONTAINER) 0.9%
CONTAINER) 0.9%
SODIUM CHLORIDE (250 ML GLASS
CONTAINER) 0.9%
CONTAINER) 0.45%
CONTAINER) 0.45%
METRONIDAZOLE (150 ML PAB
CONTAINER) 500 MG/100 ML
CHLORIDE (150 ML PAB CONTAINER) 60
MG/100 ML-0.9%
CHLORIDE (150 ML PAB CONTAINER) 80
MG/100 ML-0.9%
CHLORIDE (150 ML PAB CONTAINER)
100 MG/100 ML-0.9%
CHLORIDE (100 ML PAB CONTAINER) 1.2
MG/ML-0.9%
CHLORIDE (100 ML PAB CONTAINER) 1.6
MG/ML-0.9%
DEXTROSE (EXCEL) 5%
DEXTROSE (EXCEL) 5%
DEXTROSE (EXCEL) 5%
DEXTROSE (EXCEL) 10%
DEXTROSE (EXCEL) 10%
MANNITOL (EXCEL) 10%
DEXTROSE/SODIUM CHLORIDE (EXCEL)
2.5%-0.45%
2.5%-0.45%
3.3%-0.3%
3.3%-0.3%
3.3%-0.3%
3.3%-0.3%
5%-0.9%
5%-0.9%
5%-0.9%
5%-0.45%
5%-0.45%
5%-0.45%
5%-0.33%
Page 68 of 374
2000 ML PC
4000 ML PC
50 ML EA
IL
IL
IV
ML
ML
ML
1 EA
1 EA
500 MG
1
1
0.02
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
50 ML FC
50 ML FC
IV
IV
ML
ML
500 MG
750 MG
0.04
0.02
03/05/2003
09/15/2003
99/99/9999
99/99/9999
50 ML
1 EA
1 EA
50 ML
50 ML
IV
IV
IV
IV
IV
ML
EA
EA
ML
ML
750 MG
1 GM
1 GM
250 MG
250 MG
0.04
1
2
0.08
0.16
03/01/2004
07/01/2006
07/01/2006
07/20/2005
07/20/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1000 ML GC IV
ML
1000 ML
0.001
01/01/2002
99/99/9999
500 ML GC IV
ML
1000 ML
0.001
01/01/2002
99/99/9999
ML
1000 ML
0.0005
01/01/2002
99/99/9999
FC
FC
FC
FC
FC
1000 ML NA
IV
500 ML NA
IV
ML
1000 ML
0.0005
01/01/2002
99/99/9999
1000 ML GC IV
ML
1000 ML
0.001
01/01/2002
99/99/9999
500 ML GC IV
ML
500 ML
0.002
01/01/2002
99/99/9999
250 ML GC IV
ML
250 ML
0.004
01/01/2002
99/99/9999
IV
ML
1 EA
01/01/2002
99/99/9999
500 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
100 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
100 ML FC
IV
ML
80 MG
0.0075
01/01/2002
99/99/9999
100 ML FC
IV
ML
80 MG
0.01
01/01/2002
99/99/9999
100 ML FC
IV
ML
80 MG
0.0125
01/01/2002
99/99/9999
50 ML FC
IV
ML
80 MG
0.015
01/01/2002
99/99/9999
FC
FC
FC
FC
FC
FC
FC
FC
FC
IV
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
80 MG
500 ML
500 ML
500 ML
1 EA
1 EA
1 EA
1 EA
1 EA
0.02
0.002
0.002
0.002
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1000 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
500 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
500 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
250 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
150 ML EA
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML FC
IV
ML
5%
0.002
01/01/2002
99/99/9999
500 ML FC
IV
ML
5%
0.002
01/01/2002
99/99/9999
250 ML FC
IV
ML
5%
0.002
01/01/2002
99/99/9999
1000 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
500 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
250 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML EA
50 ML
1000 ML
500 ML
250 ML
1000 ML
500 ML
1000 ML
500 ML
250 ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00264-7614-10
J7799
00264-7614-20
J7799
00264-7616-00
J7799
00264-7616-10
J7799
00264-7616-20
J7799
00264-7620-00
J7799
00264-7622-00
J7799
00264-7623-20
00264-7750-00
00264-7750-10
00264-7750-20
J7799
J7120
J7120
J7120
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00264-7751-00
J7120
00264-7751-10
J7120
00264-7751-20
J7120
00264-7759-20
00264-7800-00
00264-7800-10
00264-7800-20
00264-7802-00
00264-7802-10
J7120
J7030
J7040
J7050
J7799
J7799
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00264-7805-10
J7799
00264-7806-10
00264-7850-00
00264-7850-00
00264-7850-10
00264-7850-10
00264-7850-20
00264-7850-20
J7799
A4712
A4217
A4712
A4217
A4712
A4217
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
00264-7865-00
J3480
00264-9200-55
A4712
00264-9200-55
A4217
00264-9201-55
A4712
00264-9201-55
A4217
00264-9205-55
A4712
00264-9205-55
A4217
00264-9554-00
J2810
00264-9554-10
J2810
00264-9558-10
J2810
00264-9558-20
J2810
00264-9567-10
J1644
00264-9577-10
J1644
00264-9587-20
J1644
00264-9592-10
J2000
1/1/2002
00264-9594-10
J2000
00264-9594-10
J2001
00264-9594-20
J2000
00264-9594-20
J2001


5%-0.33%
5%-0.33%
5%-0.2%
5%-0.2%
5%-0.2%
10%-0.9%
10%-0.45%
10%-0.2%
LACTATED RINGER'S (EXCEL)
(EXCEL)
(EXCEL)
(EXCEL)
DEXTROSE 2.5%/LACTATED RINGERS
(1/2 STR. LACTATED,EXCEL)
SODIUM CHLORIDE (EXCEL) 0.9%
SODIUM CHLORIDE
(HYPERTONIC,EXCEL) 3%
SODIUM CHLORIDE
(HYPERTONIC,EXCEL) 5%
WATER FOR INJECTION (EXCEL)
CHLORIDE (EXCEL) 2 MEQ/100 ML-0.9%
WATER FOR INJECTION (GLASS
W/SOLID STOPPER)
W/SOLID STOPPER)
W/SOLID STOPPER)
W/SOLID STOPPER)
W/SOLID STOPPER)
W/SOLID STOPPER)
DEXTROSE/THEOPHYLLINE (EXCEL) 5%80 MG/100 ML
DEXTROSE/HEPARIN SODIUM (EXCEL)
5%-4000 U/100 ML
5%-5000 U/100 ML
5%-10000 U/100 ML
DEXTROSE/LIDOCAINE HCL (EXCEL) 5%0.2%
Page 69 of 374
500 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
250 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
500 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
250 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
250 ML
1000 ML
500 ML
250 ML
FC
FC
FC
FC
IV
IV
IV
IV
ML
ML
ML
ML
1 EA
1000 ML
1000 ML
1000 ML
1
0.001
0.001
0.001
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1000 ML FC
IV
ML
1000 ML
0.0005
01/01/2002
99/99/9999
500 ML FC
IV
ML
1000 ML
0.0005
01/01/2002
99/99/9999
250 ML FC
IV
ML
1000 ML
0.0005
01/01/2002
99/99/9999
FC
FC
FC
FC
FC
FC
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
1000 ML
1000 ML
500 ML
250 ML
1 EA
1 EA
0.0005
0.001
0.002
0.004
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
500 ML FC
250 ML
1000 ML
500 ML
250 ML
1000 ML
500 ML
IV
ML
1 EA
01/01/2002
99/99/9999
FC
FC
FC
FC
FC
FC
FC
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
1 EA
10 ML
500 ML
10 ML
500 ML
10 ML
500 ML
1
0.1
0.002
0.1
0.002
0.1
0.002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
1000 ML FC
99/99/9999
500 ML
1000 ML
1000 ML
500 ML
500 ML
250 ML
250 ML
IV
ML
0.01
01/01/2002
1000 ML GC IV
ML
10 ML
0.1
01/01/2002
12/31/2003
1000 ML GC IV
ML
500 ML
0.002
01/01/2004
99/99/9999
500 ML GC IV
ML
10 ML
0.1
01/01/2002
12/31/2003
500 ML GC IV
ML
500 ML
0.002
01/01/2004
99/99/9999
2000 ML GC IV
ML
10 ML
0.1
01/01/2002
12/31/2003
2000 ML GC IV
ML
500 ML
0.002
01/01/2004
99/99/9999
1000 ML FC
IV
ML
40 MG
0.02
01/01/2002
99/99/9999
500 ML FC
IV
ML
40 MG
0.02
01/01/2002
99/99/9999
500 ML FC
IV
ML
40 MG
0.04
01/01/2002
99/99/9999
250 ML FC
IV
ML
500 ML FC
IV
ML
2 MEQ
0.04
01/01/2002
99/99/9999
1000 U
40 MG
0.04
01/01/2002
99/99/9999
500 ML FC
IV
ML
1000 U
0.05
01/01/2002
99/99/9999
250 ML FC
IV
ML
1000 U
0.1
01/01/2002
99/99/9999
500 ML FC
IV
ML
50 ML
0.02
01/01/2002
04/01/2003
500 ML FC
IV
ML
50 ML
0.02
01/01/2002
12/31/2003
500 ML FC
IV
ML
10 MG
0.4
01/01/2004
99/99/9999
250 ML FC
IV
ML
50 ML
0.02
01/01/2002
12/31/2003
250 ML FC
IV
ML
10 MG
0.4
01/01/2004
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

200 U/100 ML-0.9%
KINEVAC (VIAL) 5 MCG
KINEVAC (VIAL) 5 MCG
DIGIFAB (VIAL,PF) 40 MG
DIGIFAB (VIAL,PF) 40 MG
DILOR (AMP) 250 MG/ML
LUPRON DEPOT-PED (SRN,PREFIL
DUAL CHAMBER) 7.5 MG
LUPRON DEPOT-PED 11.25 MG
DUAL CHAMBER) 15 MG
LUPRON DEPOT (SRN,PREFIL DUAL
CHAMBER) 22.5 MG
LUPRON (2 WEEK ADMINISTRATION) 5
MG/ML
MG/ML
CHAMBER) 3.75 MG
CHAMBER) 7.5 MG
CHAMBER) 11.25 MG
CHAMBER) 30 MG
ELAVIL (M.D.V.) 10 MG/ML
ARIMIDEX 1 MG
ARIMIDEX (FILM-COATED) 1 MG
DIPRIVAN (VIAL) 10 MG/ML
1 EA
10 ML
30 EA
30 EA
100 ML
20 ML
50 ML

DIPRIVAN (SRN, PREFILLED) 10 MG/ML

DIPRIVAN NOVAPLUS (VIAL) 10 MG/ML
DIPRIVAN NOVAPLUS 10 MG/ML
DIPRIVAN NOVAPLUS (VIAL) 10 MG/ML
MERREM IV (VIAL) 1 GM
J3490
J3490
J2185
J2185
J3490

1/1/2004 99/99/9999 INJECTION, MEROPENEM, 100 MG
7/17/2006 99/99/9999 INJECTION, MEROPENEM, 100 MG
00310-0325-15
00310-0325-20
00310-0325-20
00310-0325-64
00310-0375-10
00310-0375-61
00310-0376-10
00310-0376-11
00310-0376-31
00310-0376-60
00310-0376-61
00310-0377-20
00310-0377-21
00310-0377-32
00310-0377-61
00310-0377-62
00310-0378-51
00310-0379-51
00310-0482-30
00310-0600-18
00310-0600-60
00310-0600-75
00310-0604-12
00310-0604-30
00310-0604-90
J3490
J3490
J2185
J2185
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J8565
J8999
J8999
J8999
J8999
J8999
J8999
1/1/2002
1/1/2002
1/1/2004
7/17/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2005
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
MERREM IV (VIAL, ADD-VANTAGE) 1 GM

NOVAPLUS MERREM 1 GM
MERREM IV (VIAL) 500 MG
MERREM IV (VIAL, ADD-VANTAGE) 500
MG
NOVAPLUS MERREM 500 MG
CEFOTAN (VIAL, BULK) 10 GM
CEFOTAN NOVAPLUS (VIAL) 10 GM
CEFOTAN (VIAL) 1 GM
CEFOTAN (P.B.) 1 GM
CEFOTAN (ADD-VANTAGE) 1 GM
CEFOTAN (VIAL) 2 GM
CEFOTAN (P.B.) 2 GM
CEFOTAN (ADD-VANTAGE) 2 GM
CEFOTAN (GALAXY) 1 GM/50 ML
CEFOTAN (GALAXY) 2 GM/50 ML
IRESSA 250 MG
NOLVADEX 10 MG
NOLVADEX 10 MG
NOLVADEX 10 MG
NOLVADEX 20 MG
NOLVADEX 20 MG
NOLVADEX 20 MG
00310-0720-25
J9999
00264-9598-10
J2000
00264-9598-10
J2001
00264-9598-20
J2000
00264-9598-20
J2001
00264-9872-10
00270-0556-15
00270-0556-15
00281-0365-10
00281-0365-10
00281-1112-31
J1644
J3490
J2805
Q2006
J1162
J1180
1/1/2002
1/1/2002
1/1/2006
1/29/2002
1/1/2006
1/1/2002
00300-2108-01
00300-2282-01
J9217
J9217
1/1/2002
1/1/2002

00300-2440-01
J9217
1/1/2002
00300-3346-01
J9217
1/1/2002
00300-3612-24
J9218
1/1/2002
00300-3612-28
J9218
1/1/2002
00300-3641-01
J1950
1/1/2002
8/27/2009 INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG
00300-3642-01
J9217
1/1/2002
00300-3663-01
J9217
1/1/2002
00300-3683-01
00310-0049-10
00310-0201-30
00310-0201-37
00310-0300-11
00310-0300-22
00310-0300-50
J9217
J1320
J8999
J8999
J3490
J3490
J3490

1/1/2002 5/12/2003 INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG
1/1/2002
00310-0300-54
00310-0300-61
00310-0300-64
00310-0300-65
00310-0321-11
J3490
J3490
J3490
J3490
J3490
00310-0321-15
00310-0321-30
00310-0321-30
00310-0321-65
00310-0325-11
1/1/2002
1/1/2002
11/18/2004
1/1/2002
1/1/2002

99/99/9999 INJECTION, SINCALIDE, 5 MICROGRAMS
7/1/2004 INJECTION, DYPHYLLINE, UP TO 500 MG

99/99/9999 INJECTION, MEROPENEM, 100 MG
99/99/9999 INJECTION, MEROPENEM, 100 MG
99/99/9999 GEFITINIB, ORAL, 250 MG
FASLODEX
(SRN,PREFILL,SAFETYGUIDE) 50 MG/ML
Page 70 of 374
500 ML FC
IV
ML
50 ML
0.02
01/01/2002
500 ML FC
IV
ML
10 MG
0.8
01/01/2004
99/99/9999
250 ML FC
IV
ML
50 ML
0.02
01/01/2002
12/31/2003
250 ML FC
IV
ML
10 MG
500 ML
1 EA
1 EA
1 EA
1 EA
2 ML
FC
VL
VL
VL
VL
AM
IV
IV
IV
IV
IV
IM
ML
EA
EA
EA
EA
ML
1000 U
1 EA
5 MCG
1 VIAL
1 VIAL
500 MG
1 EA BX
1 EA BX
IM
IM
EA
EA
1 EA BX
IM
1 EA BX
IM
2.8 ML VL
SC
Prior End Date #3
Prior Start Date #3
12/31/2003
0.8
01/01/2004
99/99/9999
0.002
1
1
1
1
0.5
01/01/2002
01/01/2002
01/01/2006
01/29/2002
01/01/2006
01/01/2002
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
07/01/2004
7.5 MG
7.5 MG
1
1.5
01/01/2002
01/01/2002
8/27/2009
8/27/2009
EA
7.5 MG
01/01/2002
8/27/2009
EA
7.5 MG
01/01/2002
8/27/2009
EA
1 MG
84
01/01/2002
2/13/2009
2.8 ML BX
SC
EA
1 MG
14
01/01/2002
7/24/2009
1 EA BX
IM
EA
3.75 MG
01/01/2002
8/27/2009
1 EA BX
IM
EA
7.5 MG
01/01/2002
8/27/2009
1 EA BX
IM
EA
7.5 MG
1.5
01/01/2002
5/20/2009
BX
VL
BO
DP
VL
VL
VL
IM
IM
PO
PO
IV
IV
IV
EA
ML
EA
EA
ML
ML
ML
7.5 MG
20 MG
1 EA
1 EA
1 EA
1 EA
1 EA
4
0.5
1
1
1
1
1
01/01/2002
8/27/2009
01/01/2002 05/12/2003
08/07/2008 99/99/9999 01/01/2002 06/02/2008
05/02/2008 10/20/2008
01/01/2002 03/05/2008
01/01/2002 02/20/2008
01/01/2002 04/27/2008
50 ML
100 ML
20 ML
50 ML
1 EA
SR
VL
VL
VL
VL
IV
IV
IV
IV
IV
ML
ML
ML
ML
EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
01/01/2002
01/01/2002
11/18/2004
01/01/2002
01/01/2002
02/14/2005
01/31/2008
01/14/2008
03/04/2008
06/23/2003
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
EA
EA
EA
EA
EA
1 EA
1 EA
100 MG
100 MG
1 EA
1
1
10
10
1
01/01/2002
01/01/2002
01/01/2004
07/17/2006
01/01/2002
06/23/2003
12/31/2003
99/99/9999
99/99/9999
06/23/2003
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
50 ML
50 ML
30 EA
180 EA
60 EA
2500 EA
1250 EA
30 EA
90 EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
FC
FC
BO
BO
BO
BO
BO
BO
BO
IV
IV
IV
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IV
IV
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
EA
EA
EA
EA
EA
EA
EA
1 EA
1 EA
100 MG
100 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
250 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
5
5
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2004
07/17/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2005
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/23/2003
12/31/2003
99/99/9999
99/99/9999
07/08/2004
07/08/2004
05/09/2005
07/08/2004
02/08/2005
07/08/2004
01/07/2002
05/09/2005
07/08/2004
02/08/2005
01/07/2002
07/08/2004
04/04/2006
04/04/2006
99/99/9999
02/24/2003
09/01/2006
02/24/2003
02/24/2003
09/01/2006
02/24/2003
IM
ML
1 EA
05/09/2002
12/31/2003
2.5 ML SR
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00310-0720-25
00310-0720-50
J9395
J9999
1/1/2004 10/29/2009 INJECTION, FULVESTRANT, 25 MG
FASLODEX
2.5 ML SR
IM
ML
25 MG
01/01/2004 10/29/2009
FASLODEX
5 ML SR
IM
ML
1 EA
05/09/2002
12/31/2003
25 MG
1 EA
1 EA
3.6 MG
2
1
1
1
01/01/2004
10/21/2002
10/21/2002
05/05/2003
99/99/9999
02/20/2003
02/20/2003
99/99/9999
3
1
3
1
0.5
0.5
5
10
05/05/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
05/04/2003
05/04/2003
05/24/2006
05/24/2006
05/24/2006
05/24/2006
05/24/2006
FASLODEX
ZOLADEX (SAFESYSTEM SRN) 3.6 MG
5 ML
60 EA
30 EA
1 EA
SR
BO
BO
SR
IM
PO
PO
SC
ML
EA
EA
EA
00310-0720-50
00310-0730-60
00310-0731-30
00310-0950-36
J9395
J8999
J8999
J9202
00310-0951-30
00310-0960-36
00310-0961-30
00314-0083-10
00314-0510-70
00314-0549-10
00314-0617-70
00314-0618-70
J9202
J9202
J9202
J3140
J1940
J2360
J0725
J0725
5/5/2003 99/99/9999 GOSERELIN ACETATE IMPLANT, PER 3.6 MG

1/1/2002
5/4/2003 GOSERELIN ACETATE IMPLANT, PER 3.6 MG
1/1/2002
5/4/2003 GOSERELIN ACETATE IMPLANT, PER 3.6 MG
1/1/2002 5/24/2006 INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG
ZOLADEX (SAFESYSTEM SRN) 10.8 MG

ZOLADEX 3.6 MG
ZOLADEX 10.8 MG
TESTOSTERONE (VIAL) 50 MG/ML
FUROMIDE M.D. (VIAL) 10 MG/ML
ORPHENATE (VIAL) 30 MG/ML
CHOREX 5000 U
CHOREX (W/DILUENT) 10000 U
1 EA
1 EA
1 EA
10 ML
10 ML
10 ML
1 EA
1 EA
SR
SR
SR
EA
VL
EA
NA
VL
SC
SC
SC
IM
IJ
IJ
IM
IM
EA
EA
EA
ML
ML
ML
EA
EA
3.6 MG
3.6 MG
3.6 MG
50 MG
20 MG
60 MG
1000 USP Units
1000 USP Units
30 ML VL
IM
ML
1000 MCG
01/01/2002
05/24/2006
10 ML
10 ML
10 ML
10 ML
30 ML
50 ML
50 ML
50 ML
50 ML
10 ML
10 ML
10 ML
10 ML
10 ML
VL
VL
EA
EA
VL
EA
EA
EA
EA
EA
EA
EA
EA
VL
IM
IM
IJ
IJ
IM
EP
EP
IJ
IJ
IJ
IJ
IJ
IJ
IM
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1000 MCG
1 MG
50 MG
50 MG
1000 MCG
50 ML
10 MG
50 ML
10 MG
50 MG
50 MG
1 EA
100 MG
50 MG
1
5
1
1
1
0.02
1
0.02
2
0.5
1
1
1
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
05/24/2006
05/24/2006
05/24/2006
05/24/2006
05/24/2006
12/31/2003
05/24/2006
12/31/2003
05/24/2006
05/24/2006
05/24/2006
12/31/2003
05/24/2006
05/24/2006
10 ML
30 ML
30 ML
10 ML
10 ML
30 ML
30 ML
10 ML
5 ML
VL
EA
EA
VL
EA
VL
VL
VL
VL
IM
IJ
IJ
IM
IM
IV
IV
IM
IM
ML
ML
ML
ML
ML
ML
ML
ML
ML
100 MG
1 EA
100 MG
20 MG
40 MG
10 ML
10 ML
5 MG
1 EA
1
1
1
1
1
0.1
0.1
1
1
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2002
05/24/2006
12/31/2003
05/24/2006
05/24/2006
05/24/2006
12/31/2003
05/24/2006
05/24/2006
05/24/2006
5 ML
30 ML
10 ML
5 ML
10 ML
10 ML
VL
VL
VL
VL
VL
VL
IM
IJ
IJ
IJ
IM
IJ
ML
ML
ML
ML
ML
ML
1 EA
1 MG
1 MG
1 MG
25 MG
10 MG
1
4
4
4
2
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/24/2006
05/24/2006
05/24/2006
05/24/2006
05/24/2006
05/24/2006
1/1/2004 99/99/9999 INJECTION, FULVESTRANT, 25 MG

5/5/2003 99/99/9999 GOSERELIN ACETATE IMPLANT, PER 3.6 MG
00314-0622-30
J3420
1/1/2002
00314-0622-70
00314-0644-70
00314-0661-70
00314-0673-70
00314-0678-30
00314-0679-50
00314-0679-50
00314-0680-50
00314-0680-50
00314-0684-70
00314-0685-70
00314-0758-70
00314-0758-70
00314-0771-70
J3420
J1435
J1240
J1200
J3420
J2000
J2001
J2000
J2001
J2550
J2550
J3490
J3415
J3140

1/1/2004 5/24/2006 INJECTION, PYRIDOXINE HCL, 100 MG
5/24/2006 INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG
00314-0772-70
00314-0774-30
00314-0774-30
00314-0782-70
00314-0784-70
00314-0794-30
00314-0794-30
00314-0855-70
00314-0891-75
J3150
J3490
J3411
J1390
J0970
A4712
A4216
J1000
J3490
1/1/2002 5/24/2006 INJECTION, TESTOSTERONE PROPIONATE, UP TO 100 MG

1/1/2004 5/24/2006 INJECTION, THIAMINE HCL, 100 MG
00314-0892-75
00314-0896-30
00314-0896-70
00314-0896-75
00314-1400-70
00314-2236-70
J3490
J1100
J1100
J1100
J3410
J0945
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

5/24/2006 INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG

KESTRONE 5 (VIAL) 5 MG/ML
HYDRATE (VIAL) 50 MG/ML
HYREXIN (VIAL) 50 MG/ML
LA-12 (VIAL) 1000 MCG/ML
LIDOCAINE HCL (VIAL) 1%
PROREX (VIAL) 25 MG/ML
PROREX (VIAL) 50 MG/ML
TESTOSTERONE (VIAL) 100 MG/ML
TESTOSTERONE PROPIONATE (VIAL)
100 MG/ML
VALERGEN 20 MG/ML
VALERGEN (VIAL) 40 MG/ML
DEPOGEN (VIAL) 5 MG/ML
HYLUTIN (VIAL) 250 MG/ML
(VIAL) 250 MG/ML
SOLUREX (VIAL) 4 MG/ML
HYZINE (VIAL) 50 MG/ML
ND-STAT (VIAL) 10 MG/ML
00314-3520-02
J2321
1/1/2002
HYBOLIN DECANOATE (VIAL) 50 MG/ML
2 ML EA
IM
ML
100 MG
0.5
01/01/2002
05/24/2006
00314-3525-02
J2321
1/1/2002
IM
ML
100 MG
01/01/2002
05/24/2006
J7624
HYBOLIN DECANOATE (VIAL) 100 MG/ML

MG/ML
2 ML EA
00314-6392-75

5 ML EA
IJ
ML
1 MG
01/01/2002
05/24/2006
5 ML EA
IJ
ML
1 MG
01/01/2002
05/24/2006
10 ML VL
IV
ML
10 ML
0.1
01/01/2002
05/24/2006
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
0.002
0.001
0.002
0.001
0.002
0.001
0.002
0.001
0.002
0.001
0.002
0.001
0.002
0.001
0.002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
00314-6392-75 KO J7624
1/1/2002
KO
1/1/2002
00314-9013-05
J0610
1/1/2002
00327-0011-05
00338-0003-44
00338-0003-44
00338-0003-46
00338-0003-46
00338-0003-47
00338-0003-47
00338-0003-49
00338-0003-49
00338-0004-02
00338-0004-02
00338-0004-03
00338-0004-03
00338-0004-04
00338-0004-04
Q2004
A4319
A4217
A4319
A4217
A4319
A4217
A4319
A4217
A4319
A4217
A4319
A4217
A4319
A4217
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004

IRRIGATION SOLUTION FOR TREATMENT OF BLADDER CALCULI, FOR EXAMPLE
99/99/9999 RENACIDIN, PER 500 ML
RENACIDIN
Page 71 of 374
500 ML
1000 ML
1000 ML
2000 ML
2000 ML
3000 ML
3000 ML
5000 ML
5000 ML
250 ML
250 ML
500 ML
500 ML
1000 ML
1000 ML
BO
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
500 ML
0.002
01/01/2002
99/99/9999
ML
500 ML
0.002
01/01/2002
99/99/9999
DEXTROSE (QUAD PACK, MINI-BAG) 5%
100 ML FC
IV
ML
500 ML
0.002
01/01/2002
99/99/9999
00338-0017-18
J7060
CF
HCPCS Amount #1
00338-0017-31
J7060
DEXTROSE (MULTI PACK, MINI-BAG) 5%
50 ML FC
IV
ML
500 ML
0.002
01/01/2002
99/99/9999
00338-0017-38
J7060
DEXTROSE (MULTI PACK, MINI-BAG) 5%

DEXTROSE (SINGLE PACK MINI-BAG)
5%
DEXTROSE (SINGLE PACK MINI-BAG)
5%
DEXTROSE 10%
DEXTROSE 10%
DEXTROSE 10%
DEXTROSE (VIAFLEX UNDERFILLED)
10%
10%
DEXTROSE (FULL FILL) 20%
DEXTROSE (BULK PACKAGE) 50%
50%
50%
DEXTROSE (GLASS FULL FILL) 50%
DEXTROSE 70%
SODIUM CHLORIDE (ARTHROMATIC
P.C.) 0.9%
SODIUM CHLORIDE (ARTHROMATIC
P.C.) 0.9%
SODIUM CHLORIDE (UROMATIC P.C.)
0.9%
SODIUM CHLORIDE (UROMATIC P.C.)
0.9%
SODIUM CHLORIDE (P.C.) 0.9%
SODIUM CHLORIDE (P.C.) 0.9%
100 ML FC
IV
ML
500 ML
0.002
01/01/2002
99/99/9999
00338-0017-41
J7060
00338-0017-48
00338-0023-02
00338-0023-03
00338-0023-04
J7060
J7799
J7799
J7799
1/1/2002
1/1/2002
1/1/2002
1/1/2002

00338-0023-13
J7799
1/1/2002
00338-0023-34
00338-0030-03
00338-0031-06
J7799
J7799
J7799
00338-0031-13
J7799
1/1/2002
00338-0031-34
00338-0036-03
00338-0038-04
00338-0041-46
00338-0041-46
00338-0043-03
00338-0043-04
00338-0044-02
00338-0044-03
J7799
J7799
J7799
A4323
A4217
J7799
J7799
J7050
J7040
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00338-0047-24
A4323
00338-0047-24
00338-0047-27
00338-0047-27
00338-0047-29
00338-0047-29
A4217
A4323
A4217
A4323
A4217
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
00338-0047-44
A4323
00338-0047-44
00338-0047-46
00338-0047-46
00338-0047-47
00338-0047-47
00338-0048-02
00338-0048-02
00338-0048-03
00338-0048-03
00338-0048-04
00338-0048-04
00338-0048-05
00338-0048-05
00338-0049-01
00338-0049-02
00338-0049-03
00338-0049-04
A4217
A4323
A4217
A4323
A4217
A4323
A4217
A4323
A4217
A4323
A4217
A4323
A4217
J7050
J7050
J7040
J7030
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002


Page 72 of 374
50 ML FC
IV
ML
500 ML
0.002
01/01/2002
99/99/9999
FC
FC
FC
FC
IV
IV
IV
IV
ML
ML
ML
ML
500 ML
1 EA
1 EA
1 EA
0.002
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
500 ML FC
IV
ML
1 EA
01/01/2002
4/30/2008
1000 ML FC IV
500 ML GC IV
2000 ML PC IV
ML
ML
ML
1 EA
1 EA
1 EA
1
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
100 ML
250 ML
500 ML
1000 ML
500 ML FC
IV
ML
1 EA
01/01/2002
1/31/2008
FC
GC
GC
BO
BO
FC
FC
GC
FC
IV
IV
IV
IR
IR
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 EA
1 EA
1 EA
1000 ML
500 ML
1 EA
1 EA
250 ML
500 ML
1
1
1
0.001
0.002
1
1
0.004
0.002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
1/31/2008
99/99/9999
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
1000 ML
3000 ML
3000 ML
5000 ML
5000 ML
FC
PC
PC
PC
PC
IR
IR
IR
IR
IR
ML
ML
ML
ML
ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
0.002
0.001
0.002
0.001
0.002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
1000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
1000 ML
2000 ML
2000 ML
3000 ML
3000 ML
250 ML
250 ML
500 ML
500 ML
1000 ML
1000 ML
1500 ML
1500 ML
150 ML
250 ML
500 ML
1000 ML
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
IR
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
1000 ML
500 ML
250 ML
250 ML
500 ML
1000 ML
0.002
0.001
0.002
0.001
0.002
0.001
0.002
0.001
0.002
0.001
0.002
0.001
0.002
0.004
0.004
0.002
0.001
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1000 ML
500 ML
1000 ML
2000 ML
2000 ML
500 ML
1000 ML
250 ML
500 ML
FC
BO
BO
FC
FC
PC
PC
PC
PC
PC
PC
PC
PC
FC
FC
FC
FC
ML
IV
Prior End Date #3
IV
50 ML FC
J7060
Prior Start Date #3
25 ML FC
J7060
00338-0017-11
00338-0017-10
Prior End Date #2
12/31/2003
99/99/9999
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
End Date #1
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
05/22/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
Start Date #1
0.001
0.002
1
0.1
0.002
0.1
0.002
0.1
0.002
0.1
0.002
0.002
0.002
0.002
0.002
0.002
0.002
HCPCS Measure #1
1000 ML
500 ML
1 EA
10 ML
500 ML
10 ML
500 ML
10 ML
500 ML
10 ML
500 ML
500 ML
500 ML
500 ML
500 ML
500 ML
500 ML

DEXTROSE 2.5%
WATER FOR INJECTION
WATER FOR INJECTION
WATER FOR INJECTION
WATER FOR INJECTION
WATER FOR INJECTION
WATER FOR INJECTION
WATER FOR INJECTION
WATER FOR INJECTION
DEXTROSE 5%
DEXTROSE 5%
DEXTROSE 5%
DEXTROSE 5%
DEXTROSE 5%
DEXTROSE 5%
Billing Units
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML

Prior Start Date #2
NDC Package Type
IR
IR
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
A4319
A4217
J7799
A4712
A4217
A4712
A4217
A4712
A4217
A4712
A4217
J7060
J7060
J7060
J7060
J7060
J7060
NDC Label
FC
FC
EA
FC
FC
FC
FC
PC
PC
FC
FC
GC
GC
FC
FC
FC
FC
00338-0004-05
00338-0004-05
00338-0012-04
00338-0013-04
00338-0013-04
00338-0013-06
00338-0013-06
00338-0013-08
00338-0013-08
00338-0013-29
00338-0013-29
00338-0016-02
00338-0016-03
00338-0017-01
00338-0017-02
00338-0017-03
00338-0017-04
HCPCS Description
1500 ML
1500 ML
1000 ML
1000 ML
1000 ML
2000 ML
2000 ML
3000 ML
3000 ML
5000 ML
5000 ML
250 ML
500 ML
150 ML
250 ML
500 ML
1000 ML
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
5/22/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
NDC Package Measure

Package
HCPCS Mod
HCPCS
NDC Mod
NDC
00338-0073-03
J7799
00338-0073-04
J7799
SODIUM CHLORIDE (QUAD PACK, MINIBAG) 0.9%

SODIUM CHLORIDE (MULTI PACK, MINIBAG) 0.9%
SODIUM CHLORIDE (SINGLE PACK, MINIBAG) 0.9%
SODIUM CHLORIDE (PROCESSING)
0.9%
SODIUM CHLORIDE (PROCESSING)
0.9%
TRAVENOL (STER-CO-SY FOR SLUSH)
0.9%
TRAVENOL (STER-CO-SY FOR SLUSH)
0.9%
SODIUM CHLORIDE 3%
SODIUM CHLORIDE 5%
DEXTROSE/SODIUM CHLORIDE 2.5%0.45%
DEXTROSE/SODIUM CHLORIDE 2.5%0.45%
00338-0077-02
J7799
DEXTROSE/SODIUM CHLORIDE 5%-0.2%
250 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
00338-0077-03
J7799
500 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
00338-0077-04
J7799
IV
ML
1 EA
01/01/2002
99/99/9999
00338-0081-02
J7799
1/1/2002
IV
ML
1 EA
01/01/2002
5/30/2007
00338-0081-03
J7799
IV
ML
1 EA
01/01/2002
99/99/9999
00338-0081-04
J7799
1/1/2002
IV
ML
1 EA
01/01/2002
4/30/2007
00338-0085-02
J7799
IV
ML
1 EA
01/01/2002
99/99/9999
00338-0085-03
J7799
IV
ML
1 EA
01/01/2002
99/99/9999
00338-0085-04
J7799
DEXTROSE/SODIUM CHLORIDE 5%-0.2% 1000 ML FC

250 ML FC
500 ML FC
1000 ML FC
250 ML FC
500 ML FC
1000 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
00338-0049-10
J2912
00338-0049-10
A4216
00338-0049-11
J2912
00338-0049-11
A4216
00338-0049-18
J7050
00338-0049-31
J2912
00338-0049-31
A4216
00338-0049-38
J7050
00338-0049-41
J2912
00338-0049-41
A4216
00338-0049-48
J7050
00338-0050-47
A4323
00338-0050-47
A4217
00338-0051-44
A4323
00338-0051-44
00338-0054-03
00338-0056-03
A4217
J7799
J7799

25 ML FC
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
25 ML FC
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
50 ML FC
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
50 ML FC
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
100 ML FC
IV
ML
250 ML
0.004
01/01/2002
99/99/9999
50 ML FC
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
50 ML FC
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
100 ML FC
IV
ML
250 ML
0.004
01/01/2002
99/99/9999
50 ML FC
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
50 ML FC
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
100 ML FC
IV
ML
250 ML
0.004
01/01/2002
99/99/9999
3000 ML PC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
3000 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
1000 ML FC
IR
ML
1000 ML
0.001
01/01/2002
12/31/2003
1000 ML FC
500 ML FC
500 ML FC
IR
IV
IV
ML
ML
ML
500 ML
1 EA
1 EA
0.002
1
1
01/01/2004
01/01/2002
01/01/2002
7/15/2004
99/99/9999
99/99/9999
500 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
1000 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
00338-0089-02
J7042
250 ML FC
IV
ML
5%
0.002
01/01/2002
99/99/9999
00338-0089-03
J7042
500 ML FC
IV
ML
5%
0.002
01/01/2002
99/99/9999
00338-0089-04
J7042
1000 ML FC
IV
ML
5%
0.002
01/01/2002
99/99/9999
00338-0095-03
J7799
1/1/2002
500 ML FC
IV
ML
1 EA
01/01/2002
08/30/2002
00338-0095-04
00338-0117-02
00338-0117-03
00338-0117-04
00338-0120-03
00338-0125-03
00338-0125-04
00338-0156-04
J7799
J7120
J7120
J7120
J7120
J7120
J7120
Q2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
5/1/2004 INJECTION, ELLIOTTS B SOLUTION, PER ML
FC
FC
FC
FC
PC
FC
FC
GC
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
1 EA
1000 ML
1000 ML
1000 ML
1000 ML
1000 ML
1000 ML
1 ML
1
0.001
0.001
0.001
0.0005
0.0005
0.0005
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
5/30/2006
99/99/9999
99/99/9999
99/99/9999
05/01/2004
99/99/9999
99/99/9999
05/01/2004
00338-0265-03
J7110
500 ML FC
IV
ML
500 ML
0.002
01/01/2002
99/99/9999
00338-0270-03
00338-0272-03
J7100
J7100

500 ML FC
500 ML FC
IV
IV
ML
ML
500 ML
500 ML
0.002
0.002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
00338-0318-02
00338-0351-04
00338-0353-03
00338-0353-04
J3480
J7799
J7799
J7799
1/1/2002
1/1/2002
1/1/2002
1/1/2002

LACTATED RINGER'S
LACTATED RINGER'S
LACTATED RINGER'S
DEXTROSE 2.5% IN RINGERS
LACTATED RINGER'S/DEXTROSE 5%
LACTATED RINGER'S/DEXTROSE 5%
PLASMA-LYTE R W/DEXTROSE
GENTRAN 70 W/SODIUM CHLORIDE 6%0.9%
GENTRAN 40 W/SODIUM CHLORIDE 10%
0.9%
GENTRAN 40 W/DEXTROSE 10%-5%
POTASSIUM CHLORIDE (BULK
PACKAGE) 2 MEQ/ML
OSMITROL (VIAFLEX,AF) 5%
OSMITROL (VIAFLEX) 10%
OSMITROL (VIAFLEX;12X1000ML) 10%
IV
IV
IV
IV
ML
ML
ML
ML
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999

Page 73 of 374
1000 ML
250 ML
500 ML
1000 ML
500 ML
500 ML
1000 ML
1000 ML
250 ML
1000 ML
500 ML
1000 ML
GC
FC
FC
FC
2 MEQ
1 EA
1 EA
1 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
00338-0431-03
J1644
00338-0433-04
J1644
00338-0439-03
J2810
00338-0439-04
J2810
1/1/2002
00338-0441-02
J2810
00338-0441-03
J2810
00338-0443-48
J2810
00338-0444-02
J2810
00338-0445-41
J2810
1/1/2002
00338-0445-48
J2810
00338-0501-48
J1580
00338-0503-41
J1580
1/1/2002
00338-0503-48
J1580
00338-0505-48
J1580
00338-0507-41
J1580
00338-0507-48
J1580
00338-0509-41
00338-0511-41
J1580
J1580

00338-0549-03
J1644
00338-0550-02
J1644
00338-0550-03
00338-0551-11
00338-0551-18
J1644
J7060
J7060

00338-0553-11
J2912
00338-0553-11
A4216
00338-0553-18
J7050
00338-0640-02
J7799
00338-0691-04
J3480
00338-0695-04
00338-0703-41
J3480
J3480

00338-0703-48
J3480
00338-0704-34
00338-0705-41
J3480
J3480

OSMITROL (VIAFLEX,AF) 15%

DEXTROSE/LIDOCAINE HCL 5%-0.4%
200 U/100 ML-0.9%
200 U/100 ML-0.9%
DEXTROSE/THEOPHYLLINE 5%-80
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
MG/50 ML
MG/100 ML
GENTAMICIN SULFATE 60 MG/100 ML0.9%
GENTAMICIN SULFATE 0.8 MG/ML-0.9%
GENTAMICIN SULFATE (VIAFLEX) 0.8
MG/ML-0.9%
GENTAMICIN SULFATE 100 MG/100 ML0.9%
GENTAMICIN SULFATE (24X50ML) 1.2
MG/ML-0.9%
GENTAMICIN SULFATE (24X100ML) 1.2
MG/ML-0.9%
GENTAMICIN SULFATE 1.6 MG/ML-0.9%
GENTAMICIN SULFATE 2 MG/ML-0.9%
DEXTROSE/HEPARIN SODIUM
(VIAFLEX,AF) 5%-4000 U/100 ML
DEXTROSE (MINI-BAG PLUS) 5%
DEXTROSE (MINI-BAG PLUS) 5%
SODIUM CHLORIDE (MINI-BAG PLUS)
0.9%
0.9%
0.9%
CHLORIDE 2 MEQ/100 ML-0.9%
CHLORIDE 4 MEQ/100 ML-0.9%
POTASSIUM CHLORIDE 20 MEQ/50 ML
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 EA
1 EA
1 EA
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
1
1
1
0.02
0.4
0.02
0.4
0.02
0.8
0.02
0.8
500 ML FC
IV
ML
1000 U
0.002
01/01/2002
99/99/9999
1000 ML FC
IV
ML
1000 U
0.002
01/01/2002
99/99/9999
500 ML FC
IV
ML
40 MG
0.02
01/01/2002
99/99/9999
1000 ML FC
IV
ML
40 MG
0.02
01/01/2002
8/31/2006
250 ML FC
IV
ML
40 MG
0.04
01/01/2002 12/31/2005
500 ML FC
IV
ML
40 MG
0.04
01/01/2002
100 ML FC
IV
ML
40 MG
0.05
01/01/2002 12/31/2003
250 ML PC
IV
ML
40 MG
0.08
01/01/2002 10/30/2005
50 ML FC
IV
ML
40 MG
0.1
01/01/2002
100 ML FC
IV
ML
40 MG
0.1
01/01/2002 11/30/2005
100 ML FC
IV
ML
80 MG
0.0075
01/01/2002
50 ML FC
IV
ML
80 MG
0.01
01/01/2002
8/31/2004
100 ML FC
IV
ML
80 MG
0.01
01/01/2002
99/99/9999
100 ML FC
IV
ML
80 MG
0.0125
01/01/2002
99/99/9999
50 ML FC
IV
ML
80 MG
0.015
01/01/2002
99/99/9999
100 ML FC
IV
ML
80 MG
0.015
01/01/2002
99/99/9999
50 ML FC
50 ML FC
IV
IV
ML
ML
80 MG
80 MG
0.02
0.025
01/01/2002
01/01/2002
99/99/9999
99/99/9999
500 ML FC
IV
ML
1000 U
0.04
01/01/2002
99/99/9999
250 ML FC
IV
ML
1000 U
0.05
12/08/2004
99/99/9999
500 ML PC
50 ML FC
100 ML FC
IV
IV
IV
ML
ML
ML
1000 U
500 ML
500 ML
0.05
0.002
0.002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
50 ML FC
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
50 ML FC
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
100 ML FC
IV
ML
250 ML
0.004
01/01/2002
99/99/9999
250 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
99/99/9999
6/30/2004
99/99/9999
1000 ML FC
IV
ML
2 MEQ
0.01
01/01/2002
99/99/9999
1000 ML FC
50 ML PC
IV
IV
ML
ML
2 MEQ
2 MEQ
0.02
0.2
01/01/2002
01/01/2002
99/99/9999
99/99/9999

100 ML PC
CHLORIDE (VIAFLEX BAG,PF) 2 MEQ/100
ML-0.45%
1000 ML FC
50 ML PC
IV
ML
2 MEQ
0.2
01/01/2002
99/99/9999
IV
IV
ML
ML
2 MEQ
2 MEQ
0.01
0.1
05/21/2003
01/01/2002
99/99/9999
99/99/9999
00338-0705-48
J3480
100 ML PC
IV
ML
2 MEQ
0.1
01/01/2002
99/99/9999
J3480
100 ML PC
IV
ML
2 MEQ
0.05
01/01/2002
99/99/9999
00338-0711-13
J7799
1/1/2002
00338-0711-34
J7799
1/1/2002

20%
20%
Page 74 of 374
Prior End Date #2
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 99/99/9999
01/01/2002 12/31/2003
01/01/2004 10/30/2005
00338-0709-48
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
Billing Units
500 ML
250 ML
500 ML
250 ML
250 ML
500 ML
500 ML
250 ML
250 ML
500 ML
500 ML

Package
NDC Label
HCPCS Description
NDC Package Type
J7799
J7799
J7799
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
NDC Package Measure
00338-0355-03
00338-0357-02
00338-0357-03
00338-0409-02
00338-0409-02
00338-0409-03
00338-0409-03
00338-0411-02
00338-0411-02
00338-0411-03
00338-0411-03
HCPCS Mod
HCPCS
NDC Mod
NDC
500 ML FC
IV
ML
1 EA
01/01/2002
4/30/2008
1000 ML FC
IV
ML
1 EA
01/01/2002
1/31/2008
00338-0713-13
J7799
00338-0713-34
J7799
1/1/2002
00338-0715-13
J7799
1/1/2002
00338-0715-34
00338-0719-06
00338-0719-13
J7799
J7799
J7799
00338-0811-04
J7120
00338-0815-04
J7120
00338-0873-02
J7799
00338-0960-37
J0744
00338-0960-48
J0744
00338-1005-02
Q4076
00338-1005-02
J1265
00338-1005-03
Q4076
00338-1005-03
J1265
00338-1007-02
Q4076
00338-1007-02
J1265
00338-1007-03
Q4076
00338-1007-03
J1265
00338-1009-02
Q4076
00338-1009-02
J1265
00338-1013-41
J2700
00338-1015-41
J2700
00338-1017-41
J3490
00338-1019-48
J3490
00338-1021-41
J2540
00338-1023-41
J2540
00338-1025-41
00338-1055-48
J2540
J3490

00338-1071-03
J1250
1/1/2002
00338-1073-02
J1250
00338-1073-03
J1250
00338-1075-02
J1250
00338-1077-02
00338-1452-02
00338-1452-48
J1250
J7799
J7799
00338-1762-41
J2405
00338-2689-75
J2270
00338-2690-75
J2270
00338-2691-75
J2175
00338-3502-41
J0690
1/1/2002


30%
30%
40%
40%
DEXTROSE (BULK PACKAGE) 70%
DEXTROSE (12X500ML,USP) 70%
(5%,DEXTROSE & LAC-RING)
(5%,DEXTROSE & LAC-RING)
SODIUM CHLORIDE (BULK PACKAGE)
23.4%
CIPROFLOXACIN
(1X200ML,USP,PREMIX,PF) 400 MG/200
ML
CIPROFLOXACIN
(1X100ML,USP,PREMIX,PF) 200 MG/100
ML
DEXTROSE/DOPAMINE HCL (PRE-MIX IN
D5W) 5%-80 MG/100 ML
DEXTROSE/DOPAMINE HCL (PRE-MIX IN
D5W) 5%-80 MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
MG/100 ML
OXACILLIN SODIUM (PREMIXED) 1
GM/50 ML
OXACILLIN SODIUM (PREMIXED) 2
GM/50 ML
NAFCILLIN SODIUM (GALAXY,PREMIX) 1
GM/50 ML
NAFCILLIN SODIUM (GALAXY,PREMIX) 1
GM/50 ML
PENICILLIN G POTASSIUM
(GALAXY,PREMIX) 1 Million U/50 ML
METRONIDAZOLE 500 MG/100 ML
DEXTROSE/DOBUTAMINE (12X500ML)
5%-50 MG/100 ML
DEXTROSE/DOBUTAMINE 5%-100
MG/100 ML
DEXTROSE/DOBUTAMINE (12X500ML)
5%-100 MG/100 ML
MG/100 ML
MG/100 ML
ONDANSETRON
(50MLX10,SD,USP,PREMIX) 32 MG/50 ML
MORPHINE SULFATE
(SRN,PREFILLED,GLASS) 1 MG/ML
MORPHINE SULFATE
MEPERIDINE HCL
CEFAZOLIN SODIUM (GALAXY P.C.) 500
MG/50 ML
Page 75 of 374
500 ML FC
IV
ML
1 EA
01/01/2002 12/31/2007
1000 ML FC
IV
ML
1 EA
01/01/2002
500 ML FC
IV
ML
1 EA
01/01/2002
8/31/2007
1000 ML FC
2000 ML PC
500 ML PC
IV
IV
IV
ML
ML
ML
1 EA
1 EA
1 EA
1
1
1
01/01/2002
01/01/2002
01/01/2002
9/30/2007
99/99/9999
99/99/9999
1000 ML FC
IV
ML
1000 ML
0.0005
01/01/2002
99/99/9999
1000 ML FC
IV
ML
1000 ML
0.0005
01/01/2002
99/99/9999
250 ML GC IV
ML
1 EA
01/01/2002
99/99/9999
200 ML FC
ML
200 MG
0.01
03/18/2008
99/99/9999
IV
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
3/31/2007
100 ML FC
IV
ML
200 MG
0.01
03/18/2008
99/99/9999
250 ML PC
IV
ML
40 MG
0.02
10/01/2003
12/31/2005
250 ML PC
IV
ML
40 MG
0.02
01/01/2006
99/99/9999
500 ML PC
IV
ML
40 MG
0.02
10/01/2003
12/31/2005
500 ML PC
IV
ML
40 MG
0.02
01/01/2006
99/99/9999
250 ML PC
IV
ML
40 MG
0.04
10/01/2003
12/31/2005
250 ML PC
IV
ML
40 MG
0.04
01/01/2006
99/99/9999
500 ML PC
IV
ML
40 MG
0.04
10/01/2003
12/31/2005
500 ML PC
IV
ML
40 MG
0.04
01/01/2006
99/99/9999
250 ML PC
IV
ML
40 MG
0.08
10/01/2003
12/31/2005
250 ML PC
IV
ML
40 MG
0.08
01/01/2006
99/99/9999
50 ML PC
IV
ML
250 MG
0.08
01/01/2002
99/99/9999
50 ML PC
IV
ML
250 MG
0.16
01/01/2002
99/99/9999
50 ML PC
IV
ML
1 EA
01/01/2002
99/99/9999
100 ML FC
IV
ML
1 EA
01/01/2002
99/99/9999
50 ML PC
IV
ML
600000 U
0.03333
01/01/2002
99/99/9999
50 ML PC
IV
ML
600000 U
0.06666
01/01/2002
99/99/9999
50 ML PC
100 ML FC
IV
IV
ML
ML
600000 U
1 EA
0.1
1
01/01/2002
01/01/2002
99/99/9999
99/99/9999
500 ML FC
IV
ML
250 MG
0.002
01/01/2002
7/31/2005
250 ML FC
IV
ML
250 MG
0.004
01/01/2002
99/99/9999
500 ML FC
IV
ML
250 MG
0.004
01/01/2002 10/30/2006
250 ML FC
IV
ML
250 MG
0.008
01/01/2002
250 ML FC
250 ML FC
100 ML FC
IV
IV
IV
ML
ML
ML
250 MG
1 EA
1 EA
0.016
1
1
01/01/2002 99/99/9999
09/22/2003
1/31/2005
09/22/2003 12/31/2004
50 ML PC
IV
ML
1 MG
0.64
12/27/2006
99/99/9999
50 ML SR
IJ
ML
10 MG
0.1
01/01/2002
99/99/9999
50 ML SR
IJ
ML
10 MG
0.5
01/01/2002
99/99/9999
50 ML SR
IJ
ML
100 MG
0.1
01/01/2002
99/99/9999
50 ML FC
IV
ML
500 MG
0.02
01/01/2002
8/27/2006
99/99/9999
00338-3503-41
J0690
00338-3551-48
J3370
00338-3552-48
00338-5002-41
00338-5003-41
J3370
J0696
J0696

9/6/2005 99/99/9999 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG
00338-5197-41
J3490
00338-5198-41
J3490
00338-6010-48
J2260
00338-6011-37
J2260
00338-6045-37
J1450
00338-6046-48
J1450
00338-6307-02
00338-6346-02
J7120
J7060

00338-8017-77
J2912
1/1/2002
00338-8018-70
J2912
1/1/2002
00338-8019-70
J2912
1/1/2002
00338-8020-72
J2912
1/1/2002
00338-8021-79
J2912
1/1/2002
00338-8026-69
J1642
4/2/2002
00338-8106-69
J1642
1/1/2002
00338-8110-70
J1642
1/1/2002
00338-8112-69
J1642
1/1/2002
00338-8113-70
J1642
1/1/2002
00338-8206-69
J1642
1/1/2002
00338-8209-69
J1642
1/1/2002
00338-8210-70
J1642
1/1/2002
00338-8212-69
J1642
1/1/2002
00338-8213-70
J1642
1/1/2002
00338-8301-79
A4323
00338-8301-79
A4216
1/1/2004
00338-8302-69
A4323
00338-8302-69
A4216
1/1/2004
00338-8303-70
A4323
00338-8303-70
A4216
1/1/2004
00338-8303-72
A4323
00338-8303-72
A4216
1/1/2004
00338-9302-48
00338-9307-02
00338-9309-72
00338-9311-48
J3010
J3010
J3010
J3010
1/1/2002
1/1/2002
1/1/2002
1/1/2002
CEFAZOLIN SODIUM (GALAXY P.C.) 1

GM/50 ML
VANCOCIN HCL (S.D. GALAXY PLASTIC)
5%-500 MG/100 ML
VANCOCIN HCL (S.D. GALAXY PLASTIC)
5%-500 MG/100 ML
CEFTRIAXONE 1 GM/50 ML
CEFTRIAXONE 2 GM/50 ML
FAMOTIDINE (GALAXY PC,PF) 0.4 MG/ML
FAMOTIDINE NOVAPLUS (PREMIXED
W/NS,PF) 20 MG/50 ML
DEXTROSE/MILRINONE LACTATE
(BAG,INTRAVIA) 5%-20 MG/100 ML
(BAG,INTRAVIA) 5%-20 MG/100 ML
FLUCONAZOLE (INTRAVIA CONTAINER)
400 MG/200 ML
FLUCONAZOLE (INTRAVIA
CONTAINERS) 200 MG/100 ML
LACTATED RINGER'S (USP,LATEXFREE)
DEXTROSE (USP,40X250ML,AVIVA) 5%
SODIUM CHLORIDE FLUSH
(SRN,PREFILLED) 0.9%
(SRN,PREFILLED 6 ML) 0.9%
(SRN,PREFILLED 12 ML) 0.9%
HEPARIN LOCK FLUSH (SRN,PREFILLED
6 ML) 100 U/ML
6 ML) 10 U/ML
12 ML) 10 U/ML
HEPARIN LOCK FLUSH (SRN.BLUNT
CANNULA,PF) 10 U/ML
HEPARIN LOCK FLUSH (SRN,BLUNT
CANNULA,PF) 10 U/ML
6 ML) 100 U/ML
12 ML) 100 U/ML
12 ML) 100 U/ML
CANNULA,PF) 100 U/ML
CANNULA,PF) 100 U/ML
SODIUM CHLORIDE FLUSH (SRN,BLUNT
CANNULA) 0.9%
CANNULA) 0.9%
CANNULA) 0.9%
CANNULA) 0.9%
CANNULA) 0.9%
CANNULA) 0.9%
CANNULA) 0.9%
CANNULA) 0.9%
50 ML FC
IV
ML
500 MG
0.04
01/01/2002
99/99/9999
100 ML PC
IV
ML
500 MG
0.01
01/01/2002
99/99/9999
200 ML PC
50 ML PC
50 ML PC
IV
IV
IV
ML
ML
ML
500 MG
250 MG
250 MG
0.01
0.08
0.16
01/01/2002
09/06/2005
09/06/2005
99/99/9999
99/99/9999
99/99/9999
50 ML PC
IV
ML
1 EA
01/01/2002
99/99/9999
50 ML PC
IV
ML
1 EA
11/01/2003
99/99/9999
100 ML FC
IV
ML
5 MG
0.04
06/05/2002
99/99/9999
200 ML FC
IV
ML
5 MG
0.04
06/05/2002
99/99/9999
200 ML PC
IV
ML
200 MG
0.01
07/29/2004
99/99/9999
100 ML PC
IV
ML
200 MG
0.01
07/29/2004
99/99/9999
250 ML FC
250 ML FC
IV
IV
ML
ML
1000 ML
500 ML
0.001
0.002
10/17/2007
03/01/2007
99/99/9999
99/99/9999
10/01/2004
3 ML SR
IV
ML
0.9 %
0.5
01/01/2002
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
10/01/2004
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
10/01/2004
10 ML SR
IV
ML
0.9 %
0.5
01/01/2002
10/01/2004
2 ML SR
IV
ML
0.9 %
0.5
01/01/2002
10/01/2004
3 ML SR
IV
ML
10 U
10
04/02/2002
04/02/2002
3 ML SR
IV
ML
10 U
01/01/2002
10/01/2004
5 ML SR
IV
ML
10 U
01/01/2002
10/01/2004
3 ML SR
IV
ML
10 U
01/01/2002
10/01/2004
5 ML SR
IV
ML
10 U
01/01/2002
10/01/2004
3 ML SR
IV
ML
10 U
10
01/01/2002
10/01/2004
3 ML SR
IV
ML
10 U
10
01/01/2002
10/01/2004
5 ML SR
IV
ML
10 U
10
01/01/2002
10/01/2004
3 ML SR
IV
ML
10 U
10
01/01/2002
10/01/2004
5 ML SR
IV
ML
10 U
2 ML SR
IV
ML
1000 ML
10
01/01/2002
10/01/2004
0.001
01/01/2002
12/31/2003
2 ML SR
IV
ML
10 ML
0.1
01/01/2004
10/01/2004
3 ML SR
IV
ML
1000 ML
0.001
01/01/2002
12/31/2003
3 ML SR
IV
ML
10 ML
0.1
01/01/2004
10/01/2004
5 ML SR
IV
ML
1000 ML
0.001
01/01/2002
12/31/2003
5 ML SR
IV
ML
10 ML
0.1
01/01/2004
10/01/2004
10 ML SR
IV
ML
1000 ML
0.001
01/01/2002
12/31/2003
10 ML SR
IV
ML
10 ML
0.1
01/01/2004
10/01/2004
FENTANYL CITRATE/SODIUM CHLORIDE

(INTRAVIA) 0.2 MG/100 ML-0.9%
100 ML FC
IV
ML
0.1 MG
0.02
01/01/2002
02/01/2004

250 ML FC
IV
ML
0.1 MG
0.05
01/01/2002
02/01/2004

(SRN,12 ML) 0.5 MG/100 ML-0.9%
10 ML SR
IV
ML
0.1 MG
0.05
01/01/2002
02/01/2004

(INTRAVIA) 1 MG/100 ML-0.9%
100 ML FC
IV
ML
0.1 MG
0.1
01/01/2002
02/01/2004
Page 76 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00338-9312-48
00338-9313-02
00338-9314-02
J3010
J3010
J3010
1/1/2002
1/1/2002
1/1/2002
ML
0.1 MG
0.1
01/01/2002
02/01/2004
250 ML FC
IV
ML
0.1 MG
0.1
01/01/2002
02/01/2004

(IPUMP BAG) 1 MG/100 ML-0.9%
250 ML FC
IV
ML
0.1 MG
0.1
01/01/2002
02/01/2004
100 ML EA
IV
ML
0.1 MG
0.2
01/01/2002
02/01/2004
50 ML FC
IV
ML
0.1 MG
0.5
01/01/2002
02/01/2004
50 ML PC
IV
ML
4 MG
0.05
01/01/2002
02/01/2004
25 ML SR
IV
ML
4 MG
0.05
01/01/2002
02/01/2004
50 ML SR
IV
ML
4 MG
0.05
01/01/2002
02/01/2004
1/1/2002
J3010
1/1/2002
00338-9361-41
J1170
1/1/2002
HYDROMORPHONE HCL/SODIUM
CHLORIDE (SRN,35 ML) 1 MG/5 ML-0.9%
00338-9363-75
J1170
1/1/2002
00338-9365-41
J1170
1/1/2002
00338-9366-67
J1170
1/1/2002
00338-9367-75
J1170
1/1/2002
00338-9370-41
J2175
1/1/2002
00338-9372-48
J2175
1/1/2002
00338-9373-48
J2175
1/1/2002
00338-9375-48
J2270
1/1/2002
00338-9377-41
J2270
1/1/2002
00338-9378-48
J2270
1/1/2002
00338-9379-48
J2270
1/1/2002
00338-9381-02
J2270
1/1/2002
00338-9383-48
J2270
1/1/2002
00338-9385-02
J2270
1/1/2002
00338-9386-67
J2270
1/1/2002
00338-9387-75
J2270
1/1/2002
00338-9389-48
J3490
1/1/2002
00338-9390-48
J3490
1/1/2002
00338-9391-48
J3490
1/1/2002
00338-9392-02
J3490
1/1/2002
00338-9393-41
J3490
1/1/2002
00338-9394-48
J3490
1/1/2002
00338-9424-48
J1170
1/1/2002
00364-0483-01
Q0177
1/1/2002

CHLORIDE (INTRAVIA) 50 MG/50 ML0.9%
CHLORIDE (SRN,35 ML) 1 MG/ML-0.9%
MEPERIDINE HCL/SODIUM CHLORIDE
(INTRAVIA) 1 GM/100 ML-0.9%
(IPUMP BAG) 1 GM/100 ML-0.9%
MORPHINE SULFATE/SODIUM
CHLORIDE (IPUMP BAG) 100 MG/100 ML0.9%
(INTRAVIA) 5%-100 MG/100 ML
(SRN,35 ML) 5%-2 MG/ML
BUPIVACAINE/SODIUM CHLORIDE
(INTRAVIA) 0.0625%-0.9%
(IPUMP BAG) 0.0625%-0.9%
(INTRAVIA) 0.125%-0.9%
(INTAVIA) 0.125%-0.9%
(INTRAVIA) 0.25%-0.9%
(IPUMP BAG) 0.125%-0.9%
Page 77 of 374
50 ML FC
IV
ML
4 MG
0.25
01/01/2002
02/01/2004
25 ML SR
IV
ML
4 MG
0.25
01/01/2002
02/01/2004
50 ML SR
IV
ML
4 MG
0.25
01/01/2002
02/01/2004
50 ML FC
IV
ML
100 MG
0.1
01/01/2002
02/01/2004
100 ML FC
IV
ML
100 MG
0.1
01/01/2002
02/01/2004
100 ML PC
IV
ML
100 MG
0.1
01/01/2002
02/01/2004
100 ML FC
IV
ML
10 MG
0.01
01/01/2002
02/01/2004
50 ML FC
IV
ML
10 MG
0.1
01/01/2002
02/01/2004
100 ML PC
IV
ML
10 MG
0.1
01/01/2002
02/01/2004
100 ML FC
IV
ML
10 MG
0.1
01/01/2002
02/01/2004
250 ML FC
IV
ML
10 MG
0.1
01/01/2002
02/01/2004
100 ML FC
IV
ML
10 MG
0.1
01/01/2002
02/01/2004
250 ML FC
IV
ML
10 MG
0.1
01/01/2002
02/01/2004
25 ML SR
IV
ML
10 MG
0.2
01/01/2002
02/01/2004
50 ML SR
IV
ML
10 MG
0.2
01/01/2002
02/01/2004
100 ML FC
IV
ML
1 EA
01/01/2002
02/01/2004
100 ML FC
IV
ML
1 EA
01/01/2002
02/01/2004
100 ML FC
IV
ML
1 EA
01/01/2002
02/01/2004
250 ML FC
IV
ML
1 EA
01/01/2002
02/01/2004
50 ML FC
IV
ML
1 EA
01/01/2002
02/01/2004
100 ML FC
IV
ML
1 EA
01/01/2002
02/01/2004
100 ML PC
IV
ML
4 MG
0.05
01/01/2002
02/01/2004
100 EA BO
PO
EA
25 MG
01/01/2002
02/07/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
IV
J3010
100 ML FC

00338-9318-41
1/1/2002
NDC Package Type

00338-9316-48
J1170
NDC Package Measure

FENTANYL CITRATE (INTRAVIA) 0.05
MG/ML
00338-9362-67

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00364-0483-05
Q0177
00364-0484-01
Q0178
00364-0484-05
Q0178
00364-2186-46
00364-2465-34
00364-2466-93
00364-2499-01
00364-2499-36
00364-2689-05
00364-2690-01
00364-2692-01
J2322
J0690
J0690
None
None
J8499
J8499
J8499
00364-2791-23
J2915
00364-2791-23
00364-2888-30
J2916
J3420
1/1/2002
1/1/2002 9/30/2004 INJECTION, NANDROLONE DECANOATE, UP TO 200 MG
1/1/1994
9/30/1996
1/1/2002
INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 62.5
1/1/2002 12/31/2002 MG
INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5
1/1/2003
1/1/2003 MG
00364-2906-38
J2540
00364-2908-61
J2540
1/1/2002
00364-3063-56
A4712
1/1/2002
00364-6683-54
J2675
1/1/2002
1/31/2004 INJECTION, PROGESTERONE, PER 50 MG
00364-6717-47
J2321
1/1/2002
00372-0047-04
Q0163
1/1/2002
00372-0047-16
00378-0014-01
00378-0014-50
00378-0144-05
00378-0144-91
00378-0253-01
00378-0274-01
00378-0274-93
00378-0302-01
Q0163
None
None
J8999
J8999
J8499
J8999
J8999
J8499
1/1/2002
1/1/1994
2/23/1998
2/20/2003
2/20/2003
1/1/2002
2/20/2003
2/20/2003
1/1/2002
00378-0315-53
Q0179
6/27/2007
00378-0315-93
Q0179
6/27/2007
00378-0344-53
Q0179
6/27/2007
00378-0344-93
Q0179
6/27/2007
00378-1003-94
Q0166
1/30/2007
00378-1533-83
Q0144
6/5/2007
00378-1534-59
Q0144
6/5/2007
00378-1535-93
00378-2200-01
00378-2200-05
Q0144
J8499
J8499

1/1/2002
500 EA BO
PO
EA
25 MG
01/01/2002
04/02/2002
100 EA BO
PO
EA
50 MG
01/01/2002
10/31/2003
NANDROLONE DECANOATE (S.D.V.) 200
MG/ML
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 200 MG
FERRLECIT (SINGLE USE AMP) 62.5
MG/5 ML
FERRLECIT (SINGLE USE AMP) 62.5
MG/5 ML
HYDROXOCOBALAMIN 1000 MCG/ML
PENICILLIN G POTASSIUM (VIAL) 5 Million
U
PENICILLIN G POTASSIUM (VIAL,100 ML)
20 Million U
WATER FOR INJECTION
BACTERIOSTATIC (M.D.V.)
PROGESTERONE IN SESAME OIL (VIAL)
50 MG/ML
NANDROLONE DECANOATE (M.D.V.) 100
MG/ML
500 EA BO
PO
EA
50 MG
01/01/2002
09/30/2002
1 ML
1 EA
1 EA
100 EA
36 EA
500 EA
100 EA
100 EA
IM
IJ
IJ
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
EA
200 MG
500 MG
500 MG
2.5 MG
2.5 MG
1 EA
1 EA
1 EA
1
2
20
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/1994
09/30/1996
01/01/2002
01/01/2002
01/01/2002
09/30/2004
01/16/2003
04/28/2003
06/02/1998
06/02/1997
04/09/2002
10/01/2002
12/31/2002
5 ML AM IV
ML
62.5 MG
0.2
01/01/2002
12/31/2002
5 ML AM IV
30 ML VL IM
ML
ML
12.5 MG
1000 MCG
1
1
01/01/2003
01/01/2002
01/01/2003
12/23/2003
VL
VL
VL
NA
NA
BO
BO
BO
1 EA VL
IV
EA
600000 U
8.33333
01/01/2002
12/18/2002
1 EA VL
IV
EA
600000 U
33.33333
01/01/2002
05/19/2003
30 ML VL
IV
ML
10 ML
0.1
01/01/2002
10/01/2002
10 ML VL
IM
ML
50 MG
01/01/2002
01/31/2004

2 ML VL
SCOT-TUSSIN ALLERGY RELIEF
FORMULA (CHERRY-STRAW) 12.5 MG/5
ML
120 ML BO
SCOT-TUSSIN ALLERGY RELIEF
FORMULA (CHERRY-STRAW) 12.5 MG/5
ML
480 ML BO
100 EA BO
5000 EA BO
500 EA BO
60 EA BO
ACYCLOVIR 400 MG
100 EA BO
100 EA BO
30 EA BO
ACYCLOVIR 800 MG
100 EA BO
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 ONDANSETRON HYDROCHLORIDE
(FILM-COATED) 4 MG
3 EA BX
(FILM-COATED) 4 MG
30 EA BO
(FILM-COATED) 8 MG
3 EA BX
(FILM-COATED) 8 MG
30 EA BO
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 GRANISETRON HYDROCHLORIDE (FILMCOATED) 1 MG
20 EA BO
MG
18 EA BX
MG
9 EA BX
IM
ML
100 MG
01/01/2002
04/28/2003
PO
ML
50 MG
0.05
01/01/2002
09/06/2005
PO
PO
PO
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
2.5 MG
2.5 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
0.05
1
1
1
1
1
1
1
1
01/01/2002
01/01/1994
02/23/1998
02/20/2003
02/20/2003
01/01/2002
02/20/2003
02/20/2003
01/01/2002
09/06/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
PO
EA
8 MG
0.5
06/27/2007
99/99/9999
PO
EA
8 MG
0.5
06/27/2007
99/99/9999
PO
EA
8 MG
06/27/2007
99/99/9999
PO
EA
8 MG
06/27/2007
99/99/9999

ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
Page 78 of 374
30 EA BO
100 EA BO
500 EA BO
PO
EA
1 MG
01/30/2007
99/99/9999
PO
EA
1 GM
0.25
06/05/2007
99/99/9999
PO
EA
1 GM
0.5
06/05/2007
99/99/9999
PO
PO
PO
EA
EA
EA
1 GM
1 EA
1 EA
0.6
1
1
06/05/2007
01/01/2002
01/01/2002
99/99/9999
02/03/2004
04/16/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00378-3266-94
00378-3547-25
00378-3547-52
None
J8999
J8999
00378-5105-01
Q0164
00378-5110-01
Q0165
00378-6988-58
J7620
00378-6988-91
J7620
00378-6988-93
J7620
00378-7732-93
Q0179
00378-7734-93
Q0179
00378-7734-97
00402-0055-39
00402-0055-50
00402-0056-50
00402-0171-10
00402-0191-30
Q0179
J2000
J2000
J2000
J3410
J2912
00402-0432-02
J2321
00402-0661-10
J1100
00402-0710-01
00405-4643-01
00405-4643-36
00406-0646-02
00406-0672-52
00406-0735-52
00406-1130-52
00406-1395-04
00406-1492-52
00406-1510-56
00406-1510-57
00406-1510-59
00406-1521-53
00406-1521-55
00406-1521-56
00406-1521-57
00406-1548-32
00406-1548-35
00406-1585-55
00406-2003-01
J2322
None
None
J0706
J3490
J1960
J3010
J3520
J2310
J1230
J1230
J1230
J2271
J2271
J2271
J2271
J0745
J0745
J2175
J7500
00406-2040-01
Q0169
00406-2041-01
Q0170
00406-2041-10
Q0170
00406-2042-01
00406-3245-52
00406-4200-12
Q0170
J1170
J3475
ETOPOSIDE (BLISTER PACK,SOFTGEL)

10/19/2001 99/99/9999 ETOPOSIDE, 50 MG, ORAL
50 MG
20 EA BX
MERCAPTOPURINE (U.S.P.) 50 MG
250 EA BO
MERCAPTOPURINE (U.S.P.) 50 MG
25 EA BO
100 EA BO
100 EA BO
ALBUTEROL SULFATE (30X3ML,5
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA3 ML PC
12/28/2007 99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME VIALS/POUCH) 3 MG/3 ML-0.5 MG/3 ML
ALBUTEROL SULFATE (60X3ML 5
12/28/2007 99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME VIALS/POUCH) 3 MG/3 ML-0.5 MG/3 ML
ALBUTEROL SULFATE (30X3ML,1
12/28/2007 99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME VIAL/POUCH) 3 MG/3 ML-0.5 MG/3 ML
ONDANSETRON (USP) 4 MG
30 EA BO
30 EA BO
10 EA BO
LIDOCAINE HCL (M.D.V.) 1%
50 ML VL
50 ML VL
50 ML VL
HYDROXYZINE HCL (M.D.V.) 50 MG/ML
10 ML VL
SODIUM CHLORIDE (M.D.V.) 0.9%
30 ML VL
MG/ML
2 ML VL
PHOSPHATE (M.D.V.) 10 MG/ML
10 ML VL
MG/ML
1 ML VL
1/1/1994 4/26/1996 METHOTREXATE, 2.5 MG, ORAL
100 EA NA
36 EA NA
1/1/2002 99/99/9999 INJECTION, CAFFEINE CITRATE, 5MG
CAFFEINE CITRATED (PURIFIED)
1 EA BO
SUFENTANIL CITRATE (U.S.P.)
1 EA BO
1/1/2002 99/99/9999 INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG
LEVORPHANOL TARTRATE (U.S.P.)
1 EA BO
FENTANYL CITRATE
1 EA BO
EDETATE DISODIUM (U.S.P.)
1 EA BO
NALOXONE HCL (U.S.P.)
1 EA BO
1/1/2002 99/99/9999 INJECTION, METHADONE HCL, UP TO 10 MG
METHADONE HCL
1 EA BO
METHADONE HCL
1 EA BO
METHADONE HCL
1 EA BO
MORPHINE SULFATE
1 EA BO
MORPHINE SULFATE
1 EA BO
MORPHINE SULFATE
1 EA BO
MORPHINE SULFATE
1 EA BO
CODEINE PHOSPHATE
1 EA BO
CODEINE PHOSPHATE
1 EA BO
MEPERIDINE HCL (U.S.P.)
1 EA BO
7/2/2007 3/27/2009 AZATHIOPRINE, ORAL, 50 MG
AZATHIOPRINE (USP) 50 MG
100 EA BO
(USP) 12.5 MG
100 EA BO
(USP) 25 MG
100 EA BO
(USP) 25 MG
1000 EA BO
(USP) 50 MG
100 EA BO
HYDROMORPHONE HCL
1 EA BO
MAGNESIUM SULFATE (U.S.P.)
1 EA BO
Page 79 of 374
PO
PO
PO
EA
EA
EA
50 MG
1 EA
1 EA
1
1
1
10/19/2001
07/01/2005
07/01/2005
99/99/9999
99/99/9999
99/99/9999
PO
EA
5 MG
01/01/2002
99/99/9999
PO
EA
10 MG
01/01/2002
99/99/9999
IH
ML
2.5 MG
0.33333
12/28/2007
99/99/9999
IH
ML
2.5 MG
0.33333
12/28/2007
99/99/9999
IH
ML
2.5 MG
0.33333
12/28/2007
99/99/9999
PO
EA
8 MG
0.5
06/25/2007
99/99/9999
PO
EA
8 MG
06/25/2007
99/99/9999
PO
EP
EP
IJ
IM
IV
EA
ML
ML
ML
ML
ML
8 MG
50 ML
50 ML
50 ML
25 MG
0.9 %
1
0.02
0.02
0.02
2
0.5
06/25/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
10/01/2002
10/01/2002
10/01/2002
10/01/2002
10/01/2002
IM
ML
100 MG
01/01/2002
10/01/2002
IJ
ML
1 MG
10
01/01/2002
10/01/2002
IM
PO
PO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
PO
ML
EA
EA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
EA
200 MG
2.5 MG
2.5 MG
5 MG
1 EA
2 MG
0.1 MG
150 MG
1 MG
10 MG
10 MG
10 MG
100 MG
100 MG
100 MG
100 MG
30 MG
30 MG
100 MG
50 MG
1
1
1
200
1
500
10000
6.66666
1000
100
100
100
10
10
10
10
33.33333
33.33333
10
1
01/01/2002
01/01/1994
01/01/1994
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
07/02/2007
10/01/2002
04/26/1996
04/26/1996
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
3/27/2009
PO
EA
12.5 MG
09/12/2006
3/27/2009
PO
EA
25 MG
09/12/2006
3/27/2009
PO
EA
25 MG
07/15/2007
3/27/2009
PO
NA
NA
EA
GM
GM
25 MG
4 MG
500 MG
2
250
2
09/12/2006
01/01/2002
01/01/2002
3/27/2009
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-1080-51
J7060
00409-1081-51
00409-1082-01
00409-1082-51
A4216
J7060
J7060

POTASSIUM CHLORIDE (U.S.P.)

POTASSIUM CHLORIDE (A.C.S.)
LEUPROLIDE ACETATE
DESMOPRESSIN ACETATE
UREA (U.S.P.)
NIPENT (SDV) 10 MG
CARBOCAINE 1%
CARBOCAINE (MDV) 1%
CARBOCAINE (PF) 1.5%
CARBOCAINE (SDV,USP,PF) 2%
00409-1097-32
J0745
11/15/2005
00409-1102-32
J0745
10/5/2005
00409-1120-62
00409-1129-10
00409-1129-11
00409-1129-12
00409-1130-02
J2405
J9045
J9045
J9045
J7799
1/22/2007
12/11/2006
12/11/2006
12/11/2006
5/13/2005
00409-1134-03
J2271
9/14/2005
00409-1134-05
J2271
8/8/2005
00409-1135-02
J2275
7/21/2005
00409-1141-02
J7799
4/13/2005
00409-1151-12
J1642
7/14/2005
00409-1151-12
J1642
10/1/2009
00409-1151-70
J1642
7/20/2005
00409-1151-70
J1642
10/1/2009
00409-1151-78
J1642
9/19/2005
00409-1151-78
J1642
10/1/2009
00409-1152-12
J1642
3/15/2005
00409-1152-12
J1642
10/1/2009
00409-1152-70
J1642
9/7/2005
00409-1152-70
J1642
10/1/2009
00409-1152-78
J1642
2/25/2005
00409-1152-78
J1642
10/1/2009
00409-1158-01
J3490
7/27/2005
00409-1158-02
J3490
10/28/2005
00409-1159-01
J3490
6/29/2005
00409-1159-02
J3490
8/10/2005
00409-1160-01
J3490
4/12/2005
00409-1161-01
00409-1162-01
J3490
J3490
10/18/2004
3/8/2006
00409-1162-02
J3490
11/22/2005
00409-1163-01
J3490
3/30/2005
00409-1164-01
J3490
3/24/2006
00409-1165-01
J3490
12/8/2005

99/99/9999 INJECTION, PENTOSTATIN, 10 MG
DEXTROSE (THERMOJECT,10X10ML) 5%
SODIUM CHLORIDE (THERMOJECT,
25X10ML) 0.9%
DEXTROSE (THERMOJECT KIT) 5%
DEXTROSE (USP,PF) 5%
CODEINE PHOSPHATE (LUER99/99/9999 INJECTION, CODEINE PHOSPHATE, PER 30 MG
ONDANSETRON (10X2ML,SDPFS,USP) 2
MG/ML
CARBOPLATIN 10 MG/ML
MG/ML
MORPHINE SULFATE (LATEX-FREE) 50
MG/ML
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER MORPHINE SULFATE (HIGH
99/99/9999 10 MG
CONCENTRATION,PF) 25 MG/ML
SODIUM CHLORIDE (VIAL,FLIPTOP,BULK
PKG) 23.4%
HEPARIN LOCK FLUSH (25X10ML,LATEX3/2/2009 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS
FREE) 10 U/ML
HEPARIN LOCK FLUSH (25X10ML,LATEX99/99/9999 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS
FREE) 10 U/ML
HEPARIN LOCK FLUSH (FTV,25X10ML)
10 U/ML
10 U/ML
10 U/ML
10 U/ML
HEPARIN LOCK FLUSH
HEPARIN LOCK FLUSH
100 U/ML
100 U/ML
HEPARIN LOCK FLUSH
HEPARIN LOCK FLUSH
BUPIVACAINE HCL (AMP,5X30ML,LATEX99/99/9999 UNCLASSIFIED DRUGS
FREE) 0.25%
BUPIVACAINE HCL
(AMP,25X50ML,LATEX-FREE) 0.25%
BUPIVACAINE HCL (USP,25X2ML,LATEX99/99/9999 UNCLASSIFIED DRUGS
FREE) 0.25%
BUPIVACAINE HCL (25X30ML,LATEX99/99/9999 UNCLASSIFIED DRUGS
FREE) 0.25%
BUPIVACAINE HCL (VIAL,FLIPTOP,LATEX
FREE) 0.25%
0.5%
BUPIVACAINE HCL (25X10ML) 0.5%
0.5%
BUPIVACAINE HCL (VIAL,FLIPTOP,LATEX
FREE) 0.5%
BUPIVACAINE HYDROCHLORIDE
(5X30ML,USP) 0.75%
0.75%
Page 80 of 374
NA
NA
NA
NA
NA
NA
NA
IV
IJ
IJ
IJ
IJ
GM
GM
GM
GM
GM
GM
GM
EA
ML
ML
ML
ML
10 ML VL
IV
ML
10 ML VL
10 ML VL
10 ML VL
IV
IV
IV
ML
EA
ML
2 ML SR
IJ
2 ML SR
IJ
SR
VL
VL
VL
GC
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
07/20/2007
03/21/2006
10/08/2007
04/26/2006
01/15/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
09/07/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
500 ML
0.002
03/24/2006
99/99/9999
10 ML
500 ML
500 ML
0.1
0.08
0.002
12/27/2006
04/25/2005
03/29/2006
99/99/9999
99/99/9999
99/99/9999
ML
30 MG
0.5
11/15/2005
99/99/9999
ML
30 MG
10/05/2005
99/99/9999
IJ
IV
IV
IV
IV
ML
ML
ML
ML
ML
1 MG
50 MG
50 MG
50 MG
1 EA
2
0.2
0.2
0.2
1
01/22/2007
12/11/2006
12/11/2006
12/11/2006
05/13/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 ML VL
IJ
ML
100 MG
0.5
09/14/2005
99/99/9999
50 ML VL
IJ
ML
100 MG
0.5
08/08/2005
99/99/9999
10 ML VL
IJ
ML
10 MG
2.5
07/21/2005
99/99/9999
100 ML VL
IV
ML
1 EA
04/13/2005
99/99/9999
10 ML VL
IV
ML
10 U
07/14/2005
3/2/2009
10 ML VL
IV
ML
10 U
10/1/2009
99/99/9999
10 ML VL
IV
ML
10 U
07/20/2005
3/2/2009
10 ML VL
IV
ML
10 U
10/1/2009
99/99/9999
30 ML VL
IV
ML
10 U
09/19/2005
3/2/2009
30 ML VL
IV
ML
10 U
10/1/2009
99/99/9999
10 ML VL
IV
ML
10 U
10
03/15/2005
3/2/2009
10 ML VL
IV
ML
10 U
10
10/1/2009
99/99/9999
10 ML VL
IV
ML
10 U
10
09/07/2005
3/2/2009
10 ML VL
IV
ML
10 U
10
10/1/2009
99/99/9999
30 ML VL
IV
ML
10 U
10
02/25/2005
3/2/2009
30 ML VL
IV
ML
10 U
10
10/1/2009
99/99/9999
30 ML AM IJ
ML
1 EA
07/27/2005
99/99/9999
50 ML AM IJ
ML
1 EA
10/28/2005
99/99/9999
10 ML VL
IJ
ML
1 EA
06/29/2005
99/99/9999
30 ML VL
IJ
ML
1 EA
08/10/2005
99/99/9999
50 ML VL
IJ
ML
1 EA
04/12/2005
99/99/9999
30 ML AM IJ
10 ML VL IJ
ML
ML
1 EA
1 EA
1
1
10/18/2004
03/08/2006
99/99/9999
99/99/9999
30 ML VL
IJ
ML
1 EA
11/22/2005
99/99/9999
50 ML VL
IJ
ML
1 EA
03/30/2005
99/99/9999
30 ML AM IJ
ML
1 EA
03/24/2006
99/99/9999
10 ML VL
ML
1 EA
12/08/2005
99/99/9999
IJ
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
6.71141
6.71141
6.71141
6.71141
1000
1000000
0.025
1
0.1
0.1
0.1
0.1
2 ML
5 ML
15 ML
45 ML
250 ML
2 MEQ
2 MEQ
2 MEQ
2 MEQ
1 MG
1 MCG
40 GM
10 MG
10 ML
10 ML
10 ML
10 ML
CF
HCPCS Measure #1
HCPCS Amount #1
BO
BO
BO
NA
BO
BO
BO
VL
VL
VL
VL
VL
Billing Units
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
30 ML
50 ML
30 ML
20 ML

Package
NDC Package Type
J3480
J3480
J3480
J3480
J9218
J2597
J3350
J9268
J0670
J0670
J0670
J0670
NDC Label
HCPCS Description
00406-6838-04
00406-6838-06
00406-6845-04
00406-6858-04
00406-8050-03
00406-8061-03
00406-8642-12
00409-0801-01
00409-1036-30
00409-1038-50
00409-1041-30
00409-1067-20
NDC Package Measure
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
7/20/2007
3/21/2006
10/8/2007
4/26/2006
1/15/2007
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-1165-02
J3490
00409-1176-30
J2175
00409-1178-30
J2175
00409-1179-30
J2175
00409-1180-69
J2175
00409-1181-30
J2175
00409-1187-01
00409-1201-20
J1790
J2175

00409-1203-01
J2175
00409-1207-03
J1580
00409-1212-01
J2310
00409-1215-01
J2310
00409-1219-01
J2310
00409-1253-01
00409-1254-01
J2175
J2175

00409-1255-02
J2175
00409-1256-01
J2175
00409-1258-30
00409-1260-69
J2270
J2270

00409-1261-30
J2270
00409-1264-31
J2271
00409-1273-32
J3360
00409-1275-32
J1940
00409-1276-32
J3010
00409-1280-31
J1642
3/28/2005
00409-1280-31
J1642
00409-1280-32
J1642
00409-1280-32
J1642
00409-1280-33
J1642
00409-1280-33
J1642
00409-1280-35
J1642
4/1/2005
00409-1280-35
J1642
00409-1281-31
J1642
7/22/2005
00409-1281-31
J1642
00409-1281-32
J1642
4/25/2005
00409-1281-32
J1642
00409-1281-33
J1642
7/15/2005
00409-1281-33
J1642
00409-1281-35
J1642
4/25/2005
00409-1281-35
J1642
00409-1283-31
J1170
00409-1304-31
J1170

4/8/2005
4/5/2005
BUPIVACAINE HCL (TTV,LATEX-FREE)

0.75%
DEMEROL HYDROCHLORIDE (LATEXFREE,CARPUJECT) 50 MG/ML
DEMEROL HYDROCHLORIDE (LATEXFREE,CARPUJECT) 75 MG/ML
DEMEROL (USP,MDV,STERILE) 50
MG/ML
DROPERIDOL (10X2ML AMP,LATEXFREE) 2.5 MG/ML
DEMEROL (MDV) 100 MG/ML
DEMEROL HYDROCHLORIDE (UNI-AMP,
5X5,LATEX-FREE) 50 MG/ML
GENTAMICIN SULFATE (VIAL,FLIPTOP)
40 MG/ML
NALOXONE HCL (10X1ML AMP,LATEXFREE) 0.4 MG/ML
NALOXONE HCL (VIAL,FLIPTOP,10X1ML)
0.4 MG/ML
NALOXONE HYDROCHLORIDE 0.4
MG/ML
DEMEROL HYDROCHLORIDE (LATEXFREE) 50 MG/ML
DEMEROL (25X1.5ML) 50 MG/ML
DEMEROL HYDROCHLORIDE (UNI-AMP
5X5,LATEX-FREE) 50 MG/ML
(25X1ML,LATEX-FREE) 100 MG/ML
LOCK,U.S.P.,10X1ML) 4 MG/ML
MORPHINE SULFATE 8 MG/ML
MORPHINE SULFATE (LLK,SLIM PK,
10X1ML) 10 MG/ML
DIAZEPAM (10X2ML, LUER LOCK) 5
MG/ML
FUROSEMIDE (CARPUJECT W/LUER
LOCK) 10 MG/ML
LOCK,10X2ML,PF) 0.05 MG/ML
LOCK,50X1ML) 100 U/ML
LOCK,10X1ML) 1 MG/ML
LOCK,10X1ML) 4 MG/ML
Page 81 of 374
30 ML VL
IJ
ML
1 EA
05/24/2005
1 ML SR
IJ
ML
100 MG
0.25
08/25/2005
99/99/9999
1 ML SR
IJ
ML
100 MG
0.5
09/14/2005
99/99/9999
1 ML SR
IJ
ML
100 MG
0.75
12/08/2005
99/99/9999
IJ
ML
100 MG
09/14/2005
99/99/9999
30 ML VL
IJ
ML
100 MG
0.5
01/31/2006
99/99/9999
2 ML AM IJ
20 ML VL IJ
ML
ML
5 MG
100 MG
0.5
1
08/23/2005
03/09/2006
99/99/9999
99/99/9999
ML
100 MG
0.5
12/16/2005
99/99/9999
ML
80 MG
0.5
08/30/2005
99/99/9999
2 ML VL
IJ
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
1 ML SR
0.5 ML AM IJ
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1 ML AM IJ
ML
1 MG
0.4
06/16/2005
99/99/9999
1 ML VL
IJ
ML
1 MG
0.4
07/08/2005
99/99/9999
10 ML VL
IJ
ML
1 MG
0.4
04/03/2006
99/99/9999
1 ML AM IJ
1.5 ML AM IJ
ML
ML
100 MG
100 MG
0.5
0.5
01/04/2006
03/20/2006
99/99/9999
99/99/9999
2 ML AM IJ
ML
100 MG
0.5
11/23/2005
99/99/9999
1 ML AM IJ
ML
100 MG
01/26/2006
99/99/9999
1 ML CR
1 ML SR
IJ
IJ
ML
ML
10 MG
10 MG
0.4
0.8
05/10/2005
03/22/2006
99/99/9999
99/99/9999
1 ML SR
IJ
ML
10 MG
07/21/2005
99/99/9999
1 ML CR
IJ
ML
100 MG
0.15
12/16/2005
99/99/9999
2 ML CR
IJ
ML
5 MG
08/23/2005
99/99/9999
2 ML SR
IJ
ML
20 MG
0.5
08/31/2005
99/99/9999
99/99/9999
2 ML SR
IJ
ML
0.1 MG
0.5
07/27/2005
1 ML SR
IV
ML
10 U
03/28/2005
3/2/2009
1 ML SR
IV
ML
10 U
10/01/2009
99/99/9999
2 ML SR
IV
ML
10 U
04/08/2005
3/2/2009
2 ML SR
IV
ML
10 U
10/01/2009
99/99/9999
3 ML CR
IV
ML
10 U
04/05/2005
3/2/2009
3 ML CR
IV
ML
10 U
10/01/2009
99/99/9999
5 ML CR
IV
ML
10 U
04/01/2005
3/2/2009
5 ML CR
IV
ML
10 U
03/03/2009
99/99/9999
1 ML CR
IV
ML
10 U
10
07/22/2005
3/2/2009
1 ML CR
IV
ML
10 U
10
10/01/2009
99/99/9999
2 ML CR
IV
ML
10 U
10
04/25/2005
3/2/2009
2 ML CR
IV
ML
10 U
10
10/01/2009
99/99/9999
3 ML CR
IV
ML
10 U
10
07/15/2005
3/2/2009
3 ML CR
IV
ML
10 U
10
10/01/2009
99/99/9999
5 ML CR
IV
ML
10 U
10
04/25/2005
3/2/2009
5 ML CR
IV
ML
10 U
10
10/01/2009
99/99/9999
1 ML CR
IJ
ML
4 MG
0.25
06/14/2005
99/99/9999
1 ML CR
IJ
ML
4 MG
07/13/2005
99/99/9999
00409-1312-30
J1170
00409-1316-25
00409-1316-32
J1644
J1644

00409-1316-66
J1644
00409-1317-01
J1165
00409-1317-02
00409-1323-05
J1165
J2001
00409-1402-31
J1644
00409-1410-01
J7659
00409-1410-01 KO J7659
00409-1410-01
KO
J7659
00409-1410-05 KO J7659
00409-1410-05
KO
J7660
00409-1410-01 KO J7660
00409-1410-05

KO
J7660
00409-1410-05 KO J7660
KO

7/28/2005 12/31/2006 MILLIGRAM
7/28/2005 12/31/2006 MILLIGRAM
ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT,
10/26/2005 12/31/2006 MILLIGRAM
10/26/2005 12/31/2006 MILLIGRAM
00409-1412-04
J3490
00409-1412-10
J3490
00409-1463-01
00409-1464-01
J2300
J2300

00409-1465-01
J2300
00409-1467-01
J2300
00409-1505-03
00409-1508-05
J7110
J7799
00409-1513-02
00409-1522-01
00409-1522-02
00409-1522-03
00409-1523-01
00409-1523-11
J3480
J7060
J7060
J7060
J7060
J7060
6/16/2005
4/11/2005
3/9/2005
6/16/2005
9/16/2005
7/27/2005
00409-1534-05
00409-1535-03
J7799
J7799
00409-1539-31
J2060
00409-1559-10
J3490
00409-1559-30
00409-1560-10
00409-1560-29
J3490
J3490
J3490

00409-1582-10
J3490
00409-1582-29
J3490
00409-1583-01
J7050
00409-1583-02

HYDROMORPHONE HCL
(10X1ML,LLK,SLIM PK) 2 MG/ML
HEPARIN SODIUM (10X0.5ML,W/ LUER
LOCK) 5000 U/0.5 ML
HEPARIN SODIUM (PF,CARPUJECT)
10000 U/ML
ISUPREL (AMP,25X1ML,LATEX-FREE) 0.2
MG/ML
MG/ML
MG/ML
MG/ML
ISUPREL (10X5ML,AMP,LATEX-FREE) 0.2
MG/ML
4 MG
IJ
ML
0.5
07/07/2005
99/99/9999
IJ
IJ
ML
ML
1000 U
1000 U
10
10
10/29/2007
03/23/2005
99/99/9999
99/99/9999
0.5 ML SR
1000 U
IJ
ML
10
02/11/2005
99/99/9999
2 ML AM IV
ML
50 MG
02/08/2005
99/99/9999
5 ML AM IV
5 ML SR IJ
ML
ML
50 MG
10 MG
1
2
03/30/2005
12/08/2005
99/99/9999
99/99/9999
1 ML SR
IJ
ML
03/21/2005
99/99/9999
1 ML AM IV
ML
1 MG
0.2
07/28/2005
12/31/2006
1 ML AM IV
ML
1 MG
0.2
07/28/2005
12/31/2006
1 ML AM IV
ML
1 MG
0.2
01/01/2007
99/99/9999
1 ML AM IV
ML
1 MG
0.2
01/01/2007
99/99/9999
5 ML AM IV
ML
1 MG
0.2
10/26/2005
12/31/2006

MG/ML
5 ML AM IV
MG/ML
5 ML AM IV
MG/ML
5 ML AM IV
BUMETANIDE (SDFLIPTOP VIAL,USP)
0.25 MG/ML
4 ML VL IJ
BUMETANIDE (MDV,USP,10X10ML) 0.25
MG/ML
10 ML VL IJ
10 MG/ML
1 ML AM IJ
10 ML VL IJ
20 MG/ML
1 ML AM IJ
NALBUPHINE HCL (VIAL,FLIPTOP) 20
MG/ML
10 ML VL IJ
DEXTRAN-70 W/SODIUM CHLORIDE 6%0.9%
500 ML GC IV
DEXTROSE (6X1000ML) 2.5%
1000 ML GC IV
POTASSIUM CHLORIDE
(12X250ML,LATEX-FREE) 2 MEQ/ML
250 ML VL IV
150 ML GC IV
250 ML GC IV
500 ML GC IV
DEXTROSE (50/150ML PART FILL) 5%
50 ML GC IV
100 ML GC IV
DEXTROSE AND SODIUM CHLORIDE
(6X1000ML) 10%-0.9%
1000 ML GC IV
500 ML GC IV
LORAZEPAM (10X1ML, LUER LOCK) 4
MG/ML
1 ML CR IJ
1000 U
ML
1 MG
0.2
10/26/2005
12/31/2006
ML
1 MG
0.2
01/01/2007
99/99/9999
ML
1 MG
0.2
01/01/2007
99/99/9999
ML
1 EA
06/14/2006
99/99/9999
ML
1 EA
06/29/2006
99/99/9999
ML
ML
10 MG
10 MG
1
1
03/09/2005
07/13/2005
99/99/9999
99/99/9999
ML
10 MG
11/18/2004
99/99/9999
ML
10 MG
05/12/2005
99/99/9999
ML
ML
500 ML
1 EA
0.002
1
12/29/2005
08/31/2005
99/99/9999
99/99/9999
ML
ML
ML
ML
ML
ML
2 MEQ
500 ML
500 ML
500 ML
500 ML
500 ML
1
0.002
0.002
0.002
0.002
0.002
06/16/2005
04/11/2005
03/09/2005
06/16/2005
09/16/2005
07/27/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
ML
ML
1 EA
1 EA
1
1
02/24/2006
09/08/2005
99/99/9999
99/99/9999
ML
2 MG
12/23/2005
99/99/9999
10 ML VL
IJ
ML
1 EA
08/22/2005
99/99/9999
30 ML VL
10 ML VL
30 ML VL
IJ
IJ
IJ
ML
ML
ML
1 EA
1 EA
1 EA
1
1
1
09/07/2005
08/31/2005
08/05/2005
99/99/9999
99/99/9999
99/99/9999

MARCAINE HCL (10X30ML,LATEX-FREE)
0.75%
10 ML VL
IJ
ML
1 EA
07/22/2005
99/99/9999
30 ML VL
IJ
ML
1 EA
08/04/2005
99/99/9999
150 ML FC
IV
ML
250 ML
0.004
07/20/2005
99/99/9999
J7050
250 ML GC IV
ML
250 ML
0.004
09/14/2005
99/99/9999
00409-1584-11
00409-1586-03
J7050
J7799

100 ML GC IV
500 ML GC IV
ML
ML
250 ML
1 EA
0.004
1
09/16/2005
03/24/2006
99/99/9999
99/99/9999
00409-1587-50
J3490
00409-1590-02
A4217

SODIUM CHLORIDE (12X100ML,150ML
VIAL,PF) 0.9%
SODIUM CHLORIDE (12X500ML) 5%
MARCAINE HCL (M.D.V.,LATEX-FREE)
0.25%
WATER FOR INJECTION
Page 82 of 374
IJ
ML
1 EA
01/10/2006
99/99/9999
250 ML GC IV
50 ML VL
ML
500 ML
0.002
08/05/2005
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
1 ML CR
0.5 ML SR
0.5 ML SR

0.25%
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-1590-05
00409-1610-50
A4217
J3490
00409-1623-01
J0595
00409-1623-49
J0595
00409-1626-01
J0595
00409-1626-02
J0595
00409-1626-49
J0595
00409-1626-51
J0595
00409-1630-10
J0460
00409-1639-10
J1940
00409-1754-10
J3475
00409-1761-02
J3490
00409-1762-30
J2270
00409-1775-10
J7799
00409-1782-69
J2310
00409-1800-01
J2370
00409-1844-32
J1165
00409-1902-01
00409-1903-01
J2690
J2690
3/10/2006 99/99/9999 INJECTION, PROCAINAMIDE HCL, UP TO 1 GM

00409-1918-32
J2912
00409-1918-32
A4216
00409-1918-33
J2912
00409-1918-33
A4216
00409-1918-35
J2912
00409-1918-35
A4216
00409-1920-10
J3070
9/29/2005 99/99/9999 INJECTION, PENTAZOCINE, 30 MG
00409-1941-01
J3070
00409-1952-32
J3250
00409-1955-01
J3490
00409-1955-01
J0278
1/1/2006 99/99/9999 INJECTION, AMIKACIN SULFATE, 100 MG
00409-1956-01
J3490
00409-1956-01
J0278
00409-1957-01
J3490
00409-1957-01
J0278
00409-1966-04
A4216
00409-1966-05
A4216
00409-1966-07
A4216
00409-1966-12
A4216
00409-1966-14
00409-1985-01
00409-1985-05
00409-1985-10
A4216
J2060
J2060
J2060

00409-1985-30
J2060



1/9/2006 99/99/9999 INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG


STERILE WATER (USP)

1000 ML GC
50 ML VL
MG/ML
1 ML VL
(10X1ML) 1 MG/ML
1 ML VL
MG/ML
1 ML VL
MG/ML
2 ML VL
NOVAPLUS BUTORPHANOL TARTRATE
(VHA,10X1ML) 2 MG/ML
1 ML VL
(10X2ML) 2 MG/ML
2 ML VL
ATROPINE SULFATE (ANSYR,10X10ML)
0.1 MG/ML
10 ML SR
FUROSEMIDE (10X10ML, ANSYR) 10
MG/ML
10 ML SR
MAGNESIUM SULFATE
(10X10ML,SINGLE-DOSE,USP) 500
MG/ML
10 ML SR
MARCAINE SPINAL
(AMP,W/DEXTROSE,PF) 0.75%
2 ML AM
1 ML CR
DEXTROSE (2.5GM INFANT ANSYR SYR)
25%
10 ML SR
NALOXONE HCL (10X1ML, CARPUJECT)
0.4 MG/ML
1 ML SR
NEO-SYNEPHRINE HCL (AMP,25X1ML)
10 MG/ML
1 ML AM
PHENYTOIN SODIUM (CARPUJECT) 50
MG/ML
2 ML SR
PROCAINAMIDE HYDROCHLORIDE
(25X10ML,FTV) 100 MG/ML
10 ML VL
PROCAINAMIDE HCL 500 MG/ML
2 ML VL
LOCK,50X2ML,PF) 0.9%
2 ML CR
LOCK,50X2ML,PF) 0.9%
2 ML CR
5 ML CR
5 ML CR
5 ML CR
5 ML CR
TALWIN LACTATE (VIAL,LATEX-FREE) 30
MG/ML
10 ML VL
TALWIN LACTATE (UNI-AMP,LATEXFREE) 30 MG/ML
1 ML AM
TRIMETHOBENZAMIDE HCL (LUER
2 ML SR
AMIKACIN SULFATE
2 ML VL
AMIKACIN SULFATE
2 ML VL
MG/ML
2 ML VL
MG/ML
2 ML VL
MG/ML
4 ML VL
MG/ML
4 ML VL
10 ML VL
20 ML VL
(VIAL,FLIPTOP PLASTIC) 0.9%
30 ML VL
(25X10ML, LS-PLASTIC) 0.9%
10 ML VL
30 ML VL
1 ML VL
LORAZEPAM (10X1ML) 2 MG/ML
1 ML SR
LORAZEPAM 2 MG/ML
10 ML VL
LORAZEPAM (LUER LOCK,CARPUJECT)
2 MG/ML
1 ML CR
Page 83 of 374
IJ
IJ
ML
ML
500 ML
1 EA
0.002
1
06/28/2005
11/22/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
99/99/9999
99/99/9999
IJ
ML
1 MG
09/20/2005
99/99/9999
IJ
ML
1 MG
10/19/2005
99/99/9999
IJ
ML
1 MG
03/21/2006
99/99/9999
IJ
ML
1 MG
12/21/2005
99/99/9999
IJ
ML
1 MG
05/24/2006
99/99/9999
IJ
ML
1 MG
12/08/2005
99/99/9999
IJ
ML
0.3 MG
0.33333
01/11/2006
12/31/2009
IJ
ML
20 MG
0.5
01/23/2006
99/99/9999
IJ
ML
500 MG
11/27/2006
99/99/9999
IJ
ML
1 EA
06/06/2005
99/99/9999
IJ
ML
10 MG
0.2
05/27/2005
99/99/9999
IV
ML
1 EA
02/20/2006
99/99/9999
IJ
ML
1 MG
0.4
09/29/2005
99/99/9999
IJ
ML
1 ML
04/14/2005
99/99/9999
IV
ML
50 MG
10/05/2004
99/99/9999
IJ
IV
ML
ML
1 GM
1 GM
0.1
0.5
03/10/2006
08/24/2005
99/99/9999
99/99/9999
IV
ML
0.9 %
0.5
11/23/2005
12/31/2006
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
IV
ML
0.9 %
0.5
02/17/2005
12/31/2006
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
IV
ML
0.9 %
0.5
04/08/2005
12/31/2006
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
IJ
ML
30 MG
09/29/2005
99/99/9999
IJ
ML
30 MG
11/18/2005
99/99/9999
IM
ML
200 MG
0.5
01/09/2006
99/99/9999
IJ
ML
1 EA
03/11/2005
12/31/2005
IJ
ML
100 MG
0.5
01/01/2006
99/99/9999
IJ
ML
1 EA
09/06/2005
12/31/2005
IJ
ML
100 MG
2.5
01/01/2006
99/99/9999
IJ
ML
1 EA
09/26/2005
12/31/2005
IJ
ML
100 MG
2.5
01/01/2006
99/99/9999
IV
ML
10 ML
0.1
08/30/2005
99/99/9999
IV
ML
10 ML
0.1
05/02/2005
99/99/9999
IV
ML
10 ML
0.1
04/05/2005
99/99/9999
IV
ML
10 ML
0.1
10/06/2005
99/99/9999
IV
IJ
IJ
IJ
ML
ML
ML
ML
10 ML
2 MG
2 MG
2 MG
0.1
1
1
1
06/01/2005
04/25/2005
02/08/2008
11/16/2005
99/99/9999
6/12/2009
99/99/9999
99/99/9999
IJ
ML
2 MG
06/01/2005
99/99/9999
00409-2012-32
00409-2025-20
J0592
J1250
6/17/2005 99/99/9999 INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG

00409-2025-54
J1250
00409-2043-02
00409-2047-50
J1245
J0670
3/31/2005 99/99/9999 INJECTION, DIPYRIDAMOLE, PER 10 MG

00409-2066-05
00409-2102-02
00409-2102-02
00409-2102-05
00409-2102-05
J2001
J2912
A4216
J2912
A4216
9/6/2005
8/16/2005
1/1/2007
4/3/2006
1/1/2007

00409-2168-02
J3475
00409-2168-03
J3475
00409-2169-31
J1160
6/16/2005 99/99/9999 INJECTION, DIGOXIN, UP TO 0.5 MG
00409-2172-01
J1170
00409-2172-05
J1170
00409-2173-32
J2765
00409-2265-01
J2597
00409-2287-21
J1885
00409-2287-22
J1885
00409-2287-31
J1885
00409-2287-61
J1885
00409-2288-21
J1885
00409-2288-31
J1885
00409-2290-11
J1200
00409-2290-31
J1200
00409-2305-02
00409-2305-05
J2250
J2250

2/4/2005 99/99/9999 INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG

00409-2305-49
J2250
00409-2305-50
J2250
00409-2305-61
J2250
00409-2305-62
J2250
00409-2306-22
J2250
00409-2306-62
J2250
00409-2307-21
J2250
00409-2307-60
J2250
00409-2308-01
J2250
00409-2308-02
J2250
00409-2308-49
J2250
00409-2308-50
J2250
00409-2312-02
J2550
00409-2312-31
J2550
00409-2336-10
J0895
00409-2337-25
J0895
(10X1ML,CARPUJECT) 0.3 MG/ML
DOBUTAMINE (10X20ML) 12.5 MG/ML
MG/ML
DIPYRIDAMOLE (AMP,UNI-NEST,LATEXFREE) 5 MG/ML
CARBOCAINE (M.D.V.,USP) 2%
500 MG/ML
500 MG/ML
DIGOXIN (10X1ML,LUER LOCK) 0.25
MG/ML
HYDROMORPHONE HCL (HIGH
POTENCY) 10 MG/ML
HYDROMORPHONE HCL (HIGH
POTENCY) 10 MG/ML
METOCLOPRAMIDE (LEUR
DESMOPRESSIN ACETATE (UNI-AMP) 4
MCG/ML
KETOROLAC TROMETHAMINE (10X1ML,
USP) 30 MG/ML
KETOROLAC TROMETHAMINE (10X2ML)
30 MG/ML
KETOROLAC TROMETHAMINE ((LUER
LOCK),10X2ML) 30 MG/ML
KETOROLAC TROMETHAMINE (10X1ML)
15 MG/ML
DIPHENHYDRAMINE HCL (W/LUER
LOCK,10X1ML,USP) 50 MG/ML
DIPHENHYDRAMINE HCL (LUER
MIDAZOLAM HCL (VIAL, FLIPTOP,PF) 1
MG/ML
MIDAZOLAM HCL (PF) 1 MG/ML
(10X2ML,PF) 1 MG/ML
(FTV,10X5ML,PF) 1 MG/ML
MIDAZOLAM HCL AMERINET CHOICE
MIDAZOLAM HCL AMERINET CHOICE
MIDAZOLAM HYDROCHLORIDE
(10X2ML,PF) 1 MG/ML
MIDAZOLAM HCL (LUER
LOCK,STERILE,PF) 1 MG/ML
(10X1ML,PF) 5 MG/ML
MIDAZOLAM HCL
(10X1ML,PF,CARPUJECT) 5 MG/ML
MIDAZOLAM HCL (10X1ML,PF) 5 MG/ML
MIDAZOLAM HCL (VIAL,FLIPTOP,PF) 5
MG/ML
VIAL,PF) 5 MG/ML
PROMETHAZINE
HYDROCHLORIDE(10X1ML,USP)
(25MG/ML)
DEFEROXAMINE MESYLATE (LATEXFREE) 500 MG
DEFEROXAMINE MESYLATE
(VIAL,LATEX-FREE) 2 GM
Page 84 of 374
1 ML SR
20 ML VL
IJ
IV
ML
ML
0.1 MG
250 MG
3.24
0.05
06/17/2005
02/20/2006
99/99/9999
99/99/9999
40 ML VL
IV
ML
250 MG
0.05
11/10/2005
99/99/9999
2 ML AM IV
50 ML VL IJ
ML
ML
10 MG
10 ML
0.5
0.1
03/31/2005
09/22/2006
99/99/9999
99/99/9999
5 ML
2 ML
2 ML
5 ML
5 ML
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
ML
ML
ML
ML
ML
10 MG
0.9 %
10 ML
0.9 %
10 ML
2
0.5
0.1
0.5
0.1
09/06/2005
08/16/2005
01/01/2007
04/03/2006
01/01/2007
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
20 ML VL
IJ
ML
500 MG
01/31/2005
99/99/9999
50 ML VL
IJ
ML
500 MG
10/22/2004
99/99/9999
1 ML CR
IV
ML
0.5 MG
0.5
06/16/2005
99/99/9999
1 ML AM IJ
ML
4 MG
2.5
04/19/2005
99/99/9999
5 ML AM IJ
ML
4 MG
2.5
04/19/2005
99/99/9999
2 ML SR
IV
ML
10 MG
0.5
11/28/2005
99/99/9999
1 ML AM IJ
ML
02/04/2005
99/99/9999
1 ML CT
IJ
ML
15 MG
06/22/2007
99/99/9999
2 ML CT
IJ
ML
15 MG
06/22/2007
99/99/9999
1 ML CR
IJ
ML
15 MG
04/25/2005
99/99/9999
2 ML SR
IM
ML
15 MG
06/20/2005
99/99/9999
1 ML CT
IJ
ML
15 MG
06/22/2007
99/99/9999
1 ML SR
IJ
ML
15 MG
08/29/2005
99/99/9999
1 ML CR
IJ
ML
50 MG
07/31/2008
99/99/9999
1 ML CR
IJ
ML
50 MG
04/25/2005
99/99/9999
2 ML VL
5 ML VL
IJ
IJ
ML
ML
1 MG
1 MG
1
1
08/15/2005
12/21/2005
99/99/9999
99/99/9999
2 ML VL
IJ
ML
1 MG
08/02/2005
99/99/9999
5 ML VL
IJ
ML
1 MG
09/13/2005
99/99/9999
2 ML VL
IJ
ML
1 MG
10/03/2005
99/99/9999
5 ML VL
IJ
ML
1 MG
10/03/2005
99/99/9999
2 ML SR
IJ
ML
1 MG
07/20/2007
99/99/9999
1 MCG
2 ML SR
IJ
ML
1 MG
03/10/2005
99/99/9999
1 ML SR
IJ
ML
1 MG
07/20/2007
99/99/9999
1 ML CR
IJ
ML
1 MG
04/25/2005
99/99/9999
1 ML VL
IJ
ML
1 MG
06/07/2005
99/99/9999
2 ML VL
IJ
ML
1 MG
10/10/2005
99/99/9999
1 ML VL
IJ
ML
1 MG
12/29/2005
99/99/9999
2 ML VL
IJ
ML
1 MG
11/18/2005
99/99/9999
1 ML SR
IJ
ML
50 MG
08/29/2008
99/99/9999
1 ML SR
IJ
ML
50 MG
0.5
04/05/2005
99/99/9999
1 EA VL
IJ
EA
500 MG
04/25/2005
99/99/9999
1 EA VL
IJ
EA
500 MG
03/21/2005
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-2343-31
J2560
00409-2344-01
J1250
00409-2344-02
J1250
00409-2344-88
J1250
00409-2346-32
J1250
00409-2346-34
J1250
00409-2347-32
J1250

00409-2347-33
J1250
00409-2349-31
J2560
00409-2540-01
J1170
00409-2552-01
J1170
00409-2581-02
J1644
00409-2584-02
J1644
00409-2585-01
J0690
00409-2587-05
J2250
00409-2587-53
J2250
00409-2596-03
J2250
00409-2596-05
J2250
00409-2596-52
J2250
00409-2596-53
J2250
00409-2687-15
J0295
00409-2689-01
J0295
00409-2689-11
J0295
00409-2775-02
J2260
00409-2776-02
J2260
00409-2776-23
J2260
00409-2987-03
J0295
00409-2987-13
J0295
00409-2988-01
J0295
00409-2998-03
00409-3213-02
J0295
J3360

00409-3213-12
00409-3217-05
00409-3218-05
J3360
J2920
J2930

00409-3255-03
J3260
00409-3307-03
J7608

00409-3307-03 KO J7608
00409-3308-03
KO
J7608
00409-3308-03 KO J7608
KO
LUMINAL SODIUM (LUER LOCK,10X1ML)

60 MG/ML
DOBUTAMINE HCL (VIAL,FLIPTOP) 12.5
MG/ML
DOBUTAMINE (10X20ML,FTV) 12.5
MG/ML
DOBUTAMINE NOVAPLUS (S.D.V.,
U.S.P.) 12.5 MG/ML
DOBUTAMINE IN DEXTROSE
(12X250ML,LATEX-FREE) 5%-100 MG/100
ML
DOBUTAMINE IN DEXTROSE
(12X500ML,LIFECARE) 5%-100 MG/100
ML
5%-200 MG/100 ML
DEXTROSE/DOBUTAMINE NOVAPLUS
(U.S.P.) 5%-200 MG/100 ML
HYDROMORPHONE HCL (USP,10X1ML)
4 MG/ML
HYDROMORPHONE HCL (USP,10X1ML)
1 MG/ML
HEPARIN SODIUM (ADD-VANTAGE VIAL)
2000 U/ML
HEPARIN SODIUM (25X10ML,PF,LATEXFREE) 2500 U/ML
CEFAZOLIN (SDV,ADD-VANTAGE) 1 GM
(10X10ML,FLIPTOPVIAL) 1 MG/ML
NOVAPLUS MIDAZOLAM HCL
(10X10ML,FTV) 1 MG/ML
MIDAZOLAM HCL (VIAL, FLIPTOP) 5
MG/ML
NOVAPLUS MIDAZOLAM
HYDROCHLORIDE (10X5ML) 5 MG/ML
(FTV,10X10ML,LATEX-FREE) 5 MG/ML
AMPICILLIN AND SULBACTAM 10 GM-5
GM
AMPICILLIN AND SULBACTAM (SDV,ADDVANTAGE) 1 GM-0.5 GM
NOVAPLUS AMPICILLIN AND
SULBACTAM (USP,ADD-VANTAGE) 1 GM0.5 GM
MILRINONE LACTATE (VIAL,FLIPTOP,PF)
1 MG/ML
MILRINONE LACTATE (IN 5%
DEXTROSE,10X200ML) 5%-20 MG/100
ML
ML
AMPICILLIN AND SULBACTAM (SDV,ADDVANTAGE) 2 GM-1 GM
SULBACTAM (USP,ADD-VANTAGE) 2 GM1 GM
AMPICILLIN AND SULBACTAM (USP) 1
GM-0.5 GM
GM-1 GM
DIAZEPAM (MDV,FLIPTOP) 5 MG/ML
DIAZEPAM (10X10ML,USP,MDV,FLIPTOP)
5 MG/ML
A-METHAPRED (SDV) 40 MG
A-METHAPRED (SDV) 125 MG
TOBRAMYCIN SULFATE (VIAL,ADDVANTAGE) 10 MG/ML
1 ML SR
IJ
ML
120 MG
0.5
09/19/2005
99/99/9999
20 ML VL
IV
ML
250 MG
0.05
07/27/2005
99/99/9999
20 ML VL
IV
ML
250 MG
0.05
06/29/2005
99/99/9999
20 ML VL
IV
ML
250 MG
0.05
03/21/2005
99/99/9999
250 ML FC
IV
ML
250 MG
0.004
08/11/2005
99/99/9999
500 ML FC
IV
ML
250 MG
0.004
02/07/2006
99/99/9999
250 ML FC
IV
ML
250 MG
0.008
01/11/2006
99/99/9999
250 ML FC
IV
ML
250 MG
0.008
03/21/2005
99/99/9999
1 ML SR
IJ
ML
120 MG
1.08333
09/07/2005
99/99/9999
1 ML AM IJ
ML
4 MG
09/21/2005
99/99/9999
1 ML AM IJ
ML
4 MG
0.25
09/21/2005
99/99/9999
5 ML VL
IV
ML
1000 U
03/24/2006
99/99/9999
10 ML VL
IJ
ML
1000 U
2.5
07/01/2005
99/99/9999
25 EA VL
IV
EA
500 MG
06/27/2007
99/99/9999
10 ML VL
IJ
ML
1 MG
01/27/2006
99/99/9999
10 ML VL
IJ
ML
1 MG
03/07/2006
99/99/9999
5 ML VL
IJ
ML
1 MG
10/28/2005
99/99/9999
10 ML VL
IJ
ML
1 MG
01/11/2006
99/99/9999
5 ML VL
IJ
ML
1 MG
01/23/2006
99/99/9999
10 ML VL
IJ
ML
1 MG
09/27/2005
99/99/9999
1 EA VL
IV
EA
1.5 GM
10
06/22/2007
99/99/9999
1 EA VL
IV
EA
1.5 GM
10/09/2006
99/99/9999
1 EA VL
IV
EA
1.5 GM
07/01/2007
99/99/9999
20 ML VL
IV
ML
5 MG
0.2
12/31/2004
99/99/9999
200 ML FC
IV
ML
5 MG
0.04
03/08/2006
99/99/9999
100 ML FC
IV
ML
5 MG
0.04
06/15/2005
99/99/9999
1 EA VL
IV
EA
1.5 GM
10/09/2006
99/99/9999
99/99/9999
1 EA VL
IV
EA
1.5 GM
07/01/2007
10 EA VL
IJ
EA
1.5 GM
07/20/2007
99/99/9999
10 EA VL
10 ML VL
IJ
IJ
EA
ML
1.5 GM
5 MG
2
1
07/20/2007
05/09/2005
99/99/9999
99/99/9999
10 ML VL
1 EA VL
1 EA VL
IJ
IJ
IJ
ML
EA
EA
5 MG
40 MG
125 MG
1
1
1
10/01/2007
10/02/2006
10/02/2006
99/99/9999
99/99/9999
99/99/9999
8 ML VL
IJ
ML
80 MG
0.125
03/31/2005
99/99/9999
ACETYLCYSTEINE 10%
30 ML VL
IH
ML
1 GM
0.1
04/11/2005
99/99/9999
ACETYLCYSTEINE 10%
30 ML VL
IH
ML
1 GM
0.1
04/11/2005
99/99/9999
ACETYLCYSTEINE (3X30ML) 20%
30 ML VL
IH
ML
1 GM
0.2
05/25/2005
99/99/9999
30 ML VL
IH
ML
1 GM
0.2
05/25/2005
99/99/9999
Page 85 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-3356-01
J1170
00409-3365-01
J1170
00409-3380-31
J3490
00409-3380-32
J3490
11/3/2005
00409-3380-35
J3490
12/28/2005
00409-3380-49
J3490
11/29/2005
00409-3380-50
J3490
11/7/2005
00409-3380-51
J3490
10/12/2005
00409-3382-21
J3490
7/15/2005
00409-3382-22
J3490
7/18/2005
00409-3382-25
J3490
10/19/2005
00409-3400-01
J1580
3/24/2006
00409-3401-01
J1580
1/9/2006
00409-3402-01
J1580
6/5/2006
00409-3413-01
J2765
4/21/2005
00409-3469-13
J3260
5/30/2005
00409-3470-23
J3260
9/26/2005
00409-3577-01
J3260
3/31/2005
00409-3578-01
J3260
11/2/2004
00409-3590-02
J3260
2/15/2006
00409-3613-01
J3490
1/7/2005
00409-3724-32
J1250
10/7/2005
00409-3793-01
J1885
5/31/2005
00409-3793-49
J1885
4/19/2005
00409-3795-01
J1885
1/6/2006
00409-3795-49
J1885
9/21/2005
00409-3795-61
J1885
10/31/2005
00409-3796-01
J1885
12/21/2005
00409-3796-49
J1885
11/7/2005
00409-3796-61
J1885
8/5/2005
00409-3814-12
J2275
7/19/2005
00409-3815-12
J2270
6/28/2005
00409-3863-02
J1455
2/1/2006
00409-3863-05
J1455
2/1/2006
00409-3907-03
J3480
11/24/2004
00409-3977-03
00409-4027-02
A4216
A4217
4/7/2005
5/26/2006
HYDROMORPHONE HCL (10X1ML,USP)

2 MG/ML
HYDROMORPHONE HCL (SDV,25X1ML)
2 MG/ML
SUFENTANIL CITRATE (LATEX-FREE) 50
MCG/ML
SUFENTANIL CITRATE
(AMP,10X2ML,LATEX-FREE) 50 MCG/ML
SUFENTANIL CITRATE (AMP,LATEX99/99/9999 UNCLASSIFIED DRUGS
FREE) 50 MCG/ML
(10X2ML,PF,LATEX-FREE) 50 MCG/ML
(AMP,10X5ML,PF) 50 MCG/ML
SUFENTANIL CITRATE (10X1ML,LATEX99/99/9999 UNCLASSIFIED DRUGS
FREE) 50 MCG/ML
SUFENTANIL CITRATE (10X2ML,LATEX99/99/9999 UNCLASSIFIED DRUGS
FREE) 50 MCG/ML
SUFENTANIL CITRATE (USP,10X5ML) 50
MCG/ML
GENTAMICIN SULFATE (25X6ML,ADD99/99/9999 INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG
VANTAGE) 10 MG/ML
GENTAMICIN SULFATE (VIAL-ADD99/99/9999 INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG
VANTAGE) 10 MG/ML
GENTAMICIN SULFATE (SD ADD99/99/9999 INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG
VANTGE,USP) 10 MG/ML
METOCLOPRAMIDE (AMP,25X2ML) 5
MG/ML
SULFATE (PREMIX,24X100ML) 0.9%-80
MG/100 ML
TOBRAMYCIN SULFATE
TOBRAMYCIN SULFATE (VIAL,FLIPTOP)
40 MG/ML
TOBRAMYCIN SULFATE (BULK
PACKAGE) 40 MG/ML
BUPIVACAINE SPINAL AMPUL
(AMP,LATEX-FREE) 0.25%
5%-400 MG/100 ML
(USP,FLIPTOP VIAL) 15 MG/ML
NOVAPLUS (U.S.P.,25X1ML) 15 MG/ML
KETOROLAC TROMETHAMINE (LATEX99/99/9999 INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG
FREE) 30 MG/ML
NOVATION (FTV,25X1ML,2ML VIAL) 30
MG/ML
30 MG/ML
KETOROLAC TROMETHAMINE (VIAL,
FLIPTOP) 30 MG/ML
NOVATION (FTV,25X2ML,LATEX-FREE)
30 MG/ML
AMERINET (FTV,AMERINET,LATEXFREE) 30 MG/ML
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER MORPHINE SULFATE (5X10ML,PF,LATEX
99/99/9999 10 MG
FREE) 0.5 MG/ML
MORPHINE SULFATE (5X10ML,LATEX99/99/9999 INJECTION, MORPHINE SULFATE, UP TO 10 MG
FREE) 1 MG/ML
FOSCARNET SODIUM (12X250ML,PF) 24
MG/ML
FOSCARNET SODIUM (12X500ML,PF) 24
MG/ML
POTASSIUM CHLORIDE (AMP,LATEX99/99/9999 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ
FREE) 2 MEQ/ML
WATER FOR INJECTION
STERILE WATER (5MLX25,USP)
Page 86 of 374
1 ML AM IJ
ML
4 MG
0.5
09/21/2005
99/99/9999
1 ML VL
IJ
ML
4 MG
0.5
09/21/2005
99/99/9999
1 ML AM IJ
ML
1 EA
09/01/2005
99/99/9999
2 ML AM IJ
ML
1 EA
11/03/2005
99/99/9999
5 ML AM IJ
ML
1 EA
12/28/2005
99/99/9999
1 ML AM IJ
ML
1 EA
11/29/2005
99/99/9999
2 ML AM IJ
ML
1 EA
11/07/2005
99/99/9999
5 ML AM IJ
ML
1 EA
10/12/2005
99/99/9999
1 ML VL
IJ
ML
1 EA
07/15/2005
99/99/9999
2 ML VL
IJ
ML
1 EA
07/18/2005
99/99/9999
5 ML VL
IJ
ML
1 EA
10/19/2005
99/99/9999
6 ML VL
IV
ML
80 MG
0.125
03/24/2006
99/99/9999
8 ML VL
IJ
ML
80 MG
0.125
01/09/2006
99/99/9999
10 ML VL
IV
ML
80 MG
0.125
06/05/2006
99/99/9999
2 ML AM IV
ML
10 MG
0.5
04/21/2005
99/99/9999
0.02
05/30/2005
99/99/9999
99/99/9999
50 ML FC
IV
ML
80 MG
100 ML FC
IV
ML
80 MG
0.01
09/26/2005
2 ML VL
IJ
ML
80 MG
0.125
03/31/2005
99/99/9999
2 ML VL
IJ
ML
80 MG
0.5
11/02/2004
99/99/9999
50 ML VL
IJ
ML
80 MG
0.5
02/15/2006
99/99/9999
2 ML AM IJ
ML
1 EA
01/07/2005
99/99/9999
99/99/9999
250 ML FC
IV
ML
250 MG
0.016
10/07/2005
1 ML VL
IJ
ML
15 MG
05/31/2005
99/99/9999
1 ML VL
IJ
ML
15 MG
04/19/2005
99/99/9999
1 ML VL
IJ
ML
15 MG
01/06/2006
99/99/9999
1 ML VL
IJ
ML
15 MG
09/21/2005
99/99/9999
1 ML VL
IJ
ML
15 MG
10/31/2005
99/99/9999
2 ML VL
IM
ML
15 MG
12/21/2005
99/99/9999
2 ML VL
IM
ML
15 MG
11/07/2005
99/99/9999
2 ML VL
IM
ML
15 MG
08/05/2005
99/99/9999
10 ML VL
IJ
ML
10 MG
0.05
07/19/2005
99/99/9999
10 ML VL
IJ
ML
10 MG
0.1
06/28/2005
99/99/9999
250 ML GC IV
ML
1000 MG
0.024
02/01/2006
99/99/9999
500 ML GC IV
ML
1000 MG
0.024
02/01/2006
99/99/9999
10 ML AM IV
ML
11/24/2004
99/99/9999
30 ML VL IV
5 ML AM IJ
ML
ML
0.1
0.002
04/07/2005
05/26/2006
99/99/9999
99/99/9999
2 MEQ
10 ML
500 ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-4029-03
00409-4031-01
A4216
J2150

00409-4044-02
A4216
00409-4050-01
J3490
00409-4051-01
J3490
5/31/2005
00409-4052-01
J3490
7/5/2005
00409-4053-03
J3490
5/11/2005
00409-4054-03
J3490
2/18/2005
00409-4055-03
00409-4056-01
J3490
J2001
2/24/2005
10/31/2005
00409-4057-12
J2275
12/13/2005
00409-4058-12
00409-4089-02
J2270
J7799
10/7/2005
5/18/2005
00409-4142-02
Q4076
2/1/2005
00409-4142-02
00409-4169-01
J1265
J2400
1/1/2006
6/20/2005
00409-4170-01
J2400
4/20/2005
00409-4197-01
00409-4219-02
00409-4265-01
00409-4265-01
J3490
J7799
Q4076
J1265
3/31/2005
3/30/2005
7/11/2005
1/1/2006
00409-4270-01
J2001
2/27/2006
00409-4272-01
J3490
4/6/2006
00409-4273-01
J3490
6/28/2006
00409-4274-01
00409-4275-01
00409-4276-01
00409-4276-02
J3490
J2001
J2001
J2001
3/31/2006
12/30/2005
8/12/2005
7/7/2005
WATER FOR INJECTION (AMP,PF,LATEXFREE)

MANNITOL (VIAL, FLIPTOP) 25%
WATER FOR INJECTION
CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PHOSPHATE (ADD99/99/9999 UNCLASSIFIED DRUGS
VANTAGE,25X2ML) 150 MG/ML
CLINDAMYCIN PHOSPHATE (VIAL,ADD99/99/9999 UNCLASSIFIED DRUGS
VANTAGE) 150 MG/ML
CLINDAMYCIN PHOSPHATE (VIAL,ADD99/99/9999 UNCLASSIFIED DRUGS
VANTAGE) 150 MG/ML
LIDOCAINE HCL (AMP,PF) 1.5%
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER MORPHINE SULFATE (PF,LATEX-FREE)
99/99/9999 10 MG
0.5 MG/ML
MORPHINE SULFATE (AMP,LATEX99/99/9999 INJECTION, MORPHINE SULFATE, UP TO 10 MG
FREE) 1 MG/ML
MG/100 ML
MG/100 ML
99/99/9999 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML
CHLOROPROCAINE HCL (25X30ML) 2%
CHLOROPROCAINE HCL (VIAL,25X30ML)
3%
(VIAL,BULK,LATEX-FREE) 150 MG/ML
DOPAMINE HCL (25X10ML) 80 MG/ML
LIDOCAINE HCL (STERILE PACK,SDV)
1%
BUPIVACAINE HCL
(AMP,STERILE,USP,5X20ML) 0.25%
BUPIVACAINE HYDROCHLORIDE
(SINGLE-DOSE,5X20ML,PF) 0.5%
BUPIVACAINE HCL
(AMP,STERILE,USP,5X20ML) 0.75%
LIDOCAINE HCL (FTV,25X20ML) 1%
LIDOCAINE HCL (25X50ML) 1%
LIDOCAINE HCL (25X20ML,LATEX-FREE)
2%
LIDOCAINE HCL (FTV,25X50ML,LATEX99/99/9999 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG
FREE) 2%
LIDOCAINE HCL (25X50ML) 0.5%
1%
LIDOCAINE HCL (AMP,25X2ML,LATEX99/99/9999 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG
FREE) 2%
LIDOCAINE HYDROCHLORIDE
(USP,25X10ML,SDA,PF) 2%
00409-4277-01
J2001
6/13/2005
00409-4277-02
00409-4278-01
J2001
J2001
8/12/2005
6/29/2005
00409-4279-02
J2001
8/31/2005
00409-4282-01
J2001
9/9/2005
00409-4282-02
J2001
2/8/2006
00409-4283-01
J2001
00409-4332-01
J3370
00409-4332-49
J3370
00409-4346-73
J3490
00409-4348-35
J0282
00409-4684-02
J1450
00409-4684-23
J1450
00409-4688-02
J1450
00409-4688-23
J1450
00409-4688-27
J1450
00409-4688-28
J1450

VANCOMYCIN HCL (VIAL,FLIPTOP) 500
MG
(FTV,LATEX-FREE) 500 MG
AMINOCAPROIC ACID (VIAL,FLIPTOP)
250 MG/ML
(3MLX10,SINGLE-DOSE) 50 MG/ML
FLUCONAZOLE (6X200ML,LATEX-FREE)
400 MG/200 ML
ML
ML
FLUCONAZOLE (6X100ML,LATEX FREE)
200 MG/100 ML
(100MLX6,LATEX-FREE) 200 MG/100 ML
NOVAPLUS FLUCONAZOLE (6X100ML,
LATEX-FREE) 200 MG/100 ML
Page 87 of 374
20 ML AM IV
50 ML VL IV
ML
ML
10 ML
50 ML
0.1
0.02
03/01/2005
10/19/2004
99/99/9999
99/99/9999
10 ML AM IV
ML
10 ML
0.1
02/09/2006
99/99/9999
ML
1 EA
05/13/2005
99/99/9999
2 ML VL
IJ
4 ML VL
IJ
ML
1 EA
05/31/2005
99/99/9999
6 ML VL
IJ
ML
1 EA
07/05/2005
99/99/9999
2 ML VL
IJ
ML
1 EA
05/11/2005
99/99/9999
4 ML VL
IJ
ML
1 EA
02/18/2005
99/99/9999
6 ML VL IJ
20 ML AM IJ
ML
ML
1 EA
10 MG
1
1.5
02/24/2005
10/31/2005
99/99/9999
99/99/9999
5 ML AM IJ
ML
10 MG
0.05
12/13/2005
99/99/9999
10 ML AM IJ
5 ML AM IV
ML
ML
10 MG
1 EA
0.1
1
10/07/2005
05/18/2005
99/99/9999
99/99/9999
250 ML GC IV
ML
40 MG
0.04
02/01/2005
12/31/2005
250 ML GC IV
30 ML VL IJ
ML
ML
40 MG
30 ML
0.04
0.03333
01/01/2006
06/20/2005
99/99/9999
99/99/9999
IJ
ML
30 ML
0.03333
04/20/2005
99/99/9999
IJ
IV
IV
IV
ML
ML
ML
ML
1 EA
1 EA
40 MG
40 MG
1
1
2
2
03/31/2005
03/30/2005
07/11/2005
01/01/2006
99/99/9999
99/99/9999
12/31/2005
99/99/9999
30 ML VL
60 ML
250 ML
10 ML
10 ML
VL
GC
VL
VL
ML
10 MG
02/27/2006
99/99/9999
20 ML AM IJ
30 ML VL
ML
1 EA
04/06/2006
99/99/9999
20 ML AM IJ
ML
1 EA
06/28/2006
99/99/9999
20 ML
50 ML
20 ML
50 ML
IJ
IJ
EP
EP
ML
ML
ML
ML
1 EA
10 MG
10 MG
10 MG
1
0.5
1
1
03/31/2006
12/30/2005
08/12/2005
07/07/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 ML VL
IJ
ML
10 MG
06/13/2005
99/99/9999
50 ML VL
50 ML VL
IJ
IJ
ML
ML
10 MG
10 MG
2
0.5
08/12/2005
06/29/2005
99/99/9999
99/99/9999
30 ML VL
EP
99/99/9999
AM
VL
VL
VL
EP
ML
10 MG
08/31/2005
2 ML AM IJ
ML
10 MG
09/09/2005
99/99/9999
10 ML AM IJ
ML
10 MG
02/08/2006
99/99/9999
5 ML AM IJ
ML
10 MG
05/16/2005
99/99/9999
1 EA VL
EA
500 MG
04/25/2005
99/99/9999
IV
1 EA VL
IV
EA
500 MG
08/04/2005
99/99/9999
20 ML VL
IV
ML
1 EA
04/13/2005
99/99/9999
ML
30 MG
1.66666
09/27/2006
99/99/9999
200 ML FC
3 ML AM IV
IV
ML
200 MG
0.01
03/06/2007
99/99/9999
100 ML FC
IV
ML
200 MG
0.01
04/14/2006
99/99/9999
200 ML FC
IV
ML
200 MG
0.01
07/27/2006
99/99/9999
100 ML FC
IV
ML
200 MG
0.01
06/16/2006
99/99/9999
100 ML FC
IV
ML
200 MG
0.01
05/27/2006
99/99/9999
100 ML PC
IV
ML
200 MG
0.01
06/01/2005
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-4688-33
J1450
00409-4688-34
00409-4699-24
00409-4699-30
00409-4699-33
00409-4699-40
J1450
J3490
J3490
J3490
J3490
00409-4699-61
J3490
00409-4713-02
00409-4713-32
J2001
J2001

00409-4755-01
J2405
00409-4755-02
J2405
00409-4755-61
J2405
00409-4755-62
00409-4759-01
J2405
J2405

00409-4760-13
J2405
00409-4765-86
J0744
00409-4776-01
J2001
00409-4777-02
J0744
00409-4777-23
J0744
00409-4777-61
J0744
00409-4777-62
J0744
00409-4778-86
J0744
00409-4856-05
J1720
00409-4857-02
Q2009
00409-4857-10
Q2009
8/5/2007 99/99/9999 INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT
00409-4862-02
J7799
00409-4862-03
J7799
00409-4887-10
A4216
00409-4887-20
A4216
00409-4887-50
A4216
00409-4887-99
A4216
00409-4888-10
A4216
00409-4888-12
A4216
00409-4888-20
A4216
00409-4888-50
A4216
00409-4901-18
J0170
00409-4902-34
J7799
00409-4903-34
J2001
00409-4904-34
J2001
00409-4910-34
J0460
00409-4911-34
J0460

3/2/2006
3/22/2006
3/22/2006
3/22/2006
1/31/2008


NOVAPLUS FLUCONAZOLE
PROPOFOL (FLIPTOP VIAL) 10 MG/ML
PROPOFOL (5X20ML,SDV) 10 MG/ML
AMERINET CHOICE PROPOFOL
(5X20ML,SDV,PF) 10 MG/ML
1%
ONDANSETRON (5X2ML,SDV,USP) 2
MG/ML
ONDANSETRON
(SINGLEDOSE,USP,10X2ML) 2 MG/ML
AMERINET CHOICE ONDANSETRON
(5X2ML,SDV,USP) 2 MG/ML
AMERINET CHOICE ONDANSETRON
(10X2ML,SDV,USP) 2 MG/ML
ONDANSETRON (MDV,USP) 2 MG/ML
ONDANSETRON (PF,LATEX-FREE) 32
MG/50 ML
CIPROFLOXACIN (SINGLE-DOSE,USP)
10 MG/ML
LIDOCAINE HYDROCHLORIDE
(25X20ML,PF) 1.5%
CIPROFLOXACIN
(24X200ML,SINGLEDOSE,USP) 400
MG/200 ML
CIPROFLOXACIN
MG/100 ML
AMERINET CHOICE CIPROFLOXACIN
MG/100 ML
AMERINET CHOICE CIPROFLOXACIN
MG/200 ML
CIPROFLOXACIN (SINGLE-DOSE,USP)
10 MG/ML
A-HYDROCORT (SINGLE-DOSE) 100 MG
FOSPHENYTOIN SODIUM (USP2MLX25)
75 MG/ML
FOSPHENYTOIN SODIUM
(USP,10MLX10) 75 MG/ML
WATER FOR INJECTION
(FTV,25X10ML,PF)
WATER FOR INJECTION
(25X20ML,STERILE,PF)
WATER FOR INJECTION
(FTV,25X50ML,PF)
WATER FOR INJECTION
(FTV,25X100ML,PF)
SODIUM CHLORIDE
(VIAL,FLIPTOP,ADDITIVE) 0.9%
SODIUM CHLORIDE (25X10ML,PF,LATEXFREE) 0.9%
ADDITIVE) 0.9%
SODIUM CHLORIDE
(VIAL,FLIPTOP,ADDITIVE) 0.9%
EPINEPHRINE HCL (18GX3-1/2,10X10ML)
0.1 MG/ML
DEXTROSE (LIFESHEILD, 18G1-1/2) 50%
1%
ATROPINE SULFATE (LIFESHIELD,LATEX
FREE) 0.1 MG/ML
ATROPINE SULFATE (LIFESHIELD,21GX1
1/2) 0.1 MG/ML
Page 88 of 374
200 ML FC
IV
ML
200 MG
0.01
10/25/2006
99/99/9999
200 ML
100 ML
20 ML
50 ML
20 ML
FC
VL
VL
VL
VL
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
200 MG
1 EA
1 EA
1 EA
1 EA
0.01
1
1
1
1
03/02/2006
03/22/2006
03/22/2006
03/22/2006
01/31/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
02/01/2008
20 ML VL
IV
5 ML AM EP
2 ML AM EP
ML
1 EA
12/01/2007
99/99/9999
ML
ML
10 MG
10 MG
1
1
11/21/2005
09/06/2005
99/99/9999
99/99/9999
2 ML VL
IJ
ML
1 MG
12/26/2006
99/99/9999
2 ML VL
IJ
ML
1 MG
08/24/2007
99/99/9999
2 ML VL
IJ
ML
1 MG
12/26/2006
99/99/9999
2 ML VL
20 ML VL
IJ
IJ
ML
ML
1 MG
1 MG
2
2
10/01/2007
12/26/2006
99/99/9999
99/99/9999
50 ML FC
IV
ML
1 MG
0.64
02/01/2007
99/99/9999
20 ML VL
IV
ML
200 MG
0.05
08/29/2006
99/99/9999
20 ML AM IJ
ML
10 MG
1.5
02/06/2006
99/99/9999
200 ML FC
IV
ML
200 MG
0.01
03/19/2008
99/99/9999
100 ML FC
IV
ML
200 MG
0.01
03/19/2008
99/99/9999
100 ML FC
IV
ML
200 MG
0.01
05/19/2008
99/99/9999
200 ML FC
IV
ML
200 MG
0.01
05/19/2008
99/99/9999
40 ML VL
IV
ML
200 MG
0.05
08/29/2006
99/99/9999
10 EA VL
IJ
EA
100 MG
06/27/2006
99/99/9999
2 ML VL
IJ
ML
50 MG
1.5
08/05/2007
99/99/9999
10 ML VL
IJ
ML
50 MG
1.5
08/05/2007
99/99/9999
250 ML GC IV
ML
1 EA
03/09/2005
99/99/9999
500 ML GC IV
ML
1 EA
04/04/2005
99/99/9999
10 ML VL
IV
ML
10 ML
0.1
08/18/2005
99/99/9999
20 ML VL
IV
ML
10 ML
0.1
06/16/2005
99/99/9999
50 ML VL
IV
ML
10 ML
0.1
08/05/2005
99/99/9999
100 ML VL
IV
ML
10 ML
0.1
08/03/2005
99/99/9999
10 ML VL
IV
ML
10 ML
0.1
04/22/2005
99/99/9999
10 ML VL
IV
ML
10 ML
0.1
07/15/2005
99/99/9999
20 ML VL
IV
ML
10 ML
0.1
02/23/2005
99/99/9999
50 ML VL
IV
ML
10 ML
0.1
02/14/2005
99/99/9999
10 ML SR
IJ
ML
1 ML
09/23/2005
99/99/9999
1 ML SR
IV
ML
1 EA
12/08/2005
99/99/9999
5 ML SR
IJ
ML
10 MG
12/01/2005
99/99/9999
5 ML SR
EP
ML
10 MG
08/23/2005
99/99/9999
5 ML SR
IJ
ML
0.3 MG
0.33333
08/18/2005
12/31/2009
10 ML SR
IJ
ML
0.3 MG
0.33333
11/14/2005
12/31/2009
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

00409-5086-51
J0713
00409-5092-16
00409-5092-52
00409-5093-11
J0713
J0713
J0713

00409-5093-51
J0713
00409-5684-01
J2920
00409-5685-02
00409-5820-01
00409-5820-01
J2930
Q4076
J1265

00409-5921-01
J0280
00409-5922-01
J0280
00409-6028-04
J2271
00409-6030-04
J2175
00409-6062-02
J2270
00409-6062-11
J2270
00409-6102-02
J1940
00409-6102-04
J1940
00409-6102-10
J1940
00409-6138-03
A4217
00409-6138-22
A4217
00409-6139-03
A4217
00409-6139-22
A4217
00409-6177-14
J2270
00409-6179-14
J2270
00409-6476-44
J1364
00409-6478-44
J1364
00409-6482-01
J1364
00409-6509-01
J3370
00409-6509-49
J3370
00409-6533-01
J3370
00409-6533-49
J3370
00409-6533-61
J3370
00409-6534-01
J3370
00409-6534-49
J3370
00409-6535-01
J3370
00409-6535-49
00409-6629-02
J3370
J0330

EPINEPHRINE HCL (LIFE,21GX1-1/2) 0.1

MG/ML
TAZICEF (LATEX-FREE) 1 GM
NOVAPLUS TAZICEF 1 GM
TAZICEF 2 GM
TAZICEF (BULK PHARMACY) 6 GM
NOVAPLUS TAZICEF (BULK PACKAGE) 6
GM
TAZICEF (SINGLE-DOSE ADD-VANTAGE)
1 GM
TAZICEF (ADD-VANTAGE,USP) 2 GM
NOVAPLUS TAZICEF (ADD-VANTAGE) 2
GM
40 MG
125 MG
AMINOPHYLLINE
(VIAL,FLIPTOP,25X10ML) 25 MG/ML
MORPHINE SULFATE (SDV,30MLX10) 5
MG/ML
MEPERIDINE HYDROCHLORIDE
(SDV,USP,10X30ML) 10 MG/ML
MORPHINE SULFATE IN 5% DEXTROSE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
SODIUM CHLORIDE (USP,AQUALITE,PF)
0.9%
SODIUM CHLORIDE (AQUALITE,
24X250ML,PF) 0.9%
WATER FOR IRRIGATION (AQUALITE,
U.S.P.)
WATER FOR IRRIGATION (AQUALITE,
U.S.P.)
MORPHINE SULFATE (ADD-VANTAGE,
10X4ML) 25 MG/ML
ERYTHROCIN LACTOBIONATE (ADDVANTAGE VIAL,PF) 500 MG
ERYTHROCIN LACTOBIONATE (ADDVANTAGE VIAL) 1 GM
VANCOMYCIN HCL (BULK,LATEX-FREE)
5 GM
VANCOMYCIN HCL NOVAPLUS (BULK) 5
GM
VANCOMYCIN HCL
AMERINET CHOICE VANCOMYCIN
HYDROCHLORIDE (SDV,FLIPTOP,USP) 1
GM
VANCOMYCIN HCL (ADDVANTAGE,LATEX-FREE) 500 MG
VANCOMYCIN HCL NOVATION (ADDVANTAGE,10X10) 500 MG
VANCOMYCIN HYDROCHLORIDE (ADDVANTAGE,LATEX-FREE) 1 GM
VANCOMYCIN HYDROCHLORIDE
NOVATION (ADD-VANTAGE,LATEXFREE) 1 GM
QUELICIN (VIAL,FLIPTOP) 20 MG/ML
Page 89 of 374
IJ
IJ
IJ
IJ
IJ
IV
ML
EA
EA
EA
EA
EA
1 ML
500 MG
500 MG
500 MG
500 MG
500 MG
1
2
2
4
4
12
12/23/2005
10/24/2005
10/04/2005
12/05/2005
10/04/2005
04/19/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
500 MG
12
10/04/2005
99/99/9999
1 EA VL
1 EA VL
1 EA VL
IJ
IJ
IJ
EA
EA
EA
500 MG
500 MG
500 MG
2
2
4
05/02/2006
06/27/2006
04/03/2006
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
500 MG
10/01/2006
99/99/9999
1 EA VL
IJ
EA
40 MG
11/01/2005
99/99/9999
1 EA VL
5 ML VL
5 ML VL
IJ
IV
IV
EA
ML
ML
125 MG
40 MG
40 MG
1
1
1
11/01/2005
08/23/2005
01/01/2006
99/99/9999
12/31/2005
99/99/9999
10 ML VL
IV
ML
250 MG
0.1
04/25/2005
99/99/9999
20 ML VL
IV
ML
250 MG
0.1
12/24/2004
99/99/9999
30 ML VL
IV
ML
100 MG
0.05
03/23/2007
99/99/9999
30 ML VL
IV
ML
100 MG
0.1
01/02/2007
99/99/9999
250 ML GC IV
ML
10 MG
0.1
01/10/2006
99/99/9999
100 ML GC IV
ML
10 MG
0.1
07/22/2005
99/99/9999
99/99/9999
2 ML VL
IJ
ML
20 MG
0.5
02/18/2005
4 ML VL
IJ
ML
20 MG
0.5
02/21/2005
99/99/9999
10 ML VL
IJ
ML
20 MG
0.5
03/24/2005
99/99/9999
500 ML PC
IR
ML
500 ML
0.002
06/01/2005
99/99/9999
250 ML PC
IR
ML
500 ML
0.002
09/01/2005
99/99/9999
500 ML PC
IR
ML
500 ML
0.002
05/09/2005
99/99/9999
250 ML PC
IR
ML
500 ML
0.002
05/04/2005
99/99/9999
4 ML VL
IJ
ML
10 MG
2.5
07/14/2005
99/99/9999
10 ML VL
IJ
ML
10 MG
2.5
09/01/2005
99/99/9999
1 EA VL
IV
EA
500 MG
03/10/2006
99/99/9999
1 EA VL
IV
EA
500 MG
01/10/2007
99/99/9999
1 EA VL
IV
EA
500 MG
05/23/2005
99/99/9999
1 EA VL
IV
GM
500 MG
06/06/2005
99/99/9999
1 EA VL
IV
GM
500 MG
06/03/2005
99/99/9999
1 EA VL
IV
EA
500 MG
03/15/2005
99/99/9999
1 EA VL
IV
EA
500 MG
04/06/2005
99/99/9999
1 EA VL
IV
EA
500 MG
10/01/2007
99/99/9999
1 EA VL
IV
EA
500 MG
06/08/2005
99/99/9999
1 EA VL
IV
EA
500 MG
06/10/2005
99/99/9999
1 EA VL
IV
EA
500 MG
03/29/2005
99/99/9999
1 EA VL
10 ML VL
IV
IV
EA
ML
500 MG
20 MG
2
1
04/06/2005
04/25/2005
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
SR
VL
VL
VL
VL
VL
Billing Units
10 ML
1 EA
1 EA
1 EA
1 EA
1 EA

Package
NDC Package Type
J0170
J0713
J0713
J0713
J0713
J0713
NDC Label
HCPCS Description
00409-4921-34
00409-5082-16
00409-5082-52
00409-5084-11
00409-5084-51
00409-5086-11
NDC Package Measure
12/23/2005
10/24/2005
10/4/2005
12/5/2005
10/4/2005
4/19/2006
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-6629-61
J0330
00409-6635-01
J3480
00409-6636-01
J3480
00409-6648-02
J7799
00409-6651-06
J3480
00409-6653-05
J3480
00409-6657-73
J7799
00409-6660-75
J7799
00409-6727-23
J3475
00409-6728-03
J3475
00409-6729-03
J3475
00409-6729-09
J3475
00409-6729-23
J3475
00409-6729-24
J3475
00409-6730-13
00409-6778-02
00409-6778-62
00409-6779-02
00409-6780-02
J3475
J2060
J2060
J2060
J2060
4/3/2006
1/27/2006
6/28/2005
1/5/2006
12/29/2005
00409-6781-02
00409-6940-03
J2060
J3520

00409-6970-10
J0330
00409-7074-26
J3480
00409-7075-14
J3480
00409-7075-26
J3480
00409-7076-26
J3480
00409-7077-14
J3480
00409-7077-26
J3480
00409-7100-02
J7060
00409-7100-66
J7060
00409-7100-67
J7060
00409-7101-02
J7050
00409-7101-66
A4216
00409-7101-67
J7050
00409-7111-09
J7120
00409-7113-09
J7120
00409-7115-09
J3480
00409-7116-09
J3480
00409-7118-07
00409-7119-07
A4217
J7799


AMERINET CHOICE SUCCINYLCHOLINE

CHLORIDE (USP,25X10ML,MD FLIPTOP)
20 MG/ML
POTASSIUM CHLORIDE
(FTV,25X5ML,10ML VIAL) 2 MEQ/ML
POTASSIUM CHLORIDE
(FTV,30ML,LATEX-FREE) 2 MEQ/ML
DEXTROSE (VIAL,FLIPTOP,ADDITIVE)
50%
POTASSIUM CHLORIDE
(VIAL,FLIPTOP,20ML) 2 MEQ/ML
POTASSIUM CHLORIDE
(FTV,30ML,LATEX-FREE) 2 MEQ/ML
SODIUM CHLORIDE
(FTV,50MEQ,25X20ML) 14.6%
MAGNESIUM SULFATE IN DEXTROSE
(SINGLE DOSE,LATEX-FREE) 5%-2
GM/100 ML
MAGNESIUM SULFATE
CONTAINER) 40 MG/ML
MAGNESIUM SULFATE
MAGNESIUM SULFATE (SINGLE
DOSE,LATEX-FREE) 40 MG/ML
MAGNESIUM SULFATE (LATEX-FREE) 80
MG/ML
LORAZEPAM (U.S.P., 10X10ML) 4 MG/ML
ENDRATE (25X20ML) 150 MG/ML
QUELICIN (FTV,25X10ML,20ML VIAL) 100
MG/ML
POTASSIUM CHLORIDE
(24X50ML,LATEX-FREE) 10 MEQ/50 ML
POTASSIUM CHLORIDE
(PC,24X100ML,LATEX-FREE) 20 MEQ/100
ML
POTASSIUM CHLORIDE (USP,100MLX24)
30 MEQ/100 ML
POTASSIUM CHLORIDE
(24X50ML,LATEX-FREE) 20 MEQ/50 ML
POTASSIUM CHLORIDE (HIGHLY
CONC.,24X100ML) 40 MEQ/100 ML
5%
5%
SODIUM CHLORIDE (ADDVANTAGE,24X250ML,PF) 0.9%
SODIUM CHLORIDE (ADDVANT,LIFECARE) 0.9%
SODIUM CHLORIDE (50X100ML, ADDVANTAGE) 0.9%
(12X1000ML,LATEX-FREE)
DEXTROSE/LACTATED
RINGERS/POTASSIUM CHLORIDE (5%
DEXTROSE,LATEX-FREE)
CHLORIDE (12X1000ML,LATEX-FREE) 2
MEQ/100 ML-0.9%
CHLORIDE (12X1000ML,LATEX-FREE) 4
MEQ/100 ML-0.9%
PACKAGE,PF)
DEXTROSE (2000MLX6) 50%
Page 90 of 374
20 MG
10 ML VL
IJ
ML
04/20/2006
99/99/9999
5 ML VL
IV
ML
2 MEQ
09/21/2005
99/99/9999
15 ML VL
IV
ML
2 MEQ
08/09/2005
99/99/9999
50 ML VL
IV
ML
1 EA
03/29/2005
99/99/9999
10 ML VL
IV
ML
2 MEQ
11/10/2005
99/99/9999
20 ML VL
IV
ML
2 MEQ
08/09/2005
99/99/9999
20 ML VL
IV
ML
1 EA
10/14/2005
99/99/9999
40 ML VL
IV
ML
1 EA
07/26/2005
99/99/9999
100 ML FC
IV
ML
500 MG
0.02
09/20/2005
99/99/9999
500 ML FC
IV
ML
500 MG
0.04
12/01/2006
99/99/9999
500 ML PC
IV
ML
500 MG
0.08
08/16/2005
99/99/9999
1000 ML PC
IV
ML
500 MG
0.08
09/22/2005
99/99/9999
100 ML PC
IV
ML
500 MG
0.08
10/06/2005
99/99/9999
50 ML FC
IV
ML
500 MG
0.08
12/01/2006
99/99/9999
50 ML
1 ML
1 ML
10 ML
10 ML
IV
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
500 MG
2 MG
2 MG
2 MG
2 MG
0.16
1
1
2
1
04/03/2006
01/27/2006
06/28/2005
01/05/2006
12/29/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 ML VL IJ
20 ML AM IV
ML
ML
2 MG
150 MG
2
1
01/23/2006
10/17/2007
99/99/9999
99/99/9999
20 MG
FC
VL
VL
VL
VL
10 ML VL
IV
ML
09/30/2005
99/99/9999
100 ML PC
IV
ML
2 MEQ
0.05
04/25/2005
99/99/9999
50 ML PC
IV
ML
2 MEQ
0.1
06/08/2005
99/99/9999
100 ML FC
IV
ML
2 MEQ
0.1
04/11/2005
99/99/9999
100 ML FC
IV
ML
2 MEQ
0.15
02/08/2006
99/99/9999
50 ML FC
IV
ML
2 MEQ
0.2
06/28/2005
99/99/9999
100 ML FC
IV
ML
2 MEQ
0.2
05/04/2005
99/99/9999
250 ML FC
IV
ML
500 ML
0.002
07/22/2005
99/99/9999
50 ML FC
IV
ML
500 ML
0.002
08/17/2005
99/99/9999
100 ML FC
IV
ML
500 ML
0.002
09/14/2005
99/99/9999
250 ML FC
IV
ML
250 ML
0.004
07/08/2005
99/99/9999
50 ML FC
IV
ML
10 ML
0.1
07/28/2005
99/99/9999
100 ML PC
IV
ML
250 ML
0.004
08/24/2005
99/99/9999
1000 ML FC
IV
ML
1000 ML
0.0005
08/05/2005
99/99/9999
1000 ML FC
IV
ML
1000 ML
0.0005
02/21/2005
99/99/9999
1000 ML FC
IV
ML
0.01
04/06/2005
99/99/9999
1000 ML FC
IV
ML
2000 ML FC
2000 ML FC
IR
IV
ML
ML
2 MEQ
2 MEQ
500 ML
1 EA
0.02
06/22/2005
99/99/9999
0.002
1
08/16/2005
05/27/2006
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-7120-07
J7799
00409-7132-02
J7799
00409-7132-66
J7799
00409-7132-67
J7799
00409-7138-09
A4217
00409-7138-36
A4217
00409-7139-09
00409-7139-36
00409-7241-01
A4217
A4217
J0170

00409-7332-01
J0696
00409-7333-04
J0696
00409-7333-49
J0696
00409-7334-10
J0696
00409-7335-03
J0696
00409-7336-04
J0696
00409-7336-49
00409-7337-01
00409-7338-01
J0696
J0696
J0696

00409-7385-01
J0280
00409-7386-01
J0280
00409-7418-03
J7100
00409-7419-03
J7100
00409-7444-01
J3490
00409-7445-01
00409-7447-16
J3490
J3490

00409-7517-16
J7799
00409-7551-01
J0670
00409-7620-03
J1644
00409-7620-59
J1644
00409-7650-62
J1644
00409-7651-03
J1644
00409-7651-62
J1644
00409-7665-03
J2810
00409-7665-09
J2810
00409-7666-03
J2810
5/27/2006
00409-7666-62
J2810
00409-7668-23
J2810
00409-7677-13
J2810
00409-7705-62
00409-7712-09
J2810
J7799

DEXTROSE (6X2000ML,LATEX-FREE)
70%
SODIUM CHLORIDE (USP,ADDVANTAGE) 0.45%
SODIUM CHLORIDE
SODIUM CHLORIDE
W/HANGER,PF)
WATER FOR IRRIGATION (AQUALITE)
EPINEPHRINE HCL (AMP) 1 MG/ML
CEFTRIAXONE (USP,FLIPTOP VIAL) 1
GM
CEFTRIAXONE (USP,ADD-VANTAGE
VIAL) 1 GM
CEFTRIAXONE NOVAPLUS (USP,ADDVANTAGE VIAL) 1 GM
CEFTRIAXONE (USP,BULK PACK) 10 GM
CEFTRIAXONE (USP,FLIPTOP VIAL) 2
GM
CEFTRIAXONE (USP,ADD-VANTAGE
VIAL) 2 GM
CEFTRIAXONE NOVAPLUS (USP,ADDVANTAGE VIAL) 2 GM
MG/ML
MG/ML
LMD IN DEXTROSE (12X500ML,LATEXFREE) 10%-5%
LMD W/0.9% SODIUM CHLORIDE (LATEXFREE) 10%-0.9%
CIMETIDINE HCL (LATEX-FREE) 150
MG/ML
CIMETIDINE HCL (VIAL,FLIPTOP,LATEXFREE) 150 MG/ML
CIMETIDINE HCL 300 MG/50 ML
IV
ML
1 EA
07/06/2005
99/99/9999
250 ML FC
IV
ML
1 EA
05/26/2006
99/99/9999
50 ML FC
IV
ML
1 EA
09/12/2005
99/99/9999
100 ML PC
IV
ML
1 EA
11/14/2005
99/99/9999
1000 ML FC
IR
ML
500 ML
0.002
05/11/2005
99/99/9999
1500 ML PC
IR
ML
500 ML
0.002
06/09/2005
99/99/9999
1000 ML PC IR
1500 ML PC IR
1 ML AM IJ
ML
ML
ML
500 ML
500 ML
1 ML
0.002
0.002
1
03/02/2005
05/04/2005
09/13/2005
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
250 MG
07/20/2005
99/99/9999
1 EA VL
IJ
EA
250 MG
07/20/2005
99/99/9999
1 EA VL
IJ
EA
250 MG
07/20/2005
99/99/9999
1 EA VL
IJ
EA
250 MG
40
07/20/2005
99/99/9999
1 EA VL
IJ
EA
250 MG
07/20/2005
99/99/9999
1 EA VL
IJ
EA
250 MG
07/20/2005
99/99/9999
1 EA VL
1 EA VL
1 EA VL
IJ
IJ
IJ
EA
EA
EA
250 MG
250 MG
250 MG
8
1
2
07/20/2005
07/20/2005
07/20/2005
99/99/9999
99/99/9999
99/99/9999
10 ML AM IV
ML
250 MG
0.1
12/29/2005
99/99/9999
20 ML AM IV
ML
250 MG
0.1
11/29/2005
99/99/9999
500 ML FC
IV
ML
500 ML
0.002
02/14/2006
99/99/9999
500 ML FC
IV
ML
500 ML
0.002
08/09/2005
99/99/9999
2 ML VL
IJ
ML
1 EA
04/03/2006
99/99/9999
8 ML VL
50 ML FC
IJ
IV
ML
ML
1 EA
1 EA
1
1
11/10/2005
01/09/2006
99/99/9999
99/99/9999
IV
ML
1 EA
12/07/2005
99/99/9999
IJ
ML
10 ML
0.1
05/05/2008
99/99/9999
IV
ML
1000 U
0.002
04/05/2005
99/99/9999
IV
ML
1000 U
0.002
04/13/2005
99/99/9999
IV
ML
1000 U
0.1
07/06/2005
99/99/9999
IV
ML
1000 U
0.05
06/28/2005
99/99/9999
IV
ML
1000 U
0.05
07/28/2005
99/99/9999
IV
ML
40 MG
0.02
12/29/2005
99/99/9999
IV
ML
40 MG
0.02
04/25/2005
99/99/9999
IV
ML
40 MG
0.04
05/27/2006
6/12/2009
IV
ML
40 MG
0.04
01/27/2006
99/99/9999
IV
ML
40 MG
0.05
02/06/2007
99/99/9999
IV
ML
40 MG
0.1
08/10/2006
99/99/9999
IV
IV
ML
ML
40 MG
1 EA
0.08
1
05/27/2006
08/19/2005
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
2000 ML FC
DEXTROSE (ANSYR II,LATEX-FREE) 50%

50 ML SR
MEPIVACAINE HYDROCHLORIDE
(50X1.8ML,DENTALCARPULE) 3%
1.8 ML CT
(18X500ML,LATEX-FREE) 200 U/100 ML0.9%
500 ML FC
1000 ML FC
(24X250ML,LATEX-FREE) 10000 U/100 ML
0.45%
250 ML FC
500 ML FC
250 ML FC
500 ML GC
1000 ML PC
THEOPHYLLINE IN DEXTROSE (SINGLE
DOSE,USP) 5%-160 MG/100 ML
500 ML FC
THEOPHYLLINE IN DEXTROSE
ML
250 ML FC
(24X100ML,SINGLE-DOSE) 5%-200
MG/100 ML
100 ML FC
DEXTROSE/THEOPHYLLINE
(50MLX24,DEHP,LATEX-FREE) 5%-200
MG/50 ML
50 ML FC
(USP,250MLX24) 5%-320 MG/100 ML
250 ML FC
1000 ML FC
Page 91 of 374
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-7713-09
00409-7714-03
J7799
J7799
00409-7715-02
J7799
00409-7715-03
J7799
00409-7730-20
J7799
00409-7730-36
J7799
00409-7730-37
J7799
00409-7760-03
J1644
00409-7761-03
J1644
00409-7793-23
J1644
00409-7793-62
J1644
00409-7794-62
J1644
(LIFECARE,12X250ML) 5%-80 MG/100 ML
Q4076
00409-7808-22
J1265
00409-7808-24
Q4076
00409-7808-24
J1265
00409-7809-22
Q4076
00409-7809-22
J1265
00409-7809-24
Q4076
00409-7809-24
J1265
00409-7810-22
Q4076
00409-7810-22
J1265
00409-7811-24
J3490
00409-7811-37
J3490
00409-7879-13
J1580
00409-7881-13
J1580
00409-7883-13
J1580
00409-7884-23
J1580
00409-7886-23
J1580
00409-7889-23
J1580
00409-7918-19
00409-7922-02
J7799
J7060
(LIFECARE,12X250ML) 5%-80 MG/100 ML
ML
ML
ML
ML
(LIFECARE,12X500ML) 5%-100 MG/100
ML
(LIFECARE,12X500ML) 5%-100 MG/100
ML
(LIFECARE,12X250ML) 5%-320 MG/100
ML
(LIFECARE,12X250ML) 5%-320 MG/100
ML
METRONIDAZOLE (S.D.V.,LATEX-FREE)
500 MG/100 ML
METRONIDAZOLE (LIFECARE,QUAD
PACK) 500 MG/100 ML
GENTAMICIN SULFATE IN SODIUM
CHLORIDE (LATEX-FREE) 1.2 MG/ML0.9%
CHLORIDE (LIFECARE, 24X50ML) 1.4
MG/ML-0.9%
MG/ML-0.9%
CHLORIDE (LIFECARE,24X100ML) 80
MG/100 ML-0.9%
GENTAMICIN SULFATE IN SODIUM
MG/100 ML-0.9%
MG/100 ML-0.9%
70%
Page 92 of 374
IV
IV
ML
ML
1 EA
1 EA
1
1
04/07/2006
08/30/2005
99/99/9999
99/99/9999
IV
ML
1 EA
11/14/2005
99/99/9999
IV
ML
1 EA
09/16/2005
99/99/9999
IV
ML
1 EA
07/27/2005
99/99/9999
IV
ML
1 EA
07/11/2005
99/99/9999
IV
ML
1 EA
09/16/2005
99/99/9999
IV
ML
1000 U
0.04
08/30/2005
99/99/9999
IV
ML
1000 U
0.05
07/22/2005
99/99/9999
100 ML FC
IV
ML
1000 U
0.1
01/25/2006
99/99/9999
250 ML FC
IV
ML
1000 U
0.1
10/14/2005
99/99/9999
250 ML FC
IV
ML
1000 U
0.05
06/12/2006
99/99/9999
250 ML FC
IV
ML
40 MG
0.02
06/17/2005
12/31/2005
250 ML FC
IV
ML
40 MG
0.02
01/01/2006
99/99/9999
500 ML FC
IV
ML
40 MG
0.02
08/30/2005
12/31/2005
500 ML FC
IV
ML
40 MG
0.02
01/01/2006
99/99/9999
250 ML PC
IV
ML
40 MG
0.04
04/25/2005
12/31/2005
250 ML PC
IV
ML
40 MG
0.04
01/01/2006
99/99/9999
500 ML FC
IV
ML
40 MG
0.025
10/10/2005
12/31/2005
500 ML FC
IV
ML
40 MG
0.025
01/01/2006
99/99/9999
250 ML FC
IV
ML
40 MG
0.08
08/04/2005
12/31/2005
250 ML FC
IV
ML
40 MG
0.08
01/01/2006
99/99/9999
100 ML FC
IV
ML
1 EA
08/31/2005
99/99/9999
100 ML FC
IV
ML
1 EA
09/22/2005
99/99/9999
50 ML FC
IV
ML
80 MG
0.015
03/31/2006
99/99/9999
50 ML FC
IV
ML
80 MG
0.0175
01/23/2006
99/99/9999
50 ML FC
IV
ML
80 MG
0.02
01/09/2006
99/99/9999
100 ML FC
IV
ML
80 MG
0.01
07/06/2005
99/99/9999
100 ML FC
IV
ML
80 MG
0.01125
01/27/2006
99/99/9999
100 ML FC
IV
ML
80 MG
0.0125
09/20/2005
99/99/9999
500 ML PC
250 ML FC
IV
IV
ML
ML
1 EA
500 ML
1
0.002
07/08/2005
04/05/2005
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure
MANNITOL (USP,LATEX-FREE) 10%

1000 ML FC
500 ML FC
MANNITOL (FLEX
CONTAINER,24X250ML) 20%
250 ML FC
MANNITOL (FLEX
CONTAINER,12X500ML) 20%
500 ML FC
SODIUM CHLORIDE (QUAD-PK,48X25ML)
0.45%
25 ML FC
50 ML FC
100 ML FC
500 ML FC
(24X500ML,LATEX-FREE) 5%-5000 U/100
ML
500 ML FC
HEPARIN SODIUM IN DEXTROSE
(USP,SINGLE DOSE) 5%-10000 U/100 ML
(24X250ML,LATEX-FREE) 5%-10000
U/100 ML
HEPARIN SODIUM IN DEXTROSE
(24X250ML,USP,LATEX-FREE) 5%-5000
U/100 ML
00409-7808-22

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
FC
FC
FC
FC
IV
IV
IV
IV
ML
ML
ML
ML
500 ML
500 ML
500 ML
500 ML
0.002
0.002
0.002
0.002
10/31/2006
08/05/2005
06/09/2005
06/17/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/31/2006
8/5/2005
6/9/2005
6/17/2005

CF
HCPCS Amount #1
00409-7923-23
J7060
DEXTROSE (48X100ML,LATEX-FREE) 5%
100 ML FC
IV
ML
500 ML
0.002
07/15/2005
99/99/9999
00409-7923-36
00409-7923-37
J7060
J7060

DEXTROSE (LIFECARE,QUAD PACK) 5%

(24X250ML,LATEX-FREE) 5%-0.225%
(LIFECARE, PLASTIC) 5%-0.225%
(LIFECARE, 24X250ML) 5%-0.3%
(LIFECARE,PLASTIC) 5%-0.3%
(12X1000ML) 5%-0.3%
(24X500ML,LATEX-FREE) 5%-0.45%
(12X1000ML, LIFECARE) 5%-0.45%
DEXTROSE/SODIUM CHLORIDE (VISIV
CONTAINER) 5%-0.45%
DEXTROSE/SODIUM CHLORIDE (VISIV
CONTAINER) 5%-0.45%
DEXTROSE 5% IN RINGERS (LATEXFREE)
DEXTROSE 5% IN RINGERS
(LIFECARE,LATEX-FREE)
DEXTROSE (24X250ML,LIFECARE) 10%
10%
10%
(LIFECARE,24X500ML) 5%-0.4%
(LIFECARE,12X250ML) 5%-0.4%
DEXTROSE (1000ML CONTAINER) 20%
50%
DEXTROSE (2000ML BAG,6X1000ML)
50%
40%
DEXTROSE (1000ML CONTAINER) 10%
DEXTROSE AND SODIUM CHLORIDE
(250MLX24,USP,LATEX-FREE) 5%-0.9%
(24X500ML,LATEX-FREE) 5%-0.9%
(LIFECARE,12X1000ML) 5%-0.9%
LACTATED RINGER'S
(LIFECARE,24X500ML)
LACTATED RINGER'S (VISIV
CONTAINER)
LACTATED RINGER'S (VISIV
CONTAINER)
CONTAINER,PF) 0.9%
50 ML FC
100 ML FC
IV
IV
ML
ML
500 ML
500 ML
0.002
0.002
04/05/2005
03/16/2005
99/99/9999
99/99/9999
250 ML FC
IV
ML
1 EA
07/28/2005
99/99/9999
500 ML FC
IV
ML
1 EA
07/28/2005
99/99/9999
1000 ML FC
IV
ML
1 EA
12/21/2005
99/99/9999
250 ML FC
IV
ML
1 EA
06/29/2005
99/99/9999
00409-7924-02
J7799
00409-7924-03
J7799
00409-7924-09
J7799
00409-7925-02
J7799
00409-7925-03
J7799
00409-7925-09
J7799
00409-7926-02
J7799
00409-7926-03
J7799
00409-7926-09
J7799
00409-7926-30
J7799
00409-7926-48
J7799
00409-7929-03
J7120
00409-7929-09
00409-7930-02
J7120
J7799

00409-7930-03
J7799
00409-7930-09
J7799
00409-7931-24
J2001
00409-7931-32
00409-7935-19
J2001
J7799

00409-7936-19
J7799
00409-7936-29
J7799
00409-7937-19
00409-7938-19
J7799
J7799
00409-7939-32
J2001
00409-7941-02
J7042
00409-7941-03
J7042
00409-7941-09
J7042
00409-7953-02
J7120
00409-7953-03
J7120
00409-7953-09
J7120
00409-7953-30
J7120
00409-7953-48
J7120
00409-7972-05
A4217
00409-7972-07
A4217
Page 93 of 374
500 ML FC
IV
ML
1 EA
09/16/2005
99/99/9999
1000 ML FC
IV
ML
1 EA
03/17/2006
99/99/9999
250 ML FC
IV
ML
1 EA
08/30/2005
99/99/9999
500 ML FC
IV
ML
1 EA
06/07/2005
99/99/9999
1000 ML FC
IV
ML
1 EA
08/25/2005
99/99/9999
500 ML FC
IV
ML
1 EA
04/14/2006
99/99/9999
1000 ML FC
IV
ML
1 EA
04/14/2006
99/99/9999
500 ML FC
IV
ML
1000 ML
0.0005
06/09/2005
99/99/9999
1000 ML FC
250 ML FC
IV
IV
ML
ML
1000 ML
1 EA
0.0005
1
02/07/2005
07/05/2005
99/99/9999
99/99/9999
500 ML FC
IV
ML
1 EA
01/12/2005
99/99/9999
1000 ML FC
IV
ML
1 EA
03/16/2005
99/99/9999
500 ML PC
IV
ML
10 MG
0.4
05/18/2005
99/99/9999
250 ML FC
500 ML FC
IV
IV
ML
ML
10 MG
1 EA
0.4
1
09/16/2005
09/12/2005
99/99/9999
99/99/9999
500 ML PC
IV
ML
1 EA
06/24/2005
99/99/9999
1000 ML FC
IV
ML
1 EA
10/28/2005
99/99/9999
500 ML FC
500 ML PC
IV
IV
ML
ML
1 EA
1 EA
1
1
08/24/2005
09/29/2005
99/99/9999
99/99/9999
250 ML FC
IV
ML
10 MG
250 ML FC
IV
ML
5%
0.8
01/11/2006
99/99/9999
0.002
05/27/2006
99/99/9999
500 ML FC
IV
ML
5%
0.002
09/20/2005
99/99/9999
1000 ML FC
IV
ML
5%
0.002
08/08/2005
99/99/9999
250 ML FC
IV
ML
1000 ML
0.001
03/09/2005
99/99/9999
500 ML PC
IV
ML
1000 ML
0.001
05/20/2005
99/99/9999
1000 ML PC
IV
ML
1000 ML
0.001
05/18/2005
99/99/9999
500 ML FC
IV
ML
1000 ML
0.001
04/14/2006
99/99/9999
1000 ML FC
IV
ML
1000 ML
0.001
04/14/2006
99/99/9999
1000 ML FC
IR
ML
500 ML
0.002
09/01/2005
99/99/9999
2000 ML FC
IR
ML
500 ML
0.002
04/05/2005
99/99/9999
500 ML
150 ML
50 ML
25 ML
J7060
J7060
J7060
J7060
Prior End Date #3
00409-7922-55
00409-7922-61
00409-7923-13
00409-7923-20
Prior Start Date #3
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
02/25/2005
02/21/2005
04/14/2006
04/14/2006
09/01/2005
Prior End Date #2
0.002
0.002
0.002
0.002
0.002
DEXTROSE (VISIV CONTAINER) 5%
DEXTROSE (VISIV CONTAINER) 5%
Prior Start Date #2
500 ML
500 ML
500 ML
500 ML
500 ML

End Date #1
ML
ML
ML
ML
ML
2/25/2005
2/21/2005
4/14/2006
4/14/2006
9/1/2005
Start Date #1
IV
IV
IV
IV
IV
J7060
J7060
J7060
J7060
J7060
HCPCS Measure #1
FC
FC
FC
FC
FC
00409-7922-03
00409-7922-09
00409-7922-30
00409-7922-48
00409-7922-53
Billing Units
NDC Package Type
NDC Package Measure

Package
500 ML
1000 ML
500 ML
1000 ML
250 ML
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00409-7972-08
A4217
00409-7973-05
A4217
00409-7973-07
A4217
00409-7973-08
A4217
00409-7975-07
A4217
00409-7983-02
J7050
00409-7983-03
J7040
00409-7983-09
J7030
00409-7983-30
J7040
00409-7983-48
J7030
00409-7983-53
J7050
00409-7983-55
J7040
00409-7983-61
J7050
00409-7984-13
A4216
00409-7984-20
A4216
00409-7984-23
J7050
00409-7984-36
A4216
00409-7984-37
J7050
00409-7985-02
J7799
00409-7985-03
J7799
00409-7985-09
J7799
00409-7990-09
A4217
00409-8004-15
J7799
00409-9093-32
J3010
00409-9093-35
J3010
00409-9093-36
J3010
00409-9093-38
J3010
00409-9094-22
J3010
00409-9094-25
J3010
00409-9094-28
J3010
00409-9094-31
J3010
00409-9094-61
00409-9104-20
00409-9104-20
J3010
Q4076
J1265

00409-9137-05
J2001
00409-9629-05
J0460
00409-9630-05
00409-9631-04
00433-0433-05
00436-0280-70
J0460
J1940
J1212
J2550
00436-0525-04
Q0163

1/1/2002 6/21/2007 INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML

CONTAINER,PF)
WATER FOR IRRIGATION (FLEXIBLE,
CONTAINER,PF)
SODIUM CHLORIDE (USP,6X2000ML)
0.45%
SODIUM CHLORIDE
(LIFECARE,24X250ML,PF) 0.9%
SODIUM CHLORIDE
SODIUM CHLORIDE
SODIUM CHLORIDE (VISIV CONTAINER)
0.9%
SODIUM CHLORIDE (VISIV CONTAINER)
0.9%
PORTS,PC,LF) 0.9%
PORTS,PC,LF) 0.9%
SODIUM CHLORIDE
SODIUM CHLORIDE (48X50ML,PF,LATEXFREE) 0.9%
PACK,LF) 0.9%
SODIUM CHLORIDE
(LFCARE,QUAD,LF,80X50ML) 0.9%
SODIUM CHLORIDE
(LFCARE,QUAD,LF,80X100ML) 0.9%
SODIUM CHLORIDE
(LIFECARE,24X500ML) 0.45%
SODIUM CHLORIDE
(LIFECARE,12X1000ML) 0.45%
WATER FOR INJECTION
30%
FENTANYL CITRATE (10X2ML,LATEXFREE) 0.05 MG/ML
0.05 MG/ML
FENTANYL CITRATE (SINGLEDOSE,5X10ML) 0.05 MG/ML
FENTANYL CITRATE (5X20ML) 0.05
MG/ML
FENTANYL CITRATE
(FTV,25X2ML,LATEX-FREE) 0.05 MG/ML
FENTANYL CITRATE
FENTANYL CITRATE (25X10ML,FTV) 0.05
MG/ML
FENTANYL CITRATE (FTV,LATEX-FREE)
0.05 MG/ML
FENTANYL CITRATE (VIAL, FLIPTOP)
0.05 MG/ML
LIDOCAINE HCL (ANSYR,10X5ML,LATEXFREE) 1%
ATROPINE SULFATE (10X5ML) 0.1
MG/ML
SYRINGE) 0.05 MG/ML
FUROSEMIDE (PF) 10 MG/ML
RIMSO-50 50%
PENTAZINE (VIAL) 50 MG/ML
TUSSTAT 12.5 MG/5 ML
Page 94 of 374
3000 ML PC
IR
ML
500 ML
0.002
05/18/2005
99/99/9999
1000 ML FC
IR
ML
500 ML
0.002
03/16/2005
99/99/9999
2000 ML FC
IR
ML
500 ML
0.002
08/09/2005
99/99/9999
3000 ML FC
IR
ML
500 ML
0.002
07/14/2005
99/99/9999
2000 ML FC
IR
ML
500 ML
0.002
04/26/2006
99/99/9999
250 ML FC
IV
ML
250 ML
0.004
07/01/2005
99/99/9999
500 ML FC
IV
ML
500 ML
0.002
01/05/2005
99/99/9999
1000 ML FC
IV
ML
1000 ML
0.001
02/07/2005
99/99/9999
500 ML FC
IV
ML
500 ML
0.002
04/14/2006
99/99/9999
1000 ML FC
IV
ML
1000 ML
0.001
04/14/2006
99/99/9999
250 ML FC
IV
ML
250 ML
0.004
09/30/2005
99/99/9999
500 ML FC
IV
ML
500 ML
0.002
04/11/2005
99/99/9999
150 ML FC
IV
ML
250 ML
0.004
06/17/2005
99/99/9999
50 ML FC
IV
ML
10 ML
0.1
06/20/2005
99/99/9999
25 ML FC
IV
ML
10 ML
0.1
06/17/2005
99/99/9999
100 ML PC
IV
ML
250 ML
0.004
05/18/2005
99/99/9999
50 ML FC
IV
ML
10 ML
0.1
07/14/2005
99/99/9999
100 ML FC
IV
ML
250 ML
0.004
07/15/2005
99/99/9999
250 ML FC
IV
ML
1 EA
04/06/2005
99/99/9999
500 ML FC
IV
ML
1 EA
04/06/2005
99/99/9999
1000 ML FC
IV
ML
1 EA
11/24/2004
99/99/9999
1000 ML FC
IV
ML
500 ML
0.002
09/02/2005
99/99/9999
500 ML FC
IV
ML
1 EA
08/01/2005
99/99/9999
2 ML AM IJ
ML
0.1 MG
0.5
11/14/2005
99/99/9999
5 ML AM IJ
ML
0.1 MG
0.5
12/13/2005
99/99/9999
10 ML AM IJ
ML
0.1 MG
0.5
07/12/2006
99/99/9999
20 ML AM IJ
ML
0.1 MG
0.5
03/03/2006
99/99/9999
ML
0.1 MG
0.5
10/12/2005
99/99/9999
2 ML VL
IJ
5 ML VL
IJ
ML
0.1 MG
0.5
11/07/2005
99/99/9999
10 ML VL
IJ
ML
0.1 MG
0.5
02/14/2006
99/99/9999
20 ML VL
IJ
ML
0.1 MG
0.5
09/23/2005
99/99/9999
50 ML VL
10 ML VL
10 ML VL
IJ
IV
IV
ML
ML
ML
0.1 MG
40 MG
40 MG
0.5
1
1
12/30/2005
07/01/2005
01/01/2006
99/99/9999
12/31/2005
99/99/9999
5 ML SR
EP
ML
10 MG
06/30/2005
99/99/9999
5 ML SR
IJ
ML
0.3 MG
0.33333
04/26/2006
12/31/2009
IJ
IJ
IL
IJ
ML
ML
ML
ML
0.3 MG
20 MG
50 %
50 MG
0.16666
0.5
0.02
1
10/19/2004
04/21/2006
01/01/2002
01/01/2002
12/31/2009
99/99/9999
06/21/2007
10/01/2003
PO
ML
50 MG
0.05
01/01/2002
10/01/2003
5 ML
4 ML
50 ML
10 ML
SR
SR
BO
VL
120 ML EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00436-0525-16
Q0163
1/1/2002
00436-0525-28
Q0163
1/1/2002
00436-0580-04
Q0170
1/1/2002
00436-0580-16
Q0170
1/1/2002
00436-0580-28
00436-0702-10
00451-1500-08
00451-1500-16
Q0170
J3480
J7510
J7510
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00451-2201-04
J7510
1/1/2002
00456-0521-01
G9036
12/1/2004
00456-0527-08
00463-1015-30
00463-1019-30
00463-1020-10
00463-1021-30
00463-1029-30
G9036
J3420
J2650
J2650
J3420
J1435
12/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00463-1036-10
00463-1069-10
J1700
J3140
1/1/2002
1/1/2002
00463-1073-10
00463-1074-30
00463-1074-30
00463-1080-30
00463-1086-10
00463-1089-10
00463-1091-05
00463-1092-10
J3150
J3490
J3411
J1200
J1240
J1200
J3302
J2360
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00463-1094-30
00463-1101-10
00463-1104-10
00463-1108-20
00463-6071-10
00463-6140-10
00463-6141-10
00463-6155-10
J3420
J3410
J0500
J3250
J7510
J7506
J7506
J7506
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
480 ML EA
PO
ML
50 MG
0.05
01/01/2002
10/01/2003
3840 ML EA
PO
ML
50 MG
0.05
01/01/2002
10/01/2003
120 ML NA
PO
ML
25 MG
0.05
01/01/2002
10/01/2003
480 ML NA
PO
ML
25 MG
0.05
01/01/2002
10/01/2003
PO
NA
PO
PO
ML
EA
ML
ML
25 MG
2 MEQ
5 MG
5 MG
0.05
100
0.6
0.6
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10/01/2003
12/10/2003
09/17/2003
09/17/2003
3840 ML
1 EA
240 ML
480 ML
NA
NA
BO
BO
120 ML BO
PO
ML
5 MG
0.2
01/01/2002
09/17/2003
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
240 ML
30 ML
30 ML
10 ML
30 ML
30 ML
PO
IM
IJ
IJ
IM
IM
ML
ML
ML
ML
ML
ML
100 MG
1000 MCG
1 ML
1 ML
1000 MCG
1 MG
0.1
1
1
1
0.1
5
12/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 ML VL
10 ML VL
IJ
IM
ML
ML
25 MG
50 MG
1
2
01/01/2002
01/01/2002
99/99/9999
99/99/9999
10 ML
30 ML
30 ML
30 ML
10 ML
10 ML
5 ML
10 ML
VL
VL
VL
VL
VL
VL
VL
VL
IM
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
100 MG
1 EA
100 MG
50 MG
50 MG
50 MG
5 MG
60 MG
1
1
1
0.2
1
1
8
0.5
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 ML
10 ML
10 ML
20 ML
1000 EA
1000 EA
1000 EA
1000 EA
VL
VL
VL
VL
NA
NA
NA
NA
IM
IM
IM
IM
PO
PO
PO
PO
ML
ML
ML
ML
EA
EA
EA
EA
1000 MCG
25 MG
20 MG
200 MG
5 MG
5 MG
5 MG
5 MG
1
2
0.5
0.5
1
2
4
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
BO
VL
VL
VL
VL
EA
1000 EA NA
PO
EA
25 MG
01/01/2002
99/99/9999
IM
EA
0.5 MG
30
02/28/2008
99/99/9999
IM
PO
PO
EA
EA
EA
0.5 MG
1 MG
1 MG
30
0.5
0.5
12/31/2007
01/01/2002
01/01/2002
99/99/9999
02/13/2002
99/99/9999
00463-6156-10
Q0170
J0215
2/28/2008 99/99/9999 INJECTION, ALEFACEPT, 0.5 MG
AMEVIVE (W/DILUENT PACK,PF) 15 MG
1 EA VL
00469-0021-04
00469-0607-67
00469-0607-73
J0215
J7507
J7507
12/31/2007 99/99/9999 INJECTION, ALEFACEPT, 0.5 MG

1/1/2002 2/13/2002 TACROLIMUS, ORAL, PER 1 MG
AMEVIVE (W/DILUENT PACK,PF) 15 MG

PROGRAF 0.5 MG
PROGRAF 0.5 MG
1 EA VL
100 EA BO
100 EA BO
00469-0617-10
J7507
00469-0617-11
00469-0617-71
00469-0617-73
J7507
J7507
J7507
00469-0657-10
J7508
1/1/2002
2/13/2002 TACROLIMUS, ORAL, PER 5 MG
PROGRAF (10X10,BLISTER PACK) 5 MG
100 EA BX
PO
EA
5 MG
01/01/2002
02/13/2002
00469-0657-11
J7508
100 EA BX
PO
EA
5 MG
01/01/2002
12/31/2003
00469-0657-11
00469-0657-71
00469-0657-73
00469-0657-73
J7507
J7508
J7508
J7507


PROGRAF 5 MG
PROGRAF 5 MG
PROGRAF 5 MG
100 EA
100 EA
100 EA
100 EA
PO
PO
PO
PO
EA
EA
EA
EA
1
5
5
1
5
1
1
5
01/01/2004
01/01/2002
01/01/2002
01/01/2004
99/99/9999
02/13/2002
12/31/2003
99/99/9999
1/1/2002
100 EA BX
PO
EA
1 MG
01/01/2002
02/13/2002


PROGRAF 1 MG
PROGRAF 1 MG
100 EA BX
100 EA BO
100 EA BO
PO
PO
PO
EA
EA
EA
1 MG
1 MG
1 MG
1
1
1
01/01/2002
01/01/2002
02/13/2002
99/99/9999
02/12/2002
99/99/9999
Page 95 of 374
BX
BO
BO
BO
MG
MG
MG
MG
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

PENTAZINE 6.25 MG/5 ML
POTASSIUM CHLORIDE 200 MEQ
PRELONE (CHERRY) 15 MG/5 ML
PRELONE (SF,DYE-FREE,CHERRY) 5
MG/5 ML
RIMANTADINE HYDROCHLORIDE, ORAL, BRAND, PER 100 MG (FOR USE IN A
5/31/2005 MEDICARE APPROVED DEMONSTRATION PROJECT)
FLUMADINE 100 MG
FLUMADINE 50 MG/5 ML
VITAMIN B12 (VIAL) 1000 MCG/ML
COTOLONE (VIAL) 25 MG/ML
COTOLONE (VIAL) 50 MG/ML
99/99/9999 INJECTION, ESTRONE, PER 1 MG
HYDROCORTISONE ACETATE (VIAL) 25
99/99/9999 INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG
MG/ML
99/99/9999 INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG
TESTRO AQ (VIAL) 100 MG/ML
TESTOSTERONE PROPIONATE (VIAL)
99/99/9999 INJECTION, TESTOSTERONE PROPIONATE, UP TO 100 MG
100 MG/ML
TRUXADRYL (VIAL) 10 MG/ML
99/99/9999 INJECTION, DIMENHYDRINATE, UP TO 50 MG
TRUXADRYL (VIAL) 50 MG/ML
99/99/9999 INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG
TRIAMCOT (VIAL) 40 MG/ML
99/99/9999 INJECTION, ORPHENADRINE CITRATE, UP TO 60 MG
ORFRO (VIAL) 30 MG/ML
MCG/ML
VISTACOT (VIAL) 50 MG/ML
99/99/9999 INJECTION, DICYCLOMINE HCL, UP TO 20 MG
DICYCLOCOT (VIAL) 10 MG/ML
BENZACOT (VIAL) 100 MG/ML
COTOLONE 5 MG
PREDNICOT 10 MG
PREDNICOT 20 MG
PREDNICOT 5 MG
PROMACOT 25 MG
00469-0021-03
1/1/2002
HCPCS Mod
HCPCS
NDC Mod
NDC
00469-0871-20
J0151
00469-0871-20
J0152
00469-0871-30
J0151
00469-0871-30
J0152
00469-0872-02
00469-3016-01
00469-3051-30
00469-3051-30
J0150
J7525
J0286
J0289
INJECTION, ADENOSINE, 90 MG (NOT TO BE USED TO REPORT ANY ADENOSINE

1/1/2002 12/31/2003 PHOSPHATE COMPOUNDS, INSTEAD USE A9270)
INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE USED TO
1/1/2004 99/99/9999 REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS; INSTEAD USE A9270)
INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE USED TO
1/1/2002 10/1/2003 REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, INSTEAD USE A9270)
1/1/2002 99/99/9999 TACROLIMUS, PARENTERAL, 5 MG
1/1/2002 12/31/2002 INJECTION, AMPHOTERICIN B, ANY LIPID FORMULATION, 50 MG
1/1/2003 99/99/9999 INJECTION, AMPHOTERICIN B LIPOSOME, 10 MG
00469-3211-10
00469-3250-10
00469-3250-10
00469-5117-05
00469-5118-05
00469-5119-01
00469-5119-05
J2248
J7799
J2248
J3302
J3303
J3303
J3303
1/1/2007
5/3/2005
1/1/2007
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00469-7220-01
J0715
1/1/2002
00469-7221-02
J0715
1/1/2002
00469-7234-12
J0150
1/1/2002
00469-7234-14
00469-7251-01
00469-7252-01
00469-7253-02
00469-7254-02
00469-7255-10
00469-7271-01
00469-7272-02
J0150
J0715
J0715
J0715
J0715
J0715
J0715
J0715
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00469-8234-12
J0150
6/14/2002
00469-8234-14
00472-0082-16
J0150
J8499
6/14/2002
1/1/2002
00472-0096-12
K0416
12/18/2002
00472-0212-08
00472-0212-16
J7510
J7510
1/1/2002
1/1/2002
00472-0250-08
00472-0250-16
J7510
J7510
6/5/2003
6/5/2003
00472-0742-98
Q0172
1/1/2002
00472-0750-21
J7631
1/1/2002
00472-0750-21 KO J7631
00472-0750-60
00472-0750-60 KO J7631
00472-0751-23
00472-0751-60
J7631
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
KO
J7644
00472-0751-60 KO J7644
00472-0752-21
KO
J7644
00472-0751-30 KO J7644
1/1/2002
1/1/2002
J7644
00472-0751-23 KO J7644
00472-0751-30
KO
J7631
1/1/2002
1/1/2002
KO
1/1/2002
10/22/2003
99/99/9999 INJECTION, MICAFUNGIN SODIUM, 1 MG

99/99/9999 INJECTION, MICAFUNGIN SODIUM, 1 MG
12/18/2003 INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG
3/1/2007 INJECTION, CEFTIZOXIME SODIUM, PER 500 MG
ADENOSCAN (S.D.V.,PF) 3 MG/ML
20 ML VL
IV
ML
90 MG
0.03333
01/01/2002
20 ML VL
IV
ML
30 MG
0.1
01/01/2004
99/99/9999
30 ML VL
IV
ML
90 MG
0.03333
01/01/2002
12/31/2003
30 ML VL
ADENOCARD (S.D.V.,PF) 3 MG/ML

PROGRAF (AMP,PF) 5 MG/ML
AMBISOME 50 MG
AMBISOME 50 MG
MYCAMINE (W/RED FLIP-OFF CAP) 100
MG
MYCAMINE (PF) 50 MG
MYCAMINE (PF) 50 MG
ARISTOCORT (VIAL) 25 MG/ML
ARISTOSPAN (VIAL) 5 MG/ML
CEFIZOX (S.D. GALAXY P.C.,PF) 1 GM/50
ML
CEFIZOX (S.D. GALAXY P.C.,PF) 2 GM/50
ML
ADENOCARD (SRN,LUER-TIP,PF) 3
MG/ML
ADENOCARD (SRN,LUER-TIP,PF) 3
MG/ML
CEFIZOX (S.D.V.) 1 GM
CEFIZOX (S.D.V,P.B.) 1 GM
CEFIZOX (S.D.V.,PF) 2 GM
CEFIZOX (S.D.V.,P.B.,PF) 2 GM
CEFIZOX (BULK PACKAGE,PF) 10 GM
CEFIZOX (ADD-VANTAGE,PF) 1 GM
CEFIZOX (ADD-VANTAGE,PF) 2 GM
ADENOCARD (ANSYR,LUER LOK) 3
MG/ML
ADENOCARD (ANSYR,LUER LOK) 3
MG/ML
ACYCLOVIR 200 MG/5 ML

10/1/2003 REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, INSTEAD USE A9270)
IV
ML
30 MG
0.1
01/01/2004
99/99/9999
2 ML
1 ML
1 EA
1 EA
VL
AM
VL
VL
IV
IV
IV
IV
ML
ML
EA
EA
6 MG
5 MG
50 MG
10 MG
0.5
1
1
5
01/01/2002
01/01/2002
01/01/2002
01/01/2003
10/01/2003
99/99/9999
12/31/2002
99/99/9999
1 EA
1 EA
1 EA
5 ML
5 ML
1 ML
5 ML
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IJ
IJ
IJ
IJ
EA
EA
EA
ML
ML
ML
ML
1 MG
1 EA
1 MG
5 MG
5 MG
5 MG
5 MG
100
1
50
5
1
4
4
01/01/2007
05/03/2005
01/01/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2006
99/99/9999
03/09/2004
12/18/2003
12/18/2003
12/18/2003
50 ML FC
IV
ML
500 MG
0.04
01/01/2002
03/01/2007
50 ML FC
IV
ML
500 MG
0.08
01/01/2002
03/01/2007
2 ML SR
IV
ML
6 MG
0.5
01/01/2002
10/01/2003
4 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
SR
VL
VL
VL
VL
VL
VL
VL
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
EA
EA
EA
6 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
0.5
2
2
4
4
20
2
4
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10/01/2003
08/01/2006
10/01/2006
10/01/2006
10/01/2006
10/01/2006
10/01/2006
08/01/2006
2 ML SR
IV
ML
6 MG
0.5
06/14/2002
99/99/9999
IV
PO
ML
ML
6 MG
1 EA
0.5
1
06/14/2002
01/01/2002
99/99/9999
99/99/9999
12 EA BX
RC
EA
1 MG
25
12/18/2002
07/22/2004
PREDNISOLONE (CHERRY) 15 MG/5 ML

240 ML BO
480 ML BO
PO
PO
ML
ML
5 MG
5 MG
0.6
0.6
01/01/2002
01/01/2002
06/04/2003
06/04/2003

CHLORPROMAZINE HCL 100 MG/ML
1/22/2004 MILLIGRAM
IPRATROPIUM BROMIDE (VIAL) 0.02%
1/22/2004 MILLIGRAM
9/10/2003 MILLIGRAM
9/10/2003 MILLIGRAM
9/8/2003 MILLIGRAM
9/8/2003 MILLIGRAM
240 ML BO
480 ML BO
PO
PO
ML
ML
5 MG
5 MG
0.6
0.6
06/05/2003
06/05/2003
03/27/2006
03/27/2006
240 ML BO
PO
Page 96 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
12/31/2003
4 ML SR
480 ML BO

Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
ML
25 MG
01/01/2002
04/05/2005
2 ML AM IH
ML
10 MG
01/01/2002
10/21/2003
2 ML AM IH
ML
10 MG
01/01/2002
10/21/2003
2 ML AM IH
ML
10 MG
01/01/2002
07/23/2003
2 ML AM IH
ML
10 MG
01/01/2002
07/23/2003
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
01/22/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
01/22/2004
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
09/10/2003
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
09/10/2003
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
09/08/2003
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
09/08/2003
2 ML PC
IH
ML
10 MG
10/22/2003
4/5/2005
00472-0752-60
J7631
00472-0752-60 KO J7631
00472-0753-23
00472-0753-30
00472-0753-60
00472-0831-23
00472-0831-30
00472-0831-60
KO
1/1/2008
4/1/2008
KO
4/1/2008
1/1/2008
KO
1/1/2008
4/1/2008
KO
4/1/2008
1/1/2008
KO
J7613
00472-0831-60 KO J7613
9/9/2003
1/1/2008
J7603
00472-0831-60 KO J7603
00472-0831-60
KO
J7613
00472-0831-30 KO J7613
9/11/2003
9/9/2003
J7603
00472-0831-30 KO J7603
1/23/2004
9/11/2003
KO
J7613
00472-0831-23 KO J7613
00472-0831-30
KO
J7603
00472-0831-23 KO J7603
7/24/2003
1/23/2004
J7644
00472-0753-60 KO J7644
00472-0831-23
KO
J7644
00472-0753-30 KO J7644
10/22/2003
7/24/2003
J7644
00472-0753-23 KO J7644
1/1/2008
4/1/2008
KO
4/1/2008
00472-0832-20
J7618
1/1/2002
00472-0972-08
Q0181
1/1/2002
00472-0972-33
Q0181
1/1/2002
00472-1223-94
Q0163
1/1/2002
00472-1232-04
Q0163
1/1/2002

6/30/2007 MILLIGRAM
6/30/2007 MILLIGRAM
6/30/2007 MILLIGRAM
6/30/2007 MILLIGRAM
6/30/2007 MILLIGRAM
6/30/2007 MILLIGRAM
ALBUTEROL SULFATE (PF) 0.083%
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON2/28/2009 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG
10/7/2003 (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)
9/18/2003 REGIMEN
2/24/2003 REGIMEN
HYDRAMINE 12.5 MG/5 ML
HYDRAMINE COUGH 12.5 MG/5 ML
Page 97 of 374
2 ML PC
IH
ML
10 MG
10/22/2003
4/5/2005
2 ML PC
IH
ML
10 MG
07/24/2003
4/5/2005
2 ML PC
IH
ML
10 MG
07/24/2003
4/5/2005
2.5 ML PC
IH
ML
1 MG
0.2
01/23/2004
6/30/2007
2.5 ML PC
IH
ML
1 MG
0.2
01/23/2004
6/30/2007
2.5 ML PC
IH
ML
1 MG
0.2
09/11/2003
6/30/2007
2.5 ML PC
IH
ML
1 MG
0.2
09/11/2003
6/30/2007
2.5 ML PC
IH
ML
1 MG
0.2
09/09/2003
6/30/2007
2.5 ML PC
IH
ML
1 MG
0.2
09/09/2003
6/30/2007
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
2/28/2009
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
2/28/2009
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
2/28/2009
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
2/28/2009
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
2/28/2009
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
2/28/2009
20 ML BO
IH
ML
1 MG
01/01/2002
10/07/2003
240 ML BO
PO
ML
1 EA
01/01/2002
09/18/2003
100 ML BO
PO
ML
1 EA
01/01/2002
02/24/2003
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
12/01/2002
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
12/01/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
00472-0752-21 KO J7631
NDC
HCPCS
00472-1232-16
Q0163
1/1/2002
00472-1504-04
Q0170
1/1/2002
00472-1504-08
Q0170
1/1/2002
00472-1504-16
Q0170
1/1/2002
00472-1504-28
Q0170
1/1/2002
00487-0201-01
J7620
1/1/2008
00487-0201-02
J7620
1/1/2008
00487-0201-06
J7620
1/1/2008
00487-0201-60
J7620
1/1/2008
00487-9301-02
J7051
7/20/2005
00487-9301-02
00487-9301-03
00487-9301-03
00487-9301-33
00487-9301-33
A4216
J7051
A4216
J7051
A4216
1/1/2006
1/1/2002
1/1/2006
3/1/2004
1/1/2006
00487-9501-01
J7603
1/1/2008
00487-9501-01 KO J7603
00487-9501-01
00487-9501-01 KO J7613
00487-9501-02
00487-9501-03
00487-9501-25
KO
J7603
1/1/2008
4/1/2008
KO
4/1/2008
1/1/2008
KO
J7613
00487-9501-03 KO J7613
4/1/2008
1/1/2008
J7603
00487-9501-03 KO J7603
00487-9501-03
KO
J7613
00487-9501-02 KO J7613
1/1/2008
4/1/2008
J7603
00487-9501-02 KO J7603
00487-9501-02
KO
J7613
1/1/2008
4/1/2008
KO
4/1/2008
1/1/2008

HYDRAMINE COUGH 12.5 MG/5 ML
PROMETHAZINE 6.25 MG/5 ML
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE (CHERRY) 6.25 MG/5
ML
ALBUTEROL SULFATE (30X3ML, ROBOT
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME READY) 3 MG/3 ML-0.5 MG/3 ML
SODIUM CHLORIDE (ROBOT
READY,30X3ML) 0.9%
SODIUM CHLORIDE (ROBOT
READY,30X3ML) 0.9%
ALBUTEROL SULFATE (ROBOT
READY,PF) 0.083%
READY,PF) 0.083%
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONALBUTEROL SULFATE (ROBOT
99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG
READY,PF) 0.083%
READY,PF) 0.083%
Page 98 of 374
480 ML BO
PO
ML
50 MG
0.05
01/01/2002
12/01/2002
120 ML BO
PO
ML
25 MG
0.05
01/01/2002
04/02/2003
240 ML BO
PO
ML
25 MG
0.05
01/01/2002
04/02/2003
480 ML BO
PO
ML
25 MG
0.05
01/01/2002
04/02/2003
3840 ML BO
PO
ML
25 MG
0.05
01/01/2002
03/11/2002
3 ML VL
IH
ML
2.5 MG
0.33333
01/01/2008
99/99/9999
3 ML VL
IH
ML
2.5 MG
0.33333
01/01/2008
99/99/9999
3 ML NA
IH
ML
2.5 MG
0.33333
01/01/2008 10/24/2008
3 ML PC
IH
ML
2.5 MG
0.33333
01/01/2008
99/99/9999
3 ML PC
IH
ML
5 ML
0.2
07/20/2005
12/31/2005
3
3
3
3
3
PC
PC
PC
PC
PC
IH
IH
IH
IH
IH
ML
ML
ML
ML
ML
10 ML
5 ML
10 ML
5 ML
10 ML
0.1
0.2
0.1
0.2
0.1
01/01/2006
01/01/2002
01/01/2006
03/01/2004
01/01/2006
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
ML
ML
ML
ML
ML
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00487-9501-25 KO J7603
00487-9501-25
00487-9801-01
00487-9801-25
00487-9801-60
KO
KO
KO
7/20/2005
10/11/2002
KO
10/11/2002
1/3/2003
KO
1/3/2003
1/3/2003
KO
1/3/2003
00487-9901-02
J7602
1/1/2008
00487-9901-02
J7611
4/1/2008
00487-9901-30
J7602
1/1/2008
00487-9901-30
J7611
4/1/2008
00487-9904-01
J7603
1/1/2008
00487-9904-01 KO J7603
00487-9904-01
00487-9904-01 KO J7613
00487-9904-02
KO
J7613
J7603
1/1/2008
4/1/2008
KO
4/1/2008
1/1/2008

IPRATROPIUM BROMIDE (PF) 0.02%
IPRATROPIUM BROMIDE (ROBOT
READY,PF) 0.02%
IPRATROPIUM BROMIDE (ROBOT
READY,PF) 0.02%
THROUGH DME, CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG ALBUTEROL SULFATE (UNIT OF
USE,ROBOT READY) 0.5%
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONALBUTEROL SULFATE (UNIT OF
99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MG
USE,ROBOT READY) 0.5%
THROUGH DME, CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG ALBUTEROL SULFATE (UNIT OF USE,PF)
0.5%
ALBUTEROL SULFATE (UNIT OF USE,PF)
0.5%
READY,LDPE VIAL) 0.042%
Page 99 of 374
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/03/2003
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/03/2003
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
07/20/2005
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
07/20/2005
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
10/11/2002
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
10/11/2002
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/03/2003
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/03/2003
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/03/2003
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/03/2003
99/99/9999
0.5 ML PC
IH
ML
1 MG
01/01/2008
03/31/2008
0.5 ML PC
IH
ML
1 MG
04/01/2008
99/99/9999
0.5 ML PC
IH
ML
1 MG
01/01/2008
03/31/2008
0.5 ML PC
IH
ML
1 MG
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

1/3/2003
7/20/2005
J7644
00487-9801-60 KO J7644
4/1/2008
1/3/2003
J7644
00487-9801-30 KO J7644
1/1/2008
4/1/2008
J7644
00487-9801-25 KO J7644
00487-9801-30
KO
J7644
00487-9801-02 KO J7644
4/1/2008
1/1/2008
J7644
00487-9801-01 KO J7644
00487-9801-02
KO
J7613
00487-9501-60 KO J7613
1/1/2008
4/1/2008
J7603
00487-9501-60 KO J7603
00487-9501-60
KO
J7613
00487-9501-25 KO J7613
00487-9501-60
HCPCS Mod
HCPCS
NDC Mod
NDC
00487-9904-02 KO J7603
00487-9904-02
KO
KO
1/1/2008
4/1/2008
KO
4/1/2008
00490-0075-00
Q0179
1/1/2007
00490-0075-30
Q0179
1/1/2007
00490-0075-60
Q0179
1/1/2007
00490-0075-90
Q0179
1/1/2007
00490-0091-00
Q0175
1/1/2007
00490-0091-30
Q0175
1/1/2007
00490-0091-60
Q0175
1/1/2007
00490-0091-90
Q0175
1/1/2007
00501-2050-04
Q0163
11/1/2002
00501-2053-04
Q0163
11/1/2002
00501-2431-04
Q0163
8/2/2006
00516-0060-60
J0620
1/1/2002

ALBUTEROL SULFATE (LDPE VIAL)
0.042%
ALBUTEROL SULFATE (LDPE VIAL)
0.042%
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONALBUTEROL SULFATE (LDPE VIAL)
0.042%
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONALBUTEROL SULFATE (LDPE VIAL)
0.042%
ONDANSETRON ODT 4 MG
PERPHENAZINE 4 MG
99/99/9999 REGIMEN
PERPHENAZINE 4 MG
99/99/9999 REGIMEN
PERPHENAZINE 4 MG
99/99/9999 REGIMEN
PERPHENAZINE 4 MG
99/99/9999 REGIMEN
MG/5 ML
BENADRYL ALLERGY
(CHILDREN'S,AF,SF) 12.5 MG/5 ML
CHILDREN'S PEDIA CARE (NIGHTTIME
COUGH,AF) 12.5 MG/5 ML
CALPHOSAN (M.D.V.) 50 MG/10 ML-50
99/99/9999 INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, PER 10 ML
MG/10 ML
00517-0020-10
00517-0031-25
J0706
J3420

00517-0032-25
J3420
00517-0033-10
J2710
1/1/2002
00517-0033-25
J2710
00517-0034-10
J2710
00517-0034-25
J2710
1/15/2003 99/99/9999 INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG

1/1/2002
CAFFEINE CITRATE
(USP,10X3ML,SINGLE-DOSE) 20 MG/ML
CYANOCOBALAMIN 1000 MCG/ML
MCG/ML
NEOSTIGMINE METHYLSULFATE
(M.D.V.) 1 MG/ML
(M.D.V.) 1 MG/ML
(M.D.V.) 0.5 MG/ML
(M.D.V.) 0.5 MG/ML
Page 100 of 374
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
3 ML VL
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
3 ML VL
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
100 EA BX
PO
EA
8 MG
0.5
01/01/2007
99/99/9999
30 EA BX
PO
EA
8 MG
0.5
01/01/2007
99/99/9999
60 EA BX
PO
EA
8 MG
0.5
01/01/2007
99/99/9999
90 EA BX
PO
EA
8 MG
0.5
01/01/2007
99/99/9999
100 EA BO
PO
EA
4 MG
01/01/2007
99/99/9999
30 EA BO
PO
EA
4 MG
01/01/2007
99/99/9999
60 EA BO
PO
EA
4 MG
01/01/2007
99/99/9999
90 EA BO
PO
EA
4 MG
01/01/2007
99/99/9999
118 ML BO
PO
ML
50 MG
0.05
11/01/2002
11/16/2003
118 ML BO
PO
ML
50 MG
0.05
11/01/2002
11/16/2003
120 ML BO
PO
ML
50 MG
0.05
08/02/2006
99/99/9999
60 ML VL
IJ
ML
10 ML
0.1
02/11/2004
99/99/9999
3 ML VL
1 ML VL
IV
IM
ML
ML
5 MG
1000 MCG
4
1
09/10/2007
01/01/2002
99/99/9999
99/99/9999
10 ML VL
IM
ML
1000 MCG
01/01/2002
99/99/9999
10 ML VL
IJ
ML
0.5 MG
01/01/2002
01/14/2003
10 ML VL
IJ
ML
0.5 MG
01/15/2003
99/99/9999
10 ML VL
IJ
ML
0.5 MG
01/01/2002
01/14/2003
10 ML VL
IJ
ML
0.5 MG
01/15/2003
99/99/9999
1/1/2002
2/10/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

4/1/2008
1/1/2008
J7613
00487-9904-25 KO J7613
1/1/2008
4/1/2008
J7603
00487-9904-25 KO J7603
00487-9904-25
KO
J7613
00487-9904-02 KO J7613
00487-9904-25
HCPCS Mod
HCPCS
NDC Mod
NDC
0.1
00517-0101-25
J0460
00517-0130-01
J3420
1/1/2002
00517-0130-05
00517-0132-25
J3420
J0636
00517-0299-25
J2370
00517-0401-25
J0460
00517-0405-25
J2370
00517-0601-25
00517-0625-25
00517-0625-25
00517-0626-25
00517-0626-25
J1885
J2000
J2001
J2000
J2001
4/1/2008
1/1/2002
1/1/2004
1/1/2002
1/1/2004
00517-0648-25
J2912
00517-0648-25
A4216
00517-0662-25
A4712
00517-0662-25
A4216
00517-0801-25
J1885
00517-0805-25
J0460
00517-0901-25
J0360
1/1/2002 99/99/9999 INJECTION, HYDRALAZINE HCL, UP TO 20 MG
00517-0902-25
J1885
00517-0911-25
J0360
6/1/2002
00517-1010-25
00517-1045-25
00517-1071-25
00517-1130-01
00517-1130-05
00517-1305-25
00517-1305-25
00517-1805-25
00517-1805-25
00517-1905-25
00517-1905-25
J0460
J1955
J0170
J0170
J0170
Q4076
J1265
Q4076
J1265
Q4076
J1265
1/1/2002
1/1/2002
1/1/2002
1/1/2002
8/1/2003
10/1/2003
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006

99/99/9999 INJECTION, LEVOCARNITINE, PER 1 GM
00517-2310-05
00517-2340-10
00517-2340-10
00517-2340-25
J1756
J1755
J1756
J1756
5/1/2007
1/1/2002
1/1/2003
10/1/2006
99/99/9999 INJECTION, IRON SUCROSE, 1 MG

12/31/2002 INJECTION, IRON SUCROSE, 20MG
00517-2602-25
J3475
00517-2610-25
J3475
00517-2650-25
00517-2802-25
00517-2802-25
00517-2810-25
00517-2810-25
J3475
J2912
A4216
J2912
A4216
1/1/2002
1/1/2002
1/1/2007
1/1/2002
1/1/2004


8/11/2006 INJECTION, HYDRALAZINE HCL, UP TO 20 MG

00517-2900-25
J7799
00517-2930-25
00517-3005-25
00517-3005-25
00517-3010-25
00517-3010-25
00517-3020-25
00517-3020-25
00517-3050-25
00517-3050-25
00517-3810-25
00517-3820-25
J7799
A4712
A4216
A4712
A4216
A4712
A4216
A4712
A4216
J0280
J0280
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
00517-3900-25
J0610
ATROPINE SULFATE (AMP,PF) 1 MG/ML

MCG/ML
MCG/ML
CALCITRIOL 1 MCG/ML
1 ML AM IJ
ML
0.3 MG
3.33333
01/01/2002
12/31/2009
IM
ML
1000 MCG
01/01/2002
08/01/2003
30 ML VL IM
1 ML AM IV
ML
ML
1000 MCG
0.1 MCG
1
10
05/29/2003
03/14/2005
99/99/9999
99/99/9999
99/99/9999
30 ML VL
PHENYLEPHRINE HCL (S.D.V.) 10 MG/ML

ATROPINE SULFATE (S.D.V.,PF) 0.4
MG/ML
1 ML VL
IJ
ML
1 ML
01/01/2002
1 ML VL
IJ
ML
0.3 MG
1.33333
01/01/2002
12/31/2009
PHENYLEPHRINE HCL (VIAL) 10 MG/ML

(USP,25X1ML,SDV) 15 MG/ML
(M.D.V.) 0.9%
(M.D.V.) 0.9%
WATER FOR INJECTION
WATER FOR INJECTION
ATROPINE SULFATE (AMP,PF) 0.4
MG/ML
HYDRALAZINE HYDROCHLORIDE
(S.D.V.) 20 MG/ML
HYDRALAZINE HYDROCHLORIDE
NOVAPLUS (S.D.V.) 20 MG/ML
ATROPINE SULFATE (S.D.V.,PF) 1
MG/ML
LEVOCARNITINE (S.D.V.) 200 MG/ML
EPINEPHRINE (AMP) 1 MG/ML
EPINEPHRINE (M.D.V.) 1 MG/ML
EPINEPHRINE (M.D.V.) 1 MG/ML
VENOFER (5X10ML,SDV,USP,PF) 20
MG/ML
VENOFER (S.D.V.,PF) 20 MG/ML
VENOFER (S.D.V.,PF) 20 MG/ML
VENOFER (25X5ML SDV,PF) 20 MG/ML
MAGNESIUM SULFATE (S.D.V.,PF) 500
MG/ML
MG/ML
MG/ML
SODIUM CHLORIDE (S.D.V.,PF) 0.9%
SODIUM CHLORIDE CONCENTRATE
(BULK PACKAGE) 23.4%
(S.D.V.) 23.4%
WATER FOR INJECTION (S.D.V.)
AMINOPHYLLINE (S.D.V.,PF) 25 MG/ML
AMINOPHYLLINE (S.D.V.,PF) 25 MG/ML
CALCIUM GLUCONATE (VIAL,PF) 100
MG/ML
5 ML VL
IJ
ML
1 ML
01/01/2002
99/99/9999
IJ
EP
EP
IJ
IJ
ML
ML
ML
ML
ML
15 MG
50 ML
10 MG
50 ML
10 MG
1
0.02
1
0.02
2
04/01/2008
01/01/2002
01/01/2004
01/01/2002
01/01/2004
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
30 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
30 ML VL
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
30 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
30 ML VL
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
2 ML VL
IJ
ML
15 MG
04/01/2008
99/99/9999
0.5 ML AM IJ
12/31/2009
Page 101 of 374
1 ML
50 ML
50 ML
50 ML
50 ML
VL
VL
VL
VL
VL
ML
0.3 MG
1.33333
01/01/2002
1 ML VL
IJ
ML
20 MG
01/01/2002
99/99/9999
2 ML VL
IM
ML
15 MG
04/01/2008
99/99/9999
IJ
ML
20 MG
06/01/2002
8/11/2006
1 ML
5 ML
1 ML
30 ML
30 ML
5 ML
5 ML
5 ML
5 ML
5 ML
5 ML
1 ML VL
VL
VL
AM
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IV
IJ
IJ
IJ
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
0.3 MG
1 GM
1 ML
1 ML
1 ML
40 MG
40 MG
40 MG
40 MG
40 MG
40 MG
3.33333
0.2
1
1
1
4
4
1
1
2
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/01/2003
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
12/31/2009
99/99/9999
99/99/9999
08/01/2003
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
10 ML
5 ML
5 ML
5 ML
VL
VL
VL
VL
IV
IV
IV
IV
ML
ML
ML
ML
1 MG
20 MG
1 MG
1 MG
20
1
20
20
05/01/2007
01/01/2002
01/01/2003
10/01/2006
99/99/9999
12/31/2002
99/99/9999
99/99/9999
2 ML VL
IJ
ML
500 MG
01/01/2002
99/99/9999
10 ML VL
IJ
ML
500 MG
01/01/2002
99/99/9999
50 ML
2 ML
2 ML
10 ML
10 ML
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
ML
ML
ML
ML
ML
500 MG
0.9 %
10 ML
0.9 %
10 ML
1
0.5
0.1
0.5
0.1
01/01/2002
01/01/2002
01/01/2007
01/01/2002
01/01/2004
99/99/9999
12/31/2006
99/99/9999
12/31/2003
99/99/9999
100 ML VL
IV
ML
1 EA
01/01/2002
99/99/9999
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 EA
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
250 MG
250 MG
1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
100 ML VL
IV
ML
10 ML
0.1
01/01/2002
99/99/9999
30 ML
5 ML
5 ML
10 ML
10 ML
20 ML
20 ML
50 ML
50 ML
10 ML
20 ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00517-3910-25
J0610
00517-3950-25
J0610
00517-4002-05
J2440
1/1/2002
00517-4002-25
J2440
00517-4010-01
00517-4050-25
00517-4201-25
J2440
J2150
J3410
00517-4601-25
J7643
00517-4601-25 KO J7643
00517-4602-25
00517-4605-25
KO
KO
J7643
00517-4605-25 KO J7643
00517-4620-25
9/15/2003 99/99/9999 INJECTION, PAPAVERINE HCL, UP TO 60 MG
J7643
00517-4602-25 KO J7643
KO
J7643
00517-4620-25 KO J7643
9/14/2003 INJECTION, PAPAVERINE HCL, UP TO 60 MG
KO

00517-4901-25
J1100
00517-4905-25
J1100
00517-4930-25
00517-5601-25
00517-5602-25
00517-5610-25
00517-5702-25
00517-5704-25
00517-5710-25
J1100
J3410
J3410
J3410
J1940
J1940
J1940
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00517-7504-12
J7608
1/1/2002

00517-8605-25
00517-8711-10
00517-8722-10
00517-8725-10
00517-8750-10
J0640
J0696
J0696
J0696
J0696
1/1/2002
5/6/2008
5/6/2008
5/6/2008
5/6/2008

00517-8810-01
J3490
1/1/2002
00517-7504-12 KO J7608
00517-7504-25
J7608
00517-7504-25 KO J7608
00517-7510-03
00517-7604-12
00517-7610-03
KO
1/1/2002
1/1/2002
KO
1/1/2002
1/29/2003
KO
1/29/2003
1/1/2002
KO
J7608
00517-7630-03 KO J7608
1/1/2002
1/1/2002
J7608
00517-7610-03 KO J7608
00517-7630-03
KO
J7608
00517-7604-25 KO J7608
1/24/2003
1/1/2002
J7608
00517-7604-12 KO J7608
00517-7604-25
KO
J7608
00517-7530-03 KO J7608
1/1/2002
1/24/2003
J7608
00517-7510-03 KO J7608
00517-7530-03
1/1/2002
KO
1/1/2002
1/1/2002
KO
CALCIUM GLUCONATE (S.D.V.,PF) 100

MG/ML
CALCIUM GLUCONATE (S.D.V.,PF) 100
MG/ML
PAPAVERINE HYDROCHLORIDE (S.D.V.)
30 MG/ML
PAPAVERINE HYDROCHLORIDE (S.D.V.)
30 MG/ML
PAPAVERINE HYDROCHLORIDE (M.D.V.)
30 MG/ML
MANNITOL (S.D.V.,PF) 25%
HYDROXYZINE HCL (S.D.V.) 25 MG/ML
10 ML VL
IV
ML
10 ML
0.1
01/01/2002
99/99/9999
50 ML VL
IV
ML
10 ML
0.1
01/01/2002
99/99/9999
2 ML VL
IJ
ML
60 MG
0.5
01/01/2002
09/14/2003
2 ML VL
IJ
ML
60 MG
0.5
09/15/2003
99/99/9999
10 ML VL
50 ML VL
1 ML VL
IJ
IV
IM
ML
ML
ML
60 MG
50 ML
25 MG
0.5
0.02
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
GLYCOPYRROLATE (S.D.V.) 0.2 MG/ML
1 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
2 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
2 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
GLYCOPYRROLATE (M.D.V.) 0.2 MG/ML
5 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
5 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
20 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999

PHOSPHATE (S.D.V.) 4 MG/ML
FUROSEMIDE (S.D.V.) 10 MG/ML
20 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
5 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
VL
VL
VL
VL
VL
VL
VL
IJ
IM
IM
IM
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
1 MG
25 MG
25 MG
25 MG
20 MG
20 MG
20 MG
4
2
2
2
0.5
0.5
0.5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
ACETYLCYSTEINE (PF) 10%
4 ML VL
IH
ML
1 GM
0.1
01/01/2002
01/24/2003
4 ML VL
IH
ML
1 GM
0.1
01/01/2002
01/24/2003
4 ML VL
IH
ML
1 GM
0.1
01/24/2003
99/99/9999
30 ML
1 ML
2 ML
10 ML
2 ML
4 ML
10 ML
4 ML VL
IH
ML
1 GM
0.1
01/24/2003
99/99/9999
10 ML VL
IH
ML
1 GM
0.1
01/01/2002
99/99/9999
10 ML VL
IH
ML
1 GM
0.1
01/01/2002
99/99/9999
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
07/02/2003
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
07/02/2003
4 ML VL
IH
ML
1 GM
0.2
01/01/2002
01/29/2003
4 ML VL
IH
ML
1 GM
0.2
01/01/2002
01/29/2003
4 ML VL
IH
ML
1 GM
0.2
01/29/2003
99/99/9999
4 ML VL
IH
ML
1 GM
0.2
01/29/2003
99/99/9999
10 ML VL
IH
ML
1 GM
0.2
01/01/2002
99/99/9999
10 ML VL
IH
ML
1 GM
0.2
01/01/2002
99/99/9999
30 ML VL
IH
ML
1 GM
0.2
01/01/2002
99/99/9999

LEUCOVORIN CALCIUM (S.D.V.,PF) 10
MG/ML
BRETYLIUM TOSYLATE (S.D.V.,PF) 50
MG/ML
30 ML VL
Page 102 of 374
IH
ML
1 GM
0.2
01/01/2002
99/99/9999
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
50 MG
250 MG
250 MG
250 MG
250 MG
0.2
4
8
1
2
01/01/2002
05/06/2008
05/06/2008
05/06/2008
05/06/2008
01/09/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 ML VL
IV
ML
1 EA
01/01/2002
01/01/2004
5
1
1
1
1
ML
EA
EA
EA
EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00517-8905-01
J0210
00517-8905-10
J0210
1/1/2002
00517-9120-05
J3490
00517-9120-25
00517-9702-25
00527-1201-01
00527-1201-10
J3490
J1790
J7510
J7510
00527-1296-07
J7509
1/1/2002
00527-1297-01
Q0164
1/1/2002
00527-1298-01
Q0165
1/1/2002
00536-0770-85
Q0163
1/1/2002
00536-0770-97
Q0163
1/1/2002
00536-3594-01
Q0163
1/1/2002
00536-3594-10
Q0163
9/29/2003
00536-3597-01
Q0163
1/1/2002
00536-3772-06
00536-3998-01
00536-3998-36
00548-1001-00
Q0163
None
None
J7799
1/1/2002
1/1/1994
1/1/1994
1/1/2002
00548-1014-00
00548-1015-00
J0170
J7799
1/1/2002
1/1/2002
00548-1016-00
J0170
1/1/2002
00548-1034-00
J3475
1/1/2002
00548-1038-00
J0460
1/1/2002
00548-1039-00
J0460
1/1/2002
00548-1078-00
J2000
1/1/2002
00548-1078-00
J2001
1/1/2004
00548-1079-00
J2000
1/1/2002
00548-1079-00
00548-1080-00
00548-1080-00
00548-1081-00
00548-1081-00
J2001
J2000
J2001
J2000
J2001
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
METHYLDOPATE HCL (S.D.V.) 50 MG/ML
5 ML VL
IV
ML
250 MG
0.2
01/01/2002
METHYLDOPATE HCL (S.D.V.) 50 MG/ML

AMINOCAPROIC ACID (M.D.V.) 250
MG/ML
AMINOCAPROIC ACID (M.D.V.) 250
MG/ML
DROPERIDOL (S.D.V.) 2.5 MG/ML
PREDNISOLONE 5 MG
PREDNISOLONE 5 MG
METHYLPREDNISOLONE (UNIT OF USE)
4 MG
5 ML VL
IV
ML
250 MG
0.2
02/26/2003
99/99/9999
20 ML VL
IV
ML
1 EA
01/01/2002
03/12/2003
VL
VL
BO
BO
IV
IJ
PO
PO
ML
ML
EA
EA
1 EA
5 MG
5 MG
5 MG
1
0.5
1
1

21 EA DP
100 EA BO
100 EA BO
DIPHENHIST 12.5 MG/5 ML
480 ML BO
DIPHENHIST 12.5 MG/5 ML
120 ML BO
DIPHENHIST 25 MG
100 EA BO
DIPHENHIST 25 MG
1000 EA BO
DIPHENHIST (CAPTAB) 25 MG
100 EA BO
50 EA BO
100 EA NA
36 EA NA
DEXTROSE (MIN-I-JET,18GX1 1/2") 50%
50 ML SR
EPINEPHRINE HCL (MIN-I-JET,18GX3
1/2") 0.1 MG/ML
10 ML SR
DEXTROSE (MIN-I-JET,21GX1 1/2") 25%
10 ML SR
EPINEPHRINE HCL (MIN-I-JET,21GX1
1/2") 0.1 MG/ML
10 ML SR
MAGNESIUM SULFATE (MIN-I-JET,19GX2
1/2") 500 MG/ML
10 ML SR
ATROPINE SULFATE (MIN-I-JET,21GX1
1/2) 0.1 MG/ML
5 ML SR
ATROPINE SULFATE (MIN-I-JET,21GX1
1/2") 0.1 MG/ML
10 ML SR
LIDOCAINE HCL (MINIJET CONTROL
SRN) 1%
20 ML SR
SRN) 1%
20 ML SR
SRN) 1%
30 ML SR
SRN) 1%
30 ML SR
LIDOCAINE HCL (MINIJET OB KIT) 1%
20 ML SR
20 ML SR
30 ML SR
30 ML SR
LIDOCAINE HCL (MINIJET,21GX1 1/2")
2%
5 ML SR
2%
5 ML SR
1%
5 ML SR
1%
5 ML SR
PROCAINAMIDE HCL (MIN-I-JET,21GX1
1/2") 100 MG/ML
10 ML SR
PO
EA
4 MG
01/01/2002
10/01/2003
PO
EA
5 MG
01/01/2002
01/01/2002
PO
EA
10 MG
01/01/2002
01/01/2002
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
PO
EA
50 MG
0.5
09/29/2003
02/07/2005
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
PO
PO
PO
IV
EA
EA
EA
ML
50 MG
2.5 MG
2.5 MG
1 EA
1
1
1
1
01/01/2002
01/01/1994
01/01/1994
01/01/2002
99/99/9999
10/14/1999
10/14/1999
99/99/9999
IJ
IV
ML
ML
1 ML
1 EA
1
1
01/01/2002
01/01/2002
7/1/2007
10/01/2007
1/1/2002

00548-1190-00
J2000
1/1/2002
J2001
1/1/2004
00548-1192-00
J2000
1/1/2002
00548-1192-00
J2001
1/1/2004
00548-1199-00
J2690
1/1/2002
Page 103 of 374
20 ML
2 ML
100 EA
1000 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
2/26/2003 INJECTION, METHYLDOPATE HCL, UP TO 250 MG
2/26/2003 99/99/9999 INJECTION, METHYLDOPATE HCL, UP TO 250 MG
00548-1190-00
HCPCS Mod
HCPCS
NDC Mod
NDC
02/26/2003
03/12/2003 99/99/9999
01/01/2002 99/99/9999
01/01/2002 10/01/2003
01/01/2002 10/30/2004
IJ
ML
1 ML
01/01/2002
99/99/9999
IJ
ML
500 MG
01/01/2002
07/01/2007
IJ
ML
0.3 MG
0.33333
01/01/2002
07/01/2002
IJ
ML
0.3 MG
0.33333
01/01/2002
12/31/2009
EP
ML
50 ML
0.02
01/01/2002
12/31/2003
EP
ML
10 MG
01/01/2004
07/01/2008
EP
ML
50 ML
0.02
01/01/2002
12/31/2003
EP
EP
EP
EP
EP
ML
ML
ML
ML
ML
10 MG
50 ML
10 MG
50 ML
10 MG
1
0.02
1
0.02
1
01/01/2004
9/1/2008
01/01/2002 12/31/2003
01/01/2004
9/1/2008
01/01/2002 12/31/2003
01/01/2004 11/30/2008
IV
ML
50 ML
0.02
01/01/2002
IV
ML
10 MG
01/01/2004
99/99/9999
IV
ML
50 ML
0.02
01/01/2002
12/31/2003
IV
ML
10 MG
01/01/2004
10/01/2007
IV
ML
1 GM
0.1
01/01/2002
07/01/2002
12/31/2003
00548-1390-00
J1200
1/1/2002
00548-1431-00
J1940
1/1/2002
00548-1466-00
J2310
1/1/2002
00548-1469-00
J2310
00548-1911-25
J2270
00548-1931-10
J2270
00548-1933-10
J2270
1/1/2002
00548-1937-00
J2270
1/23/2002
00548-2001-00
J7799
00548-2016-00
J0170
00548-2039-00
J0460
00548-2190-00
J2000
00548-2190-00
J2001
DIPHENHYDRAMINE HCL
(MINIJET,21GX1 1/2") 50 MG/ML
FUROSEMIDE (MIN-I-JET,21GX1 1/2) 10
MG/ML
NALOXONE HCL (21GX1
1/2",MINIJET,PF) 0.4 MG/ML
NALOXONE HCL (21GX1
1/2",MINIJET,PF) 1 MG/ML
MORPHINE SULFATE
(SRN,PREFILLED,PUMP-JET) 1 MG/ML
MORPHINE SULFATE (SRN,PREFILL,PCA
INJECT) 1 MG/ML
MORPHINE SULFATE
(SRN,PREFILLED,PCA) 1 MG/ML
MORPHINE SULFATE (DELTEC PCA
VIAL) 1 MG/ML
DEXTROSE
(SRN,PREFILLED,STICKGARD) 50%
EPINEPHRINE HCL
(SRN,PREFILLED,STICKGARD) 0.1
MG/ML
ATROPINE SULFATE
(SRN,PREFILLED,STICKGARD) 0.1
MG/ML
LIDOCAINE HCL
LIDOCAINE HCL
00548-2901-25
J2270
00548-3301-00
J7799
00548-3315-00
J7799
MORPHINE SULFATE
(SRN,PREFILLED,STICKGARD) 1 MG/ML
DEXTROSE (SRN,PREFILLED,LUER-JET)
50%
DEXTROSE (SRN,PREFILLED,LUER-JET)
25%
EPINEPHRINE HCL
(SRN,PREFILLED,LUER-JET) 0.1 MG/ML
1/1/2002
ATROPINE SULFATE
00548-3316-00
00548-3338-00
J0170
J0460
00548-3339-00
J0460
1/1/2002
00548-3366-00
J2310
1/15/2002
00548-3369-00
00548-3380-00
J2310
J0282
1/15/2002
2/1/2004
00548-3390-00
J2000
1/23/2002
00548-3390-00
J2001
1/1/2004
00548-3391-10
00548-5900-00
J2270
J0835
1/1/2002
6/26/2003
00548-6040-25
J2271
1/1/2002
00548-6041-25
J2271
1/1/2002
00548-6042-25
J2270
1/1/2002
00548-6043-25
J2270
1/1/2002
00548-6045-25
J2270
1/1/2002
00548-6356-00
J2275
1/1/2002
00548-8301-00
J2370
1/1/2002
00548-8450-00
00548-9051-00
00548-9061-00
00548-9090-00
00548-9090-10
J2270
J2912
J0170
J3470
J3470
00555-0059-02
Q0163
ATROPINE SULFATE
NALOXONE HCL
(SRN,PREFIL,LUERJET,PF) 0.4 MG/ML
NALOXONE HCL
(SRN,PREFIL,LUERJET,PF) 1 MG/ML
LIDOCAINE HCL (SRN,PREFILLED,LUER12/31/2003 INJECTION, LIDOCAINE HCL, 50 CC
JET) 2%
LIDOCAINE HCL (SRN,PREFILLED,LUER99/99/9999 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG
JET) 2%
MORPHINE SULFATE
(SRN,PREFILLED,LUER-JET) 1 MG/ML
CORTROSYN (S.D.V.) 0.25 MG
MORPHINE SULFATE
(SRN,PREFIL,DILUTE-A-JET) 50 MG/ML
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE SULFATE
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER MORPHINE SULFATE (SRN,DILUTE-A7/1/2002 10 MG
JET,PF) 50 MG/ML
7/1/2002 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML
1/23/2002
1/1/2002
11/1/2004 99/99/9999 INJECTION, HYALURONIDASE, UP TO 150 UNITS

MORPHINE SULFATE (S.D.V.,FLIPTOP) 1
MG/ML
SODIUM CHLORIDE (S.D.V.) 0.9%
EPINEPHRINE HCL (M.D.V.) 1 MG/ML
AMPHADASE 150 U/ML
AMPHADASE 150 U/ML
Page 104 of 374
1 ML SR
IJ
ML
50 MG
01/01/2002
04/01/2008
10 ML SR
IJ
ML
20 MG
0.5
01/01/2002
07/01/2007
1 ML SR
IJ
ML
1 MG
0.4
01/01/2002
07/01/2007
2 ML SR
IJ
ML
1 MG
01/01/2002
99/99/9999
30 ML SR
IJ
ML
10 MG
0.1
01/01/2002
99/99/9999
30 ML SR
IJ
ML
10 MG
0.1
01/01/2002
99/99/9999
30 ML VL
IJ
ML
10 MG
0.1
01/01/2002
07/01/2007
30 ML VL
IV
ML
10 MG
0.1
01/23/2002
07/01/2007
50 ML SR
IV
ML
1 EA
01/01/2002
99/99/9999
10 ML SR
IJ
ML
1 ML
01/01/2002
99/99/9999
10 ML SR
IJ
ML
0.3 MG
0.33333
01/01/2002
12/31/2009
5 ML SR
IV
ML
50 ML
0.02
01/01/2002
12/31/2003
5 ML SR
IV
ML
10 MG
01/01/2004
99/99/9999
10 ML SR
IJ
ML
10 MG
0.1
01/01/2002
99/99/9999
50 ML SR
IV
ML
1 EA
01/01/2002
99/99/9999
10 ML SR
IV
ML
1 EA
01/01/2002
99/99/9999
10 ML SR
IJ
ML
1 ML
01/01/2002
99/99/9999
5 ML SR
IJ
ML
0.3 MG
0.33333
01/01/2002
07/01/2007
10 ML SR
IJ
ML
0.3 MG
0.33333
01/01/2002
12/31/2009
1 ML SR
IJ
ML
1 MG
0.4
01/15/2002
07/01/2007
2 ML SR
3 ML SR
IJ
IV
ML
ML
1 MG
30 MG
1
1.66666
01/15/2002
02/01/2004
99/99/9999
04/01/2008
5 ML SR
IV
ML
50 ML
0.02
01/23/2002
12/31/2003
5 ML SR
IV
ML
10 MG
01/01/2004
99/99/9999
10 ML VL
1 EA VL
IJ
IJ
ML
EA
10 MG
0.25 MG
0.1
1
01/01/2002
06/26/2003
10/01/2007
12/31/2009
20 ML SR
IJ
ML
100 MG
0.5
01/01/2002
04/01/2004
40 ML SR
IJ
ML
100 MG
0.5
01/01/2002
07/01/2002
10 ML SR
IJ
ML
10 MG
2.5
01/01/2002
10/01/2007
20 ML SR
IJ
ML
10 MG
2.5
01/01/2002
10/01/2007
4 ML SR
IJ
ML
10 MG
2.5
01/01/2002
99/99/9999
10 ML SR
IJ
ML
10 MG
01/01/2002
07/01/2002
10 ML VL
IJ
ML
1 ML
01/01/2002
07/01/2002
50 ML
10 ML
30 ML
1 ML
1 ML
VL
VL
VL
VL
VL
IV
IV
IJ
SC
SC
ML
ML
ML
ML
ML
10 MG
0.9 %
1 ML
150 U
150 U
0.1
0.5
1
1
1
01/23/2002
01/01/2002
01/01/2002
11/01/2004
04/25/2005
06/01/2003
07/01/2002
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00555-0059-05
00555-0301-02
00555-0301-38
Q0163
J7509
J7509
1/1/2002
2/5/2002
4/10/2002
00555-0302-02
Q0178
1/1/2002
00555-0302-04
Q0178
1/1/2002
00555-0323-02
Q0177
1/1/2002
00555-0323-04
Q0177
1/1/2002
00555-0324-02
00555-0446-05
00555-0446-09
00555-0446-63
Q0178
J8999
J8999
J8999
1/1/2002
2/20/2003
1/1/2002
1/1/2002
00555-0521-02
Q0164
4/29/2004
00555-0522-02
Q0165
1/7/2002
00555-0522-04
00555-0572-02
00555-0572-35
00555-0572-45
00555-0572-46
00555-0572-47
00555-0572-48
00555-0572-49
Q0165
None
None
None
None
None
None
None
7/11/2002
1/1/1994
1/1/1994
10/4/1994
10/4/1994
10/4/1994
10/4/1994
10/4/1994
00555-0576-51
Q0166
3/17/2008
00555-0576-93
00555-0606-02
00555-0607-02
00555-0607-03
00555-0607-04
00555-0870-04
00555-0870-63
00555-0882-02
00555-0904-01
00555-0904-05
00555-0904-14
00555-0927-01
00555-0928-01
00555-0929-01
00555-0945-01
Q0166
J8999
J8999
J8999
J8999
J8999
J8999
J8999
J8999
J8999
J8999
None
None
None
None
3/17/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
2/20/2003
1/1/2002
5/1/2001
5/1/2001
5/1/2001
5/1/2001
00555-1117-05
J1170
5/8/2007
00555-1117-06
J1170
5/8/2007
00555-1117-07
J1170
5/8/2007
00555-1119-09
J2300
5/25/2007
00555-1120-09
J2300
5/25/2007

ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 GRANISETRON HYDROCHLORIDE
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 GRANISETRON HYDROCHLORIDE (FILM
COATED) 1 MG
FLUTAMIDE 125 MG
FLUTAMIDE 125 MG
HYDROXYUREA 500 MG
3/9/2006 METHOTREXATE, 5 MG
TREXALL 5 MG
3/9/2006 METHOTREXATE, 7.5 MG
TREXALL 7.5 MG
TREXALL 10 MG
TREXALL 15 MG
HYDROMORPHONE HYDROCHLORIDE
(10X1ML,PF) 10 MG/ML
(SDV,PF) 10 MG/ML
NALBUPHINE HYDROCHLORIDE
(25X10ML) 10 MG/ML
(25X10ML) 20 MG/ML
Page 105 of 374
1000 EA BO
100 EA BO
21 EA DP
PO
PO
PO
EA
EA
EA
50 MG
4 MG
4 MG
1
1
1
01/01/2002
02/05/2002
04/10/2002
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
500 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
500 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
BO
BO
BO
BO
PO
PO
PO
PO
EA
EA
EA
EA
50 MG
1 EA
1 EA
1 EA
2
1
1
1
01/01/2002
02/20/2003
02/20/2003
02/20/2003
99/99/9999
10/11/2005
12/22/2008
12/22/2008
100 EA BO
PO
EA
5 MG
04/29/2004
5/28/2009
100 EA BO
PO
EA
10 MG
01/07/2002
5/28/2009
500 EA
100 EA
36 EA
8 EA
12 EA
16 EA
20 EA
24 EA
BO
BO
BO
DP
DP
DP
DP
DP
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
10 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
1
1
1
1
1
1
1
1
07/11/2002
01/01/1994
01/01/1994
10/04/1994
10/04/1994
10/04/1994
10/04/1994
10/04/1994
06/28/2007
99/99/9999
99/99/9999
11/14/2002
12/10/2002
01/17/2003
11/14/2002
10/04/2002
20 EA BX
PO
EA
1 MG
03/17/2008
6/18/2009
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
5 MG
7.5 MG
10 MG
15 MG
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
03/17/2008
5/28/2009
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 11/13/2002
01/01/2002 99/99/9999
01/01/2002 05/07/2007
01/01/2002 12/22/2008
01/01/2002 99/99/9999
01/01/2002 12/22/2008
02/20/2003 10/11/2005
02/20/2003 12/22/2008
05/01/2001
3/9/2006
05/01/2001
3/9/2006
05/01/2001
12/2/2005
05/01/2001
12/2/2005
1 ML VL
IJ
ML
4 MG
2.5
05/08/2007
99/99/9999
5 ML VL
IJ
ML
4 MG
2.5
05/08/2007
99/99/9999
50 ML VL
IJ
ML
4 MG
2.5
05/08/2007
99/99/9999
10 ML VL
IJ
ML
10 MG
05/25/2007
99/99/9999
10 ML VL
IJ
ML
10 MG
05/25/2007
99/99/9999
100 EA
1000 EA
60 EA
180 EA
2 EA
100 EA
100 EA
250 EA
500 EA
500 EA
180 EA
100 EA
30 EA
1000 EA
90 EA
30 EA
30 EA
30 EA
30 EA
BX
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
1/1/2002
1/1/2002
8/20/2002
8/20/2002
1
1
1/1/2002
8/20/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00555-1121-05
J2300
00555-1122-05
J2300
00555-1127-10
J2275
00555-1128-10
J2275
00555-1129-10
J2275
00555-1130-10
00555-1131-11
00555-1132-12
J2275
J0895
J0895

7/10/2007 99/99/9999 10 MG
7/10/2007 99/99/9999 10 MG
7/10/2007 99/99/9999 10 MG
7/10/2007 99/99/9999 10 MG
00555-1984-14
J9265
6/3/2008
00555-1985-14
J9265
6/3/2008
00562-7805-01
J2790
00562-7805-05
J2790
00562-7805-25
J2790
00562-7806-01
J2788
00562-7806-05
J2788
00562-7806-25
00562-7807-01
J2788
J2790
(10X1ML) 10 MG/ML
(10X1ML) 20 MG/ML
MORPHINE SULFATE (USP,5X10ML,PF)
0.5 MG/ML
MORPHINE SULFATE (USP,5X10ML,PF) 1
MG/ML
MORPHINE SULFATE (USP,5X10ML,PF)
0.5 MG/ML
MORPHINE SULFATE (USP,5X10ML,PF) 1
MG/ML
DEFEROXAMINE MESYLATE 2 GM
DEFEROXAMINE MESYLATE 500 MG
PACLITAXEL (1X16.7ML,USP,MDV) 6
MG/ML
PACLITAXEL (1X50ML,USP,MDV) 6
MG/ML
RHOGAM ULTRA-FILTERED PLUS
(PF,LATEX-FREE) 300 MCG
MICRHOGAM ULTRA-FILTERED PLUS
RHOGAM (ULTRA-FILTERED,SF)
1 ML AM IJ
ML
10 MG
05/25/2007
99/99/9999
1 ML AM IJ
ML
10 MG
05/25/2007
99/99/9999
10 ML AM IJ
ML
10 MG
0.05
07/10/2007
99/99/9999
10 ML AM IJ
ML
10 MG
0.1
07/10/2007
99/99/9999
10 ML VL
IJ
ML
10 MG
0.05
07/10/2007
99/99/9999
10 ML VL
1 EA VL
1 EA VL
IJ
IJ
IJ
ML
EA
EA
10 MG
500 MG
500 MG
0.1
4
1
07/10/2007
09/05/2007
09/05/2007
99/99/9999
99/99/9999
99/99/9999
16.7 ML VL
IV
ML
30 MG
0.2
06/03/2008
6/30/2009
50 ML VL
IV
ML
30 MG
0.2
06/03/2008
6/30/2009
1 EA SR
IM
EA
300 MCG
09/01/2007
99/99/9999
5 EA SR
IM
EA
300 MCG
09/01/2007
99/99/9999
25 EA SR
IM
EA
300 MCG
09/01/2007
99/99/9999
1 EA SR
IM
EA
50 MCG
09/01/2007
99/99/9999
5 EA SR
IM
EA
50 MCG
09/01/2007
99/99/9999
25 EA SR
1 ML SR
IM
IM
EA
ML
50 MCG
300 MCG
1
1
09/01/2007
08/08/2006
99/99/9999
99/99/9999
00562-7807-06
J2790
RHOGAM (SRN,SFTY~300 MCG ANTI-D)
1 ML SR
IM
ML
300 MCG
01/01/2002
99/99/9999
00562-7807-26
00562-7808-01
J2790
J2788
RHOGAM (SRN,SFTY~300 MCG ANTI-D)

MICRHOGAM ULTRA-FILTERED (PF)
1 ML SR
1 ML SR
IM
IM
ML
ML
300 MCG
50 MCG
1
1
01/01/2002
08/08/2006
99/99/9999
99/99/9999
1/1/2002
MICRHOGAM (SRN,~50 MCG ANTI-RHO)

MICRHOGAM ULTRA-FILTERED
(SRN,~50MCG ANTI-RHO,PF)
1 ML SR
IM
ML
300 MCG
0.16667
01/01/2002
01/27/2002
1 ML SR
IM
ML
300 MCG
0.16667
02/12/2002
12/31/2002
1 ML SR
IM
ML
50 MCG
01/01/2003
99/99/9999
MICRHOGAM (SRN,~50 MCG ANTI-RHO)

BUBBLI-PRED (DYE-FREE,BUBBLE GUM)
5 MG/5 ML
BACITRACIN (VIAL) 50000 U
1 ML SR
IM
ML
300 MCG
0.16667
01/01/2002
01/27/2002
1 ML SR
IM
ML
300 MCG
0.16667
02/12/2002
12/31/2002
1 ML SR
IM
ML
50 MCG
01/01/2003
99/99/9999
120 ML BO
1 EA BO
PO
IM
ML
EA
5 MG
1 EA
0.2
1
08/04/2004
01/01/2002
06/28/2006
08/25/2003
BACITRACIN (U.S.P.,5 MU,MICRONIZED)

PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
HYDROCORTISONE ACETATE
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
PROGESTERONE (U.S.P.)
PROGESTERONE WETTABLE
(U.S.P.,MICROCRYSTALLINE)
PROGESTERONE (U.S.P., MILLED)
1 EA BO
NA
EA
1 EA
01/01/2002
11/12/2003
1 EA CN
NA
GM
1 MG
1000
01/01/2002 12/16/2008
01/01/2002 12/16/2008
00562-7808-05
J2790
00562-7808-06
J2790
00562-7808-06
J2788
00562-7808-25
J2790
1/1/2002
1/27/2002 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MCG (1500 I.U.)
00562-7808-26
J2790
00562-7808-26
J2788
00574-0148-04
00574-0200-01
J7510
J3490
8/4/2004
1/1/2002
00574-0400-05
J3490
00574-0408-10
J7638

DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
00574-0408-10 KO J7638
KO

00574-0421-01
J1700
1/1/2002 99/99/9999 INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG
00574-0421-25
00574-0430-00
00574-0430-01
00574-0430-25
J1700
J2675
J2675
J2675

1/1/2002 11/21/2008 INJECTION, PROGESTERONE, PER 50 MG
1/1/2002
00574-0431-00
J2675
1/1/2002
00574-0431-01
J2675
00574-0431-25
00574-0432-00
J2675
J2675
00574-0450-05
J7684

TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
1/1/2002
1/1/2002
1/1/2002
00574-0450-05 KO J7684
00574-0450-10
KO
J7684
00574-0450-10 KO J7684
00574-0460-00
J3140
00574-0460-05
J3140
KO
1 EA CN
NA
GM
1 MG
1000
1 EA BO
NA
GM
25 MG
40
01/01/2002
1
1
1
1
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
25 MG
50 MG
50 MG
50 MG
40
20
20
20
01/01/2002 99/99/9999
01/01/2002 11/21/2008
01/01/2002
1/6/2009
01/01/2002
1/26/2009
1 EA BO
NA
GM
50 MG
20
01/01/2002
4/6/2009
1 EA BO
NA
GM
50 MG
20
01/01/2002
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
50 MG
50 MG
20
20
01/01/2002 10/27/2008
01/01/2002 05/23/2007
TRIAMCINOLONE ACETONIDE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
9/27/2007
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/06/2004

TESTOSTERONE (U.S.P.,MICRONIZED)
1 EA BO
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
1 MG
50 MG
50 MG
1000
20
20
01/01/2002
01/01/2002
01/01/2002
01/06/2004
06/03/2002
99/99/9999
Page 106 of 374
EA
EA
EA
EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
99/99/9999
9/27/2007
00574-0460-25
00574-0461-05
00574-0461-25
J3140
J3150
J3150

00574-0820-01
J1080
12/21/2007 99/99/9999 INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG
00574-0820-10
J1080
00574-0821-05
J3130
00574-0823-01
J0706
00574-0823-81
00574-0836-25
J0706
J2550

8/1/2007 99/99/9999 INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG
00574-0850-05
J1110
8/4/2003 99/99/9999 INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG
00574-0850-10
J1110
00574-0858-01
00574-0866-10
00574-2006-25
00574-2017-01
J0770
J7516
J2271
J1170
00574-7226-12
00574-7226-12
K0416
J8498
00574-7234-12
00574-7234-12
K0416
J8498
00574-7236-12
00574-7236-12
K0416
J8498
00585-0673-02
J7631
00585-0673-02 KO J7631
00585-0673-03
3/11/2005
11/19/2004
1/1/2002
1/1/2002
KO
J7631
00585-0673-03 KO J7631
00591-0217-02
J7510
00591-0335-01
J8499
00591-0335-05
J8499
00591-0336-01
J8499
00591-0336-05
J8499
00591-0520-38
J7510
00591-0790-01
J7509
00591-0790-21
J7509
00591-0800-01
Q0177
00591-0800-05
Q0177
00591-0801-01
Q0178
00591-0801-05
Q0178
00591-2186-53
J2322
00591-2186-54
J2322
00591-2224-55
00591-2365-69
00591-2366-68
00591-2692-01
00591-2692-05
J7502
J0690
J0690
J8499
J8499
00591-3128-79
00591-3157-54
J2675
J2550
00591-3157-83
00591-3158-54
J2550
J2550
KO
TESTOSTERONE PROPIONATE
TESTOSTERONE CYPIONATE
(1X1ML,USP) 200 MG/ML
(1X10ML,USP) 200 MG/ML
TESTOSTERONE ENANTHATE
(USP,MULTIPLE DOSE) 200 MG/ML
CAFFEINE CITRATE (USP,PF) 20 MG/ML
NOVAPLUS CAFFEINE CITRATE
(USP,10X3ML,PF) 20 MG/ML
PROMETHAZINE HCL (AMP) 25 MG/ML
DIHYDROERGOTAMINE MESYLATE
(AMP) 1 MG/ML
(AMP) 1 MG/ML
COLISTIMETHATE SODIUM
(VIAL,STERILE) 150 MG
CYCLOSPORINE 50 MG/ML
MORPHINE SULFATE
HYDROMORPHONE HCL
99/99/9999 INJECTION, COLISTIMETHATE SODIUM, UP TO 150 MG

COMPRO 25 MG
COMPRO 25 MG
PHENADOZ 25 MG
PHENADOZ 25 MG
PHENADOZ 12.5 MG
PHENADOZ 12.5 MG
1/1/2002 12/14/2005 DOSE FORM, PER 10 MILLIGRAMS
INTAL 10 MG/ML
INTAL 10 MG/ML
INTAL 10 MG/ML
INTAL 10 MG/ML
PREDNISOLONE 5 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
5/15/2003
1/1/2002
7/22/2002
4 MG
HYDROXYZINE PAMOATE (USP) 25 MG
MG/ML
MG/ML
CYCLOSPORINE (1X50ML,MODIFIED)
100 MG/ML
1/22/2003
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
PROGESTERONE IN SESAME OIL (VIAL)
50 MG/ML
PROMETHAZINE HCL 25 MG/ML
PROMETHAZINE HCL (AMPULES) 25
MG/ML
Page 107 of 374
1 EA BO
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
50 MG
100 MG
100 MG
20
10
10
01/01/2002
01/01/2002
01/01/2002
1 ML VL
IM
ML
200 MG
12/21/2007
99/99/9999
IM
ML
200 MG
12/21/2007
99/99/9999
5 ML VL
IM
ML
200 MG
08/01/2007
99/99/9999
3 ML VL
IV
ML
5 MG
09/21/2006
99/99/9999
3 ML VL IV
1 ML AM IJ
ML
ML
5 MG
50 MG
4
0.5
09/28/2007
08/08/2003
99/99/9999
04/20/2006
1 ML AM IJ
ML
1 MG
08/04/2003
99/99/9999
1 ML AM IJ
ML
1 MG
03/15/2004
99/99/9999
1 EA
5 ML
1 EA
1 EA
VL
AM
JR
BO
IJ
IV
NA
NA
EA
ML
GM
GM
150 MG
250 MG
100 MG
4 MG
1
0.2
10
250
03/11/2005
11/19/2004
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
06/26/2003
01/01/2006
12/31/2005
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
07/29/2003
01/01/2006
12/31/2005
99/99/9999
2 ML PC
IH
ML
10 MG
01/01/2003
12/14/2005
1/1/2002 12/31/2002
2 ML PC
IH
ML
10 MG
01/01/2003
12/14/2005
1/1/2002 12/31/2002
2 ML PC
IH
ML
10 MG
01/01/2003
12/14/2005
1/1/2002 12/31/2002
PC
NA
BO
BO
BO
BO
BO
BO
IH
PO
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
ML
EA
10 MG
5 MG
1 EA
1 EA
1 EA
1 EA
5 MG
4 MG
1
1
1
1
1
1
0.6
1
01/01/2003
01/01/2002
10/22/2003
11/18/2003
07/02/2003
11/18/2003
05/15/2003
01/01/2002
12/14/2005
8/15/2008
99/99/9999
10/31/2005
99/99/9999
12/06/2005
08/02/2004
04/09/2007
01-Jan-02 31-Dec-02
21 EA DP
PO
EA
4 MG
07/22/2002
04/07/2006
100 EA BO
PO
EA
25 MG
09/18/2006
99/99/9999
500 EA BO
PO
EA
25 MG
09/18/2006
99/99/9999
100 EA BO
PO
EA
50 MG
09/18/2006
99/99/9999
1/1/2002
8/17/2005
1/1/2002
8/9/2005
2
20
1
500 EA BO
1 ML VL
1 ML VL
PO
EA
50 MG
09/18/2006
99/99/9999
IM
ML
200 MG
07/09/2003
03/20/2007
07/09/2003
3/20/2007
IM
ML
200 MG
PO
IJ
IJ
PO
PO
ML
EA
EA
EA
EA
100 MG
500 MG
500 MG
1 EA
1 EA
1
2
20
1
1
12/23/2008 99/99/9999
03/07/2005 01/02/2007 1/22/2003 11/18/2004
03/07/2005 08/24/2006 4/29/2003 10/14/2004
4/3/2009 99/99/9999 01/01/2003 2/13/2009
11/18/2003 12/06/2005
10 ML VL IM
1 ML AM IJ
ML
ML
50 MG
50 MG
1
0.5
12/17/2002
01/20/2003
99/99/9999
10/5/2006
1 ML AM IJ
1 ML AM IJ
ML
ML
50 MG
50 MG
0.5
1
01/23/2003
01/20/2003
10/05/2006
2/28/2006
50 ML
1 EA
1 EA
100 EA
500 EA
VL
VL
VL
BO
BO
99/99/9999
99/99/9999
99/99/9999
10 ML VL
2 ML
1000 EA
100 EA
500 EA
100 EA
500 EA
236 ML
100 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00591-3158-83
J2550
1/23/2003
00591-3189-02
J9206
3/4/2008
00591-3189-02 QR J9206
00591-3189-26
QR
J9206
00591-3189-26 QR J9206
3/4/2008
3/4/2008
QR
3/4/2008
00591-3221-26
00591-3222-47
J3130
J2360
3/9/2004
9/7/2004
00591-3223-79
00591-3336-26
00591-3337-12
00591-3338-89
00591-3365-45
00591-3365-70
J1080
J9045
J9045
J9045
J2060
J2060
3/29/2004
1/19/2007
1/19/2007
1/19/2007
2/22/2005
2/22/2005
00591-3433-30
J7620
1/2/2008
00591-3433-60
J7620
1/2/2008
00591-3454-60
J9045
1/19/2007
00591-3467-53
J7603
1/1/2008
00591-3467-53 KO J7603
00591-3467-53
00591-3467-53 KO J7613
00591-3468-53
KO
4/1/2008
1/1/2008
KO
J7613
00591-3468-53 KO J7613
1/1/2008
4/1/2008
J7603
00591-3468-53 KO J7603
00591-3468-53
KO
J7613
1/1/2008
4/1/2008
KO
4/1/2008
00591-3469-83
J9178
10/23/2007
00591-3470-57
00591-3549-69
00591-3550-68
J9178
J0690
J0690
10/23/2007
1/3/2007
8/25/2006
00591-3553-69
00591-3559-11
00591-5052-01
00591-5052-10
00591-5059-01
J2590
J0770
J7506
J7506
J7510
12/6/2006
1/30/2007
1/1/2002
1/1/2002
1/1/2002
00591-5307-01
Q0170
4/15/2002
00591-5307-10
Q0170
4/15/2002
00591-5319-01
00591-5442-01
00591-5442-05
00591-5442-10
00591-5443-01
00591-5443-05
Q0170
J7506
J7506
J7506
J7506
J7506
4/15/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
PROMETHAZINE HCL (AMPULE) 50

MG/ML
1 ML AM
IRINOTECAN HYDROCHLORIDE
(1X2ML,SINGLE-USE) 20 MG/ML
2 ML VL
2 ML VL
5 ML VL
5 ML VL
TESTOSTERONE ENANTHATE 200
99/99/9999 INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG
MG/ML
5 ML VL
ORPHENADRINE CITRATE 30 MG/ML
2 ML AM
TESTOSTERONE CYPIONATE (M.D.V.)
200 MG/ML
10 ML VL
CARBOPLATIN (MDV,PF) 10 MG/ML
5 ML VL
15 ML VL
45 ML VL
LORAZEPAM (SDV) 2 MG/ML
1 ML VL
LORAZEPAM (MDV) 2 MG/ML
10 ML VL
CARBOPLATIN (MDV,600MG/60ML,PF) 10
MG/ML
60 ML VL
ALBUTEROL SULFATE (25X3ML,PF)
0.021%
3 ML PC
0.021%
3 ML PC
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONALBUTEROL SULFATE (25X3ML,PF)
0.021%
3 ML PC
0.021%
3 ML PC
0.042%
3 ML PC
0.042%
3 ML PC
0.042%
3 ML PC
0.042%
3 ML PC
EPIRUBICIN HYDROCHLORIDE (PF) 2
MG/ML
25 ML VL
MG/ML
100 ML VL
CEFAZOLIN (USP) 1 GM
1 EA VL
1 EA VL
OXYTOCIN (USP,SYNTHETIC,1MLX25) 10
11/19/2007 INJECTION, OXYTOCIN, UP TO 10 UNITS
U/ML
1 ML VL
COLISTIMETHATE (USP) 150 MG
1 EA VL
PREDNISONE 5 MG
100 EA BO
PREDNISONE 5 MG
1000 EA BO
PREDNISOLONE 5 MG
100 EA BO
100 EA BO
1000 EA BO
100 EA BO
PREDNISONE 10 MG
100 EA BO
PREDNISONE 10 MG
500 EA BO
PREDNISONE 10 MG
1000 EA BO
PREDNISONE 20 MG
100 EA BO
PREDNISONE 20 MG
500 EA BO
Page 108 of 374
IJ
ML
50 MG
01/23/2003
10/05/2006
IV
ML
20 MG
03/04/2008
5/1/2008
IV
ML
20 MG
03/04/2008
5/1/2008
IV
ML
20 MG
03/04/2008
5/1/2008
IV
ML
20 MG
03/04/2008
5/1/2008
IM
IJ
ML
ML
200 MG
60 MG
1
0.5
03/09/2004
09/07/2004
99/99/9999
99/99/9999
IM
IV
IV
IV
IJ
IJ
ML
ML
ML
ML
ML
ML
200 MG
50 MG
50 MG
50 MG
2 MG
2 MG
1
0.2
0.2
0.2
1
1
03/29/2004
01/19/2007
01/19/2007
01/19/2007
08/16/2006
02/22/2005
99/99/9999
10/17/2007
10/17/2007
10/17/2007
09/12/2007
7/17/2007
IH
ML
2.5 MG
0.33333
01/02/2008
99/99/9999
IH
ML
2.5 MG
0.33333
01/02/2008
99/99/9999
IV
ML
50 MG
0.2
01/19/2007
10/17/2007
IH
ML
1 MG
0.21
01/01/2008
03/31/2008
IH
ML
1 MG
0.21
01/01/2008
03/31/2008
IH
ML
1 MG
0.21
04/01/2008
99/99/9999
IH
ML
1 MG
0.21
04/01/2008
99/99/9999
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
IV
ML
2 MG
10/23/2007 10/26/2007
IV
IJ
IV
ML
EA
EA
2 MG
500 MG
500 MG
1
2
20
10/23/2007 10/26/2007
01/03/2007
1/12/2009
08/25/2006
11/7/2008
IJ
IJ
PO
PO
PO
ML
EA
EA
EA
EA
10 U
150 MG
5 MG
5 MG
5 MG
1
1
1
1
1
12/06/2006
01/30/2007
01/01/2002
01/01/2002
01/01/2002
11/19/2007
5/22/2008
99/99/9999
99/99/9999
8/15/2008
PO
EA
25 MG
04/15/2002
99/99/9999
PO
EA
25 MG
04/15/2002
99/99/9999
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
25 MG
5 MG
5 MG
5 MG
5 MG
5 MG
2
2
2
2
4
4
04/15/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2/22/2005
2/27/2006
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00591-5443-10
J7506
00591-5726-01
Q0177
00591-5726-05
Q0177

2/13/2002
00591-6717-02
J2321
4/29/2003
00591-6717-47
00597-0060-11
J2321
J0706
00597-0080-62
J7644
PREDNISONE 20 MG
PO
EA
25 MG
02/13/2002
08/01/2005
MG/ML
MG/ML
CAFCIT (S.D.V.) 20 MG/ML
500 EA BO
09/27/2005
Q0181
J7510
11/5/2007
00603-1567-58
J7510
11/5/2007
00603-1584-54
Q0170
00603-1584-58
Q0170
00603-0823-58
Q0163
00603-0823-81
Q0163
00603-0823-94
Q0163
00603-0860-54
Q0163
00603-1005-40
J7619
00603-1005-40 KO J7619
KO
PO
EA
25 MG
01/01/2002
2 ML VL
IM
ML
100 MG
04/29/2003
3/20/2007
2 ML VL
3 ML VL
IM
IJ
ML
ML
100 MG
5 MG
1
4
04/29/2003
01/01/2002
01/05/2007
12/31/2003
2.5 ML VL
IH
ML
1 MG
0.2
01/01/2002
07/06/2004
2.5 ML VL
IH
ML
1 MG
0.2
01/01/2002
07/06/2004
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
10/14/2004
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
06/04/2007
24 EA BO
PO
EA
50 MG
0.5
06/05/2007
99/99/9999
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
473 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
240 ML BO
PO
ML
50 MG
0.05
07/25/2002
99/99/9999
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2002
10/14/2004
3 ML PC
IH
ML
1 MG
0.83
01/01/2002
10/14/2004
20 ML BO
IH
ML
1 MG
01/01/2002
12/31/2004
20 ML BO
IH
ML
1 MG
01/01/2005
01/25/2005
480 ML BO
PO
ML
100 MG
0.1
12/01/2004
05/31/2005
240 ML BO
PO
ML
1 EA
01/01/2002
01/10/2003
240 ML BO
PO
ML
5 MG
0.6
11/05/2007
8/7/2009

ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE PLAIN (USP) 6.25 MG/5
ML
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE PLAIN (USP) 6.25 MG/5
ML
480 ML BO
PO
ML
5 MG
0.6
11/05/2007
8/7/2009
118 ML BO
PO
ML
25 MG
0.05
05/12/2006
99/99/9999
473 ML BO
PO
ML
25 MG
0.05
05/12/2006
99/99/9999
Page 109 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
100 EA BO
00603-1567-56
Q0163
Start Date #1
00603-1145-56
00603-0823-54
CF
99/99/9999
G9017
Q0163
HCPCS Measure #1
01/01/2002
00603-1010-58
00603-0241-18
HCPCS Amount #1
J7611
Q0163
Billing Units
5 MG
J7618
00603-0240-18
EA
00603-1006-43
Q0163
NDC Package Type
PO
00603-1006-43
00603-0239-18
KO
NDC Package Measure
1000 EA BO
4/29/2003
ATROVENT (VIAL) 0.02%
1/1/2002
7/6/2004 MILLIGRAM
ATROVENT (VIAL) 0.02%
1/1/2002
7/6/2004 MILLIGRAM
Q-DRYL (CAPLET) 25 MG
Q-DRYL 25 MG
1/1/2002
Q-DRYL 25 MG
Q-DRYL (AF,CHERRY) 12.5 MG/5 ML
Q-DRYL 12.5 MG/5 ML
Q-DRYL 12.5 MG/5 ML
Q-DRYL (UNBOXED,AF,CHERRY) 12.5
MG/5 ML
QUENALIN 12.5 MG/5 ML
1/1/2002 12/31/2004 (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON1/1/2005 1/25/2005 COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MG
12/1/2004 5/31/2005 APPROVED DEMONSTRATION PROJECT)
AMANTADINE HCL 50 MG/5 ML
1/1/2002 1/10/2003 REGIMEN
00597-0080-62 KO J7644

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00603-3337-21
Q0163
12/16/2002
00603-3337-32
Q0163
1/1/2002
00603-3338-21
Q0163
12/16/2002
00603-3338-32
Q0163
1/1/2002
00603-3339-21
Q0163
5/24/2007
00603-3339-32
Q0163
6/5/2007
00603-3340-21
Q0163
4/3/2007
00603-3340-32
00603-3946-21
00603-4499-21
Q0163
J8999
None
4/3/2007
1/1/2002
1/1/1994
00603-4593-15
00603-4593-21
J7509
J7509
00603-5090-21
Q0175
00603-5090-28
Q0175
00603-5091-21
Q0175
00603-5091-28
Q0175
00603-5092-21
Q0176
00603-5092-28
Q0176
00603-5093-21
00603-5332-15
00603-5332-21
00603-5332-31
00603-5332-32
00603-5333-15
00603-5333-21
00603-5333-31
00603-5333-32
00603-5334-21
00603-5334-32
00603-5335-21
00603-5335-32
00603-5336-21
00603-5337-15
00603-5337-21
00603-5337-31
Q0176
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506

1/1/2002 99/99/9999 METHYLPREDNISOLONE ORAL, PER 4 MG

1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002
1/1/2002
1/1/2002
1/1/2002
100 EA BO
PO
EA
50 MG
0.5
12/16/2002
05/23/2007
1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
06/04/2007
100 EA BO
PO
EA
50 MG
12/16/2002
04/02/2007
1000 EA BO
PO
EA
50 MG
01/01/2002
04/02/2007
DIPHENHYDRAMINE HYDROCHLORIDE
(USP) 25 MG
100 EA BO
PO
EA
50 MG
0.5
05/24/2007
99/99/9999
(USP) 25 MG
1000 EA BO
PO
EA
50 MG
0.5
06/05/2007
99/99/9999
(USP) 50 MG
100 EA BO
PO
EA
50 MG
04/03/2007
99/99/9999
1000 EA BO
100 EA BO
100 EA NA
PO
PO
PO
EA
EA
EA
50 MG
1 EA
2.5 MG
1
1
1
04/03/2007
01/01/2002
01/01/1994
99/99/9999
01/30/2002
08/24/2000
21 EA DP
100 EA BO
PO
PO
EA
EA
4 MG
4 MG
1
1
01/01/2002
01/01/2002
99/99/9999
99/99/9999
PERPHENAZINE 2 MG
100 EA BO
PO
EA
4 MG
0.5
7/2/2009
99/99/9999 01/01/2002
9/19/2008
0.5
PERPHENAZINE 2 MG
500 EA BO
PO
EA
4 MG
0.5
7/2/2009
99/99/9999 01/01/2002
9/19/2008
0.5
PERPHENAZINE 4 MG
100 EA BO
PO
EA
4 MG
7/2/2009
99/99/9999 01/01/2002
9/19/2008
PERPHENAZINE 4 MG
500 EA BO
PO
EA
4 MG
7/2/2009
99/99/9999 01/01/2002
9/19/2008
PERPHENAZINE 8 MG
100 EA BO
PO
EA
8 MG
7/2/2009
99/99/9999 01/01/2002
9/19/2008
PERPHENAZINE 8 MG
500 EA BO
PO
EA
8 MG
7/2/2009
99/99/9999 01/01/2002
9/19/2008
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
8 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
2
1
1
1
1
2
2
2
2
4
4
0.2
0.2
0.5
1
1
1
7/2/2009
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/03/2005
01/03/2005
01/03/2005
08/20/2003
01/16/2003
08/20/2003
99/99/9999 01/01/2002
08/19/2003
01/15/2003
08/19/2003
01/15/2003
03/05/2003
01/29/2003
04/01/2003
01/29/2003
09/09/2003
09/09/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
9/19/2008
(USP) 50 MG
HYDROXYUREA 500 MG
4 MG
PERPHENAZINE 16 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 1 MG
PREDNISONE 1 MG
PREDNISONE 2.5 MG
PREDNISONE 5 MG
Page 110 of 374
100 EA
21 EA
100 EA
48 EA
1000 EA
21 EA
100 EA
48 EA
1000 EA
100 EA
1000 EA
100 EA
1000 EA
100 EA
21 EA
100 EA
48 EA
BO
DP
BO
DP
BO
DP
BO
DP
BO
BO
BO
BO
BO
BO
DP
BO
DP
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/16/2003
3/6/2003
1/30/2003
1/30/2003
4/2/2003
1/30/2003
9/10/2003
9/10/2003
9/10/2003
00603-5437-21
Q0169
8/25/2006
00603-5438-21
Q0170
8/25/2006
00603-5438-32
Q0170
8/25/2006
00603-5439-21
Q0170
8/25/2006
00603-6256-21
Q0173
1/1/2002
00615-0331-53
Q0177
1/1/2002
00615-0331-63
Q0177
1/1/2002
00615-0332-53
Q0178
1/1/2002
00615-0332-63
Q0178
1/1/2002
00615-0368-53
Q0163
4/1/2003
00615-0368-63
Q0163
4/1/2003
00615-0369-53
Q0163
1/1/2002
00615-0369-63
00615-0536-53
00615-0536-63
Q0163
J7506
J7506
1/1/2002
1/1/2002
1/1/2002
00615-3570-53
00615-3570-63
00615-3593-53
00615-3593-63
J8999
J8999
J7506
J7506
1/1/2002
1/1/2002
1/1/2002
1/1/2002
00641-0121-21
J1170
12/8/2004
00641-0121-25
J1170
1/1/2002
00641-0130-25
J2175
1/1/2002
00641-0140-25
J2175
1/1/2002
00641-0150-25
J2175
1/1/2002
00641-0160-25
J2175
1/1/2002
Page 111 of 374
100 EA BO
PO
EA
12.5 MG
08/25/2006
99/99/9999
100 EA BO
PO
EA
25 MG
08/25/2006
99/99/9999
1000 EA BO
PO
EA
25 MG
08/25/2006
99/99/9999
100 EA BO
PO
EA
25 MG
08/25/2006
99/99/9999
100 EA BO
PO
EA
250 MG
01/01/2002
05/02/2002
31 EA BX
PO
EA
25 MG
01/01/2002
10/31/2003
31 EA BX
PO
EA
25 MG
01/01/2002
10/31/2003
31 EA BX
PO
EA
50 MG
01/01/2002
10/31/2003
31 EA BX
PO
EA
50 MG
01/01/2002
10/31/2003
31 EA BX
PO
EA
50 MG
0.5
04/01/2003
10/31/2003
31 EA BX
PO
EA
50 MG
0.5
04/01/2003
10/31/2003
31 EA BX
PO
EA
50 MG
01/01/2002
10/30/2003
31 EA BX
31 EA BX
31 EA BX
PO
PO
PO
EA
EA
EA
50 MG
5 MG
5 MG
1
1
1
01/01/2002
01/01/2002
01/01/2002
10/31/2003
10/31/2003
10/31/2003
31 EA
31 EA
31 EA
31 EA
PO
PO
PO
PO
EA
EA
EA
EA
1 EA
1 EA
5 MG
5 MG
1
1
2
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10/31/2003
10/31/2003
10/31/2003
10/31/2003
1 ML VL
IJ
ML
4 MG
0.5
12/08/2004
99/99/9999
1 ML VL
IJ
ML
4 MG
0.5
01/01/2002
99/99/9999
1 ML VL
IJ
ML
100 MG
0.25
01/01/2002
04/24/2003
1 ML VL
IJ
ML
100 MG
0.5
01/01/2002
04/24/2003
1 ML VL
IJ
ML
100 MG
0.75
01/01/2002
04/24/2003
1 ML VL
IJ
ML
100 MG
01/01/2002
04/24/2003
BX
BX
BX
BX
CF
HCPCS Amount #1
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior End Date #3
01/16/2003
03/06/2003
01/30/2003
01/30/2003
04/02/2003
01/30/2003
09/10/2003
09/10/2003
09/10/2003
Prior Start Date #3
1
2
2
2
2
2
4
4
4
MG
MG
MG
MG
MG
MG
MG
MG
MG
Prior End Date #2
5
5
5
5
5
5
5
5
5
End Date #1
EA
EA
EA
EA
EA
EA
EA
EA
EA
Start Date #1
PO
PO
PO
PO
PO
PO
PO
PO
PO
HCPCS Measure #1
BO
DP
BO
BO
DP
BO
BO
BO
BO
Billing Units
1000 EA
21 EA
100 EA
500 EA
48 EA
1000 EA
100 EA
500 EA
1000 EA
Prior Start Date #2

Package
NDC Label
HCPCS Description

PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
(USP) 12.5 MG
(USP) 25 MG
(USP) 25 MG
(USP) 50 MG
HYDROXYZINE PAMOATE
(31X10,CARDED) 25 MG
HYDROXYZINE PAMOATE (31X10) 25 MG
HYDROXYZINE PAMOATE
DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE HCL (31X10) 25 MG
DIPHENHYDRAMINE HCL
PREDNISONE (31X10,CARDED) 5 MG
MEGESTROL ACETATE (31X10,CARDED)
40 MG
HYDROMORPHONE HCL (VIAL,
DOSETTE) 2 MG/ML
HYDROMORPHONE HCL (VIAL,
DOSETTE) 2 MG/ML
MEPERIDINE HCL (VIAL, DOSETTE) 25
MG/ML
MG/ML
MG/ML
MG/ML
NDC Package Type
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
NDC Package Measure
00603-5337-32
00603-5338-15
00603-5338-21
00603-5338-28
00603-5338-31
00603-5338-32
00603-5339-21
00603-5339-28
00603-5339-32
HCPCS Mod
HCPCS
NDC Mod
NDC
J2270
00641-0170-21
J2270
00641-0170-25
J2270
00641-0180-25
J2270
1/1/2002
00641-0190-21
J2271
00641-0190-25
00641-0272-21
00641-0272-25
00641-0273-21
00641-0273-25
J2271
J1642
J1642
J1642
J1642
00641-0367-21
J1100

1/1/2002
5/5/2007
10/17/2005
5/5/2007
10/17/2005

J1100
J2730
J2730

00641-0376-21
J1200
00641-0376-25
00641-0387-21
00641-0387-25
00641-0389-21
00641-0389-25
00641-0391-02
J1200
J1642
J1642
J1642
J1642
J1644
1/1/2002
12/8/2004
1/1/2002
12/8/2004
1/1/2002
10/1/2007
00641-0391-21
J1644
00641-0391-25
00641-0391-64
00641-0392-21
00641-0392-25
00641-0393-21
00641-0393-25
J1644
J1644
J1642
J1642
J1642
J1642
1/1/2002
10/1/2007
12/8/2004
1/1/2002
12/8/2004
1/1/2002
00641-0394-25
J1580
1/1/2002
00641-0395-25
00641-0400-02
J1580
J1644

00641-0400-21
J1644
00641-0400-25
00641-0400-64
00641-0410-02
J1644
J1644
J1644
1/1/2002
00641-0410-21
J1644
00641-0410-25
00641-0410-64
J1644
J1644

00641-0411-21
J1642
00641-0411-25
J1642
00641-0414-21
J1642
00641-0414-25
J1642
00641-0476-21
J2560
00641-0476-25
J2560
00641-0477-21
J2560
00641-0477-25
J2560
00641-0489-25
J2690
1/1/2002
00641-0491-21
J0780
00641-0491-25
J0780


MORPHINE SULFATE (VIAL, DOSETTE) 5

MG/ML
MG/ML
MG/ML
MORPHINE SULFATE (VIAL, DOSETTE)
10 MG/ML
MORPHINE SULFATE (DOSETTE, VIAL)
15 MG/ML
MORPHINE SULFATE (DOSETTE, VIAL)
15 MG/ML
HEP-LOCK U/P (PF) 10 U/ML
HEP-LOCK U/P (PF) 10 U/ML
HEP-LOCK 100 U/ML
HEP-LOCK 100 U/ML
PHOSPHATE (VIAL, DOSETTE) 10 MG/ML
PHOSPHATE (VIAL, DOSETTE) 10 MG/ML
DIPHENHYDRAMINE HCL (DOSETTE
VIAL) 50 MG/ML
DIPHENHYDRAMINE HCL (DOSETTE
VIAL) 50 MG/ML
HEP-LOCK (DOSETTE VIAL) 100 U/ML
HEPARIN SODIUM (VIAL, DOSETTE) 1000
U/ML
U/ML
GENTAMICIN SULFATE (VIAL, DOSETTE)
10 MG/ML
GENTAMICIN SULFATE (VIAL, DOSETTE)
40 MG/ML
U/ML
U/ML
HEPARIN SODIUM (VIAL, DOSETTE)
10000 U/ML
HEPARIN SODIUM (VIAL, DOSETTE)
10000 U/ML
HEP-LOCK U/P (DOSETTE VIAL,PF) 100
U/ML
U/ML
U/ML
U/ML
PHENOBARBITAL SODIUM (VIAL,
DOSETTE) 65 MG/ML
PHENOBARBITAL SODIUM (VIAL,
DOSETTE) 65 MG/ML
PHENOBARBITAL SODIUM (DOSETTE
VIAL) 130 MG/ML
PHENOBARBITAL SODIUM (DOSETTE
VIAL) 130 MG/ML
PROCAINAMIDE HCL (M.D.V.) 500 MG/ML
PROCHLORPERAZINE EDISYLATE (VIAL,
DOSETTE) 5 MG/ML
PROCHLORPERAZINE EDISYLATE (VIAL,
DOSETTE) 5 MG/ML
Page 112 of 374
1 ML VL
IJ
ML
10 MG
0.5
01/01/2002
04/29/2004
1 ML VL
IJ
ML
10 MG
0.8
12/08/2004
12/14/2006
1 ML VL
IJ
ML
10 MG
0.8
01/01/2002
12/14/2006
1 ML VL
IJ
ML
10 MG
01/01/2002
05/18/2004
1 ML VL
IJ
ML
100 MG
0.15
12/08/2004
12/14/2006
1 ML
1 ML
1 ML
1 ML
1 ML
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
ML
ML
ML
ML
ML
100 MG
10 U
10 U
10 U
10 U
0.15
1
1
10
10
01/01/2002
05/05/2007
10/17/2005
05/05/2007
10/17/2005
12/14/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
IJ
ML
1 MG
10
12/08/2004
99/99/9999
1 ML VL
1 EA VL
1 EA VL
IJ
IJ
IJ
ML
EA
EA
1 MG
1 GM
1 GM
10
1
1
01/01/2002
12/08/2004
03/14/2003
99/99/9999
99/99/9999
12/19/2004
1 ML VL
IJ
ML
50 MG
12/08/2004
99/99/9999
1 ML
2 ML
2 ML
1 ML
1 ML
1 ML
VL
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
IJ
ML
ML
ML
ML
ML
ML
50 MG
10 U
10 U
10 U
10 U
1000 U
1
10
10
10
10
1
01/01/2002
12/08/2004
01/01/2002
12/08/2004
01/01/2002
10/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
IJ
ML
1000 U
12/08/2004
99/99/9999
1 ML
1 ML
1 ML
1 ML
2 ML
2 ML
VL
VL
VL
VL
VL
VL
IJ
IJ
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
1000 U
1000 U
10 U
10 U
10 U
10 U
1
1
1
1
1
1
01/01/2002
10/01/2007
12/08/2004
01/01/2002
12/08/2004
01/01/2002
4/1/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML VL
IJ
ML
80 MG
0.125
01/01/2002
05/21/2003
2 ML VL
1 ML VL
IJ
IJ
ML
ML
80 MG
1000 U
0.5
5
01/01/2002
10/01/2007
05/21/2003
99/99/9999
1 ML VL
IJ
ML
1000 U
12/08/2004
99/99/9999
1 ML VL
1 ML VL
1 ML VL
IJ
IJ
IJ
ML
ML
ML
1000 U
1000 U
1000 U
5
5
10
01/01/2002
10/01/2007
10/01/2007
4/1/2008
99/99/9999
99/99/9999
1 ML VL
IJ
ML
1000 U
10
12/08/2004
99/99/9999
1 ML VL
1 ML VL
IJ
IJ
ML
ML
1000 U
1000 U
10
10
01/01/2002
10/01/2007
99/99/9999
99/99/9999
1 ML VL
IV
ML
10 U
10
12/08/2004
12/14/2006
1 ML VL
IV
ML
10 U
10
01/01/2002
12/14/2006
1 ML VL
IV
ML
10 U
12/08/2004
12/14/2006
1 ML VL
IV
ML
10 U
01/01/2002
12/14/2006
1 ML VL
IJ
ML
120 MG
0.54166
12/08/2004
99/99/9999
1 ML VL
IJ
ML
120 MG
0.54166
01/01/2002
99/99/9999
1 ML VL
IJ
ML
120 MG
1.08333
12/08/2004
99/99/9999
1 ML VL
IJ
ML
120 MG
1.08333
01/01/2002
99/99/9999
2 ML VL
IV
ML
1 GM
0.5
01/01/2002
05/07/2002
2 ML VL
IJ
ML
10 MG
0.5
12/08/2004
99/99/9999
2 ML VL
IJ
ML
10 MG
0.5
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
00641-0168-25
00641-0367-25
00641-0374-01
00641-0374-06
1/1/2002
HCPCS Mod
HCPCS
NDC Mod
NDC
00641-0493-21
J1165
00641-0493-25
J1165
00641-0495-17
J2912
00641-0495-25
J2912
1/1/2002
00641-0610-25
J3490
1/1/2002
00641-0928-21
J2550
00641-0928-25
J2550
00641-0929-21
J2550
00641-0929-25
J2550
00641-0948-31
J2550
00641-0948-35
J2550
00641-0949-31
J2550
00641-0949-35
J2550
00641-0955-21
J2550
00641-0955-25
J2550
00641-0956-21
J2550
00641-0956-25
J2550
00641-1112-33
J2275
00641-1114-33
J2275
00641-1117-33
J3010
1/1/2002
00641-1118-34
J3010
1/1/2002
00641-1119-34
J3010
00641-1120-35
J2175
2/28/2002
00641-1130-35
J2175
2/28/2002
00641-1131-31
J2275
1/1/2002
00641-1132-31
J2275
1/1/2002

3/31/2005 10 MG
4/19/2004 10 MG
00641-1138-34
J1245
00641-1139-31
J1245
1/1/2002
00641-1140-35
J2175
1/19/2004
00641-1141-33
J3490
1/1/2002
00641-1142-33
J3490
1/1/2002
00641-1143-33
J3490
1/1/2002
00641-1150-35
J2175
1/19/2004
00641-1170-35
J2270
1/1/2002
00641-1180-35
J2270
1/1/2002
00641-1190-35
J2271
1/1/2002
00641-1397-31
J3230
00641-1397-35
J3230
00641-1398-31
J3230
00641-1398-35
00641-1408-33
J3230
J3360



1/1/2002 5/18/2004 10 MG
1/1/2002 4/29/2004 10 MG
8/29/2005 INJECTION, DIPYRIDAMOLE, PER 10 MG

PHENYTOIN SODIUM (DOSETTE,VIAL) 50

MG/ML
PHENYTOIN SODIUM (DOSETTE,VIAL) 50
MG/ML
SODIUM CHLORIDE (VIAL, DOSETTE)
0.9%
SODIUM CHLORIDE (VIAL, DOSETTE,PF)
0.9%
THIAMINE HCL (VIAL, DOSETTE) 100
MG/ML
PROMETHAZINE HCL (DOSETTE,VIAL)
25 MG/ML
25 MG/ML
50 MG/ML
50 MG/ML
PROMETHAZINE HCL NOVAPLUS
(AMP,DOSETTE) 25 MG/ML
(DOSETTE) 50 MG/ML
(DOSETTE) 25 MG/ML
(VIAL,DOSETTE) 25 MG/ML
(DOSETTE) 50 MG/ML
DURAMORPH (AMP,DOSETTE,PF) 0.5
MG/ML
DURAMORPH (AMP,DOSETTE,PF) 1
MG/ML
FENTANYL CITRATE (AMP,DOSETTE,PF)
0.05 MG/ML
0.05 MG/ML
0.05 MG/ML
MEPERIDINE HCL (DOSETTE AMP) 25
MG/ML
MG/ML
INFUMORPH (AMP, DOSETTE,PF) 10
MG/ML
INFUMORPH (AMP, DOSETTE,PF) 25
MG/ML
DIPYRIDAMOLE (DOSETTE AMP) 5
MG/ML
DIPYRIDAMOLE (DOSETTE AMP) 5
MG/ML
MG/ML
SUFENTANIL CITRATE (DOSETTE AMP)
50 MCG/ML
50 MCG/ML
50 MCG/ML
MG/ML
MORPHINE SULFATE (AMP, DOSETTE) 8
MG/ML
MORPHINE SULFATE (AMP, DOSETTE)
10 MG/ML
MORPHINE SULFATE (AMP, DOSETTE)
15 MG/ML
CHLORPROMAZINE HCL (USP) 25
MG/ML
CHLORPROMAZINE HCL (AMP,
DOSETTE) 25 MG/ML
CHLORPROMAZINE HCL (USP) 25
MG/ML
CHLORPROMAZINE HCL (AMP,
DOSETTE) 25 MG/ML
DIAZEPAM (AMP, DOSETTE) 5 MG/ML
Page 113 of 374
2 ML VL
IV
ML
50 MG
12/08/2004
2 ML VL
IV
ML
50 MG
01/01/2002
99/99/9999
2 ML VL
IV
ML
0.9 %
0.5
12/08/2004
12/14/2006
2 ML VL
IV
ML
0.9 %
0.5
01/01/2002
05/01/2002
1 ML VL
IJ
ML
1 EA
01/01/2002
05/12/2003
1 ML VL
IJ
ML
50 MG
0.5
12/08/2004
99/99/9999
1 ML VL
IJ
ML
50 MG
0.5
12/27/2002
99/99/9999
1 ML VL
IJ
ML
50 MG
12/08/2004
99/99/9999
1 ML VL
IJ
ML
50 MG
12/27/2002
99/99/9999
1 ML AM IJ
ML
50 MG
0.5
12/08/2004
99/99/9999
1 ML AM IJ
ML
50 MG
0.5
01/06/2003
99/99/9999
1 ML AM IJ
ML
50 MG
05/05/2007
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
1 ML AM IJ
ML
50 MG
01/06/2003
99/99/9999
1 ML VL
ML
50 MG
0.5
05/05/2007
99/99/9999
IJ
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1 ML VL
IJ
ML
50 MG
0.5
12/27/2002
99/99/9999
1 ML VL
IJ
ML
50 MG
05/05/2007
99/99/9999
1 ML VL
IJ
ML
50 MG
12/27/2002
99/99/9999
10 ML AM IJ
ML
10 MG
0.05
01/01/2002
05/18/2004
10 ML AM IJ
ML
10 MG
0.1
01/01/2002
04/29/2004
5 ML AM IJ
ML
0.1 MG
0.5
01/01/2002
06/10/2004
10 ML AM IJ
ML
0.1 MG
0.5
01/01/2002
5/2/2006
20 ML AM IJ
ML
0.1 MG
0.5
01/01/2002
10/25/2004
1 ML AM IJ
ML
100 MG
0.25
02/28/2002
01/18/2004
1 ML AM IJ
ML
100 MG
0.5
02/28/2002
07/06/2004
20 ML AM IJ
ML
10 MG
01/19/2004
03/31/2005
1/1/2002
6/1/2002
20 ML AM IJ
ML
10 MG
2.5
01/19/2004
04/19/2004
1/1/2002
6/1/2002
2.5
1/1/2002 12/20/2002
2 ML AM IV
ML
10 MG
0.5
01/01/2002
11/11/2004
10 ML AM IV
ML
10 MG
0.5
01/01/2002
08/29/2005
1 ML AM IJ
ML
100 MG
0.75
01/19/2004
02/06/2004
1 ML AM IJ
ML
1 EA
01/01/2002
08/25/2004
2 ML AM IJ
ML
1 EA
01/01/2002
04/29/2004
5 ML AM IJ
ML
1 EA
01/01/2002
06/01/2004
1 ML AM IJ
ML
100 MG
01/19/2004
02/06/2004
1 ML AM IJ
ML
10 MG
0.8
01/01/2002
06/10/2004
1 ML AM IJ
ML
10 MG
01/01/2002
10/08/2004
1 ML AM IJ
ML
100 MG
0.15
01/01/2002
09/06/2005
1 ML AM IJ
ML
50 MG
0.5
05/05/2007
99/99/9999
1 ML AM IJ
ML
50 MG
0.5
01/01/2002
99/99/9999
2 ML AM IJ
ML
50 MG
0.5
05/05/2007
99/99/9999
2 ML AM IJ
2 ML AM IJ
ML
ML
50 MG
5 MG
0.5
1
01/01/2002
12/08/2004
99/99/9999
05/14/2007
00641-1410-31
00641-1410-35
J1160
J1160
00641-1438-35
J7659
00641-1438-35 KO J7659
00641-1495-31
J2550
KO

1/1/2002 12/20/2002 MILLIGRAM
1/1/2002 12/20/2002 MILLIGRAM
05/05/2007
01/01/2002
99/99/9999
99/99/9999
ISOPROTERENOL HCL (AMP,DOSETTE)

0.2 MG/ML
5 ML AM IV
ML
1 MG
0.2
01/01/2002
12/20/2002
5 ML AM IV
1 ML AM IJ
ML
ML
1 MG
50 MG
0.2
0.5
01/01/2002
05/05/2007
12/20/2002
99/99/9999
1 ML AM IJ
1 ML AM IJ
ML
ML
50 MG
50 MG
0.5
1
01/01/2002
05/05/2007
99/99/9999
99/99/9999
1 ML AM IJ
10 ML VL IJ
ML
ML
50 MG
5 MG
1
1
01/01/2002
12/08/2004
99/99/9999
7/28/2008
10 ML VL
ML
5 MG
08/05/2004
99/99/9999
ISOPROTERENOL HCL (AMP,DOSETTE)

0.2 MG/ML
PROMETHAZINE HCL (USP) 25 MG/ML
PROMETHAZINE HCL (AMP, DOSETTE)
25 MG/ML
PROMETHAZINE HCL (USP) 50 MG/ML
PROMETHAZINE HCL (AMP, DOSETTE)
50 MG/ML
DIAZEPAM (M.D.V.) 5 MG/ML

00641-2289-43
J3360
00641-2331-43
J1580
00641-2341-39
J1170
00641-2341-41
J1170
00641-2343-41
J2270
00641-2345-41
J2271
1/1/2002
00641-2402-41
J3010
1/1/2002
00641-2403-41
00641-2436-41
00641-2436-45
00641-2438-41
00641-2438-45
00641-2440-41
00641-2440-45
00641-2442-41
00641-2442-45
00641-2443-41
00641-2443-45
00641-2450-41
00641-2450-45
00641-2460-41
00641-2460-45
00641-2470-41
00641-2470-45
00641-2555-41
J3010
J1642
J1642
J1642
J1642
J1644
J1644
J1642
J1642
J1642
J1642
J1644
J1644
J1644
J1644
J1644
J1644
J1165
1/1/2002
5/5/2007
1/1/2002
5/5/2007
1/1/2002
12/8/2004
1/1/2002
5/5/2007
1/1/2002
5/5/2007
1/1/2002
12/8/2004
1/1/2002
12/8/2004
1/1/2002
12/8/2004
1/1/2002
5/5/2007
00641-2555-45
00641-2569-41
00641-2569-44
J1165
J1245
J1245

00641-2587-45
00641-2764-43
00641-2765-43
00641-2766-41
J2690
J3490
J3490
J3490

00641-5141-33
00677-0117-01
00677-0117-10
00677-0427-01
00677-0427-05
00677-0427-10
00677-0565-01
00677-0565-13
J3490
J7506
J7506
J7506
J7506
J7506
J7509
J7509
00677-0596-01
Q0177
00677-0597-01
Q0178
00677-0601-42
00677-0698-01
00677-0698-05
00677-0698-10
Q0181
J7506
J7506
J7506
1/1/2002
1/1/2002 4/10/2003 REGIMEN
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
DIAZEPAM (USP,MDV,10X10ML) 5 MG/ML

GENTAMICIN SULFATE (M.D.V.) 40
MG/ML
IJ
20 ML VL
IJ
ML
80 MG
0.5
01/01/2002
12/20/2002
1 ML NA
IJ
ML
4 MG
0.5
05/05/2007
99/99/9999
20 ML VL
IJ
ML
4 MG
0.5
01/01/2002
99/99/9999
10 ML VL
IJ
ML
10 MG
01/01/2002
07/08/2004
20 ML VL
IJ
ML
100 MG
0.15
01/01/2002
03/23/2004
30 ML VL
IJ
ML
0.1 MG
0.5
01/01/2002
05/01/2004
50 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
30 ML
30 ML
30 ML
30 ML
30 ML
30 ML
10 ML
10 ML
4 ML
4 ML
1 ML
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
IJ
IJ
IV
IV
IV
IV
IJ
IJ
IJ
IJ
IJ
IJ
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
0.1 MG
10 U
10 U
10 U
10 U
1000 U
1000 U
10 U
10 U
10 U
10 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
50 MG
0.5
10
10
1
1
1
1
1
1
10
10
1
1
5
5
10
10
1
01/01/2002
05/05/2007
01/01/2002
05/05/2007
01/01/2002
12/08/2004
01/01/2002
05/05/2007
01/01/2002
05/05/2007
01/01/2002
12/08/2004
01/01/2002
12/08/2004
01/01/2002
12/08/2004
01/01/2002
05/05/2007
04/29/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
5 ML VL
10 ML VL
10 ML VL
IV
IV
IV
ML
ML
ML
50 MG
10 MG
10 MG
1
0.5
0.5
01/01/2002
05/05/2007
01/01/2002
99/99/9999
99/99/9999
99/99/9999
PROCAINAMIDE HCL (M.D.V.) 100 MG/ML

10 ML VL
SMZ-TMP (S.D.V.) 80 MG/ML-16 MG/ML
5 ML VL
SMZ-TMP (S.D.V.) 80 MG/ML-16 MG/ML
10 ML VL
SMZ-TMP (M.D.V.) 80 MG/ML-16 MG/ML
30 ML VL
50 MCG/ML
1 ML AM
PREDNISONE 5 MG
100 EA BO
PREDNISONE 5 MG
1000 EA BO
PREDNISONE 20 MG
100 EA BO
PREDNISONE 20 MG
500 EA BO
PREDNISONE 20 MG
1000 EA BO
100 EA BO
21 EA BO
IV
IV
IV
IV
ML
ML
ML
ML
1
1
1
1
GM
EA
EA
EA
0.1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/31/2002
12/20/2002
12/20/2002
12/20/2002
IJ
PO
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
EA
1 EA
5 MG
5 MG
5 MG
5 MG
5 MG
4 MG
4 MG
1
1
1
4
4
4
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/07/2002
10/29/2007
10/29/2007
05/14/2007
05/14/2007
05/14/2007
05/20/2002
06/26/2002
100 EA BO
PO
EA
25 MG
01/01/2002
04/15/2002
100 EA BO
PO
EA
50 MG
01/01/2002
04/15/2002
PO
PO
PO
PO
ML
EA
EA
EA
1 EA
5 MG
5 MG
5 MG
1
2
2
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/10/2003
05/23/2007
05/23/2007
05/23/2007
HYDROMORPHONE HCL (USP) 2 MG/ML

HYDROMORPHONE HCL (M.D.V.) 2
MG/ML
1/1/2002
MORPHINE SULFATE (M.D.V.) 10 MG/ML

FENTANYL CITRATE (S.D.V.,PF) 0.05
MG/ML
MG/ML
HEP-LOCK (MDV) 100 U/ML
HEP-LOCK (M.D.V.) 100 U/ML
PHENYTOIN SODIUM (USP) 50 MG/ML
PHENYTOIN SODIUM (VIAL, DOSETTE)
50 MG/ML
DIPYRIDAMOLE (SDV) 5 MG/ML
DIPYRIDAMOLE (S.D.V.) 5 MG/ML
Page 114 of 374
240 ML
100 EA
500 EA
1000 EA
BO
BO
BO
BO
1/1/2002
1/10/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
0.5
0.5
J2550
J3360
Billing Units
0.5 MG
0.5 MG
00641-1496-35
00641-2289-41
ML
ML


NDC Package Type
2 ML AM IV
2 ML AM IV
J2550
J2550
NDC Package Measure
DIGOXIN (USP) 0.25 MG/ML

DIGOXIN (AMP, DOSETTE) 0.25 MG/ML
00641-1495-35
00641-1496-31

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
Q0173
None
J8999
J7509
J7509
1/1/2002
6/3/1996
1/1/2002
1/1/2002
3/1/2002
00677-1856-01
Q0163
1/29/2003
00677-1856-10
Q0163
1/29/2003
00677-1857-01
Q0163
2/14/2003
00677-1857-10
Q0163
2/14/2003
00677-1858-01
Q0163
1/28/2003
00703-0031-01
J1030
00703-0031-04
J1030
3/9/2005 99/99/9999 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG
00703-0043-01
J1030
00703-0045-01
J1030
00703-0051-01
J1040
00703-0051-04
J1040
00703-0063-01
J1040
00703-0315-03
J0696
00703-0325-03
J0696
00703-0335-04
J0696
00703-0346-03
J0696
00703-0359-01
00703-0404-02
00703-0405-02
J0696
J1955
J1955

1/1/2002 99/99/9999 INJECTION, LEVOCARNITINE, PER 1 GM
00703-0956-03
J0744
00703-0958-03
J0744
00703-0960-36
J0744
00703-0969-36
00703-1010-09
00703-1019-09
J0744
J1450
J1450

00703-1020-30
J1450
00703-1029-30
00703-1271-04
00703-1335-01
J1450
J3105
J0282
00703-1501-02
J0270

1/1/2002 99/99/9999 FOR USE WHEN DRUG IS SELF ADMINISTERED)
00703-1631-04
00703-1652-02
00703-1654-02
00703-1985-01
00703-1995-01
00703-2191-04
00703-2201-04
J2370
J1245
J1245
J1325
J1325
J2550
J2550
1/1/2002
1/1/2002
1/1/2002
4/23/2008
4/23/2008
9/30/2002
9/30/2002

100 EA BO
PO
EA
50 MG
0.5
01/29/2003
04/19/2007
1000 EA BO
PO
EA
50 MG
0.5
01/29/2003
07/19/2007
100 EA BO
PO
EA
50 MG
02/14/2003
04/19/2007
1000 EA BO
PO
EA
50 MG
02/14/2003
04/19/2007
DIPHENHYDRAMINE HCL (CAPTAB) 25

MG
METHYLPREDNISOLONE ACETATE
(SDV) 40 MG/ML
(SDV) 40 MG/ML
(MDV,USP) 40 MG/ML
(MDV,USP) 40 MG/ML
(SDV) 80 MG/ML
(SDV) 80 MG/ML
(MDV,USP) 80 MG/ML
CEFTRIAXONE (USP,SINGLE-DOSE) 250
MG
MG
GM
GM
CEFTRIAXONE (USP,PHARMACY BULK
PCKGE) 10 GM
LEVOCARNITINE (VIAL) 200 MG/ML
LEVOCARNITINE (VIAL) 200 MG/ML
CIPROFLOXACIN
(SDV,10X20ML,200MG,1%) 10 MG/ML
CIPROFLOXACIN
(SDV,10X40ML,400MG,1%) 10 MG/ML
CIPROFLOXACIN (1X200ML,USP,LATEXFREE) 400 MG/200 ML
FLUCONAZOLE IV 400 MG/200 ML
FLUCONAZOLE IV 200 MG/100 ML
ML
FLUCONAZOLE IV (6X100ML) 200 MG/100
ML
TERBUTALINE SULFATE 1 MG/ML
ALPROSTADIL (S.D.V.) 0.5 MG/ML

EPOPROSTENOL SODIUM 0.5 MG
EPOPROSTENOL SODIUM 1.5 MG
Page 115 of 374
100 EA BO
1 ML VL
CF
HCPCS Amount #1
PO
EA
50 MG
0.5
01/28/2003
06/13/2007
IJ
ML
40 MG
03/09/2005
99/99/9999
1 ML VL
IJ
ML
40 MG
03/09/2005
99/99/9999
5 ML VL
IJ
ML
40 MG
10/31/2006
99/99/9999
10 ML VL
IJ
ML
40 MG
10/31/2006
99/99/9999
1 ML VL
IJ
ML
80 MG
03/09/2005
99/99/9999
1 ML VL
IJ
ML
80 MG
03/09/2005
99/99/9999
5 ML VL
IJ
ML
80 MG
10/31/2006
99/99/9999
1 EA VL
IJ
EA
250 MG
12/21/2007
99/99/9999
1 EA VL
IJ
EA
250 MG
12/21/2007
99/99/9999
1 EA VL
IJ
EA
250 MG
12/21/2007
99/99/9999
1 EA VL
IJ
EA
250 MG
12/21/2007
99/99/9999
1 EA VL
5 ML VL
12.5 ML VL
IV
IV
IV
EA
ML
ML
250 MG
1 GM
1 GM
40
0.2
0.2
12/21/2007
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
20 ML VL
IV
ML
200 MG
0.05
08/28/2006
99/99/9999
40 ML VL
IV
ML
200 MG
0.05
08/28/2006
99/99/9999
200 ML FC
IV
ML
200 MG
0.01
03/18/2008
99/99/9999
100 ML FC
200 ML VL
100 ML VL
IV
IV
IV
ML
ML
ML
200 MG
200 MG
200 MG
0.01
0.01
0.01
03/18/2008
08/02/2004
08/02/2004
99/99/9999
99/99/9999
99/99/9999
200 ML PC
IV
ML
200 MG
0.01
03/14/2005
99/99/9999
100 ML PC
1 ML VL
9 ML VL
IV
SC
IV
ML
ML
ML
200 MG
1 MG
30 MG
0.01
1
1.66666
03/16/2005
07/22/2004
12/04/2003
99/99/9999
99/99/9999
99/99/9999
IV
ML
1.25 MCG
400
01/01/2002
99/99/9999
IJ
IV
IV
IV
IV
IJ
IJ
ML
ML
ML
EA
EA
ML
ML
1 ML
10 MG
10 MG
0.5 MG
0.5 MG
50 MG
50 MG
1
0.5
0.5
1
3
0.5
1
01/01/2002
01/01/2002
01/01/2002
04/23/2008
04/23/2008
09/30/2002
09/30/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
1 ML
2 ML
10 ML
1 EA
1 EA
1 ML
1 ML
VL
VL
VL
VL
VL
VL
VL
04/22/2002
11/18/1999
05/23/2002
03/16/2006
05/26/2006
Prior End Date #3
01/01/2002
06/03/1996
01/01/2002
01/01/2002
03/01/2002
Prior Start Date #3
1
1
1
1
1
250 MG
2.5 MG
1 EA
4 MG
4 MG
Prior End Date #2
EA
EA
EA
EA
EA
End Date #1
PO
PO
PO
PO
PO
Start Date #1
BO
NA
BO
BO
DP
HCPCS Measure #1
100 EA
100 EA
100 EA
100 EA
21 EA
Billing Units

HYDROXYUREA 500 MG
Prior Start Date #2

Package
NDC Package Type
00677-1383-01
00677-1610-01
00677-1680-01
00677-1831-01
00677-1831-13
NDC Package Measure

NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00703-2704-03
J2710
1/1/2002
00703-2711-03
J2710
1/1/2002
00703-2714-03
00703-2856-04
00703-2858-09
00703-2859-03
00703-3015-13
00703-3015-13 QR
J2710
J3490
J3490
J3490
J9190
J9190
QR
1/1/2002
6/26/2007
6/26/2007
6/26/2007
9/2/2003
1/28/2005

00703-3018-12
J9190
QR
1/28/2005 99/99/9999 INJECTION, FLUOROURACIL, 500 MG
00703-3018-12 QR J9190
00703-3019-12
J9190
00703-3019-12 QR J9190

QR
00703-3067-11
J9178
8/9/2007 99/99/9999 INJECTION, EPIRUBICIN HCL, 2 MG
00703-3069-11
00703-3154-01
J9178
J9040

1/1/2002 99/99/9999 INJECTION, BLEOMYCIN SULFATE, 15 UNITS
00703-3154-91
00703-3155-01
J9040
J9040

00703-3155-91
00703-3244-11
00703-3246-11
00703-3248-11
J9040
J9045
J9045
J9045
2/20/2002
6/24/2004
6/24/2004
6/24/2004
00703-3249-11
00703-3264-01
00703-3266-01
00703-3268-01
00703-3268-71
00703-3274-01
00703-3276-01
00703-3278-01
J9045
J9045
J9045
J9045
J9045
J9045
J9045
J9045
11/17/2005
6/24/2004
6/24/2004
6/24/2004
5/1/2006
5/1/2006
5/1/2006
5/1/2006
00703-3301-04
J2354
11/14/2005
00703-3311-04
J2354
11/14/2005
00703-3321-04
J2354
11/14/2005
00703-3333-01
J2354
11/23/2005
00703-3343-01
00703-3427-11
00703-3429-11
J2354
J9208
J9208
11/23/2005
7/26/2007
7/26/2007
00703-3524-03
J1100
00703-4014-18
J9218
00703-4014-19
00703-4075-19
J9218
J2430
1/1/2002 99/99/9999 LEUPROLIDE ACETATE, PER 1 MG

9/23/2002 4/24/2006 INJECTION, PAMIDRONATE DISODIUM, PER 30 MG
00703-4075-59
00703-4085-11
00703-4085-51
J2430
J2430
J2430


99/99/9999 INTRAVENOUS INJECTION, 25 MCG

1/1/2002 99/99/9999 LEUPROLIDE ACETATE, PER 1 MG
00703-4085-91
J2430
00703-4100-48
J9999
00703-4100-58
J9999
00703-4100-68
00703-4109-48
J9999
J9999

00703-4109-58
J9999
5/1/2006
00703-4109-68
J9999
5/1/2006
00703-4154-11
J9211
00703-4155-11
J9211
(M.D.V.) 1 MG/ML
(S.D.V.) 0.5 MG/ML
(M.D.V.) 0.5 MG/ML
PROPOFOL (SDV,25X20ML) 10 MG/ML
ADRUCIL (S.D.V.) 50 MG/ML
ADRUCIL (S.D.V.) 50 MG/ML
ADRUCIL (PHARMACY BULK PACKAGE)
50 MG/ML
50 MG/ML
50 MG/ML
50 MG/ML
EPIRUBICIN HYDROCHLORIDE (SDV,PF)
2 MG/ML
EPIRUBICIN HYDROCHLORIDE (SDV,PF)
2 MG/ML
BLEOMYCIN SULFATE (S.D.V.) 15 U
BLEOMYCIN SULFATE NOVAPLUS
(S.D.V.) 15 U
BLEOMYCIN SULFATE (S.D.V.) 30 U
BLEOMYCIN SULFATE NOVAPLUS
(S.D.V.) 30 U
CARBOPLATIN (M.D.V.) 10 MG/ML
CARBOPLATIN (AQUEOUS SOLUTION)
10 MG/ML
CARBOPLATIN 50 MG
CARBOPLATIN (VIAL) 150 MG
CARBOPLATIN 450 MG
CARBOPLATIN 450 MG
CARBOPLATIN 50 MG
CARBOPLATIN 150 MG
CARBOPLATIN 450 MG
OCTREOTIDE ACETATE (1MLX25 VIALS)
50 MCG/ML
100 MCG/ML
500 MCG/ML
10 ML VL
IJ
ML
0.5 MG
01/01/2002
1 ML VL
IJ
ML
0.5 MG
01/01/2002
05/03/2007
VL
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
0.5 MG
1 EA
1 EA
1 EA
500 MG
500 MG
1
1
1
1
0.1
0.1
01/01/2002
06/26/2007
06/26/2007
06/26/2007
09/02/2003
01/28/2005
05/03/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
50 ML VL
IV
ML
500 MG
0.1
09/02/2003
99/99/9999
50 ML VL
IV
ML
500 MG
0.1
01/28/2005
99/99/9999
100 ML VL
IV
ML
500 MG
0.1
09/02/2003
99/99/9999
100 ML VL
IV
ML
500 MG
0.1
01/28/2005
99/99/9999
25 ML VL
IV
ML
2 MG
08/09/2007
99/99/9999
100 ML VL
1 EA VL
IV
IJ
ML
EA
2 MG
15 U
1
1
08/09/2007
01/01/2002
99/99/9999
99/99/9999
1 EA VL
1 EA VL
IJ
IJ
EA
EA
15 U
15 U
1
2
02/20/2002 12/31/2008
01/01/2002 99/99/9999
10 ML
20 ML
50 ML
100 ML
10 ML
10 ML
1 EA
5 ML
15 ML
45 ML
VL
VL
VL
VL
IJ
IV
IV
IV
EA
ML
ML
ML
15 U
50 MG
50 MG
50 MG
2
0.2
0.2
0.2
02/20/2002 12/31/2008
06/24/2004 99/99/9999
06/24/2004 99/99/9999
06/24/2004 99/99/9999
60 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
IV
IV
ML
EA
EA
EA
EA
EA
EA
EA
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
0.2
1
3
9
9
1
3
9
11/17/2005 99/99/9999
06/24/2004 99/99/9999
06/24/2004 99/99/9999
06/24/2004 99/99/9999
05/01/2006 99/99/9999
05/01/2006 12/23/2008
05/01/2006 12/23/2008
05/01/2006 12/23/2008
1 ML VL
IJ
ML
25 MCG
11/14/2005
99/99/9999
1 ML VL
IJ
ML
25 MCG
11/14/2005
99/99/9999
99/99/9999
1 ML VL
IJ
ML
25 MCG
20
11/14/2005
5 ML VL
IJ
ML
25 MCG
11/23/2005
99/99/9999
OCTREOTIDE ACETATE 1000 MCG/ML

IFOSFAMIDE 1 GM
IFOSFAMIDE 3 GM
LEUPROLIDE ACETATE (M.D.V.) 5
MG/ML
PAMIDRONATE DISODIUM 3 MG/ML
PAMIDRONATE DISODIUM (S.D.V) 3
MG/ML
PAMIDRONATE DISODIUM (SINGLE-USE
VIAL) 9 MG/ML
IFOSFAMIDE/MESNA (COMBO-PACK) 5
GM-3 GM
GM-10 GM
GM-6 GM
IFOSFAMIDE/MESNA 5 GM-3 GM
IFOSFAMIDE/MESNA (NOV) 10 GM-10
GM
5 ML VL
1 EA VL
1 EA VL
IJ
IV
IV
ML
EA
EA
25 MCG
1 GM
1 GM
40
1
3
11/23/2005
07/26/2007
07/26/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 116 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
05/03/2007
OCTREOTIDE ACETATE 200 MCG/ML
IFOSFAMIDE/MESNA (NOV) 6 GM-6 GM

IDARUBICIN HYDROCHLORIDE (S.D.V.) 1
MG/ML
MG/ML
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
10 ML VL
IJ
ML
1 MG
10
02/20/2002
2.8 ML BX
SC
EA
1 MG
14
01/01/2002
99/99/9999
2.8 ML VL
10 ML VL
SC
IV
ML
ML
1 MG
30 MG
5
0.1
01/01/2002
09/23/2002
99/99/9999
4/24/2006
10 ML VL
10 ML VL
10 ML VL
IV
IV
IV
ML
ML
ML
30 MG
30 MG
30 MG
0.1
0.3
0.3
11/08/2005
09/23/2002
11/08/2005
99/99/9999
4/24/2006
99/99/9999
10 ML VL
IV
ML
30 MG
0.3
07/01/2003
99/99/9999
1 EA BX
IV
EA
1 EA
04/08/2002
99/99/9999
1 EA BX
IV
EA
1 EA
04/08/2002
99/99/9999
1 EA BX
1 EA BX
IV
IV
EA
EA
1 EA
1 EA
1
1
04/08/2002
05/01/2006
99/99/9999
8/19/2008
1 EA BX
IV
EA
1 EA
05/01/2006
4/28/2009
1 EA BX
IV
EA
1 EA
05/01/2006
4/28/2009
5 ML VL
IV
ML
5 MG
0.2
09/24/2002
99/99/9999
10 ML VL
IV
ML
5 MG
0.2
09/24/2002
99/99/9999
00703-4156-11
J9211
00703-4182-01
J9390
2/10/2003 99/99/9999 INJECTION, VINORELBINE TARTRATE, 10 MG
00703-4182-81
J9390
00703-4182-91
J9390
00703-4183-01
J9390
00703-4183-81
J9390
00703-4183-91
00703-4244-01
00703-4246-01
00703-4248-01
00703-4301-02
00703-4303-01
J9390
J9045
J9045
J9045
J9340
J9340
5/1/2006
5/1/2006
5/1/2006
2/1/2006
1/1/2002
1/1/2002
00703-4402-11
J9370
1/1/2002 99/99/9999 VINCRISTINE SULFATE, 1 MG
00703-4412-11
J9370
00703-4432-11
J9206
00703-4432-11 QR J9206
00703-4434-11
2/28/2008 99/99/9999 INJECTION, IRINOTECAN, 20 MG

QR
J9206
00703-4434-11 QR J9206
00703-4502-04
J2765
00703-4636-01
J9320
00703-4658-01
J9140
00703-4680-01
J9293
00703-4680-91
J9293
00703-4685-01
J9293
00703-4685-91
J9293
00703-4686-01
J9293
00703-4686-91
J9293
00703-4805-03
J9209

6/17/2008 INJECTION, THIOTEPA, 15 MG

QR
2/28/2008
1/1/2002
12/3/2003
1/1/2002
4/11/2006
11/6/2006
4/11/2006
11/6/2006
4/11/2006
11/6/2006
2/22/2002

99/99/9999 INJECTION, STREPTOZOCIN, 1 GRAM
9/20/2002 DACARBAZINE, 200 MG
99/99/9999 INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG
00703-4852-11
J9185
5/2/2007 99/99/9999 INJECTION, FLUDARABINE PHOSPHATE, 50 MG
00703-4852-81
J9185
00703-5003-01
J2680
1/1/2002
00703-5040-01
J9000
00703-5043-03
J9000
00703-5046-01
J9000
00703-5051-03
J2597
00703-5054-01
00703-5075-01
00703-5075-03
J2597
J9140
J9140

1/1/2002 99/99/9999 DACARBAZINE, 200 MG
1/1/2002 99/99/9999 DACARBAZINE, 200 MG
00703-5140-01
00703-5145-01
00703-5182-03
00703-5193-02
00703-5194-01
00703-5195-01
J0640
J0640
J9100
J9110
J9110
J9110
1/1/2002 99/99/9999 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG

1/1/2002 2/14/2002 INJECTION, CYTARABINE, 100 MG
00703-5233-13
J9150
00703-5653-01
J9181
00703-5656-01
00703-5657-01
00703-5747-11
00703-5748-11
00703-5854-01
J9181
J9181
J9060
J9060
J9185
1/1/2002
1/1/2002
1/1/2002
1/1/2002
9/12/2003
00703-6121-01
J1080
00703-6125-01
00703-6271-04
J1080
J2590

1/24/2008 99/99/9999 INJECTION, OXYTOCIN, UP TO 10 UNITS
1/27/2003 99/99/9999 INJECTION, DAUNORUBICIN, 10 MG

99/99/9999 CISPLATIN, POWDER OR S0LUTION, PER 10 MG
99/99/9999 INJECTION, FLUDARABINE PHOSPHATE, 50 MG

MG/ML
VINORELBINE TARTRATE (S.D.V.,PF) 10
MG/ML
VINORELBINE TARTRATE (OTN,PF) 10
MG/ML
VINORELBINE TARTRATE (NOV,PF) 10
MG/ML
MG/ML
VINORELBINE TARTRATE (OTN,PF) 10
MG/ML
VINORELBINE TARTRATE (NOV,PF) 10
MG/ML
CARBOPLATIN (1X5ML) 10 MG/ML
CARBOPLATIN (1X15ML) 10 MG/ML
THIOTEPA (S.D.V.) 15 MG
20 ML VL
IV
ML
5 MG
0.2
09/24/2002
99/99/9999
1 ML VL
IV
ML
10 MG
02/10/2003
99/99/9999
1 ML VL
IV
ML
10 MG
05/01/2006
99/99/9999
1 ML VL
IV
ML
10 MG
05/01/2006
99/99/9999
5 ML VL
IV
ML
10 MG
02/10/2003
99/99/9999
5 ML VL
IV
ML
10 MG
05/01/2006
99/99/9999
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IJ
IJ
ML
ML
ML
ML
EA
EA
10 MG
50 MG
50 MG
50 MG
15 MG
15 MG
1
0.2
0.2
0.2
1
2
05/01/2006
05/01/2006
05/01/2006
02/01/2006
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
06/17/2008
99/99/9999
VINCRISTINE SULFATE (S.D.V.) 1 MG/ML
1 ML VL
IV
ML
1 MG
01/01/2002
99/99/9999
VINCRISTINE SULFATE (S.D.V.) 1 MG/ML

(1X2ML,SINGLE DOSE) 20 MG/ML
METOCLOPRAMIDE (S.D.V.) 5 MG/ML
ZANOSAR 1 GM
DACARBAZINE (VIAL) 500 MG
MITOXANTRONE (MDV,PF) 2 MG/ML
MITOXANTRONE (M.D.V,PF) 2 MG/ML
MESNA (M.D.V.) 100 MG/ML
FLUDARABINE PHOSPHATE (SDV) 25
MG/ML
OTN FLUDARABINE PHOSPHATE (SDV)
25 MG/ML
FLUPHENAZINE DECANOATE (M.D.V.) 25
MG/ML
DOXORUBICIN HCL (M.D.V. POLYMER) 2
MG/ML
DOXORUBICIN HCL (S.D.V. POLYMER) 2
MG/ML
DOXORUBICIN HCL (S.D.V. POLYMER) 2
MG/ML
DESMOPRESSIN ACETATE (VIAL) 4
MCG/ML
DESMOPRESSIN ACETATE (M.D.V.) 4
MCG/ML
DACARBAZINE (S.D.V.) 200 MG
DACARBAZINE (VIAL) 200 MG
LEUCOVORIN CALCIUM (VIAL,PF) 100
MG
LEUCOVORIN CALCIUM (PF) 350 MG
CYTARABINE (M.D.V.,GLASS) 100 MG
CYTARABINE (M.D.V.,GLASS) 500 MG
CYTARABINE (M.D.V.,GLASS) 1 GM
CYTARABINE (M.D.V.,GLASS) 2 GM
DAUNORUBICIN HCL (S.D.V.,PF) 5
MG/ML
ETOPOSIDE (M.D.V. POLYMER) 20
MG/ML
ETOPOSIDE (M.D.V. POLYMER) 20
MG/ML
ETOPOSIDE (M.D.V.) 20 MG/ML
CISPLATIN (M.D.V.) 1 MG/ML
FLUDARABINE PHOSPHATE 50 MG
(USP,MDV) 200 MG/ML
(USP,MDV) 200 MG/ML
OXYTOCIN (25X1ML) 10 U/ML
2 ML VL
IV
ML
1 MG
01/01/2002
99/99/9999
2 ML VL
IV
ML
20 MG
02/28/2008
99/99/9999
2 ML VL
IV
ML
20 MG
02/28/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/28/2008
99/99/9999
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
EA
EA
ML
ML
ML
ML
ML
ML
ML
20 MG
10 MG
1 GM
200 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
200 MG
1
0.5
1
2.5
0.4
0.4
0.4
0.4
0.4
0.4
0.5
02/28/2008
01/01/2002
12/03/2003
01/01/2002
04/11/2006
11/06/2006
04/11/2006
11/06/2006
04/11/2006
11/06/2006
02/22/2002
99/99/9999
99/99/9999
99/99/9999
09/20/2002
99/99/9999
8/19/2008
99/99/9999
8/19/2008
99/99/9999
8/19/2008
99/99/9999
Page 117 of 374
5 ML
5 ML
15 ML
45 ML
1 EA
1 EA
5 ML
2 ML
1 EA
1 EA
12.5 ML
12.5 ML
10 ML
10 ML
15 ML
15 ML
10 ML
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
2 ML VL
IV
ML
50 MG
0.5
05/02/2007
99/99/9999
2 ML VL
IV
ML
50 MG
0.5
08/03/2006
99/99/9999
5 ML VL
IJ
ML
25 MG
01/01/2002
01/10/2007
100 ML VL
IV
ML
10 MG
0.2
01/01/2002
99/99/9999
5 ML VL
IV
ML
10 MG
0.2
01/01/2002
99/99/9999
25 ML VL
IV
ML
10 MG
0.2
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1 MCG
01/01/2002
99/99/9999
10 ML VL
1 EA VL
1 EA VL
IJ
IV
IV
ML
EA
EA
1 MCG
200 MG
200 MG
4
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
50 MG
50 MG
100 MG
500 MG
500 MG
500 MG
2
7
1
1
2
4
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
02/14/2002
02/14/2002
02/14/2002
02/14/2002
4 ML VL
IV
ML
10 MG
0.5
01/27/2003
99/99/9999
5 ML VL
IV
ML
10 MG
01/01/2002
99/99/9999
IV
IV
IV
IV
IV
ML
ML
ML
ML
EA
10 MG
10 MG
10 MG
10 MG
50 MG
2
2
0.1
0.1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/12/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
25 ML
50 ML
50 ML
100 ML
1 EA
VL
VL
VL
VL
VL
1 ML VL
IM
ML
200 MG
04/16/2007
99/99/9999
10 ML VL
1 ML VL
IM
IJ
ML
ML
200 MG
10 U
1
1
04/16/2007
01/24/2008
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00703-6275-03
J2590
00703-6801-01
J1055

9/13/2004 99/99/9999 MG
9/13/2004 99/99/9999 MG
9/16/2005 99/99/9999 MG
00703-6801-04
J1055
00703-6811-21
J1055
00703-7011-03
J1631
00703-7013-01
J1631
00703-7021-03
J1631
00703-7023-01
J1631
00703-7041-03
J1630
00703-7045-01
J1630
00703-7101-04
J1165
00703-7105-03
J1165
00703-7171-04
J0780
6/17/2003
00703-7175-01
J0780
6/17/2003
00703-7221-02
J2405
00703-7221-03
J2405
11/22/2006
00703-7221-04
00703-7226-01
J2405
J2405

00703-7226-03
J2405
00703-7239-39
00703-7311-04
J2405
J0636

00703-7871-03
J1626
1/3/2008 10/19/2009 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG
00703-7891-02
J1626
00703-7971-03
J1626
00703-7973-01
00703-8005-03
00703-8006-03
00703-8008-01
00703-8201-04
J1626
J2260
J2260
J2260
J0360

00703-8463-09
J0895
00703-8465-01
J0895
00703-8771-03
J0150
00703-8773-01
J0150

00703-9032-03
J3490
00703-9032-03
00703-9040-03
00703-9040-03
00703-9085-03
OXYTOCIN 10 U/ML
MEDROXYPROGESTERONE ACETATE
(ODOR-FREE) 150 MG/ML
MG/ML
HALOPERIDOL DECANOATE (M.D.V.) 50
MG/ML
MG/ML
MG/ML
HALOPERIDOL LACTATE (S.D.V.) 5
MG/ML
HALOPERIDOL LACTATE (M.D.V.) 5
MG/ML
FOSPHENYTOIN SODIUM (USP,25X2ML)
50 MG/ML
FOSPHENYTOIN SODIUM
(USP,10X10ML) 50 MG/ML
(S.D.V.) 5 MG/ML
(M.D.V.) 5 MG/ML
ONDANSETRON (SDV,USP,5X2ML) 2
MG/ML
MG/ML
MG/ML
ONDANSETRON (MDV,USP,10X20ML) 2
MG/ML
ONDANSETRON (SINGLE
DOSE,6X50ML,PF) 32 MG/50 ML
CALCITRIOL (25X1ML) 1 MCG/ML
GRANISETRON HYDROCHLORIDE
(10X1ML,SINGLE-USE,PF) 1 MG/ML
(5X1ML,SINGLE-USE,PF) 0.1 MG/ML
(1X4ML) 1 MG/ML
MILRINONE LACTATE (S.D.V.) 1 MG/ML
HYDRALAZINE HCL (VIAL) 20 MG/ML
DEFEROXAMINE MESYLATE (USP,SDV)
500 MG
DEFEROXAMINE MESYLATE (USP,SDV)
2 GM
10 ML VL
IJ
ML
10 U
01/24/2008
99/99/9999
1 ML VL
IM
ML
150 MG
09/13/2004
99/99/9999
1 ML VL
IM
ML
150 MG
09/13/2004
99/99/9999
1 ML SR
IM
ML
150 MG
09/16/2005
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
5 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
5 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
1 ML VL
IM
ML
5 MG
01/18/2002
99/99/9999
10 ML VL
IM
ML
5 MG
01/18/2002
99/99/9999
2 ML VL
IV
ML
50 MG
09/14/2007
99/99/9999
10 ML VL
IV
ML
50 MG
09/14/2007
99/99/9999
2 ML VL
IJ
ML
10 MG
0.5
06/17/2003
7/1/2008
10 ML VL
IJ
ML
10 MG
0.5
06/17/2003
7/1/2008
2 ML VL
IJ
ML
1 MG
11/22/2006
99/99/9999
2 ML VL
IJ
ML
1 MG
11/22/2006
05/10/2007
2 ML VL
20 ML VL
IJ
IJ
ML
ML
1 MG
1 MG
2
2
11/22/2006
11/22/2006
99/99/9999
99/99/9999
20 ML VL
IJ
ML
1 MG
11/22/2006
99/99/9999
50 ML FC
1 ML VL
IV
IV
ML
ML
1 MG
0.1 MCG
0.64
10
11/22/2006
01/17/2005
99/99/9999
99/99/9999
1 ML VL
IV
ML
100 MCG
10
1 ML VL
IV
ML
100 MCG
01/03/2008
99/99/9999
1 ML VL
IV
ML
100 MCG
10
01/03/2008
99/99/9999
VL
VL
VL
VL
VL
IV
IV
IV
IV
IJ
ML
ML
ML
ML
ML
100 MCG
5 MG
5 MG
5 MG
20 MG
10
0.2
0.2
0.2
1
06/30/2008
06/19/2003
06/19/2003
06/19/2003
01/01/2002
99/99/9999
04/17/2008
04/17/2008
99/99/9999
01/15/2002
1 EA VL
IJ
EA
500 MG
03/31/2006 12/23/2008
1 EA VL
IJ
EA
500 MG
03/31/2006 12/23/2008
ADENOSINE 3 MG/ML
2 ML VL
IV
ML
6 MG
0.5
06/16/2004
ADENOSINE 3 MG/ML
4 ML VL
IV
ML
6 MG
0.5
06/16/2004
99/99/9999
AMIKACIN SULFATE (S.D.V.) 250 MG/ML
2 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2005
J0278
J3490
J0278
J0456
1/1/2006
1/1/2002
1/1/2006
3/1/2007
2 ML
4 ML
4 ML
1 EA
IJ
IJ
IJ
IV
ML
ML
ML
EA
100 MG
1 EA
100 MG
500 MG
2.5
1
2.5
1
01/01/2006
01/01/2002
01/01/2006
03/01/2007
99/99/9999
12/31/2005
99/99/9999
99/99/9999
00703-9089-01
J0456
3/1/2007 99/99/9999 INJECTION, AZITHROMYCIN, 500 MG
00703-9402-04
J3260
00703-9416-01
J3260
00703-9503-03
J3490
00703-9514-03
00703-9526-01
00703-9785-01
J3490
J3490
J0285
AMIKACIN SULFATE (S.D.V.) 250 MG/ML

AMIKACIN SULFATE (VIAL) 250 MG/ML
AZITHROMYCIN (SDV) 500 MG
AZITHROMYCIN (PHARMACY BULK PKG)
2.5 GM
MG/ML
MG/ML
SMZ-TMP CONCENTRATE (S.D.V.) 80
MG/ML-16 MG/ML
SMZ-TMP CONCENTRATE (M.D.V.) 80
MG/ML-16 MG/ML
SMZ-TMP (M.D.V.) 80 MG/ML-16 MG/ML
AMPHOTERICIN B (S.D.V.) 50 MG
00713-0135-12
00713-0135-12
K0416
J8498

1/1/2002 99/99/9999 INJECTION, AMPHOTERICIN B, 50 MG

Page 118 of 374
4 ML
10 ML
20 ML
50 ML
1 ML
VL
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
01/03/2008 10/19/2009
99/99/9999
1 EA VL
IV
EA
500 MG
03/01/2007
99/99/9999
2 ML VL
IJ
ML
80 MG
0.5
01/01/2002
99/99/9999
30 ML VL
IJ
ML
80 MG
0.5
01/01/2002
99/99/9999
5 ML VL
IV
ML
1 EA
01/01/2002
99/99/9999
10 ML VL
30 ML VL
1 EA VL
IV
IV
IV
ML
ML
EA
1 EA
1 EA
50 MG
1
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999

1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002 99/99/9999 REGIMEN
1/1/2002
00713-0526-12
00713-0526-12
K0416
J8498
00713-0536-12
00713-0536-12
K0416
J8498
00761-0914-20
Q0163
00781-1046-01
Q0175
00781-1046-10
Q0175
00781-1046-13
Q0175
00781-1047-01
Q0175
00781-1047-10
Q0175
00781-1047-13
Q0175
00781-1048-01
Q0176
00781-1048-10
Q0176
00781-1048-13
Q0176
00781-1049-01
Q0176
00781-1049-13
00781-1059-01
00781-1076-01
00781-1076-36
Q0176
J7500
None
None
00781-1491-31
Q0144
00781-1491-33
Q0144
00781-1496-31
Q0144
00781-1496-68
Q0144
PROMETHEGAN 25 MG
PROMETHEGAN 25 MG
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
02/12/2002
01/01/2006
12/31/2005
99/99/9999
PROMETHEGAN 12.5 MG
PROMETHEGAN 12.5 MG
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
03/31/2003
01/01/2006
12/31/2005
99/99/9999
ANTI-HIST 25 MG
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
PERPHENAZINE 2 MG
100 EA BO
PO
EA
4 MG
0.5
01/01/2002
99/99/9999
PERPHENAZINE 2 MG
1000 EA BO
PO
EA
4 MG
0.5
05/16/2008
99/99/9999
PERPHENAZINE 2 MG
100 EA BX
PO
EA
4 MG
0.5
01/01/2002
99/99/9999
PERPHENAZINE 4 MG
100 EA BO
PO
EA
4 MG
01/01/2002
99/99/9999
PERPHENAZINE 4 MG
1000 EA BO
PO
EA
4 MG
05/16/2008
99/99/9999
PERPHENAZINE 4 MG
100 EA BX
PO
EA
4 MG
01/01/2002
99/99/9999
PERPHENAZINE 8 MG
100 EA BO
PO
EA
8 MG
01/01/2002
99/99/9999
PERPHENAZINE 8 MG
1000 EA BO
PO
EA
8 MG
05/16/2008
99/99/9999
PERPHENAZINE 8 MG
100 EA BX
PO
EA
8 MG
01/01/2002
99/99/9999
PERPHENAZINE 16 MG
100 EA BO
PO
EA
8 MG
01/01/2002
99/99/9999
PERPHENAZINE 16 MG
AZATHIOPRINE 50 MG
100 EA
100 EA
100 EA
36 EA
BX
BO
NA
NA
PO
PO
PO
PO
EA
EA
EA
EA
8 MG
50 MG
2.5 MG
2.5 MG
2
1
1
1
05/16/2008
01/01/2002
01/01/1994
01/01/1994
99/99/9999
04/03/2003
10/04/1999
10/04/1999

AZITHROMYCIN (3X3,UNIT OF USE) 500
MG
30 EA NA
PO
EA
1 GM
0.5
11/14/2005 11/15/2005
3 EA NA
PO
EA
1 GM
0.5
11/14/2005 11/15/2005

MG
30 EA BO
PO
EA
1 GM
0.25
01/09/2006
99/99/9999
3 EA DP
PO
EA
1 GM
0.25
11/14/2005
99/99/9999
00781-1496-69
Q0144
50 EA BX
PO
EA
1 GM
0.25
11/14/2005
99/99/9999
00781-1497-31
Q0144
30 EA BO
PO
EA
1 GM
0.6
11/14/2005
99/99/9999
00781-1830-01
Q0170
100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
00781-1830-10
Q0170
1000 EA BO
PO
EA
25 MG
01/20/2005
99/99/9999
00781-1832-01
Q0170

100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
Page 119 of 374
1/1/2002
12/1/2004
0.5
1/1/2002
12/1/2004
1/1/2002
1/1/2005
01-Jan-02 25-Aug-03
1/1/2002
8/25/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00781-1941-31
Q0144
00781-1941-33
Q0144

00781-2048-01
G9017
00781-2048-05
00781-2102-01
00781-2103-01
00781-2104-01
G9017
J7507
J7507
J7507
00781-3001-07
J2941
00781-3001-26
J2941
00781-3001-44
J2941
00781-3009-95
00781-3029-75
00781-3030-75
00781-3031-75
J0330
J1390
J1380
J0970
4/15/2005
10/4/2007
10/4/2007
10/4/2007
00781-3032-95
J0295
00781-3033-95
J0295
00781-3034-46
J0295
00781-3052-71
J0835

3/26/2008 12/31/2009 INJECTION, COSYNTROPIN, PER 0.25 MG
00781-3052-95
J0835
00781-3057-14
J2405
00781-3057-80
00781-3059-95
J2405
J1160

00781-3066-72
J9206
00781-3066-72 QR J9206
00781-3066-75
3/26/2008 12/31/2009 INJECTION, COSYNTROPIN, PER 0.25 MG

QR
J9206
00781-3066-75 QR J9206

QR
00781-3073-70
J1070
10/17/2006 99/99/9999 INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG
00781-3074-70
J1080
00781-3074-71
00781-3084-75
J1080
J3303

1/29/2007 99/99/9999 INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG
00781-3094-15
J2700
00781-3094-92
J2700
00781-3095-80
J2700
00781-3095-92
00781-3099-95
00781-3101-80
J2700
J2700
J2700

00781-3101-95
J2700
00781-3103-95
00781-3124-85
J2700
J3490

00781-3124-92
00781-3124-95
00781-3125-85
J3490
J3490
J3490
2/23/2005
00781-3125-92
00781-3125-95
00781-3126-46
J3490
J3490
J3490

00781-3126-95
J3490
00781-3128-92
J3490

MG
30 EA BO
PO
EA
1 GM
0.5
11/16/2005
99/99/9999
3 EA DP
PO
EA
1 GM
0.5
11/16/2005
99/99/9999
AMANTADINE HCL 100 MG
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005

TACROLIMUS (HARD GELATIN) 0.5 MG
TACROLIMUS (HARD GELATIN) 1 MG
TACROLIMUS (HARD GELATIN) 5 MG
OMNITROPE (1X1.5ML,W/DILUENT) 5
MG/1.5 ML
MG/1.5 ML
MG/1.5 ML
ANECTINE (MDV,10MLX10VIALS) 20
MG/ML
ESTRADIOL VALERATE 20 MG/ML
GM-0.5 GM
GM-1 GM
GM-5 GM
500 EA
100 EA
100 EA
100 EA
BO
BO
BO
BO
PO
PO
PO
PO
EA
EA
EA
EA
100 MG
1 MG
1 MG
1 MG
1
0.5
1
5
01/20/2005
08/10/2009
08/10/2009
08/10/2009
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1.5 ML CT
SC
ML
1 MG
3.33333
03/12/2008
99/99/9999
1.5 ML CT
SC
ML
1 MG
3.33333
03/12/2008
99/99/9999
1.5 ML CT
SC
ML
1 MG
3.33333
03/12/2008
99/99/9999
10 ML
5 ML
5 ML
5 ML
IV
IM
IM
IM
ML
ML
ML
ML
20 MG
20 MG
10 MG
40 MG
1
1
1
1
04/15/2005
10/04/2007
10/04/2007
10/04/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
1.5 GM
09/05/2006
99/99/9999
1 EA VL
IJ
EA
1.5 GM
09/05/2006
99/99/9999
1 EA VL
IV
EA
1.5 GM
10
09/05/2006
99/99/9999
1 ML VL
IV
ML
0.25 MG
03/26/2008
12/31/2009
10 ML VL
IV
ML
0.25 MG
03/26/2008
12/31/2009
2 ML VL
IJ
ML
1 MG
11/22/2006
99/99/9999
20 ML VL IJ
2 ML AM IJ
ML
ML
1 MG
0.5 MG
2
0.5
11/22/2006
07/21/2006
99/99/9999
99/99/9999
99/99/9999
COSYNTROPIN (NO
ANTMCRBIAL&PRESRVATV) 0.25 MG/ML
COSYNTROPIN (NO
ANTMCRBIAL&PRESRVATV) 0.25 MG/ML
ONDANSETRON HYDROCHLORIDE
(S.D.V,5X2ML) 2 MG/ML
(MULTIPLE DOSE VIAL) 2 MG/ML
DIGOXIN (USP,10X2ML) 0.25 MG/ML
(1X2ML,S.D.V) 20 MG/ML
(USP,MDV) 100 MG/ML
(USP,MDV) 200 MG/ML
(USP,MDV) 200 MG/ML
ARISTOSPAN 5 MG/ML
OXACILLIN (USP,ADD-VANTAGE VIAL) 1
GM
OXACILLIN (1X10,USP,ADD-VANTAGE) 1
GM
OXACILLIN (USP,ADD-VANTAGE VIAL) 2
GM
OXACILLIN (1X10,USP,ADD-VANTAGE) 2
GM
OXACILLIN SODIUM 1 GM
OXACILLIN (USP) 2 GM
OXACILLIN SODIUM (VIAL,PIGGYBACK) 2
GM
OXACILLIN SODIUM (PHARMACY BULK
PACKAGE) 10 GM
NAFCILLIN SODIUM 1 GM
NAFCILLIN SODIUM (ADD-VANTAGE
VIAL) 1 GM
NAFCILLIN SODIUM (ADD-VANTAGE
VIAL) 2 GM
BULK) 10 GM
NAFCILLIN (USP,ADD-VANTAGE VIAL) 1
GM
Page 120 of 374
VL
VL
VL
VL
2 ML VL
IV
ML
20 MG
02/27/2008
2 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
10 ML VL
IM
ML
100 MG
10/17/2006
99/99/9999
10 ML VL
IM
ML
200 MG
10/17/2006
99/99/9999
1 ML VL
5 ML VL
IM
IJ
ML
ML
200 MG
5 MG
1
1
10/17/2006
01/29/2007
99/99/9999
99/99/9999
1 EA VL
IV
EA
250 MG
03/19/2008
99/99/9999
1 EA VL
IV
EA
250 MG
03/19/2008
99/99/9999
1 EA VL
IV
EA
250 MG
03/19/2008
99/99/9999
1 EA VL
1 EA VL
1 EA VL
IV
IJ
IJ
EA
EA
EA
250 MG
250 MG
250 MG
8
4
8
03/19/2008
02/08/2005
02/01/2007
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
250 MG
07/02/2004
99/99/9999
1 EA VL
1 EA VL
IJ
IJ
EA
EA
250 MG
1 EA
40
1
08/31/2004
09/09/2005
99/99/9999
99/99/9999
1 EA VL
1 EA VL
1 EA VL
IJ
IJ
IJ
EA
EA
EA
1 EA
1 EA
1 EA
1
1
1
02/23/2005
04/27/2004
09/09/2005
08/01/2006
99/99/9999
99/99/9999
1 EA VL
1 EA VL
1 EA VL
IJ
IJ
IJ
EA
EA
EA
1 EA
1 EA
1 EA
1
1
1
02/23/2005
04/27/2004
09/09/2005
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
1 EA
04/27/2004
99/99/9999
1 EA VL
IV
EA
1 EA
04/17/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00781-3129-92
00781-3147-84
00781-3148-70
00781-3157-96
00781-3177-96
00781-3178-95
J3490
J2430
J2430
J0690
J0713
J0713
2/22/2006
10/3/2005
10/3/2005
7/17/2002
2/23/2007
2/23/2007

00781-3179-86
00781-3182-73
00781-3182-84
00781-3206-95
00781-3207-95
00781-3208-95
00781-3209-95
00781-3210-46
J0713
J1451
J1451
J0696
J0696
J0696
J0696
J0696
2/23/2007
4/2/2008
4/2/2008
7/19/2005
7/19/2005
7/19/2005
7/19/2005
7/19/2005

99/99/9999 INJECTION, FOMEPIZOLE, 15 MG
00781-3222-80
J0692
4/14/2008 99/99/9999 INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG
00781-3222-95
J0692
00781-3223-91
J0692
00781-3223-95
J0692
NAFCILLIN SODIUM (2GMX10, ADDVANTAGE) 2 GM

PAMIDRONATE DISODIUM 30 MG
PAMIDRONATE DISODIUM 90 MG
CEFTAZIDIME (USP) 1 GM
CEFTAZIDIME (USP) 2 GM
CEFTAZIDIME (USP,PHARMACY BULK
PKG) 6 GM
FOMEPIZOLE (1X1.5ML,PF) 1 GM/ML
CEFTRIAXONE 250 MG
CEFTRIAXONE 500 MG
CEFTRIAXONE 1 GM
CEFTRIAXONE 2 GM
CEFTRIAXONE 10 GM
CEFEPIME HYDROCHLORIDE
(S.D.V,USP) 1 GM
CEFEPIME HYDROCHLORIDE (USP) 1
GM
CEFEPIME HYDROCHLORIDE
(S.D.V,USP) 2 GM
CEFEPIME HYDROCHLORIDE (USP) 2
GM
00781-3239-09
J0744
00781-3240-09
J0744
00781-3338-70
J0690
00781-3338-95
00781-3346-46
00781-3346-95
00781-3400-95
00781-3402-95
00781-3404-95
00781-3407-95
00781-3408-95
00781-3409-95
J0690
J0690
J0690
J0290
J0290
J0290
J0290
J0290
J0290
8/23/2004
6/18/2004
6/18/2004
5/12/2004
12/1/2005
12/1/2005
12/1/2005
12/1/2005
5/12/2004
00781-3412-92
J0290
00781-3413-92
00781-3450-95
00781-3451-96
00781-3452-95
J0290
J0690
J0690
J0690
3/20/2007
11/8/2006
9/13/2006
9/13/2006
00781-3777-95
00781-3918-96
00781-3922-96
00781-3926-95
J1800
J0697
J0697
J0697

00781-4004-36
J2941
00781-5020-01
Q0164
00781-5021-01
00781-5022-01
Q0165
J7509
00781-5022-07
J7509
00781-5029-01
00781-5075-01
G9020
J7500
00781-5257-13
Q0179
00781-5257-31
Q0179



CEFAZOLIN SODIUM (1X10ML VIAL) 500
MG
CEFAZOLIN SODIUM (10 VIAL PACK) 500
MG
AMPICILLIN SODIUM 125 MG
AMPICILLIN SODIUM (U.S.P.) 250 MG
AMPICILLIN SODIUM (U.S.P.) 1 GM
AMPICILLIN SODIUM (U.S.P.) 500 MG
AMPICILLIN SODIUM (U.S.P.) 2 GM
AMPICILLIN SODIUM 10 GM
AMPICILLIN SODIUM (ADDVANTAGE,USP) 1 GM
AMPICILLIN SODIUM (ADDVANTAGE,ADD-VANTAGE) 2 GM
CEFAZOLIN SODIUM (USP) 500 MG
OMNITROPE (W/ 8 VIALS OF DILUENT)
5.8 MG

4 MG
AZATHIOPRINE 50 MG
(FILM COATED) 4 MG
(FILM COATED) 4 MG
Page 121 of 374
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
IV
IV
IV
IJ
IJ
IV
EA
EA
EA
EA
EA
EA
1 EA
30 MG
30 MG
500 MG
500 MG
500 MG
1
1
3
2
2
4
02/22/2006
10/03/2005
10/03/2005
07/17/2002
02/23/2007
02/23/2007
99/99/9999
99/99/9999
99/99/9999
09/21/2006
99/99/9999
99/99/9999
1 EA
1.5 ML
1.5 ML
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IJ
IJ
IJ
IJ
IJ
EA
ML
ML
EA
EA
EA
EA
EA
500 MG
15 MG
15 MG
250 MG
250 MG
250 MG
250 MG
250 MG
12
66.66666
66.66666
1
2
4
8
40
02/23/2007
04/02/2008
04/02/2008
07/19/2005
07/19/2005
07/19/2005
07/19/2005
07/19/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
500 MG
04/14/2008
99/99/9999
1 EA VL
IJ
EA
500 MG
04/14/2008
99/99/9999
1 EA VL
IJ
EA
500 MG
04/14/2008
99/99/9999
1 EA VL
IJ
EA
500 MG
04/14/2008
99/99/9999
100 ML FC
IV
ML
200 MG
0.01
03/18/2008
99/99/9999
200 ML FC
IV
ML
200 MG
0.01
03/18/2008
99/99/9999
1 EA VL
IJ
EA
500 MG
08/23/2004
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
EA
EA
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
1
20
20
0.25
0.5
2
1
4
20
08/23/2004
06/18/2004
06/18/2004
05/12/2004
12/01/2005
12/01/2005
12/01/2005
12/01/2005
05/12/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
500 MG
03/20/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
IJ
IJ
IJ
IV
EA
EA
EA
EA
500 MG
500 MG
500 MG
500 MG
4
1
2
20
03/20/2007
11/08/2006
09/13/2006
09/13/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1
1
1
1
VL
VL
VL
VL
IV
IJ
IJ
IJ
ML
EA
EA
EA
1 MG
750 MG
750 MG
750 MG
1
1
2
10
02/15/2007
01/01/2002
01/01/2002
01/01/2002
99/99/9999
08/11/2006
08/11/2006
08/11/2006
1 EA VL
SC
EA
1 MG
5.8
01/15/2007
99/99/9999
100 EA BO
PO
EA
5 MG
01/01/2002
99/99/9999
100 EA BO
100 EA BO
PO
PO
EA
EA
10 MG
4 MG
1
1
01/01/2002
04/04/2003
99/99/9999
99/99/9999
ML
EA
EA
EA
21 EA DP
PO
EA
4 MG
04/04/2003
99/99/9999
100 EA BO
100 EA BO
PO
PO
EA
EA
100 MG
50 MG
1
1
12/01/2004
04/04/2003
05/31/2005
99/99/9999
100 EA BX
PO
EA
8 MG
0.5
12/27/2006
99/99/9999
30 EA BO
PO
EA
8 MG
0.5
12/27/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

(FILM COATED) 4 MG
(FILM COATED) 8 MG
(FILM COATED) 8 MG
(FILM COATED) 8 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 ONDANSETRON (3X10,STRAWBERRY) 4
MG
MG
MG
PENICILLIN G POTASSIUM 5 Million U
PENICILLIN G POTASSIUM 20 Million U
00781-5257-33
Q0179
12/27/2006
00781-5258-13
Q0179
12/27/2006
00781-5258-31
Q0179
12/27/2006
00781-5258-33
Q0179
12/27/2006
00781-5265-64
Q0179
12/26/2006
00781-5266-64
Q0179
12/26/2006
00781-5266-80
00781-6135-95
00781-6136-94
Q0179
J2540
J2540
12/26/2006
11/25/2002
11/25/2002
00781-6153-95
J3490
00781-6153-97
00781-9109-85
00781-9109-95
J3490
J2700
J2700

00781-9110-15
J2700
00781-9110-92
00781-9111-80
00781-9111-95
J2700
J2700
J2700

00781-9112-20
J2700
00781-9112-92
00781-9113-46
00781-9113-95
00781-9124-85
00781-9124-95
00781-9125-85
00781-9125-95
00781-9126-46
J2700
J2700
J2700
J3490
J3490
J3490
J3490
J3490
3/19/2008
2/1/2007
5/3/2006
2/1/2007
2/1/2006
2/1/2007
2/1/2006
3/31/2007
00781-9126-95
J3490
00781-9164-75
J2354
00781-9165-75
J2354
00781-9166-95
J2354
00781-9167-95
J2354
00781-9168-95
00781-9205-70
00781-9205-96
00781-9206-80
00781-9206-96
J2354
J0697
J0697
J0697
J0697


00781-9207-46
J0697
00781-9207-95
J0697
5/1/2003
00781-9224-15
J3490
00781-9224-92
J3490
00781-9225-20
J3490
00781-9225-92
J3490
3 EA BX
PO
EA
8 MG
0.5
12/27/2006
99/99/9999
100 EA BX
PO
EA
8 MG
12/27/2006
99/99/9999
30 EA BO
PO
EA
8 MG
12/27/2006
99/99/9999
3 EA BX
PO
EA
8 MG
12/27/2006
99/99/9999
30 EA BX
PO
EA
8 MG
0.5
12/26/2006
99/99/9999
30 EA BX
PO
EA
8 MG
12/26/2006
99/99/9999
10 EA BX
1 EA VL
1 EA VL
PO
IV
IV
EA
EA
EA
8 MG
600000 U
600000 U
1
8.33333
33.33333
12/26/2006
11/25/2002
11/25/2002
99/99/9999
99/99/9999
99/99/9999
PENICILLIN G SODIUM (VIAL) 5 Million U
1 EA VL
IV
EA
1 EA
01/01/2002
99/99/9999
PENICILLIN G SODIUM (VIAL) 5 Million U

NOVAPLUS OXACILLIN 1 GM
NOVAPLUS OXACILLIN (USP) 1 GM
NOVAPLUS OXACILLIN (USP,ADDVANTAGE VIAL) 1 GM
NOVAPLUS OXACILLIN (1X10,USP,ADDVANTAGE) 1 GM
NOVAPLUS OXACILLIN (USP) 2 GM
NOVAPLUS OXACILLIN (USP,ADDVANTAGE VIAL) 2 GM
NOVAPLUS OXACILLIN (1X10,USP,ADDVANTAGE) 2 GM
NOVAPLUS NAFCILLIN 1 GM
NOVAPLUS NAFCILLIN (BULK PACKAGE)
10 GM
OCTREOTIDE ACETATE NOVAPLUS
(M.D.V.) 1000 MCG/ML
(M.D.V.) 200 MCG/ML
(M.D.V.) 50 MCG/ML
(M.D.V.) 100 MCG/ML
(M.D.V.) 500 MCG/ML
CEFUROXIME NOVAPLUS 750 MG
CEFUROXIME NOVAPLUS 750 MG
CEFUROXIME NOVAPLUS 1.5 GM
CEFUROXIME NOVAPLUS 1.5 GM
CEFUROXIME NOVAPLUS (PHARMACY
BULK PACKAGE) 7.5 GM
CEFUROXIME NOVAPLUS (PHARMACY
BULK PACKAGE) 7.5 GM
NOVAPLUS NAFCILLIN (ADD-VANTAGE)
1 GM
NOVAPLUS NAFCILLIN (USP,ADDVANTAGE) 1 GM
NOVAPLUS NAFCILLIN (ADD-VANTAGE)
2 GM
NOVAPLUS NAFCILLIN (USP,ADDVANTAGE) 2 GM
1 EA VL
1 EA VL
1 EA VL
IV
IJ
IJ
EA
EA
EA
1 EA
250 MG
250 MG
1
4
4
01/01/2002
02/01/2007
03/01/2006
08/25/2003
99/99/9999
99/99/9999
Page 122 of 374
1 EA VL
IV
EA
250 MG
03/19/2008
99/99/9999
1 EA VL
1 EA VL
1 EA VL
IV
IJ
IJ
EA
EA
EA
250 MG
250 MG
250 MG
4
8
8
03/19/2008
02/01/2007
05/04/2006
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IV
EA
250 MG
03/19/2008
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
EA
250 MG
250 MG
250 MG
1 EA
1 EA
1 EA
1 EA
1 EA
8
40
40
1
1
1
1
1
03/19/2008
02/01/2007
05/03/2006
02/01/2007
02/01/2006
02/01/2007
02/01/2006
03/31/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
VL
VL
VL
VL
1 EA VL
IJ
EA
1 EA
02/01/2006
99/99/9999
5 ML VL
IJ
ML
25 MCG
40
04/07/2005
99/99/9999
5 ML VL
99/99/9999
IJ
ML
25 MCG
04/07/2005
1 ML AM IJ
ML
25 MCG
04/07/2005
99/99/9999
1 ML AM IJ
ML
25 MCG
04/07/2005
99/99/9999
1 ML
1 EA
1 EA
1 EA
1 EA
AM
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
25 MCG
750 MG
750 MG
750 MG
750 MG
20
1
1
2
2
04/07/2005
05/01/2003
05/01/2003
05/01/2003
05/01/2003
99/99/9999
99/99/9999
08/18/2006
99/99/9999
08/18/2006
1 EA VL
IJ
EA
750 MG
10
05/01/2003
99/99/9999
1 EA VL
IJ
EA
750 MG
10
05/01/2003
08/18/2006
1 EA VL
IV
EA
1 EA
02/01/2007
99/99/9999
1 EA VL
IV
EA
1 EA
09/18/2006
99/99/9999
1 EA VL
IV
EA
1 EA
02/01/2007
99/99/9999
1 EA VL
IV
EA
1 EA
09/18/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00781-9326-95
00781-9327-95
00781-9328-95
00781-9329-90
00781-9329-95
00781-9330-46
J0696
J0696
J0696
J0696
J0696
J0696
7/19/2005
7/19/2005
7/19/2005
3/31/2007
7/19/2005
7/19/2005
00781-9337-46
J0690
00781-9337-95
00781-9338-85
00781-9338-95
00781-9339-85
00781-9339-96
00781-9401-78
00781-9401-95
00781-9402-78
00781-9402-95
00781-9404-85
00781-9404-95
00781-9407-78
00781-9407-95
00781-9408-80
J0690
J0690
J0690
J0690
J0690
J0290
J0290
J0290
J0290
J0290
J0290
J0290
J0290
J0290
4/25/2007
2/27/2006
2/27/2006
5/15/2007
5/15/2007
2/1/2007
2/1/2006
1/24/2006
2/1/2006
1/24/2006
2/1/2006
1/24/2006
2/1/2006
1/24/2006
00781-9408-92
00781-9408-95
00781-9409-95
00781-9409-96
J0290
J0290
J0290
J0290
2/1/2007
2/1/2006
2/1/2006
2/1/2007
00781-9412-15
J0290
00781-9412-92
J0290
00781-9413-92
00781-9451-96
00781-9452-95
J0290
J0690
J0690

1/1/2002
1/1/2002
1/1/2002
1/1/2002
00832-0111-00
G9017
00832-0111-50
G9017
00832-1015-00
G9017
00832-1015-50
00839-7905-06
G9017
None
00904-0360-60
Q0178
00904-0362-40
Q0177
00904-0362-60
Q0177
00904-0362-61
Q0177
00904-0363-40
Q0178
00904-0363-60
Q0178


500 MG
500 MG
500 MG
500 MG
CEFTRIAXONE NOVAPLUS 250 MG

CEFTRIAXONE NOVAPLUS 500 MG
CEFTRIAXONE NOVAPLUS 1 GM
NOVAPLUS CEFAZOLIN (PHARMACY
BULK PACKAGE) 10 GM
NOVAPLUS CEFAZOLIN (PHARMACY
BULK PACKAGE) 10 GM
NOVAPLUS CEFAZOLIN 500 MG
NOVAPLUS CEFAZOLIN (USP) 500 MG
NOVAPLUS CEFAZOLIN 1 GM
NOVAPLUS CEFAZOLIN (USP) 1 GM
NOVAPLUS AMPICILLIN 125 MG
NOVAPLUS AMPICILLIN (USP) 125 MG
NOVAPLUS AMPICILLIN 1 GM
NOVAPLUS AMPICILLIN (USP) 1 GM
NOVAPLUS AMPICILLIN (ADD-VANTAGE)
2 GM
1 GM
1 GM
2 GM
1
1
1
1
1
1
EA
EA
EA
EA
EA
EA
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
1
2
4
8
8
40
07/19/2005
07/19/2005
07/19/2005
03/31/2007
07/19/2005
07/19/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
500 MG
20
04/25/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
20
1
1
2
2
0.25
0.25
0.5
0.5
2
2
1
1
4
04/25/2007
02/27/2006
02/27/2006
05/15/2007
05/15/2007
02/01/2007
02/01/2006
01/24/2006
02/01/2006
01/24/2006
02/01/2006
01/24/2006
02/01/2006
01/24/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
IJ
IJ
IJ
IJ
EA
EA
EA
EA
500 MG
500 MG
500 MG
500 MG
4
4
20
20
02/01/2007
02/01/2006
02/01/2006
02/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
500 MG
02/01/2007
99/99/9999
1 EA VL
IJ
EA
500 MG
03/20/2007
99/99/9999
1 EA VL
1 EA VL
1 EA VL
IJ
IJ
IV
EA
EA
EA
500 MG
500 MG
500 MG
4
2
20
03/20/2007
01/04/2007
01/09/2007
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
500 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005

500 EA BO
100 EA NA
PO
PO
EA
EA
100 MG
2.5 MG
1
1
12/01/2004
03/08/1994
05/31/2005
11/14/1997
100 EA BO
PO
EA
50 MG
01/01/2002
03/03/2003
500 EA BO
PO
EA
25 MG
01/01/2002
03/03/2003
100 EA BO
PO
EA
25 MG
01/01/2002
03/03/2003
100 EA BX
PO
EA
25 MG
01/01/2002
11/13/2002
500 EA BO
PO
EA
50 MG
01/01/2002
07/19/2002
100 EA BO
PO
EA
50 MG
01/01/2002
03/03/2003
00904-0363-61
Q0178
100 EA BX
PO
EA
50 MG
01/01/2002
11/13/2002
00904-0889-10
J3420
1/1/2002
10 ML VL
IM
ML
1000 MCG
01/01/2002
02/05/2002
00904-0889-30
J3420
1/1/2002
30 ML VL
IM
ML
1000 MCG
01/01/2002
02/05/2002
00904-0972-09
Q0181
1/1/2002

3/3/2003 REGIMEN
240 ML BO
PO
ML
01/01/2002
03/03/2003
Page 123 of 374
1 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00904-1228-00
Q0163
1/1/2002
00904-1228-20
00904-1749-60
00904-1749-73
Q0163
None
None
1/1/2002
1/1/1994
1/1/1994
00904-2035-24
Q0163
1/1/2002
00904-2035-59
Q0163
1/1/2002
00904-2056-61
Q0163
00904-2175-19
00904-2175-60
00904-3570-60
00904-3571-60
00904-3571-61
J7509
J7509
J8999
J8999
J8999
00904-4274-51
Q0163
00904-5147-24
Q0163
00904-5174-16
Q0163
00904-5306-60
Q0163
00904-5306-61
Q0163
00904-5306-80
Q0163
00904-5307-60
Q0163
00904-5307-80
Q0163
00904-5551-59
00904-5789-61
00904-5790-61
00904-5799-61
Q0163
J8499
J8499
J8499
00904-5840-61
Q0170
00904-7658-55
J7602
00904-7658-55
J7611
00905-1847-24
J3490
1/1/2002

BANOPHEN (AF) 12.5 MG/5 ML
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
BANOPHEN (BOXED) 12.5 MG/5 ML

120 ML BO
100 EA BO
36 EA BO
PO
PO
PO
ML
EA
EA
50 MG
2.5 MG
2.5 MG
0.05
1
1
01/01/2002
01/01/1994
01/01/1994
99/99/9999
5/25/2007
01/31/2000
BANOPHEN 25 MG
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
BANOPHEN 25 MG
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
21 EA
100 EA
100 EA
100 EA
100 EA
DP
BO
BO
BO
BX
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
4 MG
4 MG
1 EA
1 EA
1 EA
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
03/04/2002
05/06/2002
05/06/2002
99/99/9999
50 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA BO
PO
EA
50 MG
0.5
01/01/2002
07/22/2002
480 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BX
PO
EA
50 MG
0.5
05/12/2003
99/99/9999
1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
1000 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
BX
BX
BX
BX
PO
PO
PO
PO
EA
EA
EA
EA
50 MG
1 EA
1 EA
1 EA
0.5
1
1
1
08/13/2002
01/03/2007
01/08/2007
01/12/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BX
PO
EA
25 MG
05/06/2008
99/99/9999
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML BO
IH
ML
1 MG
04/01/2008
99/99/9999
100 ML FC
IV
ML
1 EA
01/01/2002
09/27/2004

METHYLPREDNISOLONE (UNIPAK) 4 MG
1/1/2002
1/1/2002
1/1/2002
SLEEP TABS 25 MG
BANOPHEN (DYE-FREE,SOFTGEL) 25
MG
BANOPHEN 12.5 MG/5 ML
BANOPHEN (MINI TABS,MINI TAB) 25 MG
ACYCLOVIR (10X10,USP) 200 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE HYDROCHLORIDE 25
MG
1/1/2008 3/31/2008 (LEVALBUTEROL)
FLAGYL I.V. RTU (S.D. CONTAINER) 500
MG/100 ML
Page 124 of 374
100 EA
100 EA
100 EA
100 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
00927-0221-24
Q0163
00927-0616-34
Q0163
00927-0617-12
Q0163
00944-0471-69
Q9941
00944-0471-69
J1566
00944-0471-72
Q9941
00944-0471-72
J1566
00944-0471-75
Q9941
00944-0471-75
J1566
00944-0471-80
Q9941
00944-0471-80
J1566
00944-0581-01
00944-1301-01
00944-1301-10
00944-1302-01
00944-1302-10
00944-1303-01
00944-1303-10
00944-1304-01
00944-1304-10
00944-2620-01
J7194
J7190
J7190
J7190
J7190
J7190
J7190
J7190
J7190
Q9941
00944-2620-01
00944-2620-02
J1566
Q9941
00944-2620-02
00944-2620-03
J1566
Q9941
00944-2620-03
00944-2620-04
J1566
Q9941
00944-2620-04
J1566
00944-2655-03
J1566
00944-2655-04
J1566
00944-2700-02
Q4088
00944-2700-02
J1569
00944-2700-03
Q4088
00944-2700-03
J1569
00944-2700-04
Q4088
00944-2700-04
J1569
00944-2700-05
Q4088
00944-2700-05
J1569
00944-2700-06
Q4088
00944-2700-06
00944-2801-01
00944-2801-02
J1569
J0256
J0256
00944-2802-01
J0256
00944-2802-02
J0256

ALLERMAX 50 MG
24 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
TWILITE 50 MG
20 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
ALLERMAX 12.5 MG/5 ML

POLYGAM S/D (S.D.V. W/DILUENT) 0.5
GM
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT POLYGAM S/D (S.D.V. W/DILUENT) 0.5
1/1/2006
GM
GM
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT POLYGAM S/D (S.D.V. W/DILUENT) 2.5
1/1/2006
GM
POLYGAM S/D (S.D.V. W/DILUENT) 5 GM
1/1/2006
POLYGAM S/D (S.D.V.W/DILUENT) 10
GM
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT POLYGAM S/D (S.D.V.W/DILUENT) 10
1/1/2006
GM
PROPLEX T (ACTIVATED IN 30 ML) (7001/1/2002 12/31/2006 FACTOR IX, COMPLEX, PER I.U.
3900 IU) 1 IU
MONARC-M (220IU-400IU,PF) 1 IU
GAMMAGARD S/D 0.5 GM
GAMMAGARD S/D 5 GM
GAMMAGARD S/D 5 GM
GAMMAGARD S/D 10 GM
GAMMAGARD S/D 10 GM
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT GAMMAGARD S/D (W/TRANSFER SET) 5
GM
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT GAMMAGARD S/D (W/TRANSFER SET)
10 GM
INJECTION, IMMUNE GLOBULIN (GAMMAGARD LIQUID), INTRAVENOUS, NONGAMMAGARD LIQUID (PF,LATEX-FREE)
7/1/2007 12/31/2007 LYOPHILIZED (E.G. LIQUID), 500 MG
100 MG/ML
INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS, NONGAMMAGARD LIQUID (PF,LATEX-FREE)
1/1/2008 99/99/9999 LYOPHILIZED,(E.G. LIQUID), 500 MG
100 MG/ML
100 MG/ML
100 MG/ML
100 MG/ML
100 MG/ML
100 MG/ML
100 MG/ML
100 MG/ML
100 MG/ML
ARALAST (500MG VIAL,PF) 1 MG
ARALAST (1000MG VIAL,PF) 1 MG
ARALAST NP (SDV,APPROX 500MG,PF)
1 MG
ARALAST NP (SDV,APRROX 1000MG,PF)
1 MG
Page 125 of 374
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
1 EA VL
IV
EA
1 GM
0.5
07/01/2005
12/31/2005
1 EA VL
IV
EA
500 MG
01/01/2006
5/1/2008
1 EA VL
IV
EA
1 GM
2.5
1 EA VL
IV
EA
500 MG
01/01/2006
5/1/2008
1 EA VL
IV
EA
1 GM
07/01/2005
12/31/2005
1 EA VL
IV
EA
500 MG
10
01/01/2006
5/1/2008
IV
EA
1 GM
10
07/01/2005
12/31/2005
5/1/2008
1 EA VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
07/01/2005 12/31/2005
1 EA VL
IV
EA
500 MG
20
01/01/2006
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 IU
1 IU
1 IU
1 IU
1 IU
1 IU
1 IU
1 IU
1 IU
1 GM
1
1
1
1
1
1
1
1
1
0.5
01/01/2002 12/31/2006
11/01/2005 01/31/2006
02/01/2006 99/99/9999
11/01/2005 01/31/2006
02/01/2006 99/99/9999
11/01/2005 01/31/2006
02/01/2006 99/99/9999
11/01/2005 01/31/2006
02/01/2006 99/99/9999
04/01/2005 12/31/2005
1 EA VL
1 EA VL
IV
IV
EA
EA
500 MG
1 GM
1
2.5
01/01/2006
04/01/2005
99/99/9999
12/31/2005
1 EA VL
1 EA VL
IV
IV
EA
EA
500 MG
1 GM
5
5
01/01/2006
04/01/2005
99/99/9999
12/31/2005
1 EA VL
1 EA VL
IV
IV
EA
EA
500 MG
1 GM
10
10
01/01/2006
04/01/2005
99/99/9999
12/31/2005
3900 IU
400 IU
400 IU
800 IU
800 IU
1700 IU
1700 IU
2000 IU
2000 IU
1 EA
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1 EA VL
IV
EA
500 MG
20
01/01/2006
99/99/9999
1 EA VL
IV
EA
500 MG
10
06/01/2007
99/99/9999
1 EA VL
IV
EA
500 MG
20
06/01/2007
99/99/9999
10 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
10 ML VL
IV
ML
500 MG
0.2
01/01/2008
99/99/9999
25 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
25 ML VL
IV
ML
500 MG
0.2
01/01/2008
99/99/9999
50 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
50 ML VL
IV
ML
500 MG
0.2
01/01/2008
99/99/9999
100 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
100 ML VL
IV
ML
500 MG
0.2
01/01/2008
99/99/9999
200 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
200 ML VL
500 MG VL
1000 MG VL
IV
IV
IV
ML
EA
EA
500 MG
10 MG
10 MG
0.2
0.1
0.1
01/01/2008
02/13/2006
02/13/2006
99/99/9999
99/99/9999
99/99/9999
500 MG VL
IV
EA
10 MG
0.1
02/25/2008
99/99/9999
1000 MG VL
IV
EA
10 MG
0.1
02/25/2008
99/99/9999
00944-2831-10
J7192
00944-2832-10
J7192
00944-2833-10
00944-2935-01
00944-2935-02
00944-2935-03
J7192
J7190
J7190
J7190
00944-2935-04
J7190
00944-2938-01
J7192
00944-2938-02
J7192
00944-2938-03
J7192
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISERECOMBINATE (SINGLE-DOSE,220-400
10/5/2007 99/99/9999 SPECIFIED
IU) 1 IU
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISERECOMBINATE (SINGLE-DOSE,401-800
10/5/2007 99/99/9999 SPECIFIED
IU) 1 IU
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISERECOMBINATE (SINGLE-DOSE,80110/5/2007 99/99/9999 SPECIFIED
1240IU) 1 IU
HEMOFIL-M (220-400 IU) 1 IU
HEMOFIL M (MID,401-800IU) 1 IU
HEMOFIL M (HIGH,801-1700IU) 1 IU
HEMOFIL M (SUPERHIGH,1701-2000IU) 1
IU
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISERECOMBINATE (APPROX. 250 IU/VIAL) 1
IU
1/1/2002 99/99/9999 SPECIFIED
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISERECOMBINATE (APPROX. 500 IU/VIAL) 1
1/1/2002 99/99/9999 SPECIFIED
IU
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISERECOMBINATE (APPROX. 1000 IU/VIAL)
1/1/2002 99/99/9999 SPECIFIED
1 IU
400 IU
VL
IV
EA
1 IU
10/05/2007
800 IU
VL
IV
EA
1 IU
10/05/2007
99/99/9999
1240 IU
400 IU
800 IU
1700 IU
VL
VL
VL
VL
IV
IV
IV
IV
EA
EA
EA
EA
1
1
1
1
IU
IU
IU
IU
1
1
1
1
10/05/2007
01/01/2002
04/17/2006
04/17/2006
99/99/9999
6/30/2008
6/30/2008
6/30/2008
2000 IU
VL
IV
EA
1 IU
04/17/2006
6/30/2008
250 IU
VL
IV
EA
1 IU
01/01/2002
99/99/9999
500 IU
VL
IV
EA
1 IU
01/01/2002
99/99/9999
1000 IU
VL
IV
EA
1 IU
01/01/2002
99/99/9999
J7192
7/28/2003
ADVATE (APPROX. 250 IU/VIAL,PF) 1 IU
250 IU
VL
MR
EA
1 IU
07/28/2003
1/22/2007
00944-2940-02
J7192
7/28/2003
500 IU
VL
MR
EA
1 IU
07/28/2003
1/22/2007
00944-2940-03
J7192
7/28/2003
1000 IU
VL
MR
EA
1 IU
07/28/2003
1/22/2007
00944-2940-04
00944-2940-10
J7192
J7192
7/28/2003
4/17/2006

ADVATE (1800-2200IU,PF) 1 IU
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISEADVATE (AP 250IU/VIAL,W/DILUENT) 1
IU
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISEADVATE (AP 500IU/VIAL,W/DILUENT) 1
IU
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISEADVATE (AP1000IU/VIAL,W/DILUENT) 1
IU
IU
IU
ADVATE (2400-3600,PF) 1 IU
INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVENT
1/1/2008 DETERGENT, 100 IU
WINRHO SDF (S.D.V.,PF) 600 IU
WINRHO SDF (S.D.V.,PF) 1500 IU
WINRHO SDF (VIAL,PF) 5000 IU
10/31/2007 DETERGENT, 100 IU
WINRHO SDF (SDV,PF) 600 IU
99/99/9999 DETERGENT, 100 IU
99/99/9999 DETERGENT, 100 IU
99/99/9999 DETERGENT, 100 IU
99/99/9999 DETERGENT, 100 IU
CEPROTIN (400-600IU) 1 IU
99/99/9999 INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IU
99/99/9999 INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IU
DERMAL (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITHOUT
OTHER BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY VERITAS COLLAGEN MATRIX
(2CMX8CM)
12/31/2007 ACTIVE ELEMENTS, PER SQUARE CENTIMETER
VERITAS COLLAGEN MATRIX
(2CMX8CM)
(4CMX7CM)
(4CMX7CM)
(4CMX15CM)
(4CMX15CM)
(6CMX8CM)
(6CMX8CM)
(8CMX14CM)
1500 IU
2000 IU
VL
VL
MR
MR
EA
EA
1 IU
1 IU
1
1
07/28/2003
04/17/2006
1/22/2007
1/22/2007
250 IU
VL
IV
EA
1 IU
01/22/2007
99/99/9999
500 IU
VL
IV
EA
1 IU
01/22/2007
99/99/9999
1000 IU
VL
IV
EA
1 IU
01/22/2007
99/99/9999
1500 IU
VL
IV
EA
1 IU
01/22/2007
99/99/9999
2000 IU
VL
IV
EA
1 IU
01/22/2007
99/99/9999
1 EA VL
IV
EA
1 IU
07/05/2007
99/99/9999
1 EA VL
IV
EA
100 IU
03/25/2005
01/01/2008
1 EA VL
IV
EA
100 IU
15
03/25/2005
01/01/2008
01/01/2008
00944-2941-10
J7192
1/22/2007
J7192
1/22/2007
00944-2943-10
J7192
1/22/2007
00944-2944-10
J7192
1/22/2007
00944-2945-10
J7192
1/22/2007
00944-2946-10
J7192
7/5/2007
00944-2950-02
J2792
3/25/2005
00944-2950-04
J2792
3/25/2005
00944-2950-06
J2792
3/25/2005
00944-2967-01
J2792
3/1/2006
00944-2967-03
J2792
3/1/2006
00944-2967-05
J2792
3/1/2006
00944-2967-07
J2792
3/1/2006
00944-2967-09
00944-4175-05
00944-4175-05
00944-4175-10
00944-4175-10
J2792
J3590
J2724
J3590
J2724
3/1/2006
6/28/2007
1/1/2008
6/28/2007
1/1/2008
03221-0208-11
J7345
8/1/2007
03221-0208-11
J3490
1/1/2008
03221-0407-11
J7345
8/1/2007
03221-0407-11
J3490
1/1/2008
03221-0415-11
J7345
8/1/2007
03221-0415-11
J3490
1/1/2008
03221-0608-11
J7345
8/1/2007
03221-0608-11
J3490
1/1/2008
03221-0814-11
J7345
8/1/2007
Page 126 of 374
1 EA VL
IV
EA
100 IU
50
03/25/2005
0.5 ML VL
IV
ML
100 IU
12
03/01/2006 10/31/2007
1.3 ML VL
IV
ML
100 IU
11.53846
03/01/2006
99/99/9999
4.4 ML VL
IV
ML
100 IU
11.36363
03/01/2006
99/99/9999
2.2 ML VL
IV
ML
100 IU
11.36363
03/01/2006
99/99/9999
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
ML
EA
EA
EA
EA
100 IU
1 EA
10 IU
1 EA
10 IU
11.53846
1
0.1
1
0.1
03/01/2006
06/28/2007
01/01/2008
06/28/2007
01/01/2008
99/99/9999
12/31/2007
99/99/9999
12/31/2007
99/99/9999
1 EA NA
IP
EA
1 SQCM
16
08/01/2007
12/31/2007
1 EA NA
IP
EA
1 EA
01/01/2008
99/99/9999
1 EA NA
IP
EA
1 SQCM
28
08/01/2007
12/31/2007
1 EA NA
IP
EA
1 EA
01/01/2008
99/99/9999
1 EA NA
IP
EA
1 SQCM
60
08/01/2007
12/31/2007
1 EA NA
IP
EA
1 EA
01/01/2008
99/99/9999
1 EA NA
IP
EA
1 SQCM
48
08/01/2007
12/31/2007
1 EA NA
IP
EA
1 EA
01/01/2008
99/99/9999
1 EA NA
IP
EA
1 SQCM
112
08/01/2007
12/31/2007
13 ML
600 IU
600 IU
1200 IU
1200 IU
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
00944-2940-01
00944-2942-10
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
03221-1225-11
J7345
03221-1225-11
J3490

(8CMX14CM)
(10CMX16CM)
8/1/2007 12/31/2007 ACTIVE ELEMENTS, PER SQUARE CENTIMETER
(10CMX16CM)
(12CMX25CM)
8/1/2007 12/31/2007 ACTIVE ELEMENTS, PER SQUARE CENTIMETER
(12CMX25CM)
05324-5027-45
J3480
1/1/2002
POTASSIUM CHLORIDE (U.S.P., F.C.C.)
1 EA BO
NA
GM
2 MEQ
6.71141
01/01/2002
08/09/2004
05324-5027-60
05324-5031-35
05324-5031-45
05324-5098-10
05324-5098-15
05324-5119-45
05324-5119-60
05324-5166-45
05324-5166-60
J3480
J3490
J3490
J3420
J3420
J2150
J2150
J3350
J3350
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

BENZOCAINE (U.S.P.)
BENZOCAINE (U.S.P.)
CYANOCOBALAMIN (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
UREA (U.S.P.)
UREA (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
NA
NA
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
2 MEQ
1 EA
1 EA
1000 MCG
1000 MCG
50 ML
50 ML
40 GM
40 GM
6.71141
1
1
1000
1000
0.08
0.08
0.025
0.025
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/09/2004
08/09/2004
08/09/2004
08/09/2004
08/09/2004
08/09/2004
08/09/2004
08/09/2004
08/09/2004
05324-5175-15
J7636
ATROPINE SULFATE (U.S.P.)
1 EA VL
NA
GM
1 MG
1000
01/01/2002
08/09/2004
1 EA VL
NA
GM
1 MG
1000
01/01/2002
08/09/2004
1 EA VL
NA
GM
1 MG
1000
01/01/2002
08/09/2004
1/1/2002
1/1/2002

8/9/2004 INJECTION, MANNITOL, 25% IN 50 ML
ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
8/9/2004 THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
1 EA VL
1 EA NA
NA
NA
GM
GM
1 MG
50 MG
1000
20
01/01/2002
01/01/2002
08/09/2004
08/09/2004
1 EA BO
NA
GM
25 MG
40
01/01/2002
08/09/2004
1 EA BO
NA
GM
25 MG
40
01/01/2002
08/09/2004
1 EA BO
NA
GM
25 MG
40
01/01/2002
08/09/2004
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
25 MG
25 MG
25 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
40
40
40
4
100
4
100
4
100
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
08/09/2004
08/09/2004
08/09/2004
12/31/2003
08/09/2004
12/31/2003
08/09/2004
12/31/2003
08/09/2004
03221-0814-11
J3490
03221-1016-11
J7345
03221-1016-11
J3490
05324-5175-15 KO J7636
05324-5175-25
1/1/2002
KO
J7636
05324-5175-25 KO J7636
05324-5218-35
J1200
1/1/2002
1/1/2002
IP
EA
1 EA
1 EA NA
IP
EA
1 SQCM
1 EA NA
IP
EA
1 EA
1 EA NA
IP
EA
1 SQCM
1 EA NA
IP
EA
1 EA
01/01/2008
99/99/9999
160
08/01/2007
12/31/2007
01/01/2008
99/99/9999
300
08/01/2007
12/31/2007
01/01/2008
99/99/9999
05324-5232-15
J1700
1/1/2002
05324-5232-25
J1700
1/1/2002
05324-5232-35
J1700
1/1/2002
05324-5232-55
05324-5233-35
05324-5233-45
05324-5245-25
05324-5245-25
05324-5245-35
05324-5245-35
05324-5245-45
05324-5245-45
J1700
J3410
J3410
J2000
J2001
J2000
J2001
J2000
J2001
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2004
1/1/2004

DIPHENHYDRAMINE HCL (U.S.P.)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
HYDROXYZINE HCL (U.S.P.)
LIDOCAINE HCL (U.S.P.)
05324-5257-15
05324-5273-25
05324-5273-35
05324-5309-35
05324-5309-45
J2440
J2675
J2675
J2810
J2810
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
PAPAVERINE HYDROCHLORIDE (U.S.P.)

PROGESTERONE (U.S.P., WETTABLE)
THEOPHYLLINE ANHYDROUS (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
60 MG
50 MG
50 MG
40 MG
40 MG
16.66666
20
20
25
25
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/09/2004
08/09/2004
08/09/2004
08/09/2004
08/09/2004
05324-5315-10
J7684
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/09/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/09/2004
HYALGAN (VIAL) 10 MG/ML
2 ML VL
IJ
ML
1 DOSE
0.5
01/01/2007
12/31/2007
05324-5315-10 KO J7684
KO
1 EA NA
1/1/2002
KO
1/1/2002

HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTICULAR
12/31/2007 INJECTION, PER DOSE
08024-0724-12
Q4083
1/1/2007
08024-0724-12
J7321
1/1/2008
08024-0724-20
Q4083
1/1/2007
08024-0724-20
08080-1000-00
J7321
A4217
1/1/2008
3/1/2006
08080-1020-00
A4217
08080-1022-00
A4217

DERMAL TISSUE, OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENGINEERED
OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS, PER
GRAFTJACKET (MAXIMUM FORCE)
1/1/2005 12/31/2008 SQUARE CENTIMETER
08121-8600-47
J7344
08121-8600-47
Q4107
08121-8600-55
08121-8600-55
J7344
Q4107
HYALGAN (VIAL) 10 MG/ML

HYALGAN (SRN,PREFILLED,LUER LOCK)
10 MG/ML
HYALGAN (SRN,PREFILLED,LUER LOCK)
10 MG/ML
CURITY STERILE WATER
CURITY STERILE SALINE (100MLX48)
0.9%
CURITY STERILE SALINE (100MLX48)
0.9%
GRAFTJACKET (MAXIMUM FORCE, 28SQ

1/1/2009 99/99/9999 SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER
CM)
GRAFTJACKET (MAX FORCE,25SQ CM)
GRAFTJACKET (MAX FORCE,25SQ CM)
Page 127 of 374
2 ML VL
IJ
ML
1 DOSE
0.5
01/01/2008
99/99/9999
2 ML SR
IJ
ML
1 DOSE
0.5
01/01/2007
12/31/2007
2 ML SR
100 ML NA
IJ
IR
ML
ML
1 DOSE
500 ML
0.5
0.002
01/01/2008
03/01/2006
99/99/9999
99/99/9999
100 ML NA
IR
ML
500 ML
0.002
03/01/2006
99/99/9999
100 ML NA
IR
ML
500 ML
0.002
03/01/2006
99/99/9999
1 EA NA
TP
EA
1 SQCM
28
01/01/2005
12/31/2008
1 EA NA
TP
EA
1 SQCM
28
01/01/2009
99/99/9999
1 EA NA
1 EA NA
TP
TP
EA
EA
1 SQCM
1 SQCM
25
25
02/03/2005
01/01/2009
12/31/2008
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS, PER GRAFTJACKET (HAND SURGERY,8SQ
CM)
GRAFTJACKET (HAND SURGERY,8SQ
CM)
GRAFTJACKET (4X4 CM)
GRAFTJACKET (4X4 CM)
GRAFTJACKET (MAXFORCE-EXTREME)
08121-8602-04
J7344
08121-8602-04
Q4107
08121-8604-04
08121-8604-04
J7344
Q4107
08121-8604-07
J7344
08121-8604-07
Q4107
08121-8605-05
J7344
GRAFTJACKET (MAXFORCE EXTREME

28SQ CM)
GRAFTJACKET
08121-8605-05
Q4107
GRAFTJACKET (TISSUE MATRIX, 25SQ

CM)
08121-8605-10
J7344
08121-8605-10
Q4107

GRAFTJACKET
08121-8605-30
J7344
GRAFTJACKET (TISSUE MATRIX, 50SQ

CM)
GRAFTJACKET SLR (SMALL LIGAMENT)
08121-8605-30
Q4107
08166-1100-03
J1642
08166-1100-05
J1642
08166-1109-03
J2912
08166-1109-03
A4216
08166-1109-05
J2912
08166-1109-05
A4216
08166-1109-10
J2912
08166-1109-10
A4216
08166-1110-03
J1642
08166-1110-05
J1642
08290-0310-02
J2912
08290-0310-02
A4216
08290-0310-03
J2912
08290-0310-03
A4216
08290-0311-02
A4323
08290-0311-02
A4216
1/1/2004
08290-0311-03
A4323
08290-0311-03
A4216
08290-0320-03
J2912
08290-0320-03
A4216
08290-0320-05
J2912
08290-0320-05
A4216
08290-0321-03
A4323
08290-0321-03
A4216
1/1/2004
08290-0321-05
A4323
GRAFTJACKET SLR (SMALL LIGAMENT,

1.5SQ CM)
VASCEZE HEPARIN LOCK FLUSH (LUER
SLIP NOZZLE) 100 U/ML
SLIP NOZZLE) 100 U/ML
VASCEZE SODIUM CHLORIDE (LUER
SLIP NOZZLE) 0.9%
SLIP NOZZLE) 0.9%
SLIP NOZZLE) 0.9%
SLIP NOZZLE) 0.9%
SLIP NOZZLE) 0.9%
SLIP NOZZLE) 0.9%
SLIP NOZZLE,PF) 10 U/ML
SLIP NOZZLE,PF) 10 U/ML
NORMAL SALINE FLUSH (SRN,3 ML,PF)
0.9%
0.9%
0.9%
0.9%
NORMAL SALINE FLUSH (SRN,3 ML
W/CANNULA,PF) 0.9%
W/CANNULA,PF) 0.9%
W/CANNULA,PF) 0.9%
W/CANNULA,PF) 0.9%
0.9%
0.9%
0.9%
0.9%
W/CANNULA,PF) 0.9%
W/CANNULA,PF) 0.9%
W/CANNULA,PF) 0.9%
Page 128 of 374
1 EA NA
TP
EA
1 SQCM
01/01/2005
12/31/2008
1 EA NA
TP
EA
1 SQCM
01/01/2009
99/99/9999
1 EA PT
1 EA PT
TP
TP
EA
EA
1 SQCM
1 SQCM
16
16
01/01/2005
01/01/2009
12/31/2008
99/99/9999
1 EA NA
TP
EA
1 SQCM
28
06/30/2005
12/31/2008
1 EA NA
TP
EA
1 SQCM
28
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
25
01/01/2005
12/31/2008
1 EA NA
TP
EA
1 SQCM
25
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
50
01/01/2005
12/31/2008
1 EA NA
TP
EA
1 SQCM
50
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
1.5
01/04/2005
12/31/2008
1 EA NA
TP
EA
1 SQCM
1.5
01/01/2009
99/99/9999
3 ML NA
IV
ML
10 U
10
01/01/2002
99/99/9999
5 ML NA
IV
ML
10 U
10
01/01/2002
99/99/9999
3 ML NA
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
3 ML NA
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML NA
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
5 ML NA
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
10 ML NA
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
10 ML NA
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
3 ML NA
IV
ML
10 U
01/01/2002
99/99/9999
5 ML NA
IV
ML
10 U
01/01/2002
99/99/9999
2 ML SR
IV
ML
0.9 %
0.5
08/15/2002
12/31/2006
2 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
0.9 %
0.5
08/15/2002
12/31/2006
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
2 ML SR
IV
ML
1000 ML
0.001
08/15/2002
12/31/2003
2 ML SR
IV
ML
10 ML
0.1
01/01/2004
8/15/2008
3 ML SR
IV
ML
1000 ML
0.001
08/15/2002
12/31/2003
3 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
3 ML SR
IV
ML
0.9 %
0.5
08/15/2002
12/31/2006
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
0.9 %
0.5
08/15/2002
12/31/2006
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
1000 ML
0.001
08/15/2002
12/31/2003
3 ML SR
IV
ML
10 ML
0.1
01/01/2004
8/15/2008
5 ML SR
IV
ML
1000 ML
0.001
08/15/2002
12/31/2003
1/1/2002
4/1/2002
0.5
1/1/2002
4/1/2002
0.5
1/1/2002
4/1/2002
0.001
1/1/2002
4/1/2002
0.001
1/1/2002
4/1/2002
0.5
1/1/2002
4/1/2002
0.5
1/1/2002
4/1/2002
0.001
1/1/2002
4/1/2002
0.001
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
08290-0321-05
A4216
08290-0330-03
J2912
08290-0330-03
A4216
08290-0330-05
J2912
08290-0330-05
A4216
08290-0330-06
J2912
08290-0330-06
A4216
1/1/2007
08290-0330-10
J2912
08290-0330-10
A4216
08290-0331-03
A4323
08290-0331-03
A4216
1/1/2004
08290-0331-05
A4323
08290-0331-05
A4216
08290-0331-10
A4323
08290-0331-10
A4216
08290-0340-02
J1642
08290-0340-03
J1642
08290-0350-05
J1642
08290-0360-03
J1642
08290-0360-05
J1642
08290-0360-06
J1642
08290-0361-05
J1642
08290-0370-02
J1642
08290-0370-03
J1642
08290-0380-03
J1642
08290-0380-05
J1642
08290-0390-03
J1642
08290-0390-05
J1642
08290-0391-05
J1642
08290-0400-03
J1642
1/1/2002
08290-0410-03
J1642
1/25/2002
08290-0420-05
J1642
1/25/2002
08290-0910-02
J2912
08290-0910-02
A4216
08290-0910-03
J2912
08290-0910-03
A4216
08290-0911-02
A4323
08290-0911-02
A4216
08290-0911-03
A4323

W/CANNULA,PF) 0.9%
0.9%
0.9%
0.9%
0.9%
0.9%
0.9%
0.9%
0.9%
NORMAL SALINE FLUSH (SRN, 12 ML
W/CANN,PF) 0.9%
W/CANN,PF) 0.9%
NORMAL SALINE FLUSH (SRN, 12 ML W/
CANN,PF) 0.9%
NORMAL SALINE FLUSH (SRN, 12 ML W/
CANN,PF) 0.9%
W/CANN,PF) 0.9%
W/CANN,PF) 0.9%
HEPARIN LOCK FLUSH (3 ML SRN) 10
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
HEPARIN LOCK FLUSH (12 ML SRN
W/CANNULA) 10 U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
HEPARIN LOCK FLUSH (12 ML SRN
W/CANNULA) 100 U/ML
HEPARIN LOCK FLUSH/SALINE FLUSH
(2X3ML SAL.&1X3ML HEP.) 10 U/ML-0.9%
(2X3ML SAL.&1X3ML HEP.) 100 U/ML0.9%
(2X5ML SAL.&1X5ML HEP.) 100 U/ML0.9%
NORMAL SALINE FLUSH (SRN, 2ML,PF)
0.9%
0.9%
0.9%
0.9%
NORMAL SALINE FLUSH (SRN,
W/CANNULA,PF) 0.9%
W/CANNULA,PF) 0.9%
W/CANNULA,PF) 0.9%
Page 129 of 374
5 ML SR
IV
ML
10 ML
0.1
01/01/2004
3 ML SR
IV
ML
0.9 %
0.5
08/15/2002
12/31/2006
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
0.9 %
0.5
08/15/2002
12/31/2006
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
6 ML SR
IV
ML
0.9 %
0.5
08/15/2002
12/31/2006
6 ML SR
IV
ML
10 ML
0.1
01/01/2007
9/5/2007
10 ML SR
IV
ML
0.9 %
0.5
08/15/2002
12/31/2006
10 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
1000 ML
0.001
08/15/2002
12/31/2003
3 ML SR
IV
ML
10 ML
0.1
01/01/2004
9/20/2007
5 ML SR
IV
ML
1000 ML
0.001
08/15/2002
12/31/2003
5 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
10 ML SR
IV
ML
1000 ML
0.001
08/15/2002
12/31/2003
10 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
2 ML SR
IV
ML
10 U
08/01/2002
99/99/9999
3 ML SR
IV
ML
10 U
08/15/2002
5 ML SR
IV
ML
10 U
08/15/2002
3 ML SR
IV
ML
10 U
5 ML SR
IV
ML
10 U
6 ML SR
IV
ML
10 U
5 ML SR
IV
ML
2 ML SR
IV
3 ML SR
IV
3 ML SR
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
99/99/9999
1/1/2002
4/1/2002
0.5
1/1/2002
4/1/2002
0.5
01-Jan-02
01-Apr-02
0.5
01-Jan-02
01-Apr-02
0.5
01-Jan-02
01-Apr-02
0.001
1/1/2002
4/1/2002
0.001
01-Jan-02
01-Apr-02
0.001
99/99/9999
01-Jan-02
01-Apr-02
99/99/9999
01-Jan-02
01-Apr-02
08/15/2002
99/99/9999
1/1/2002
4/1/2002
08/15/2002
99/99/9999
1/1/2002
4/1/2002
09/09/2002
99/99/9999
1/1/2002
4/1/2002
10 U
08/15/2002
99/99/9999
1/1/2002
4/1/2002
ML
10 U
10
08/01/2002
99/99/9999
ML
10 U
10
08/15/2002
99/99/9999
1/1/2002
4/1/2002
10
IV
ML
10 U
10
08/15/2002
99/99/9999
1/1/2002
4/1/2002
10
5 ML SR
IV
ML
10 U
10
08/15/2002
99/99/9999
1/1/2002
4/1/2002
10
3 ML SR
IV
ML
10 U
10
08/15/2002
99/99/9999
1/1/2002
4/1/2002
10
5 ML SR
IV
ML
10 U
10
07/18/2002
99/99/9999
1/1/2002
4/1/2002
10
5 ML SR
IV
ML
10 U
10
08/15/2002
99/99/9999
1/1/2002
4/1/2002
10
3 ML SR
IV
EA
10 U
01/01/2002
04/01/2002
3 ML SR
IV
EA
10 U
30
01/25/2002
04/01/2002
5 ML SR
IV
EA
10 U
50
01/25/2002
04/01/2002
2 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
2 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
2 ML SR
IV
ML
1000 ML
0.001
06/01/2003
12/31/2003
2 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
3 ML SR
IV
ML
1000 ML
0.001
06/01/2003
12/31/2003
08290-0911-03
A4216
08290-0920-05
J2912
08290-0920-05
A4216
08290-0921-05
A4323
08290-0921-05
A4216
08290-0930-10
J2912
08290-0930-10
A4216
08290-0940-10
J2912
08290-0940-10
A4216
08290-0941-10
A4323
08290-0941-10
A4216
08290-0950-10
J2912
08290-0950-10
A4216

W/CANNULA,PF) 0.9%
0.9%
0.9%
W/CANNULA,PF) 0.9%
W/CANNULA,PF) 0.9%
0.9%
0.9%
NORMAL SALINE FLUSH (REG LENGTH
PLUNGER ROD) 0.9%
NORMAL SALINE FLUSH (REG LENGTH
PLUNGER ROD) 0.9%
W/CANNULA,PF) 0.9%
W/CANNULA,PF) 0.9%
BD POSIFLUSH SF (SALINE FLUSH
SYRINGE) 0.9%
BD POSIFLUSH SF (SALINE FLUSH
SYRINGE) 0.9%
08290-3065-00
J2912
1/1/2002
08290-3065-01
J2912
1/1/2002
08290-3065-02
J2912
1/1/2002
08290-3065-03
J2912
08290-3065-04
J2912
08290-3065-05
3 ML SR
IV
ML
10 ML
0.1
01/01/2004
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
1000 ML
0.001
06/01/2003
12/31/2003
5 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
10 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
10 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
10 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
10 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
10 ML SR
IV
ML
1000 ML
0.001
06/01/2003
12/31/2003
10 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
10 ML SR
IV
ML
0.9 %
0.5
11/01/2005
12/31/2006
10 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
NORMAL SALINE FLUSH (SRN,PF) 0.9%
10 ML SR
IV
ML
0.9 %
0.5
01/01/2002
04/01/2002
6 ML SR
IV
ML
0.9 %
0.5
01/01/2002
04/01/2002
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
04/01/2002
1/1/2002
3 ML SR
IV
ML
0.9 %
0.5
01/01/2002
04/01/2002
1/1/2002
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
04/01/2002
J2912
1/1/2002
3 ML SR
IV
ML
0.9 %
0.5
01/01/2002
04/01/2002
08290-3065-07
J2912
1/1/2002
3 ML SR
IV
ML
0.9 %
0.5
01/01/2002
04/01/2002
08290-3065-08
08290-3065-09
08290-3065-10
08290-3065-11
08290-3065-12
08290-3065-13
08290-3065-14
08290-3065-15
08290-3065-16
08290-3065-17
J2912
J1642
J1642
J1642
J1642
J1642
J1642
J1642
J1642
J1642
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002


HEPARIN LOCK FLUSH (SRN) 10 U/ML
NORMAL SALINE FLUSH (SRN
W/CANNULA,PF) 0.9%
NORMAL SALINE FLUSH (SRN
W/CANNULA,PF) 0.9%
HEPARIN LOCK FLUSH (SRN W/BLUNT
CANNULA) 10 U/ML
HEPARIN LOCK FLUSH (SRN W/BLUNT
CANNULA) 100 U/ML
2
6
5
5
3
5
3
5
3
3
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
0.9 %
10 U
10 U
10 U
10 U
10 U
10 U
10 U
10 U
10 U
0.5
1
1
1
1
10
10
10
10
10
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/01/2002
04/01/2002
04/01/2002
04/01/2002
04/01/2002
04/01/2002
04/01/2002
04/01/2002
04/01/2002
04/01/2002
10 ML SR
IV
ML
1000 ML
0.001
01/01/2002
04/01/2002
5 ML SR
3 ML SR
IV
IV
ML
ML
1000 ML
10 U
0.001
1
01/01/2002
01/01/2002
04/01/2002
04/01/2002
08290-3065-18
A4323
1/1/2002
08290-3065-19
08290-3065-21
A4323
J1642
1/1/2002
1/1/2002

08290-3065-25
J1642
1/1/2002
08290-3065-31
J1642
1/1/2002
08363-7761-01
Q4083
1/1/2007
08363-7761-01
J7321
1/1/2008
08363-7765-01
Q4083
1/1/2007
08363-7765-01
J7321
1/1/2008
08450-0901-02
J2912
08450-0901-02
A4216
08450-0903-03
J2912
08450-0903-03
A4216
08450-0905-05
J2912
08450-0905-05
A4216


ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
5 ML SR
IV
ML
10 U
01/01/2002
04/01/2002
5 ML SR
IV
ML
10 U
10
01/01/2002
04/01/2002
SUPARTZ (SRN,PREFILLED) 10 MG/ML
2.5 ML SR
IJ
ML
1 DOSE
0.4
01/01/2007
12/31/2007
2.5 ML SR
IJ
ML
1 DOSE
0.5
01/01/2008
99/99/9999
2.5 ML SR
IJ
ML
1 DOSE
0.4
01/01/2007
12/31/2007

SODIUM CHLORIDE FLUSH (3ML,PREFILLED SYRINGE) 0.9%
2.5 ML SR
IJ
ML
1 DOSE
0.5
01/01/2008
99/99/9999
2 ML SR
IV
ML
0.9 %
0.5
11/01/2003
12/31/2006
2 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
0.9 %
0.5
11/01/2003
12/31/2006
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
0.9 %
0.5
11/01/2003
12/31/2006
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
Page 130 of 374
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
08450-0906-10
J2912
08450-0906-10
A4216
08450-6011-02
A4323
08450-6011-02
A4216
08450-6012-03
A4323
08450-6012-03
A4216
08450-6013-05
A4323
08450-6013-05
A4216
08450-6014-10
A4323
08450-6014-10
A4216
08450-6026-03
J1642
08450-6030-05
J1642
08450-6034-03
J1642
08450-6037-05
J1642
08450-6046-03
J1642
08450-6049-03
J1642
08450-6050-05
J1642
08450-6055-03
J1642
08450-6058-05
J1642
08478-4004-02
J7347
08478-4004-02
Q4104
08478-4004-05
J7347
08478-4004-05
Q4104
08478-4004-06
J7347
08478-4004-06
Q4104
08478-4004-08
J7347
08478-4004-08
Q4104
08478-4014-02
J7347
08478-4014-02
Q4108
08478-4014-05
J7347
08478-4014-05
Q4108
08478-4014-06
J7347
08478-4014-06
Q4108


SODIUM CHLORIDE FLUSH (3ML
W/CANNULA) 0.9%
W/CANNULA) 0.9%
W/CANNULA) 0.9%
W/CANNULA) 0.9%
W/CANNULA) 0.9%
W/CANNULA) 0.9%
W/CANNULA) 0.9%
W/CANNULA) 0.9%
HEPARIN LOCK FLUSH (6ML,PRE-FILLED
SYRINGE) 10 U/ML
HEPARIN LOCK FLUSH (12ML,PREFILLED SYRINGE) 10 U/ML
HEPARIN LOCK FLUSH (6ML
W/CANNULA) 10 U/ML
W/CANNULA) 10 U/ML
HEPARIN LOCK FLUSH (6ML,PRE-FILLED
SYRINGE) 100 U/ML
W/CANNULA) 100 U/ML
W/CANNULA) 100 U/ML
10 ML SR
IV
ML
0.9 %
0.5
11/01/2003
12/31/2006
10 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
2 ML SR
IV
ML
1000 ML
0.001
11/01/2003
12/31/2003
2 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
3 ML SR
IV
ML
1000 ML
0.001
11/01/2003
12/31/2003
3 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
5 ML SR
IV
ML
1000 ML
0.001
11/01/2003
12/31/2003
5 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
10 ML SR
IV
ML
1000 ML
0.001
11/01/2003
12/31/2003
10 ML SR
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
3 ML EA
IV
ML
10 U
11/01/2003
99/99/9999
5 ML SR
IV
ML
10 U
11/01/2003
99/99/9999
3 ML EA
IV
ML
10 U
11/01/2003
99/99/9999
5 ML SR
IV
ML
10 U
11/01/2003
99/99/9999
3 ML EA
IV
ML
10 U
10
11/01/2003
99/99/9999
3 ML SR
IV
ML
10 U
10
11/01/2003
99/99/9999
5 ML SR
IV
ML
10 U
10
11/01/2003
99/99/9999
3 ML EA
IV
ML
10 U
10
11/01/2003
99/99/9999
10 U
10
11/01/2003
99/99/9999
5 ML SR
IV
ML
DERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHOUT OTHER

BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE INTEGRA BILAYER MATRIX WOUND
DRESSING (2"X2")
1/1/2008 12/31/2008 ELEMENTS (INTEGRA MATRIX), PER SQUARE CENTIMETER
SKIN SUBSTITUTE, INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER
INTEGRA BILAYER MATRIX WOUND
DRESSING (2"X2")
1 EA NA
TP
EA
1 SQCM
25.806
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
25.806
01/01/2009
99/99/9999

DRESSING (4"X5")
DRESSING (4"X5")
1 EA NA
TP
EA
1 SQCM
129.032
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
129.032
01/01/2009
99/99/9999

DRESSING (4"X10")
DRESSING (4"X10")
1 EA NA
TP
EA
1 SQCM
258.064
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
258.064
01/01/2009
99/99/9999

DRESSING (8"X10")
DRESSING (8"X10")
1 EA NA
TP
EA
1 SQCM
516.128
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
516.128
01/01/2009
99/99/9999

BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE INTEGRA MATRIX WOUND DRESSING
(2"X2")
INTEGRA MATRIX WOUND DRESSING
1/1/2009 99/99/9999 SKIN SUBSTITUTE, INTEGRA MATRIX, PER SQUARE CENTIMETER
(2"X2")
1 EA NA
TP
EA
1 SQCM
25.806
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
25.806
01/01/2009
99/99/9999

(4"X5")
(4"X5")
1 EA NA
TP
EA
1 SQCM
129.032
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
129.032
01/01/2009
99/99/9999

(4"X10")
(4"X10")
1 EA NA
TP
EA
1 SQCM
258.064
01/01/2008
99/99/9999
1 EA NA
TP
EA
1 SQCM
258.064
01/01/2009
99/99/9999
Page 131 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
08478-4014-08
J7347
08478-4014-08
Q4108
08478-8004-02
J7347
08478-8004-02
Q4105
08478-8004-05
J7347
08478-8004-05
Q4105
08478-8004-06
J7347
08478-8004-06
Q4105
1 EA NA
TP
EA
1 SQCM
516.128
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
516.128
01/01/2009
99/99/9999

BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE INTEGRA DERMAL REGENERATION
TEMPLATE (2"X2")
SKIN SUBSTITUTE, INTEGRA DERMAL REGENERATION TEMPLATE (DRT), PER
INTEGRA DERMAL REGENERATION
TEMPLATE (2"X2")
1 EA NA
TP
EA
1 SQCM
25.806
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
25.806
01/01/2009
99/99/9999

TEMPLATE (4"X5")
TEMPLATE (4"X5")
1 EA NA
TP
EA
1 SQCM
129.032
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
129.032
01/01/2009
99/99/9999

TEMPLATE (4"X10")
TEMPLATE (4"X10")
1 EA NA
TP
EA
1 SQCM
258.064
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
258.064
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
516.128
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
516.128
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
30
01/01/2008
12/31/2008
1 EA NA
TP
EA
30 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
72
01/01/2008
12/31/2008
1 EA NA
TP
EA
72 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
100
01/01/2008
12/31/2008
1 EA NA
TP
EA
100 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
150
01/01/2008
12/31/2008
1 EA NA
TP
EA
150 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
200
01/01/2008
12/31/2008
1 EA NA
TP
EA
200 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
320
01/01/2008
12/31/2008
1 EA NA
TP
EA
320 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
325
01/01/2008
12/31/2008
1 EA NA
TP
EA
325 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
64
01/01/2008
12/31/2008
1 EA NA
TP
EA
64 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
01/01/2008
12/31/2008
1 EA NA
TP
EA
9 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
28
01/01/2008
12/31/2008
1 EA NA
TP
EA
28 SQCM
01/01/2009
99/99/9999
J7347
1/1/2008
08478-8004-08
Q4105
1/1/2009
08533-6010-02
J7349
1/1/2008
08533-6010-02
Q4100
1/1/2009
08533-6010-04
J7349
1/1/2008
08533-6010-04
Q4100
1/1/2009
08533-6010-05
J7349
1/1/2008
08533-6010-05
Q4100
1/1/2009
08533-6010-06
J7349
1/1/2008
08533-6010-06
Q4100
1/1/2009
08533-6010-07
J7349
1/1/2008
08533-6010-07
Q4100
1/1/2009
08533-6010-08
J7349
1/1/2008
08533-6010-08
Q4100
1/1/2009
08533-6010-09
J7349
1/1/2008
08533-6010-09
Q4100
1/1/2009
08533-6010-10
J7349
1/1/2008
08533-6010-10
Q4100
1/1/2009
08533-6010-12
J7349
1/1/2008
08533-6010-12
Q4100
1/1/2009
08533-6010-13
J7349
1/1/2008
08533-6010-13
Q4100
1/1/2009

TEMPLATE (8"X10")
12/31/2008 ELEMENTS (INTEGRA MATRIX), PER SQUARE CENTIMETER
99/99/9999 SQUARE CENTIMETER
TEMPLATE (8"X10")
BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE SURGIMEND COLLAGEN MATRIX
(5X6CM,THICK,SINGLE USE)
12/31/2008 ELEMENTS (PRIMATRIX), PER SQUARE CENTIMETER
SURGIMEND COLLAGEN MATRIX
99/99/9999 SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED
(10X10CM,THICK,SINGLEUSE)
Page 132 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

(8"X10")
(8"X10")
08478-8004-08
HCPCS Mod
HCPCS
NDC Mod
NDC
08533-6078-12
J7349
08533-6078-12
Q4110
08533-6078-80
J7349
08533-6078-80
Q4110

1/1/2008 12/31/2008 ELEMENTS (PRIMATRIX), PER SQUARE CENTIMETER
1/1/2009 99/99/9999 SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED
(4X7CM,THIN,SINGLE USE)
(.3X25CM,STRIP,SINGLEUSE)
(1X25CM,SINGLE USE)
(1X25CM,SINGLE USE)
BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE PRIMATRIX DERMAL REPAIR SCAFFOLD
(0.2X26.5CM,SINGLE USE)
PRIMATRIX DERMAL REPAIR SCAFFOLD
1/1/2009 99/99/9999 SKIN SUBSTITUTE, PRIMATRIX, PER SQUARE CENTIMETER
(0.2X26.5CM,SINGLE USE)
(4X4CM)
(4X4CM)
(8X12CM)
(8X12CM)
(8X8CM)
(8X8CM)
08533-6495-01
08533-6495-01
J7348
Q4109

BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE
TISSUEMEND (5X6CM)
1/1/2008 12/31/2008 ELEMENTS (TISSUEMEND), PER SQUARE CENTIMETER
1/1/2009 99/99/9999 SKIN SUBSTITUTE, TISSUEMEND, PER SQUARE CENTIMETER
TISSUEMEND (5X6CM)
1 EA NA
1 EA NA
IP
IP
EA
EA
1 SQCM
1 SQCM
30
30
01/01/2008
01/01/2009
12/31/2008
99/99/9999
08533-6495-03
08533-6495-03
J7348
Q4109

TISSUEMEND (4X4CM)
TISSUEMEND (4X4CM)
1 EA NA
1 EA NA
IP
IP
EA
EA
1 SQCM
1 SQCM
16
16
01/01/2008
01/01/2009
12/31/2008
99/99/9999
08533-6495-04
08533-6495-04
J7348
Q4109

TISSUEMEND (6X10CM)
TISSUEMEND (6X10CM)
1 EA NA
1 EA NA
IP
IP
EA
EA
1 SQCM
1 SQCM
60
60
01/01/2008
01/01/2009
12/31/2008
99/99/9999
08533-6495-06
08533-6495-06
J7348
Q4109
1 EA NA
1 EA NA
IP
IP
EA
EA
1 SQCM
1 SQCM
9
9
01/01/2008
01/01/2009
12/31/2008
99/99/9999
08533-6010-14
J7349
08533-6010-14
Q4100
08533-6020-02
J7349
08533-6020-02
Q4100
08533-6020-03
J7349
08533-6020-03
Q4100
08533-6020-05
J7349
08533-6020-05
Q4100
08533-6030-01
J7349
08533-6030-01
Q4100
08533-6030-02
J7349
08533-6030-02
Q4100
08533-6030-03
J7349
08533-6030-03
Q4100
08533-6070-09
J7349
08533-6070-09
Q4110
08533-6074-40
J7349
08533-6074-40
Q4110
08541-0001-01
J7342
08541-0001-01
Q4106

TISSUEMEND (3X3CM)
TISSUEMEND (3X3CM)
OR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE ELEMENTS, PER
DERMAGRAFT (W/CRYOPROTECTANT)
1/1/2009 99/99/9999 SKIN SUBSTITUTE, DERMAGRAFT, PER SQUARE CENTIMETER
DERMAGRAFT
(W/CRYOPROTECT,5X7.5CM,FR)
Page 133 of 374
1 EA NA
TP
EA
1 SQCM
48
01/01/2008
12/31/2008
1 EA NA
TP
EA
48 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
28
01/01/2008
12/31/2008
1 EA NA
TP
EA
28 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
30
01/01/2008
12/31/2008
1 EA NA
TP
EA
30 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
01/01/2008
12/31/2008
1 EA NA
TP
EA
9 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
7.5
01/01/2008
12/31/2008
1 EA NA
TP
EA
7.5 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
15
01/01/2008
12/31/2008
1 EA NA
TP
EA
15 SQCM
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
25
01/01/2008
12/31/2008
1 EA NA
TP
EA
25 SQCM
01/01/2009
99/99/9999
3 EA NA
TP
EA
1 SQCM
5.3
01/01/2008
12/31/2008
3 EA NA
TP
EA
1 SQCM
5.3
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
16
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
16
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
96
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
96
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
64
01/01/2008
12/31/2008
1 EA NA
TP
EA
1 SQCM
64
01/01/2009
99/99/9999
1 EA NA
TP
EA
1 SQCM
37.5
07/10/2006
12/31/2008
1 EA NA
TP
EA
1 SQCM
37.5
01/01/2009
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
08881-0125-02
J1642
08881-5701-28
A4216
08881-5701-29
A4216
08881-5801-21
J1642
08881-5801-23
J1642
08881-5801-25
J1642
08881-5901-21
J1642
08881-5901-23
J1642
08881-5901-25
J1642
08888-7131-15
J2000
08888-7131-15
J2001
08888-7131-23
J2000
08888-7131-23
J2001
08888-7131-31
J2000
08888-7131-31
J2001
08888-7141-13
J2000
08888-7141-13
J2001
09978-0001-99
09978-0001-99
J7340
Q4101
10019-0006-73
J2275
10019-0007-73
10019-0013-01
J2275
J3490

DERMAL AND EPIDERMAL TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT
BIOENGINEERED OR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE
1/1/2002 12/31/2008 ELEMENTS, PER SQUARE CENTIMETER
1/1/2009 99/99/9999 SKIN SUBSTITUTE, APLIGRAF, PER SQUARE CENTIMETER
1/1/2002 4/22/2004 10 MG
1/1/2002 3/26/2004 10 MG
10019-0013-02
J3490
10019-0013-03
J3490
10019-0013-04
10019-0013-06
J3490
J3490
10019-0016-02
J7643
10019-0016-02 KO J7643
10019-0016-17
10019-0016-63
J7643
1/1/2002
5/5/2007
KO
5/5/2007
1/1/2002
KO
J7643
10019-0016-63 KO J7643
10019-0016-81
KO
J7643
10019-0016-54 KO J7643
9/28/2005
1/1/2002
J7643
10019-0016-29 KO J7643
10019-0016-54
9/28/2005
KO
J7643
10019-0016-17 KO J7643
10019-0016-29
1/1/2002
10/1/2002
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002

MONOJECT PREFILL HEPARIN LOCK

FLUSH (SRN,3 ML,LATEX-FREE) 100
U/ML (2.5 ML, 180S)
MONOJECT PREFILL ADVANCED
(60X10ML,PF,LATEX-FREE) 0.9%
(120X10ML,PF,LATEX-FREE) 0.9%
FLUSH (SRN, 12 ML,LATEX-FREE) 10
U/ML (10 ML 180S)
FLUSH (SRN,12 ML, PF, LATEX-FREE) 10
U/ML (2.5 ML 180S)
FLUSH (SRN,12 ML,PF,LATEX-FREE) 10
U/ML (5 ML 180S)
U/ML (10ML 180S)
U/ML (10ML 180S)
HEPARIN LOCK FLUSH (SRN,12
ML,PF,LATEX-FREE) 100 U/ML (2.5 ML
180S)
SENSI-TOUCH LUMBAR PUNCTURE
TRAY (ADULT) 1%
TRAY (ADULT) 1%
TRAY (ADULT) 1%
TRAY (ADULT) 1%
TRAY (ADULT) 1%
TRAY (ADULT) 1%
TRAY (PEDIATRIC) 1%
TRAY (PEDIATRIC) 1%
APLIGRAF (75MM DIAM DISK)

APLIGRAF (75MM DIAM DISK)
MG/ML
MG/ML
PROPOFOL (S.D.V.) 10 MG/ML
PROPOFOL (S.D.V. W/VENTED SPIKE)
10 MG/ML
PROPOFOL (S.D.V. W/4-WAY
STOPCOCK) 10 MG/ML
2.5 ML SR
IV
10 U
10.0
8/23/2006
99/99/9999
10 ML SR
IV
ML
10 ML
0.1
07/01/2006
99/99/9999
10 ML SR
IV
ML
10 ML
0.1
07/01/2006
99/99/9999
10 ML SR
IV
10 U
3/14/2002
99/99/9999
2.5 ML SR
IV
10 U
3/14/2002
99/99/9999
10 ML SR
IV
10 U
8/23/2006
99/99/9999
10 ML SR
IV
10 U
10
3/14/2002
99/99/9999
10 ML SR
IV
10 U
3/14/2002
99/99/9999
5 ML SR
IV
10 U
10
8/23/2006
99/99/9999
8 ML VL
EP
EA
50 ML
0.64
01/01/2002
12/31/2003
8 ML VL
EP
EA
10 MG
32
01/01/2004
99/99/9999
8 ML VL
EP
EA
50 ML
0.64
01/01/2002
12/31/2003
8 ML VL
EP
EA
10 MG
32
01/01/2004
99/99/9999
8 ML VL
EP
EA
50 ML
0.64
01/01/2002
12/31/2003
8 ML VL
EP
EA
10 MG
32
01/01/2004
99/99/9999
8 ML VL
EP
EA
50 ML
0.64
01/01/2002
12/31/2003
8 ML VL
EP
EA
10 MG
32
01/01/2004
99/99/9999
1 EA BG
1 EA BG
TP
TP
44.17865
44.17865
01/01/2002
01/01/2009
12/31/2008
99/99/9999
10 ML AM IJ
ML
EA
EA
10 MG
1 SQCM
1 SQCM
0.5
01/01/2002
04/22/2004
10 ML AM IJ
20 ML VL IV
ML
ML
10 MG
1 EA
0.1
1
01/01/2002
01/01/2002
03/26/2004
99/99/9999
99/99/9999
50 ML VL
IV
ML
1 EA
01/01/2002
100 ML VL
IV
ML
1 EA
01/01/2002
99/99/9999
PROPOFOL (SRN,PREFILLED) 10 MG/ML

PROPOFOL 10 MG/ML
20 ML SR
10 ML VL
IV
IV
ML
ML
1 EA
1 EA
1
1
01/01/2002
10/01/2002
05/28/2002
03/30/2007
20 ML VL
IJ
ML
1 MG
0.2
09/28/2005
99/99/9999
20 ML VL
IJ
ML
1 MG
0.2
09/28/2005
99/99/9999
2 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
2 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
GLYCOPYRROLATE (MDV) 0.2 MG/ML
20 ML VL
IJ
ML
1 MG
0.2
05/05/2007
99/99/9999
GLYCOPYRROLATE (MDV) 0.2 MG/ML
20 ML VL
IJ
ML
1 MG
0.2
05/05/2007
99/99/9999
5 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
5 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
20 ML VL
IJ
ML
1 MG
0.2
01/01/2002
12/14/2006
20 ML VL
IJ
ML
1 MG
0.2
01/01/2002
12/14/2006
1 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
Page 134 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
10019-0016-81 KO J7643
10019-0017-56
J2000
10019-0017-57
J2000
10019-0019-57
J2000
KO

10019-0021-09
J1885
10019-0022-09
J1885
10019-0022-32
10019-0027-01
10019-0027-02
10019-0027-03
10019-0027-04
10019-0027-05
10019-0027-10
10019-0027-29
10019-0027-36
10019-0027-37
10019-0027-39
10019-0028-02
10019-0028-03
10019-0028-05
10019-0028-10
10019-0028-36
10019-0028-37
10019-0028-39
J1885
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
10019-0029-02
J1885
10019-0029-12
J1885
1/1/2002
12/8/2005
1/1/2002
12/10/2003
12/10/2003
12/8/2005
1/1/2002
5/5/2007
5/5/2007
5/5/2007
5/5/2007
12/8/2005
12/10/2003
1/1/2002
1/1/2002
5/5/2007
5/5/2007
5/5/2007

10019-0030-03
J1885
10019-0030-04
J1885
10019-0030-12
J1885
10019-0030-17
J1885

KETOROLAC TROMETHAMINE (SRN) 15
MG/ML
MG/ML
MG/ML
MIDAZOLAM HCL (10X1ML) 5 MG/ML
MIDAZOLAM HCL (DOSETTE) 5 MG/ML
MIDAZOLAM HCL (M.D.V.) 5 MG/ML
MIDAZOLAM HCL 5 MG/ML
KETOROLAC TROMETHAMINE (1X25) 15
MG/ML
ML
ML
ML
ML
1 MG
50 ML
50 ML
50 ML
0.2
0.02
0.02
0.02
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
08/19/2002
04/19/2002
07/10/2002
1 ML SR
IJ
ML
15 MG
01/01/2002
99/99/9999
1 ML SR
IJ
ML
15 MG
01/01/2002
99/99/9999
IM
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
15 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
2
5
5
5
5
5
5
5
5
5
5
1
1
1
1
1
1
1
01/01/2002
12/08/2005
12/08/2005
12/10/2003
12/10/2003
12/08/2005
01/01/2002
05/05/2007
05/05/2007
05/05/2007
05/05/2007
12/08/2005
12/10/2003
01/01/2002
01/01/2002
05/05/2007
05/05/2007
05/05/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
SR
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
1 ML VL
IJ
ML
15 MG
07/21/2004
99/99/9999
IJ
ML
15 MG
05/05/2007
99/99/9999
1 ML VL
IJ
ML
15 MG
07/21/2004
99/99/9999
2 ML VL
IJ
ML
15 MG
07/21/2004
99/99/9999
1 ML VL
IJ
ML
15 MG
05/05/2007
99/99/9999
2 ML VL
IJ
ML
15 MG
05/05/2007
99/99/9999
10019-0033-72
J3010
J3010
10019-0035-74
J3010
10019-0036-39
J3010
10019-0036-82
J3010
10019-0037-83
J3010
10019-0038-67
J3010
10019-0043-01
J0780
10019-0043-44
10019-0045-01
10019-0045-02
10019-0045-17
10019-0046-02
10019-0046-03
10019-0046-04
10019-0046-14
10019-0046-63
J0780
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
5/5/2007
1/1/2002
11/1/2003
5/5/2007
1/1/2002
1/1/2002
11/1/2003
5/5/2007
5/5/2007
10019-0047-01
J3490
10019-0047-17
J3490
10019-0048-02
J3490
10019-0048-03
J3490
10019-0048-14
J3490
10019-0048-63
J3490
10019-0050-06
J3490
SUFENTANIL CITRATE (AMP) 50 MCG/ML
Page 135 of 374
5 ML AM IJ
ML
0.1 MG
0.5
01/01/2002
99/99/9999
10 ML AM IJ
ML
0.1 MG
0.5
01/01/2002
99/99/9999
20 ML AM IJ
ML
0.1 MG
0.5
01/01/2002
99/99/9999
30 ML VL
IJ
ML
0.10 MG
0.5
8/21/1998
99/99/9999
30 ML VL
IJ
ML
0.1 MG
0.5
01/01/2002
99/99/9999
50 ML VL
IJ
ML
0.1 MG
0.5
01/01/2002
99/99/9999
2 ML AM IJ
ML
0.1 MG
0.5
01/01/2002
99/99/9999
2 ML AM IJ
ML
10 MG
0.5
01/14/2005
99/99/9999
AM
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
10 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
0.5
1
1
1
1
1
1
1
1
05/05/2007
08/19/2002
11/01/2003
05/05/2007
01/01/2002
01/01/2002
11/01/2003
05/05/2007
05/05/2007
99/99/9999
11/01/2003
99/99/9999
99/99/9999
11/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML VL
IV
ML
1 EA
11/01/2003
99/99/9999
2 ML VL
IV
ML
1 EA
05/05/2007
99/99/9999
4 ML VL
IV
ML
1 EA
11/01/2003
99/99/9999
20 ML VL
IV
ML
1 EA
01/01/2004
99/99/9999
2 ML
2 ML
2 ML
2 ML
4 ML
20 ML
4 ML
4 ML
20 ML
4 ML VL
IV
ML
1 EA
05/05/2007
99/99/9999
20 ML VL
IV
ML
1 EA
05/05/2007
99/99/9999
5 ML AM IJ
ML
1 EA
01/01/2002
99/99/9999
1/1/2002
9/27/2004
1/1/2002
5/28/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure
IJ
EP
EP
IJ
2 ML
1 ML
2 ML
1 ML
2 ML
5 ML
10 ML
5 ML
2 ML
1 ML
10 ML
2 ML
2 ML
5 ML
10 ML
2 ML
5 ML
10 ML
VL
VL
VL
VL
1 ML VL
10019-0034-73
1 ML
30 ML
50 ML
50 ML
KETOROLAC TROMETHAMINE 15 MG/ML

MG/ML
MG/ML
KETOROLAC TROMETHAMINE (USP) 30
MG/ML
FENTANYL CITRATE (AMP,PF) 0.05
MG/ML
MG/ML
MG/ML
FENTANYL CITRATE (1x30ML, SDV,
USP,PF) 0.05 MG/ML
MG/ML
MG/ML
MG/ML
NOVAPLUS PROCHLORPERAZINE
EDISYLATE (USP,DOSETTE
VIAL,25X2ML) 5 MG/ML
NOVAPLUS PROCHLORPERAZINE
EDISYLATE (USP) 5 MG/ML
FAMOTIDINE (S.D.V.,PF) 10 MG/ML
FAMOTIDINE (SDV,PF) 10 MG/ML
FAMOTIDINE (M.D.V.) 10 MG/ML
FAMOTIDINE (MDV) 10 MG/ML
FAMOTIDINE (MDV) 10 MG/ML
FAMOTIDINE NOVAPLUS (S.D.V.,PF) 10
MG/ML
FAMOTIDINE NOVAPLUS (SDV,PF) 10
MG/ML
FAMOTIDINE NOVAPLUS (M.D.V.) 10
MG/ML
MG/ML
FAMOTIDINE NOVAPLUS (MDV) 10
MG/ML
FAMOTIDINE NOVAPLUS (MDV) 10
MG/ML


Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
10019-0050-43
J3490
10019-0053-03
J1626
10019-0053-14
J1626


SUFENTANIL CITRATE 50 MCG/ML
2
5
2
1
IJ
IJ
IJ
IJ
ML
ML
ML
ML

(1X4ML,INNER,LATEX-FREE) 1 MG/ML
1 ML AM IJ
ML
4 ML VL
IV
ML
4 ML NA
IV
ML
ADENOSINE (SDV,PF) 3 MG/ML
2 ML VL
IV
ADENOSINE (PF) 3 MG/ML

ADENOSINE (SINGLE-DOSE
SYRINGE,PF) 3 MG/ML
ADENOSINE (SINGLE-DOSE
SYRINGES,PF) 3 MG/ML
2 ML VL
IV
2 ML SR
2 ML SR
10019-0063-02
J0150
J0150
10019-0063-07
J0150
10019-0063-08
J0150
10019-0063-34
10019-0070-01
10019-0070-02
10019-0070-03
10019-0070-10
10019-0070-20
J0150
J2260
J2260
J2260
J2260
J2260
10019-0097-01
J2550
10019-0097-44
J2550
ADENOSINE (SINGLE DOSE,PF) 3 MG/ML

MILRINONE LACTATE (SDV) 1 MG/ML
MILRINONE LACTATE (SDV) 1 MG/ML
PROMETHAZINE HCL AMERINET
CHOICE 25 MG/ML
PROMETHAZINE HCL AMERINET
CHOICE 25 MG/ML
10019-0098-01
J0696
CEFTRIAXONE AMERINET CHOICE 1 GM
10019-0098-71
10019-0102-01
10019-0102-10
10019-0102-37
10019-0102-39
10019-0103-01
10019-0103-10
10019-0103-37
10019-0103-39
10019-0103-46
J0696
J2060
J2060
J2060
J2060
J2060
J2060
J2060
J2060
J2060
5/5/2007
1/1/2002
1/1/2002
5/5/2007
5/5/2007
1/1/2002
1/1/2002
5/5/2007
5/5/2007
1/1/2002
10019-0105-01
J2060
10019-0105-02
J2060
CEFTRIAXONE AMERINET CHOICE 1 GM

LORAZEPAM (S.D.V.) 2 MG/ML
LORAZEPAM (M.D.V.) 2 MG/ML
LORAZEPAM 2 MG/ML
LORAZEPAM 2 MG/ML
LORAZEPAM 4 MG/ML
LORAZEPAM 4 MG/ML
ATIVAN (2 ML TUBEX) 4 MG/ML
NOVAPLUS LORAZEPAM (25X1ML,SDV)
2 MG/ML
NOVAPLUS LORAZEPAM
(10X10ML,MDV) 2 MG/ML
10019-0105-44
J2060
10019-0105-71
J2060
10019-0106-01
J2060
10019-0106-02
10019-0106-44
10019-0106-71
J2060
J2060
J2060

10019-0127-08
10019-0131-01
10019-0133-01
10019-0133-02
10019-0133-04
10019-0133-13
10019-0133-19
10019-0145-01
10019-0145-43
10019-0152-44
10019-0153-44
10019-0153-47
J2250
J0282
J0282
J0282
J0282
J0282
J0282
J1800
J1800
J2175
J2175
J2175

1/1/2002
10/16/2002
11/20/2003
11/20/2003
6/16/2004
5/5/2007
5/5/2007
1/15/2004
5/5/2007
1/1/2002
1/1/2002
1/1/2002

1/1/2002
10019-0154-44
J2175
10019-0155-68
J2175
10019-0156-68
J2175
2/26/2002
10019-0157-68
J2175
10019-0158-68
J2175
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA
01/01/2002
99/99/9999
100 MCG
10
12/31/2007
99/99/9999
100 MCG
10
12/31/2007
99/99/9999
ML
6 MG
0.5
05/05/2007
99/99/9999
ML
6 MG
0.5
06/17/2004
99/99/9999
IV
ML
6 MG
0.5
05/24/2005
7/15/2008
IV
ML
6 MG
0.5
05/24/2005
99/99/9999
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
6 MG
5 MG
5 MG
5 MG
5 MG
5 MG
0.5
0.2
0.2
0.2
0.2
0.2
05/05/2007
05/22/2002
05/22/2002
05/22/2002
05/05/2007
05/05/2007
99/99/9999
99/99/9999
99/99/9999
11/20/2003
99/99/9999
99/99/9999
1 ML AM IJ
ML
50 MG
0.5
01/17/2005
99/99/9999
1 ML AM IJ
ML
50 MG
0.5
05/05/2007
99/99/9999
1 EA VL
IJ
EA
250 MG
07/05/2005
99/99/9999
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
ML
ML
ML
ML
ML
ML
ML
ML
ML
250 MG
2 MG
2 MG
2 MG
2 MG
2 MG
2 MG
2 MG
2 MG
2 MG
4
1
1
1
1
2
2
2
2
2
05/05/2007
01/01/2002
01/01/2002
05/05/2007
05/05/2007
01/01/2002
01/01/2002
05/05/2007
05/05/2007
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/21/2002
1 EA
1 ML
10 ML
10 ML
1 ML
1 ML
10 ML
10 ML
25 ML
1 ML
VL
VL
VL
VL
VL
VL
VL
VL
VL
SR
1 ML VL
IJ
ML
2 MG
05/03/2006
99/99/9999
10 ML VL
IJ
ML
2 MG
05/03/2006
99/99/9999
NOVAPLUS LORAZEPAM (USP) 2 MG/ML
1 ML VL
IJ
ML
2 MG
05/05/2007
99/99/9999
NOVAPLUS LORAZEPAM (USP) 2 MG/ML

NOVAPLUS LORAZEPAM (25X1ML,SDV)
4 MG/ML
NOVAPLUS LORAZEPAM
NOVAPLUS LORAZEPAM 4 MG/ML
NOVAPLUS LORAZEPAM 4 MG/ML
MIDAZOLAM HCL (SRN,RAPI-JECT) 5
MG/ML
AMIODARONE HCL (SDV) 50 MG/ML
INDERAL 1 MG/ML
MEPERIDINE HCL (S.D.V.) 50 MG/ML
MEPERIDINE HCL (TUBEX) 75 MG/ML
MEPERIDINE HCL (DOSETTE VIAL) 100
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
1 ML VL
IJ
ML
2 MG
05/05/2007
99/99/9999
1 ML VL
IJ
ML
2 MG
05/03/2006
99/99/9999
10 ML VL
1 ML VL
1 ML VL
IJ
IJ
IJ
ML
ML
ML
2 MG
2 MG
2 MG
2
2
2
05/03/2006
05/05/2007
05/05/2007
99/99/9999
99/99/9999
99/99/9999
2 ML
3 ML
3 ML
18 ML
9 ML
3 ML
9 ML
1 ML
1 ML
1 ML
1 ML
1 ML
SR
AM
VL
VL
VL
VL
VL
AM
AM
VL
VL
NA
IJ
IV
IV
IV
IV
IV
IV
IV
IV
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 MG
30 MG
30 MG
30 MG
30 MG
30 MG
30 MG
1 MG
1 MG
100 MG
100 MG
100 MG
5
1.66666
1.66666
1.66666
1.66666
1.66666
1.66666
1
1
0.5
0.75
0.75
01/01/2002
10/16/2002
11/20/2003
11/20/2003
06/16/2004
05/05/2007
05/05/2007
01/15/2004
05/05/2007
01/01/2002
01/01/2002
01/01/2002
06/01/2002
05/18/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
04/19/2002
04/19/2002
04/19/2002
1 ML VL
Page 136 of 374
IJ
ML
100 MG
01/01/2002
04/19/2002
1 ML AM IJ
ML
100 MG
0.25
03/27/2002
12/14/2006
1 ML AM IJ
ML
100 MG
0.5
02/26/2002
02/22/2006
1 ML AM IJ
ML
100 MG
0.75
03/27/2002
12/14/2006
1 ML AM IJ
ML
100 MG
03/27/2002
12/14/2006
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
01/01/2002
05/05/2007
05/05/2007
05/05/2007
NA
VL
VL
VL
VL
VL
EA
EA
EA
EA
Start Date #1
1
1
1
1
2 ML
10 ML
20 ML
50 ML
10 ML
20 ML
1
1
1
1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
AM
AM
AM
AM

Package
ML
ML
ML
ML

10019-0063-03
NDC Package Type
J3490
J3490
J3490
J3490
NDC Label
HCPCS Description
10019-0050-21
10019-0050-36
10019-0050-37
10019-0050-39
NDC Package Measure
1/1/2002
5/5/2007
5/5/2007
5/5/2007
HCPCS Mod
HCPCS
NDC Mod
NDC
10019-0159-01
10019-0159-44
J2175
J2175

10019-0160-01
10019-0160-44
J2175
J2175

10019-0161-01
10019-0161-44
J2175
J2175

10019-0162-01
10019-0162-44
J2175
J2175

MEPERIDINE HCL (SDV (DOSETTE)) 25

MG/ML
MG/ML
MG/ML
MG/ML
1 ML VL
1 ML VL
IJ
IJ
ML
ML
100 MG
100 MG
0.25
0.25
01/07/2004
05/05/2007
99/99/9999
99/99/9999
1 ML VL
1 ML VL
IJ
IJ
ML
ML
100 MG
100 MG
0.5
0.5
01/07/2004
05/05/2007
99/99/9999
99/99/9999
1 ML VL
1 ML VL
IJ
IJ
ML
ML
100 MG
100 MG
0.75
0.75
01/07/2004
05/05/2007
99/99/9999
99/99/9999
1 ML VL
1 ML VL
IJ
IJ
ML
ML
100 MG
100 MG
1
1
01/07/2004
05/05/2007
99/99/9999
99/99/9999
10019-0163-01
J2370
5 ML VL
IJ
ML
1 ML
01/01/2002
99/99/9999
10019-0163-12
J2370
1 ML VL
IJ
ML
1 ML
01/01/2002
99/99/9999
10019-0176-39
10019-0176-44
10019-0177-37
J2270
J2270
J2270

1 ML VL IJ
1 ML VL IJ
1 ML AM IJ
ML
ML
ML
10 MG
10 MG
10 MG
0.5
0.5
0.8
8/21/1998
01/01/2002
05/05/2007
99/99/9999
99/99/9999
99/99/9999
10019-0177-39
J2270
1 ML VL
IJ
ML
10 MG
0.8
9/13/2001
99/99/9999
10019-0177-44
10019-0177-68
10019-0178-36
J2270
J2270
J2270

1 ML VL IJ
1 ML AM IJ
10 ML NA IJ
ML
ML
ML
10 MG
10 MG
10 MG
0.8
0.8
1
01/01/2002
01/01/2002
05/05/2007
99/99/9999
99/99/9999
99/99/9999
10019-0178-37
10019-0178-39
J2270
J2270

ML
ML
10 MG
10 MG
1
1
8/21/1998
05/05/2007
99/99/9999
99/99/9999
10019-0178-44
J2270

MORPHINE SULFATE (1X1ML,SDV,USP)
5MG/ML
MORPHINE SULFATE (S.D.V.) 5 MG/ML
MORPHINE SULFATE (1X1ML,USP)
8MG/ML
MORPHINE SULFATE (VIAL,DOSETTE) 8
MG/ML
MORPHINE SULFATE (AMP) 8 MG/ML
MORPHINE SULFATE (MDV) 10 MG/ML
MORPHINE SULFATE (1X1ML,USP)
10MG/ML
MORPHINE SULFATE (S.D.V.,25X1ML) 10
MG/ML
10019-0178-62
10019-0178-68
10019-0179-36
J2270
J2270
J2271

10019-0179-39
J2270

MORPHINE SULFATE (AMP) 10 MG/ML
MORPHINE SULFATE (MDV) 15 MG/ML
MORPHINE SULFATE (1X1ML,SDV, USP)
15MG/ML
1 ML VL
IJ
ML
10 MG
1.5
5/5/1999
99/99/9999
10019-0179-44
J2271
1 ML VL
IJ
ML
100 MG
0.15
01/01/2002
99/99/9999

MORPHINE SULFATE (25X1ML AMP) 15
MG/ML
DOBUTAMINE HCL (S.D.V.) 12.5 MG/ML
PROPOFOL 10 MG/ML
PROPOFOL 10 MG/ML
PROPOFOL 10 MG/ML
PROPOFOL (SDV) 10 MG/ML
PROPOFOL 10 MG/ML
PROPOFOL (SDV) 10 MG/ML
20 ML VL
IJ
ML
100 MG
0.15
01/01/2002
99/99/9999
IJ
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
100 MG
250 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
0.15
0.05
1
1
1
1
1
1
09/06/2005
01/01/2002
05/05/2007
05/05/2007
05/05/2007
05/05/2007
05/05/2007
05/05/2007
03/30/2007
01/20/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
1 ML VL
IJ
IJ
1 ML VL
IJ
ML
10 MG
12/22/2005
99/99/9999
10 ML VL IJ
1 ML AM IJ
20 ML NA IJ
ML
ML
ML
10 MG
10 MG
100 MG
1
1
0.15
01/01/2002
01/01/2002
05/05/2007
99/99/9999
99/99/9999
99/99/9999
10019-0179-63
J2271
10019-0179-68
10019-0184-20
10019-0213-01
10019-0213-02
10019-0213-03
10019-0213-11
10019-0213-20
10019-0213-52
J2271
J1250
J3490
J3490
J3490
J3490
J3490
J3490
10019-0250-12
J0460
ATROPINE SULFATE (S.D.V.) 0.4 MG/ML
1 ML VL
IJ
ML
0.3 MG
1.33333
01/01/2002
12/31/2009
10019-0250-20
J0460
ATROPINE SULFATE (M.D.V.) 0.4 MG/ML

ATROPINE SULFATE (MDV,1X20ML,USP)
0.4 MG/ML
ATROPINE SULFATE (SDV,1X1ML,USP)
0.4 MG/ML
ATROPINE SULFATE (S.D.V.) 1 MG/ML
ATROPINE SULFATE (SDV,1X1ML,USP) 1
MG/ML
FOSPHENYTOIN SODIUM (USP,SINGLE
DOSE,25X2) 75 MG/ML
DOSE,10X10) 75 MG/ML
(M.D.V.) 1 MG/ML
(S.D.V.) 0.5 MG/ML
(M.D.V.) 0.5 MG/ML
OXYTOCIN (1MLX25,SDV,USP) 10 U/ML
20 ML VL
IJ
ML
0.3 MG
1.33333
01/01/2002
12/31/2009
20 ML VL
IJ
ML
0.3 MG
1.33333
9/9/1997
12/31/2009
1 ML VL
1 ML VL
IJ
IJ
ML
ML
0.3 MG
0.3 MG
1.33333
3.33333
9/9/1997
01/01/2002
12/31/2009
12/31/2009
9/6/2005
1/1/2002
9/10/2002
9/10/2002
9/10/2002
5/5/2007
5/5/2007
5/5/2007

10019-0250-37
J0460
10019-0250-39
10019-0251-12
J0460
J0460

10019-0251-39
J0460
10019-0263-01
Q2009
10019-0263-03
Q2009
10019-0270-10
J2710
10019-0271-02
J2710
1/1/2002
10019-0271-10
10019-0291-02
J2710
J2590

10019-0291-04
10019-0291-12
10019-0291-71
J2590
J2590
J2590
10019-0450-02
10019-0450-39
J2765
J2765

10019-0461-01
J3490

OXYTOCIN (10MLX25,MDV,USP) 10 U/ML

OXYTOCIN (SDV,USP) 10 U/ML
OXYTOCIN (MDV,USP) 10 U/ML
METOCLOPRAMIDE HCL (S.D.V.) 5
MG/ML
METOCLOPRAMIDE HCL 5 MG/ML
BUTORPHANOL TARTRATE (S.D.V.) 1
MG/ML
Page 137 of 374
1 ML
20 ML
20 ML
50 ML
100 ML
20 ML
100 ML
50 ML
AM
VL
VL
VL
VL
VL
VL
VL
1 ML VL
IJ
ML
0.3 MG
3.33333
9/9/1997
12/31/2009
2 ML VL
IJ
ML
50 MG
1.5
08/06/2007
99/99/9999
10 ML VL
IJ
ML
50 MG
1.5
08/06/2007
99/99/9999
10 ML VL
IJ
ML
0.5 MG
01/01/2002
99/99/9999
1 ML VL
IJ
ML
0.5 MG
01/01/2002
6/30/2007
10 ML VL
1 ML VL
IJ
IJ
ML
ML
0.5 MG
10 U
1
1
01/01/2002
05/07/2007
99/99/9999
99/99/9999
10 ML VL
1 ML VL
10 ML VL
IJ
IJ
IJ
ML
ML
ML
10 U
10 U
10 U
1
1
1
05/07/2007
05/29/2007
05/29/2007
99/99/9999
99/99/9999
99/99/9999
2 ML VL
2 ML VL
IV
IV
ML
ML
10 MG
10 MG
0.5
0.5
01/01/2002
05/05/2007
99/99/9999
99/99/9999
1 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
9/10/2002 12/14/2005
9/10/2002 12/14/2005
9/10/2002 12/14/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1
1
1
10019-0461-01
J0595
10019-0462-01
J3490
10019-0462-01
10019-0506-02
10019-0506-10
10019-0506-45
J0595
J3490
J3490
J3490
1/1/2004
1/1/2002
1/1/2002
1/1/2002

10019-0610-01
10019-0610-10
10019-0611-03
10019-0611-10
J0690
J0690
J0690
J0690
3/1/2004
5/5/2007
3/1/2004
5/5/2007

10019-0612-05
10019-0612-11
J0690
J0690
10019-0613-06
J0690
3/1/2004
10019-0620-01
10019-0620-10
J0697
J0697

10019-0621-03
10019-0621-20
J0697
J0697

10019-0622-05
10019-0622-11
J0697
J0697

10019-0630-01
J0295
10019-0630-02
J0295
10019-0630-03
10019-0630-33
10019-0631-01
10019-0631-31
J0295
J0295
J0295
J0295


10019-0632-03
J0295
10019-0633-02
J0295
10019-0633-33
J0295
10019-0634-01
J0295
10019-0634-31
J0295
10019-0635-03
J0295
10019-0636-01
J0295
10019-0636-31
J0295
10019-0637-02
J0295
10019-0637-33
J0295
10019-0638-03
10019-0648-02
10019-0648-71
10019-0660-01
10019-0660-71
10019-0661-02
10019-0661-27
10019-0662-03
10019-0662-11
10019-0680-01
10019-0680-15
10019-0681-02
10019-0681-15
10019-0682-03
10019-0682-15
10019-0685-01
10019-0685-71
10019-0686-02
J0295
J0456
J0456
J0694
J0694
J0694
J0694
J0694
J0694
J0698
J0698
J0698
J0698
J0698
J0698
J0696
J0696
J0696
5/2/2006
4/12/2006
5/5/2007
12/1/2003
5/5/2007
12/1/2003
5/5/2007
12/1/2003
5/5/2007
7/5/2005
5/5/2007
7/5/2005
5/5/2007
7/5/2005
5/5/2007
7/5/2005
5/5/2007
7/5/2005
99/99/9999 INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM


MG/ML
MG/ML
MG/ML
BUMETANIDE (S.D.V.) 0.25 MG/ML
BUMETANIDE (M.D.V.) 0.25 MG/ML
CEFAZOLIN SODIUM (10ML VIAL) 500 MG
CEFAZOLIN SODIUM 500 MG
CEFAZOLIN SODIUM (10ML VIAL) 1 GM
CEFAZOLIN SODIUM 1 GM
CEFAZOLIN (USP,PHARMACY BULK) 10
GM
CEFAZOLIN 10 GM
CEFAZOLIN SODIUM (100ML VIAL, BULK
PKG) 20 GM
CEFUROXIME SODIUM (10ML VIAL) 750
MG
CEFUROXIME SODIUM (20ML VIAL) 1.5
GM
CEFUROXIME SODIUM (100ML VIAL,
BULK PKG) 7.5 GM
AMPICILLIN/SULBACTAM (VIAL) 1 GM-0.5
GM
AMPICILLIN/SULBACTAM (VIAL) 2 GM-1
GM
AMPICILLIN/SULBACTAM (BULK
PACKAGE) 10 GM-5 GM
AMPICILLIN/SULBACTAM 2 GM-1 GM
AMPICILLIN/SULBACTAM 1 GM-0.5 GM
PACKAGE) 10 GM-5 GM
AMERINET CHOICE AMPICILLIN AND
SULBACTAM 2 GM-1 GM
SULBACTAM 2 GM-1 GM
SULBACTAM (10X10MLVIALS) 1 GM-0.5
GM
SULBACTAM 1 GM-0.5 GM
SULBACTAM (PHARMACY BULK) 10 GM5 GM
SULBACTAM (USP,10MLX10) 1 GM-0.5
GM
SULBACTAM 1 GM-0.5 GM
SULBACTAM (USP,20MLX10) 2 GM-1 GM
SULBACTAM 2 GM-1 GM
SULBACTAM (USP,PHARMACYBULK) 10
GM-5 GM
AZITHROMYCIN (10X10ML) 500 MG
AZITHROMYCIN 500 MG
CEFOXITIN SODIUM (VIAL) 1 GM
CEFOXITIN SODIUM 1 GM
CEFOTAXIME (S.D.V.,USP) 500 MG
CEFOTAXIME (USP,SDV) 500 MG
CEFOTAXIME (S.D.V.,USP) 1 GM
CEFOTAXIME (USP,SDV) 1 GM
CEFOTAXIME (S.D.V.,USP) 2 GM
CEFOTAXIME (USP,SDV) 2 GM
CEFTRIAXONE 250 MG
CEFTRIAXONE 500 MG
Page 138 of 374
1 ML VL
IJ
ML
1 MG
01/01/2004
12/14/2006
1 ML VL
IJ
ML
1 EA
03/14/2002
12/31/2003
VL
VL
VL
VL
IJ
IJ
IJ
IJ
ML
ML
ML
ML
1 MG
1 EA
1 EA
1 EA
2
1
1
1
01/01/2004
01/01/2002
01/01/2002
01/01/2002
12/14/2006
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
IJ
IJ
IJ
IJ
EA
EA
EA
EA
500 MG
500 MG
500 MG
500 MG
1
1
2
2
03/01/2004
05/05/2007
03/01/2004
05/05/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
1 EA VL
IV
IV
EA
EA
500 MG
500 MG
20
20
10/05/2006
05/05/2007
99/99/9999
99/99/9999
1 ML
2 ML
10 ML
4 ML
1
1
1
1
EA
EA
EA
EA
1 EA VL
IJ
EA
500 MG
40
03/01/2004
07/21/2005
1 EA VL
1 EA VL
IJ
IJ
EA
EA
750 MG
750 MG
1
1
03/01/2004
05/05/2007
99/99/9999
99/99/9999
1 EA VL
1 EA VL
IJ
IJ
EA
EA
750 MG
750 MG
2
2
03/01/2004
05/05/2007
99/99/9999
99/99/9999
1 EA VL
1 EA VL
IJ
IJ
EA
EA
750 MG
750 MG
10
10
03/01/2004
05/05/2007
99/99/9999
99/99/9999
1 EA VL
IJ
EA
1.5 GM
12/15/2003
11/17/2005
1 EA VL
IJ
EA
1.5 GM
12/15/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
IV
IJ
IJ
IJ
EA
EA
EA
EA
1.5 GM
1.5 GM
1.5 GM
1.5 GM
10
2
1
1
12/15/2003
05/05/2007
11/18/2005
05/05/2007
02/22/2006
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
1 EA VL
IV
EA
1.5 GM
10
11/18/2005
99/99/9999
1 EA VL
IJ
EA
1.5 GM
03/10/2006
99/99/9999
1 EA VL
IJ
EA
1.5 GM
05/05/2007
99/99/9999
1 EA VL
IJ
EA
1.5 GM
03/10/2006
99/99/9999
1 EA VL
IJ
EA
1.5 GM
05/05/2007
99/99/9999
1 EA VL
IJ
EA
1.5 GM
10
12/14/2005
99/99/9999
1 EA VL
IJ
EA
1.5 GM
05/02/2006
99/99/9999
1 EA VL
IJ
EA
1.5 GM
05/05/2007
99/99/9999
1 EA VL
IJ
EA
1.5 GM
05/02/2006
99/99/9999
1 EA VL
IJ
EA
1.5 GM
05/05/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
IV
IV
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1.5 GM
500 MG
500 MG
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
250 MG
250 MG
250 MG
10
1
1
1
1
2
2
10
10
0.5
0.5
1
1
2
2
1
1
2
05/02/2006
04/12/2006
05/05/2007
12/01/2003
05/05/2007
12/01/2003
05/05/2007
12/01/2003
05/05/2007
07/05/2005
05/05/2007
07/05/2005
05/05/2007
07/05/2005
05/05/2007
07/05/2005
05/05/2007
07/05/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
10019-0686-71
10019-0687-03
10019-0687-71
10019-0688-04
10019-0688-27
J0696
J0696
J0696
J0696
J0696
5/5/2007
7/5/2005
5/5/2007
7/5/2005
5/5/2007

10019-0689-05
10019-0691-02
10019-0691-27
10019-0692-03
10019-0692-50
10019-0693-04
10019-0693-11
J0696
J0713
J0713
J0713
J0713
J0713
J0713
10/5/2006
3/22/2007
5/5/2007
3/22/2007
5/5/2007
3/22/2007
5/5/2007

10019-0905-01
J2405
10019-0905-17
J2405
10019-0906-03
J2405
10019-0906-63
10019-0910-01
10019-0910-02
10019-0912-01
10019-0912-02
10019-0912-03
10019-0915-01
10019-0916-01
10019-0917-01
10019-0920-01
10019-0921-02
10019-0925-01
10019-0925-82
10019-0926-02
10019-0926-16
10019-0930-01
10019-0930-02
J2405
J9060
J9060
J9045
J9045
J9045
J9045
J9045
J9045
J9000
J9000
J9208
J9208
J9208
J9208
J9181
J9181
10019-0934-01
J9206
10019-0934-01 QR J9206
10019-0934-02
QR
J9206

CEFTRIAXONE 1 GM
CEFTRIAXONE 2 GM
CEFTRIAXONE (USP,PHARMACY BULK)
10 GM
CEFTAZIDIME (SDV) 1 GM
CEFTAZIDIME 2 GM
CEFTAZIDIME (SDV,BULK) 6 GM
CEFTAZIDIME 6 GM
ONDANSETRON (2MLX25,SDV,USP) 2
MG/ML
1
1
1
1
1
EA
EA
EA
EA
EA
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
250 MG
250 MG
250 MG
250 MG
250 MG
2
4
4
8
8
05/05/2007
07/05/2005
05/05/2007
07/05/2005
05/05/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1
1
1
1
1
1
1
EA
EA
EA
EA
EA
EA
EA
VL
VL
VL
VL
VL
VL
VL
IV
IJ
IJ
IV
IV
IV
IV
EA
EA
EA
EA
EA
EA
EA
250 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
40
2
2
4
4
12
12
10/05/2006
03/22/2007
05/05/2007
03/22/2007
05/05/2007
03/22/2007
05/05/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML VL
IJ
ML
1 MG
12/26/2006
99/99/9999
1 ML VL
IJ
ML
1 MG
05/05/2007
99/99/9999
ONDANSETRON (LATEX-FREE) 2 MG/ML

ONDANSETRON (MDV,USP,LATEXFREE) 2 MG/ML
12/26/2006
99/99/9999
5/5/2007
1/1/2002
1/1/2002
10/15/2004
10/15/2004
10/15/2004
10/15/2004
10/15/2004
10/15/2004
1/1/2002
1/1/2002
9/12/2005
5/5/2007
9/12/2005
5/5/2007
1/1/2002
9/1/2003
ONDANSETRON (LATEX-FREE) 2 MG/ML

CARBOPLATIN (S.D.V.,PF) 50 MG
DOXORUBICIN HCL (S.D.V.,PF) 10 MG
DOXORUBICIN HCL (SDV,PF) 50 MG
IFOSFAMIDE (SDV,30ML VIAL) 1 GM
IFOSFAMIDE (SDV,30ML) 1 GM
IFOSFAMIDE (SDV,75ML VIAL) 3 GM
IFOSFAMIDE (SDV,75ML) 3 GM

20 ML VL
1 ML
50 ML
100 ML
5 ML
15 ML
45 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
5 ML
25 ML
IJ
ML
1 MG
NA
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
1 MG
10 MG
10 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
10 MG
10 MG
1 GM
1 GM
1 GM
1 GM
10 MG
10 MG
2
0.1
0.1
0.2
0.2
0.2
1
3
9
1
5
1
1
3
3
2
2
05/05/2007 99/99/9999
01/01/2002 12/22/2005
01/01/2002
4/5/2006
10/15/2004 05/18/2006
10/15/2004 05/18/2006
10/15/2004
4/5/2006
10/15/2004 12/31/2006
10/15/2004
4/5/2006
10/15/2004 12/14/2006
06/10/2003
9/30/2007
06/10/2003
6/30/2008
09/12/2005 99/99/9999
05/05/2007 99/99/9999
09/12/2005 99/99/9999
05/05/2007 99/99/9999
01/01/2002 12/14/2006
09/01/2003 12/14/2006
(1X2ML,SDV,AMBER GLASS) 20 MG/ML
2 ML VL
IV
ML
20 MG
02/21/2008
99/99/9999
2 ML VL
IV
ML
20 MG
02/21/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/21/2008
99/99/9999
10019-0940-01
J9250
1/1/2002
5/27/2002 METHOTREXATE SODIUM, 5 MG
10019-0940-02
J9250
1/1/2002
10019-0941-01
10019-0953-01
10019-0953-02
10019-0953-62
J9250
J9209
J9209
J9209
1/1/2002 5/27/2002 METHOTREXATE SODIUM, 5 MG

10019-0955-01
J9090
4/30/2004 99/99/9999 CYCLOPHOSPHAMIDE, 500 MG
(1X2ML,SDV,INNER NDC) 20 MG/ML
METHOTREXATE SODIUM (S.D.V.,PF) 25
MG/ML
MG/ML
METHOTREXATE SODIUM (M.D.V.) 25
MG/ML
MESNA (S.D.V.) 100 MG/ML
MESNA (S.D.V.) 100 MG/ML
MESNA 100 MG/ML
CYCLOPHOSPHAMIDE (S.D.V.,PF) 500
MG
1 EA VL
IV
EA
500 MG
04/30/2004
99/99/9999
10019-0956-01
J9091
4/30/2004 99/99/9999 CYCLOPHOSPHAMIDE, 1.0 GRAM
CYCLOPHOSPHAMIDE (S.D.V.,PF) 1 GM
1 EA VL
IV
EA
1 GM
04/30/2004
99/99/9999
10019-0957-01
J9092
IV
EA
2 GM
04/30/2004
99/99/9999
J9092
CYCLOPHOSPHAMIDE (S.D.V.,PF) 2 GM
CYCLOPHOSPHAMIDE (SDV,USP,PF) 2
GM
1 EA VL
10019-0957-11
1 EA VL
IV
GM
2 GM
4/30/2004
99/99/9999
10019-0970-01
J9390
VINORELBINE TARTRATE (PF) 10 MG/ML
1 ML VL
IV
ML
10 MG
12/01/2003
12/14/2006
10019-0970-02
10106-0061-01
10106-0061-04
10106-0062-01
J9390
J9017
J9017
J9017
12/1/2003
1/1/2002
1/1/2002
1/1/2002
VINORELBINE TARTRATE (PF) 10 MG/ML

ARSENIC TRIOXIDE (A.C.S., REAGENT)
ARSENIC TRIOXIDE (A.C.S., REAGENT)
ARSENIC TRIOXIDE (REAGENT)
5
1
1
1
IV
NA
NA
NA
ML
GM
GM
GM
10 MG
1 MG
1 MG
1 MG
1
1000
1000
1000
12/01/2003
01/01/2002
01/01/2002
01/01/2002
12/14/2006
99/99/9999
99/99/9999
99/99/9999
10019-0934-02 QR J9206
10019-0934-17
10019-0934-17 QR J9206
10019-0934-79
QR
J9206
QR
J9206
10019-0934-79 QR J9206

QR

99/99/9999 INJECTION, ARSENIC TRIOXIDE, 1 MG
Page 139 of 374
5 ML VL
IV
ML
20 MG
02/21/2008
99/99/9999
2 ML VL
IV
ML
20 MG
02/21/2008
99/99/9999
2 ML VL
IV
ML
20 MG
02/21/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/21/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/21/2008
99/99/9999
2 ML VL
IJ
ML
5 MG
01/01/2002
05/27/2002
4 ML VL
IJ
ML
5 MG
01/01/2002
05/27/2002
IJ
IV
IV
IV
ML
ML
ML
ML
5 MG
200 MG
200 MG
200 MG
5
0.5
0.5
0.5
01/01/2002
03/15/2004
03/15/2004
05/05/2007
05/27/2002
99/99/9999
99/99/9999
99/99/9999
2 ML
10 ML
10 ML
1 ML
ML
EA
EA
EA
VL
VL
VL
VL
VL
NA
NA
BO
1/1/2002
1/1/2002
4/3/2002
8/19/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1
5
99/99/9999
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1 EA BO
NA
GM
2 MEQ
6.71141
01/01/2002
99/99/9999
1 EA BO
NA
GM
2 MEQ
6.71141
01/01/2002
99/99/9999
1 EA BO
NA
GM
2 MEQ
6.71141
01/01/2002
99/99/9999
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002

PYRIDOXINE HCL (U.S.P., F.C.C.)
PYRIDOXINE HCL (U.S.P., F.C.C.)
UREA (U.S.P.)
UREA (U.S.P.)
DIMETHYL SULFOXIDE (A.C.S.,
REAGENT)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
2 MEQ
1 EA
100 MG
40 GM
40 GM
150 MG
6.71141
1
10
0.025
0.025
6.66666
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
500 ML EA
NA
ML
50 %
0.02
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
10106-3046-01
10106-3046-05
J3480
J3480
10106-3052-01
J3480
10106-3052-05
10106-3343-01
10106-3343-01
10106-4206-01
10106-4206-05
10106-8994-01
J3480
J3490
J3415
J3350
J3350
J3520
10106-9224-01
J1212
10135-0149-01
Q0163
10135-0149-10
Q0163
10135-0149-24
Q0163
10135-0149-61
Q0163
10135-0151-10
Q0163
10135-0151-24
Q0163
10135-0151-50
Q0163
10135-0151-52
Q0163
10135-0151-57
Q0163
10135-0156-01
Q0163
10135-0156-10
Q0163
10135-0156-13
Q0163
10135-0166-13
Q0163


CF
HCPCS Amount #1
10 EA BO
PO
EA
50 MG
0.5
11/01/2002
99/99/9999
DIPHENHYDRAMINE HCL (CAPLET) 25

MG
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999

MG
1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999

MG
24 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999

MG
50 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
DIPHENHYDRAMINE HCL
(BOXED,CAPLET) 25 MG
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
DIPHENHYDRAMINE HCL
(BOXED,CAPLET) 25 MG
100 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
11/01/2002
99/99/9999
1000 EA BO
PO
EA
50 MG
11/01/2002
99/99/9999
100 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
DIPHENHYDRAMINE HCL (BLISTER

PACK,CAPLET) 25 MG
100 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
Page 140 of 374
01/01/2002
2
0.08
Prior End Date #3
500 MG
50 ML
Prior Start Date #3
500 MG
GM
GM

GM
NA
NA
J3475
J2150
Prior End Date #2
NA
1 EA BO
1 EA BO
J3475
10106-2506-05
10106-2555-05
Prior Start Date #2
1 EA BO
10106-2506-01
End Date #1
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Start Date #1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
ARSENIC TRIOXIDE (REAGENT)

BENZOCAINE (FINE, U.S.P.)
MAGNESIUM SULFATE ANHYDROUS
(REAGENT)
(REAGENT)
MANNITOL (U.S.P.)
HCPCS Measure #1
1000
1
200
200

Billing Units
NDC Package Type
1 MG
1 EA
5 MG
5 MG
1/1/2002
1/1/2002
1/1/2002
1/1/2002
Q0163
NDC Package Measure
GM
GM
GM
GM
J9017
J3490
J0706
J0706
NDC Label
NA
NA
NA
NA
HCPCS Description
BO
BO
BO
BO
1 EA
1 EA
1 EA
1 EA
10106-0062-04
10106-1080-01
10106-1649-01
10106-1649-04
10135-0151-01

Package
HCPCS Mod
HCPCS
NDC Mod
NDC
10139-0025-21
Q2009
8/8/2007
10139-0025-22
10139-0050-03
10139-0050-09
10139-0050-10
10139-0050-11
10139-0050-28
Q2009
J0282
J0282
J0282
J0282
J0282
8/8/2007
3/15/2005
3/15/2005
3/28/2005
3/28/2005
3/28/2005
10139-0057-10
10139-0057-20
J2260
J2260

10139-0060-05
J9045
5/31/2009 INJECTION, FOSPHENYTOIN, 50 MG

6/30/2009 INJECTION, FOSPHENYTOIN, 50 MG
10139-0060-15
J9045
10139-0060-45
J9045
10139-0061-01
J9178
11/30/2007
10139-0061-25
J9178
11/30/2007
10139-0062-02
J9250
10139-0062-10
J9250
J9250
10139-0062-40
10139-0063-01
J9190
10139-0063-01 QR J9190
10139-0063-11
10139-0063-12
QR
J9190
10139-0063-11 QR J9190

QR
J9190
10139-0063-12 QR J9190
10139-0063-50
J9190
10139-0063-50 QR J9190

QR
QR

10139-0070-11
J0295
10139-0071-10
10139-0075-01
10139-0075-02
10139-0075-05
J0295
J3490
J3490
J3490
7/3/2007
11/20/2006
11/20/2006
11/20/2006
10139-0075-10
J3490
10139-0075-12
10139-0075-15
10139-0230-10
J3490
J3490
J2360
10139-0501-12
J3370
10148-0101-00
J7699
10148-0101-00
Q4080
1.5
08/08/2007
5/31/2009
50 MG
30 MG
30 MG
30 MG
30 MG
30 MG
1.5
1.66666
1.66666
1.66666
1.66666
1.66666
08/08/2007
03/15/2005
03/15/2005
03/28/2005
03/28/2005
03/28/2005
6/30/2009
09/30/2006
03/31/2006
09/30/2006
03/31/2006
02/28/2006
20 ML VL
20 ML NA
IV
IV
ML
ML
5 MG
5 MG
0.2
0.2
04/15/2005
04/07/2005
12/31/2006
12/31/2006
5 ML VL
IV
ML
50 MG
0.2
07/09/2007
99/99/9999
15 ML VL
IV
ML
50 MG
0.2
07/09/2007
99/99/9999
45 ML VL
IV
ML
50 MG
0.2
07/09/2007
99/99/9999
100 ML VL
IV
ML
2 MG
11/30/2007
6/30/2009
25 ML VL
IV
ML
2 MG
11/30/2007
6/30/2009
2 ML VL
IJ
ML
5 MG
07/02/2007
99/99/9999
10 ML VL
IJ
ML
5 MG
06/07/2007
99/99/9999
40 ML VL
100 ML VL
100 ML VL
IJ
IV
IV
ML
ML
ML
5 MG
500 MG
500 MG
5
0.1
0.1
06/07/2007
07/02/2007
07/02/2007
99/99/9999
99/99/9999
99/99/9999
10 ML VL
IV
ML
500 MG
0.1
06/11/2007
99/99/9999
10 ML VL
IV
ML
500 MG
0.1
06/11/2007
99/99/9999
20 ML VL
IV
ML
500 MG
0.1
06/11/2007
99/99/9999
20 ML VL
50 ML VL
50 ML VL
IV
IV
IV
ML
ML
ML
500 MG
500 MG
500 MG
0.1
0.1
0.1
06/11/2007
06/07/2007
06/07/2007
99/99/9999
99/99/9999
99/99/9999
EA
1.5 GM
07/03/2007
99/99/9999
1.5 GM
1 EA
1 EA
1 EA
2
1
1
1
07/03/2007
11/20/2006
11/20/2006
11/20/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
SUFENTANIL CITRATE
(1MLX10,USP,SINGLE-DOSE) 50 MCG/ML
1 ML AM IJ
ML
1 EA
11/20/2006
99/99/9999
SUFENTANIL CITRATE
2 ML AM IJ
ML
1 EA
11/20/2006
99/99/9999
SUFENTANIL CITRATE
5 ML AM IJ
ML
1 EA
11/20/2006
99/99/9999
ORPHENADRINE CITRATE
(10X2ML,SINGLE DOSE,USP) 30 MG/ML
2 ML VL
ML
60 MG
0.5
01/05/2007
99/99/9999

2/1/2005
2/1/2005
7/1/2005

ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20
7/31/2008 MICROGRAMS
(USP,PF,LYOPHILIZED) (1GM = 1000 MG)
VENTAVIS (UNIT-DOSE VIAL,PF) 10
MCG/ML
VL
NA
NA
NA
EA
500 MG
08/19/2008
99/99/9999
2 ML GC IH
ML
1 EA
02/01/2005
06/30/2005

MCG/ML
2 ML GC IH
ML
20 MCG
0.5
07/01/2005
7/31/2008

MCG/ML
2 ML VL
IH
ML
20 MCG
0.5
07/01/2005
12/31/2009
2 ML VL
0.5
01/01/2010
99/99/9999
02/01/2005
06/30/2005
0.5
07/01/2005
7/31/2008

MCG/ML
MCG/ML
MCG/ML
Page 141 of 374
10 EA NA
IJ
NA
IH
ML
20 MCG
2 ML GC IH
ML
1 EA
2 ML GC IH
ML
20 MCG
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
50 MG
ML
ML
ML
ML
ML
ML
EA
ML
ML
ML
J7699
ML
IJ
IV
IV
IV
IV
IV
IJ
Q4074
Q4080
IJ
VL
NA
NA
VL
VL
VL
IJ
IJ
IJ
IJ
10148-0101-01
10148-0101-30
CARBOPLATIN
(MDV,PURPLESEAL,1X15ML) 10 MG/ML
CARBOPLATIN
(MDV,BLUESEAL,1X45ML) 10 MG/ML
EPIRUBICIN HYDROCHLORIDE (SINGLE
DOSE,1X100ML,PF) 2 MG/ML
DOSE,1X25ML,PF) 2 MG/ML
METHOTREXATE (USP,SDV,PF) 25
MG/ML
MG/ML
MG/ML
FLUOROURACIL (USP,BULK) 50 MG/ML
FLUOROURACIL (USP,BULK) 50 MG/ML
FLUOROURACIL (USP,SDV,10MLX10) 50
MG/ML
MG/ML
MG/ML
MG/ML
FLUOROURACIL (USP) 50 MG/ML
FLUOROURACIL (USP) 50 MG/ML
GM-0.5 GM
GM-1 GM
SUFENTANIL CITRATE (PF) 50 MCG/ML
2 ML VL
10 ML
3 ML
9 ML
3 ML
9 ML
18 ML
1 EA VL
10148-0101-30
Q4080

DOSE,2X10) 75 MG/ML
DOSE,10X10) 75 MG/ML
AMIODARONE HCL (10X3ML) 50 MG/ML
AMIODARONE HCL (10X9ML) 50 MG/ML
MILRINONE LACTATE (10X20ML) 1
MG/ML
MILRINONE LACTATE 1 MG/ML
CARBOPLATIN
(MDV,YELLOWSEAL,1X5ML) 10 MG/ML
1 EA
1 ML
2 ML
5 ML
99/99/9999 INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM


7/1/2005 7/31/2008 MICROGRAMS
7/1/2005 12/31/2009 MICROGRAMS
ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 20
1/1/2010 99/99/9999 MICROGRAMS
10148-0101-01
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
10148-0102-00
Q4080
12/8/2005
10148-0102-30
Q4080
12/8/2005
10158-0042-01
Q0163
1/1/2002
10158-0043-02
Q0163
1/1/2002
10158-0043-04
Q0163
1/1/2002
10158-0043-06
Q0163
1/1/2002
10158-0420-10
Q0163
1/1/2002
10158-0430-20
Q0163
1/1/2002
10158-0430-40
Q0163
1/1/2002
10158-0430-60
Q0163
1/1/2002
10267-0020-01
Q0173
1/1/2002
10267-0835-01
Q0163
1/1/2002
10267-0835-04
Q0163
1/1/2002
10267-0836-01
Q0163
1/1/2002
10267-0836-04
10454-0710-10
10454-0711-10
10454-0712-10
10518-0102-07
10518-0102-08
10518-0102-09
Q0163
J0587
J0587
J0587
J9265
J9265
J9265
1/1/2002
8/1/2005
8/1/2005
6/30/2006
4/19/2007
4/19/2007
4/19/2007
10518-0103-10
J9206
10518-0103-10 QR J9206
10518-0103-11
QR
J9206
10518-0103-11 QR J9206
QR
99/99/9999 INJECTION, RIMABOTULINUMTOXINB, 100 UNITS
2/27/2008
2/27/2008
2/27/2008
2/27/2008
10518-0104-10
J9178
8/24/2007
10518-0104-11
10544-0322-21
J9178
J7509
10544-0328-30
Q0177

VENTAVIS (PF) 10 MCG/ML
1 ML GC IH
ML
20 MCG
0.5
01/01/2008
1/14/2009
12/8/2005 12/31/2007
VENTAVIS (PF) 10 MCG/ML
1 ML GC IH
ML
20 MCG
0.5
01/01/2008
1/14/2009
12/8/2005 12/31/2007
NYTOL QUICKGELS MAXIMUM

STRENGTH (SOFTGEL) 50 MG
8 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
NYTOL QUICKCAPS 25 MG
16 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
32 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
72 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
8 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
16 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
32 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
72 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA NA
PO
EA
250 MG
01/01/2002
12/31/2002
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
PO
IM
IM
IM
IV
IV
IV
EA
ML
ML
ML
ML
ML
ML
50 MG
100 U
100 U
100 U
30 MG
30 MG
30 MG
1
50
50
50
0.2
0.2
0.2
01/01/2002
08/01/2005
08/01/2005
06/30/2006
04/19/2007
04/19/2007
04/19/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
7/5/2009
7/5/2009
7/5/2009
2 ML VL
IV
ML
20 MG
02/27/2008
3/11/2009
2 ML VL
IV
ML
20 MG
02/27/2008
3/11/2009
5 ML VL
IV
ML
20 MG
02/27/2008
6/1/2009
5 ML VL
IV
ML
20 MG
02/27/2008
6/1/2009
25 ML VL
IV
ML
2 MG
08/24/2007
8/20/2009
100 ML VL
21 EA BO
IV
PO
ML
EA
2 MG
4 MG
1
1
08/24/2007
01/11/2008
8/20/2009
99/99/9999
30 EA BO
PO
EA
25 MG
01/01/2008
99/99/9999
NYTOL QUICKGELS MAXIMUM

MYOBLOC (PF) 2500 U/0.5 ML
MYOBLOC (PF) 5000 U/ML
MYOBLOC 5000 U/ML
PACLITAXEL (USP,MDV) 6 MG/ML
IRINOTECAN HYDROCHLORIDE (1X2ML)
20 MG/ML
20 MG/ML
20 MG/ML
20 MG/ML
EPIRUBICIN HYDROCHLORIDE (SINGLEUSE,PF) 2 MG/ML
EPIRUBICIN HYDROCHLORIDE (SINGLEUSE,PF) 2 MG/ML
Page 142 of 374
1000 EA
0.5 ML
1 ML
2 ML
5 ML
16.7 ML
50 ML
BO
VL
VL
VL
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
10544-0343-20
Q0170
1/11/2008
10544-0343-30
Q0170
1/21/2008
10702-0002-01
Q0169
5/10/2007
10702-0003-01
Q0170
1/16/2007
10702-0003-10
Q0170
1/16/2007
10702-0004-01
10768-7085-01
Q0170
J7506
1/16/2007
5/12/2006
10768-7283-01
J7506
5/12/2006
10768-7283-02
10768-7283-03
10768-7283-04
J7506
J7506
J7506
5/12/2006
5/12/2006
5/12/2006
10768-7733-01
J7506
5/12/2006
10768-7733-02
10768-7733-03
10768-7733-04
J7506
J7506
J7506
5/12/2006
5/12/2006
5/12/2006
10892-0112-65
Q0163
1/1/2002
10956-0593-04
Q0163
1/1/2002
10956-0601-24
Q0163
1/1/2002
10956-0601-48
Q0163
1/1/2002
10956-0607-24
Q0163
1/1/2002
10956-0607-48
Q0163
1/1/2002
10956-0750-24
Q0163
11/2/2004
10956-0750-48
Q0163
11/2/2004
10956-0751-24
Q0163
11/2/2004
10956-0751-48
Q0163
11/2/2004
10960-0590-24
Q0163
1/1/2002

MG
(USP) 12.5 MG
(USP) 25 MG
(USP) 25 MG
(USP) 50 MG
PREDNISONE (USP) 20 MG
PREDNISONE (USP,BLISTER PACK) 10
MG
MG
MG
MG
DYTUSS 12.5 MG/5 ML
ALER-DRYL 12.5 MG/5 ML
SLEEP-ETTES D 50 MG
SLEEP-ETTES D 50 MG
ALER-DRYL 50 MG
ALER-DRYL 50 MG
SLEEP-ETTES D 50 MG
SLEEP-ETTES D 50 MG
ALER-DRYL 50 MG
ALER-DRYL 50 MG
ALLER-MED (CAPLET) 25 MG
Page 143 of 374
20 EA BO
PO
EA
25 MG
01/11/2008
10/1/2009
30 EA BO
PO
EA
25 MG
01/21/2008
99/99/9999
100 EA BO
PO
EA
12.5 MG
05/10/2007
99/99/9999
100 EA BO
PO
EA
25 MG
01/16/2007
99/99/9999
1000 EA BO
PO
EA
25 MG
01/16/2007
99/99/9999
100 EA BO
100 EA BO
PO
PO
EA
EA
25 MG
5 MG
2
4
01/16/2007
05/12/2006
99/99/9999
99/99/9999
21 EA DP
PO
EA
5 MG
05/12/2006
12/11/2007
48 EA DP
100 EA BO
1000 EA BO
PO
PO
PO
EA
EA
EA
5 MG
5 MG
5 MG
2
2
2
05/12/2006
05/12/2006
05/12/2006
12/11/2007
99/99/9999
99/99/9999
21 EA DP
PO
EA
5 MG
05/12/2006
12/11/2007
48 EA DP
100 EA BO
1000 EA BO
PO
PO
PO
EA
EA
EA
5 MG
5 MG
5 MG
1
1
1
05/12/2006
05/12/2006
05/12/2006
12/11/2007
99/99/9999
99/99/9999
480 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
03/31/2002
24 EA BX
PO
EA
50 MG
01/01/2002
11/01/2004
48 EA BO
PO
EA
50 MG
01/01/2002
11/01/2004
24 EA BX
PO
EA
50 MG
01/01/2002
11/01/2004
48 EA BO
PO
EA
50 MG
01/01/2002
11/01/2004
24 EA NA
PO
EA
50 MG
11/02/2004
99/99/9999
48 EA BO
PO
EA
50 MG
11/02/2004
99/99/9999
24 EA BX
PO
EA
50 MG
11/02/2004
99/99/9999
48 EA BO
PO
EA
50 MG
11/02/2004
99/99/9999
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
05/20/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

99/99/9999 INJECTION, DIMERCAPROL, PER 100 MG
99/99/9999 INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG
11743-0210-02
J1644
11743-0250-01
J2720
1/1/2002
11822-0527-10
Q0163
5/2/2006
11845-0896-01
Q0163
1/1/2002
11845-0896-07
Q0163
1/1/2002
11926-0616-16
Q0163
1/1/2002
11926-0616-32
Q0163
1/1/2002
11926-0621-08
11994-0005-05
11994-0011-04
12120-5025-03
Q0163
J1245
J3490
J2675
1/1/2002
1/1/2002
1/1/2002
1/1/2002
12120-5026-03
12280-0057-30
J2675
Q0144
12280-0068-24
Q0163
12280-0068-30
Q0163
12280-0072-15
12280-0073-10
12280-0092-15
J2941
J0696
J2941
12280-0094-30
J7644
12280-0094-30 KO J7644
12280-0109-30
Q0144
12280-0139-30
J7500
12280-0185-00
Q0163
12280-0205-04
12280-0227-10
12280-0229-01
12280-0230-01
12280-0232-01
Q0177
J1200
J2800
J2001
J2930
5/2/2005 INJECTION, PROTAMINE SULFATE, PER 10 MG


7/12/2005
3/21/2005
KO
INAPSINE (AMP) 2.5 MG/ML

INAPSINE (AMP) 2.5 MG/ML
SUBLIMAZE (AMP) 0.05 MG/ML
SUFENTA (AMP) 50 MCG/ML
BAL IN OIL (AMP) 10%
MYOCHRYSINE (VIAL) 50 MG/ML
MYOCHRYSINE (VIAL) 50 MG/ML
MIO-REL (AMP) 30 MG/ML
MIO-REL (AMP) 30 MG/ML
NEUROFORTE-R (VIAL) 1000 MCG/ML
HEPARIN SODIUM (HEMOCHRON
RXDX,VIAL) 1000 U/ML
PROTAMINE SULFATE (HEMOCHRON
RXDX,M.D.V.) 10 MG/ML
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IM
IM
IM
IJ
IJ
IM
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
5 MG
5 MG
0.1 MG
0.1 MG
0.1 MG
0.1 MG
1 EA
1 EA
1 EA
100 MG
50 MG
50 MG
60 MG
60 MG
1000 MCG
10 ML VL
IJ
ML
1000 U
25 ML VL
IV
ML
10 MG
RITE AID ALLERGY (AF,SF,DYE-FREE)

12.5 MG/5 ML
118 ML NA
PO
ML
ALLERGY RELIEF MEDICINE 25 MG
100 EA BO
PO
ALLERGY RELIEF MEDICINE

(COMPLETE) 25 MG
24 EA BO
SLEEPINAL 50 MG
0.5
0.5
0.5
0.5
0.5
0.5
1
1
1
1
1
1
0.5
0.5
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/21/2002
06/21/2002
01/01/2002
01/01/2002
01/01/2002
6/3/2009
6/3/2009
99/99/9999
99/99/9999
03/15/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2002
99/99/9999
01/01/2002
05/02/2005
50 MG
0.05
05/02/2006
99/99/9999
EA
50 MG
0.5
01/01/2002
99/99/9999
PO
EA
50 MG
0.5
01/01/2002
09/24/2004
16 EA NA
PO
EA
50 MG
01/01/2002
12/03/2002
SLEEPINAL 50 MG
32 EA NA
PO
EA
50 MG
01/01/2002
12/03/2002
SLEEPINAL (SOFTGEL) 50 MG
IV PERSANTINE (VIAL) 5 MG/ML
DEFINITY (VIAL,GLASS)
PROGESTERONE (MICRONIZED)
PROGESTERONE
(WETTABLE,MICRONIZED)
ZITHROMAX 600 MG
8 EA
10 ML
2 ML
1 EA
BX
VL
VL
BO
PO
IV
IV
NA
EA
ML
ML
GM
50 MG
10 MG
1 EA
50 MG
1
0.5
1
20
01/01/2002
01/01/2002
01/01/2002
01/01/2002
07/15/2002
10/06/2003
99/99/9999
11/12/2002
1 EA NA
30 EA BO
NA
PO
GM
EA
50 MG
1 GM
20
0.6
01/01/2002
03/21/2005
11/12/2002
99/99/9999
BENADRYL (DYE-FREE,SOFTGEL) 25
MG
24 EA BO
PO
EA
50 MG
0.5
07/12/2005
4/1/2009
BENADRYL 25 MG
3/21/2005
NORDITROPIN NORDIFLEX 5 MG/1.5 ML
ROCEPHIN (10 VIALS X 6ML) 500 MG
3/23/2005
NORDITROPIN 5 MG/1.5 ML
3/30/2005
4/1/2009 MILLIGRAM
3/30/2005
4/1/2009 MILLIGRAM
4/21/2005
AZATHIOPRINE 50 MG
6/22/2005
VISTARIL 25 MG/5 ML
8/8/2005
BENADRYL 50 MG/ML
ROBAXIN 100 MG/ML
8/16/2005
SOLU-MEDROL 125 MG
Page 144 of 374
30 EA BO
PO
EA
50 MG
0.5
03/21/2005
4/1/2009
1.5 ML SR
1 EA VL
1.5 ML CT
SC
IJ
SC
ML
EA
ML
1 MG
250 MG
1 MG
3.33333
2
3.33333
03/21/2005
03/21/2005
03/23/2005
4/1/2009
99/99/9999
4/1/2009
2.5 ML PC
IH
ML
1 MG
0.2
03/30/2005
4/1/2009
2.5 ML PC
30 ML BO
30 EA BO
IH
PO
PO
ML
ML
EA
1 MG
1 GM
50 MG
0.2
0.04
1
03/30/2005
03/24/2005
04/21/2005
4/1/2009
99/99/9999
4/1/2009
100 EA BO
PO
EA
50 MG
06/22/2005
4/1/2009
120 ML
10 ML
10 ML
50 ML
1 EA
PO
IJ
IJ
IJ
IJ
ML
ML
ML
ML
EA
25 MG
50 MG
10 ML
10 MG
125 MG
0.2
1
0.1
2
1
06/29/2005
08/08/2005
08/16/2005
08/16/2005
08/18/2005
99/99/9999
4/1/2009
99/99/9999
4/1/2009
99/99/9999
BO
VL
VL
NA
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
VL
VL
AM
AM
VL
Billing Units
1 ML
2 ML
2 ML
5 ML
10 ML
20 ML
1 ML
2 ML
5 ML
3 ML
1 ML
10 ML
2 ML
2 ML
10 ML

Package
NDC Label
HCPCS Description

1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
6/21/2002
6/21/2002
1/1/2002
1/1/2002
1/1/2002
NDC Package Type
J1790
J1790
J3010
J3010
J3010
J3010
J3490
J3490
J3490
J0470
J1600
J1600
J2360
J2360
J3420
NDC Package Measure
11098-0010-01
11098-0010-02
11098-0030-02
11098-0030-05
11098-0030-10
11098-0030-20
11098-0050-01
11098-0050-02
11098-0050-05
11098-0526-03
11098-0533-01
11098-0533-10
11584-1016-02
11584-1016-05
11584-1025-01
HCPCS Mod
HCPCS
NDC Mod
NDC
12280-0233-01
A4216
12280-0241-25
J7603
12280-0241-25 KO J7603
12280-0241-25
KO
J7613
12280-0241-25 KO J7613
12280-0256-01
J1030
12280-0256-05
J1030
12280-0268-06
Q0144
12280-0269-03
Q0144
12280-0276-30
Q0175
12280-0276-60
Q0175
12280-0276-90
Q0175
12280-0277-30
Q0176
12280-0277-60
Q0176
12280-0277-90
12280-0346-30
Q0176
J8999
12280-0456-10
12496-0757-01
12496-0757-01
J1885
J3490
J0592
12547-0170-21
Q0163
12547-0170-31
Q0163
12547-0170-33
Q0163
12547-0170-55
Q0163
12547-0171-36
Q0163
12547-0171-37
Q0163
12547-0172-38
Q0163
12547-1702-10
Q0163
KO

1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON4/1/2008
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON4/1/2008
5/19/2006
12/14/2005
3/8/2006
3/8/2006
3/21/2006 99/99/9999 REGIMEN
3/21/2006 99/99/9999 REGIMEN
3/21/2006 99/99/9999 REGIMEN
3/21/2006 99/99/9999 REGIMEN
3/21/2006 99/99/9999 REGIMEN
3/21/2006 99/99/9999 REGIMEN
1/9/2008
10/4/2005
WATER FOR INJECTION

BACTERIOSTATIC (LATEX-FREE)
30 ML VL
IV
ML
10 ML
0.1
08/18/2005
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
4/1/2009

DEPO-MEDROL 40 MG/ML
AZITHROMYCIN (1X6) 250 MG
AZITHROMYCIN (1X3) 500 MG
3 ML
1 ML
5 ML
6 EA
3 EA
PC
VL
VL
DP
DP
IH
IJ
IJ
PO
PO
ML
ML
ML
EA
EA
1 MG
40 MG
40 MG
1 GM
1 GM
0.83
1
1
0.25
0.5
04/01/2008
05/19/2006
12/14/2005
03/08/2006
03/08/2006
4/1/2009
4/1/2009
4/1/2009
4/1/2009
4/1/2009
PERPHENAZINE 4 MG
30 EA BO
PO
EA
4 MG
03/21/2006
99/99/9999
PERPHENAZINE 4 MG
60 EA BO
PO
EA
4 MG
03/21/2006
99/99/9999
PERPHENAZINE 4 MG
90 EA BO
PO
EA
4 MG
03/21/2006
99/99/9999
PERPHENAZINE 8 MG
30 EA BO
PO
EA
8 MG
03/21/2006
99/99/9999
PERPHENAZINE 8 MG
60 EA BO
PO
EA
8 MG
03/21/2006
99/99/9999
PERPHENAZINE 8 MG
ARIMIDEX 1 MG
90 EA BO
30 EA BO
PO
PO
EA
EA
8 MG
1 EA
1
1
03/21/2006
01/09/2008
99/99/9999
4/1/2009
ML
ML
ML
15 MG
1 EA
0.1 MG
2
1
3.24
10/04/2005
01/01/2002
01/01/2003
08/01/2007
12/31/2002
99/99/9999

BUPRENEX (AMP) 0.3 MG/ML
2 ML NA IM
1 ML AM IJ
1 ML AM IJ
MG
24 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
BENADRYL (ULTRATAB) 25 MG
24 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999

MG/5 ML
240 ML NA
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
48 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
118 ML NA
PO
ML
50 MG
0.05
11/17/2003
99/99/9999
BENADRYL ALLERGY 12.5 MG
24 EA NA
PO
EA
50 MG
0.25
01/01/2002
99/99/9999
MG
24 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
BENADRYL ALLERGY
Page 145 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
12547-1703-10
Q0163
1/1/2002
12547-1703-30
Q0163
1/1/2002
12547-1705-50
Q0163
1/1/2002
12547-1713-60
Q0163
1/1/2002
12547-1713-70
Q0163
11/17/2003
12547-1723-80
Q0163
1/1/2002
12810-0379-26
13411-0131-01
13411-0131-03
13411-0131-06
13411-0131-09
13411-0131-15
13411-0182-01
13411-0182-03
13411-0182-06
13411-0182-09
13411-0182-10
13411-0183-01
13411-0183-03
13411-0183-06
13411-0183-09
13411-0183-10
13436-0700-01
13436-0700-02
Q0163
Q0144
Q0144
Q0144
Q0144
Q0144
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J0170
J0170
1/1/2002
8/23/2006
6/1/2005
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/23/2006
8/3/2005
8/3/2005

24 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999

MG/5 ML
240 ML EA
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
48 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
118 ML BO
PO
ML
50 MG
0.05
11/17/2003
99/99/9999
24 EA NA
PO
EA
50 MG
0.25
01/01/2002
99/99/9999
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
IJ
IJ
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
1 GM
1 GM
1 GM
1 GM
1 GM
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 ML
1 ML
0.05
0.25
0.25
0.25
0.25
0.25
1
1
1
1
1
1
1
1
1
1
1
1
01/01/2002
08/23/2006
06/01/2005
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/23/2006
08/03/2005
08/03/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
BENADRYL ALLERGY
BENADRYL ALLERGY 12.5 MG
ANTIHISTAMINE 12.5 MG/5 ML

ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
TWINJECT (0.3MG DELIVERY) 1 MG/ML
120 ML
10 EA
30 EA
60 EA
90 EA
15 EA
10 EA
30 EA
60 EA
90 EA
100 EA
10 EA
30 EA
60 EA
90 EA
100 EA
0.3 ML
0.3 ML
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
SR
SR
13436-0701-01
J0170
0.15 ML SR
IJ
EA
1 ML
08/03/2005
13436-0701-02
J0170
0.15 ML SR
IJ
EA
1 ML
08/03/2005
99/99/9999
13533-0601-30
J0256
500 MG VL
IV
EA
10 MG
0.1
10/20/2005
99/99/9999
13533-0601-35
J0256
0.1
10/20/2005
99/99/9999
13533-0603-20
J7197
10/14/2006
99/99/9999
13533-0603-30
J7197
99/99/9999
13533-0631-02
J2792
13533-0631-06
13533-0634-02
J2792
J1670

12/21/2005 99/99/9999 DETERGENT, 100 IU
12/21/2005 99/99/9999 DETERGENT, 100 IU
10/14/2006 99/99/9999 INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS

PROLASTIN (W/20ML DILUENT,PF) 500
MG
PROLASTIN (W/40ML DILUENT,PF) 1000
MG
THROMBATE III
(W/DILUENT,~500IU/VIAL) 1 IU
THROMBATE III
(W/DILUENT,~1000IU/VIAL) 1 IU
13533-0635-03
13533-0635-04
13533-0635-12
13533-0636-01
13533-0636-02
J1460
J1460
J1460
J3590
J3590
1/17/2008
10/4/2005
10/4/2005
10/14/2006
1/18/2006
13533-0636-03
13533-0636-05
J3590
J3590
13533-0645-12
Q4092
13533-0645-12
J1561
13533-0645-15
Q4092
13533-0645-15
J1561
13533-0645-20
Q4092


INJECTION, IMMUNE GLOBULIN (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
INJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1000 MG VL
IV
EA
10 MG
500 IU
VL
IV
EA
1 IU
1000 IU
VL
IV
EA
1 IU
10/14/2006
1 ML SR
IM
ML
100 IU
15
12/21/2005
99/99/9999
0.17 ML SR
1 ML SR
IM
IM
ML
ML
100 IU
250 U
12.5
1
12/21/2005
10/14/2006
99/99/9999
99/99/9999
SR
VL
VL
VL
SR
IM
IM
IM
IM
IM
ML
ML
ML
ML
ML
1 ML
1 ML
1 ML
1 EA
1 EA
1
1
1
1
1
01/17/2008
10/04/2005
10/04/2005
10/14/2006
01/18/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
0.5 ML SR
5 ML VL
IM
IM
ML
ML
1 EA
1 EA
1
1
01/18/2006
01/18/2006
99/99/9999
99/99/9999
10 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
10 ML VL
IV
ML
500 MG
0.2
01/01/2008
99/99/9999
25 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
25 ML VL
IV
ML
500 MG
0.2
01/01/2008
99/99/9999
50 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
HYPERRHO S/D (FULL DOSE,PF)

HYPERRHO S/D (MINI-DOSE)
HYPERTET S/D (PF) 250 U
GAMASTAN S/D (1X2ML,PF,LATEXFREE)
GAMASTAN S/D (S.D.V.,PF)
GAMASTAN S/D (S.D.V.,PF)
HYPERHEP B S/D (PF)
HYPERHEP B S/D (SINGLE DOSE,PF)
HYPERHEP B S/D (NEONATAL SINGLE
DOSE,PF)
HYPERHEP B S/D (SDV,PF)
Page 146 of 374
2 ML
2 ML
10 ML
1 ML
1 ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
13533-0645-20
J1561
13533-0645-24
Q4092
13533-0645-24
J1561
13533-0645-71
Q4092
13533-0645-71
13533-0665-20
13533-0665-30
13533-0665-50
13632-0123-01
15054-1040-05
15054-1040-05
15210-0061-12
15210-0063-12
15210-0066-12
15210-0067-12
J1561
J7190
J7190
J7190
J8999
J3490
J2170
J9045
J9045
J9045
J9045

1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
7/10/2006
1/1/2007 99/99/9999 INJECTION, MECASERMIN, 1 MG

KOATE-DVI (250IU) 1 IU
SOLTAMOX (SF,LICORICE) 10 MG/5 ML
INCRELEX (10X4ML,M.D.V.) 10 MG/ML
INCRELEX (10X4ML,M.D.V.) 10 MG/ML
CARBOPLATIN (MDV) 10 MG/ML
50 ML VL
IV
ML
500 MG
0.2
01/01/2008
99/99/9999
200 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
200 ML VL
IV
ML
500 MG
0.2
01/01/2008
99/99/9999
100 ML VL
IV
ML
500 MG
0.2
07/01/2007
12/31/2007
IV
IV
IV
IV
PO
SC
SC
IV
IV
IV
IV
ML
EA
EA
EA
ML
ML
ML
ML
ML
ML
ML
500 MG
1 IU
1 IU
1 IU
1 EA
1 EA
1 MG
50 MG
50 MG
50 MG
50 MG
0.2
1
1
1
1
1
10
0.2
0.2
0.2
0.2
01/01/2008
11/01/2007
11/01/2007
11/01/2007
07/10/2006
11/01/2005
01/01/2007
01/15/2007
01/15/2007
01/15/2007
01/15/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1/1/2008
12/31/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 ML
250 IU
500 IU
1000 IU
120 ML
4 ML
4 ML
5 ML
15 ML
45 ML
60 ML
VL
VL
VL
VL
BO
VL
VL
VL
VL
VL
VL
15210-0401-11
J2430
OTN PAMIDRONATE DISODIUM 3 MG/ML
10 ML VL
IV
ML
30 MG
0.1
07/12/2006
99/99/9999
15210-0402-11
J2430
OTN PAMIDRONATE DISODIUM 9 MG/ML
10 ML VL
IV
ML
30 MG
0.3
07/12/2006
99/99/9999
8/14/2006 99/99/9999 INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG
OTN MITOXANTRONE
(USP,MDV,PF,CONCENTRATE) 2 MG/ML
10 ML VL
IV
ML
5 MG
0.4
08/14/2006
99/99/9999
OTN MITOXANTRONE
(MDV,USP,PF,CONCENTRATE) 2 MG/ML
12.5 ML NA
IV
ML
5 MG
0.4
07/31/2006
99/99/9999
15210-0403-35
15210-0403-36
J9293
J9293
OTN MITOXANTRONE
(USP,MDV,PF,CONCENTRATE) 2 MG/ML
SODIUM CHLORIDE
(USP,100X3ML,LATEX-FREE) 0.9%
SODIUM CHLORIDE
(USP,100X5ML,LATEX-FREE) 0.9%
EPINEPHRINE (BASE)
15210-0403-37
J9293
15686-0111-03
A4216
4/2/2007
15686-0111-05
15927-3220-00
A4216
J7799
16252-0097-22
J7603

ALBUTEROL SULFATE (25X3ML,LDPE)
0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONALBUTEROL SULFATE (25X3ML,LDPE)
4/1/2008 99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG
0.083%
0.083%
0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
0.083%
0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
0.083%
0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
0.083%
0.083%
IPRATROPIUM BROMIDE
(25X2.5ML,LDPE) 0.02%
4/1/2006 99/99/9999 MILLIGRAM
IPRATROPIUM BROMIDE
(25X2.5ML,LDPE) 0.02%
4/1/2006 99/99/9999 MILLIGRAM
16252-0097-22 KO J7603
16252-0097-22
KO
J7613
16252-0097-66 KO J7613
16252-0098-22
KO
J7603
16252-0097-66 KO J7603
16252-0097-66
KO
J7613
16252-0097-33 KO J7613
16252-0097-66
KO
J7603
16252-0097-33 KO J7603
16252-0097-33
KO
J7613
16252-0097-22 KO J7613
16252-0097-33
KO
J7644
16252-0098-22 KO J7644
KO
Page 147 of 374
15 ML VL
IV
ML
5 MG
0.4
08/14/2006
99/99/9999
3 ML PC
IH
ML
10 ML
0.1
04/02/2007
7/10/2008
5 ML PC
1 EA BO
IH
NA
ML
GM
10 ML
1 EA
0.1
1
04/02/2007
09/08/2003
7/10/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/01/2006
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/01/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
16252-0098-33
J7644
16252-0098-33 KO J7644
16252-0098-66
KO
J7644
16252-0098-66 KO J7644
16252-0536-08
J8515
16252-0547-33
J7620
16252-0547-66
J7620
16477-0510-08
J8499
16500-0102-00
Q0163
16500-0102-20
16590-0003-30
16590-0003-60
Q0163
J8499
J8499
16590-0078-20
Q0163
16590-0079-20
16590-0149-21
Q0163
J7509
16590-0191-10
Q0170
16590-0191-15
Q0170
16590-0191-20
Q0170
16590-0191-30
Q0170
16590-0191-60
Q0170
16590-0191-90
16590-0193-12
16590-0194-12
Q0170
J8498
J8498
16590-0240-10
Q0173
16590-0240-20
16590-0248-06
16590-0326-10
16590-0326-20
16590-0326-21
16590-0326-30
16590-0326-45
16590-0326-60
Q0173
Q0144
J7506
J7506
J7506
J7506
J7506
J7506
KO

IPRATROPIUM BROMIDE
(30X2.5ML,LDPE) 0.02%
4/1/2006 99/99/9999 MILLIGRAM
IPRATROPIUM BROMIDE
(30X2.5ML,LDPE) 0.02%
4/1/2006 99/99/9999 MILLIGRAM
IPRATROPIUM BROMIDE
(60X2.5ML,LDPE) 0.02%
4/1/2006 99/99/9999 MILLIGRAM
IPRATROPIUM BROMIDE
(60X2.5ML,LDPE) 0.02%
4/1/2006 99/99/9999 MILLIGRAM
5/1/2008 99/99/9999 CABERGOLINE, ORAL, 0.25 MG
CABERGOLINE 0.5 MG
IPRATROPIUM BROMIDE/ALBUTEROL
SULFATE (30X3ML) 3 MG/3 ML-0.5 MG/3
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA12/31/2007 99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME ML
IPRATROPIUM BROMIDE/ALBUTEROL
SULFATE (60X3ML) 3 MG/3 ML-0.5 MG/3
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA12/31/2007 99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME ML
MILLIPRED (1X237ML,AF,DYE-FREE) 10
MG/5 ML
MILES NERVINE 25 MG
1/1/2002
MILES NERVINE 25 MG
1/1/2002
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
DIPHENHYDRAMINE 25 MG
METHYLPRED-DP 4 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 12.5 MG
PROMETHAZINE 25 MG
TRIMETHOBENZAMIDE 250 MG
ZITHROMAX Z-PAK 250 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
Page 148 of 374
2.5 ML PC
IH
ML
1 MG
0.2
04/01/2006
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/01/2006
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/01/2006
99/99/9999
2.5 ML PC
8 EA BO
IH
PO
ML
EA
1 MG
0.25 MG
0.2
2
04/01/2006
05/01/2008
99/99/9999
99/99/9999
3 ML VL
IH
ML
2.5 MG
0.33333
12/31/2007
99/99/9999
3 ML VL
IH
ML
2.5 MG
0.33333
12/31/2007
99/99/9999
237 ML BO
PO
ML
1 EA
04/30/2008
99/99/9999
30 EA NA
PO
EA
50 MG
0.5
01/01/2002
01/01/2002
12 EA NA
30 EA BO
60 EA BO
PO
PO
PO
EA
EA
EA
50 MG
1 EA
1 EA
0.5
1
1
01/01/2002
02/01/2006
02/01/2006
01/01/2002
99/99/9999
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
02/01/2006
99/99/9999
20 EA BO
21 EA DP
PO
PO
EA
EA
50 MG
4 MG
1
1
02/01/2006
01/01/2006
99/99/9999
99/99/9999
10 EA BO
PO
EA
25 MG
04/01/2007
99/99/9999
15 EA BO
PO
EA
25 MG
02/01/2006
99/99/9999
20 EA BO
PO
EA
25 MG
06/01/2006
99/99/9999
30 EA BO
PO
EA
25 MG
02/01/2006
99/99/9999
60 EA BO
PO
EA
25 MG
02/01/2006
99/99/9999
90 EA BO
12 EA BX
12 EA BX
PO
RC
RC
EA
EA
EA
25 MG
1 EA
1 EA
1
1
1
02/01/2006
02/01/2006
02/01/2006
99/99/9999
99/99/9999
99/99/9999
10 EA NA
PO
EA
250 MG
02/01/2006
99/99/9999
20 EA
6 EA
10 EA
20 EA
21 EA
30 EA
45 EA
60 EA
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
250 MG
1 GM
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
0.25
4
4
4
4
4
4
02/01/2006
02/01/2006
06/01/2006
06/01/2006
06/01/2006
06/01/2006
06/01/2006
11/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
NA
DP
BO
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
16590-0327-10
Q0165
4/1/2007
16590-0357-09
Q0177
5/1/2006
16590-0357-12
Q0177
5/1/2006
16590-0357-20
Q0177
5/1/2006
16590-0357-30
16590-0362-06
16590-0370-20
16590-0370-30
16590-0370-40
16590-0404-10
16590-0404-20
16590-0404-21
16590-0404-30
16590-0404-45
Q0177
Q0144
J8499
J8499
J8499
J7506
J7506
J7506
J7506
J7506
5/1/2006
12/1/2006
6/1/2006
6/1/2006
6/1/2006
6/1/2006
6/1/2006
6/1/2006
6/1/2006
6/1/2006
16714-0221-30
Q0166
5/15/2008
16714-0221-32
16887-0211-01
16887-0211-01
16887-0211-05
16887-0211-05
17236-0495-01
Q0166
J3490
J0364
J3490
J0364
J8999
5/15/2008
12/15/2006
1/1/2007
12/15/2006
1/1/2007
10/1/2002
17236-0516-01
Q0163
1/1/2002
17236-0516-10
Q0163
1/1/2002
17236-0518-01
Q0163
1/1/2002
17236-0518-10
17236-0697-01
17236-0854-01
17236-0855-01
Q0163
J8999
J8499
J8499
1/1/2002
10/1/2002
1/1/2002
1/1/2002
17236-0905-01
Q0163
10/1/2002
17236-0905-10
17314-7253-03
Q0163
J0207
10/1/2002
1/1/2002
17314-9600-01
J9001
1/1/2002
17314-9600-02
17317-0022-01
17317-0022-04
17317-0022-05
J9001
J0280
J0280
J0280
1/1/2002
1/1/2002
1/1/2002
1/1/2002
17317-0036-02
J7636
17317-0036-02 KO J7636
1/1/2002
KO
1/1/2002

10 EA BO
9 EA BO
12 EA BO
20 EA BO
30 EA BO
AZITHROMYCIN 250 MG
6 EA DP
ACYCLOVIR 400 MG
20 EA BO
ACYCLOVIR 400 MG
30 EA BO
ACYCLOVIR 400 MG
40 EA BO
PREDNISONE 10 MG
10 EA BO
PREDNISONE 10 MG
20 EA BO
PREDNISONE 10 MG
21 EA BO
PREDNISONE 10 MG
30 EA BO
PREDNISONE 10 MG
45 EA BO
2 EA BX
20 EA BX
APOKYN 10 MG/ML
3 ML CT
6/23/2009 INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG
APOKYN 10 MG/ML
3 ML CT
APOKYN (5X3ML) 10 MG/ML
3 ML CT
APOKYN (5X3ML) 10 MG/ML
3 ML CT
100 EA BO
100 EA BO
1000 EA BO
100 EA BO
1000 EA BO
100 EA BO
ACYCLOVIR 400 MG
100 EA BO
ACYCLOVIR 800 MG
100 EA NA
DIPHENHYDRAMINE HCL
(CAPLET,CAPLET) 25 MG
100 EA BO
DIPHENHYDRAMINE HCL
(CAPLET,CAPLET) 25 MG
1000 EA BO
1/2/2002 INJECTION, AMIFOSTINE, 500 MG
ETHYOL (S.D.V.) 500 MG
1 EA VL
DOXIL (S.D.V.,STEALTH LIPOSOME) 2
99/99/9999 INJECTION, DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MG
MG/ML
10 ML VL
DOXIL (S.D.V.,STEALTH LIPOSOME) 2
99/99/9999 INJECTION, DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MG
MG/ML
25 ML VL
AMINOPHYLLINE ANHYDROUS (U.S.P.)
1 EA VL
1 EA VL
1 EA VL
1 EA VL
1 EA VL
Page 149 of 374
PO
EA
10 MG
04/01/2007
99/99/9999
PO
EA
25 MG
05/01/2006
99/99/9999
PO
EA
25 MG
05/01/2006
99/99/9999
PO
EA
25 MG
05/01/2006
99/99/9999
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
25 MG
1 GM
1 EA
1 EA
1 EA
5 MG
5 MG
5 MG
5 MG
5 MG
1
0.25
1
1
1
2
2
2
2
2
05/01/2006
12/01/2006
06/01/2006
06/01/2006
06/01/2006
06/01/2006
06/01/2006
06/01/2006
06/01/2006
06/01/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
PO
EA
1 MG
05/15/2008
99/99/9999
PO
SC
SC
SC
SC
PO
EA
ML
ML
ML
ML
EA
1 MG
1 EA
1 MG
1 EA
1 MG
1 EA
1
1
10
1
10
1
05/15/2008
12/15/2006
01/01/2007
12/15/2006
01/01/2007
10/01/2002
99/99/9999
12/31/2006
6/23/2009
12/31/2006
6/23/2009
04/01/2003
PO
EA
50 MG
0.5
01/01/2002
01/01/2005
PO
EA
50 MG
0.5
01/01/2002
01/01/2005
PO
EA
50 MG
01/01/2002
01/01/2005
PO
PO
PO
PO
EA
EA
EA
EA
50 MG
1 EA
1 EA
1 EA
1
1
1
1
01/01/2002
10/01/2002
01/01/2002
01/01/2002
01/01/2005
04/01/2003
08/31/2004
04/01/2003
PO
EA
50 MG
0.5
10/01/2002
01/01/2005
PO
IV
EA
EA
50 MG
500 MG
0.5
1
10/01/2002
01/01/2002
01/01/2005
01/02/2002
IV
ML
10 MG
0.2
01/01/2002
99/99/9999
IV
NA
NA
NA
ML
GM
GM
GM
10 MG
250 MG
250 MG
250 MG
0.2
4
4
4
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
NA
GM
1 MG
1000
01/01/2002
99/99/9999
NA
GM
1 MG
1000
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
17317-0036-05
J7636
17317-0036-05 KO J7636
17317-0036-07
KO
J7636
17317-0036-07 KO J7636
17317-0049-01
J3490
17317-0049-04
J3490
17317-0049-05
J3490
17317-0073-01
J0706
17317-0073-04
J0706
17317-0073-05
J0706
17317-0073-08
J0706
17317-0146-03
J1200
17317-0146-05
J1200
17317-0146-06
J1200
1 EA VL
NA
GM
1 MG
1000
01/01/2002
1 EA VL
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA VL
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
NA
NA
NA
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
1 EA
1 EA
1 EA
5 MG
5 MG
5 MG
5 MG
50 MG
50 MG
50 MG
1000
1
1
1
200
200
200
200
20
20
20
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA NA
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
25 MG
500 MG
40
2
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
500 MG
500 MG
2
2
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1 EA FC
NA
GM
500 MG
01/01/2002
99/99/9999
1 EA FC
NA
GM
500 MG
01/01/2002
99/99/9999
1 EA FC
NA
GM
500 MG
01/01/2002
99/99/9999
J1700
17317-0199-02
J1700
17317-0199-03
J1700
17317-0199-08
17317-0345-01
J1700
J3475

17317-0345-05
17317-0345-08
J3475
J3475

17317-0346-01
J3475
17317-0346-05
J3475
17317-0346-08
J3475
17317-0398-01
J2440
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
99/99/9999
17317-0398-04
17317-0413-01
17317-0417-02
17317-0417-03
17317-0417-05
J2440
J2560
J7799
J7799
J7799
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002


SODIUM PHENOBARBITAL (U.S.P.)
PHENYLEPHRINE HCL (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
60 MG
120 MG
1 EA
1 EA
1 EA
16.66666
8.33333
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
17317-0438-01
17317-0438-05
17317-0438-08
17317-0447-02
17317-0447-03
17317-0455-02
17317-0455-02
17317-0455-03
17317-0455-03
17317-0455-05
17317-0455-05
17317-0455-06
17317-0455-06
17317-0477-08
17317-0567-02
17317-0567-03
17317-0567-08
J3480
J3480
J3480
J7510
J7510
J3490
J3415
J3490
J3415
J3490
J3415
J3490
J3415
J7510
J3140
J3140
J3140
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002


POTASSIUM CHLORIDE (U.S.P./F.C.C.)
POTASSIUM CHLORIDE (U.S.P./F.C.C.)
PREDNISOLONE ANHYDROUS (U.S.P.)
PYRIDOXINE HCL (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
FC
FC
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
2 MEQ
2 MEQ
2 MEQ
5 MG
5 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
5 MG
50 MG
50 MG
50 MG
6.71141
6.71141
6.71141
200
200
1
10
1
10
1
10
1
10
200
20
20
20
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
17317-0568-02
J3150
TESTOSTERONE PROPIONATE (U.S.P.)
1 EA BO
NA
GM
100 MG
10
01/01/2002
99/99/9999
17317-0568-03
J3150
1 EA BO
NA
GM
100 MG
10
01/01/2002
99/99/9999
17317-0568-08
J3150
1 EA BO
NA
GM
100 MG
10
01/01/2002
99/99/9999
17317-0571-01
J2810
1 EA NA
NA
GM
40 MG
25
01/01/2002
99/99/9999
17317-0571-04
J2810
1 EA NA
NA
GM
40 MG
25
01/01/2002
99/99/9999
17317-0571-05
J2810
1 EA NA
NA
GM
40 MG
25
01/01/2002
99/99/9999
17317-0571-08
17317-0593-01
17317-0593-05
17317-0593-08
17317-0626-01
17317-0626-02
J2810
J3350
J3350
J3350
J2675
J2675
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

THEOPHYLLINE ANHYDROUS
(ANHYDROUS, U.S.P.)
(ANHYDROUS, U.S.P.)
(ANHYDROUS, U.S.P.)
(ANHYDROUS, U.S.P.)
UREA (U.S.P.)
UREA (U.S.P.)
UREA (U.S.P.)
1
1
1
1
1
1
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
40 MG
40 GM
40 GM
40 GM
50 MG
50 MG
25
0.025
0.025
0.025
20
20
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 150 of 374
EA
EA
EA
EA
EA
EA
NA
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
17317-0199-01

Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

1/1/2002 99/99/9999 THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM

BENZOCAINE (U.S.P.)
BENZOCAINE (U.S.P.)
BENZOCAINE (U.S.P.)
(U.S.P,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
MAGNESIUM SULFATE HEPTAHYDRATE
(U.S.P.)
MAGNESIUM SULFATE (PURIFIED,
U.S.P./F.C.C.)
U.S.P./F.C.C.)
U.S.P./F.C.C.)
KO
HCPCS Mod
HCPCS
NDC Mod
NDC
17317-0626-03
17317-0626-08
J2675
J2675
17317-0719-01
J7684
17317-0719-01 KO J7684
17317-0719-07
KO
J7684
17317-0719-07 KO J7684
17317-0735-01
J2000
17317-0735-01
J2001
17317-0735-02
J2000
17317-0735-02
J2001
17317-0735-03
J2000
17317-0735-03
J2001
17317-0735-04
J2000
17317-0735-04
J2001
17317-0735-06
J2000
17317-0735-06
J2001
KO

1 EA BO
1 EA BO
NA
NA
GM
GM
50 MG
50 MG
20
20
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
1000
4
100
4
100
4
100
4
100
4
100
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
500 ML EA
NA
ML
50 %
0.02
01/01/2002
99/99/9999
1 EA BO
NA
GM
150 MG
6.66666
01/01/2002
99/99/9999
1 EA BO
NA
GM
150 MG
6.66666
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
NA
NA
NA
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
150 MG
50 MG
50 MG
50 MG
50 MG
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
6.66666
20
20
20
20
0.08
0.08
0.08
0.08
0.08
0.08
0.08
0.08
0.08
0.08
0.08
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
500 MG
01/01/2002
99/99/9999
1 EA BO
1 EA NA
1 EA NA
NA
NA
NA
GM
GM
GM
500 MG
40 GM
40 GM
2
0.025
0.025
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
17317-0828-01
J1212
17317-0829-01
J3520
17317-0829-05
J3520
17317-0829-08
17317-0934-01
17317-0934-02
17317-0934-03
17317-0934-08
17317-1010-01
17317-1010-03
17317-1010-05
17317-1010-08
17317-1011-01
17317-1011-05
17317-1011-08
17317-1011-09
17317-1012-01
17317-1012-03
17317-1012-08
J3520
J2675
J2675
J2675
J2675
J2150
J2150
J2150
J2150
J2150
J2150
J2150
J2150
J2150
J2150
J2150
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
17317-1413-01
J3475
17317-1413-03
17317-1466-01
17317-1466-05
J3475
J3350
J3350

1/1/2002 99/99/9999 INJECTION, UREA, UP TO 40 GM

DIMETHYL SULFOXIDE (A.C.S.,
REAGENT)
EDETATE DISODIUM DIHYDRATE
(U.S.P.)
(U.S.P.)
(U.S.P.)
PROGESTERONE (WETTABLE)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (REAGENT)
MANNITOL (REAGENT)
MANNITOL (REAGENT)
(REAGENT)
(REAGENT)
UREA (A.C.S., REAGENT)
UREA (A.C.S., REAGENT)
17317-1485-01
J3520
EDETATE DISODIUM (A.C.S., REAGENT)
1 EA NA
NA
GM
150 MG
6.66666
01/01/2002
99/99/9999
17317-1485-04
J3520
1 EA NA
NA
GM
150 MG
6.66666
01/01/2002
99/99/9999
17317-1485-05
17317-1565-01
17317-1565-05
17317-1565-08
17317-2409-02
J3520
J3520
J3520
J3520
J0600

1
1
1
1
1
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
150 MG
150 MG
150 MG
150 MG
1000 MG
6.66666
6.66666
6.66666
6.66666
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
04/18/2008
99/99/9999
04/18/2008
99/99/9999
17474-0123-01
J1642
3/14/2002

EDETATE DISODIUM
EDETATE DISODIUM
EDETATE DISODIUM
EDETATE CALCIUM DISODIUM (U.S.P.)
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
HEPARIN LOCK FLUSH (SRN,12
ML,PF,LATEX-FREE) 100 U/ML
10 ML SR
IV
ML
10 U
03/14/2002
3/14/2002
2.5 ML SR
IV
ML
10 U
03/14/2002
8/29/2008
2.5 ML SR
IV
ML
10 U
03/14/2002
3/14/2002
5 ML SR
IV
ML
10 U
03/14/2002
3/14/2002
10 ML SR
IV
ML
10 U
10
03/14/2002
3/14/2002
2.5 ML SR
IV
ML
10 U
10
03/14/2002
3/14/2002
2.5 ML SR
IV
ML
10 U
10
03/14/2002
3/14/2002

17474-0123-02
J1642
3/14/2002
17474-0123-03
J1642
3/14/2002
17474-0123-05
J1642
3/14/2002
17474-0125-01
J1642
3/14/2002
17474-0125-02
J1642
3/14/2002
17474-0125-03
J1642
3/14/2002
Page 151 of 374
EA
EA
EA
EA
EA
NA
NA
NA
NA
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
17474-0125-05
J1642
3/14/2002
17474-3002-01
J2912
17474-3002-01
A4216
17474-3002-02
J2912
17474-3002-02
A4216
17474-3002-03
J2912
17474-3002-03
A4216
17474-3002-05
J2912
17474-3002-05
17478-0040-01
17478-0524-02
17478-0524-05
17478-0524-10
A4216
J2060
J2250
J2250
J2250

17478-0538-02
17478-0560-01
J2360
J3470
17714-0020-01
Q0163
17714-0020-10
Q0163
17714-0021-01
Q0163
17714-0021-10
Q0163
17714-0042-01
Q0163
17714-0042-24
Q0163

18111-0002-02
J9206
18111-0002-02 QR J9206
18111-0002-03
1/1/2007
18837-0043-30
18837-0086-21
Q0163
J7509
18837-0127-10
Q0170
18837-0127-30
Q0170
18837-0127-45
Q0170
18837-0127-60
Q0170

1/1/2007

1/1/2007
QR
J9206
18111-0002-03 QR J9206
18837-0037-30
J8540

QR

U/ML
MONOJECT PREFILL FLUSH (SRN,12
ML) 0.9%
ML) 0.9%
MONOJECT PREFILL FLUSH (SRN,3 ML)
0.9%
MONOJECT PREFILL FLUSH (SRN,3 ML)
0.9%
ML) 0.9%
ML) 0.9%
ML) 0.9%
ML) 0.9%
ORPHENADRINE CITRATE (10X2ML) 30
MG/ML
HYDASE (6X1ML) 150 U/ML
5 ML SR
IV
ML
10 U
10
03/14/2002
3/14/2002
10 ML SR
IV
ML
0.9 %
0.5
03/14/2002
12/31/2006
10 ML SR
IV
ML
10 ML
0.1
01/01/2007
3/14/2002
2.5 ML SR
IV
ML
0.9 %
0.5
03/14/2002
12/31/2006
2.5 ML SR
IV
ML
10 ML
0.1
01/01/2007
3/14/2002
2.5 ML SR
IV
ML
0.9 %
0.5
03/14/2002
12/31/2006
2.5 ML SR
IV
ML
10 ML
0.1
01/01/2007
3/14/2002
5 ML SR
IV
ML
0.9 %
0.5
03/14/2002
12/31/2006
IV
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
10 ML
2 MG
1 MG
1 MG
1 MG
0.1
1
5
5
5
01/01/2007
03/28/2005
04/29/2005
04/29/2005
04/29/2005
3/14/2002
99/99/9999
03/29/2006
03/29/2006
03/29/2006
2 ML VL
1 ML VL
IJ
SC
ML
ML
60 MG
150 U
0.5
1
10/01/2006
05/16/2007
99/99/9999
4/30/2009
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
1000 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
100 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
2 ML VL
IV
ML
20 MG
02/28/2008
99/99/9999

MG
COMPLETE ALLERGY MEDICATION

(CAPLET) 25 MG
20 MG/ML
20 MG/ML
20 MG/ML
20 MG/ML
DEXAMETHASONE 4 MG

9/1/2006
6/1/2007
METHYLPREDNISOLONE DP 4 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
9/1/2006
PROMETHAZINE 25 MG
Page 152 of 374
5 ML
1 ML
2 ML
5 ML
10 ML
SR
VL
VL
VL
VL
2 ML VL
IV
ML
20 MG
02/28/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/28/2008
99/99/9999
5 ML VL
30 EA NA
IV
PO
ML
EA
20 MG
0.25 MG
1
16
02/28/2008
09/01/2006
99/99/9999
06/01/2007
30 EA BX
21 EA DP
PO
PO
EA
EA
50 MG
4 MG
1
1
11/01/2007
06/01/2007
99/99/9999
7/1/2009
10 EA BO
PO
EA
25 MG
08/01/2007
99/99/9999
30 EA BO
PO
EA
25 MG
09/01/2006
99/99/9999
45 EA NA
PO
EA
25 MG
09/01/2006
06/01/2007
60 EA BO
PO
EA
25 MG
09/01/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
18837-0127-90
Q0170
9/1/2006
18837-0184-40
Q0179
9/1/2006
18837-0213-30
Q0163
10/26/2006
18837-0213-98
Q0163
10/26/2006
18837-0265-02
Q4083
6/1/2007
18837-0265-02
18837-0267-21
18837-0267-30
18837-0267-48
J7321
J7506
J7506
J7506
1/1/2008
2/15/2008
8/1/2007
2/15/2008
18837-0299-30
Q0163
18837-0338-06
18837-0353-10
18837-0353-30
Q0144
J7506
J7506
18864-0211-03
Q0163
18864-2110-30
Q0163
19458-5076-01
Q0163
19458-5076-02
Q0163
19458-9163-02
Q0163
20254-0018-01
Q0173
20254-0018-03
Q0173
20254-0207-06
Q0163
20254-0207-10
Q0163
20254-0208-06
Q0163
20254-0208-10
20694-0111-01
20694-0112-01
21695-0010-20
21695-0010-25
21695-0010-30
21695-0010-60
Q0163
J1325
J1325
J8499
J8499
J8499
J8499
2/1/2008

PROMETHAZINE 25 MG
ZOFRAN 8 MG
HYALGAN 10 MG/ML
HYALGAN 10 MG/ML
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG

9/24/2008
5/22/2008
1/1/2002
1/1/2002
1/1/2002
10/1/2006 11/17/2006 INJECTION, EPOPROSTENOL, 0.5 MG
10/1/2006 11/17/2006 INJECTION, EPOPROSTENOL, 0.5 MG
90 EA BO
PO
EA
25 MG
09/01/2006
99/99/9999
40 EA NA
PO
EA
8 MG
09/01/2006
06/01/2007
30 EA NA
PO
EA
50 MG
10/26/2006
06/01/2007
120 EA NA
PO
EA
50 MG
10/26/2006
06/01/2007
IJ
ML
1 DOSE
0.5
06/01/2007
12/31/2007
IJ
PO
PO
PO
ML
EA
EA
EA
1 DOSE
5 MG
5 MG
5 MG
0.5
2
2
2
01/01/2008
02/15/2008
08/01/2007
02/15/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML SR
2 ML
21 EA
30 EA
48 EA
SR
BO
BO
BO
30 EA BX
PO
EA
50 MG
0.5
02/01/2008
99/99/9999
6 EA BO
10 EA BO
30 EA BO
PO
PO
PO
EA
EA
EA
1 GM
5 MG
5 MG
0.25
4
4
04/15/2008
09/24/2008
05/22/2008
99/99/9999
7/1/2009
7/1/2009
SERABRINA LA FRANCE 50 MG/15 ML
480 ML NA
PO
ML
50 MG
0.06666
01/01/2002
99/99/9999
SERABRINA LA FRANCE 50 MG/15 ML
480 ML EA
PO
ML
50 MG
0.06666
01/01/2002
99/99/9999
DIPHEDRYL (MINI-TABS) 25 MG
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
6/4/2007
DIPHEDRYL (MINI-TABS) 25 MG
48 EA BX
PO
EA
50 MG
0.5
01/01/2002
6/4/2007
SLEEPING AID 25 MG
16 EA BO
PO
EA
50 MG
0.5
01/01/2002
6/4/2007
100 EA NA
PO
EA
250 MG
01/01/2002
99/99/9999
500 EA NA
PO
EA
250 MG
01/01/2002
99/99/9999

MG
60 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999

MG
10 EA DP
PO
EA
50 MG
0.5
01/01/2002
99/99/9999

MG
60 EA NA
PO
EA
50 MG
01/01/2002
99/99/9999

MG
FLOLAN 0.5 MG
FLOLAN 1.5 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
10 EA
1 EA
1 EA
20 EA
25 EA
30 EA
60 EA
PO
IV
IV
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
50 MG
0.5 MG
0.5 MG
1 EA
1 EA
1 EA
1 EA
1
1
3
1
1
1
1
01/01/2002
10/01/2006
10/01/2006
11/30/2006
05/19/2008
02/01/2007
11/30/2006
99/99/9999
11/17/2006
11/17/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999

PREDNISONE 20 MG
PREDNISONE 20 MG
Page 153 of 374
NA
NA
NA
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
5/19/2008
7/19/2007
1/1/2007
12/15/2006
12/15/2006
2/1/2007
1/1/2007
21695-0245-20
J7602
1/24/2008
21695-0245-20
J7611
4/1/2008
21695-0304-30
Q0163
2/1/2007
21695-0304-90
21695-0306-20
21695-0306-21
21695-0306-28
21695-0306-30
21695-0306-42
21695-0307-10
21695-0307-15
21695-0307-18
21695-0307-20
21695-0307-21
21695-0307-30
Q0163
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
9/17/2007
4/1/2007
4/1/2007
4/1/2007
4/1/2007
4/1/2007
2/1/2007
9/3/2008
4/1/2007
7/27/2007
8/14/2008
2/1/2007
21695-0313-03
Q4084
2/1/2007
21695-0313-03
J7322
1/1/2008
21695-0332-25
J7603
1/1/2008
21695-0332-25 KO J7603
21695-0332-25
KO
J7613
21695-0332-25 KO J7613
21695-0365-08
J7510
21695-0365-16
J7510
1/1/2008
4/1/2008
KO
4/1/2008
10/15/2007
10/15/2007
21695-0374-02
Q4083
2/1/2007
21695-0374-02
21695-0382-04
J7321
J8540
1/1/2008
2/1/2007
21695-0414-60
Q0175
4/1/2007
21695-0415-60
Q0176
6/27/2007
21695-0453-10
Q0170
4/1/2007
21695-0453-15
Q0170
1/15/2008
21695-0453-20
Q0170
4/1/2007
21695-0453-25
Q0170
4/1/2007
Page 154 of 374
PO
PO
PO
PO
PO
IJ
IJ
EA
EA
EA
EA
EA
EA
ML
1 EA
1 GM
4 MG
1 MG
250 MG
250 MG
30 MG
1
0.25
1
1
1
2
1
05/19/2008
07/19/2007
01/01/2007
12/15/2006
12/15/2006
02/01/2007
01/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 ML BO
IH
ML
1 MG
01/24/2008
03/31/2008
20 ML BO
IH
ML
1 MG
04/01/2008
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
02/01/2007
99/99/9999
90 EA
20 EA
21 EA
28 EA
30 EA
42 EA
10 EA
15 EA
18 EA
20 EA
21 EA
30 EA
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
0.5
2
2
2
2
2
4
4
4
4
4
4
09/17/2007
04/01/2007
04/01/2007
04/01/2007
04/01/2007
04/01/2007
02/01/2007
09/03/2008
04/01/2007
07/27/2007
08/14/2008
02/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML SR
IJ
ML
1 DOSE
0.5
02/01/2007
12/31/2007
2 ML SR
IJ
ML
1 DOSE
0.5
01/01/2008
12/31/2009
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
IH
PO
PO
ML
ML
ML
1 MG
5 MG
5 MG
0.83
0.6
0.6
04/01/2008
10/15/2007
10/15/2007
99/99/9999
99/99/9999
99/99/9999
2 ML SR
IJ
ML
1 DOSE
0.5
02/01/2007
12/31/2007
2 ML SR
4 EA BO
IJ
PO
ML
EA
1 DOSE
0.25 MG
0.5
16
01/01/2008
02/01/2007
99/99/9999
99/99/9999
60 EA BO
PO
EA
4 MG
04/01/2007
99/99/9999
60 EA BO
PO
EA
8 MG
06/27/2007
99/99/9999
10 EA BO
PO
EA
25 MG
04/01/2007
99/99/9999
15 EA BO
PO
EA
25 MG
01/15/2008
99/99/9999
20 EA BO
PO
EA
25 MG
04/01/2007
99/99/9999
25 EA BO
PO
EA
25 MG
04/01/2007
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
3 ML PC
240 ML BO
480 ML BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
DP
BO
BO
BO
VL
AM
Billing Units
30 EA
6 EA
21 EA
100 EA
100 EA
1 EA
1 ML

Package
NDC Label
HCPCS Description

ACYCLOVIR 800 MG
AZITHROMYCIN 250 MG
METHYLPREDNISONE 4 MG
PROGRAF 1 MG
CELLCEPT 250 MG
CEFTRIAXONE (SDV) 500 MG
TALWIN 30 MG/ML
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER SYNVISC HYLAN G-F (3X2ML SYRINGES)
12/31/2007 DOSE
8 MG/ML
HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER SYNVISC HYLAN G-F (3X2ML SYRINGES)
12/31/2009 DOSE
8 MG/ML
ALBUTEROL SULFATE (3MLX25) 0.083%
HYALGAN L/L 10 MG/ML
HYALGAN L/L 10 MG/ML
DEXAMETHASONE 4 MG
PERPHENAZINE 4 MG
99/99/9999 REGIMEN
PERPHENAZINE (FILM-COATED) 8 MG
99/99/9999 REGIMEN
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
NDC Package Type
J8499
Q0144
J7509
J7507
J7517
J0696
J3070
NDC Package Measure
21695-0011-30
21695-0012-06
21695-0080-21
21695-0170-00
21695-0171-00
21695-0202-10
21695-0241-01
HCPCS Mod
HCPCS
NDC Mod
NDC
21695-0500-30
Q0163
4/15/2008
21695-0571-30
Q0164
8/22/2008
21695-0572-30
Q0165
7/24/2007
21695-0573-20
Q0177
8/14/2008
21695-0573-30
21695-0580-05
21695-0587-10
21695-0588-25
Q0177
J7506
J2930
J1885
8/14/2008
7/25/2007
8/9/2007
8/9/2007
21695-0649-12
J8498
11/12/2007
21695-0703-04
21695-0721-25
21695-0765-48
23360-0016-02
Q0170
J1940
J7506
J2405
3/14/2008
3/20/2008
6/9/2008
10/15/2008
23360-0016-20
23490-1113-02
23490-1113-03
23490-1911-02
23490-5011-01
23490-5012-01
23490-5012-02
23490-5012-03
23490-5012-04
23490-5013-01
23490-5013-02
23490-5013-03
23490-5013-04
23490-5015-01
23490-5015-02
J2405
J7506
J7506
J7509
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
10/15/2008
10/3/2006
9/21/2006
10/3/2006
10/11/2007
2/7/2007
2/7/2007
2/7/2007
2/7/2007
2/7/2007
2/7/2007
2/7/2007
10/11/2007
2/7/2007
10/11/2007
23490-5020-01
J7603
1/1/2008
23490-5020-01 KO J7603
23490-5020-01
23490-5020-01 KO J7613
23490-5020-02
23490-5020-03
KO
KO
1/1/2008
4/1/2008
KO
J7603
23490-5020-03 KO J7603
4/1/2008
1/1/2008
J7613
23490-5020-02 KO J7613
1/1/2008
4/1/2008
J7603
23490-5020-02 KO J7603
23490-5020-02
KO
J7613
4/1/2008
1/1/2008
KO
1/1/2008

PREDNISONE 50 MG
KETOROLAC (1MLX25) 30 MG/ML
PROMETHAZINE HYDROCHLORIDE 25
MG
PROMETHAZINE HCL
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 (1X120ML,FRUIT,TROPICAL) 6.25 MG/5
ML
FUROSEMIDE (25X2ML) 10 MG/ML
PREDNISONE 10 MG
ONDANSETRON (USP,SDV,5X2ML)
ONDANSETRON (USP,SDV,5X2ML);
(2MG/ML)
PREDNISONE 10 MG
PREDNISONE 10 MG
ACYCLOVIR 200 MG/5 ML
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ALBUTEROL SULFATE (24X3ML) 0.083%
Page 155 of 374
30 EA BO
PO
EA
50 MG
04/15/2008
99/99/9999
30 EA BO
PO
EA
5 MG
08/22/2008
99/99/9999
30 EA BO
PO
EA
10 MG
07/24/2007
99/99/9999
20 EA BO
PO
EA
25 MG
08/14/2008
99/99/9999
30 EA
5 EA
1 EA
1 ML
BO
BO
VL
VL
PO
PO
IJ
IJ
EA
EA
EA
ML
25 MG
5 MG
125 MG
15 MG
1
10
1
2
08/14/2008
07/25/2007
08/09/2007
08/09/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA BX
RC
EA
1 EA
11/12/2007
99/99/9999
120 ML
2 ML
48 EA
2 ML
BO
VL
NA
VL
PO
IJ
PO
IJ
ML
ML
EA
ML
25 MG
20 MG
5 MG
1 MG
0.05
0.5
2
2
03/14/2008
03/20/2008
06/09/2008
10/15/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 ML
21 EA
30 EA
21 EA
120 ML
25 EA
30 EA
40 EA
100 EA
15 EA
25 EA
40 EA
30 EA
25 EA
30 EA
VL
NA
NA
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
IJ
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 MG
5 MG
5 MG
4 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
10/15/2008
10/03/2006
09/21/2006
10/03/2006
10/11/2007
02/07/2007
02/07/2007
02/07/2007
02/07/2007
02/07/2007
02/07/2007
02/07/2007
10/11/2007
02/07/2007
10/11/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
3 ML VL
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML VL
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
23490-5020-03
J7613
23490-5020-03 KO J7613
23490-5021-02
J7602
23490-5021-02
23490-5110-09
23490-5186-02
23490-5404-01
23490-5407-01
23490-5407-02
J7611
J7500
J0595
J8540
J8540
J8540
23490-5413-00
J1100
23490-5455-01
Q0163
23490-5457-00
Q0163
23490-5457-01
Q0163
23490-5457-02
Q0163
23490-5457-03
Q0163
23490-5457-04
Q0163
23490-5457-05
Q0163
23490-5459-01
Q0163
23490-5459-02
Q0163
23490-5459-03
Q0163
23490-5459-04
Q0163
23490-5497-02
23490-5621-02
J0170
J1940
23490-5733-01
Q0177
23490-5733-02
Q0177
23490-5761-01
J7644
23490-5761-01 KO J7644
23490-5792-04
J1885
KO
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON4/1/2008 99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG
1/1/2008 3/31/2008 (LEVALBUTEROL)
KO
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008

AZATHIOPRINE 50 MG
BUTORPHANOL TARTRATE 2 MG/ML
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
PHOSPHATE 4 MG/ML
20 ML
90 EA
10 ML
12 EA
6 EA
12 EA
IH
PO
IJ
PO
PO
PO
ML
EA
ML
EA
EA
EA
1 MG
50 MG
1 MG
0.25 MG
0.25 MG
0.25 MG
5
1
2
3
16
16
04/01/2008
04/30/2007
04/09/2007
02/07/2007
02/07/2007
11/30/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
IJ
ML
1 MG
04/09/2007
99/99/9999
BO
BO
VL
BO
BO
BO
5 ML VL
(1X120ML) 12.5 MG/5 ML
120 ML BO
PO
ML
50 MG
0.05
11/30/2007
99/99/9999
25 MG
24 EA BO
PO
EA
50 MG
0.5
11/30/2007
99/99/9999
25 MG
6 EA BO
PO
EA
50 MG
0.5
02/07/2007
99/99/9999
25 MG
15 EA BO
PO
EA
50 MG
0.5
02/07/2007
99/99/9999
25 MG
20 EA BO
PO
EA
50 MG
0.5
02/07/2007
99/99/9999
25 MG
30 EA BO
PO
EA
50 MG
0.5
02/07/2007
99/99/9999
25 MG
60 EA BO
PO
EA
50 MG
0.5
02/07/2007
99/99/9999
50 MG
6 EA BO
PO
EA
50 MG
02/07/2007
99/99/9999
50 MG
15 EA BO
PO
EA
50 MG
02/07/2007
99/99/9999
50 MG
30 EA BO
PO
EA
50 MG
02/07/2007
99/99/9999
50 MG
EPINEPHRINE HYDROCHLORIDE 1
MG/ML
FUROSEMIDE 10 MG/ML
Page 156 of 374
60 EA BO
PO
EA
50 MG
02/07/2007
99/99/9999
IJ
IJ
ML
ML
1 ML
20 MG
1
0.5
04/30/2007
04/30/2007
99/99/9999
99/99/9999
20 EA BO
PO
EA
25 MG
02/07/2007
99/99/9999
30 EA BO
PO
EA
25 MG
02/07/2007
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/09/2007
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/09/2007
99/99/9999
1 ML NA
IJ
ML
15 MG
04/09/2007
99/99/9999
1 ML NA
2 ML VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

IPRATROPIUM BROMIDE (25X2.5ML)
4/9/2007 99/99/9999 MILLIGRAM
0.02%
IPRATROPIUM BROMIDE (25X2.5ML)
4/9/2007 99/99/9999 MILLIGRAM
0.02%

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
23490-5854-01
23490-5889-00
23490-5902-01
J1055
None
J7509
23490-5914-01
J2765
23490-5932-01
J2250

2/7/2007 99/99/9999 MG
150 MG/ML
METHOTREXATE 2.5 MG
METOCLOPRAMIDE HYDROCHLORIDE 5
MG/ML
MIDAZOLAM HYDROCHLORIDE 1 MG/ML

(10X10ML) 5 MG/ML
NALBUPHINE HYDROCHLORIDE 10
MG/ML
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PROMETHAZINE HYDROCHLORIDE 12.5
MG
MG
MG
MG
23490-5933-01
J2250
23490-5933-02
J2250
23490-5955-01
23490-6144-01
23490-6144-02
23490-6144-03
23490-6145-01
23490-6145-02
23490-6145-03
23490-6157-01
23490-6157-02
23490-6157-03
23490-6157-04
23490-6157-05
23490-6157-06
23490-6157-07
23490-6157-08
23490-6158-00
23490-6158-01
23490-6158-02
23490-6158-03
23490-6158-04
23490-6158-05
23490-6158-07
23490-6158-08
23490-6158-09
23490-6159-01
23490-6159-02
23490-6159-03
23490-6159-04
23490-6159-05
23490-6159-06
23490-6174-01
J2300
J7510
J7510
J7510
J7510
J7510
J7510
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J8498
23490-6180-01
J8498
23490-6182-01
J8498
23490-6182-02
J8498
23490-6182-03
J8498
23490-6183-01
Q0170
23490-6183-02
Q0170
23490-6183-03
Q0170
23490-6183-04
Q0170
23490-6183-06
Q0170
23490-6183-07
Q0170
23490-6183-08
Q0170
4/9/2007
4/9/2007
10/11/2007
10/11/2007
10/11/2007
10/11/2007
10/11/2007
2/7/2007
2/7/2007
2/7/2007
4/9/2007
2/7/2007
11/30/2007
2/7/2007
4/9/2007
4/9/2007
2/7/2007
2/7/2007
2/7/2007
2/7/2007
10/11/2007
4/9/2007
4/9/2007
10/11/2007
2/7/2007
2/7/2007
2/7/2007
2/7/2007
11/30/2007
11/30/2007
2/7/2007


MG
MG
MG
MG
MG
MG
MG
Page 157 of 374
1 ML VL
24 EA BO
21 EA BO
IM
PO
PO
ML
EA
EA
150 MG
2.5 MG
4 MG
1
1
1
02/07/2007
11/30/2007
02/07/2007
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
99/99/9999
99/99/9999
2 ML VL
IV
ML
10 MG
0.5
04/09/2007
99/99/9999
2 ML VL
IJ
ML
1 MG
04/30/2007
99/99/9999
2 ML VL
IJ
ML
1 MG
04/30/2007
99/99/9999
10 ML VL
IJ
ML
1 MG
04/30/2007
99/99/9999
VL
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BX
IJ
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
RC
ML
ML
ML
ML
ML
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
10 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1 EA
1
0.6
0.6
0.6
0.6
0.6
0.6
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
4
1
1
1
1
1
1
1
04/09/2007
04/09/2007
10/11/2007
10/11/2007
10/11/2007
10/11/2007
10/11/2007
02/07/2007
02/07/2007
02/07/2007
04/09/2007
02/07/2007
11/30/2007
02/07/2007
04/09/2007
04/09/2007
02/07/2007
02/07/2007
02/07/2007
02/07/2007
10/11/2007
04/09/2007
04/09/2007
10/11/2007
02/07/2007
02/07/2007
02/07/2007
02/07/2007
11/30/2007
11/30/2007
02/07/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA BX
RC
EA
1 EA
02/07/2007
99/99/9999
6 EA BX
RC
EA
1 EA
02/07/2007
99/99/9999
12 EA BX
RC
EA
1 EA
02/07/2007
99/99/9999
10 EA BX
RC
EA
1 EA
11/30/2007
99/99/9999
10 EA BO
PO
EA
25 MG
02/07/2007
99/99/9999
12 EA BO
PO
EA
25 MG
02/07/2007
99/99/9999
30 EA BO
PO
EA
25 MG
02/07/2007
99/99/9999
20 EA BO
PO
EA
25 MG
04/09/2007
99/99/9999
60 EA BO
PO
EA
25 MG
11/30/2007
99/99/9999
90 EA BO
PO
EA
25 MG
03/12/2008
99/99/9999
100 EA BO
PO
EA
25 MG
03/12/2008
99/99/9999
10 ML
240 ML
180 ML
120 ML
240 ML
180 ML
120 ML
10 EA
20 EA
40 EA
37 EA
21 EA
30 EA
60 EA
100 EA
6 EA
10 EA
18 EA
20 EA
30 EA
21 EA
25 EA
15 EA
90 EA
10 EA
20 EA
21 EA
40 EA
28 EA
30 EA
3 EA
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
23490-6187-01
Q0170
11/30/2007
23490-6343-01
J1080
2/7/2007
23490-6509-03
Q0165
11/30/2007
23490-6512-01
Q0164
2/7/2007
23490-6512-02
23490-6687-00
23490-6904-01
Q0164
J1815
Q0144
2/7/2007
4/30/2007
11/12/2007
23490-6905-00
Q0144
4/9/2007
23490-6905-01
Q0144
10/11/2007
23490-6905-02
23490-7545-02
23490-7758-01
23490-7760-01
23490-7760-02
23490-7854-00
23535-0608-61
23535-0608-68
23535-6086-10
23535-6086-80
Q0144
J3360
Q0144
Q0144
Q0144
J7506
J3475
J3475
J3475
J3475
10/11/2007
4/9/2007
2/7/2007
2/7/2007
4/9/2007
11/30/2007
1/1/2002
1/1/2002
1/1/2002
1/1/2002
24208-0347-20
J7602
1/1/2008
24208-0347-20
J7611
4/1/2008
24208-0373-60
J7631
1/1/2002
24208-0373-60 KO J7631
24208-0373-62
KO
J7631
24208-0373-62 KO J7631
24208-0412-01
J7310
1/1/2002
1/1/2002
KO
1/1/2002
7/26/2005

(1X120ML) 6.25 MG/5 ML
TESTOSTERONE CYPIONATE 200
MG/ML
INSULIN HUMAN REGULAR 100 U/ML
AZITHROMYCIN (1X15ML) 100 MG/5 ML
AZITHROMYCIN DIHYDRATE 200 MG/5
ML
ML
ML
DIAZEPAM 5 MG/ML
AZITHROMYCIN 500 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
PREDNISONE (1X120ML) 5 MG/5 ML
MAGNESIUM SULFATE
MAGNESIUM SULFATE
MAGNESIUM SULFATE
MAGNESIUM SULFATE
ALBUTEROL SULFATE (STERILE) 0.5%
CROMOLYN SODIUM (AMP) 10 MG/ML
99/99/9999 GANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANT
VITRASERT 4.5 MG
120 ML BO
PO
ML
25 MG
0.05
11/30/2007
99/99/9999
10 ML NA
IM
ML
200 MG
02/07/2007
99/99/9999
30 EA BO
PO
EA
10 MG
11/30/2007
99/99/9999
6 EA BO
PO
EA
5 MG
02/07/2007
99/99/9999
10 EA BO
10 ML NA
15 ML BO
PO
IJ
PO
EA
ML
ML
5 MG
5U
1 GM
1
20
0.02
02/07/2007
04/30/2007
11/12/2007
99/99/9999
99/99/9999
99/99/9999
15 ML BO
PO
ML
1 GM
0.04
04/09/2007
99/99/9999
22.5 ML BO
PO
ML
1 GM
0.04
10/11/2007
99/99/9999
30 ML
10 ML
3 EA
4 EA
6 EA
120 ML
1 EA
1 EA
1 EA
1 EA
PO
IJ
PO
PO
PO
PO
NA
NA
NA
NA
ML
ML
EA
EA
EA
ML
GM
GM
GM
GM
1 GM
5 MG
1 GM
1 GM
1 GM
5 MG
500 MG
500 MG
500 MG
500 MG
0.04
1
0.5
0.25
0.25
0.2
2
2
2
2
10/11/2007
04/09/2007
02/07/2007
02/07/2007
04/09/2007
11/30/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML BO
IH
ML
1 MG
04/01/2008
99/99/9999
2 ML AM IH
ML
10 MG
01/01/2002
01/01/2003
2 ML AM IH
ML
10 MG
01/01/2002
01/01/2003
2 ML AM IH
ML
10 MG
01/01/2002
01/01/2003
2 ML AM IH
1 EA BX IO
ML
EA
10 MG
4.5 MG
1
1
01/01/2002
07/26/2005
01/01/2003
99/99/9999
BO
NA
DP
BO
BO
BO
NA
NA
NA
NA
24208-0416-01
J3490
RETISERT (DIRECT SHIP ONLY) 0.59 MG
1 EA PG
IO
EA
1 EA
06/20/2005
12/31/2006
24208-0416-01
J7311
RETISERT (DIRECT SHIP ONLY) 0.59 MG
1 EA PG
IO
EA
1 IMPLANT
01/01/2007
99/99/9999
24385-0379-26
Q0163
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
24385-0406-73
Q0163
SLEEP TABLETS 25 MG
16 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24385-0431-26
Q0163
NIGHTTIME SLEEP AID (CAPLET) 25 MG
24 EA NA
PO
EA
50 MG
0.5
02/13/2002
07/08/2003
24385-0431-26
Q0163
NIGHTTIME SLEEP AID (CAPLET) 25 MG
24 EA NA
PO
EA
50 MG
0.5
08/03/2009
99/99/9999
24385-0462-62
Q0163
DIPHEDRYL 25 MG
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24385-0462-78
Q0163
1/1/2007 99/99/9999 FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT

2/13/2002
DIPHEDRYL 25 MG
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
DIPHEDRYL (CHERRY) 12.5 MG/5 ML
Page 158 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
24385-0479-62
Q0163
1/1/2002
24385-0479-78
Q0163
1/1/2002
24385-0897-62
Q0163
1/1/2002
24385-0901-26
24430-1001-01
24430-1003-01
25208-0002-01
25208-0002-02
25332-0004-30
25332-0010-05
25332-0011-05
25332-0011-05
25332-0019-10
25332-0026-50
25332-0026-50
25332-0027-50
25332-0027-50
25332-0073-30
25332-0073-30
25332-0078-10
25332-0088-05
25332-0117-10
25682-0001-01
25682-0001-01
Q0163
J3365
J3365
J3246
J3246
J3420
J1100
J1095
J1094
J1435
J2000
J2001
J2000
J2001
J3490
J3415
J3420
J3490
J1390
J3490
J1300
1/1/2002
4/1/2007
4/7/2008
4/1/2008
4/1/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
3/26/2007
1/1/2008
30103-0322-54
Q0163
1/1/2002
30103-0722-54
Q0163
1/1/2002
30103-3225-40
Q0163
1/1/2002
30103-7225-40
Q0163
1/1/2002
30170-0000-01
30170-0000-01
30727-0314-80
J7340
Q4100
J3420
1/1/2002
1/1/2009
1/1/2002
33261-0335-21
33358-0009-25
33358-0010-15
33358-0010-28
33358-0010-30
33358-0010-60
33358-0011-25
33358-0011-30
33358-0011-35
33358-0040-06
33358-0041-10
J7509
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
Q0144
Q0144
1/15/2008
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
33358-0110-30
Q0163
33358-0111-20
Q0163
33358-0111-30
Q0163

12/31/2002 INJECTION, DEXAMETHASONE ACETATE, PER 8 MG
99/99/9999 INJECTION, DEXAMETHASONE ACETATE, 1 MG
99/99/9999 INJECTION, ECULIZUMAB, 10 MG
DERMAL AND EPIDERMAL TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT
BIOENGINEERED OR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE
12/31/2008 ELEMENTS, PER SQUARE CENTIMETER

DIPHEDRYL 25 MG
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
DIPHEDRYL 25 MG
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
07/08/2003
BO
VL
VL
PC
PC
VL
VL
VL
VL
VL
NA
NA
NA
NA
VL
VL
VL
VL
VL
VL
VL
PO
IV
IV
IV
IV
IM
IJ
IJ
IJ
IM
EP
EP
IJ
IJ
IJ
IJ
IM
IM
IM
IV
IV
ML
EA
EA
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
0.05
1
1
0.2
0.2
1
4
1
8
5
0.02
1
0.02
2
1
1
1
1
1
1
1
01/01/2002
04/01/2007
04/07/2008
04/01/2008
04/01/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
03/26/2007
01/01/2008
08/01/2002
04/06/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
03/01/2006
12/31/2002
99/99/9999
03/01/2006
12/31/2003
03/01/2006
12/31/2003
03/01/2006
12/31/2003
99/99/9999
99/99/9999
99/99/9999
12/31/2002
12/31/2007
99/99/9999
DORMIN SLEEP AID 25 MG
32 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
72 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
32 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
72 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
ORCEL (36 SQUARE CM)

ORCEL (36 SQUARE CM)
COBAL 1000 MCG/ML
4 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 500 MG
1 EA NA
1 EA NA
30 ML VL
TP
TP
IM
EA
EA
ML
1 SQCM
36 SQCM
1000 MCG
36
1
1
01/01/2002 12/31/2008
01/01/2009 99/99/9999
01/01/2002 12/31/2002
21 EA
25 EA
15 EA
28 EA
30 EA
60 EA
25 EA
30 EA
35 EA
6 EA
10 EA
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
4 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 GM
1 GM
1
1
1
1
1
1
1
1
1
0.25
0.5
01/15/2008
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
07/10/2007
99/99/9999
20 EA BO
PO
EA
50 MG
07/10/2007
99/99/9999
30 EA BO
PO
EA
50 MG
07/10/2007
99/99/9999
DIPHEDRYL (DYE-FREE,SOFTGEL) 25
MG
DIPHEDRYL (AF,BUBBLEGUM) 12.5 MG/5

ML
ABBOKINASE (PF) 250000 IU
KINLYTIC (LYOPHILIZED) 250000 IU
AGGRASTAT (1X100ML) 0.05 MG/ML
AGGRASTAT (1X250ML) 0.05 MG/ML
COBOLIN-M (VIAL) 1000 MCG/ML
DEXASONE (VIAL) 4 MG/ML
DEXASONE L.A. (VIAL) 8 MG/ML
DEXASONE L.A. (VIAL) 8 MG/ML
LIDOCAINE HCL 1%
LIDOCAINE HCL 1%
LIDOCAINE HCL 2%
LIDOCAINE HCL 2%
RODEX (VIAL) 100 MG/ML
RODEX (VIAL) 100 MG/ML
DEPO-COBOLIN (VIAL) 1000 MCG/ML
PRODROX (VIAL) 250 MG/ML
MENAVAL-20 (VIAL) 20 MG/ML
SOLIRIS (PF) 10 MG/ML
SOLIRIS (PF) 10 MG/ML
Page 159 of 374
118 ML
1 EA
1 EA
100 ML
250 ML
30 ML
5 ML
5 ML
5 ML
10 ML
50 ML
50 ML
50 ML
50 ML
30 ML
30 ML
30 ML
5 ML
10 ML
30 ML
30 ML
50 MG
250000 IU
250000 IU
0.25 MG
0.25 MG
1000 MCG
1 MG
8 MG
1 MG
1 MG
50 ML
10 MG
50 ML
10 MG
1 EA
100 MG
1000 MCG
1 EA
20 MG
1 EA
10 MG
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
33358-0182-20
Q0177
7/10/2007
33358-0182-30
33358-0241-21
33358-0291-08
33358-0292-12
33358-0292-15
33358-0292-21
33358-0292-30
33358-0292-78
33358-0293-20
33358-0293-30
33358-0293-40
33358-0294-15
33358-0294-20
33358-0294-30
33358-0294-40
33358-0294-60
Q0177
J7509
J7510
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
7/10/2007
33358-0299-20
Q0164
7/10/2007
33358-0299-30
Q0164
7/10/2007
33358-0300-10
Q0165
7/10/2007
33358-0300-20
Q0165
7/10/2007
33358-0300-30
Q0165
7/10/2007
33358-0300-60
33358-0301-02
33358-0301-12
Q0165
J8498
J8498
7/10/2007
7/10/2007
7/10/2007
33358-0302-08
Q0170
7/10/2007
33358-0302-10
Q0170
7/10/2007
33358-0302-30
Q0170
7/10/2007
HYDROXYZINE PAM 25 MG
HYDROXYZINE PAM 25 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
33358-0302-60
Q0170
7/10/2007
33358-0313-01
J3415
33358-0352-10
Q0173
33358-0352-20
33358-0367-01
33358-0367-03
33358-0368-04
33358-0368-30
33358-0368-50
Q0173
Q0144
Q0144
Q0144
Q0144
Q0144

PYRIDOXINE (SINGLE-DOSE) 100 MG/ML
20 EA BO
PO
EA
25 MG
07/10/2007
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
25 MG
4 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
1
0.6
1
1
1
1
1
2
2
2
4
4
4
4
4
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 EA BO
PO
EA
5 MG
07/10/2007
99/99/9999
30 EA BO
PO
EA
5 MG
07/10/2007
99/99/9999
10 EA BO
PO
EA
10 MG
07/10/2007
99/99/9999
20 EA BO
PO
EA
10 MG
07/10/2007
99/99/9999
30 EA BO
PO
EA
10 MG
07/10/2007
99/99/9999
60 EA BO
2 EA BX
12 EA BX
PO
RC
RC
EA
EA
EA
10 MG
1 EA
1 EA
1
1
1
07/10/2007
07/10/2007
07/10/2007
99/99/9999
99/99/9999
99/99/9999
8 EA BO
PO
EA
25 MG
07/10/2007
99/99/9999
10 EA BO
PO
EA
25 MG
07/10/2007
99/99/9999
30 EA BO
PO
EA
25 MG
07/10/2007
99/99/9999
30 EA
21 EA
240 ML
12 EA
15 EA
21 EA
30 EA
78 EA
20 EA
30 EA
40 EA
15 EA
20 EA
30 EA
40 EA
60 EA
60 EA BO
1 ML VL
PO
EA
25 MG
07/10/2007
99/99/9999
IJ
ML
100 MG
07/10/2007
99/99/9999
10 EA NA
PO
EA
250 MG
07/10/2007
99/99/9999
ZITHROMAX 1 GM/Packet
ZITHROMAX 1 GM/Packet
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
20 EA
1 EA
1 EA
4 EA
30 EA
50 EA
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
250 MG
1 GM
1 GM
1 GM
1 GM
1 GM
1
1
1
0.25
0.25
0.25
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
07/10/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 160 of 374
NA
BX
BX
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
33358-0369-02
Q0179
7/10/2007
33358-0370-02
Q0179
7/10/2007
33358-0418-30
35356-0017-03
35356-0018-10
35356-0019-10
35356-0020-10
Q0169
Q0144
J1650
J1650
J1650
7/24/2007
9/14/2007
9/14/2007
9/14/2007
9/14/2007
35356-0034-01
Q4084
10/19/2007
35356-0034-01
J7322
1/1/2008
35356-0034-03
Q4084
10/19/2007

ZOFRAN 4 MG
ZOFRAN 4 MG
AZITHROMYCIN 500 MG
LOVENOX (10X0.4ML) 40 MG/0.4 ML
HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER
12/31/2007 DOSE
SYNVISC HYLAN GF 8 MG/ML
12/31/2009 DOSE
SYNVISC HYLAN GF 8 MG/ML
12/31/2007 DOSE
SYNVISC HYLAN GF (3X2ML) 8 MG/ML
7/2/2009 DOSE
SYNVISC HYLAN GF (3X2ML) 8 MG/ML
SUPARTZ 10 MG/ML
SUPARTZ 10 MG/ML
PHENADOZ 25 MG
AZITHROMYCIN 100 MG/5 ML
DEPO-TESTOSTERONE 100 MG/ML
7/2/2009 INJECTION, FONDAPARINUX SODIUM, 0.5 MG
ARIXTRA (2X0.5ML) 2.5 MG/0.5 ML
ARIXTRA (2X0.4ML) 5 MG/0.4 ML
99/99/9999 INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG
KENALOG 10 MG/ML
METHYLPREDNISOLONE 40 MG/ML
CELESTONE SOLUSPAN 3 MG/ML-3
99/99/9999 PHOSPHATE 3MG
MG/ML
PERPHENAZINE 8 MG
99/99/9999 REGIMEN
CHLORPROMAZINE 100 MG
35356-0034-03
J7322
1/1/2008
35356-0036-01
J7321
1/10/2008
35356-0036-02
35356-0039-12
35356-0044-15
35356-0058-10
35356-0078-02
35356-0078-10
35356-0079-02
35356-0079-10
35356-0080-02
35356-0080-10
35356-0081-02
35356-0081-10
35356-0082-01
35356-0083-01
J7321
J8498
Q0144
J1070
J1652
J1652
J1652
J1652
J1652
J1652
J1652
J1652
J3301
J1030
1/10/2008
10/19/2007
10/26/2007
11/9/2007
1/25/2008
1/25/2008
1/25/2008
1/25/2008
1/25/2008
1/25/2008
1/25/2008
1/25/2008
2/8/2008
2/8/2008
35356-0084-01
J0702
2/8/2008
35356-0096-60
Q0176
2/29/2008
35356-0098-90
Q0172
2/29/2008
35356-0102-00
J1817
35356-0124-30
J7644
3/7/2008 99/99/9999 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS HUMALOG (100X10ML) 100 U/ML
IPRATROPIUM BROMIDE (30X2.5ML,PF)
0.02%
3/13/2008 99/99/9999 MILLIGRAM
IPRATROPIUM BROMIDE (30X2.5ML,PF)
0.02%
3/13/2008 99/99/9999 MILLIGRAM
CEFTRIAXONE (1X15ML) 1 GM
(1X5ML) 80 MG/ML
2%
MEDROL (DOSE PACK) 4 MG
5/30/2008 99/99/9999 INJECTION, ENFUVIRTIDE, 1 MG
FUZEON 90 MG
6/5/2008 99/99/9999 INJECTION, PER DOSE
HYALGAN 10 MG/ML
DEXAMETHASONE 1 MG
SLEEP AID MAXIMUM STRENGTH
1/1/2002
(LIQUICAP) 50 MG
35356-0124-30 KO J7644
35356-0128-15
Q0144
35356-0177-15
J0696
35356-0178-05
J1040
35356-0180-50
J2001
35356-0181-30
35356-0194-21
35356-0206-60
A4216
J7509
J1324
35356-0219-01
J7321
35356-0325-00
35356-0359-30
Q0165
J8540
37205-0120-73
Q0163
KO
Page 161 of 374
2 EA BO
PO
EA
8 MG
0.5
07/10/2007
99/99/9999
2 EA BO
PO
EA
8 MG
0.5
07/10/2007
99/99/9999
PO
PO
SC
SC
SC
EA
EA
ML
ML
ML
12.5 MG
1 GM
10 MG
10 MG
10 MG
1
0.5
10
10
10
07/24/2007
09/14/2007
09/14/2007
09/14/2007
09/14/2007
99/99/9999
99/99/9999
7/2/2009
99/99/9999
99/99/9999
12/31/2007
30 EA
3 EA
0.4 ML
0.6 ML
0.8 ML
BO
BO
SR
SR
SR
2 ML SR
IJ
ML
1 DOSE
0.5
10/19/2007
2 ML SR
IJ
ML
1 DOSE
0.5
01/01/2008
12/31/2009
2 ML SR
IJ
ML
1 DOSE
0.5
10/19/2007
12/31/2007
7/2/2009
2 ML SR
IJ
ML
1 DOSE
0.5
01/01/2008
2.5 ML SR
IJ
ML
1 DOSE
0.5
01/10/2008
7/2/2009
2.5 ML
12 EA
15 ML
10 ML
0.5 ML
0.5 ML
0.4 ML
0.4 ML
0.6 ML
0.6 ML
0.8 ML
0.8 ML
5 ML
5 ML
IJ
RC
PO
IM
SC
SC
SC
SC
SC
SC
SC
SC
IJ
IJ
ML
EA
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 DOSE
1 EA
1 GM
100 MG
0.5 MG
0.5 MG
0.5 MG
0.5 MG
0.5 MG
0.5 MG
0.5 MG
0.5 MG
10 MG
40 MG
0.5
1
0.02
1
10
10
25
25
25
25
25
25
1
1
01/10/2008
10/19/2007
10/26/2007
11/09/2007
01/25/2008
01/25/2008
01/25/2008
01/25/2008
01/25/2008
01/25/2008
01/25/2008
01/25/2008
02/08/2008
02/08/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
7/2/2009
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
IJ
ML
3 MG
02/08/2008
99/99/9999
PO
EA
8 MG
02/29/2008
99/99/9999
SR
BX
BO
VL
SR
SR
SR
SR
SR
SR
SR
SR
VL
VL
5 ML VL
60 EA BO
90 EA BO
PO
EA
25 MG
02/29/2008
99/99/9999
10 ML VL
SC
ML
50 U
03/07/2008
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
03/13/2008
99/99/9999
2.5 ML PC
15 ML BO
15 ML NA
IH
PO
IJ
ML
ML
ML
1 MG
1 GM
250 MG
0.2
0.02
4
03/13/2008
03/13/2008
05/16/2008
99/99/9999
99/99/9999
99/99/9999
5 ML NA
IJ
ML
80 MG
05/16/2008
99/99/9999
50 ML NA
IJ
ML
10 MG
05/16/2008
99/99/9999
30 ML NA
21 EA NA
1 EA PG
IV
PO
SC
ML
EA
EA
10 ML
4 MG
1 MG
0.1
1
90
05/16/2008
05/16/2008
05/30/2008
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
0.5
06/05/2008
99/99/9999
1 EA BO
1 EA BO
PO
PO
EA
EA
10 MG
0.3 MG
1
4
8/1/2008
8/8/2008
99/99/9999
99/99/9999
16 EA BX
PO
EA
50 MG
01/01/2002
9/9/2005
1 DOSE
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
37205-0270-62
Q0163
1/1/2002
37205-0270-78
Q0163
1/1/2002
37205-0277-62
Q0163
1/1/2002
37205-0277-78
Q0163
1/1/2002
37205-0565-26
Q0163
1/1/2002
37205-0565-34
38172-0020-20
Q0163
J3490
1/1/2002
1/1/2002

OR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE ELEMENTS, PER
7/9/2006 SQUARE CENTIMETER
38172-0020-20
J7342
1/1/2003
38423-0110-01
38739-0150-08
38779-0006-03
38779-0006-04
38779-0006-05
J1190
J7510
J3490
J3490
J3490
9/6/2007
9/24/2007
1/1/2002
1/1/2002
1/1/2002
38779-0008-01
J1700
38779-0008-04
J1700
38779-0008-05
J1700
38779-0008-08
J1700
38779-0008-09
J1700
38779-0011-01
J7684
38779-0011-01 KO J7684
38779-0011-03
38779-0011-03 KO J7684
38779-0011-04
KO
J7636
38779-0014-08 KO J7636
38779-0015-01
J3490
38779-0015-04
J3490
38779-0015-05
J3490
38779-0017-01
KO
J7636
38779-0014-05 KO J7636
38779-0014-08
KO
J7636
38779-0014-04 KO J7636
38779-0014-05
KO
J7636
38779-0014-01 KO J7636
38779-0014-04
KO
J7684
38779-0011-05 KO J7684
38779-0014-01
KO
J7684
38779-0011-04 KO J7684
38779-0011-05
KO
J7684
J7624
KO


COMPLETE ALLERGY MEDICINE 25 MG
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
COMPLETE ALLERGY (AF,CHERRY) 12.5

MG/5 ML
118 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
COMPLETE ALLERGY (AF,CHERRY) 12.5

MG/5 ML
DERMAGRAFT (2"X3")
240 ML BO
1 EA EA
PO
TP
ML
EA
50 MG
1 EA
0.05
1
01/01/2002
01/01/2002
99/99/9999
12/31/2002
1 EA EA
DERMAGRAFT (2"X3")
TOTECT (W/10 VIALS OF DILUENT) 500
MG
CLINDAMYCIN PHOSPHATE (U.S.P.)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
TRIAMCINOLONE ACETONIDE
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
ATROPINE SULFATE
(U.S.P.,MICRONIZED)
ATROPINE SULFATE
(U.S.P.,MICRONIZED)
ATROPINE SULFATE
(U.S.P.,MICRONIZED)
ATROPINE SULFATE
(U.S.P.,MICRONIZED)
ATROPINE SULFATE
(U.S.P.,MICRONIZED)
ATROPINE SULFATE
(U.S.P.,MICRONIZED)
ATROPINE SULFATE (U.S.P.,
MICRONIZED)
ATROPINE SULFATE (U.S.P.,
MICRONIZED)
BACITRACIN (U.S.P.,MICRONIZED)
BETAMETHASONE DIPROPIONATE
(U.S.P.,MICRONIZED)
Page 162 of 374
TP
EA
38.71
01/01/2003
07/09/2006
VL
BO
BO
BO
BO
IV
PO
NA
NA
NA
EA
ML
GM
GM
GM
250 MG
5 MG
1 EA
1 EA
1 EA
2
0.6
1
1
1
09/06/2007
09/24/2007
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA
240 ML
1 EA
1 EA
1 EA
1 SQCM
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
04/22/2002
04/25/2002
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 MG
1 EA
1 EA
1 EA
1000
1
1
1
04/22/2002
04/26/2002
04/26/2002
04/26/2002
04/25/2002
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
38779-0017-03
J7624
38779-0017-03 KO J7624
38779-0017-04
KO
J7624
38779-0017-04 KO J7624
KO

1/1/2002 99/99/9999 INJECTION, LINCOMYCIN HCL, UP TO 300 MG
1/1/2002
1/1/2004 METHOTREXATE; ORAL, 2.5 MG
1/1/2002
1/1/2002
4/25/2002 99/99/9999 INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
FLUOROURACIL (U.S.P., 5-FU)
FLUOROURACIL (U.S.P., 5-FU)
FLUOROURACIL (U.S.P.)
LINCOMYCIN HCL (U.S.P.)
METHOTREXATE (U.S.P.)
OXYTETRACYCLINE HCL (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
300 MG
300 MG
300 MG
2.5 MG
2.5 MG
2.5 MG
50 MG
1000
2
2
2
2
2
2
2
3.33333
3.33333
3.33333
400
400
400
20
01/01/2002
01/01/2002
01/28/2005
01/01/2002
01/28/2005
01/01/2002
01/28/2005
01/01/2002
01/01/2002
01/01/2002
08/26/2002
01/01/2002
01/01/2002
01/01/2002
04/25/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
04/25/2002
99/99/9999
99/99/9999
99/99/9999
01/01/2004
01/01/2004
01/01/2004
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
38779-0017-06
J7624
38779-0017-06
38779-0025-01
38779-0025-01
38779-0025-04
38779-0025-04
38779-0025-05
38779-0025-05
38779-0025-09
38779-0034-04
38779-0034-05
38779-0034-08
38779-0035-03
38779-0035-04
38779-0035-06
38779-0042-05
KO J7624
J9190
QR J9190
J9190
QR J9190
J9190
QR J9190
J9190
J2010
J2010
J2010
J8610
J8610
J8610
J2460
38779-0043-01
J2675
PROGESTERONE (U.S.P.,MICRONIZED)
1 EA BO
NA
GM
50 MG
20
09/26/2008
99/99/9999 01/01/2002 04/25/2002
38779-0043-04
J2675
1 EA BO
NA
GM
50 MG
20
01/01/2002
99/99/9999
38779-0043-05
J2675
1 EA BO
NA
GM
50 MG
20
01/01/2002
99/99/9999
38779-0043-08
J2675
PROGESTERONE MICRONIZED (U.S.P.)
1 EA BO
NA
GM
50 MG
20
04/25/2002
99/99/9999
38779-0043-09
38779-0044-03
38779-0044-04
38779-0044-05
38779-0047-03
38779-0047-04
38779-0047-05
38779-0047-08
38779-0047-09
J2675
J7506
J7506
J7506
J3140
J3140
J3140
J3140
J3140
PREDNISONE (U.S.P.)
PREDNISONE (U.S.P.)
PREDNISONE (U.S.P.)
TESTOSTERONE (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
50 MG
5 MG
5 MG
5 MG
50 MG
50 MG
50 MG
50 MG
50 MG
20
200
200
200
20
20
20
20
20
01/01/2002
03/07/2002
03/07/2002
03/07/2002
01/01/2002
01/01/2002
01/01/2002
04/30/2002
04/30/2002
99/99/9999
04/25/2002
04/25/2002
04/25/2002
10/09/2003
10/09/2003
01/01/2004
01/01/2004
01/01/2004
38779-0051-01
J7684

1/1/2002
4/30/2002
4/30/2002
TRIAMCINOLONE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
04/30/2002
99/99/9999
38779-0051-01 KO J7684
38779-0051-03
QR
KO
KO
J7684
38779-0051-04 KO J7684
38779-0051-05
QR
J7684
38779-0051-03 KO J7684
38779-0051-04
KO
QR
KO
J7684
38779-0051-05 KO J7684
1 EA BO
NA
GM
1 MG
1000
04/30/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
04/30/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
04/30/2002
99/99/9999
38779-0054-03
J3150
1/1/2002
1 EA BO
NA
GM
100 MG
10
01/01/2002
10/09/2003
38779-0054-04
J3150
1/1/2002
1 EA BO
NA
GM
100 MG
10
01/01/2002
10/09/2003
38779-0054-05
38779-0057-01
38779-0057-04
38779-0057-05
38779-0057-09
38779-0063-05
38779-0063-08
38779-0063-09
J3150
J2675
J2675
J2675
J2675
J3490
J3490
J3490
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
JR
JR
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
100 MG
50 MG
50 MG
50 MG
50 MG
1 EA
1 EA
1 EA
10
20
20
20
20
1
1
1
01/01/2002
09/26/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10/09/2003
99/99/9999 01/01/2002 04/25/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
38779-0070-01
J1095
1/1/2002
1 EA BO
NA
GM
8 MG
125
01/01/2002
04/25/2002
38779-0070-03
J1095
1/1/2002
1 EA BO
NA
GM
8 MG
125
01/01/2002
04/25/2002
38779-0070-04
J1095
1/1/2002

PROGESTERONE (USP, WETTABLE)
BENZOCAINE (U.S.P.)
BENZOCAINE (U.S.P.)
BENZOCAINE (U.S.P.)
DEXAMETHASONE ACETATE
MONOHYDRATE (U.S.P.,MICRONIZED)
1 EA BO
NA
GM
8 MG
125
01/01/2002
04/25/2002
KO
Page 163 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
38779-0017-01 KO J7624
NDC
HCPCS
20
20
38779-0071-01
J7638
38779-0071-01 KO J7638
38779-0071-03
KO
J7638
38779-0103-03 KO J7638
38779-0103-04
KO
J7638
38779-0103-01 KO J7638
38779-0103-03
KO
J7638
38779-0071-08 KO J7638
38779-0082-04
J2000
38779-0082-04
J2001
38779-0082-05
J2000
38779-0082-05
J2001
38779-0082-08
J2000
38779-0082-08
J2001
38779-0082-09
J2000
38779-0082-09
J2001
38779-0101-08
J3350
38779-0101-09
J3350
38779-0103-01
KO
J7638
38779-0071-05 KO J7638
38779-0071-08
KO
J7638
38779-0071-04 KO J7638
38779-0071-05
KO
J7638
38779-0071-03 KO J7638
38779-0071-04
KO
J7638
38779-0103-04 KO J7638
38779-0104-03
J1230
38779-0104-04
J1230
38779-0104-05
J1230
38779-0123-04
J3490
38779-0123-05
J3490
38779-0123-08
J3490
38779-0123-09
J3490
KO

38779-0126-01
J3490
38779-0126-03
J3490
38779-0126-04
J3490
38779-0126-06
38779-0141-03
38779-0141-04
38779-0141-06
J3490
J7509
J7509
J7509

38779-0142-03
J7509
38779-0142-04
J7509
38779-0142-06
J7509
38779-0144-03
J1030
38779-0144-04
J1030
38779-0144-05
J1030
38779-0144-06
38779-0146-04
38779-0146-05
38779-0146-08
38779-0146-09
J1030
J3490
J3490
J3490
J3490
1/1/2002
1/1/2002
1/1/2002
1/1/2002
9/3/2002
38779-0150-01
J7510
1/1/2002

PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
UREA (U.S.P.)
UREA (U.S.P.)
PHOSPHATE (U.S.P.,MICRONIZED)
METHADONE HCL (U.S.P.)
RIFAMPIN (U.S.P.)
RIFAMPIN (U.S.P.)
RIFAMPIN (U.S.P.)
RIFAMPIN (U.S.P.)
BETAMETHASONE ACETATE
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
METHYLPREDNISOLONE (U.S.P.)
METHYLPREDNISOLONE
(U.S.P.,MICRONIZED)
METHYLPREDNISOLONE
(U.S.P.,MICRONIZED)
METHYLPREDNISOLONE
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
METRONIDAZOLE (U.S.P.)
PREDNISOLONE ANHYDROUS
(U.S.P.,MICRONIZED)
Page 164 of 374
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA NA
NA
GM
1 MG
1000
09/03/2002
99/99/9999
1 EA NA
NA
GM
1 MG
1000
09/03/2002
99/99/9999
1 EA NA
NA
GM
1 MG
1000
09/03/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
40 GM
40 GM
1000
4
100
4
100
4
100
4
100
0.025
0.025
09/03/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
08/26/2002
01/01/2004
01/01/2002
01/01/2002
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
NA
BO
BO
BO
BO
BO
BO
JR
JR
BO
BO
1 EA BO
NA
GM
1 MG
1000
03/08/2002
04/25/2002
1 EA BO
NA
GM
1 MG
1000
03/08/2002
04/25/2002
1 EA BO
NA
GM
1 MG
1000
03/08/2002
04/25/2002
1 EA BO
NA
GM
1 MG
1000
03/08/2002
04/25/2002
1 EA BO
NA
GM
1 MG
1000
03/08/2002
04/25/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
10 MG
10 MG
10 MG
1 EA
1 EA
1 EA
1 EA
1000
100
100
100
1
1
1
1
03/08/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/25/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 EA
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 EA
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 EA
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 EA
4 MG
4 MG
4 MG
1
250
250
250
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
04/25/2002
04/25/2002
04/25/2002
1 EA BO
NA
GM
4 MG
250
01/01/2002
99/99/9999
1 EA BO
NA
GM
4 MG
250
01/01/2002
99/99/9999
1 EA BO
NA
GM
4 MG
250
01/01/2002
99/99/9999
1 EA BO
NA
GM
40 MG
25
01/01/2002
99/99/9999
1 EA BO
NA
GM
40 MG
25
01/01/2002
99/99/9999
1 EA BO
NA
GM
40 MG
25
09/03/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
40 MG
1 EA
1 EA
1 EA
1 EA
25
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/03/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
5 MG
200
01/01/2002
04/25/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
38779-0150-03
J7510
38779-0150-04
J7510
38779-0150-05
J7510
38779-0150-08
J7510
38779-0150-09
J7510
38779-0151-03
38779-0151-05
38779-0154-03
38779-0154-04
38779-0154-05
J7510
J7510
J7506
J7506
J7506

38779-0154-08
J7506
38779-0154-09
38779-0163-03
38779-0163-04
38779-0163-05
38779-0163-08
38779-0163-09
38779-0164-03
38779-0164-04
38779-0164-05
38779-0164-08
38779-0164-09
J7506
J3140
J3140
J3140
J3140
J3140
J1070
J1070
J1070
J1070
J1070
8/26/2002
1/1/2002
1/1/2002
1/1/2002
4/30/2002
4/30/2002
1/1/2002
1/1/2002
1/1/2002
4/30/2002
1/1/2002
38779-0165-03
J3150
38779-0165-04
J3150
38779-0165-05
J3150
38779-0165-08
38779-0166-01
38779-0166-03
38779-0166-04
38779-0166-05
J3150
J3302
J3302
J3302
J3302
4/30/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
38779-0171-01
J7669
1/1/2002
38779-0171-01 KO J7669
38779-0171-04
J7669
38779-0171-04 KO J7669
38779-0171-05
38779-0171-09
KO
KO
1/1/2002
1/1/2002
KO
J7669
38779-0171-09 KO J7669
38779-0173-01
Q4075
38779-0173-01
J0133
38779-0173-04
Q4075
38779-0173-04
J0133
38779-0173-05
Q4075
J0133
38779-0173-05
38779-0173-08
Q4075
38779-0173-08
J0133
1/1/2002
1/1/2002
J7669
38779-0171-08 KO J7669
1/1/2002
1/1/2002
J7669
38779-0171-05 KO J7669
38779-0171-08
KO
1/1/2002
1/1/2002
KO
1/1/2002
10/1/2003
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006

(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(ANHYDROUS,MICRONIZED)
(U.S.P.,MICRONIZED)
PREDNISOLONE HYDROUS
(U.S.P.,MICRONIZED)
PREDNISOLONE HYDROUS
PREDNISONE (U.S.P.,MICRONIZED)
PREDNISONE ANHYDROUS
(U.S.P.,MICRONIZED)
PREDNISONE ANHYDROUS
(U.S.P.,MICRONIZED)
TESTOSTERONE CYPIONATE (U.S.P.)
(USP,MICRONIZED)
(USP,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
TRIAMCINOLONE DIACETATE (U.S.P.)
TRIAMCINOLONE DIACETATE (USP)

METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL
PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM
METAPROTERENOL SULFATE (U.S.P.)
99/99/9999 PER 10 MILLIGRAMS
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
Page 165 of 374
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA NA
NA
GM
5 MG
200
04/25/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
09/03/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
5 MG
5 MG
5 MG
5 MG
5 MG
200
200
200
200
200
03/08/2002
03/08/2002
03/07/2002
01/01/2002
01/01/2002
04/25/2002
04/25/2002
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
5 MG
200
08/26/2002
99/99/9999
1
1
1
1
1
1
1
1
1
1
1
BO
BO
JR
BO
JR
JR
BO
BO
BO
BO
JR
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
5 MG
50 MG
50 MG
50 MG
50 MG
50 MG
100 MG
100 MG
100 MG
100 MG
100 MG
200
20
20
20
20
20
10
10
10
10
10
08/26/2002
01/01/2002
01/01/2002
01/01/2002
04/30/2002
04/30/2002
01/01/2002
01/01/2002
01/01/2002
04/30/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
100 MG
10
01/01/2002
99/99/9999
1 EA BO
NA
GM
100 MG
10
01/01/2002
99/99/9999
1 EA BO
NA
GM
100 MG
10
01/01/2002
99/99/9999
1
1
1
1
1
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
100 MG
5 MG
5 MG
5 MG
5 MG
10
200
200
200
200
04/30/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
05/12/2004
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/26/2008
99/99/9999 01/01/2002 03/29/2004
100
1 EA BO
NA
GM
10 MG
100
09/26/2008
99/99/9999 01/01/2002 03/29/2004
100
1 EA BO
NA
GM
10 MG
100
09/26/2008
99/99/9999 01/01/2002 03/29/2004
100
1 EA BO
NA
GM
10 MG
100
09/26/2008
99/99/9999 01/01/2002 03/29/2004
100
1 EA BO
NA
GM
10 MG
100
09/26/2008
99/99/9999 01/01/2002 03/29/2004
100
1 EA BO
NA
GM
10 MG
100
09/26/2008
99/99/9999 01/01/2002 03/29/2004
100
1 EA BO
NA
GM
10 MG
100
09/26/2008
99/99/9999 01/01/2002 03/29/2004
100
1 EA BO
NA
GM
10 MG
100
09/26/2008
99/99/9999 01/01/2002 03/29/2004
100
1 EA BO
NA
GM
10 MG
100
09/26/2008
99/99/9999 01/01/2002 03/29/2004
100
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
10 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
100
200
200
200
200
200
200
200
200
09/26/2008
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
99/99/9999 01/01/2002 03/29/2004

12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
100
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
38779-0180-04
Q0165
3/8/2002
38779-0180-05
Q0165
1/1/2002
38779-0180-08
38779-0183-03
38779-0183-04
38779-0183-05
38779-0183-08
Q0165
J1800
J1800
J1800
J1800
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
38779-0184-04
J7619
1/1/2002
38779-0184-04 KO J7619
38779-0184-05
J7619
38779-0184-05 KO J7619
38779-0184-08
38779-0185-04
38779-0185-05
38779-0185-08
38779-0185-09
J7624
1/1/2007
1/1/2005
KO
1/1/2005
1/1/2007
KO
1/1/2007
1/1/2005
KO
1/1/2005
1/1/2007
KO
1/1/2007
1/1/2005
KO
J7609
38779-0185-09 KO J7609
38779-0189-03
J1320
38779-0189-04
J1320
38779-0189-05
J1320
38779-0191-03
J0285
38779-0191-04
J0285
38779-0191-05
J0285
38779-0191-06
J0285
38779-0191-08
J0285
38779-0191-09
J0285
38779-0194-03
J0515
38779-0194-04
J0515
J0515
38779-0194-06
38779-0195-01
KO
J7613
38779-0185-09 KO J7613
1/1/2005
1/1/2007
J7609
38779-0185-08 KO J7609
38779-0185-09
KO
J7613
38779-0185-08 KO J7613
1/1/2002
1/1/2005
J7609
38779-0185-05 KO J7609
38779-0185-08
KO
J7613
38779-0185-05 KO J7613
1/1/2002
1/1/2002
J7609
38779-0185-04 KO J7609
38779-0185-05
KO
J7613
38779-0185-04 KO J7613
1/1/2002
1/1/2002
J7619
38779-0184-08 KO J7619
38779-0185-04
KO
1/1/2005
1/1/2007
KO
1/1/2007
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
11/27/2003
1/1/2002
1/1/2002
1/1/2002
4/19/2002
1/1/2002
1/1/2002

PROCHLORPERAZINE MALEATE (U.S.P.)
PROPRANOLOL HCL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL SULFATE (U.S.P.)
ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
99/99/9999 THROUGH DME, UNIT DOSE, 1 MG
99/99/9999 INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG
AMITRIPTYLINE HCL (U.S.P.)
AMPHOTERICIN B (U.S.P.)
BENZTROPINE MESYLATE (U.S.P.)
PHOSPHATE (U.S.P.)
Page 166 of 374
1 EA BO
NA
GM
10 MG
100
03/08/2002
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
10 MG
1 MG
1 MG
1 MG
1 MG
100
1000
1000
1000
1000
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/01/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/01/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/01/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/01/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
04/25/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
04/25/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
BO
BO
BO
BO
BO
BO
JR
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
20 MG
20 MG
20 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
1 MG
1 MG
1 MG
1000
50
50
50
20
20
20
20
20
20
1000
1000
1000
01/01/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
11/27/2003
01/01/2002
01/01/2002
01/01/2002
04/19/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
38779-0195-03
J7624
38779-0195-03 KO J7624
38779-0195-06
KO
J7624
38779-0195-06 KO J7624
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
J0945
1/1/2002
BROMPHENIRAMINE MALEATE (U.S.P.)
1 EA BO
NA
GM
10 MG
100
01/01/2002
01/01/2004
38779-0197-05
J0945
1/1/2002
1 EA BO
NA
GM
10 MG
100
01/01/2002
01/01/2004
J7626
BUDESONIDE (MICRONIZED)
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.25 MG
2000
04/19/2002
12/31/2005
1 EA BO
NA
GM
0.25 MG
2000
04/19/2002
12/31/2005
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.25 MG
2000
09/26/2008
99/99/9999 04/19/2002 04/25/2002
2000
2000
38779-0198-00 KO J7626
38779-0198-00
38779-0198-00 KO J7627
38779-0198-03
KO
J7626
38779-0198-03 KO J7626
38779-0198-03
KO
J7627
KO
J7627
38779-0198-03 KO J7627
BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
1/1/2006 99/99/9999 THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG
KO
J7626
38779-0198-04 KO J7626
1 EA BO
NA
GM
0.25 MG
2000
09/26/2008
99/99/9999 04/19/2002 04/25/2002
BUDESONIDE
(MICRONIZED,MICRONIZED)
1 EA NA
NA
GM
0.25 MG
2000
06/02/2003
12/31/2005
BUDESONIDE
BUDESONIDE
BUDESONIDE
38779-0198-04
38779-0198-05
38779-0198-05 KO J7626
38779-0198-05
KO
J7626
38779-0198-06 KO J7626
38779-0198-06
KO
J7627
38779-0198-05 KO J7627
38779-0198-06
KO
J7626
KO
J7627
38779-0198-06 KO J7627
38779-0215-00
J1160
38779-0215-06
J1160
38779-0215-09
J1160
J1165
38779-0216-04
38779-0216-05
J1165
38779-0216-08
J1165
38779-0226-04
J1940
38779-0226-05
J1940
38779-0226-08
J1940
1/1/2002
1/1/2006
KO
1/1/2006
2/5/2002
2/5/2002
2/5/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
38779-0228-04
Q0178
1/1/2002
38779-0228-05
Q0178
1/1/2002
38779-0230-03
J7644
1/1/2002
BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON12/31/2005 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG BUDESONIDE (MICRONIZED)
99/99/9999 THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG
DIGOXIN (U.S.P.)
DIGOXIN (U.S.P.)
DIGOXIN (U.S.P.)
PHENYTOIN SODIUM (U.S.P.)
FUROSEMIDE (U.S.P.)
FUROSEMIDE (U.S.P.)
FUROSEMIDE (U.S.P.)
HYDROXYZINE PAMOATE (U.S.P.)
IPRATROPIUM BROMIDE
Page 167 of 374
1 EA NA
NA
GM
0.25 MG
2000
06/02/2003
12/31/2005
1 EA NA
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA NA
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
0.5 MG
0.5 MG
0.5 MG
0.5 MG
50 MG
50 MG
50 MG
20 MG
20 MG
20 MG
2000
2000
2000
2000
20
20
20
50
50
50
01/01/2006
02/05/2002
02/05/2002
02/05/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
50 MG
20
01/01/2002
99/99/9999
1 EA BO
NA
GM
50 MG
20
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

38779-0197-04
38779-0198-00
KO
HCPCS Mod
KO
NDC Mod
38779-0195-01 KO J7624
NDC
HCPCS
38779-0230-03
J7645
38779-0230-03 KO J7645
38779-0230-04
J7644
38779-0230-04 KO J7644
38779-0230-04
KO
J7659
38779-0249-04 KO J7659
38779-0249-05
KO
J7659
38779-0249-03 KO J7659
38779-0249-04
KO
J7645
38779-0230-06 KO J7645
38779-0246-03
J3310
38779-0246-04
J3310
38779-0246-06
J3310
38779-0247-04
J7799
38779-0247-05
J7799
38779-0249-03
KO
J7644
38779-0230-06 KO J7644
38779-0230-06
KO
J7645
38779-0230-05 KO J7645
38779-0230-06
KO
J7644
38779-0230-05 KO J7644
38779-0230-05
KO
J7645
38779-0230-04 KO J7645
38779-0230-05
KO
KO
J7659
38779-0249-05 KO J7659
38779-0253-04
J2550
38779-0253-05
J2550
38779-0253-08
J2550
J2550
38779-0253-09
38779-0274-03
J3370
38779-0274-04
J3370
38779-0274-05
J3370
38779-0274-06
J3370
38779-0281-04
J1240
38779-0281-05
J1240
38779-0281-08
J1240
38779-0282-04
J1200
38779-0282-05
J1200
38779-0282-08
J1200
38779-0282-09
J1200
38779-0295-03
J3490
38779-0295-03
J0278
J3490
38779-0295-04
38779-0295-04
J0278
38779-0295-05
J3490
38779-0295-05
J0278
KO

IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
3/18/2002
PERPHENAZINE (U.S.P.)
3/18/2002
9/3/2002
ISOPROTERENOL HCL (U.S.P.)
5/6/2002
1/1/2004 MILLIGRAM
5/6/2002
1/1/2004 MILLIGRAM
5/6/2002
1/1/2004 MILLIGRAM
5/6/2002
1/1/2004 MILLIGRAM
5/6/2002
1/1/2004 MILLIGRAM
5/6/2002
1/1/2004 MILLIGRAM
PROMETHAZINE HCL (U.S.P.)
PROMETHAZINE HCL
VANCOMYCIN HCL (U.S.P.)
DIMENHYDRINATE (U.S.P.)
AMIKACIN SULFATE (U.S.P.)
Page 168 of 374
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
1 MG
5 MG
5 MG
5 MG
1 EA
1 EA
1000
200
200
200
1
1
01/01/2007
03/18/2002
03/18/2002
09/03/2002
01/01/2002
01/01/2002
99/99/9999
01/01/2004
01/01/2004
01/01/2004
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
05/06/2002
01/01/2004
1 EA BO
NA
GM
1 MG
1000
05/06/2002
01/01/2004
1 EA BO
NA
GM
1 MG
1000
05/06/2002
01/01/2004
1 EA BO
NA
GM
1 MG
1000
05/06/2002
01/01/2004
1 EA BO
NA
GM
1 MG
1000
05/06/2002
01/01/2004
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
50 MG
50 MG
50 MG
50 MG
500 MG
500 MG
500 MG
500 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
1000
20
20
20
20
2
2
2
2
20
20
20
20
20
20
20
1
10
1
10
1
10
05/06/2002
01/01/2002
01/01/2002
01/01/2002
09/03/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/05/2002
02/05/2002
02/05/2002
01/01/2002
01/01/2002
01/01/2002
04/22/2002
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
04/25/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
38779-0230-03 KO J7644
NDC
HCPCS
38779-0298-04
38779-0298-05
38779-0301-03
J3410
J3410
J7699
38779-0301-03
J7632
38779-0301-03 KO J7632
38779-0301-04
J7699
38779-0301-04
KO
J7632
38779-0301-08 KO J7632
38779-0301-09
J7699
38779-0301-09
KO
J7632
38779-0301-05 KO J7632
38779-0301-08
J7699
38779-0301-08
KO
J7632
38779-0301-04 KO J7632
38779-0301-05
J7699
38779-0301-05
KO
J7632
38779-0301-09 KO J7632
KO

CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT,
1/1/2008 99/99/9999 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
38779-0303-03
J1110
38779-0303-04
J1110
2/5/2002
38779-0303-06
38779-0305-04
38779-0305-05
38779-0305-08
38779-0305-09
38779-0310-04
38779-0310-05
38779-0310-09
38779-0312-03
38779-0312-04
38779-0312-06
J1110
J3000
J3000
J3000
J3000
J2675
J2675
J2675
J7501
J7501
J7501
1/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
38779-0319-01
J7682
1/1/2002
38779-0319-01 KO J7682
38779-0319-01
38779-0319-01 KO J7685
38779-0319-03
38779-0319-04
38779-0319-05
J7685
1/1/2002
1/1/2007
KO
1/1/2007
5/13/2002
KO
5/13/2002
1/1/2007
KO
J7682
38779-0319-05 KO J7682
38779-0319-05
KO
J7685
38779-0319-04 KO J7685
1/1/2007
1/1/2002
J7682
38779-0319-04 KO J7682
38779-0319-04
KO
J7685
38779-0319-03 KO J7685
1/1/2002
1/1/2007
J7682
38779-0319-03 KO J7682
38779-0319-03
KO
J7685
1/1/2007
5/13/2002
KO
5/13/2002
1/1/2007

1/1/2004 INJECTION, STREPTOMYCIN, UP TO 1 GM
99/99/9999 AZATHIOPRINE, PARENTERAL, 100 MG
TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
99/99/9999 THROUGH DME, UNIT DOSE FORM, PER 300 MILLIGRAMS

CROMOLYN SODIUM (U.S.P.)
1 EA BO
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
25 MG
25 MG
1 EA
40
40
1
04/30/2002
04/30/2002
01/01/2007
99/99/9999
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA JR
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA JR
NA
GM
10 MG
100
01/01/2008
99/99/9999

(U.S.P.)
(U.S.P.)
(U.S.P.)
STREPTOMYCIN SULFATE
PROGESTERONE (MILLED, U.S.P.)
AZATHIOPRINE (U.S.P.)
1 EA JR
NA
GM
10 MG
100
01/01/2008
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
02/05/2002
04/25/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
1 GM
1 GM
1 GM
1 GM
50 MG
50 MG
50 MG
100 MG
100 MG
100 MG
1000
1
1
1
1
20
20
20
10
10
10
01/01/2002
04/01/2002
04/01/2002
04/01/2002
04/01/2002
01/01/2002
01/01/2002
09/26/2008
01/01/2002
01/01/2002
01/01/2002
99/99/9999
01/01/2004
01/01/2004
01/01/2004
01/01/2004
03/29/2004
03/29/2004
99/99/9999 01/01/2002 03/29/2004
99/99/9999
99/99/9999
99/99/9999
TOBRAMYCIN SULFATE (U.S.P.)
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
05/13/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
05/13/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
05/13/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
05/13/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
Page 169 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
20
38779-0319-06
J7682
38779-0319-06 KO J7682
38779-0319-06
KO
J7685
38779-0319-06 KO J7685
38779-0323-04
J0120
38779-0323-05
J0120
38779-0323-08
J0120
38779-0324-03
J1730
38779-0324-04
J1730
38779-0324-06
J1730
38779-0330-01
J1630
38779-0330-03
J1630
38779-0330-04
J1630
38779-0330-05
J1630
38779-0330-06
J1630
KO

1/1/2007 99/99/9999 THROUGH DME, UNIT DOSE FORM, PER 300 MILLIGRAMS
1/1/2002 12/31/2006 MILLIGRAMS
1/1/2002 12/31/2006 MILLIGRAMS
5/13/2002
1/1/2004 INJECTION, TETRACYCLINE, UP TO 250 MG
5/13/2002
5/13/2002
38779-0337-00
J0640
1/1/2002
38779-0337-03
J0640
1/1/2002
38779-0337-04
J0640
1/1/2002
38779-0337-06
J0640
1/1/2002
38779-0337-09
J0640
4/25/2002
38779-0364-01
J7622
2/7/2002
38779-0364-01 KO J7622
38779-0364-03
38779-0364-03 KO J7622
38779-0364-06
38779-0381-03
38779-0381-05
KO
KO
1/1/2002
9/3/2002
KO
9/3/2002
1/1/2002
KO
J7681
38779-0381-05 KO J7681
38779-0388-03
J0475
38779-0388-04
J0475
J0475
38779-0388-05
38779-0388-09
J0475
2/7/2002
1/1/2002
J7681
38779-0381-04 KO J7681
2/7/2002
2/7/2002
J7681
38779-0381-03 KO J7681
38779-0381-04
KO
J7681
38779-0381-01 KO J7681
2/7/2002
2/7/2002
J7622
38779-0364-06 KO J7622
38779-0381-01
KO
J7622
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
1/1/2002
1/1/2002
4/22/2002
38779-0393-03
J0520
1/1/2002
38779-0393-04
J0520
1/1/2002
38779-0393-05
J0520
4/19/2002
38779-0393-06
38779-0400-00
38779-0400-04
38779-0400-05
38779-0400-08
38779-0400-09
38779-0403-01
38779-0403-04
38779-0403-05
J0520
J2690
J2690
J2690
J2690
J2690
J2765
J2765
J2765
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
11/27/2003
4/25/2002
1/1/2002
1/1/2002

BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
99/99/9999 INJECTION, BACLOFEN, 10 MG
INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, UP TO 5
99/99/9999 MG
99/99/9999 MG
99/99/9999 MG
99/99/9999 MG
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999

TETRACYCLINE (U.S.P.)
DIAZOXIDE (U.S.P.)
DIAZOXIDE (U.S.P.)
DIAZOXIDE (U.S.P.)
HALOPERIDOL (U.S.P.)
LEUCOVORIN CALCIUM HYDRATED
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
BECLOMETHASONE DIPROPIONATE
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
300 MG
250 MG
250 MG
250 MG
300 MG
300 MG
300 MG
5 MG
5 MG
5 MG
5 MG
5 MG
3.33333
4
4
4
3.33333
3.33333
3.33333
200
200
200
200
200
01/01/2007
05/13/2002
05/13/2002
05/13/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
01/01/2004
01/01/2004
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
50 MG
20
01/01/2002
01/01/2004
1 EA BO
NA
GM
50 MG
20
01/01/2002
01/01/2004
1 EA BO
NA
GM
50 MG
20
01/01/2002
04/25/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
01/01/2004
1 EA BO
NA
GM
50 MG
20
04/25/2002
01/01/2004
1 EA BO
NA
GM
1 MG
1000
02/07/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
02/07/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
02/07/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
02/07/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
02/07/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
02/07/2002
99/99/9999
TERBUTALINE SULFATE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/03/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/03/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2002
99/99/9999

BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
BO
BO
JR
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1 MG
10 MG
10 MG
10 MG
10 MG
1000
100
100
100
100
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/22/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
BETHANECHOL CHLORIDE (U.S.P.)
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
04/19/2002
99/99/9999

PROCAINAMIDE HCL (U.S.P.)
METOCLOPRAMIDE HCL (U.S.P.)
1
1
1
1
1
1
1
1
1
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
5 MG
1 GM
1 GM
1 GM
1 GM
1 GM
10 MG
10 MG
10 MG
200
1
1
1
1
1
100
100
100
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
11/27/2003
04/25/2002
01/01/2002
01/01/2002
99/99/9999
11/26/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 170 of 374
EA
EA
EA
EA
EA
EA
EA
EA
EA
BO
BO
BO
BO
BO
JR
JR
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
38779-0319-05 KO J7685
NDC
HCPCS
38779-0405-01
J7638
38779-0405-01 KO J7638
38779-0405-03
KO
J7641
38779-0406-06 KO J7641
38779-0406-09
KO
J7641
38779-0406-03 KO J7641
38779-0406-06
KO
J7641
38779-0406-00 KO J7641
38779-0406-03
KO
J7638
38779-0405-06 KO J7638
38779-0406-00
KO
J7638
38779-0405-05 KO J7638
38779-0405-06
KO
J7638
38779-0405-04 KO J7638
38779-0405-05
KO
J7638
38779-0405-03 KO J7638
38779-0405-04
KO
J7641
38779-0406-09 KO J7641
38779-0407-03
J0760
38779-0407-06
J0760
38779-0423-04
J3230
38779-0423-05
J3230
38779-0436-04
J7799
38779-0436-05
J7799
38779-0437-00
J1330
38779-0437-01
J1330
38779-0437-03
J1330
38779-0437-06
J1330
KO

FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
1/1/2002 99/99/9999 THROUGH DME, UNIT DOSE, PER MILLIGRAM
1/1/2002
1/1/2004 INJECTION, COLCHICINE, PER 1MG
1/1/2002
1/1/2002
1/1/2004 INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG
4/23/2002 4/25/2002 INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG
1/1/2002
1/1/2002
DEXAMETHASONE (U.S.P.,MICRONIZED)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
04/23/2002
04/25/2002
1 EA BO
NA
GM
1 MG
1000
04/23/2002
04/25/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
04/26/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
1 MG
1 MG
50 MG
50 MG
1 EA
1 EA
0.2 MG
0.2 MG
0.2 MG
0.2 MG
1000
1000
1000
20
20
1
1
5000
5000
5000
5000
04/26/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/21/2002
08/21/2002
01/01/2002
04/23/2002
01/01/2002
01/01/2002
99/99/9999
01/01/2004
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2004
04/25/2002
01/01/2004
01/01/2004
1 EA BO
NA
GM
50 MG
20
01/01/2002
01/01/2004
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
50 MG
60 MG
60 MG
60 MG
20
16.66666
16.66666
16.66666
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
03/29/2004
03/29/2004
03/29/2004
38779-0441-03
J1710
1/1/2002
38779-0441-06
38779-0452-04
38779-0452-05
38779-0452-08
J1710
J2360
J2360
J2360
1/1/2002
1/1/2002
1/1/2002
1/1/2002

38779-0454-03
J2440
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
99/99/9999
38779-0454-04
J2440
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
99/99/9999
38779-0454-05
38779-0468-03
38779-0468-04
38779-0468-05
38779-0468-06
38779-0486-05
38779-0486-08
38779-0495-04
J2440
J3420
J3420
J3420
J3420
J0282
J0282
J7699

AMIODARONE HCL
AMIODARONE HCL
ACETYLCYSTEINE (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
BO
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
60 MG
1000 MCG
1000 MCG
1000 MCG
1000 MCG
30 MG
30 MG
1 EA
16.66666
1000
1000
1000
1000
33.33333
33.33333
1
01/01/2002
04/25/2003
04/25/2003
04/25/2003
04/25/2003
01/28/2002
01/28/2002
01/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2004
01/01/2004
12/31/2007
38779-0495-04
J7604
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
38779-0495-04 KO J7604
38779-0495-05
J7699
38779-0495-05
1/1/2008
KO
J7604
38779-0495-05 KO J7604
38779-0495-08
J7699
38779-0495-08
1/1/2002
4/25/2003
4/25/2003
4/25/2003
4/25/2003
1/28/2002
1/28/2002
1/1/2007
1/1/2008
KO
J7604
38779-0495-08 KO J7604
38779-0495-09
J7699
1/1/2008
1/1/2007
1/1/2008
1/1/2007
1/1/2008
KO
1/1/2008
1/1/2007

ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
99/99/9999 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM
Page 171 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
FLUNISOLIDE ANHYDROUS
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
COLCHICINE (U.S.P.)
COLCHICINE (U.S.P.)
CHLORPROMAZINE HCL (U.S.P.)
EPINEPHRINE (U.S.P.)
ERGONOVINE MALEATE (U.S.P.)
ERGONOVINE MALEATE
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
ORPHENADRINE CITRATE (U.S.P.)
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
38779-0495-09
J7604
38779-0495-09 KO J7604
38779-0501-00
J1790
38779-0501-06
J1790
38779-0506-03
J9096
38779-0506-04
J9096
38779-0506-05
J9096
38779-0516-03
J2545
38779-0516-06
38779-0534-05
38779-0534-08
38779-0534-09
38779-0536-04
38779-0536-05
38779-0536-08
38779-0536-09
38779-0553-07
38779-0553-09
38779-0561-01
38779-0561-03
38779-0561-04
38779-0561-06
38779-0562-05
38779-0562-08
38779-0568-03
38779-0568-04
38779-0568-06
38779-0571-05
38779-0571-08
38779-0599-01
38779-0599-08
38779-0599-09
38779-0632-04
38779-0632-05
38779-0632-08
38779-0632-09
38779-0652-06
38779-0652-09
38779-0655-04
38779-0655-05
38779-0655-08
38779-0660-03
38779-0660-04
38779-0660-05
38779-0660-06
38779-0673-03
38779-0673-04
38779-0673-05
38779-0673-07
38779-0679-03
38779-0679-04
38779-0679-05
38779-0710-03
38779-0710-04
38779-0722-03
38779-0722-06
38779-0722-09
38779-0731-01
38779-0731-03
38779-0731-04
38779-0731-05
38779-0731-06
38779-0767-03
38779-0767-06
38779-0784-03
38779-0784-06
38779-0813-04
38779-0813-05
38779-0813-08
38779-0813-09
38779-0853-04
38779-0853-05
38779-0855-03
38779-0855-04
38779-0873-04
J2545
J3490
J3490
J3490
J2780
J2780
J2780
J2780
J9290
J9290
J0735
J0735
J0735
J0735
J0280
J0280
J0970
J0970
J0970
J0280
J0280
J2150
J2150
J2150
J7699
J7699
J7699
J7699
J9000
J9000
J3490
J3490
J3490
J7516
J7516
J7516
J7516
J2271
J2271
J2271
J2271
J0745
J0745
J0745
J1980
J1980
J9360
J9360
J9360
J1170
J1170
J1170
J1170
J1170
J2310
J2310
J9182
J9182
J3000
J3000
J3000
J3000
J2560
J2560
J3130
J3130
J3490
KO

1/1/2008 99/99/9999 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM
DROPERIDOL (U.S.P.)
DROPERIDOL (U.S.P.)
CYCLOPHOSPHAMIDE (U.S.P.)
PENTAMIDINE ISETHIONATE (BP)
4/25/2002
1/1/2004 PER 300 MG
PENTAMIDINE ISETHIONATE (BP)
4/25/2002
1/1/2004 PER 300 MG
CIPROFLOXACIN HCL (U.S.P.)
5/20/2002 99/99/9999 INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG
RANITIDINE HCL (U.S.P.)
5/24/2002 99/99/9999 MITOMYCIN, 20 MG
MITOMYCIN (U.S.P.)
5/29/2002 99/99/9999 MITOMYCIN, 20 MG
MITOMYCIN (U.S.P.)
1/1/2002 99/99/9999 INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG
CLONIDINE HCL (U.S.P.)
1/28/2002
1/28/2002
ESTRADIOL VALERATE (U.S.P.)
AMINOPHYLLINE DIHYDRATE (U.S.P.)
AMINOPHYLLINE DIHYDRATE (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (USP,D-MANNITOL)
GENTAMICIN SULFATE (U.S.P.)
4/24/2002
DOXORUBICIN HCL (U.S.P.)
4/24/2002
FAMOTIDINE (U.S.P.)
FAMOTIDINE (U.S.P.)
FAMOTIDINE (U.S.P.)
2/6/2002 99/99/9999 CYCLOSPORIN, PARENTERAL, 250 MG
CYCLOSPORIN A
CYCLOSPORIN A
CYCLOSPORIN A
CYCLOSPORIN A
MORPHINE SULFATE (U.S.P.)
CODEINE PHOSPHATE (U.S.P.)
4/30/2002
HYOSCYAMINE SULFATE (U.S.P.)
4/30/2002
5/9/2002 10/9/2003 INJECTION, VINBLASTINE SULFATE, 1 MG
VINBLASTINE SULFATE (U.S.P.)
5/9/2002
1/1/2004 INJECTION, VINBLASTINE SULFATE, 1 MG
5/9/2002
HYDROMORPHONE HCL (U.S.P.)
HYDROMORPHONE HCL (1X100GM)
NALOXONE HCL DIHYDRATE (U.S.P.)
4/25/2002 99/99/9999 ETOPOSIDE, 100 MG
ETOPOSIDE (U.S.P.)
4/25/2002 99/99/9999 ETOPOSIDE, 100 MG
ETOPOSIDE (U.S.P.)
5/15/2002 99/99/9999 INJECTION, STREPTOMYCIN, UP TO 1 GM
STREPTOMYCIN SULFATE (B.P.)
PHENOBARBITAL SODIUM (U.S.P.)
Page 172 of 374
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
1 GM
5 MG
5 MG
1 GM
1 GM
1 GM
1
200
200
1
1
1
01/01/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
04/25/2002
01/01/2004
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
300 MG
1 EA
1 EA
1 EA
25 MG
25 MG
25 MG
25 MG
20 MG
20 MG
1 MG
1 MG
1 MG
1 MG
250 MG
250 MG
40 MG
40 MG
40 MG
250 MG
250 MG
50 ML
50 ML
50 ML
1 EA
1 EA
1 EA
1 EA
10 MG
10 MG
1 EA
1 EA
1 EA
250 MG
250 MG
250 MG
250 MG
100 MG
100 MG
100 MG
100 MG
30 MG
30 MG
30 MG
0.25 MG
0.25 MG
1 MG
1 MG
1 MG
4 MG
4 MG
4 MG
4 MG
4 MG
1 MG
1 MG
100 MG
100 MG
1 GM
1 GM
1 GM
1 GM
120 MG
120 MG
200 MG
200 MG
1 EA
3.33333
1
1
1
40
40
40
40
50
50
1000
1000
1000
1000
4
4
25
25
25
4
4
0.08
0.08
0.08
1
1
1
1
100
100
1
1
1
4
4
4
4
10
10
10
10
33.33333
33.33333
33.33333
4000
4000
1000
1000
1000
250
250
250
250
250
1000
1000
10
10
1
1
1
1
8.33333
8.33333
5
5
1
04/25/2002
04/25/2002
04/25/2002
04/25/2002
05/20/2002
05/20/2002
05/20/2002
05/20/2002
05/24/2002
05/29/2002
01/01/2002
01/01/2002
09/03/2002
01/01/2002
01/28/2002
01/28/2002
01/01/2002
01/01/2002
01/01/2002
09/26/2008
09/26/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/24/2002
04/24/2002
08/21/2002
08/21/2002
08/21/2002
02/06/2002
02/06/2002
02/06/2002
02/06/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/30/2002
04/30/2002
05/09/2002
05/09/2002
05/09/2002
04/23/2002
01/01/2002
01/01/2002
09/27/2007
01/01/2002
01/01/2002
01/01/2002
09/26/2008
09/26/2008
05/15/2002
05/15/2002
05/15/2002
05/15/2002
05/23/2002
05/23/2002
04/25/2002
04/25/2002
04/25/2002
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2004
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2004
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2004
01/01/2004
10/09/2003
01/01/2004
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2003
BO
BO
BO
JR
JR
JR
JR
JR
BO
BO
BO
BO
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
JR
BO
BO
BO
BO
BO
NA
NA
NA
NA
BO
BO
NA
NA
BO
01/01/2002 11/27/2003
01/01/2002 11/27/2003
4
4
04/25/2002 01/01/2004
04/25/2002 01/01/2004
10
10
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

38779-0888-00
J3490
38779-0888-00
J0592
38779-0888-06
J3490
38779-0888-06
J0592
38779-0888-09
J3490
38779-0888-09
38779-0891-03
38779-0891-04
38779-0891-05
38779-0891-06
38779-0925-05
38779-0925-08
38779-0925-09
38779-0927-01
38779-0927-03
38779-0927-04
38779-0927-05
38779-0927-06
38779-0927-08
J0592
J1435
J1435
J1435
J1435
J3360
J3360
J3360
J2060
J2060
J2060
J2060
J2060
J2060
1/1/2003
1/1/2002
1/1/2002
8/21/2002
1/1/2002
4/25/2002
4/25/2002
4/25/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
38779-0944-00
J0270
1/1/2002
38779-0944-07
J0270
1/1/2002
38779-0944-09
J0270
1/1/2002
38779-0963-03
J0151
4/22/2002
38779-0963-03
J0152
1/1/2004
38779-0963-04
J0151
1/1/2002
38779-0963-04
38779-0989-04
38779-0989-05
38779-0989-08
38779-0989-09
38779-1073-05
38779-1073-08
38779-1203-03
38779-1203-06
J0152
J3490
J3490
J3490
J3490
J0706
J0706
J0770
J0770
1/1/2004
1/28/2002
1/28/2002
1/28/2002
1/28/2002
1/28/2002
1/28/2002
2/7/2002
2/7/2002


12/31/2003 PHOSPHATE COMPOUNDS, INSTEAD USE A9270)
3/29/2004 REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS; INSTEAD USE A9270)
12/31/2003 PHOSPHATE COMPOUNDS, INSTEAD USE A9270)
3/29/2004 REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS; INSTEAD USE A9270)
38779-1239-04
J0500
2/6/2002
38779-1239-05
J0500
2/6/2002
38779-1239-08
38779-1502-00
38779-1502-03
38779-1502-06
38779-1502-09
38779-1636-04
38779-1636-05
38779-1756-00
38779-1756-03
38779-1756-06
38779-1756-09
38779-1764-00
38779-1764-00
38779-1764-03
38779-1764-03
38779-1764-04
J0500
J2760
J2760
J2760
J2760
J0330
J0330
J3010
J3010
J3010
J3010
J3490
J0364
J3490
J0364
J3490
2/6/2002
1/1/2002
5/22/2002
1/1/2002
5/22/2002
1/1/2002
1/1/2002
1/1/2002
4/23/2002
1/1/2002
1/1/2002
1/28/2002
1/1/2007
1/28/2002
1/1/2007
1/28/2002

99/99/9999 INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG
12/31/2002
01/01/2003
99/99/9999
1 EA BO
NA
GM
1 EA
02/11/2002
12/31/2002
1 EA BO
NA
GM
0.1 MG
10000
01/01/2003
99/99/9999
1 EA BO
NA
GM
1 EA
02/11/2002
12/31/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
0.1 MG
1 MG
1 MG
1 MG
1 MG
5 MG
5 MG
5 MG
2 MG
2 MG
2 MG
2 MG
2 MG
2 MG
10000
1000
1000
1000
1000
200
200
200
500
500
500
500
500
500
01/01/2003
01/01/2002
01/01/2002
08/21/2002
01/01/2002
04/25/2002
04/25/2002
04/25/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
ALPROSTADIL (U.S.P.)
1 EA BO
NA
GM
1.25 MCG
800000
01/01/2002
04/25/2002
1 EA BO
NA
GM
1.25 MCG
800000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1.25 MCG
1 EA BO
NA
GM
90 MG
CF
HCPCS Amount #1
NDC Label
ADENOSINE
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
800000
01/01/2002
99/99/9999
11.11111
04/22/2002
12/31/2003
ADENOSINE
1 EA BO
NA
GM
30 MG
33.33333
01/01/2004
03/29/2004
ADENOSINE
1 EA BO
NA
GM
90 MG
11.11111
01/01/2002
12/31/2003
ADENOSINE
AMINOCAPROIC ACID (U.S.P.)
CAFFEINE CITRATE (PURIFIED)
DICYCLOMINE HYDROCHLORIDE
(U.S.P.)
(U.S.P.)
(U.S.P.)
PHENTOLAMINE MESYLATE (U.S.P.)
SUCCINYLCHOLINE CHLORIDE (U.S.P.)
SUCCINYLCHOLINE CHLORIDE (U.S.P.)
FENTANYL CITRATE (U.S.P.)
APOMORPHINE HCL (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
30 MG
1 EA
1 EA
1 EA
1 EA
5 MG
5 MG
150 MG
150 MG
33.33333
1
1
1
1
200
200
6.66666
6.66666
01/01/2004
01/28/2002
01/28/2002
01/28/2002
01/28/2002
01/28/2002
01/28/2002
02/07/2002
02/07/2002
03/29/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
20 MG
50
02/06/2002
01/01/2004
1 EA BO
NA
GM
20 MG
50
02/06/2002
01/01/2004
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
20 MG
5 MG
5 MG
5 MG
5 MG
20 MG
20 MG
0.1 MG
0.1 MG
0.1 MG
0.1 MG
1 EA
1 MG
1 EA
1 MG
1 EA
50
200
200
200
200
50
50
10000
10000
10000
10000
1
1000
1
1000
1
02/06/2002
01/01/2002
05/22/2002
01/01/2002
05/22/2002
01/01/2002
01/01/2002
01/01/2002
04/23/2002
01/01/2002
01/01/2002
01/28/2002
01/01/2007
01/28/2002
01/01/2007
01/28/2002
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2004
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
04/25/2002
Page 173 of 374
BO
BO
BO
BO
BO
BO
BO
BO
JR
JR
BO
BO
BO
BO
BO
BO
02/11/2002
10000
Prior End Date #3
0.1 MG
Prior Start Date #3
1 EA
GM
GM
NA
01/01/2004
04/25/2002
01/01/2004
04/25/2002
01/01/2004
04/25/2002
01/01/2004
11/22/2002
11/22/2002
11/22/2002
Prior End Date #2
NA
1 EA BO
10
1
10
1
10
1
10
500
500
500
End Date #1
1 EA BO
100 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
2 MG
2 MG
2 MG
Start Date #1
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
HCPCS Measure #1
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Billing Units
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO

(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
DIAZEPAM (U.S.P.)
DIAZEPAM (U.S.P.)
DIAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
Prior Start Date #2

Package
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
HCPCS Description

1/1/2004
4/25/2002
1/1/2004
4/25/2002
1/1/2004
4/25/2002
1/1/2004
11/22/2002
11/22/2002
11/22/2002
NDC Package Type
J3415
J3490
J3415
J3490
J3415
J3490
J3415
J1960
J1960
J1960
NDC Package Measure
38779-0873-04
38779-0873-05
38779-0873-05
38779-0873-08
38779-0873-08
38779-0873-09
38779-0873-09
38779-0885-03
38779-0885-04
38779-0885-06
HCPCS Mod
HCPCS
NDC Mod
NDC
1/28/2002
1/1/2007
1/1/2002
1/1/2002
1/1/2002
5/1/2002
5/1/2002
4/25/2002
4/25/2002
4/25/2002
1/1/2002
1/1/2002
1/1/2002

38779-1905-01
J1095
38779-1905-01
J1094
38779-1905-03
J1095
38779-1905-03
J1094
38779-1905-04
J1095
38779-1905-04
J1094
38779-1905-05
J1095
38779-1905-05
38779-1931-01
38779-1943-05
38779-1943-08
38779-1943-09
38779-1968-07
38779-1968-09
38779-1981-01
38779-1981-04
38779-1981-05
38779-1981-08
38779-2062-04
38779-2062-05
38779-2062-08
38779-2065-03
38779-2065-06
38779-2078-03
38779-2078-06
J1094
J1835
J2800
J2800
J2800
J3490
J3490
J1840
J1840
J1840
J1840
J1245
J1245
J1245
J7799
J7799
J2680
J2680
38779-2087-03
J7643
38779-2087-03 KO J7643
38779-2087-06

1/1/2003
4/25/2002
4/25/2002
4/25/2002
4/25/2002
1/1/2002
1/1/2002
4/25/2002
4/25/2002
4/25/2002
4/25/2002
4/25/2002
4/25/2002
4/25/2002
5/2/2002
5/2/2002
4/25/2002
4/25/2002
5/2/2002
KO
J7643
38779-2087-06 KO J7643
38779-2096-03
J0360
38779-2096-04
J0360
38779-2096-05
J0360
38779-2144-04
J2515
38779-2144-05
J2515
38779-2144-08
J2515
5/2/2002
5/2/2002
KO
5/2/2002
5/2/2002
5/2/2002
5/2/2002
5/23/2002
5/23/2002
5/23/2002

99/99/9999 INJECTION, ITRACONAZOLE, 50 MG
38779-2165-03
J0780
38779-2165-06
38779-2196-03
38779-2196-04
38779-2196-05
J0780
J3250
J3250
J3250
4/25/2002
4/25/2002
4/25/2002
4/25/2002
38779-2363-05
39822-0200-05
39822-0277-02
J1956
J3490
J3490

39822-0277-07
J3490
39822-0277-09
J3490
39822-0412-01
2/1/2006
J7682
39822-0412-01 KO J7682
KO


1/1/2002 12/31/2006 MILLIGRAMS
1/1/2002 12/31/2006 MILLIGRAMS
125
04/25/2002
12/31/2002
1 MG
1000
01/01/2003
99/99/9999
1 EA NA
NA
GM
8 MG
125
04/25/2002
12/31/2002
1 EA NA
NA
GM
1 MG
1000
01/01/2003
99/99/9999
1 EA NA
NA
GM
8 MG
125
04/25/2002
12/31/2002
1 EA NA
NA
GM
1 MG
1000
01/01/2003
99/99/9999
1 EA BO
NA
GM
8 MG
125
02/06/2002
12/31/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
BO
BO
BO
NA
NA
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
50 MG
10 ML
10 ML
10 ML
1 EA
1 EA
500 MG
500 MG
500 MG
500 MG
10 MG
10 MG
10 MG
1 EA
1 EA
25 MG
25 MG
1000
20
1
1
1
1
1
2
2
2
2
100
100
100
1
1
40
40
01/01/2003
04/25/2002
04/25/2002
04/25/2002
04/25/2002
01/01/2002
01/01/2002
04/25/2002
04/25/2002
04/25/2002
04/25/2002
04/25/2002
04/25/2002
04/25/2002
05/02/2002
05/02/2002
04/25/2002
04/25/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2004
01/01/2004
01/01/2004
99/99/9999
99/99/9999
01/01/2004
01/01/2004
GLYCOPYRROLATE (U.S.P.)
1 EA JR
NA
GM
1 MG
1000
05/02/2002
99/99/9999
1 EA JR
NA
GM
1 MG
1000
05/02/2002
99/99/9999
1 EA JR
NA
GM
1 MG
1000
05/02/2002
99/99/9999
HYDRALAZINE HCL (U.S.P.)
PENTOBARBITAL SODIUM (U.S.P.)
(U.S.P.)
(U.S.P.)
TRIMETHOBENZAMIDE HCL (U.S.P.)
LEVOFLOXACIN HEMIHYDRATE
(1X100GM)
BACI-RX (U.S.P.,5 MMU,MICRONIZED)
BACIIM (STERILE) 50000 U
BACIIM (STERILE,USP,LATEX-FREE)
50000 U
AMERINET CHOICE BACIIM (STERILE)
50000 U
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
1 MG
20 MG
20 MG
20 MG
50 MG
50 MG
50 MG
1000
50
50
50
20
20
20
05/02/2002
05/02/2002
05/02/2002
05/02/2002
05/23/2002
05/23/2002
05/23/2002
99/99/9999
01/01/2004
01/01/2004
01/01/2004
10/09/2003
10/09/2003
10/09/2003
1 EA BO
NA
GM
10 MG
100
04/25/2002
99/99/9999
1
1
1
1
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
10 MG
200 MG
200 MG
200 MG
100
5
5
5
04/25/2002
09/26/2008
09/26/2008
09/26/2008
99/99/9999
99/99/9999 04/25/2002 03/29/2004
99/99/9999 04/25/2002 03/29/2004
99/99/9999 04/25/2002 03/29/2004
1 EA BO
1 EA BO
1 EA VL
NA
NA
IM
GM
EA
EA
250 MG
1 EA
1 EA
4
1
1
10/25/2007
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
EA
EA
EA
EA
12/31/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2004
01/01/2004
01/01/2004
99/99/9999
99/99/9999
99/99/9999
CF
HCPCS Amount #1
1 EA VL
IM
EA
1 EA
11/16/2005
99/99/9999
10 EA VL
IM
EA
1 EA
02/01/2006
6/1/2009
TOBRAMYCIN SULFATE (BULK VIAL,PF)

1.2 GM
1 EA VL
IV
EA
300 MG
01/01/2002
12/31/2006

1.2 GM
1 EA VL
IV
EA
300 MG
01/01/2002
12/31/2006
Page 174 of 374
8 MG
GM
Prior End Date #3
GM
NA
Prior Start Date #3
NA
1 EA NA
01/28/2002
01/01/2007
01/01/2002
01/01/2002
01/01/2002
05/01/2002
05/01/2002
04/25/2002
04/25/2002
04/25/2002
01/01/2002
01/01/2002
01/01/2002
Prior End Date #2
1 EA NA
1
1000
10
10
10
25
25
4
4
4
200
200
200
Prior Start Date #2
1 EA
1 MG
100 MG
100 MG
100 MG
40 MG
40 MG
250 MG
250 MG
250 MG
5 MG
5 MG
5 MG
End Date #1
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
Start Date #1
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
HCPCS Measure #1
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA

THEOPHYLLINE ANHYDROUS (USP)
THEOPHYLLINE ANHYDROUS (USP)
DOBUTAMINE HCL (U.S.P.)
ESTRADIOL CYPIONATE (U.S.P.)
MICRONIZED (ANHYDROUS)
ANHYDROUS (U.S.P.,MICRONIZED)
ANHYDROUS (U.S.P.,MICRONIZED)
ITRACONAZOLE
METHOCARBAMOL (U.S.P.)
SUFENTANIL CITRATE (USP)
SUFENTANIL CITRATE (USP)
KANAMYCIN SULFATE (XXX U/MG)
DIPYRIDAMOLE (U.S.P.)
EPINEPHRINE HCL
EPINEPHRINE HCL
FLUPHENAZINE DECANOATE (U.S.P.)

Package
NDC Package Type
J3490
J0364
J2175
J2175
J2175
J2810
J2810
J1250
J1250
J1250
J1000
J1000
J1000
NDC Package Measure
38779-1764-06
38779-1764-06
38779-1766-03
38779-1766-04
38779-1766-05
38779-1816-05
38779-1816-08
38779-1821-01
38779-1821-03
38779-1821-06
38779-1901-03
38779-1901-04
38779-1901-05
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
5
5
5
39822-0412-01
J7685
39822-0412-01 KO J7685
39822-0412-06
KO
J7682
39822-0412-06 KO J7682
39822-0412-06
KO
J7685
39822-0412-06 KO J7685
KO

1/1/2002 12/31/2006 MILLIGRAMS
1/1/2002 12/31/2006 MILLIGRAMS
1/1/2002 99/99/9999 INJECTION, COLISTIMETHATE SODIUM, UP TO 150 MG
39822-0706-01
J3000
1/1/2002
39822-0706-02
39822-0710-01
39822-1055-05
39822-1055-07
J3000
J1451
J0285
J0285
1/1/2002
12/14/2007
1/1/2002
3/20/2006

39822-5090-01
J1700
39822-5090-03
J1700
39822-5090-05
J1700
39822-5090-09
J1700
1/1/2002
39822-5300-05
J7684
IV
EA
300 MG
01/01/2007
99/99/9999
IV
EA
300 MG
01/01/2007
99/99/9999

1.2 GM
1 EA VL
IV
EA
300 MG
01/01/2002
12/31/2006
1 EA VL
IV
EA
300 MG
01/01/2002
12/31/2006
1 EA VL
IV
EA
300 MG
01/01/2007
99/99/9999
1 EA VL
IV
EA
300 MG
01/01/2007
99/99/9999
1 EA VL
IJ
EA
150 MG
01/01/2002
99/99/9999
1 EA VL
IM
EA
1 GM
01/01/2002
09/30/2005
VL
VL
VL
VL
IM
IV
IV
IV
EA
ML
EA
EA
1 GM
15 MG
50 MG
50 MG
1
66.66666
1
1
01/01/2002
12/14/2007
01/01/2002
03/20/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA
1.5 ML
1 EA
1 EA
1 EA DR
NA
GM
25 MG
40
01/01/2002
06/01/2005
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
39822-6000-01
J2675
1/1/2002
PROGESTERONE (U.S.P., MICRONIZED)
1 EA BO
NA
GM
50 MG
20
01/01/2002
5/18/2009
39822-6000-03
J2675
1/1/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
5/18/2009
39822-6000-05
J2675
1 EA BO
NA
GM
50 MG
20
01/01/2002
11/22/2004
39822-6000-07
J2675
1/1/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
5/18/2009
39822-6000-09
39822-6100-01
39822-6100-03
39822-6100-05
39822-6100-07
39822-6100-09
J2675
J2675
J2675
J2675
J2675
J2675
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
PROGESTERONE (USP,WETTABLE)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
DR
BO
BO
BO
BO
DR
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
20
20
20
20
20
20
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2006
99/99/9999
99/99/9999
11/22/2004
99/99/9999
01/01/2006
41280-0220-59
42023-0101-01
Q0163
J0170
72 EA NA
30 ML VL
PO
IJ
EA
ML
50 MG
1 ML
0.5
1
01/01/2002
02/28/2008
99/99/9999
99/99/9999
42023-0110-01
J1380
5 ML VL
IM
ML
10 MG
12/10/2007
99/99/9999
42023-0111-01
J1390
5 ML VL
IM
ML
20 MG
12/18/2007
99/99/9999
42023-0112-01
42023-0116-01
42023-0116-25
J0970
J2590
J2590

5 ML VL
10 ML VL
1 ML VL
IM
IJ
IJ
ML
ML
ML
40 MG
10 U
10 U
1
1
1
03/31/2008
02/29/2008
02/01/2008
99/99/9999
99/99/9999
99/99/9999
42023-0118-01
42023-0119-25
J3250
J3250

20 ML VL
2 ML VL
IM
IM
ML
ML
200 MG
200 MG
0.5
1
08/01/2008
7/22/2008
99/99/9999
99/99/9999
42023-0122-25
J0170
1 ML VL
IJ
ML
1 ML
06/04/2008
99/99/9999
43292-0556-31
Q0163
43292-0557-05
Q0163
43292-0557-19
Q0163


SLEEP FORMULA 25 MG
ADRENALIN (1X30ML,MDV) 1 MG/ML
DELESTROGEN (1X5ML,MULTIDOSE) 10
MG/ML
DELESTROGEN (1X5ML,MULTIDOSE) 20
MG/ML
DELESTROGEN (1X5ML,MDV,USP) 40
MG/ML
PITOCIN (1X10ML,MDV) 10 U/ML
PITOCIN (25X1ML) 10 U/ML
(MDV,1X20ML) 100 MG/ML
TIGAN (SDV, 25X2ML) 100 MG/ML
ADRENALIN CHLORIDE (25X1ML,SDV) 1
MG/ML
ALERTAB 25 MG
100 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
ALERCAP 25 MG
100 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
36 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
SLEEP-TABS 25 MG
Page 175 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
1 EA VL
1 EA VL

J0770
KO

1.2 GM
1.2 GM

1.2 GM
1.2 GM
1.2 GM
(VIAL,STERILE) 150 MG
STREPTOMYCIN SULFATE (STERILE) 1
GM
STREPTOMYCIN SULFATE (STERILE) 1
GM
AMPHOTERICIN B (STERILE) 50 MG
NOVAPLUS AMPHOTERICIN B 50 MG
HYDROCORTISONE ACETATE (U.S.P.,
MICRONIZED)
(U.S.P.,MICRONIZED)
HYDROCORTISONE ACETATE (U.S.P.,
MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
39822-0615-01
39822-5300-05 KO J7684
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

43292-0557-65
Q0163
1/1/2002
43292-0557-78
44087-0004-07
44087-0005-07
44087-0006-07
Q0163
J2941
J2941
J2941
1/1/2002
1/1/2002
1/1/2002
1/1/2002
44087-0022-03
J3490
44087-0022-03
Q3026
44087-0044-03
J3490
44087-0044-03
44087-0088-04
44087-0250-01
44087-1005-02
Q3026
J2941
J3490
J2941
1/1/2003 99/99/9999 INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE

44087-1080-01
J2941
44087-1080-02
44087-1088-01
J2941
J2941

44087-1112-01
J3490
44087-1113-01
J3490
44087-1114-01
J3490
44087-1150-01
44087-1200-01
44087-1520-01
44087-1525-01
44087-1530-01
J3490
J3490
J9293
J9293
J9293
44087-3388-07
44087-4005-01
44087-4010-01
44087-4050-01
44087-4050-01
44087-6075-01
44087-6075-01
44087-6075-03
44087-6075-03
44087-6075-04
44087-6075-04
44087-6150-01
44087-6150-01
44087-7075-01
44087-7075-03
44087-8010-03
J2941
Q2014
Q2014
Q2014
Q0515
Q2018
J3355
Q2018
J3355
Q2018
J3355
Q2018
J3355
Q2018
Q2018
J0725
4/7/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2002
1/1/2002
44087-8822-01
44087-9005-01
44087-9005-06
44087-9030-01
44087-9070-01
44087-9075-01
44087-9075-03
44087-9075-04
44087-9150-01
44087-9375-01
44087-9375-03
Q3026
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
J3490
2/14/2005
6/7/2004
6/7/2004
5/10/2004
5/7/2007
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
44206-0300-01
Q4089
7/1/2007
44206-0300-01
J2791
1/1/2008
44206-0300-10
Q4089
7/1/2007
44206-0300-10
J2791
1/1/2008
44206-0415-01
Q9941
4/1/2005
44206-0415-01
J1566
1/1/2006

1/1/2003 99/99/9999 INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE

6/11/2003
6/11/2003
7/31/2003 INJECTION, SERMORELIN ACETATE, 0.5 MG
8/1/2008 INJECTION, SERMORELIN ACETATE, 1 MICROGRAM
12/31/2005 INJECTION, UROFOLLITROPIN, 75 IU
DIPHENHYDRAMINE HCL (MAX. STR.) 50

MG
SLEEP-TABS 25 MG
SEROSTIM 4 MG
SEROSTIM (S.D.V., W/DILUENT) 5 MG
SEROSTIM (S.D.V., W/DILUENT) 6 MG
REBIF (SRN,PREFILLED,27G,PF) 22
MCG/0.5 ML
MCG/0.5 ML
MCG/0.5 ML
MCG/0.5 ML
SEROSTIM (W/DILUENT) 8.8 MG
OVIDREL (VIAL W/DILUENT) 0.25 MG
SAIZEN (VIAL, W/DILUENT) 5 MG
SAIZEN CLICK EASY CARTRIDGE
(W/DILUENT) 8.8 MG
SAIZEN CLICK EASY CARTRIDGE
(W/DILUENT) 8.8 MG
SAIZEN (VIAL W/DILUENT) 8.8 MG
GONAL-F RFF (29GX1/2 NEEDLE,PEN)
450 IU/0.75 ML
GONAL-F RFF (29GX1/2,PEN) 300 IU/0.5
ML
GONAL-F RFF (29GX1/2,PEN) 900 IU/1.5
ML
OVIDREL (SRN,PREFILLED SYRINGE)
0.25 MG/0.5 ML
GONAL-F (VIAL) 1200 IU
NOVANTRONE (M.D.V.) 2 MG/ML
ZORBTIVE (MDV, VIALS W/ DILUENT) 8.8
MG
GEREF (VIAL) 0.5 MG
GEREF (VIAL) 1 MG
GEREF DIAGNOSTIC (AMP) 50 MCG
GEREF DIAGNOSTIC (AMP) 50 MCG
METRODIN 75 IU
METRODIN 75 IU
METRODIN 75 IU
METRODIN 75 IU
METRODIN 75 IU
METRODIN 75 IU
METRODIN 150 IU
METRODIN 150 IU
FERTINEX 75 IU
FERTINEX 75 IU
PROFASI 10000 U
99/99/9999 INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE

REBIF (TITRATION PACK,PF) 44 MCG/ML
GONAL-F RFF 75 IU
GONAL-F RFF 75 IU
GONAL-F (M.D.V.) 450 IU
GONAL-F (MDV) 1200 IU
GONAL-F (AMP) 75 IU
GONAL-F (AMP) 75 IU
GONAL-F (AMP) 75 IU
GONAL-F (AMP) 150 IU
GONAL-F (AMP) 37.5 IU
GONAL-F (AMP) 37.5 IU
INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC) INTRAMUSCULARRHOPHYLAC (W/SAFETY NEEDLE) 750
IU/ML
12/31/2007 OR INTRAVENOUS, 100 IU
INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTRAMUSCULAR RHOPHYLAC (W/SAFETY NEEDLE) 750
IU/ML
INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC) INTRAMUSCULARRHOPHYLAC (W/SAFETY NEEDLE) 750
IU/ML
INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTRAMUSCULAR RHOPHYLAC (W/SAFETY NEEDLE) 750
IU/ML
CARIMUNE NF (PF,NANOFILTERED) 1
GM
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT CARIMUNE NF (PF,NANOFILTERED) 1
GM
Page 176 of 374
50 EA NA
PO
EA
50 MG
01/01/2002
99/99/9999
NA
VL
VL
VL
PO
SC
SC
SC
EA
EA
EA
EA
50 MG
1 MG
1 MG
1 MG
0.5
4
5
6
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
0.5 ML SR
SC
ML
1 EA
03/13/2002
12/31/2002
0.5 ML SR
SC
ML
11 MCG
01/01/2003
99/99/9999
0.5 ML SR
SC
ML
1 EA
03/13/2002
12/31/2002
0.5 ML
1 EA
1 EA
1 EA
SC
SC
SC
SC
ML
EA
EA
EA
11 MCG
1 MG
1 EA
1 MG
8
8.8
1
5
01/01/2003
10/15/2007
01/01/2002
01/01/2002
99/99/9999
99/99/9999
11/09/2003
99/99/9999
1 CT VL
IJ
EA
1 MG
8.8
10/22/2004
99/99/9999
1 EA CT
1 EA VL
IJ
IJ
EA
EA
1 MG
1 MG
8.8
8.8
10/22/2004
01/01/2002
09/20/2006
99/99/9999
0.75 ML CR
SC
ML
1 EA
06/15/2004
99/99/9999
0.5 ML CR
SC
ML
1 EA
06/15/2004
99/99/9999
1.5 ML CR
SC
ML
1 EA
06/15/2004
99/99/9999
1 EA
1 EA
5 MG
5 MG
5 MG
1
1
0.4
0.4
0.4
11/10/2003
01/01/2002
06/11/2003
06/11/2003
06/11/2003
99/99/9999
07/20/2005
99/99/9999
06/07/2007
09/04/2007
8.8
1
2
0.1
50
1
1
1
1
1
1
2
2
1
1
10
04/07/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2002
01/01/2002
99/99/9999
07/31/2003
06/07/2003
12/31/2005
8/1/2008
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
02/14/2003
02/14/2003
02/14/2004
4
1
1
1
1
1
1
1
1
1
1
02/14/2005
06/07/2004
06/07/2004
05/10/2004
05/07/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
07/05/2004
07/05/2004
07/05/2004
07/05/2004
07/05/2004
07/05/2004
100 EA
1 EA
1 EA
1 EA
SR
VL
VL
VL
0.5 ML
1 EA
10 ML
12.5 ML
15 ML
SR
VL
VL
VL
VL
SC
SC
IV
IV
IV
ML
EA
ML
ML
ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
NA
NA
NA
NA
NA
NA
NA
NA
VL
VL
VL
SC
IJ
IJ
IJ
IJ
IM
IM
IM
IM
IM
IM
IM
IM
SC
SC
IM
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
4.2 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BX
VL
VL
VL
VL
AM
AM
AM
AM
AM
AM
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 MG
0.5 MG
0.5 MG
0.5 MG
1 MCG
75 IU
75 IU
75 IU
75 IU
75 IU
75 IU
75 IU
75 IU
75 IU
75 IU
1000 USP Units
11 MCG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
2 ML SR
IJ
ML
100 IU
7.5
07/01/2007
12/31/2007
2 ML SR
IJ
ML
100 IU
7.5
01/01/2008
99/99/9999
2 ML SR
IJ
ML
100 IU
7.5
07/01/2007
12/31/2007
2 ML SR
IJ
ML
100 IU
7.5
01/01/2008
99/99/9999
1 EA VL
IV
EA
1 GM
04/01/2005
12/31/2005
1 EA VL
IV
EA
500 MG
01/01/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
44206-0416-03
Q9941
44206-0416-03
J1566
44206-0417-06
Q9941
44206-0417-06
J1566
44206-0418-12
Q9941
44206-0418-12
J1566
44206-0436-05
Q4097
44206-0436-05
J1459
44206-0437-10
Q4097
44206-0437-10
J1459
44206-0438-20
Q4097
44206-0438-20
44206-0506-53
44206-0507-56
44206-0508-62
J1459
J1563
J1563
J1563
44206-3101-01
J0850
45802-0127-14
Q0179
45802-0127-65
Q0179
45802-0205-14
Q0179
45802-0205-65
Q0179
45802-0303-21
J7506
45802-0303-67
J7506
45802-0733-21
J7506
45802-0733-67
J7506
45802-0758-30
45802-0758-30
K0416
J8498
45802-0759-30
45802-0759-30
K0416
J8498
46287-0015-01
G9017
46672-0606-16
G9017
47682-0182-32
Q0163
47682-0182-47
Q0163
47682-0182-64
Q0163
47682-0847-87
Q0163
GM
GM
GM
GM
GM
GM
INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED
4/1/2008 12/31/2008 (E.G., LIQUID), 500 MG
PRIVIGEN (PF,LATEX-FREE) 10%
INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G
1/1/2009 99/99/9999 LIQUID), 500 MG
4/1/2008 12/31/2008 (E.G., LIQUID), 500 MG
1/1/2009 99/99/9999 LIQUID), 500 MG
4/1/2008 12/31/2008 (E.G., LIQUID), 500 MG
1/1/2009 99/99/9999 LIQUID), 500 MG
CARIMUNE 3 GM
CARIMUNE 6 GM
CARIMUNE 12 GM
INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER
2/20/2007 99/99/9999 VIAL
CYTOGAM (PF)
(FILM-COATED) 4 MG
(FILM-COATED) 4 MG
(FILM-COATED) 8 MG
(FILM-COATED) 8 MG
MG
MG
MG
MG
AMANTADINE HCL (RASPBERRY) 50
MG/5 ML
DIPHEN (SF) 25 MG
DIPHEN (200X1,SF) 25 MG
DIPHEN (SF) 25 MG
MEDI-FIRST DIPHENHYDRAMINE
HYDROCHLORIDE 25 MG
1/1/2007
Page 177 of 374
1 EA VL
IV
EA
1 GM
04/01/2005
12/31/2005
1 EA VL
IV
EA
500 MG
01/01/2006
99/99/9999
1 EA VL
IV
EA
1 GM
04/01/2005
12/31/2005
1 EA VL
IV
EA
500 MG
12
01/01/2006
99/99/9999
1 EA VL
IV
EA
1 GM
12
04/01/2005
12/31/2005
1 EA VL
IV
EA
500 MG
24
01/01/2006
99/99/9999
50 ML VL
IV
ML
500 MG
0.2
04/01/2008
12/31/2008
50 ML VL
IV
ML
500 MG
0.2
01/01/2009
99/99/9999
100 ML VL
IV
ML
500 MG
0.2
4/1/2008
12/31/2008
100 ML VL
IV
ML
500 MG
0.2
01/01/2009
99/99/9999
200 ML VL
IV
ML
500 MG
0.2
04/01/2008
12/31/2008
200 ML
1 EA
1 EA
1 EA
VL
VL
PT
VL
IV
IV
IV
IV
ML
EA
EA
EA
500 MG
1 GM
1 GM
1 GM
0.2
3
6
12
01/01/2009
01/01/2002
01/01/2002
01/01/2002
99/99/9999
08/11/2004
08/12/2004
08/27/2004
50 ML NA
IV
ML
1 EA
0.02
02/20/2007
99/99/9999
3 EA BX
PO
EA
8 MG
0.5
06/25/2007
99/99/9999
30 EA BO
PO
EA
8 MG
0.5
06/25/2007
99/99/9999
3 EA BX
PO
EA
8 MG
06/25/2007
99/99/9999
30 EA BO
PO
EA
8 MG
06/25/2007
99/99/9999
21 EA DP
PO
EA
5 MG
12/12/2007
99/99/9999
48 EA DP
PO
EA
5 MG
12/12/2007
99/99/9999
21 EA DP
PO
EA
5 MG
12/12/2007
99/99/9999
48 EA DP
PO
EA
5 MG
12/12/2007
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
06/30/2003
01/01/2006
12/31/2005
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
06/30/2003
01/01/2006
12/31/2005
99/99/9999
473 ML BO
PO
ML
100 MG
0.1
12/01/2004
05/31/2005
480 ML BO
PO
ML
100 MG
0.1
12/01/2004
05/31/2005
12 EA NA
PO
EA
50 MG
0.5
01/01/2007
99/99/9999
200 EA PG
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA BX
PO
EA
50 MG
0.5
01/01/2007
99/99/9999
100 EA BX
PO
EA
50 MG
0.5
01/01/2007
6/1/2008
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
Q0163
J7051
A4216
J7051
A4216
J7051
A4216
J7051
A4216
J7051
A4216
J7051
A4216
J7051
A4216
1/1/2007
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
49072-0145-30
49072-0291-30
49072-0297-10
49072-0299-05
49072-0433-05
J3420
J1644
J1644
J1644
J1212
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
49072-0475-50
J3475
1/1/2002
49072-0571-30
J3480
1/1/2002
49072-0669-30
J2912
49072-0669-30
A4216
1/1/2004
49072-0704-20
J0610
1/1/2002
49072-0704-50
J0610
1/1/2002
49072-0807-30
A4712
1/1/2002
49281-0545-05
J3490
49281-0880-01
J9031
49348-0044-04
Q0163
49348-0044-10
Q0163
49348-0045-34
Q0163
49348-0204-34
Q0163
49348-0205-37
Q0163
49348-0282-08
Q0163
49348-0564-04
49452-0001-01
49452-0001-01
49452-0001-02
49452-0001-02
49452-0001-03
49452-0001-03
49452-0001-04
49452-0001-04
49452-0001-05
49452-0006-01
Q0163
J7799
Q4075
J7799
Q4075
Q4075
J0133
Q4075
J0133
Q4075
J7699

11/1/2002 INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML
1/1/2002 99/99/9999 BCG (INTRAVESICAL) PER INSTILLATION

10/1/2003
MEDI-FIRST DIPHENHYDRAMINE
HYDROCHLORIDE 25 MG
WATER FOR INHALATION (AL7023)
SALINE SOLUTION (AL7453) 0.45%
MCG/ML
DIMETHYL SULFOXIDE (M.D.V.) 50%
MAGNESIUM SULFATE (S.D.V.) 500
MG/ML
POTASSIUM CHLORIDE (M.D.V.) 2
MEQ/ML
(M.D.V.) 0.9%
(M.D.V.) 0.9%
CALCIUM GLUCONATE (S.D.V.) 100
MG/ML
MG/ML
WATER FOR INJECTION
ACTHIB (SDV W/DIL,TAX INCL,PF) 10
MCG
THERACYS (S.D.V. W/DILUENT,PF) 81
MG
VL
VL
VL
VL
VL
IM
IJ
IJ
IJ
IL
ML
ML
ML
ML
ML
1000 MCG
1000 U
1000 U
1000 U
50 %
1
1
5
10
0.02
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
11/01/2002
11/01/2002
11/01/2002
11/01/2004
11/01/2002
500 MG
01/01/2002
11/01/2002
01/01/2002
12/1/2007
0.5
01/01/2002
12/31/2003
50 ML VL
IJ
ML
30 ML VL
IV
ML
30 ML VL
IV
ML
0.9 %
CF
HCPCS Amount #1
2 MEQ
30 ML VL
IV
ML
10 ML
0.1
01/01/2004
12/1/2007
10 ML VL
IV
ML
10 ML
0.1
01/01/2002
11/01/2002
50 ML VL
IV
ML
10 ML
0.1
01/01/2002
11/01/2002
30 ML VL
IV
ML
10 ML
0.1
01/01/2002
11/01/2002
1 EA VL
IM
EA
1 EA
01/01/2002
99/99/9999
1 EA VL
IL
EA
1 INSTILLATION
01/01/2002
99/99/9999
VALU-DRYL ALLERGY 25 MG
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
VALU-DRYL ALLERGY CHILDREN'S 12.5

MG/5 ML
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
VALU-DRYL CLEAR (AF,SF,DYE-FREE)

12.5 MG/5 ML
118 ML BO
PO
ML
50 MG
0.05
01/01/2002
03/31/2002
VALU-DRYL ALLERGY CHILDREN'S

(AF,CHERRY) 12.5 MG/5 ML
236 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
48 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
24 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
PO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
EA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
50 MG
1 EA
5 MG
1 EA
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1 EA
0.5
1
200
1
200
200
200
200
200
200
1
01/01/2002
02/05/2002
10/01/2003
02/05/2002
10/01/2003
10/01/2003
01/01/2006
01/01/2004
01/01/2006
01/01/2004
01/01/2007
99/99/9999
09/30/2003
01/01/2004
09/30/2003
11/15/2004
12/31/2005
99/99/9999
12/31/2005
99/99/9999
11/15/2004
12/31/2007
Page 178 of 374
BX
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
30 ML
30 ML
10 ML
4 ML
50 ML
Prior End Date #3
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
Prior Start Date #3
01/01/2007
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
0.5
0.2
0.1
0.2
0.1
0.2
0.1
0.2
0.1
0.2
0.1
0.2
0.1
0.2
0.1
Prior End Date #2
50 MG
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
End Date #1
EA
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
Start Date #1
PO
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
HCPCS Measure #1
BX
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
PC
PC
Billing Units
100 EA
3 ML
3 ML
5 ML
5 ML
3 ML
3 ML
5 ML
5 ML
3 ML
3 ML
5 ML
5 ML
15 ML
15 ML
Prior Start Date #2

Package
NDC Package Type
47682-0858-87
48879-0001-01
48879-0001-01
48879-0001-02
48879-0001-02
48879-0002-01
48879-0002-01
48879-0002-02
48879-0002-02
48879-0003-01
48879-0003-01
48879-0003-02
48879-0003-02
48879-0003-07
48879-0003-07
NDC Package Measure

NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
49452-0006-01
J7632
49452-0006-01 KO J7632
49452-0006-02
J7699
49452-0006-02
KO
1/1/2008
1/1/2007
1/1/2008
KO
1/1/2008

3/15/2008 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
49452-0011-01
J3150

49452-0011-02
J3150
49452-0011-03
49452-0023-01
49452-0023-02
49452-0023-03
49452-0027-02
49452-0027-03
49452-0027-04
49452-0028-01
49452-0028-02
49452-0028-03
49452-0028-04
49452-0029-01
49452-0029-02
49452-0029-03
49452-0029-04
49452-0031-01
49452-0031-02
49452-0031-03
49452-0032-01
49452-0032-02
J3150
J0285
J0285
J0285
J0745
J0745
J0745
J2271
J2271
J2271
J2271
J1170
J1170
J1170
J1170
J2175
J2175
J2175
J3010
J3010
1/1/2002
1/24/2002
1/24/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
11/15/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
49452-0073-01
J0270
1/1/2002
49452-0073-02
J0270
2/5/2002
49452-0073-03
J0270
2/5/2002
49452-0073-04
49452-0097-01
J0270
J7699
11/15/2004
1/1/2007
49452-0097-01
J7604
49452-0097-01 KO J7604
49452-0097-02
J7699
49452-0097-02
J7604
49452-0097-02 KO J7604
49452-0097-03
J7699
49452-0097-03
49452-0097-05
1/1/2008
1/1/2007
1/1/2008
KO
J7608
49452-0097-05 KO J7608
49452-0105-01
J1212
1/1/2008
1/1/2007
1/1/2008
KO
J7604
49452-0097-04 KO J7604
1/1/2008
1/1/2007
1/1/2008
KO
J7604
49452-0097-03 KO J7604
49452-0097-04
J7699
49452-0097-04
1/1/2008
KO
1/1/2008
1/1/2002
KO
1/1/2002
1/1/2002

1 EA BO
NA
GM
10 MG
100
01/01/2008
3/15/2008

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
3/15/2008
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
MORPHINE SULFATE
MORPHINE SULFATE
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999
1 EA BO
NA
GM
100 MG
10
01/01/2002
99/99/9999
1 EA BO
NA
GM
100 MG
10
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
JR
BO
BO
JR
BO
JR
JR
JR
BO
BO
JR
BO
JR
BO
BO
BO
BO
JR
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
100 MG
50 MG
50 MG
50 MG
30 MG
30 MG
30 MG
100 MG
100 MG
100 MG
100 MG
4 MG
4 MG
4 MG
4 MG
100 MG
100 MG
100 MG
0.1 MG
0.1 MG
10
20
20
20
33.33333
33.33333
33.33333
10
10
10
10
250
250
250
250
10
10
10
10000
10000
01/01/2002
01/24/2002
01/24/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
11/15/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
3/15/2008
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1.25 MCG
800000
01/01/2002
02/05/2002
1 EA BO
NA
GM
1.25 MCG
800000
02/05/2002
04/01/2005
1 EA BO
NA
GM
1.25 MCG
800000
11/15/2004
99/99/9999
N-ACETYL-L-CYSTEINE (U.S.P.)
1 EA BO
1 EA BO
NA
NA
GM
GM
1.25 MCG
1 EA
800000
1
11/15/2004
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
NA
GM
1 GM
01/01/2002
01/17/2002
DIMETHYL SULFOXIDE (U.S.P.)
1 EA BO
500 ML BO
NA
NA
GM
ML
1 GM
50 %
1
0.02
01/01/2002
01/01/2002
01/17/2002
01/31/2002
Page 179 of 374
2/5/2002 11/14/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

1/1/2008
1/1/2007
1/1/2008
KO
J7632
49452-0006-04 KO J7632
1/1/2008
1/1/2007
1/1/2008
KO
J7632
49452-0006-03 KO J7632
49452-0006-04
J7699
49452-0006-04
1/1/2008
J7632
49452-0006-02 KO J7632
49452-0006-03
J7699
49452-0006-03
HCPCS Mod
HCPCS
NDC Mod
NDC
800000
49452-0105-02
J1212
49452-0225-01
J7613
49452-0225-01 KO J7613
49452-0225-01
KO
J7609
49452-0227-03 KO J7609
49452-0399-01
J3490
49452-0399-02
J3490
49452-0409-01
J3490
49452-0409-02
J3490
J3490
49452-0409-03
49452-0409-04
J3490
49452-0430-01
J0280
49452-0430-02
J0280
49452-0430-03
J0280
49452-0430-06
J0280
49452-0460-01
J1320
49452-0460-02
J1320
49452-0460-03
J1320
49452-0601-01
J0300
49452-0601-02
J0300
49452-0606-03
J0285
49452-0735-01
J9017
49452-0735-02
J9017
49452-0770-01
KO
J7613
49452-0227-03 KO J7613
49452-0227-03
KO
J7609
49452-0227-02 KO J7609
49452-0227-03
KO
J7613
49452-0227-02 KO J7613
49452-0227-02
KO
J7609
49452-0227-01 KO J7609
49452-0227-02
KO
J7613
49452-0227-01 KO J7613
49452-0227-01
KO
J7619
49452-0226-03 KO J7619
49452-0227-01
KO
J7619
49452-0226-02 KO J7619
49452-0226-03
KO
J7619
49452-0226-01 KO J7619
49452-0226-02
KO
J7609
49452-0225-03 KO J7609
49452-0226-01
KO
J7613
49452-0225-03 KO J7613
49452-0225-03
KO
J7609
49452-0225-01 KO J7609
49452-0225-03
KO
J7636
49452-0770-01 KO J7636
KO

ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
1/1/2007 99/99/9999 THROUGH DME, UNIT DOSE, 1 MG
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
ALBUTEROL (U.S.P.)
2/5/2002
2/5/2002
1/1/2002
1/25/2002
1/1/2003 INJECTION, AMOBARBITAL, UP TO 125 MG
AMOBARBITAL SODIUM (U.S.P.)
1/25/2002
AMOBARBITAL SODIUM (U.S.P.)
11/15/2004 99/99/9999 INJECTION, ARSENIC TRIOXIDE, 1 MG
ARSENIC TRIOXIDE (A.C.S.,REAGENT)
ARSENIC TRIOXIDE (A.C.S.,REAGENT)
ATROPINE (U.S.P.)
ATROPINE (U.S.P.)
Page 180 of 374
50 %
4000 ML BO
NA
ML
0.02
01/01/2002
01/31/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2002
11/14/2004
1 EA JR
NA
GM
1 MG
1000
01/01/2002
11/14/2004
1 EA JR
NA
GM
1 MG
1000
01/01/2002
11/14/2004
1 EA JR
NA
GM
1 MG
1000
01/01/2002
11/14/2004
1 EA JR
NA
GM
1 MG
1000
01/01/2002
11/14/2004
1 EA JR
NA
GM
1 MG
1000
01/01/2002
11/14/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
3/15/2007
1 EA BO
NA
GM
1 MG
1000
01/01/2007
3/15/2007
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
250 MG
250 MG
250 MG
250 MG
20 MG
20 MG
20 MG
125 MG
125 MG
50 MG
1 MG
1 MG
1000
1
1
1
1
1
1
4
4
4
4
50
50
50
8
8
20
1000
1000
01/01/2007
02/05/2002
02/05/2002
01/01/2002
01/01/2002
01/01/2002
11/15/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/25/2002
01/25/2002
01/01/2002
11/15/2004
11/15/2004
99/99/9999
01/01/2003
01/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/02/2002
3/14/2008
99/99/9999
99/99/9999
99/99/9999
01/01/2003
01/01/2003
01/24/2002
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
49452-0770-02
J7636
49452-0770-02 KO J7636
49452-0770-03
KO
J7624
49452-1070-05 KO J7624
49452-1070-06
KO
J7624
49452-1070-04 KO J7624
49452-1070-05
KO
J7622
49452-0876-03 KO J7622
49452-0970-01
J3490
49452-0970-02
J3490
49452-0970-03
J3490
49452-1016-01
J0515
49452-1016-02
J0515
49452-1016-03
J0515
49452-1070-04
KO
J7622
49452-0876-02 KO J7622
49452-0876-03
KO
J7622
49452-0876-01 KO J7622
49452-0876-02
KO
J7622
49452-0802-03 KO J7622
49452-0807-01
J0475
49452-0807-02
J0475
49452-0807-03
J0475
49452-0807-04
J0475
49452-0876-01
KO
J7622
49452-0802-02 KO J7622
49452-0802-03
KO
J7622
49452-0802-01 KO J7622
49452-0802-02
KO
J7636
49452-0780-03 KO J7636
49452-0782-03
J7501
49452-0783-01
J7501
49452-0783-02
J7501
49452-0783-03
J7501
49452-0800-01
J3490
49452-0801-01
J3490
49452-0802-01
KO
J7636
49452-0780-02 KO J7636
49452-0780-03
KO
J7636
49452-0780-01 KO J7636
49452-0780-02
KO
J7636
49452-0770-03 KO J7636
49452-0780-01
KO
J7624
49452-1070-06 KO J7624
KO

1/1/2002
1/24/2002 99/99/9999 AZATHIOPRINE, PARENTERAL, 100 MG
1/1/2002 11/15/2004 INJECTION, BACLOFEN, 10 MG
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002 99/99/9999 INJECTION, BENZTROPINE MESYLATE, PER 1 MG
49452-1072-02
J3490
49452-1072-03
J3490
49452-1075-01
J7624

49452-1075-01 KO J7624
KO
ATROPINE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
ATROPINE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
ATROPINE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
ATROPINE (U.S.P.)
ATROPINE SULFATE MONOHYDRATE
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
BACITRACIN (MICRNZD, U.S.P./5MU)
BACITRACIN (U.S.P. STERILE)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
BENZOCAINE (U.S.P.)
BENZOCAINE (U.S.P.)
BENZOCAINE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
JR
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
EA
GM
1 MG
100 MG
100 MG
100 MG
100 MG
1 EA
1 EA
1000
10
10
10
10
1
1
01/01/2002
01/01/2002
01/24/2002
01/24/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
01/03/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1 MG
10 MG
10 MG
10 MG
10 MG
1000
100
100
100
100
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
11/15/2004
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/08/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/08/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/08/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/08/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/08/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
1 MG
1 EA
1 EA
1 EA
1 MG
1 MG
1 MG
1000
1
1
1
1000
1000
1000
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2005
01/08/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
BETAMETHASONE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
Page 181 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
1 EA BO
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
(U.S.P.)
(U.S.P.)
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 EA
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 EA
01/08/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
49452-1083-01
J0520
49452-1083-02
J0520
49452-1083-03
J0520

1/1/2002 3/15/2008 MG
1/1/2002 99/99/9999 MG
1/1/2002 99/99/9999 MG
J7626
49452-1075-02
J7624
49452-1075-02 KO J7624
49452-1075-03
J7624
49452-1075-03 KO J7624
49452-1075-04
49452-1291-01 KO J7626
49452-1291-01
KO
KO
KO
J7627
49452-1291-03 KO J7627
J7626
49452-1291-03 KO J7626
49452-1291-03
KO
J7627
49452-1291-02 KO J7627
49452-1291-03
KO
J7626
49452-1291-02 KO J7626
49452-1291-02
KO
J7627
49452-1291-01 KO J7627
49452-1291-02
KO
J7624
49452-1077-04 KO J7624
49452-1291-01
KO
J7624
49452-1077-03 KO J7624
49452-1077-04
KO
J7624
49452-1077-02 KO J7624
49452-1077-03
KO
J7624
49452-1077-01 KO J7624
49452-1077-02
KO
J7624
49452-1075-04 KO J7624
49452-1077-01
KO
KO
49452-1304-01
J3490
1/1/2002

(U.S.P.)
(U.S.P.)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2004
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2004
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/15/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/15/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/15/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/15/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2004
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2004
1 EA BO
NA
GM
5 MG
200
01/01/2002
3/15/2008
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
BUDESONIDE (EP,MICRONIZED)
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
(U.S.P.)
(U.S.P.)
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA JR
NA
GM
1 EA
01/01/2002
01/08/2002
1 EA JR
NA
GM
1 EA
01/01/2002
01/08/2002
1 EA BO
NA
GM
10 MG
100
01/01/2002
99/99/9999
49452-1304-02
J3490
1/1/2002
49452-1309-01
J0945
1/1/2002 99/99/9999 INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG
49452-1309-02
J0945
1/1/2002
1 EA BO
NA
GM
10 MG
100
01/01/2002
01/08/2002
49452-1309-04
J0945
1 EA BO
NA
GM
10 MG
100
01/01/2002
99/99/9999
49452-1309-05
49452-1317-01
49452-1317-01
49452-1317-02
49452-1317-02
49452-1330-01
J0945
J3490
J0595
J3490
J0595
J0706
1/1/2002
1/1/2003
1/1/2004
1/1/2003
1/1/2004
1/1/2002

BUTORPHANOL TARTRATE (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
10 MG
1 EA
1 MG
1 EA
1 MG
5 MG
100
1
1000
1
1000
200
01/01/2002
01/01/2003
01/01/2004
01/01/2003
01/01/2004
01/01/2002
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
7/7/2007

Page 182 of 374
BO
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
49452-2339-01
J7631
49452-2339-01 KO J7631
49452-2339-02
KO
KO
2/14/2002
2/14/2002
KO
2/14/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/30/2002
49452-2460-01
J1095
1/1/2002
49452-2460-01
J1094
1/1/2003
49452-2460-02
J1095
1/1/2002
49452-2460-02
J1094
1/1/2003
49452-2460-03
J1095
1/1/2002
49452-2460-03
J1094
1/1/2003
49452-2465-01
J7638
49452-2465-01 KO J7638
49452-2465-02
J7638
49452-2465-02 KO J7638
49452-2465-03
49452-2470-01
49452-2470-03
KO
KO
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
KO
J7638
49452-2470-03 KO J7638
1/1/2002
1/1/2002
J7638
49452-2470-02 KO J7638
1/1/2002
1/1/2002
J7638
49452-2470-01 KO J7638
49452-2470-02
KO
J7638
49452-2465-04 KO J7638
1/1/2002
1/1/2002
J7638
49452-2465-03 KO J7638
49452-2465-04
1/1/2002
KO
1/1/2002
1/1/2002
KO
1/1/2002

L-CARNITINE FREE BASE
L-CARNITINE HYDROCHLORIDE
L-CARNITINE HYDROCHLORIDE
99/99/9999 INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG
CISPLATIN (U.S.P.)
CISPLATIN (U.S.P.)
CISPLATIN (U.S.P.)
COLCHICINE (U.S.P.)
COLCHICINE (U.S.P.)
COLCHICINE (U.S.P.)
ANHYDROUS (U.S.P,MICRONIZED)
DEXAMETHASONE MICRONIZED (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
Page 183 of 374
NA
GM
10 MG
100
02/04/2002
11/14/2004
1 EA BO
NA
GM
10 MG
100
02/04/2002
11/14/2004
1 EA BO
NA
GM
10 MG
100
02/14/2002
11/14/2004
1 EA BO
NA
GM
10 MG
100
02/14/2002
11/14/2004
1 EA BO
NA
GM
10 MG
100
02/14/2002
11/14/2004
CF
HCPCS Amount #1
1 EA BO
NA
GM
10 MG
100
02/14/2002
11/14/2004
1 EA BO
NA
GM
10 MG
100
02/14/2002
11/14/2004
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
10 MG
1000 MCG
1000 MCG
1000 MCG
1000 MCG
10 MG
100
1000
1000
1000
1000
100
02/14/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/30/2002
11/14/2004
11/15/2004
99/99/9999
99/99/9999
99/99/9999
01/01/2003
1 EA BO
NA
GM
8 MG
125
01/01/2002
12/31/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2003
99/99/9999
1 EA BO
NA
GM
8 MG
125
01/01/2002
12/31/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2003
99/99/9999
1 EA BO
NA
GM
8 MG
125
01/01/2002
12/31/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
Prior End Date #3
7/7/2007
7/7/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
3/15/2008
99/99/9999
99/99/9999
11/15/2004
99/99/9999
99/99/9999
99/99/9999
11/15/2004
99/99/9999
99/99/9999
Prior Start Date #3
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/30/2002
01/30/2002
01/30/2002
01/01/2002
01/01/2002
01/01/2002
11/15/2004
01/01/2002
01/01/2002
01/01/2002
200
200
1
1
1
1
1
20
20
20
100
100
100
1000
1000
1000
1000
1000
1000
1000
Prior End Date #2
5 MG
5 MG
1 GM
1 GM
1 GM
1 GM
1 GM
50 MG
50 MG
50 MG
10 MG
10 MG
10 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
End Date #1
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
Start Date #1
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
HCPCS Measure #1
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
Prior Start Date #2

Package
NDC Label
HCPCS Description

2/14/2002
2/14/2002
J7631
49452-2339-04 KO J7631
49452-2400-01
J3420
49452-2400-02
J3420
49452-2400-03
J3420
49452-2400-04
J3420
49452-2437-01
J9000
2/4/2002
2/14/2002
J7631
49452-2339-03 KO J7631
49452-2339-04
2/4/2002
KO
J7631
49452-2339-02 KO J7631
49452-2339-03
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/30/2002
1/30/2002
1/30/2002
1/1/2002
1/1/2002
1/1/2002
11/15/2004
1/1/2002
1/1/2002
1/1/2002
NDC Package Type
J0706
J0706
J1955
J1955
J1955
J1955
J1955
J3230
J3230
J3230
J9060
J9060
J9060
J0735
J0735
J0735
J0735
J0760
J0760
J0760
NDC Package Measure
49452-1330-02
49452-1330-03
49452-1775-01
49452-1775-02
49452-1775-03
49452-1776-01
49452-1776-02
49452-1990-01
49452-1990-02
49452-1990-03
49452-2078-01
49452-2078-02
49452-2078-03
49452-2147-01
49452-2147-02
49452-2147-03
49452-2147-04
49452-2210-01
49452-2210-02
49452-2210-03
HCPCS Mod
HCPCS
NDC Mod
NDC
49452-2470-04
J7638
49452-2470-04 KO J7638
49452-2540-01
J3360
49452-2540-02
J3360
49452-2540-03
J3360
49452-2541-01
J1730
49452-2541-02
J1730
49452-2541-03
J1730
49452-2584-01
J0500
49452-2584-02
J0500
49452-2588-01
J1212
49452-2588-02
J1212
49452-2588-04
J1212
49452-2612-01
J1160
49452-2612-02
J1160
49452-2615-01
J1240
49452-2615-02
J1240
49452-2615-03
J1240
KO

1/1/2002
1/1/2003 INJECTION, DIAZOXIDE, UP TO 300 MG
1/28/2002
49452-2616-01
J1110
49452-2616-02
J1110
49452-2616-03
49452-2640-01
49452-2640-02
49452-2641-03
49452-2641-04
49452-2641-05
49452-2641-06
49452-2696-01
49452-2696-02
49452-2697-01
49452-2697-02
49452-2697-03
J1110
J1200
J1200
J1245
J1245
J1245
J1245
J1790
J1790
J0600
J0600
J0600
1/31/2002
1/1/2002
1/1/2002
1/1/2003
1/1/2003
1/1/2003
1/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
49452-2700-03
J3520
49452-2702-01
J3520
49452-2702-02
J3520
49452-2702-03
49452-2740-01
49452-2745-01
49452-2745-02
49452-2762-01
49452-2762-02
49452-2762-03
49452-2791-01
49452-2791-02
49452-2791-03
49452-2795-01
49452-2795-02
49452-2795-03
49452-2795-04
49452-3038-02
49452-3038-03
49452-3038-04
49452-3038-05
49452-3151-01
49452-3151-02
49452-3151-03
J3520
J7799
J7799
J7799
J1330
J1330
J1330
J0970
J0970
J0970
J1435
J1435
J1435
J1435
J3490
J3490
J3490
J3490
J1450
J1450
J1450
49452-3162-01
J7641
49452-3162-01 KO J7641
49452-3162-02
1/1/2002
1/1/2002
1/25/2002
1/25/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
11/15/2004
1/31/2002
1/31/2002
1/31/2002
1/31/2002
1/1/2003
1/1/2003
11/15/2004
1/1/2002
KO
J7641
49452-3162-02 KO J7641
49452-3162-03
1/1/2002

99/99/9999 INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG
1/1/2002
KO
J7641
49452-3162-03 KO J7641
49452-3175-01
J9190
49452-3175-01 QR J9190
49452-3175-02
J9190
49452-3175-02 QR J9190
1/1/2002
1/1/2002
1/1/2002
KO
QR
QR
1/1/2002
1/1/2002
1/28/2005
1/1/2002
1/28/2005

99/99/9999 THROUGH DME, UNIT DOSE, PER MILLIGRAM
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
DIAZEPAM (BP)
DIAZEPAM (BP)
DIAZEPAM (BP)
DIAZOXIDE (U.S.P./N.F.)
DICYCLOMINE HCL (U.S.P.)
DICYCLOMINE HCL (U.S.P.)
DIGOXIN (U.S.P.)
DIGOXIN (U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
DROPERIDOL (U.S.P.)
DROPERIDOL (U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
EPINEPHRIN HCL (U.S.P.)
EPINEPHRIN HCL (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
FAMOTIDINE (U.S.P.)
FAMOTIDINE (U.S.P.)
FAMOTIDINE (U.S.P.)
FAMOTIDINE (U.S.P.)
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
(MICRONIZED)
(MICRONIZED)
(MICRONIZED)
(MICRONIZED)
(MICRONIZED)
(MICRONIZED)
5-FLUOROURACIL (U.S.P.)
Page 184 of 374
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
ML
ML
ML
GM
GM
GM
GM
GM
1 MG
5 MG
5 MG
5 MG
300 MG
300 MG
300 MG
20 MG
20 MG
50 %
50 %
50 %
0.5 MG
0.5 MG
50 MG
50 MG
50 MG
1000
200
200
200
3.33333
3.33333
3.33333
50
50
0.02
0.02
0.02
2000
2000
20
20
20
01/01/2002
01/01/2003
01/01/2003
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/31/2002
01/31/2002
01/31/2002
01/31/2002
01/31/2002
01/01/2002
01/01/2002
01/28/2002
01/28/2002
01/28/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2003
99/99/9999
99/99/9999
11/15/2004
11/15/2004
99/99/9999
99/99/9999
99/99/9999
11/15/2004
99/99/9999
99/99/9999
99/99/9999
01/01/2003
1 EA BO
NA
GM
1 MG
1000
01/31/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/31/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
50 MG
50 MG
10 MG
10 MG
10 MG
10 MG
5 MG
5 MG
1000 MG
1000 MG
1000 MG
1000
20
20
100
100
100
100
200
200
1
1
1
01/31/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2003
01/01/2003
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
11/15/2004
3/15/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
150 MG
6.66666
01/01/2002
01/11/2002
1 EA BO
NA
GM
150 MG
6.66666
01/11/2002
99/99/9999
1 EA BO
NA
GM
150 MG
6.66666
01/11/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
150 MG
1 EA
1 EA
1 EA
0.2 MG
0.2 MG
0.2 MG
40 MG
40 MG
40 MG
1 MG
1 MG
1 MG
1 MG
1 EA
1 EA
1 EA
1 EA
200 MG
200 MG
200 MG
6.66666
1
1
1
5000
5000
5000
25
25
25
1000
1000
1000
1000
1
1
1
1
5
5
5
01/01/2002
01/01/2002
01/25/2002
01/25/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
11/15/2004
01/31/2002
01/31/2002
01/31/2002
01/31/2002
01/01/2003
01/01/2003
11/15/2004
99/99/9999
99/99/9999
01/01/2003
01/01/2003
11/15/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
11/14/2004
99/99/9999
3/15/2008
99/99/9999
99/99/9999
99/99/9999
3/15/2008
3/15/2008
3/15/2008
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
500 ML
4000 ML
100 ML
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1 MG
500 MG
500 MG
500 MG
500 MG
1000
2
2
2
2
01/01/2002
01/01/2002
01/28/2005
01/01/2002
01/28/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
QR

49452-3261-01
J7699
49452-3261-02
J7699
49452-3261-03
J7699
49452-3358-01
J7643

49452-3358-01 KO J7643
49452-3358-02
KO
J7643
49452-3358-02 KO J7643
49452-3446-01
J1630
49452-3446-02
J1630
3/15/2007
99/99/9999 01/01/2002 01/01/2003
1 EA
3/15/2007
99/99/9999 01/01/2002 01/01/2003
1 EA BO
NA
GM
1 EA
3/15/2007
99/99/9999 01/01/2002 01/01/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2003
99/99/9999
1 EA BO
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
1 MG
5 MG
5 MG
1000
200
200
01/01/2003
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
CF
HCPCS Amount #1
NDC Label
J1644
1 EA BO
NA
GM
1000 U
160
01/01/2002
99/99/9999
49452-3450-02
J1644
HEPARIN SODIUM (USP, 160 UNITS/MG)
1 EA BO
NA
GM
1000 U
160
01/01/2002
99/99/9999
49452-3450-03
J1644
1 EA BO
NA
GM
1000 U
160
01/01/2002
99/99/9999
J7317
J3490
HYALURONIC ACID
HYALURONIC ACID
1 EA BO
1 EA BO
NA
NA
GM
GM
20 MG
1 EA
40
1
01/01/2003
01/01/2007
12/31/2006
99/99/9999
49452-3543-02
49452-3543-02
49452-3544-01
49452-3544-02
49452-3544-03
49452-3545-01
49452-3545-02
49452-3545-03
J7317
J3490
J0360
J0360
J0360
J0360
J0360
J0360

SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR
1/1/2003 12/31/2006 INJECTION
1/1/2003 12/31/2006 INJECTION
1/1/2002
1/1/2002
HEPARIN SODIUM (USP, 160 UNITS/MG)
49452-3543-01
49452-3543-01
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
20 MG
1 EA
20 MG
20 MG
20 MG
20 MG
20 MG
20 MG
40
1
50
50
50
50
50
50
01/01/2003
01/01/2007
02/04/2002
02/04/2002
04/01/2005
01/01/2002
01/01/2002
02/04/2002
12/31/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
02/04/2002
02/04/2002
3/15/2008
49452-3590-01
J1700
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
49452-3590-02
J1700
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
49452-3590-03
J1700
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
49452-3590-04
J1700
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
49452-3590-05
J1700
1/1/2002
1 EA BO
NA
GM
25 MG
40
01/01/2002
01/11/2002
49452-3590-06
J1700
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
49452-3596-01
J1710
1/1/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
01/01/2003
49452-3596-02
J1710
1/1/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
01/01/2003
49452-3652-01
49452-3652-02
49452-3652-03
49452-3656-01
49452-3656-02
J3410
J3410
J3410
J1980
J1980
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
HYALURONIC ACID
HYALURONIC ACID
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
PHOSPHATE (U.S.P., N.F.)
PHOSPHATE (U.S.P., N.F.)
HYDROXYZINE HYDROCHLORIDE
(U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
25 MG
25 MG
25 MG
0.25 MG
0.25 MG
40
40
40
4000
4000
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/16/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
49452-3659-01
Q0178
1/10/2002
1 EA BO
NA
GM
50 MG
20
01/10/2002
99/99/9999
49452-3659-02
Q0178
1/1/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
99/99/9999
49452-3791-02
J7644
1/1/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
49452-3791-02
KO
J7645
49452-3791-02 KO J7645
1/1/2002
1/1/2007
KO
1/1/2007

HYDROXYZINE PAMOATE (U.S.P./N.F.)
HYDROXYZINE PAMOATE (U.S.P./N.F.)
IPRATROPIUM BROMIDE (B.P.,E.P.)
Page 185 of 374
1 EA
GM
Prior End Date #3
GM
NA
Prior Start Date #3
NA
1 EA BO
Prior End Date #2
1 EA BO
Prior Start Date #2
01/01/2002
01/28/2005
01/01/2004
01/28/2005
01/01/2002
01/01/2002
01/01/2004
End Date #1
2
2
2
2
50
50
50
Start Date #1
500 MG
500 MG
500 MG
500 MG
20 MG
20 MG
20 MG
HCPCS Measure #1
GM
GM
GM
GM
GM
GM
GM
Billing Units
NA
NA
NA
NA
NA
NA
NA
49452-3450-01

Package
BO
BO
BO
BO
BO
BO
BO
FUROSEMIDE (U.S.P./N.F.)
GENTAMICIN SULFATE
(U.S.P.,CRYSTALLINE)
GENTAMICIN SULFATE
GENTAMICIN SULFATE
HEPARIN SODIUM (U.S.P., 160
UNITS/MG)
49452-3791-02 KO J7644
KO
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
HCPCS Description

1/1/2002
1/28/2005
1/1/2004
1/28/2005
1/1/2002
1/1/2002
1/1/2004
NDC Package Type
QR
NDC Package Measure
49452-3175-03
J9190
49452-3175-03 QR J9190
49452-3175-04
J9190
49452-3175-04 QR J9190
49452-3222-01
J1940
49452-3222-02
J1940
49452-3222-03
J1940
HCPCS Mod
HCPCS
NDC Mod
NDC
49452-3791-03
J7644
49452-3791-03 KO J7644
49452-3791-03
49452-4050-01
J2000
49452-4050-01
J2001
49452-4050-02
J2000
49452-4050-02
J2001
49452-4050-03
J2000
49452-4050-03
49452-4140-01
49452-4140-02
49452-4140-03
49452-4140-04
J2001
J2060
J2060
J2060
J2060
49452-4300-01
J3475
49452-4300-03
49452-4380-01
49452-4380-02
49452-4380-03
49452-4381-02
KO
J7659
49452-3850-03 KO J7659
49452-3885-01
J1840
49452-3885-02
J1840
49452-3885-03
J1840
49452-3919-01
J1885
49452-3919-02
J1885
49452-3919-03
J1885
49452-3919-05
J1885
49452-3956-01
J2060
49452-3956-02
J2060
49452-3956-03
J2060
49452-3956-04
J2060
49452-4036-01
J0640
49452-4036-02
J0640
49452-4036-04
J0640
49452-4300-02
KO
J7659
49452-3850-02 KO J7659
49452-3850-03
KO
J7659
49452-3850-01 KO J7659
49452-3850-02
KO
J7644
49452-3791-04 KO J7644
49452-3845-01
J1835
49452-3845-02
J1835
49452-3845-03
J1835
49452-3845-04
J1835
49452-3850-01
KO
J7645
49452-3791-03 KO J7645
49452-3791-04
J3475
J3475
J2150
J2150
J2150
J2150
KO

1/1/2002 12/31/2006 MILLIGRAM
1/1/2002 12/31/2006 MILLIGRAM
1/1/2002 11/15/2004 MILLIGRAM
1/1/2002 11/15/2004 MILLIGRAM
1/1/2003 99/99/9999 INJECTION, ITRACONAZOLE, 50 MG
ITRACONAZOLE
ITRACONAZOLE
ITRACONAZOLE
ITRACONAZOLE
1/1/2002 11/15/2004 MILLIGRAM
1/1/2002 11/15/2004 MILLIGRAM
1/1/2002 11/15/2004 MILLIGRAM
1/1/2002 11/15/2004 MILLIGRAM
1/1/2002
1/1/2003 MILLIGRAM
1/1/2002
1/1/2003 MILLIGRAM
1/29/2002 99/99/9999 INJECTION, KANAMYCIN SULFATE, UP TO 500 MG
KANAMYCIN SULFATE (U.S.P.)
KETOROLAC TROMETHAMINE (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LEUCOVORIN CALCIUM (U.S.P.)
LIDOCAINE HCL MONOHYDRATE
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
1/1/2002
11/15/2004
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1 MG
50 MG
50 MG
50 MG
50 MG
1000
20
20
20
20
1/1/2002 11/15/2004
01/01/2003 99/99/9999
01/01/2003 99/99/9999
01/01/2003 99/99/9999
01/01/2003 99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/15/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/15/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/15/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/15/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/01/2003
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
JR
JR
JR
JR
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
500 MG
500 MG
500 MG
15 MG
15 MG
15 MG
15 MG
2 MG
2 MG
2 MG
2 MG
50 MG
50 MG
50 MG
1000
2
2
2
66.66666
66.66666
66.66666
66.66666
500
500
500
500
20
20
20
01/01/2002
11/15/2004
11/15/2004
11/15/2004
01/01/2003
01/01/2003
01/01/2003
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/16/2002
01/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/16/2002
01/16/2002
01/16/2002
01/16/2002
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
50 ML
01/01/2002
12/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2004
99/99/9999
1 EA BO
NA
GM
50 ML
01/01/2002
12/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2004
99/99/9999
1 EA BO
NA
GM
50 ML
01/01/2002
12/31/2003
1
1
1
1
1
BO
JR
JR
JR
JR
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
10 MG
2 MG
2 MG
2 MG
2 MG
100
500
500
500
500
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
EA
EA
EA
EA
EA

(U.S.P.,E.P.,B.P.,J.P.)
1 EA BO
NA
GM
500 MG
01/01/2002
99/99/9999

(U.S.P.,E.P.,B.P.,J.P.)
1 EA BO
NA
GM
500 MG
01/01/2002
99/99/9999
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

(U.S.P.,E.P.,B.P.,J.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
500 MG
50 ML
50 ML
50 ML
50 ML
2
0.08
0.08
0.08
0.08
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
11/14/2004

Page 186 of 374
BO
BO
BO
BO
BO
1/29/2002
1/29/2002
1/29/2002
1/1/2003
1/1/2003
1/1/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
2
2
2
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/31/2002
1/31/2002
11/15/2004
49452-4555-01
J7669
1/1/2002
49452-4555-01 KO J7669
49452-4555-02
J7669
49452-4555-02 KO J7669
49452-4555-02
49452-4555-03
KO
KO
KO
KO
49452-4555-05 KO J7670
49452-4600-01
J8610
49452-4600-02
J8610
49452-4600-03
J8610
49452-4601-01
J8610
49452-4601-02
J8610
49452-4601-03
J8610
49452-4601-04
J8610
METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT,

1/1/2007
1/1/2002
1/1/2002
1/1/2002
3/4/2002
3/4/2002
3/4/2002
3/4/2002
49452-4686-01
J7509
49452-4686-02
J7509
49452-4686-03
J7509
49452-4688-01
J1030
49452-4688-02
J1030
49452-4688-03
J1030
49452-4715-01
J2765
49452-4715-02
J2765
49452-4715-03
49452-4726-01
49452-4726-02
49452-4726-03
49452-4785-01
49452-4785-02
49452-4800-01
49452-4800-02
J2765
J3490
J3490
J3490
J9290
J9290
J2300
J2300
1/1/2002
3/19/2002
3/19/2002
3/19/2002
1/28/2002
11/15/2004
1/29/2002
1/29/2002

01/01/2002
01/16/2002
1 EA BO
NA
GM
10 MG
100
01/01/2002
01/16/2002
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999

METHOTREXATE
METHOTREXATE
METHYLPREDNISOLONE
(U.S.P.,MICRONIZED)
METHYLPREDNISOLONE
(U.S.P.,MICRONIZED)
METHYLPREDNISOLONE
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
METOCLOPRAMIDE HCL
MONOHYDRATE (U.S.P.)
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
MITOMYCIN (U.S.P.)
MITOMYCIN (U.S.P.)
NALBUPHINE HCL
NALBUPHINE HCL
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
10 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
100
400
400
400
400
400
400
400
01/01/2007
01/01/2002
01/01/2002
01/01/2002
03/04/2002
03/04/2002
03/04/2002
03/04/2002
99/99/9999
03/04/2002
03/04/2002
03/04/2002
01/01/2003
01/01/2003
01/01/2003
01/01/2003
1 EA BO
NA
GM
4 MG
250
01/01/2002
99/99/9999
1 EA BO
NA
GM
4 MG
250
01/01/2002
99/99/9999
1 EA BO
NA
GM
4 MG
250
01/01/2002
99/99/9999
1 EA BO
NA
GM
40 MG
25
01/01/2002
99/99/9999
1 EA BO
NA
GM
40 MG
25
01/01/2002
99/99/9999
1 EA BO
NA
GM
40 MG
25
01/01/2002
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
10 MG
1 EA
1 EA
1 EA
20 MG
20 MG
10 MG
10 MG
100
1
1
1
50
50
100
100
01/01/2002
03/19/2002
03/19/2002
03/19/2002
01/28/2002
11/15/2004
01/29/2002
01/29/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
11/15/2004
99/99/9999
99/99/9999
99/99/9999
Page 187 of 374
BO
BO
JR
BO
BO
BO
BO
BO
CF
HCPCS Amount #1
100
Prior End Date #3
10 MG
Prior Start Date #3
GM
NA
Prior End Date #2
1 EA BO
End Date #1
11/14/2004
11/14/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Start Date #1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/31/2002
01/31/2002
11/15/2004
HCPCS Measure #1
0.08
0.08
1000
1000
100
100
100
Billing Units
50 ML
50 ML
1 MG
1 MG
10 MG
10 MG
10 MG
Prior Start Date #2

Package
GM
GM
GM
GM
GM
GM
GM
NDC Label
HCPCS Description
J7670
KO
NA
NA
NA
NA
NA
NA
NA

1/1/2002 12/31/2006 PER 10 MILLIGRAMS
1/1/2002 12/31/2006 PER 10 MILLIGRAMS
49452-4555-05
BO
BO
BO
BO
JR
JR
JR

1/1/2002 12/31/2006 PER 10 MILLIGRAMS
1/1/2002 12/31/2006 PER 10 MILLIGRAMS
J7669
49452-4555-05 KO J7669
1/1/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA

MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
99/99/9999 INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG
MENADIONE (U.S.P.)
MENADIONE (U.S.P.)

J7670
49452-4555-03 KO J7670
49452-4555-05
KO
J7669
49452-4555-03 KO J7669
1/1/2002
1/1/2002
J7670
49452-4555-02 KO J7670
49452-4555-03
KO
NDC Package Type
J2150
J2150
J3430
J3430
J1230
J1230
J1230
NDC Package Measure
49452-4381-03
49452-4381-04
49452-4410-01
49452-4410-02
49452-4553-01
49452-4553-02
49452-4553-03
HCPCS Mod
HCPCS
NDC Mod
NDC
NALBUPHINE HCL
NANDROLONE DECANOATE (U.S.P.)
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
10 MG
1 MG
1 MG
1 MG
1 MG
100 MG
100 MG
100 MG
60 MG
60 MG
100
1000
1000
1000
1000
10
10
10
16.66666
16.66666
01/29/2002
04/16/2002
04/15/2002
04/16/2002
04/16/2002
01/01/2003
01/01/2003
01/01/2003
05/15/2002
05/15/2002
J2440
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
99/99/9999
49452-5000-02
J2440
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
99/99/9999
49452-5000-03
49452-5073-01
49452-5073-02
49452-5073-03
49452-5130-01
49452-5130-02
49452-5130-03
49452-5200-03
49452-5217-01
49452-5217-02
49452-5217-03
49452-5217-04
49452-5217-05
49452-5252-01
49452-5252-02
49452-5252-04
49452-5290-01
49452-5290-02
49452-5290-03
49452-5344-01
49452-5344-02
49452-5344-03
49452-5390-01
49452-5390-02
49452-5390-03
49452-5770-01
49452-5770-02
49452-5770-03
49452-5780-01
49452-5780-02
49452-5780-03
49452-5971-01
49452-5971-02
49452-5971-03
49452-5980-01
49452-5980-02
49452-5980-03
J2440
J2515
J2515
J2515
J3310
J3310
J3310
J2560
J2760
J2760
J2760
J2760
J2760
J2760
J2760
J2760
J7799
J7799
J7799
J1165
J1165
J1165
J3430
J3430
J3430
J3480
J3480
J3480
J3480
J3480
J3480
J2730
J2730
J2730
J7510
J7510
J7510

PHYTONADIONE (U.S.P.)
PRALIDOXIME CHLORIDE (U.S.P.)
PREDNISOLONE (U.S.P.,MICRONIZED)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
60 MG
50 MG
50 MG
50 MG
5 MG
5 MG
5 MG
120 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1 EA
1 EA
1 EA
50 MG
50 MG
50 MG
1 MG
1 MG
1 MG
2 MEQ
2 MEQ
2 MEQ
2 MEQ
2 MEQ
2 MEQ
1 GM
1 GM
1 GM
5 MG
5 MG
5 MG
16.66666
20
20
20
200
200
200
8.33333
200
200
200
200
200
200
200
200
1
1
1
20
20
20
1000
1000
1000
6.71141
6.71141
6.71141
6.71141
6.71141
6.71141
1
1
1
200
200
200
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/29/2002
01/29/2002
01/29/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/07/2002
03/07/2002
03/07/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2003
01/01/2003
01/01/2002
01/01/2002
01/01/2002
99/99/9999
01/08/2002
01/08/2002
01/08/2002
01/01/2003
01/01/2003
01/01/2003
99/99/9999
99/99/9999
99/99/9999
01/17/2002
99/99/9999
99/99/9999
01/17/2002
01/17/2002
01/17/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
49452-6000-01
J7506
PREDNISONE (U.S.P.,ANH,MICRONIZED)
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
49452-6000-02
J7506
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
49452-6000-03
49452-6030-01
49452-6030-02
49452-6030-03
49452-6031-01
49452-6031-02
49452-6031-03
J7506
J2690
J2690
J2690
J2690
J2690
J2690
1/1/2002
1/1/2002
1/1/2002
1/1/2002
3/1/2002
3/1/2002
3/1/2002
1
1
1
1
1
1
1
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
5
1
1
1
1
1
1
MG
GM
GM
GM
GM
GM
GM
200
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/01/2002
03/01/2002
03/01/2002
99/99/9999
03/01/2002
03/01/2002
03/01/2002
11/15/2004
11/15/2004
11/15/2004
49452-6052-01
J0780
3/13/2002
1 EA BO
NA
GM
10 MG
100
03/13/2002
01/01/2003
49452-6052-02
J0780
3/26/2002
PROCAINAMIDE HCL
PROCAINAMIDE HCL (USP)
PROCAINAMIDE HCL
(U.S.P.)
(U.S.P.)
1 EA BO
NA
GM
10 MG
100
03/26/2002
01/01/2003
49452-6053-01
Q0165
1 EA BO
NA
GM
10 MG
100
02/13/2002
99/99/9999
49452-6053-02
Q0165
1 EA BO
NA
GM
10 MG
100
02/13/2002
99/99/9999
49452-6053-03
Q0165
1 EA BO
NA
GM
10 MG
100
02/13/2002
99/99/9999

99/99/9999 INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM


ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROCHLORPERAZINE MALEATE (U.S.P.,
N.F.)
N.F.)
N.F.)
Page 188 of 374
EA
EA
EA
EA
EA
EA
EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
12/31/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
49452-5000-01
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/29/2002
1/29/2002
1/29/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
3/7/2002
3/7/2002
3/7/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2003
1/1/2003
1/1/2003
1/1/2002
1/1/2002
1/1/2002
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
BO
BO
JR
BO
BO
BO
BO
BO
BO
Billing Units
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA

Package
NDC Label
HCPCS Description

NDC Package Type
1/29/2002
4/16/2002
4/15/2002
4/16/2002
4/16/2002
1/1/2003
1/1/2003
1/1/2003
5/15/2002
5/15/2002
HCPCS Mod
HCPCS
J2300
J2310
J2310
J2310
J2310
J2321
J2321
J2321
J2360
J2360
NDC Package Measure
49452-4800-03
49452-4836-01
49452-4836-02
49452-4836-03
49452-4836-04
49452-4838-03
49452-4838-04
49452-4838-05
49452-4936-01
49452-4936-02
NDC Mod
NDC
49452-6053-05
Q0165

1 EA BO
NA
GM
10 MG
100
04/01/2005
Q0165
1 EA BO
NA
GM
10 MG
100
02/13/2002
3/15/2008
49452-6060-01
J2675
1 EA BO
NA
GM
50 MG
20
01/01/2002
11/15/2004
49452-6060-02
J2675
1/1/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
3/15/2008
49452-6060-03
J2675
1/1/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
3/15/2008
49452-6060-04
J2675
1/1/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
3/15/2008
49452-6060-05
J2675
1/1/2002
1 EA BO
NA
GM
50 MG
20
01/01/2002
01/18/2002
49452-6060-06
J2675
1/1/2002
NA
GM
50 MG
20
01/01/2002
3/15/2008
J2675
1 EA JR
NA
GM
50 MG
20
01/01/2002
11/15/2004
49452-6061-02
J2675
1 EA JR
NA
GM
50 MG
20
3/15/2007
99/99/9999 01/01/2002 11/15/2004
20
49452-6061-03
J2675
1 EA JR
NA
GM
50 MG
20
3/15/2007
99/99/9999 01/01/2002 11/15/2004
20
49452-6061-04
J2675
1 EA JR
NA
GM
50 MG
20
3/15/2007
99/99/9999 01/01/2002 11/15/2004
20
49452-6061-05
49452-6070-01
49452-6070-02
49452-6070-03
49452-6070-04
49452-6070-05
49452-6070-06
49452-6080-01
49452-6080-02
49452-6080-03
49452-6080-04
49452-6080-05
49452-6080-06
49452-6087-01
49452-6087-02
49452-6087-04
49452-6089-01
49452-6089-02
49452-6089-03
49452-6089-04
49452-6109-01
49452-6109-02
49452-6109-03
49452-6140-01
49452-6140-01
49452-6140-02
49452-6140-02
49452-6140-03
49452-6140-03
49452-6212-01
49452-6212-04
49452-6212-05
49452-6212-06
49452-6222-04
49452-6222-05
49452-6222-06
49452-6273-01
49452-6273-02
49452-6273-03
49452-6273-04
49452-7320-01
49452-7320-02
49452-7320-03
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2550
J2550
J2550
J1800
J1800
J1800
J1800
J2720
J2720
J2720
J3490
J3415
J3490
J3415
J3490
J3415
J2780
J2780
J2780
J2780
J3490
J3490
J3490
J2780
J2780
J2780
J2780
J3000
J3000
J3000
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
1 MG
1 MG
1 MG
1 MG
10 MG
10 MG
10 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
25 MG
25 MG
25 MG
25 MG
1 EA
1 EA
1 EA
25 MG
25 MG
25 MG
25 MG
1 GM
1 GM
1 GM
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
1000
1000
1000
1000
100
100
100
1
10
1
10
1
10
40
40
40
40
1
1
1
40
40
40
40
1
1
1
3/15/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/28/2002
02/28/2002
02/28/2002
02/05/2002
11/15/2004
11/15/2004
11/15/2004
01/01/2003
01/01/2003
01/01/2003
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999 01/01/2002 11/15/2004

3/15/2008
99/99/9999
99/99/9999
99/99/9999
01/18/2002
99/99/9999
11/15/2004
99/99/9999
99/99/9999
99/99/9999
01/18/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
11/14/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
3/15/2008
3/15/2008
3/15/2008
3/15/2008
99/99/9999
99/99/9999
99/99/9999
01/18/2002
01/18/2002
01/18/2002
01/18/2002
01/01/2003
01/01/2003
01/01/2003
20
49452-7395-01
J0330
1 EA BO
NA
GM
20 MG
50
01/01/2002
11/15/2004
49452-7395-02
J0330
1 EA BO
NA
GM
20 MG
50
01/01/2002
11/15/2004
49452-7395-03
J0330
1 EA BO
NA
GM
20 MG
50
01/01/2002
11/15/2004
49452-7631-01
J7681

PROGESTERONE
(U.S.P.,YAM,MICRONIZED)
PROGESTERONE
PROGESTERONE
PROGESTERONE
PROGESTERONE
PROGESTERONE (MILLED/U.S.P.)
PROGESTERONE (WETTABLE/U.S.P.)
PROTAMINE SULFATE (U.S.P.)
RIFAMPIN (U.S.P.)
RIFAMPIN (U.S.P.)
RIFAMPIN (U.S.P.)
SUCCINYLCHOLINE CHLORIDE
DIHYDRATE (U.S.P.)
DIHYDRATE (U.S.P.)
DIHYDRATE (U.S.P., N.F.)
1 EA JR
49452-6061-01
1 EA BO
NA
GM
1 MG
1000
05/09/2002
99/99/9999

Page 189 of 374
99/99/9999
49452-6059-04
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
2/28/2002
2/28/2002
2/28/2002
2/5/2002
11/15/2004
11/15/2004
11/15/2004
1/1/2003
1/1/2003
1/1/2003
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
49452-7631-02
J7681
49452-7631-02 KO J7681
49452-7631-05
KO
J7681
49452-7631-05 KO J7681
49452-7649-01
J3130
49452-7649-02
J3130
49452-7649-03
J3130
49452-7650-01
J3140
49452-7650-02
J3140
49452-7650-03
J3140
49452-7652-01
J3140
49452-7652-02
J3140
49452-7652-03
J3140
49452-7653-01
J3140
49452-7653-02
J3140
49452-7653-03
J3140
49452-7660-01
J1070
49452-7660-02
J1070
49452-7660-03
J1070
KO

1 EA BO
NA
GM
1 MG
1000
05/09/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
05/09/2002
99/99/9999

TESTOSTERONE ENANTHATE (U.S.P.)
TESTOSTERONE MICRONIZED (U.S.P.)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
200 MG
200 MG
200 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
100 MG
100 MG
100 MG
1000
5
5
5
20
20
20
20
20
20
20
20
20
10
10
10
05/09/2002
01/01/2003
01/01/2003
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2003
01/01/2003
01/01/2002
01/01/2002
01/01/2002
99/99/9999
3/15/2008
3/15/2008
3/15/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
11/15/2004
11/15/2004
11/15/2004
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
05/09/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
05/09/2002
99/99/9999
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
49452-7670-01
J3150
1/1/2002
1 EA JR
NA
GM
100 MG
10
01/01/2002
01/01/2003
49452-7670-02
J3150
1/1/2002
1 EA JR
NA
GM
100 MG
10
01/01/2002
01/01/2003
49452-7670-03
49452-7699-01
49452-7699-02
49452-7720-01
49452-7720-02
49452-7720-03
J3150
J0120
J0120
J2810
J2810
J2810

TETRACYCLINE
TETRACYCLINE
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
JR
NA
NA
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
100 MG
250 MG
250 MG
40 MG
40 MG
40 MG
10
4
4
25
25
25
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2003
01/01/2003
99/99/9999
99/99/9999
99/99/9999
49452-7823-01
J7682
TOBRAMYCIN (U.S.P.)
1 EA BO
NA
GM
300 MG
3.33333
11/15/2004
12/31/2006
TOBRAMYCIN (U.S.P.)
1 EA BO
NA
GM
300 MG
3.33333
11/15/2004
12/31/2006
TOBRAMYCIN (U.S.P.)
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
TOBRAMYCIN (U.S.P.)
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
TOBRAMYCIN (U.S.P.)
1 EA BO
NA
GM
300 MG
3.33333
11/15/2004
12/31/2006
TOBRAMYCIN (U.S.P.)
1 EA BO
NA
GM
300 MG
3.33333
11/15/2004
12/31/2006
TOBRAMYCIN (U.S.P.)
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
TOBRAMYCIN (U.S.P.)
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/01/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
01/01/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
49452-7823-01 KO J7682
49452-7823-01
49452-7823-01 KO J7685
49452-7823-02
KO
J7684
49452-7900-02 KO J7684
49452-7900-03
KO
J7684
49452-7900-01 KO J7684
49452-7900-02
KO
J7684
49452-7890-03 KO J7684
49452-7900-01
KO
J7684
49452-7890-02 KO J7684
49452-7890-03
KO
J7684
49452-7890-01 KO J7684
49452-7890-02
KO
J7685
49452-7823-02 KO J7685
49452-7890-01
KO
J7682
49452-7823-02 KO J7682
49452-7823-02
KO
J7685
KO
J7684
49452-7900-03 KO J7684
KO
1/1/2002
1/1/2002
1/1/2002
11/15/2004 12/31/2006 MILLIGRAMS
11/15/2004 12/31/2006 MILLIGRAMS
11/15/2004 12/31/2006 MILLIGRAMS
11/15/2004 12/31/2006 MILLIGRAMS
1/1/2002
1/1/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
Page 190 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
49452-7631-01 KO J7681
NDC
HCPCS
49452-7900-04
J7684
49452-7900-04 KO J7684
KO

49452-7910-01
J3302
1/1/2002 99/99/9999 INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG
49452-7910-02
J3302
49452-7910-03
J3302
49452-7910-04
49452-7924-01
49452-7924-02
49452-7924-03
49452-8070-01
49452-8070-02
49452-8070-03
49452-8095-01
49452-8095-02
49452-8112-01
49452-8112-02
49452-8112-03
49452-8114-01
49452-8114-02
49452-8114-04
J3302
J3250
J3250
J3250
J3350
J3350
J3350
J3370
J3370
J9360
J9360
J9360
J9370
J9370
J9370
1/1/2002
1/1/2003
1/1/2003
1/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
49452-8253-01
J3490
49452-8253-01
J0592
49452-8253-02
J3490
49452-8253-02
J0592
49452-8253-03
J3490
49452-8253-03
J0592
49452-8253-04
J0592
49452-8808-01
J2675
1/1/2002
49452-8808-02
J2675
1/1/2002
49452-8808-03
J2675
1/1/2002
49452-8808-04
J2675
1/1/2002
49452-8808-05
49452-9201-01
49452-9201-02
49452-9201-03
49452-9201-05
49452-9201-06
J2675
J1960
J1960
J1960
J1960
J1960
1/1/2002
11/14/2004
1/1/2003
1/1/2003
11/15/2004
11/15/2004
49483-0061-01
Q0163
1/1/2002
49483-0061-10
Q0163
1/1/2002
49502-0105-01
J7618
1/1/2002
49502-0181-04
J7608
1/1/2002
49502-0181-04 KO J7608
49502-0181-10
J7608
49502-0181-10 KO J7608
49502-0181-30
J7608
1/1/2002
1/1/2002
KO
J7608
49502-0181-30 KO J7608
49502-0182-00
KO
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002


1 EA JR
NA
GM
1 MG
1000
01/01/2002

TRIAMCINOLONE DIACETATE
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
UREA (U.S.P.,J.P.)
UREA (U.S.P.,J.P.)
UREA (U.S.P.,J.P.)
VINCRISTINE SULFATE (U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
PROGESTERONE
PROGESTERONE
PROGESTERONE
PROGESTERONE
PROGESTERONE
1 EA JR
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
5 MG
200 MG
200 MG
200 MG
40 GM
40 GM
40 GM
500 MG
500 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
200
5
5
5
0.025
0.025
0.025
2
2
1000
1000
1000
1000
1000
1000
01/01/2002
01/01/2003
01/01/2003
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2003
01/01/2003
01/01/2003
01/01/2003
01/01/2003
01/01/2003
01/01/2003
01/01/2003
1 EA JR
NA
GM
1 EA
01/01/2002
12/31/2002
1 EA JR
NA
GM
0.1 MG
10000
01/01/2003
99/99/9999
1 EA JR
NA
GM
1 EA
01/01/2002
12/31/2002
1 EA JR
NA
GM
0.1 MG
10000
01/01/2003
99/99/9999
1 EA JR
NA
GM
1 EA
01/01/2002
12/31/2002
1 EA JR
NA
GM
0.1 MG
10000
01/01/2003
99/99/9999
NA
GM
0.1 MG
10000
01/01/2004
99/99/9999
1 EA JR
NA
GM
50 MG
20
01/01/2002
01/18/2002
1 EA JR
NA
GM
50 MG
20
01/01/2002
01/18/2002
1 EA JR
NA
GM
50 MG
20
01/01/2002
01/18/2002
1 EA JR
NA
GM
50 MG
20
01/01/2002
01/18/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
50 MG
2 MG
2 MG
2 MG
2 MG
2 MG
20
500
500
500
500
500
01/01/2002
11/14/2004
01/01/2003
01/01/2003
11/15/2004
11/15/2004
01/18/2002
99/99/9999
11/14/2004
11/14/2004
99/99/9999
99/99/9999
ANTIHISTAMINE 25 MG
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
ANTIHISTAMINE 25 MG
1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
20 ML BO
IH
ML
1 MG
01/01/2002
07/01/2003
ACETYLCYSTEINE 10%
4 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/31/2002
ACETYLCYSTEINE 10%
4 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/31/2002
ACETYLCYSTEINE 10%
10 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/31/2002
ACETYLCYSTEINE 10%
10 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/31/2002
ACETYLCYSTEINE 10%
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/31/2002
ACETYLCYSTEINE 10%
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/31/2002
ACETYLCYSTEINE 20%
100 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/31/2002
Page 191 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
1 EA BO
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
49502-0182-04
J7608
49502-0182-04 KO J7608
49502-0182-10
49502-0182-30
49502-0501-20
49502-0605-61 KO J7606
49502-0640-15
J7051
49502-0640-15
A4216
49502-0641-15
J7699
KO
J7620
49502-0672-31
J7616
49502-0672-31
J7620
49502-0672-60
J7616
1/1/2002
1/1/2002
KO
1/1/2002
KO
KO
49502-0678-03
49502-0678-03 KO J7669
49502-0678-24
J7669
49502-0678-24 KO J7669
49502-0685-03
49502-0685-24
49502-0685-26
KO
J7644
1/1/2002
2/1/2004
1/1/2002
KO
J7644
49502-0685-24 KO J7644
2/1/2004
2/1/2004
J7644
49502-0685-03 KO J7644
1/1/2002
1/1/2002
KO
1/1/2002
12/17/2003
KO
12/17/2003
4/20/2006
01/01/2002
03/31/2002
0.2
01/01/2002
03/31/2002
ACETYLCYSTEINE 20%
4 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/31/2002
ACETYLCYSTEINE 20%
10 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/31/2002
ACETYLCYSTEINE 20%
10 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/31/2002
ACETYLCYSTEINE 20%
30 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/31/2002
ACETYLCYSTEINE 20%
SODIUM CHLORIDE (NEBU-SOL/MTR
DOSE DSPNS) 0.9%
SODIUM CHLORIDE (NEBU-SOL/MTR
DOSE DSPNS) 0.9%
PERFOROMIST 20 MCG/2 ML
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDADUONEB (VIAL,U.D.) 3 MG/3 ML-0.5 MG/3
99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME ML
PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM METAPROTERENOL SULFATE (SULFITE1/31/2004 PER 10 MILLIGRAMS
FREE) 0.6%
FREE) 0.6%
FREE) 0.6%
FREE) 0.6%
FREE) 0.4%
FREE) 0.4%
FREE) 0.4%
FREE) 0.4%
4/19/2006 MILLIGRAM
4/19/2006 MILLIGRAM
IPRATROPIUM BROMIDE (2.5X25) 0.02%
Page 192 of 374
30 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/31/2002
120 ML EA
IH
ML
10 ML
0.1
01/01/2004
12/31/2005
120 ML EA
2 ML PC
IH
IH
ML
ML
10 ML
20 MCG
0.1
0.5
01/01/2006
04/01/2008
99/99/9999
12/31/2008
PC
PC
PC
PC
IH
IH
IH
IH
ML
ML
ML
ML
20 MCG
5 ML
10 ML
1 EA
0.5
0.2
0.1
1
01/01/2009
01/01/2002
01/01/2006
01/01/2002
99/99/9999
12/31/2005
99/99/9999
99/99/9999
3 ML PC
IH
ML
5 MG
0.16666
01/01/2005
12/31/2005
2 ML
15 ML
15 ML
15 ML
3 ML PC
IH
ML
2.5 MG
0.33333
01/01/2006
99/99/9999
3 ML PC
IH
ML
5 MG
0.16666
01/01/2005
12/31/2005
3 ML PC
IH
ML
2.5 MG
0.33333
01/01/2006
01/29/2008
3 ML PC
IH
ML
5 MG
0.16666
01/01/2005
12/31/2005
3 ML PC
IH
ML
2.5 MG
0.33333
01/01/2006
99/99/9999
2.5 ML PC
IH
ML
10 MG
0.6
01/01/2002
01/31/2004
2.5 ML PC
IH
ML
10 MG
0.6
01/01/2002
01/31/2004
2.5 ML PC
IH
ML
10 MG
0.6
02/01/2004
06/03/2008
2.5 ML PC
IH
ML
10 MG
0.6
02/01/2004
06/03/2008
2.5 ML PC
IH
ML
10 MG
0.4
01/01/2002
01/31/2004
2.5 ML PC
IH
ML
10 MG
0.4
01/01/2002
01/31/2004
2.5 ML PC
IH
ML
10 MG
0.4
02/01/2004
06/03/2008
2.5 ML PC
IH
ML
10 MG
0.4
02/01/2004
06/03/2008
2.5 ML VL
IH
ML
1 MG
0.2
01/01/2002
12/16/2003
2.5 ML VL
IH
ML
1 MG
0.2
01/01/2002
12/16/2003
2.5 ML PC
IH
ML
1 MG
0.2
12/17/2003
04/19/2006
2.5 ML PC
IH
ML
1 MG
0.2
12/17/2003
04/19/2006
2.5 ML PC
IH
ML
1 MG
0.2
04/20/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
HCPCS Description
NDC Label
0.2
1 GM
DUONEB (VIAL,U.D.) 3 MG/3 ML-0.5 MG/3

ML
ML
2/1/2004
J7669
1 GM
ML
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA1/1/2006 1/29/2008 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME
ALBUTEROL, UP TO 5 MG AND IPRATROPIUM BROMIDE, UP TO 1 MG,
1/1/2005 12/31/2005 COMPOUNDED INHALATION SOLUTION, ADMINISTERED THROUGH DME
1/1/2002
KO
ML
IH

ML
ML
J7669
49502-0676-24 KO J7669
IH
4 ML VL
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA1/1/2006 99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME
49502-0676-03
J7669
100 ML VL
FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL

PERFOROMIST 20 MCG/2 ML
99/99/9999 20 MICROGRAMS
SODIUM CHLORIDE 3%
SODIUM CHLORIDE 3%
SODIUM CHLORIDE (PF) 10%
ML
1/1/2006
KO
ACETYLCYSTEINE 20%
ACETYLCYSTEINE 20%
1/1/2009
1/1/2002
1/1/2006
1/1/2002
J7620
49502-0676-24
1/1/2006 99/99/9999 STERILE SALINE OR WATER, METERED DOSE DISPENSER, 10 ML

4/1/2008 12/31/2008 FORMOTEROL FUMARATE, INH
49502-0672-60
49502-0676-03 KO J7669

J7616
49502-0672-30
1/1/2002
1/1/2002
A4216
A4218
49502-0501-20
49502-0605-61 KO Q4099
49502-0672-30
KO
J7608
49502-0182-30 KO J7608
1/1/2002
1/1/2002
J7608
49502-0182-10 KO J7608
HCPCS Mod
KO
NDC Mod
49502-0182-00 KO J7608
NDC
HCPCS
49502-0685-29
J7644
49502-0685-29 KO J7644
49502-0685-30
J7644
49502-0685-30 KO J7644
49502-0685-31
KO
J7603
49502-0693-03 KO J7603
49502-0693-03
KO
J7613
49502-0692-03 KO J7613
49502-0693-03
KO
J7603
49502-0692-03 KO J7603
49502-0692-03
KO
J7631
49502-0689-61 KO J7631
49502-0692-03
KO
J7631
49502-0689-12 KO J7631
49502-0689-61
KO
J7631
49502-0689-02 KO J7631
49502-0689-12
KO
J7644
49502-0685-62 KO J7644
49502-0689-02
KO
J7644
49502-0685-61 KO J7644
49502-0685-62
KO
J7644
49502-0685-60 KO J7644
49502-0685-61
KO
J7644
49502-0685-33 KO J7644
49502-0685-60
KO
J7644
49502-0685-31 KO J7644
49502-0685-33
KO
KO
J7613
49502-0693-03 KO J7613
KO

IPRATROPIUM BROMIDE (2.5X25) 0.02%
4/20/2006 99/99/9999 MILLIGRAM
12/17/2003 7/31/2006 MILLIGRAM
12/17/2003 7/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE (SINGLE-PAK)
0.02%
1/1/2005 99/99/9999 MILLIGRAM
IPRATROPIUM BROMIDE (SINGLE-PAK)
0.02%
1/1/2005 99/99/9999 MILLIGRAM
6/1/2005 99/99/9999 MILLIGRAM
6/1/2005 99/99/9999 MILLIGRAM
1/1/2002 12/16/2003 MILLIGRAM
1/1/2002 12/16/2003 MILLIGRAM
1/1/2002 1/31/2004 MILLIGRAM
1/1/2002 1/31/2004 MILLIGRAM
2/1/2004 5/31/2006 MILLIGRAM
2/1/2004 5/31/2006 MILLIGRAM
6/1/2005 99/99/9999 MILLIGRAM
6/1/2005 99/99/9999 MILLIGRAM
3/1/2004
3/1/2004
ACCUNEB (PF) 0.021%
1/1/2008 3/31/2008 (LEVALBUTEROL)
ACCUNEB (PF) 0.021%
1/1/2008 3/31/2008 (LEVALBUTEROL)
ACCUNEB (PF) 0.021%
ACCUNEB (PF) 0.021%
ACCUNEB (PF) 0.042%
1/1/2008 3/31/2008 (LEVALBUTEROL)
ACCUNEB (PF) 0.042%
1/1/2008 3/31/2008 (LEVALBUTEROL)
ACCUNEB (PF) 0.042%
ACCUNEB (PF) 0.042%
Page 193 of 374
2.5 ML PC
IH
ML
1 MG
0.2
04/20/2006
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
12/17/2003
07/31/2006
2.5 ML PC
IH
ML
1 MG
0.2
12/17/2003
07/31/2006
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2005
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2005
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
06/01/2005
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
06/01/2005
99/99/9999
2.5 ML VL
IH
ML
1 MG
0.2
01/01/2002
12/16/2003
2.5 ML VL
IH
ML
1 MG
0.2
01/01/2002
12/16/2003
2.5 ML VL
IH
ML
1 MG
0.2
01/01/2002
01/31/2004
2.5 ML VL
IH
ML
1 MG
0.2
01/01/2002
01/31/2004
2.5 ML PC
IH
ML
1 MG
0.2
02/01/2004
05/31/2006
2.5 ML PC
IH
ML
1 MG
0.2
02/01/2004
05/31/2006
2.5 ML PC
IH
ML
1 MG
0.2
06/01/2005
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
06/01/2005
99/99/9999
2 ML AM IH
ML
10 MG
01/01/2002
02/29/2004
2 ML AM IH
ML
10 MG
01/01/2002
02/29/2004
2 ML AM IH
ML
10 MG
01/01/2002
12/31/2003
2 ML AM IH
ML
10 MG
01/01/2002
12/31/2003
2 ML PC
IH
ML
10 MG
03/01/2004
02/06/2008
2 ML PC
IH
ML
10 MG
03/01/2004
02/06/2008
3 ML PC
IH
ML
1 MG
0.21
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.21
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.21
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.21
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
49502-0685-26 KO J7644
NDC
HCPCS
49502-0697-03
J7619
49502-0697-03 KO J7619
49502-0697-24
KO
J7603
49502-0697-61 KO J7603
49502-0697-61
KO
J7619
49502-0697-60 KO J7619
49502-0697-61
KO
J7619
49502-0697-33 KO J7619
49502-0697-60
KO
J7613
49502-0697-30 KO J7613
49502-0697-33
KO
J7603
49502-0697-30 KO J7603
49502-0697-30
KO
J7613
49502-0697-29 KO J7613
49502-0697-30
KO
J7603
49502-0697-29 KO J7603
49502-0697-29
KO
J7613
49502-0697-24 KO J7613
49502-0697-29
KO
J7603
49502-0697-24 KO J7603
49502-0697-24
KO
J7613
49502-0697-61 KO J7613
49502-0810-03
J7051
49502-0810-03
A4216
49502-0810-05
J7051
49502-0810-05
A4216
49502-0820-03
J7051
49502-0820-03
A4216
49502-0820-05
J7051
49502-0820-05
A4216
49502-0830-03
J7051
49502-0830-03
A4216
49502-0830-05
J7051
A4216
49502-0830-05
49502-0830-50
J7051
49502-0830-50
A4216
KO

ALBUTEROL SULFATE (VIAL) 0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
ALBUTEROL SULFATE (SINGLE-PAK)
0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
ALBUTEROL SULFATE (SINGLE-PAK)
0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONALBUTEROL SULFATE (SINGLE-PAK)
0.083%
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONALBUTEROL SULFATE (SINGLE-PAK)
0.083%
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2002 12/31/2005 STERILE SALINE OR WATER, UP TO 5 CC
WATER FOR INHALATION (PF)
SODIUM CHLORIDE (PF) 0.45%
Page 194 of 374
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
12/31/2003
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
12/31/2003
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
12/31/2003
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
12/31/2003
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
02/29/2004
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
02/29/2004
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 MG
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
5 ML
10 ML
0.83
0.2
0.1
0.2
0.1
0.2
0.1
0.2
0.1
0.2
0.1
0.2
0.1
0.2
0.1
04/01/2008
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
99/99/9999
12/31/2005
12/15/2006
12/31/2005
12/15/2006
12/31/2005
04/19/2007
12/31/2005
04/19/2007
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
3 ML
3 ML
3 ML
5 ML
5 ML
3 ML
3 ML
5 ML
5 ML
3 ML
3 ML
5 ML
5 ML
15 ML
15 ML
PC
PC
PC
PC
PC
PC
PC
PC
PC
PC
PC
PC
PC
PC
PC
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
49614-0143-56
Q0163
49614-0146-62
Q0163

1/1/2002
49614-0379-26
Q0163
49669-1612-01
J1563
1/1/2002
49669-1613-01
J1563
1/1/2002
49669-1614-01
J1563
1/1/2002
49669-1622-01
J1563
1/1/2002
49669-1623-01
J1563
1/1/2002
49669-1624-01
J1563
1/1/2002
49669-3200-02
J7194
1/1/2002
7/24/2003 FACTOR IX, COMPLEX, PER I.U.
49669-3200-03
J7194
1/1/2002
49669-3600-02
49669-4600-01
J7193
J3590
1/1/2002
1/1/2003
7/24/2003 FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.

49669-4600-02
J3590
1/1/2003
49669-5800-01
J0256
2/27/2003
49669-5800-02
49727-0722-10
49727-0722-30
49884-0289-01
49884-0290-01
49884-0290-04
49884-0290-05
J0256
J3420
J3420
J8999
J8999
J8999
J8999
2/27/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

49884-0368-26
J9218
4/27/2006
49884-0490-59
J7509
1/1/2002
49884-0549-01
Q0164
1/1/2002
49884-0550-01
49884-0565-01
49884-0566-01
49884-0567-01
49884-0673-14
49884-0673-14
49884-0724-01
49884-0753-05
49884-0753-13
49884-0907-38
49884-0907-61
49884-0922-02
49884-0922-04
Q0165
J8499
J8499
J8499
Q2001
J8515
J8999
J8999
J8999
J8999
J8999
J8999
J8999
1/1/2002
1/1/2002
1/1/2002
1/1/2002
12/29/2005
1/1/2006
1/1/2002
1/26/2006
1/26/2006
1/1/2002
5/1/2004
2/9/2004
11/18/2004
49999-0003-00
Q0163
8/12/2004
49999-0003-06
Q0163
7/11/2002
49999-0003-15
Q0163
7/11/2002
MEDI-SLEEP MAXIMUM STRENGTH

(SOFTGEL) 50 MG
16 EA BX
PO
EA
50 MG
01/01/2002
09/01/2004
MEDICINE SHOPPE NITE TIME SLEEP

(MINI-CAPLET) 25 MG
24 EA BO
PO
EA
50 MG
0.5
10/13/2003
99/99/9999
BO
PO
ML
50 MG
0.05
01/01/2004
99/99/9999
VL
IV
ML
1 GM
0.05
01/01/2002
07/24/2003
VL
IV
ML
1 GM
0.05
01/01/2002
07/24/2003
VL
IV
ML
1 GM
0.05
01/01/2002
07/24/2003
VL
IV
ML
1 GM
0.1
01/01/2002
07/24/2003
VL
IV
ML
1 GM
0.1
01/01/2002
07/24/2003
THE MEDICINE SHOPPE MEDI-PHEDRYL

(MAY CAUSE DROWSINESS,AF) 12.5
MG/5 ML
118 ML
VENOGLOBULIN-S 5% (2.5GM
VIAL,W/ADMIN SET) 50 MG/ML
50 ML
VENOGLOBULIN-S 5% (5
GM/VIAL,W/ADMIN SET) 50 MG/ML
100 ML
200 ML
50 ML
100 ML
200 ML
PROFILNINE SD (APPROX. 500 IU/VIAL) 1
IU
500 IU
PROFILNINE SD (APPROX 10001500IU/VIAL) 1 IU
1250 IU
ALPHANINE SD (250-1500 FIX I.U/VIAL) 1
IU
850 IU
ALPHANATE (250-500 FVIII IU/5ML) 1 IU
500 IU
ALPHANATE (1000-1500 FVIII IU/10ML) 1
IU
1500 IU
ARALAST (APPRX 500MG VIAL,PF) 1 MG
ARALAST (APPRX 1000MG VIAL,PF) 1
MG
LEUPROLIDE ACETATE (14-DAY
4 MG

ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
12/31/2005 ORAL, CABERGOLINE, 0.5 MG
CABERGOLINE 0.5 MG
CABERGOLINE 0.5 MG
HYDROXYUREA 500 MG
FLUTAMIDE 125 MG
FLUTAMIDE 125 MG
MEGESTROL ACETATE 40 MG/ML
MERCAPTOPURINE 50 MG
Page 195 of 374
VL
IV
ML
1 GM
0.1
01/01/2002
07/24/2003
VL
IV
EA
1 IU
01/01/2002
07/24/2003
VL
IV
EA
1 IU
01/01/2002
07/24/2003
VL
VL
IV
IV
EA
EA
1 IU
1 EA
1
1
01/01/2002
01/01/2003
07/24/2003
07/24/2003
VL
IV
EA
1 EA
01/01/2003
06/21/2004
500 MG VL
IV
EA
10 MG
0.1
02/27/2003
02/12/2006
IV
IM
IM
PO
PO
PO
PO
EA
ML
ML
EA
EA
EA
EA
10 MG
1000 MCG
1000 MCG
1 EA
1 EA
1 EA
1 EA
0.1
1
1
1
1
1
1
02/27/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/12/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1000 MG
10 ML
30 ML
100 EA
100 EA
250 EA
500 EA
VL
VL
VL
BO
BO
BO
BO
2.8 ML BX
SC
EA
1 MG
14
04/27/2006
1/22/2009
21 EA DP
PO
EA
4 MG
01/01/2002
03/02/2007
100 EA BO
PO
EA
5 MG
01/01/2002
03/02/2007
100 EA
100 EA
100 EA
100 EA
8 EA
8 EA
100 EA
500 EA
180 EA
240 ML
480 ML
60 EA
250 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
EA
EA
10 MG
1 EA
1 EA
1 EA
0.5 MG
0.25 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
2
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/29/2005
01/01/2006
01/01/2002
01/26/2006
01/26/2006
01/01/2002
05/01/2004
02/09/2004
11/18/2004
03/02/2007
1/22/2009
1/22/2009
1/22/2009
12/31/2005
99/99/9999
99/99/9999
9/12/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
08/12/2004
99/99/9999
6 EA BO
PO
EA
50 MG
0.5
07/11/2002
99/99/9999
15 EA BO
PO
EA
50 MG
0.5
07/11/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
49999-0003-20
Q0163
2/24/2005
49999-0003-21
Q0163
10/15/2004
49999-0003-24
Q0163
8/8/2002
49999-0003-30
Q0163
7/11/2002
49999-0003-40
Q0163
8/8/2002
49999-0003-60
49999-0008-00
49999-0008-05
49999-0008-20
49999-0008-30
49999-0008-40
49999-0008-55
49999-0028-05
49999-0028-12
49999-0028-14
49999-0028-15
49999-0028-20
49999-0028-21
49999-0028-28
49999-0028-30
49999-0028-40
49999-0028-48
49999-0028-50
49999-0028-60
49999-0028-90
Q0163
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
6/2/2005
12/1/2003
5/16/2008
7/16/2002
7/6/2004
1/27/2006
8/28/2002
3/13/2008
7/16/2002
1/27/2006
7/11/2002
7/16/2002
8/8/2008
7/1/2005
7/11/2002
7/16/2002
7/6/2004
7/16/2002
3/30/2005
3/30/2005
49999-0036-12
Q0178
10/15/2004
49999-0036-60
Q0178
7/1/2002
49999-0059-06
49999-0059-06
49999-0086-00
49999-0086-25
49999-0086-30
49999-0086-90
Q0181
J8540
J8499
J8499
J8499
J8499
8/5/2002
1/1/2006
9/1/2006
7/29/2002
7/13/2005
7/13/2005
49999-0090-05
Q0170
4/15/2005
49999-0090-10
Q0170
6/5/2002
49999-0090-12
Q0170
5/7/2003
49999-0090-15
Q0170
12/1/2003
49999-0090-20
Q0170
10/15/2003

PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
Page 196 of 374
20 EA BO
PO
EA
50 MG
0.5
02/24/2005
99/99/9999
21 EA BO
PO
EA
50 MG
0.5
10/15/2004
99/99/9999
24 EA BO
PO
EA
50 MG
0.5
08/08/2002
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
07/11/2002
99/99/9999
40 EA BO
PO
EA
50 MG
0.5
08/08/2002
99/99/9999
BO
BO
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
0.5
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
06/02/2005
12/01/2003
05/16/2008
07/16/2002
07/06/2004
01/27/2006
08/28/2002
03/13/2008
07/16/2002
01/27/2006
07/11/2002
07/16/2002
8/8/2008
07/01/2005
07/11/2002
07/16/2002
07/06/2004
07/16/2002
03/30/2005
03/30/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA BO
PO
EA
50 MG
10/15/2004
99/99/9999
60 EA BO
PO
EA
50 MG
07/01/2002
99/99/9999
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
1 EA
0.25 MG
1 EA
1 EA
1 EA
1 EA
1
16
1
1
1
1
08/05/2002
01/01/2006
09/01/2006
07/29/2002
07/13/2005
07/13/2005
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
5 EA BO
PO
EA
25 MG
04/15/2005
99/99/9999
10 EA BO
PO
EA
25 MG
06/05/2002
99/99/9999
12 EA BO
PO
EA
25 MG
05/07/2003
99/99/9999
15 EA BO
PO
EA
25 MG
12/01/2003
99/99/9999
20 EA BO
PO
EA
25 MG
10/15/2003
99/99/9999
60 EA
100 EA
5 EA
20 EA
30 EA
40 EA
55 EA
5 EA
12 EA
14 EA
15 EA
20 EA
21 EA
28 EA
30 EA
40 EA
48 EA
50 EA
60 EA
90 EA
6 EA
6 EA
100 EA
25 EA
30 EA
90 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

ZITHROMAX 250 MG
ZITHROMAX 250 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
ACYCLOVIR 800 MG
HYDRAMINE 12.5 MG/5 ML
TAMIFLU 75 MG
49999-0090-30
Q0170
4/15/2005
49999-0090-60
Q0170
2/10/2004
49999-0091-04
Q0163
5/7/2003
49999-0091-15
Q0163
3/26/2003
49999-0091-20
Q0163
9/3/2002
49999-0091-30
Q0163
5/7/2003
49999-0091-60
49999-0096-04
49999-0096-06
49999-0110-00
49999-0110-06
49999-0110-07
49999-0110-10
49999-0110-12
49999-0110-14
49999-0110-15
49999-0110-18
49999-0110-20
49999-0110-21
49999-0110-30
49999-0153-21
49999-0231-35
Q0163
Q0144
Q0144
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7509
J8499
5/7/2003
1/27/2006
8/8/2002
7/6/2004
8/27/2002
4/6/2005
7/6/2004
7/6/2004
7/6/2004
3/27/2006
10/15/2004
7/11/2002
2/24/2005
3/26/2003
9/3/2002
6/2/2005
49999-0247-04
49999-0260-15
Q0163
Q0144
5/7/2003
7/1/2003
49999-0262-04
Q0170
7/1/2003
49999-0290-30
Q0170
12/1/2003
49999-0298-10
G9035
12/1/2004
49999-0324-15
G9017
12/1/2004
49999-0324-20
49999-0335-08
G9017
J7510
12/1/2004
2/10/2004

1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
49999-0335-24
J7510
49999-0339-12
49999-0339-12
K0416
J8498
49999-0340-12
49999-0340-12
K0416
J8498
49999-0344-25
J7603
49999-0344-25 KO J7603
49999-0344-25
J7613
KO
30 EA BO
PO
EA
25 MG
04/15/2005
99/99/9999
60 EA BO
PO
EA
25 MG
02/10/2004
99/99/9999
4 EA BO
PO
EA
50 MG
05/07/2003
99/99/9999
15 EA BO
PO
EA
50 MG
03/26/2003
99/99/9999
20 EA BO
PO
EA
50 MG
09/03/2002
99/99/9999
30 EA BO
PO
EA
50 MG
05/07/2003
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
DP
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
1 GM
1 GM
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
4 MG
1 EA
1
0.25
0.25
4
4
4
4
4
4
4
4
4
4
4
1
1
05/07/2003
01/27/2006
08/08/2002
07/06/2004
08/27/2002
04/06/2005
07/06/2004
07/06/2004
07/06/2004
03/27/2006
10/15/2004
07/11/2002
02/24/2005
03/26/2003
09/03/2002
06/02/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
120 ML BO
15 ML BO
PO
PO
ML
ML
50 MG
1 GM
0.05
0.04
05/07/2003
07/01/2003
99/99/9999
99/99/9999
120 ML BO
PO
ML
25 MG
0.05
07/01/2003
99/99/9999
30 EA NA
PO
EA
25 MG
12/01/2003
1/1/2006
10 EA BO
PO
EA
75 MG
12/01/2004
05/31/2005
15 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 EA BO
240 ML BO
PO
PO
EA
ML
100 MG
5 MG
1
0.6
12/01/2004
02/10/2004
05/31/2005
99/99/9999
60 EA
4 EA
6 EA
100 EA
6 EA
7 EA
10 EA
12 EA
14 EA
15 EA
18 EA
20 EA
21 EA
30 EA
21 EA
35 EA
240 ML BO
PO
ML
5 MG
0.6
05/10/2004
99/99/9999

12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
02/10/2004
09/01/2006
05/23/2005
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
02/10/2004
01/01/2006
12/31/2005
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
Page 197 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
49999-0416-02
49999-0425-05
J1885
J3590
49999-0434-25
49999-0437-03
49999-0525-10
49999-0582-15
49999-0586-01
49999-0586-10
J1100
J7506
J1200
Q0144
J0696
J0696
4/25/2008
8/12/2004
1/25/2008
1/27/2006
2/24/2005
2/24/2005
49999-0594-30
Q0170
6/6/2005
49999-0594-90
49999-0671-50
Q0170
J2001
5/23/2005
5/16/2008
49999-0783-30
49999-0786-06
Q0179
Q0144
1/11/2006
1/11/2006
49999-0902-20
49999-0929-01
49999-0936-00
49999-0936-30
49999-0937-30
49999-0986-30
49999-0993-10
49999-0994-10
Q0169
J7510
J7517
J7517
J7517
J8999
J1815
J1815
1/11/2007
4/20/2007
12/21/2007
4/30/2007
4/30/2007
6/14/2007
6/14/2007
6/14/2007
50111-0767-28
Q0144
50111-0787-10
Q0144
50111-0787-52
Q0144
50111-0787-66
Q0144
50111-0788-10
Q0144
50111-0788-52
Q0144
50111-0788-67
Q0144
50111-0789-10
Q0144
50111-0791-20
Q0144
50111-0792-22
Q0144
50111-0793-20
50111-0794-78
Q0144
J0456
50111-0819-42
50111-0885-42
50111-0909-43
50111-0920-43
Q0179
J7502
J7515
J7502
50111-0945-43
Q0179
50111-0946-43
Q0179
7/6/2004
7/6/2006

ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
STERAPRED 5 MG
KETOROLAC TROMETHAMINE (S.D.V.)
30 MG/ML
NABI-HB (S.D.V.,312 IU/ML)
PHOSPHATE (25X1ML) 4 MG/ML
PREDNISONE 50 MG
DIPHENHYDRAMINE 50 MG/ML
ROCEPHIN 1 GM
ROCEPHIN 1 GM

PHENERGAN 25 MG
PHENERGAN 25 MG
ZOFRAN (CAPLET) 8 MG
AZITHROMYCIN 250 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE HYDROCHLORIDE 12.5
MG
CELLCEPT 250 MG
CELLCEPT 250 MG
CELLCEPT 500 MG
AROMASIN 25 MG
HUMULIN 70 U/ML-30 U/ML
LANTUS 100 U/ML
MG/5 ML
IH
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
1 MG
2.5 MG
1 EA
1 EA
1 EA
1 EA
5 MG
0.83
1
1
1
1
1
1
04/01/2008
06/09/2004
06/09/2004
06/09/2004
06/09/2004
06/02/2005
06/09/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
IM
IM
ML
ML
15 MG
1 EA
2
1
07/06/2004
07/06/2004
7/2/2009
99/99/9999
VL
BO
VL
BO
VL
VL
IJ
PO
IJ
PO
IJ
IJ
ML
EA
ML
ML
EA
EA
1 MG
5 MG
50 MG
1 GM
250 MG
250 MG
4
10
1
0.02
4
4
04/25/2008
08/12/2004
01/25/2008
01/27/2006
02/24/2005
02/24/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 EA BO
PO
EA
25 MG
06/06/2005
99/99/9999
90 EA BO
50 ML NA
PO
EP
EA
ML
25 MG
10 MG
1
1
05/23/2005
05/16/2008
99/99/9999
99/99/9999
30 EA BO
6 EA BO
PO
PO
EA
EA
8 MG
1 GM
1
0.25
01/11/2006
01/11/2006
99/99/9999
99/99/9999
PO
PO
PO
PO
PO
PO
SC
SC
EA
ML
EA
EA
EA
EA
ML
ML
12.5 MG
5 MG
250 MG
250 MG
250 MG
1 EA
5U
5U
1
0.2
1
1
2
1
20
20
01/11/2007
04/20/2007
12/21/2007
04/30/2007
04/30/2007
06/14/2007
06/14/2007
06/14/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML VL
5 ML VL
1 ML
3 EA
1 ML
15 ML
1 EA
1 EA
20 EA
120 ML
100 EA
30 EA
30 EA
30 EA
10 ML
10 ML
BO
BO
BO
BO
BO
BO
VL
VL
22.5 ML BO
PO
ML
1 GM
0.04
07/06/2006

AZITHROMYCIN (5X10,FILM-COATED)
250 MG
MG
30 EA BO
PO
EA
1 GM
0.25
12/15/2005
99/99/9999
50 EA BX
PO
EA
1 GM
0.25
08/10/2006
99/99/9999
18 EA DP
PO
EA
1 GM
0.25
12/15/2005
99/99/9999

500 MG
MG
30 EA BO
PO
EA
1 GM
0.5
12/15/2005
99/99/9999
50 EA BX
PO
EA
1 GM
0.5
08/10/2006
99/99/9999
9 EA DP
PO
EA
1 GM
0.5
12/15/2005
99/99/9999

MG/5 ML
MG/5 ML
MG/5 ML
AZITHROMYCIN (USP) 500 MG
30 EA BO
PO
EA
1 GM
0.6
12/15/2005
99/99/9999
15 ML BO
PO
ML
1 GM
0.04
07/06/2006
99/99/9999
30 ML BO
PO
ML
1 GM
0.04
07/06/2006
99/99/9999
15 ML BO
10 EA VL
PO
IV
ML
EA
1 GM
500 MG
0.02
1
07/06/2006
07/25/2007
99/99/9999
99/99/9999
50 ML
50 ML
30 EA
30 EA
BO
BO
BX
BX
PO
PO
PO
PO
ML
ML
EA
EA
8 MG
100 MG
25 MG
100 MG
0.1
1
1
1
11/27/2006 99/99/9999
01/25/2002 12/22/2008
01/01/2002 12/22/2008
01/01/2002 12/22/2008
30 EA BX
PO
EA
8 MG
0.5
12/26/2006
7/2/2008
30 EA BX
PO
EA
8 MG
12/26/2006
7/2/2008

ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 ONDANSETRON HYDROCHLORIDE 4
MG/5 ML
MG
12/26/2006
ONDANSETRON (STRAWBERRY) 8 MG
12/26/2006
Page 198 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
PC
DP
BO
BO
BO
BO
DP
Billing Units
3 ML
24 EA
10 EA
15 EA
25 EA
40 EA
21 EA

Package
NDC Label
HCPCS Description

4/1/2008
6/9/2004
6/9/2004
6/9/2004
6/9/2004
6/2/2005
6/9/2004
NDC Package Type
KO
NDC Package Measure
49999-0344-25 KO J7613
49999-0380-24
None
49999-0385-10
J8499
49999-0385-15
J8499
49999-0385-25
J8499
49999-0385-40
J8499
49999-0390-21
J7506
HCPCS Mod
HCPCS
NDC Mod
NDC
J2941
50242-0026-08
50242-0028-49
50242-0030-50
J2941
J2940
J2940
1/1/2002
1/1/2002 10/15/2003 INJECTION, SOMATREM, 1 MG
1/1/2002 10/30/2004 INJECTION, SOMATREM, 1 MG
50242-0032-35
J2941
1/1/2002
50242-0034-41
50242-0034-50
J2941
J2941
1/1/2002
1/1/2002

50242-0036-54
J2941
1/1/2002
50242-0038-61
J3100
1/1/2002 12/31/2008 INJECTION, TENECTEPLASE, 50MG
50242-0038-61
50242-0040-62
50242-0040-62
50242-0041-63
50242-0041-64
J3101
J3590
J2357
J2997
J2997
50242-0041-65
50242-0042-01
J2997
J7799
2/18/2003
3/8/2006 INJECTION, ALTEPLASE RECOMBINANT, 1 MG
50242-0043-14
50242-0044-13
50242-0051-21
50242-0053-06
50242-0058-01
J2941
J2997
J9310
J9310
J3490
5/10/2002
1/1/2002
1/1/2002
1/1/2002
10/27/2003

99/99/9999 INJECTION, RITUXIMAB, 100 MG
99/99/9999 INJECTION, RITUXIMAB, 100 MG
50242-0058-04
J3490
50242-0060-01
J9999
50242-0060-01
J9035
50242-0060-01 QR J9035
50242-0060-02
J9999
50242-0061-01
J9999
50242-0061-01
J9035
50242-0061-01 QR J9035
50242-0072-03
J2941
50242-0073-01
J2941
10/27/2003
2/26/2004
1/1/2005
1/28/2005
2/26/2004
10/8/2004
1/1/2005
1/28/2005
1/1/2002
1/28/2008

99/99/9999 INJECTION, BEVACIZUMAB, 10 MG
99/99/9999 INJECTION, TENECTEPLASE, 1 MG

99/99/9999 INJECTION, OMALIZUMAB, 5 MG
01/01/2002
99/99/9999
5
5
10
01/01/2002
01/01/2002
01/01/2002
05/09/2002
10/15/2003
10/30/2004
1 EA BX
SC
EA
1 MG
13.5
01/01/2002
06/23/2005
1 EA BX
1 EA VL
SC
SC
EA
EA
1 MG
1 MG
18
10
01/01/2002
01/01/2002
06/23/2005
05/09/2002
06/30/2005
12/26/2006
7/2/2008
02/01/2005 12/22/2008
02/01/2005 12/22/2008
02/01/2005 10/15/2009
01/01/2002 10/15/2003
01/01/2002 10/30/2004
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 99/99/9999
01/01/2002 05/09/2002
CF
HCPCS Amount #1
1 EA BX
SC
EA
1 MG
22.5
01/01/2002
1 EA BX
IV
EA
50 MG
01/01/2002
12/31/2008
1 EA
1 EA
1 EA
1 EA
1 EA
BX
VL
VL
VL
VL
IV
SC
SC
IV
IV
EA
EA
EA
EA
EA
1 MG
1 EA
5 MG
1 MG
1 MG
50
1
30
2
2
01/01/2009
06/20/2003
01/01/2005
01/18/2007
01/01/2002
99/99/9999
12/31/2004
99/99/9999
99/99/9999
99/99/9999
1 EA VL
1 EA VL
IV
SC
EA
EA
1 MG
1 EA
2
1
02/18/2003
10/29/2004
03/08/2006
10/30/2004
2 ML
1 EA
10 ML
50 ML
1 EA
CT
VL
VL
VL
DP
SC
IV
IV
IV
SC
ML
EA
ML
ML
EA
1 MG
1 MG
100 MG
100 MG
1 EA
5
50
0.1
0.1
1
05/10/2002
01/01/2002
01/01/2002
01/01/2002
10/27/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
6/8/2009
1 EA
4 ML
4 ML
4 ML
16 ML
16 ML
16 ML
16 ML
1 EA
2 ML
DP
VL
VL
VL
VL
VL
VL
VL
VL
CT
SC
IV
IV
IV
IV
IV
IV
IV
SC
SC
EA
ML
ML
ML
ML
ML
ML
ML
EA
ML
1 EA
1 EA
10 MG
10 MG
1 EA
1 EA
10 MG
10 MG
1 MG
1 MG
1
1
2.5
2.5
1
1
2.5
2.5
5
10
10/27/2003
02/26/2004
01/01/2005
01/28/2005
02/26/2004
10/08/2004
01/01/2005
01/28/2005
01/01/2002
01/28/2008
6/8/2009
12/31/2004
99/99/9999
99/99/9999
10/07/2004
12/31/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
0.05 ML VL
IO
ML
1 EA
06/30/2006
12/31/2007
0.05 ML VL
1 EA VL
IO
IV
ML
EA
0.1 MG
1 MG
1
100
01/01/2008
01/01/2002
99/99/9999
99/99/9999
J3490
50242-0080-01
50242-0085-27
J2778
J2997
1/1/2008 99/99/9999 INJECTION, RANIBIZUMAB, 0.1 MG

1/1/2002 99/99/9999 INJECTION, ALTEPLASE RECOMBINANT, 1 MG
50242-0100-39
J7639
DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON- PULMOZYME (AMP,INNER NDC) 2.5
1/1/2002 99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMMG/2.5 ML
2.5 ML PC
IH
ML
1 MG
01/01/2002
99/99/9999
50242-0100-39 KO J7639
DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON- PULMOZYME (AMP,INNER NDC) 2.5
1/1/2002 99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMMG/2.5 ML
2.5 ML PC
IH
ML
1 MG
01/01/2002
99/99/9999
J7639
DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON1/1/2002 99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMPULMOZYME (AMP) 2.5 MG/2.5 ML
2.5 ML PC
IH
ML
1 MG
01/01/2002
99/99/9999
50242-0100-40 KO J7639
DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON1/1/2002 99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMPULMOZYME (AMP) 2.5 MG/2.5 ML
2.5 ML PC
IH
ML
1 MG
01/01/2002
99/99/9999
1 EA VL
IV
EA
10 MG
44
01/01/2002
08/31/2003
1 EA VL
IV
EA
10 MG
44
09/01/2003
99/99/9999
PO
EA
50 MG
0.5
06/01/2007
99/99/9999
KO
KO
50242-0134-60
J9355
1/1/2002
50242-0134-68
J9355
50332-0132-08
Q0163
9/1/2003 99/99/9999 INJECTION, TRASTUZUMAB, 10 MG

8/31/2003 INJECTION, TRASTUZUMAB, 10 MG
HERCEPTIN (M.D.V.,W/DILUENT) 440 MG

HERCEPTIN (M.D.V.,W/DILUENT 20ML)
440 MG
HISTAPRIN (CAPLET) 25 MG
Page 199 of 374
200 EA NA
1 MG
1 MG
1 MG
Prior End Date #3
1 MG
ML
EA
EA
Prior Start Date #3
ML
SC
IJ
IJ
SC
2 ML VL
1 EA VL
1 EA VL
Prior End Date #2
2 ML VL
End Date #1
NUTROPIN AQ (VIAL CARTON) 5 MG/ML

NUTROPIN AQ (VIAL CARTON) 5 MG/ML
PROTROPIN (VIAL W/DILUENT) 5 MG
PROTROPIN (VIAL W/DILUENT) 10 MG
NUTROPIN DEPOT (VIAL/DILUENT/3
NDLS,PF) 13.5 MG
NDLS,PF) 18 MG
NUTROPIN (VIAL W/DILUENT) 10 MG
NDLS,PF) 22.5 MG
TNKASE (VIAL W/DILUENT,SRN,PADS)
50 MG
TNKASE (VIAL W/DILUENT,SRN,PADS)
50 MG
XOLAIR 150 MG
XOLAIR 150 MG
CATHFLO ACTIVASE (INNER) 2 MG
CATHFLO ACTIVASE (VIAL) 2 MG
CATHFLO ACTIVASE (NOVAPLUS,VIAL) 2
MG
XOLAIR (PF) 75 MG
NUTROPIN AQ PEN CARTRIDGE 5
MG/ML
ACTIVASE (W/DILUENT) 50 MG
RITUXAN (S.D.V.,PF) 10 MG/ML
RITUXAN (S.D.V.,PF) 10 MG/ML
RAPTIVA 125 MG
RAPTIVA (4 DOSE PACK CARTON) 125
MG
AVASTIN (PF) 25 MG/ML
NUTROPIN AQ PEN (1X2ML) 10 MG/ML
LUCENTIS (INTRAVITREAL INJECTION)
0.5 MG/0.05 ML
LUCENTIS (INTRAVITREAL INJECTION)
0.5 MG/0.05 ML
ACTIVASE (W/DILUENT) 100 MG
Start Date #1
1
1
3
9
5
10
10
5
10
10
HCPCS Measure #1
8 MG
50 MG
50 MG
50 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
Billing Units
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
Prior Start Date #2
PO
IV
IV
IV
IJ
IJ
SC
SC
SC
SC
50242-0080-01
50242-0100-40

Package
NDC Package Type
50242-0022-20
QR
BX
VL
VL
VL
VL
VL
VL
VL
VL
VL
NDC Label
HCPCS Description
Q0179
J9045
J9045
J9045
J2940
J2940
J2941
J2941
J2941
J2941
QR
10 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA

CARBOPLATIN (S.D.V.) 50 MG
10/15/2003 INJECTION, SOMATREM, 1 MG
PROTROPIN (VIAL) 5 MG
10/30/2004 INJECTION, SOMATREM, 1 MG
PROTROPIN (VIAL) 10 MG
NUTROPIN (VIAL) 5 MG
50111-0946-69
50111-0965-76
50111-0966-76
50111-0967-76
50242-0015-64
50242-0016-65
50242-0018-21
50242-0019-02
50242-0020-20
50242-0020-67
1/1/2009
6/20/2003
1/1/2005
1/18/2007
1/1/2002
NDC Package Measure
12/26/2006
2/1/2005
2/1/2005
2/1/2005
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
HCPCS Mod
HCPCS
NDC Mod
NDC
50383-0040-04
50383-0042-24
50383-0042-48
J7510
J7510
J7510
50383-0177-08
J7510
50383-0578-16
Q0163
50383-0741-20
J7602
50383-0741-20
J7611
50383-0742-25
J7613
50383-0742-25 KO J7613
50383-0742-25
50383-0801-16
Q0170
50383-0807-16
50383-0810-16
50419-0002-33
50419-0050-30
50419-0150-57
50419-0150-57
50419-0355-10
50419-0355-10
50419-0355-12
G9017
J8499
J2820
J2820
Q2021
J1945
J9999
J9010
J9999
50419-0357-03
J9010
50419-0421-01
50419-0511-06
J7302
J9185
50419-0521-03
J1830
50419-0521-15
J1830
50419-0523-15
J1830
J1830
J2820
J2820
50419-0810-01
J7308
50419-0810-06
J7308
50458-0298-01
50458-0306-11
50458-0306-11
50458-0307-11
50458-0307-11
50458-0308-11
50458-0308-11
50458-0309-11
50486-0078-22
50486-0078-22
50486-0078-23
50486-0078-23
J1835
J3490
J2794
J3490
J2794
J3490
J2794
J2794
J7051
A4216
J7051
A4216
KO
KO

(AF,SF,DYE-FREE) 5 MG/5 ML
(DYE-FREE,GRAPE) 15 MG/5 ML

ALLERGY RELIEF MEDICINE
CHILDREN'S (AF) 12.5 MG/5 ML
1/1/2002
1/1/2008 3/31/2008 (LEVALBUTEROL)
7/1/2007 7/31/2007 (LEVALBUTEROL)
7/1/2007 7/31/2007 (LEVALBUTEROL)
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE HCL (CHERRY) 6.25
MG/5 ML
ACYCLOVIR (BANANA) 200 MG/5 ML
10/23/2003 99/99/9999 INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG
LEUKINE (VIAL) 250 MCG
LEUKINE (M.D.V.) 500 MCG/ML
1/1/2002 12/31/2005 INJECTION, LEPIRUDIN, 50 MG
1/1/2006 99/99/9999 INJECTION, LEPIRUDIN, 50 MG
CAMPATH (AMP) 10 MG/ML
1/1/2003 9/30/2005 INJECTION, ALEMTUZUMAB, 10 MG
CAMPATH (AMP) 10 MG/ML
1/1/2002
CAMPATH (AMP,3X4) 10 MG/ML
CAMPATH (CLEAR GLASS VIAL,PF) 30
1/28/2005 99/99/9999 INJECTION, ALEMTUZUMAB, 10 MG
MG/ML
1/1/2002 99/99/9999 LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG
INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE
1/2/2002 8/20/2002 NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)
AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SINGLE UNIT
1/1/2002
9/1/2002 DOSAGE FORM (354 MG)
1/1/2002
9/1/2002 DOSAGE FORM (354 MG)
1/1/2002
10/30/2003
1/1/2005
10/30/2003
1/1/2005
10/30/2003
1/1/2005
4/23/2007
1/1/2002
1/1/2006
1/1/2002
1/1/2006

99/99/9999 INJECTION, RISPERIDONE, LONG ACTING, 0.5 MG
120 ML BO
240 ML BO
480 ML BO
PO
PO
PO
ML
ML
ML
5 MG
5 MG
5 MG
0.2
0.6
0.6
01/22/2003
03/24/2003
03/17/2003
237 ML BO
PO
ML
5 MG
0.6
03/21/2005 11/12/2008
480 ML BO
PO
ML
50 MG
0.05
01/01/2002
09/01/2005
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML BO
IH
ML
1 MG
04/01/2008
99/99/9999
3 ML BO
IH
ML
1 MG
0.83
01/01/2005
06/30/2007
3 ML BO
IH
ML
1 MG
0.83
01/01/2005
06/30/2007
3 ML BO
IH
ML
1 MG
0.83
07/01/2007
07/31/2007
3 ML BO
IH
ML
1 MG
0.83
07/01/2007
07/31/2007
473 ML BO
PO
ML
25 MG
0.05
03/01/2004
99/99/9999
473 ML
473 ML
1 EA
1 ML
1 EA
1 EA
3 ML
3 ML
3 ML
PO
PO
IV
IV
IV
IV
IV
IV
IV
ML
ML
EA
ML
EA
EA
ML
ML
ML
100 MG
1 EA
50 MCG
50 MCG
50 MG
50 MG
1 EA
10 MG
1 EA
0.1
1
5
10
1
1
1
1
1
12/01/2004
06/13/2005
10/23/2003
05/19/2008
01/01/2002
01/01/2006
01/01/2002
01/01/2003
01/01/2002
05/31/2005
99/99/9999
99/99/9999
99/99/9999 10/23/2003 03/31/2007
12/31/2005
99/99/9999
12/31/2002
09/30/2005
04/01/2002
BO
BO
VL
VL
VL
VL
AM
AM
AM
1 ML VL
IV
ML
10 MG
01/28/2005
99/99/9999
1 EA BX
1 EA VL
IU
IV
EA
EA
52 MG
50 MG
1
1
01/01/2002
01/01/2002
99/99/9999
99/99/9999
BETASERON (W/DEXTROSE) 0.3 MG
1 EA NA
SC
EA
0.25 MG
1.2
01/02/2002
08/20/2002
BETASERON (W/DEXTROSE) 0.3 MG
1 EA VL
SC
EA
0.25 MG
1.2
01/01/2002
08/20/2002
BETASERON (W/MANNITOL) 0.3 MG
1 EA VL
SC
EA
0.25 MG
1.2
04/02/2002
01/18/2004
15 EA VL
1 ML VL
1 ML VL
MR
IV
IV
EA
ML
ML
0.25 MG
50 MCG
50 MCG
18
10
10
01/02/2004
06/29/2007
01/30/2006
99/99/9999
01/23/2008
01/23/2008
LEVULAN KERASTICK 20%
1 EA SK
TP
EA
354 MG
01/01/2002
09/01/2002

SPORANOX (AMP,0.9% NACL,INFUS
SET) 10 MG/ML-0.9%
RISPERDAL CONSTA 25 MG
RISPERDAL CONSTA 37.5 MG
BRONCHO SALINE 0.9%
BRONCHO SALINE 0.9%
BRONCHO SALINE 0.9%
BRONCHO SALINE 0.9%
1 EA SK
TP
EA
354 MG
01/01/2002
09/01/2002
IV
IM
IM
IM
IM
IM
IM
IM
IH
IH
IH
IH
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
ML
ML
50 MG
1 EA
0.5 MG
1 EA
0.5 MG
1 EA
0.5 MG
0.5 MG
5 ML
10 ML
5 ML
10 ML
5
1
50
1
75
1
100
25
0.2
0.1
0.2
0.1
Page 200 of 374
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
90 ML
90 ML
240 ML
240 ML
BX
VL
VL
VL
VL
VL
VL
VL
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
99/99/9999
99/99/9999
MIRENA 52 MG
FLUDARA 50 MG
BETASERON (15 BLISTER UNITS,PF) 0.3

MG-0.54%
LEUKINE 500 MCG/ML
LEUKINE (5X1ML, M.D.V.) 500 MCG/ML
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

Q4094
50383-0742-25 KO Q4094
50419-0523-25
50419-0595-01
50419-0595-05
HCPCS Mod
HCPCS
NDC Mod
NDC
10
01/01/2002 10/12/2007
10/30/2003 12/31/2004
01/01/2005 99/99/9999
10/30/2003 12/31/2004
01/01/2005 99/99/9999
10/30/2003 12/31/2004
01/01/2005 99/99/9999
04/23/2007 99/99/9999
01/01/2002 12/31/2005
01/01/2006 99/99/9999
01/01/2002 12/31/2005
01/01/2006 99/99/9999

50486-0616-16
Q0163
12/4/2002
50486-0616-32
Q0163
12/4/2002
50580-0512-24
Q0163
1/1/2002
50580-0512-48
Q0163
1/1/2002
50580-0843-10
Q0163
3/26/2004
50580-0843-13
Q0163
4/8/2004
50580-0843-24
Q0163
1/1/2002
50580-0843-25
Q0163
7/8/2002
50580-0843-48
Q0163
1/1/2002
50580-0843-72
50962-0453-60
50962-0650-01
50962-0650-01
51079-0022-17
Q0163
J8499
J7051
A4216
J7506
1/1/2002
1/1/2002
1/1/2002
1/1/2006
1/1/2002
51079-0022-19
51079-0022-20
51079-0032-17
J7506
J7506
J7506

51079-0032-19
51079-0032-20
51079-0033-17
J7506
J7506
J7506

51079-0033-19
51079-0033-20
J7506
J7506
51079-0066-01
Q0163
51079-0066-19
Q0163
51079-0066-20
Q0163
51079-0077-01
Q0177
51079-0077-20
Q0177
51079-0078-01
Q0178

SLEEPINAL 50 MG
16 EA NA
PO
EA
50 MG
12/04/2002
99/99/9999
SLEEPINAL 50 MG
32 EA NA
PO
EA
50 MG
12/04/2002
99/99/9999
SIMPLY ALLERGY (CAPLET) 25 MG
24 EA BX
PO
EA
50 MG
0.5
01/01/2002
09/29/2004
SIMPLY ALLERGY (CAPLET) 25 MG
48 EA BX
PO
EA
50 MG
0.5
01/01/2002
09/29/2004
SIMPLY SLEEP (CAPLET) 25 MG
100 EA BO
PO
EA
50 MG
0.5
03/26/2004
99/99/9999
130 EA BO
PO
EA
50 MG
0.5
04/08/2004
99/99/9999
24 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
2500 EA PT
PO
EA
50 MG
0.5
07/08/2002
99/99/9999
48 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999

ACYCLOVIR (5X10) 200 MG/5 ML
SODIUM CHLORIDE (INHALATION) 0.9%
SODIUM CHLORIDE (INHALATION) 0.9%
PREDNISONE (ROBOT READY 25X1) 20
MG
MG
MG
72 EA
5 ML
1 ML
1 ML
1 EA
BO
VL
EA
EA
BX
PO
PO
IH
IH
PO
EA
ML
ML
ML
EA
50 MG
1 EA
5 ML
10 ML
5 MG
0.5
1
0.2
0.1
4
01/01/2002
01/01/2002
01/01/2002
01/01/2006
01/01/2002
99/99/9999
12/01/2002
12/31/2005
99/99/9999
99/99/9999
25 EA BX
100 EA BX
1 EA BX
PO
PO
PO
EA
EA
EA
5 MG
5 MG
5 MG
4
4
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
03/15/2002
99/99/9999
25 EA BX
100 EA BX
1 EA BX
PO
PO
PO
EA
EA
EA
5 MG
5 MG
5 MG
1
1
2
01/01/2002
01/01/2002
01/01/2002
99/99/9999
03/15/2002
99/99/9999
25 EA BX
100 EA BX
PO
PO
EA
EA
5 MG
5 MG
2
2
01/01/2002
01/01/2002
99/99/9999
03/15/2002
1 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
25 EA BX
PO
EA
50 MG
01/01/2002
01/15/2008
100 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
1 EA NA
PO
EA
25 MG
11/26/2007
99/99/9999
100 EA BX
PO
EA
25 MG
11/26/2007
99/99/9999
1 EA NA
PO
EA
50 MG
11/26/2007
99/99/9999
SIMPLY SLEEP (2500X2,CAPLET) 25 MG
DIPHENHYDRAMINE HCL (USP) 50 MG
DIPHENHYDRAMINE HCL (ROBOT

READY 25X1) 50 MG
Page 201 of 374
1/1/2002
4/1/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
51079-0435-19
51079-0435-20
J8999
J8999
51079-0472-01
Q0166

MEGESTROL ACETATE (USP) 20 MG
MEGESTROL ACETATE (ROBOT READY
25X1) 40 MG
PO
PO
EA
EA
1 EA
1 EA
1
1
01/01/2002
01/01/2002
06/02/2008
99/99/9999
1 EA BX
PO
EA
1 MG
03/03/2008
99/99/9999
20 EA BX
PO
EA
1 MG
03/03/2008
99/99/9999
1 EA BX
PO
EA
100 MG
12/01/2004
05/31/2005
100 EA BX
PO
EA
100 MG
12/01/2004
05/31/2005
1 EA BX
PO
EA
8 MG
0.5
07/09/2007
99/99/9999
100 EA BX
PO
EA
8 MG
0.5
07/09/2007
99/99/9999
1 EA BX
PO
EA
8 MG
07/09/2007
99/99/9999
100 EA BX
PO
EA
8 MG
07/09/2007
99/99/9999
1 EA BX
PO
EA
5 MG
01/01/2002
99/99/9999
25 EA BX
PO
EA
5 MG
01/01/2002
10/15/2006
100 EA BX
PO
EA
5 MG
01/01/2002
99/99/9999
1 EA BX
PO
EA
10 MG
01/01/2002
99/99/9999
25 EA BX
PO
EA
10 MG
01/01/2002
08/01/2006
99/99/9999
CF
HCPCS Amount #1
51079-0542-20
Q0165
51079-0591-01
Q0144
51079-0591-20
Q0144
51079-0670-01
None
METHOTREXATE SODIUM (USP) 2.5 MG
1 EA BX
PO
EA
2.5 MG
01/01/1994
99/99/9999
51079-0670-05
None
20 EA BX
PO
EA
2.5 MG
01/01/1994
99/99/9999
51079-0670-86
None
12 EA DP
PO
EA
2.5 MG
11/09/1994
11/11/1996
51079-0670-87
None
16 EA DP
PO
EA
2.5 MG
11/09/1994
11/11/1996
51079-0670-88
None
20 EA DP
PO
EA
2.5 MG
11/09/1994
11/11/1996
51079-0670-89
51079-0876-01
51079-0876-20
51079-0877-01
None
J8499
J8499
J8499
11/9/1994
1/1/2002
1/1/2002
1/1/2002
METHOTREXATE SODIUM (2X10) 2.5 MG

METHOTREXATE SODIUM (DOSE PACK,
4X3) 2.5 MG
4X4) 2.5 MG
4X5) 2.5 MG
4X6) 2.5 MG
ACYCLOVIR (USP) 200 MG
PO
PO
PO
PO
EA
EA
EA
EA
2.5 MG
1 EA
1 EA
1 EA
1
1
1
1
11/09/1994
01/01/2002
01/01/2002
01/01/2002
11/11/1996
99/99/9999
99/99/9999
99/99/9999
51079-0472-05
Q0166
51079-0481-01
G9017
51079-0481-20
G9017
51079-0524-01
Q0179
51079-0524-20
Q0179
51079-0525-01
Q0179
51079-0525-20
Q0179
51079-0541-01
Q0164
51079-0541-19
Q0164
51079-0541-20
Q0164
51079-0542-01
Q0165
51079-0542-19
Q0165


250 MG
Page 202 of 374
100 EA BX
PO
EA
10 MG
01/01/2002
1 EA BX
PO
EA
1 GM
0.25
06/25/2007
99/99/9999
100 EA BX
PO
EA
1 GM
0.25
06/25/2007
99/99/9999
24 EA
1 EA
100 EA
1 EA
DP
BX
BX
BX
4/1/2002
25 EA BX
100 EA BX
1/1/2002
(2CARDSX10,FILM-COATED) 1 MG
AMANTADINE HCL (USP) 100 MG
AMANTADINE HCL (10X10) 100 MG
(FILM-COATED) 4 MG
(USP,10X10,FILM-COATED) 4 MG
(FILM-COATED) 8 MG
(USP,10X10,FILM-COATED) 8 MG
PROCHLORPERAZINE MALEATE (USP) 5
MG
PROCHLORPERAZINE MALEATE
(ROBOT READY 25X1) 5 MG
PROCHLORPERAZINE MALEATE (10X10)
5 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROCHLORPERAZINE MALEATE (USP)
10 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROCHLORPERAZINE MALEATE
(ROBOT READY 25X1) 10 MG
1/1/2002
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROCHLORPERAZINE MALEATE (10X10)
10 MG
1/1/2002
Prior End Date #3
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
11/26/2007
01/01/2002
01/01/2002
01/01/2002
1
1
1
1
Prior End Date #2
50 MG
1 EA
1 EA
1 EA
End Date #1
EA
EA
EA
EA
Start Date #1
PO
PO
PO
PO
HCPCS Measure #1
BX
BX
BX
BX
Billing Units
100 EA
1 EA
100 EA
1 EA
Prior Start Date #2

Package
NDC Label
HCPCS Description

1/1/2002
1/1/2002
1/1/2002
1/1/2002
NDC Package Type
Q0178
J8999
J8999
J8999
NDC Package Measure
51079-0078-20
51079-0434-01
51079-0434-20
51079-0435-01
HCPCS Mod
HCPCS
NDC Mod
NDC
51079-0877-20
51079-0878-01
51079-0878-20
J8499
J8499
J8499
51079-0895-01
Q0170
51079-0895-20
51079-0961-01
51079-0962-01
51079-0963-01
Q0170
J9265
J9265
J9265
51079-0965-05
None
51079-0967-01
Q0163
51079-0967-17
Q0163
51079-0967-19
Q0163
51079-0967-20
Q0163
51079-0967-98
51285-0301-02
Q0163
J7509
51285-0301-21
51285-0366-01
51285-0367-01
51285-0368-01
51285-0369-01
51285-0509-02
J7509
None
None
None
None
None
51285-0522-04
51432-0522-03
Q0165
None
51479-0011-03
J7629
51479-0011-03 KO J7629
51479-0011-06
KO
J7629
51479-0011-06 KO J7629
51479-0040-05
J3490
51479-0041-10
J3490
51479-0041-15
J3490
51479-0042-10
J3490
51479-0042-15
J3490
51479-0048-01
J3490
51479-0049-01
51479-0050-05
51479-0051-10
51479-0051-15
51479-0052-10
51479-0052-30
51479-0053-01
51479-0053-10
51479-0054-01
51479-0054-02
51479-0054-03
51479-0054-10
J3490
J3490
J3490
J3490
J3490
J3490
J0692
J0692
J0692
J0692
J0692
J0692
51479-0054-20
51479-0054-30
51479-0055-01
J0692
J0692
J0692
KO

(USP) 25 MG
PROMETHAZINE HCL (10X10) 25 MG
PACLITAXEL (M.D.V.) 6 MG/ML
ETOPOSIDE (BLISTERPACK, 2X10) 50
MG
DIPHENHYDRAMINE HCL
(MINITAB,MINITAB) 25 MG
DIPHENHYDRAMINE HCL
(MINITAB,MINITAB) 25 MG
DIPHENHYDRAMINE HCL (MINITAB) 25
MG
DIPHENHYDRAMINE HCL
(10X10,MINITAB) 25 MG
DIPHENHYDRAMINE HCL (MINITAB; EMSCRIPT,15X4) 25 MG
1/1/2002
1/1/2002
4 MG
3/9/2006 99/99/9999 METHOTREXATE, 5 MG
TREXALL (FILM-COATED) 5 MG
3/9/2006 99/99/9999 METHOTREXATE, 7.5 MG
TREXALL (FILM-COATED) 7.5 MG
12/1/2005 99/99/9999 METHOTREXATE, 10 MG
12/1/2005 99/99/9999 METHOTREXATE, 15 MG
1/1/1994
BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT,
TORNALATE 0.2%
TORNALATE 0.2%
TORNALATE 0.2%
TORNALATE 0.2%
9/30/2005
AZACTAM (S.D.V.) 500 MG
9/30/2005
AZACTAM 1 GM
AZACTAM (S.D.V.) 1 GM
9/30/2005
AZACTAM 2 GM
AZACTAM (GALAXY P.C.,24X50ML) 1
GM/50 ML
AZACTAM (GALAXY P.C.,24X50ML) 2
GM/50 ML
1/1/2002
1/1/2002
AZACTAM (BOTTLE) 1 GM
1/1/2002
1/1/2002
AZACTAM (BOTTLE) 2 GM
1/1/2002
MAXIPIME 500 MG
MAXIPIME 500 MG
MAXIPIME (P.B.) 1 GM
MAXIPIME (ADD-VANTAGE) 1 GM
MAXIPIME (VIAL) 1 GM
1/1/2002
MAXIPIME (ADD-VANTAGE,ADD1/1/2002 99/99/9999 INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG
VANTAGE) 1 GM
Page 203 of 374
100 EA BX
1 EA BX
100 EA BX
PO
PO
PO
EA
EA
EA
1 EA
1 EA
1 EA
1
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
1 EA BX
PO
EA
25 MG
02/01/2007
99/99/9999
BX
VL
VL
VL
PO
IV
IV
IV
EA
ML
ML
ML
25 MG
30 MG
30 MG
30 MG
1
0.2
0.2
0.2
02/01/2007
01/01/2002
01/01/2002
01/01/2002
99/99/9999
10/15/2004
12/01/2005
12/01/2005
20 EA BX
PO
EA
50 MG
1 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
1 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
25 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
60 EA BX
100 EA BO
PO
PO
EA
EA
50 MG
4 MG
0.5
1
01/01/2002
01/01/2002
09/01/2003
02/12/2002
21 EA
30 EA
30 EA
30 EA
30 EA
100 EA
DP
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
4 MG
5 MG
7.5 MG
10 MG
15 MG
2.5 MG
1
1
1
1
1
1
01/01/2002
03/09/2006
03/09/2006
12/01/2005
12/01/2005
07/23/1999
04/04/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
11/10/2001
500 EA BO
100 EA NA
PO
PO
EA
EA
10 MG
2.5 MG
1
1
01/01/2002
01/01/1994
07/10/2002
01/01/1994
30 ML BO
IH
ML
1 MG
01/01/2002
05/31/2002
30 ML BO
IH
ML
1 MG
01/01/2002
05/31/2002
60 ML BO
IH
ML
1 MG
01/01/2002
05/31/2002
60 ML
1 EA
1 EA
1 EA
1 EA
1 EA
BO
VL
VL
VL
VL
VL
IH
IJ
IV
IJ
IV
IJ
ML
EA
EA
EA
EA
EA
1 MG
1 EA
1 EA
1 EA
1 EA
1 EA
2
1
1
1
1
1
01/01/2002
09/30/2005
09/30/2005
09/30/2005
09/30/2005
09/30/2005
05/31/2002
01/01/2007
01/01/2007
99/99/9999
01/01/2007
99/99/9999
50 ML PC
IV
ML
1 EA
09/30/2005
99/99/9999
50 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
FC
VL
VL
VL
VL
VL
NA
VL
VL
NA
VL
VL
IV
IJ
IV
IJ
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
1
1
1
1
1
1
1
1
2
2
2
2
09/30/2005
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
11/08/2002
11/08/2002
11/08/2002
11/08/2002
11/08/2002
01/01/2002
99/99/9999
05/06/2002
05/06/2002
05/06/2002
05/06/2002
05/06/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2007
1 EA VL
1 EA VL
1 EA NA
IJ
IJ
IJ
EA
EA
EA
500 MG
500 MG
500 MG
2
2
4
01/01/2002
01/01/2002
11/08/2002
99/99/9999
99/99/9999
99/99/9999
100 EA
5 ML
16.7 ML
50 ML
3/14/2005
5/24/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
10/29/2001 10/10/2008
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
25 MG
25 MG
25 MG
25 MG
25 MG
25 MG
25 MG
25 MG
8 MG
1 MG
1 MG
1 MG
20
20
20
20
20
20
20
20
20
20
40
40
40
40
40
40
40
40
125
1000
1000
1000
09/01/2003
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2003
09/01/2003
09/01/2003
99/99/9999
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
08/31/2003
12/31/2002
99/99/9999
99/99/9999
99/99/9999
1
1
1
1
1
EA
EA
EA
EA
EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1
8
1
8
1
1000
125
1000
125
1000
09/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2003
99/99/9999
12/31/2002
08/31/2003
12/31/2002
08/31/2003
1 EA BO
NA
GM
8 MG
125
01/01/2002
12/31/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2003
08/31/2003
51552-0024-04
51552-0024-05
51552-0024-05
51552-0024-10
51552-0024-10
J1094
J1095
J1094
J1095
J1094

51552-0024-25
J1095
51552-0024-25
J1094
1/1/2003
51552-0025-01
J7638
51552-0025-02
J7638
51552-0025-02 KO J7638
51552-0025-03
51552-0025-05
51552-0025-25
KO
KO
9/1/2003
1/1/2002
KO
1/1/2002
1/1/2002
KO
J7638
51552-0025-25 KO J7638
51552-0026-02
J7510
51552-0026-04
J7510
51552-0026-05
J7510
51552-0026-25
J7510
51552-0026-99
J7510
51552-0028-01
J7506
51552-0028-02
J7506
J7506
51552-0028-04
51552-0028-05
J7506
51552-0028-25
J7506
51552-0028-99
J7506
9/1/2003
9/1/2003
J7638
51552-0025-10 KO J7638
9/1/2003
9/1/2003
J7638
51552-0025-05 KO J7638
51552-0025-10
KO
J7638
51552-0025-04 KO J7638
1/1/2002
9/1/2003
J7638
51552-0025-03 KO J7638
51552-0025-04
1/1/2002
1/1/2002
1/1/2002
KO
1/1/2002
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002

Page 204 of 374
CF
HCPCS Amount #1
MG
MG
MG
MG
MG
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1000
200
200
200
200
200
200
200
200
200
200
200
01/01/2002
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
08/31/2003
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
9/1/2003
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2003
9/1/2003
9/1/2003
Prior End Date #3
PROGESTERONE (WETTABLE,U.S.P.)
HYDROCORTISONE ACETATE (U.S.P.)
DEXAMETHASONE ACETATE (U.S.P.)
DEXAMETHASONE ACETATE (U.S.P.,
MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PREDNISONE
PREDNISONE (U.S.P.)
PREDNISONE (U.S.P.)
PREDNISONE (U.S.P.)
PREDNISONE (U.S.P.)
PREDNISONE (U.S.P.)
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J2675
J1700
J1700
J1700
J1700
J1700
J1700
J1700
J1700
J1095
J1094
J1094
J1094
Prior Start Date #3

51552-0005-07
51552-0005-10
51552-0005-25
51552-0006-01
51552-0006-03
51552-0006-04
51552-0006-05
51552-0006-07
51552-0006-10
51552-0006-25
51552-0021-01
51552-0021-02
51552-0021-03
51552-0021-04
51552-0021-05
51552-0021-10
51552-0021-25
51552-0021-99
51552-0024-01
51552-0024-01
51552-0024-02
51552-0024-03
99/99/9999
99/99/9999
99/99/9999
01/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior End Date #2
11/08/2002
11/08/2002
01/01/2002
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
Prior Start Date #2
4
4
4
4
4
20
20
20
20
End Date #1
500 MG
500 MG
500 MG
500 MG
500 MG
50 MG
50 MG
50 MG
50 MG
Start Date #1
EA
EA
EA
EA
EA
GM
GM
GM
GM
HCPCS Measure #1
IJ
IJ
IJ
IJ
IJ
NA
NA
NA
NA
Billing Units
NDC Package Type

VL
VL
VL
VL
VL
BO
BO
BO
JR
11/8/2002
11/8/2002
1/1/2002
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
KO
NDC Package Measure

EA
EA
EA
EA
EA
EA
EA
EA
EA
J0692
J0692
J0692
J0692
J0692
J2675
J2675
J2675
J2675
51552-0025-01 KO J7638

Package
1
1
1
1
1
1
1
1
1
51479-0055-02
51479-0055-03
51479-0055-10
51479-0055-20
51479-0055-30
51552-0005-01
51552-0005-03
51552-0005-04
51552-0005-05
NDC Label
HCPCS Description

HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002
9/1/2003
9/1/2003
1/1/2002
9/1/2003
1/1/2002
1/1/2002
99/99/9999
CF
HCPCS Amount #1
51552-0030-01
J3150
1 EA BO
NA
GM
100 MG
10
01/01/2002
51552-0030-02
J3150
1 EA BO
NA
GM
100 MG
10
09/01/2003
99/99/9999
51552-0030-03
J3150
1/1/2002

(U.S.P.,MICRONIZED)
1 EA BO
NA
GM
100 MG
10
01/01/2002
08/31/2003
99/99/9999
51552-0030-04
J3150
1 EA BO
NA
GM
100 MG
10
09/01/2003
51552-0030-05
J3150
1 EA BO
NA
GM
100 MG
10
09/01/2003
99/99/9999
51552-0030-06
J3150
1/1/2002
1 EA BO
NA
GM
100 MG
10
01/01/2002
08/31/2003
51552-0030-08
J3150
1 EA BO
NA
GM
100 MG
10
09/01/2003
99/99/9999
51552-0030-09
J3150

(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
1 EA BO
NA
GM
100 MG
10
09/01/2003
99/99/9999
51552-0030-25
J3150
1/1/2002
1 EA JR
NA
GM
100 MG
10
01/01/2002
08/31/2003
51552-0030-99
J3150
1/1/2002
1 EA JR
NA
GM
100 MG
10
01/01/2002
08/31/2003
51552-0033-01
J7684
1/1/2002

(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
ALBUTEROL SULFATE (U.S.P.,N.F.)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
51552-0033-01 KO J7684
51552-0033-02
J7684
51552-0033-02 KO J7684
51552-0033-03
51552-0033-10
51552-0042-01
51552-0044-02
51552-0044-04
KO
KO
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2005
KO
1/1/2005
1/1/2007
KO
J7613
51552-0044-04 KO J7613
1/1/2002
1/1/2002
J7609
51552-0044-02 KO J7609
9/1/2003
1/1/2002
J7613
51552-0044-02 KO J7613
51552-0044-02
KO
J7619
51552-0044-01 KO J7619
9/1/2003
9/1/2003
J7643
51552-0042-01 KO J7643
51552-0044-01
KO
J7684
51552-0033-99 KO J7684
51552-0038-03
J3490
51552-0038-04
J3490
51552-0038-05
J3490
51552-0038-06
J3490
51552-0038-10
J3490
51552-0038-25
J3490
51552-0038-50
J3490
51552-0038-99
J3490
9/1/2003
9/1/2003
J7684
51552-0033-10 KO J7684
51552-0033-99
KO
J7684
51552-0033-05 KO J7684
1/1/2002
9/1/2003
J7684
51552-0033-03 KO J7684
51552-0033-05
KO
1/1/2007
1/1/2005
KO
1/1/2005
Page 205 of 374
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
JR
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1000
1
1
1
1
1
1
1
1
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
08/31/2003
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
99/99/9999
99/99/9999
99/99/9999
08/31/2003
99/99/9999
08/31/2003
08/31/2003
Prior End Date #3
01/01/2002
09/01/2003
09/01/2003
01/01/2002
09/01/2003
01/01/2002
01/01/2002
Prior Start Date #3
20
20
20
20
20
20
20
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
Prior End Date #2
GM
GM
GM
GM
GM
GM
GM
End Date #1
NA
NA
NA
NA
NA
NA
NA
Start Date #1
BO
JR
BO
BO
BO
BO
BO
HCPCS Measure #1
EA
EA
EA
EA
EA
EA
EA
Billing Units
1
1
1
1
1
1
1
Prior Start Date #2

Package
NDC Label
HCPCS Description

NDC Package Type
J3140
J3140
J3140
J3140
J3140
J3140
J3140
NDC Package Measure
51552-0029-01
51552-0029-02
51552-0029-04
51552-0029-05
51552-0029-07
51552-0029-10
51552-0029-25
HCPCS Mod
HCPCS
NDC Mod
NDC
51552-0044-04
J7609
51552-0044-04 KO J7609
51552-0044-05
KO
J7624
51552-0064-02 KO J7624
51552-0064-05
KO
J7624
51552-0064-01 KO J7624
51552-0064-02
KO
J7619
51552-0044-25 KO J7619
51552-0057-04
J3350
51552-0057-05
J3350
51552-0057-06
J3350
51552-0057-08
J3350
51552-0057-16
J3350
51552-0061-06
J3480
51552-0061-16
J3480
51552-0064-01
KO
J7619
51552-0044-10 KO J7619
51552-0044-25
KO
J7609
51552-0044-07 KO J7609
51552-0044-10
KO
J7613
51552-0044-07 KO J7613
51552-0044-07
KO
J7609
51552-0044-06 KO J7609
51552-0044-07
KO
J7613
51552-0044-06 KO J7613
51552-0044-06
KO
J7609
51552-0044-05 KO J7609
51552-0044-06
KO
J7613
51552-0044-05 KO J7613
51552-0044-05
KO
J7624
51552-0064-05 KO J7624
51552-0074-05
Q0165
51552-0074-09
Q0165
51552-0074-20
Q0165
51552-0074-99
Q0165
51552-0079-02
J7669
51552-0079-02 KO J7669
KO
KO

1/1/2002
1/1/2002
UREA (U.S.P.,N.F.)
UREA (U.S.P.,N.F.)
UREA (U.S.P.,N.F.)
UREA (U.S.P.,N.F.)
UREA (U.S.P.,N.F.)
POTASSIUM CHLORIDE (U.S.P.,N.F.)
POTASSIUM CHLORIDE (U.S.P.,N.F.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE
PHOSPHATE
PHOSPHATE
PHOSPHATE
PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM METAPROTERENOL SULFATE
(U.S.P.,N.F.)
9/1/2003 12/31/2006 PER 10 MILLIGRAMS
(U.S.P.,N.F.)
9/1/2003 12/31/2006 PER 10 MILLIGRAMS
Page 206 of 374
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2002
09/01/2003
1 EA JR
NA
GM
1 MG
1000
01/01/2002
09/01/2003
1 EA JR
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1
1
1
1
1
1
1
1
JR
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
40 GM
40 GM
40 GM
40 GM
40 GM
2 MEQ
2 MEQ
1000
0.025
0.025
0.025
0.025
0.025
6.71141
6.71141
01/01/2002
01/01/2002
01/01/2002
09/01/2003
09/01/2003
01/01/2002
09/01/2003
01/01/2002
08/31/2003
99/99/9999
08/31/2003
99/99/9999
99/99/9999
08/31/2003
99/99/9999
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
EA
EA
EA
EA
EA
EA
EA
EA
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
09/01/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/01/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
09/01/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
09/01/2003
12/31/2006
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
51552-0079-02
KO
KO
1/1/2002
1/1/2002
KO
1/1/2002
51552-0104-02
J1070
9/1/2003
51552-0104-05
51552-0106-01
51552-0106-04
51552-0106-04
51552-0106-05
51552-0106-05
51552-0106-06
51552-0106-06
51552-0106-09
51552-0106-09
51552-0106-25
51552-0106-99
51552-0124-02
51552-0124-04
51552-0124-05
51552-0124-06
51552-0124-25
51552-0124-50
J1070
J2000
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2000
J1200
J1200
J1200
J1200
J1200
J1200
1/1/2002
1/1/2002
9/1/2003
1/1/2004
9/1/2003
1/1/2004
9/1/2003
1/1/2004
9/1/2003
1/1/2004
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
METAPROTERENOL SULFATE
(U.S.P.,N.F.)
METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, METAPROTERENOL SULFATE

(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
LIDOCAINE HCL (U.S.P.,N.F.)
DIPHENHYDRAMINE HCL (U.S.P.,N.F.)
Page 207 of 374
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/01/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
09/01/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/01/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
09/01/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/01/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
09/01/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
100 MG
10
09/01/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
100 MG
50 ML
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
50 ML
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
10
4
4
100
4
100
4
100
4
100
4
4
20
20
20
20
20
20
01/01/2002
01/01/2002
09/01/2003
01/01/2004
09/01/2003
01/01/2004
09/01/2003
01/01/2004
09/01/2003
01/01/2004
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
08/31/2003
08/31/2003
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
BO
BO
BO
BO
JR
JR
BO
BO
BO
BO
JR
BO
JR
JR
JR
JR
JR
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

1/1/2002
1/1/2002
J7669
51552-0079-99 KO J7669
1/1/2007
1/1/2002
J7669
51552-0079-25 KO J7669
51552-0079-99
KO
(U.S.P.,N.F.)

(U.S.P.,N.F.)
(U.S.P.,N.F.)
9/1/2003 12/31/2006 PER 10 MILLIGRAMS
(U.S.P.,N.F.)
9/1/2003 12/31/2006 PER 10 MILLIGRAMS
J7669
51552-0079-10 KO J7669
51552-0079-25
KO
J7670
51552-0079-07 KO J7670
51552-0079-10
KO
(U.S.P.,N.F.)

(U.S.P.,N.F.)
(U.S.P.,N.F.)
9/1/2003 12/31/2006 PER 10 MILLIGRAMS
(U.S.P.,N.F.)
9/1/2003 12/31/2006 PER 10 MILLIGRAMS
J7669
51552-0079-07 KO J7669
51552-0079-07
KO
J7670
51552-0079-05 KO J7670
51552-0079-07
KO
(U.S.P.,N.F.)

(U.S.P.,N.F.)
(U.S.P.,N.F.)
9/1/2003 12/31/2006 PER 10 MILLIGRAMS
(U.S.P.,N.F.)
9/1/2003 12/31/2006 PER 10 MILLIGRAMS
J7669
51552-0079-05 KO J7669
51552-0079-05
KO
J7670
51552-0079-04 KO J7670
51552-0079-05
KO
J7669
51552-0079-04 KO J7669
51552-0079-04

J7670
51552-0079-02 KO J7670
51552-0079-04
HCPCS Mod
HCPCS
NDC Mod
NDC
51552-0156-02
J7636
51552-0156-02 KO J7636
51552-0156-04
KO
KO
1/1/2002
1/1/2002
KO
1/1/2002
9/1/2003
9/1/2003
1/1/2002
1/1/2002

51552-0180-03
J2765
51552-0180-04
J2765
51552-0180-05
J2765
51552-0180-10
J2765
1/1/2002
51552-0180-25
J2765
1/1/2002
51552-0180-99
51552-0188-01
51552-0188-05
51552-0188-07
51552-0188-10
51552-0188-99
J2765
J1330
J1330
J1330
J1330
J1330
51552-0201-01
J7608

51552-0201-01 KO J7608
51552-0201-04
J7699
51552-0201-04
J7604
51552-0201-04 KO J7604
51552-0201-05
J7699
51552-0201-05
KO
KO
J7604
51552-0201-05 KO J7604
51552-0201-07
J7699
KO

BENZOCAINE (U.S.P.,N.F.)
CHLORPROMAZINE HCL (U.S.P.,N.F.)
HYOSCYAMINE SULFATE (U.S.P.,N.F.)
PROMETHAZINE HCL (U.S.P.,N.F.)
PROMETHAZINE HCL (U.S.P.,N.F)
PYRIDOXINE HCL (U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
ERGONOVINE MALEATE (U.S.P.,N.F.)
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
CF
HCPCS Amount #1
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1
1
1
1
1
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1
5
5
5
5
MG
MG
MG
MG
MG
1000
200
200
200
200
01/01/2002
09/01/2003
09/01/2003
01/01/2002
01/01/2002
08/31/2003
99/99/9999
99/99/9999
08/31/2003
08/31/2003
1 EA BO
NA
GM
10 MG
100
09/01/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/01/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/01/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1
1
1
1
1
1
BO
BO
VL
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
10 MG
0.2 MG
0.2 MG
0.2 MG
0.2 MG
0.2 MG
100
5000
5000
5000
5000
5000
01/01/2002
01/01/2002
09/01/2003
09/01/2003
01/01/2002
01/01/2002
08/31/2003
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
ACETYLCYSTEINE (U.S.P.,N.F.)
1 EA BO
NA
GM
1 GM
01/01/2002
08/31/2003
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2002
01/01/2007
08/31/2003
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
Page 208 of 374
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 EA BO
Prior End Date #3
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
99/99/9999
99/99/9999
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
12/31/2003
99/99/9999
12/31/2003
99/99/9999
08/31/2003
08/31/2003
Prior Start Date #3
01/01/2002
01/01/2002
09/01/2003
01/01/2002
09/01/2003
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
09/01/2003
09/01/2003
01/01/2002
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
09/01/2003
01/01/2004
09/01/2003
01/01/2004
01/01/2002
01/01/2002
20
1
1
1
1
1
20
20
20
20
20
20
4000
4000
4000
4000
20
20
20
20
20
20
1
10
1
10
1
1
Prior End Date #2
50 MG
1 EA
1 EA
1 EA
1 EA
1 EA
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
0.25 MG
0.25 MG
0.25 MG
0.25 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
1 EA
100 MG
1 EA
100 MG
1 EA
1 EA
End Date #1
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
Start Date #1
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
HCPCS Measure #1
BO
NA
BO
BO
BO
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
JR
BO
JR
BO
JR
JR
JR
JR
BO
BO
BO
BO
Billing Units
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
Prior Start Date #2

Package
NDC Label
HCPCS Description

9/1/2003
1/1/2002
J7636
51552-0156-25 KO J7636
51552-0178-05
J0706
51552-0178-06
J0706
51552-0178-16
J0706
51552-0178-99
J0706
9/1/2003
9/1/2003
J7636
51552-0156-05 KO J7636
51552-0156-25
9/1/2003
KO
J7636
51552-0156-04 KO J7636
51552-0156-05
1/1/2002
1/1/2002
9/1/2003
1/1/2002
9/1/2003
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
9/1/2003
9/1/2003
1/1/2002
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
9/1/2003
1/1/2004
9/1/2003
1/1/2004
1/1/2002
1/1/2002
NDC Package Type
J1200
J3490
J3490
J3490
J3490
J3490
J3230
J3230
J3230
J3230
J3230
J3230
J1980
J1980
J1980
J1980
J2550
J2550
J2550
J2550
J2550
J2550
J3490
J3415
J3490
J3415
J3490
J3490
NDC Package Measure
51552-0124-99
51552-0130-01
51552-0130-02
51552-0130-04
51552-0130-06
51552-0130-16
51552-0139-01
51552-0139-04
51552-0139-05
51552-0139-07
51552-0139-25
51552-0139-99
51552-0141-02
51552-0141-04
51552-0141-05
51552-0141-25
51552-0147-01
51552-0147-02
51552-0147-04
51552-0147-05
51552-0147-25
51552-0147-99
51552-0149-04
51552-0149-04
51552-0149-05
51552-0149-05
51552-0149-25
51552-0149-99
HCPCS Mod
HCPCS
NDC Mod
NDC
51552-0201-07
J7604
51552-0201-07 KO J7604
51552-0201-25
KO
J7608
51552-0201-25 KO J7608
51552-0201-99
KO
J7608
51552-0201-99 KO J7608
51552-0232-02
J7799
51552-0232-04
J7799
51552-0232-05
J7799
51552-0232-25
J7799
51552-0232-99
J7799
KO

51552-0233-01
J1110
51552-0233-02
J1110
51552-0233-05
J1110
1/1/2002
51552-0278-01
J3302
51552-0278-02
J3302
51552-0278-03
J3302
51552-0278-05
J3302
1/1/2002
51552-0278-10
51552-0304-00
51552-0304-01
51552-0304-02
51552-0304-03
51552-0304-04
51552-0304-05
51552-0304-06
51552-0304-07
51552-0304-09
51552-0304-10
51552-0304-50
51552-0313-05
51552-0313-06
51552-0313-16
51552-0313-99
51552-0324-05
51552-0324-06
51552-0324-08
51552-0324-09
51552-0324-16
51552-0324-25
51552-0380-01
51552-0380-05
51552-0380-06
51552-0380-08
51552-0380-09
51552-0380-16
51552-0380-25
51552-0380-80
51552-0380-99
J3302
J0285
J0285
J0285
J0285
J0285
J0285
J0285
J0285
J0285
J0285
J0285
J0280
J0280
J0280
J0280
J3480
J3480
J3480
J3480
J3480
J3480
J2150
J2150
J2150
J2150
J2150
J2150
J2150
J2150
J2150
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/1/2002
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
9/1/2003
9/1/2003
1/1/2002
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
51552-0393-01
J7644
1/1/2002
51552-0393-01 KO J7644
51552-0393-01
51552-0393-01 KO J7645
51552-0393-02
J7645
1/1/2002
1/1/2007
KO
J7644
51552-0393-02 KO J7644
51552-0393-02
KO
J7645
1/1/2007
9/1/2003
KO
9/1/2003
1/1/2007
1 EA BO
NA
GM
1 GM
01/01/2008
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
NA
GM
1 GM
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 GM
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 GM
01/01/2002
08/31/2003
PHENYLEPHRINE HCL (U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,N.F.)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
AMPHOTERICIN B
AMPHOTERICIN B
AMPHOTERICIN B
AMPHOTERICIN B (1X25GM)
AMPHOTERICIN B
AMPHOTERICIN B (1X500GM)
AMPHOTERICIN B
AMPHOTERICIN B
AMPHOTERICIN B
MANNITOL (U.S.P.,N.F.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
MANNITOL (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
JR
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
1 GM
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
1
01/01/2002
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
08/31/2003
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
5 MG
200
01/01/2002
99/99/9999
1 EA BO
NA
GM
5 MG
200
09/01/2003
99/99/9999
1 EA BO
NA
GM
5 MG
200
09/01/2003
99/99/9999
1 EA BO
NA
GM
5 MG
200
01/01/2002
08/31/2003
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
JR
JR
JR
BO
JR
JR
JR
JR
JR
JR
JR
BO
BO
VL
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
5 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
250 MG
250 MG
250 MG
250 MG
2 MEQ
2 MEQ
2 MEQ
2 MEQ
2 MEQ
2 MEQ
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
50 ML
200
20
20
20
20
20
20
20
20
20
20
20
4
4
4
4
6.71141
6.71141
6.71141
6.71141
6.71141
6.71141
0.08
0.08
0.08
0.08
0.08
0.08
0.08
0.08
0.08
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
09/01/2003
09/01/2003
01/01/2002
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
99/99/9999
99/99/9999
08/31/2003
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
08/31/2003
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
09/01/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
Page 209 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999

IPRATROPIUM BROMIDE (B.P.)
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002
8/31/2003
20
51552-0393-04
J7644
51552-0393-04 KO J7644
51552-0393-04
51552-0393-04 KO J7645
51552-0393-05
KO
J7644
51552-0393-25 KO J7644
51552-0393-99
KO
J7645
51552-0393-05 KO J7645
51552-0393-25
KO
J7644
51552-0393-05 KO J7644
51552-0393-05
KO
J7645
KO
J7644
51552-0393-99 KO J7644
51552-0397-04
J2690
51552-0397-05
J2690
51552-0397-25
J2690
51552-0397-99
J2690
KO

9/1/2003 12/31/2006 MILLIGRAM
9/1/2003 12/31/2006 MILLIGRAM
9/1/2003 12/31/2006 MILLIGRAM
9/1/2003 12/31/2006 MILLIGRAM
1/1/2002 8/31/2003 MILLIGRAM
1/1/2002 8/31/2003 MILLIGRAM
1/1/2002 8/31/2003 MILLIGRAM
1/1/2002 8/31/2003 MILLIGRAM
PROCAINAMIDE HCL
PROCAINAMIDE HCL
PROCAINAMIDE HCL
PROCAINAMIDE HCL
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
09/01/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
09/01/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1 MG
1 GM
1 GM
1 GM
1 GM
1000
1
1
1
1
01/01/2002
09/01/2003
09/01/2003
01/01/2002
01/01/2002
08/31/2003
02/29/2008
02/29/2008
08/31/2003
08/31/2003
BO
NA
VL
BO
BO
51552-0416-01
J2440
1/1/2002
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
08/31/2003
51552-0416-02
J2440
1 EA BO
NA
GM
60 MG
16.66666
09/01/2003
99/99/9999
51552-0416-04
J2440
1 EA BO
NA
GM
60 MG
16.66666
09/01/2003
99/99/9999
51552-0416-05
J2440
1 EA BO
NA
GM
60 MG
16.66666
09/01/2003
99/99/9999
51552-0416-07
J2440
1 EA BO
NA
GM
60 MG
16.66666
09/01/2003
99/99/9999
51552-0416-25
J2440
1/1/2002
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
08/31/2003
51552-0416-99
J2440
1/1/2002
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
08/31/2003
51552-0423-01
J7631
1/1/2002

1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2002
01/01/2007
08/31/2003
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
51552-0423-01 KO J7631
51552-0423-02
J7699
51552-0423-02
J7632
51552-0423-02 KO J7632
51552-0423-04
J7699
51552-0423-04
51552-0423-07
51552-0423-25
1/1/2008
1/1/2007
1/1/2008
KO
J7631
51552-0423-25 KO J7631
1/1/2008
1/1/2007
1/1/2008
KO
J7632
51552-0423-07 KO J7632
1/1/2008
1/1/2007
1/1/2008
KO
J7632
51552-0423-05 KO J7632
51552-0423-07
J7699
1/1/2002
1/1/2007
1/1/2008
KO
J7632
51552-0423-04 KO J7632
51552-0423-05
J7699
51552-0423-05
KO
1/1/2008
1/1/2002
KO
1/1/2002
Page 210 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
51552-0393-02 KO J7645
NDC
HCPCS
51552-0423-99
J7631
51552-0423-99 KO J7631
51552-0430-01
KO
KO
KO
9/1/2003
1/1/2002
KO
1/1/2002
51552-0435-05
J0600
9/1/2003
51552-0435-99
51552-0445-01
51552-0445-02
51552-0445-04
51552-0445-05
51552-0445-25
J0600
J1435
J1435
J1435
J1435
J1435
1/1/2002
1/1/2002
9/1/2003
9/1/2003
1/1/2002
1/1/2002
51552-0446-03
J7681
51552-0446-03 KO J7681
51552-0446-04
J7681
51552-0446-04 KO J7681
51552-0446-10
KO
9/1/2003
1/1/2002
KO
J7681
51552-0446-25 KO J7681
51552-0464-02
J1320
51552-0464-04
J1320
51552-0464-05
J1320
51552-0464-06
J1320
51552-0464-25
J1320
51552-0480-01
J0735
51552-0480-02
J0735
51552-0480-05
J0735
51552-0487-05
J2810
51552-0487-99
J2810
51552-0496-01
J2760
51552-0496-02
J2760
51552-0496-04
J2760
51552-0496-05
J2760
51552-0496-09
J2760
51552-0496-10
J2760
51552-0496-20
J2760
51552-0496-50
J2760
9/1/2003
9/1/2003
J7681
51552-0446-10 KO J7681
51552-0446-25
9/1/2003
KO
1/1/2002
1/1/2002
KO
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
9/1/2003
1/1/2002
9/1/2003
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
1/1/2002
51552-0498-01
J0270
9/1/2003
51552-0498-03
J0270
9/1/2003
51552-0498-05
J0270
9/1/2003
51552-0498-09
J0270
9/1/2003
51552-0498-10
51552-0519-01
51552-0519-02
51552-0519-05
51552-0526-05
51552-0526-99
J0270
J1630
J1630
J1630
J7799
J7799
1/1/2002
1/1/2002
9/1/2003
1/1/2002
9/1/2003
1/1/2002
51552-0529-02
J3490
9/1/2003

DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE (MICRONIZED)
DEXAMETHASONE (MICRONIZED)
DEXAMETHASONE
DEXAMETHASONE
EDETATE CALCIUM DISODIUM
(U.S.P.,F.C.C.)
EDETATE CALCIUM DISODIUM
(U.S.P.,F.C.C.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
TERBUTALINE SULFATE (U.S.P., NF)
TERBUTALINE SULFATE (U.S.P., NF)
AMITRIPTYLINE HCL (1X5GM)
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
PROSTAGLANDIN E1 (1X1MG,USP)
PROSTAGLANDIN E1 (U.S.P.)
99/99/9999 INJECTION, HALOPERIDOL, UP TO 5 MG
EPINEPHRINE (U.S.P. ,N.F.)
EPINEPHRINE (U.S.P./N.F.)
CLINDAMYCIN PHOSPHATE (U.S.P.,
N.F.)
Page 211 of 374
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
10 MG
100
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1000 MG
09/01/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
1000 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1
1000
1000
1000
1000
1000
01/01/2002
01/01/2002
09/01/2003
09/01/2003
01/01/2002
01/01/2002
08/31/2003
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
JR
BO
JR
BO
BO
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
20 MG
20 MG
20 MG
20 MG
20 MG
1 MG
1 MG
1 MG
40 MG
40 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1000
50
50
50
50
50
1000
1000
1000
25
25
200
200
200
200
200
200
200
200
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
09/01/2003
01/01/2002
09/01/2003
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
01/01/2002
08/31/2003
99/99/9999
05/06/2008
99/99/9999
99/99/9999
08/31/2003
99/99/9999
99/99/9999
08/31/2003
99/99/9999
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
08/31/2003
1 EA BO
NA
GM
1.25 MCG
800000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1.25 MCG
800000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1.25 MCG
800000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1.25 MCG
800000
09/01/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
1.25 MCG
5 MG
5 MG
5 MG
1 EA
1 EA
800000
200
200
200
1
1
01/01/2002
01/01/2002
09/01/2003
01/01/2002
09/01/2003
01/01/2002
08/31/2003
99/99/9999
99/99/9999
08/31/2003
99/99/9999
08/31/2003
1 EA BO
NA
GM
1 EA
09/01/2003
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

1/1/2002
9/1/2003
J7638
51552-0430-05 KO J7638
1/1/2002
1/1/2002
J7638
51552-0430-02 KO J7638
51552-0430-05
1/1/2002
J7638
51552-0430-01 KO J7638
51552-0430-02
HCPCS Mod
HCPCS
NDC Mod
NDC
51552-0529-03
J3490
CLINDAMYCIN PHOSPHATE (U.S.P.,

N.F.)
1 EA BO
NA
GM
1 EA
09/01/2003
99/99/9999
51552-0529-05
J3490
1/1/2002
CLINDAMYCIN PHOSPHATE (U.S.P./N.F.)
1 EA BO
NA
GM
1 EA
01/01/2002
08/31/2003
51552-0529-10
51552-0532-04
51552-0532-25
51552-0564-04
51552-0564-05
51552-0564-07
51552-0564-10
51552-0564-25
51552-0564-99
51552-0588-04
51552-0588-06
J3490
J1165
J1165
J3140
J3140
J3140
J3140
J3140
J3140
J3520
J3520
1/1/2002
9/1/2003
1/1/2002
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
9/1/2003
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
JR
NA
JR
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 EA
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
150 MG
150 MG
1
20
20
20
20
20
20
20
20
6.66666
6.66666
01/01/2002
09/01/2003
01/01/2002
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/01/2003
08/31/2003
99/99/9999
08/31/2003
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
08/31/2003
08/31/2003
99/99/9999
51552-0603-02
J7509
1 EA BO
NA
GM
4 MG
250
09/01/2003
99/99/9999
51552-0603-05
J7509
1/1/2002
1 EA BO
NA
GM
4 MG
250
01/01/2002
08/31/2003
51552-0611-01
J7641
1/1/2002
CLINDAMYCIN PHOSPHATE (U.S.P./N.F.)

PHENYTOIN SODIUM
PHENYTOIN SODIUM
METHYLPREDNISOLONE
(U.S.P.,MICRONIZED)
METHYLPREDNISOLONE
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
BACLOFEN (1X5GM)
BACLOFEN (1X25GM)
BACLOFEN (1X100GM)
MICRONIZED (U.S.P.)
PROGESTERONE (MILLED,U.S.P.)
PROGESTERONE (MILLED,U.S.P.)
APOMORPHINE HCL (1X1GM)
CYCLOSPORIN A
CYCLOSPORINE (1X5GM,USP)
CYCLOSPORINE (1X25GM,USP)
CYCLOSPORINE (1X500MG,USP)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
08/31/2003
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
JR
JR
JR
BO
BO
BO
JR
JR
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
10 MG
10 MG
10 MG
25 MG
25 MG
25 MG
25 MG
25 MG
1000
100
100
100
40
40
40
40
40
01/01/2002
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/01/2002
01/01/2002
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
08/31/2003
08/31/2003
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 EA
50 MG
50 MG
1 EA
1 MG
1 EA
1 MG
1 EA
1 MG
1 EA
250 MG
250 MG
250 MG
250 MG
1
20
20
1
1000
1
1000
1
1000
1
4
4
4
4
01/01/2002
01/01/2002
09/01/2003
09/01/2003
01/01/2007
09/01/2003
01/01/2007
09/01/2003
01/01/2007
01/01/2002
01/01/2002
09/01/2003
09/01/2003
09/01/2003
99/99/9999
08/31/2003
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
08/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA JR
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA JR
NA
GM
0.25 MG
2000
01/01/2002
12/31/2005
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
LINCOMYCIN HYDROCHLORIDE
(USP,1X100GM)
LINCOMYCIN HYDROCHLORIDE
(USP,1X1000GM)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
0.5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
2000
200
200
200
200
200
200
200
200
200
200
200
200
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
51552-0611-01 KO J7641
51552-0611-02
51552-0611-02 KO J7641
51552-0611-05
KO
J7641
J7641
51552-0611-05 KO J7641
51552-0613-02
J0475
51552-0613-04
J0475
51552-0613-05
J0475
51552-0620-02
J2780
51552-0620-04
J2780
51552-0620-05
J2780
51552-0620-25
J2780
51552-0620-99
J2780
1/1/2002
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/1/2002
1/1/2002

1/1/2002
9/1/2003
1/1/2002
KO


9/1/2003
KO
51552-0628-01
51552-0643-01
51552-0643-07
51552-0652-01
51552-0652-01
51552-0652-02
51552-0652-02
51552-0652-04
51552-0652-04
51552-0652-25
51552-0663-01
51552-0663-02
51552-0663-04
51552-0663-06
J3490
J2675
J2675
J3490
J0364
J3490
J0364
J3490
J0364
J3490
J7516
J7516
J7516
J7516
1/1/2002
1/1/2002
9/1/2003
9/1/2003
1/1/2007
9/1/2003
1/1/2007
9/1/2003
1/1/2007
1/1/2002
1/1/2002
9/1/2003
9/1/2003
9/1/2003
51552-0668-01
J7626
51552-0668-01 KO J7626
51552-0668-01
KO
J7627
51552-0668-01 KO J7627
51552-0671-01
Q4075
51552-0671-01
J0133
51552-0671-02
Q4075
51552-0671-02
J0133
51552-0671-03
Q4075
51552-0671-03
J0133
51552-0671-04
Q4075
51552-0671-04
J0133
51552-0671-05
Q4075
51552-0671-05
J0133
51552-0671-06
Q4075
51552-0671-06
J0133
1/1/2002
1/1/2006
KO
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006
BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON12/31/2005 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG
51552-0674-05
J2010
51552-0674-07
J2010
Page 212 of 374
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
1 EA BO
NA
GM
300 MG
3.33333
09/01/2003
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
09/01/2003
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
51552-0682-01
J1170
51552-0682-02
J1170
51552-0682-03
J1170
51552-0682-04
J1170
51552-0686-01
J2175
51552-0686-02
J2175
51552-0686-04
J2175
51552-0686-06
51552-0687-01
51552-0687-09
51552-0688-02
51552-0688-03
51552-0688-04
51552-0688-06
51552-0701-02
51552-0715-04
51552-0715-05
51552-0715-06
51552-0728-01
51552-0728-02
51552-0728-04
51552-0729-01
51552-0729-02
51552-0729-04
51552-0729-05
51552-0729-09
51552-0733-01
51552-0733-01
51552-0733-02
51552-0733-02
51552-0733-04
51552-0733-04
51552-0733-05
51552-0733-05
J2175
J3010
J3010
J0745
J0745
J0745
J0745
J2710
J3490
J3490
J3490
J1230
J1230
J1230
J2060
J2060
J2060
J2060
J2060
J9190
J9190
J9190
J9190
J9190
J9190
J9190
J9190
QR
QR
QR
QR
QR
QR
QR
QR
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2004
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
1/28/2005
9/1/2003
1/28/2005
9/1/2003
1/28/2005
9/1/2003
1/28/2005


DIMENHYDRINATE (1X25GM,USP)
DIMENHYDRINATE (1X100GM,USP)
MORPHINE SULFATE (1X5GM,USP)
(1X1GM,USP)
(1X5GM,USP)
(1X10GM,USP)
(1X25GM,USP)
(USP,1X1GM)
(USP,1X5GM)
(USP,1X25GM)
(USP,1X100GM)
FENTANYL CITRATE (1X1GM,USP)
FENTANYL CITRATE (1X500MG,USP)
CODEINE PHOSPHATE (1X5GM,USP)
RIFAMPIN (USP,1X25GM)
LORAZEPAM (1X1GM,USP)
LORAZEPAM (1X500MG,USP)
FLUOROURACIL (1X1GM,USP)
NALTREXONE HYDROCHLORIDE
(1X1GM,USP)
NALTREXONE HYDROCHLORIDE
(1X5GM,USP)
PROGESTERONE
(1X25GM,USP,MICRONIZED)
PROGESTERONE
PROGESTERONE
PROGESTERONE
NA
GM
4 MG
250
09/01/2003
99/99/9999
1 EA BO
NA
GM
4 MG
250
09/01/2003
99/99/9999
1 EA BO
NA
GM
4 MG
250
09/01/2003
99/99/9999
1 EA BO
NA
GM
4 MG
250
09/01/2003
99/99/9999
1 EA BO
NA
GM
100 MG
10
09/01/2003
99/99/9999
1 EA BO
NA
GM
100 MG
10
09/01/2003
99/99/9999
1 EA BO
NA
GM
100 MG
10
09/01/2003
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
JR
BO
BO
BO
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
ML
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
100 MG
0.1 MG
0.1 MG
30 MG
30 MG
30 MG
30 MG
0.5 MG
1 EA
1 EA
1 EA
10 MG
10 MG
10 MG
2 MG
2 MG
2 MG
2 MG
2 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
10
10000
10000
33.33333
33.33333
33.33333
33.33333
2000
1
1
1
100
100
100
500
500
500
500
500
2
2
2
2
2
2
2
2
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2004
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
01/28/2005
09/01/2003
01/28/2005
09/01/2003
01/28/2005
09/01/2003
01/28/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA
1 EA
500 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
51552-0737-01
J3490
51552-0737-02
J3490
51552-0738-04
J2675
51552-0738-05
J2675
51552-0738-06
J2675
51552-0738-07
J2675
51552-0741-04
51552-0763-05
51552-0763-07
J0500
J3490
J3490
DICYCLOMINE HYDROCHLORIDE (USP)

6-AMINOCAPROIC ACID (1X100GM)
6-AMINOCAPROIC ACID (1X1000GM)
51552-0768-01
J7684

TRIAMCINOLONE (1X1GM,USP)
1 EA BO
NA
TRIAMCINOLONE (1X1GM,USP)
GENTAMYCIN SULFATE (1X1GM,USP)
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
NA
NA
NA
NA
9/1/2003
9/1/2003
9/1/2003
9/1/2003

AZATHIOPRINE (1X5GM)
1
1
1
1
BO
BO
BO
BO
NA
NA
NA
NA
TOBRAMYCIN SULFATE (1X1GM,USP)
1 EA BO
1 EA BO
51552-0768-01 KO J7684
51552-0775-01
J7699
51552-0775-02
J7699
51552-0775-04
J7699
51552-0775-05
51552-0779-02
51552-0779-04
51552-0779-05
J7699
J7501
J7501
J7501
51552-0789-01
J7682
51552-0789-01 KO J7682
KO
KO

9/1/2003 12/31/2006 MILLIGRAMS
9/1/2003 12/31/2006 MILLIGRAMS
Page 213 of 374
CF
HCPCS Amount #1
1 EA JR
NA
GM
1 EA
09/01/2003
1 EA BO
NA
GM
1 EA
09/01/2003
99/99/9999
1 EA BO
NA
GM
50 MG
20
09/01/2003
99/99/9999
1 EA JR
NA
GM
50 MG
20
09/01/2003
99/99/9999
1 EA BO
NA
GM
50 MG
20
09/01/2003
99/99/9999
1 EA BO
NA
GM
50 MG
20
09/01/2003
99/99/9999
1 EA BO
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
20 MG
1 EA
1 EA
50
1
1
09/01/2003
09/01/2003
09/01/2003
99/99/9999
99/99/9999
99/99/9999
GM
1 MG
1000
09/01/2003
99/99/9999
GM
GM
GM
GM
1 MG
1 EA
1 EA
1 EA
1000
1
1
1
09/01/2003
09/01/2003
09/01/2003
09/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
GM
GM
GM
GM
1 EA
100 MG
100 MG
100 MG
1
10
10
10
09/01/2003
09/01/2003
09/01/2003
09/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
NA
GM
300 MG
3.33333
09/01/2003
12/31/2006
NA
GM
300 MG
3.33333
09/01/2003
12/31/2006
EA
EA
EA
EA
1 EA BO
Prior End Date #3
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
20
20
10
10
10
Prior End Date #2
50 MG
50 MG
100 MG
100 MG
100 MG
End Date #1
GM
GM
GM
GM
GM
Start Date #1
NA
NA
NA
NA
NA
HCPCS Measure #1
BO
BO
NA
JR
JR
Billing Units
EA
EA
EA
EA
EA
1
1
1
1
1
Prior Start Date #2

Package
NDC Package Type
J1240
J1240
J2271
J2271
J2271
NDC Package Measure
51552-0676-04
51552-0676-05
51552-0678-02
51552-0678-04
51552-0678-06
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
51552-0789-01
J7685
51552-0789-01 KO J7685
51552-0789-02
51552-0879-02
J0520
51552-0879-04
J0520
51552-0883-01
J7622
51552-0883-01 KO J7622
KO
KO
J7622
51552-0883-02 KO J7622
51552-0883-09
KO
J7685
51552-0789-05 KO J7685
51552-0802-02
J0360
51552-0829-01
J2675
51552-0829-03
J2675
51552-0829-04
J2675
51552-0829-05
J2675
51552-0829-06
J2675
51552-0829-07
J2675
51552-0829-08
J2675
51552-0839-05
J2360
51552-0883-02
KO
J7682
51552-0789-05 KO J7682
51552-0789-05
KO
J7685
51552-0789-04 KO J7685
51552-0789-05
KO
J7682
51552-0789-04 KO J7682
51552-0789-04
KO
J7685
51552-0789-02 KO J7685
51552-0789-04
KO
J7682
51552-0789-02 KO J7682
51552-0789-02
KO
J7622
51552-0883-09 KO J7622
51552-0888-01
J0970
51552-0888-02
J0970
51552-0888-04
J0970
51552-0889-02
J3490
J3490
51552-0889-03
51552-0889-04
J3490
51552-0889-09
J3490
KO

9/1/2003 12/31/2006 MILLIGRAMS
9/1/2003 12/31/2006 MILLIGRAMS
9/1/2003 12/31/2006 MILLIGRAMS
9/1/2003 12/31/2006 MILLIGRAMS
9/1/2003 12/31/2006 MILLIGRAMS
9/1/2003 12/31/2006 MILLIGRAMS
9/1/2003 99/99/9999 MG
9/1/2003 99/99/9999 MG
51552-0894-02
J0945
51552-0894-04
J0945
51552-0894-05
J0945
51552-0910-04
J1800
51552-0910-05
51552-0913-01
51552-0913-02
51552-0920-02
51552-0920-04
51552-0920-05
J1800
J1840
J1840
J1835
J1835
J1835
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003

1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
09/01/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
09/01/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
09/01/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
09/01/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
09/01/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
09/01/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999

PROGESTERONE (1X1GM,USP)
BETHANECHOL CHLORIDE
(1X5GM,USP)
BETHANECHOL CHLORIDE
(1X25GM,USP)
(1X1GM,USP)
(1X1GM,USP)
(1X5GM,USP)
(1X5GM,USP)
(1X250MG,USP)
(1X250MG,USP)
ESTRADIOL VALERATE (1X1GM,USP)
SUFENTANIL CITRATE (1X10MG,USP)
BROMPHENIRAMINE MALEATE
(1X5GM,USP)
(1X25GM,USP)
(1X100GM,USP)
(USP,1X25GM)
(USP,1X100GM)
KANAMYCIN SULFATE (1X1GM,USP)
KANAMYCIN SULFATE (1X5GM,USP)
ITRACONAZOLE (1X5GM)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
300 MG
20 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
60 MG
3.33333
50
20
20
20
20
20
20
20
16.66666
01/01/2007
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 214 of 374
BO
BO
NA
BO
BO
BO
BO
BO
BO
BO
1 EA JR
NA
GM
5 MG
200
09/01/2003
99/99/9999
1 EA JR
NA
GM
5 MG
200
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
40 MG
40 MG
40 MG
1 EA
1 EA
1 EA
1 EA
1000
25
25
25
1
1
1
1
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
1 EA BO
NA
GM
10 MG
100
09/01/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/01/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/01/2003
99/99/9999
1 EA JR
NA
GM
1 MG
1000
09/01/2003
99/99/9999
1
1
1
1
1
1
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
1 MG
500 MG
500 MG
50 MG
50 MG
50 MG
1000
2
2
20
20
20
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
EA
EA
EA
EA
EA
EA
BO
BO
BO
JR
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
51552-0920-06
51552-0940-02
J1835
J1940

FUROSEMIDE (U.S.P.)
1 EA NA
1 EA BO
NA
NA
GM
GM
51552-0952-01
J0515
NA
J1030
1 EA BO
NA
51552-0958-04
J1030
1 EA BO
51552-0958-05
J1030
51552-0958-06
51552-0978-05
J1030
J3000
51552-0979-04
51552-0991-01
Q0178
J0760
51552-0999-02
J7636
51552-0999-04
51552-1018-05
51552-1025-02
51552-1025-04
51552-1025-05
51552-1031-01
51552-1031-02
51552-1031-04
J7636
J2800
J3360
J3360
J3360
J1450
J1450
J1450

9/1/2003 99/99/9999 INJECTION, COLCHICINE, PER 1MG
BENZTROPINE MESYLATE (1X1GM,USP)

(USP,1X5GM,MICRONIZED)
STREPTOMYCIN SULFATE (U.S.P.)
1 EA BO
51552-0958-02
51552-1036-01
J3370
51552-1036-09
51552-1043-02
51552-1045-01
51552-1045-09
51552-1053-06
51552-1054-01
51552-1054-09
51552-1063-02
51552-1069-02
51552-1076-09
J3370
J2321
J3420
J3420
J1212
J8610
J8610
J3430
J2460
J9060
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
9/1/2003
51641-0030-46
Q0163
1/1/2002
51641-0030-64
Q0163
1/1/2002
51641-0030-76
Q0163
1/1/2002
51641-0030-94
51655-0020-24
51655-0020-52
51655-0020-53
51655-0020-80
Q0163
J7506
J7506
J7506
J7506
1/1/2002
1/1/2002
1/1/2002
1/1/2002
6/22/2005
51655-0084-27
Q0170
1/1/2002
51655-0084-53
51655-0086-24
51655-0086-27
51655-0086-51
51655-0087-24
51655-0087-28
51655-0087-49
Q0170
J7506
J7506
J7506
J7506
J7506
J7506
6/22/2005
1/1/2002
1/1/2002
6/22/2005
1/1/2005
6/22/2005
6/22/2005
51655-0088-24
Q0163
1/1/2002

COLCHICINE (1X1GM,USP)
50 MG
20 MG
20
50
09/01/2003
09/01/2003
99/99/9999
99/99/9999
GM
1 MG
1000
09/01/2003
99/99/9999
GM
40 MG
25
09/01/2003
99/99/9999
NA
GM
40 MG
25
09/01/2003
99/99/9999
1 EA BO
NA
GM
40 MG
25
09/01/2003
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
40 MG
1 GM
25
1
09/01/2003
09/01/2003
99/99/9999
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
50 MG
1 MG
20
1000
09/01/2003
09/01/2003
99/99/9999
99/99/9999
ATROPINE (1X5GM)
1 EA BO
NA
GM
1 MG
1000
09/01/2003
99/99/9999
ATROPINE (1X25GM)
METHOCARBAMOL (USP,1X100GM)
DIAZEPAM (1X5GM,USP)
FLUCONAZOLE (1X1GM)
FLUCONAZOLE (1X5GM)
FLUCONAZOLE (1X25GM)
(1X1GM,USP)
(1X250MG,USP)
CYANOCOBALAMIN (1X1GM,USP)
CYANOCOBALAMIN (1X500MG,USP)
DIMETHYLSULFOXIDE
METHOTREXATE (USP,1X1GM)
METHOTREXATE (USP,1X100MG)
PHYTONADIONE (USP,1X5GM)
CISPLATIN (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
10 ML
5 MG
5 MG
5 MG
200 MG
200 MG
200 MG
1000
1
200
200
200
5
5
5
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999

99/99/9999 INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG
DPH 12.5 MG/5 ML
DPH 12.5 MG/5 ML
DPH 12.5 MG/5 ML
DPH 12.5 MG/5 ML
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
Page 215 of 374
BO
BO
BO
BO
BO
JR
JR
JR
1 EA JR
NA
GM
500 MG
09/01/2003
99/99/9999
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
ML
GM
GM
GM
GM
GM
500 MG
100 MG
1000 MCG
1000 MCG
50 %
2.5 MG
2.5 MG
1 MG
50 MG
10 MG
2
10
1000
1000
0.02
400
400
1000
20
100
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
09/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/04/2003
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/04/2003
480 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/04/2003
BO
BO
BO
BO
NA
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
0.05
4
4
4
4
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/22/2005
08/04/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
10 EA
30 EA
12 EA
40 EA
30 EA
21 EA
42 EA
NA
BO
BO
NA
NA
NA
NA
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
25 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
1
1
1
2
2
2
06/22/2005
01/01/2002
01/01/2002
06/22/2005
01/01/2005
06/22/2005
06/22/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
473 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1920 ML
30 EA
20 EA
10 EA
8 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
51655-0088-52
Q0163
1/1/2002
51655-0093-87
Q0164
6/22/2005
51655-0113-24
Q0163
1/1/2002
51655-0113-25
Q0163
1/1/2002
51655-0113-27
Q0163
1/1/2002
51655-0113-80
Q0163
6/22/2005
51655-0133-54
Q0163
6/22/2005
51655-0294-89
51655-0296-51
51655-0296-54
51655-0296-76
51655-0300-51
51655-0300-54
51655-0300-76
Q0165
J8499
J8499
J8499
J8499
J8499
J8499
6/22/2005
6/22/2005
6/22/2005
6/22/2005
6/22/2005
6/22/2005
6/22/2005
51655-0523-53
Q0173
1/1/2002
51655-0533-52
Q0177
6/22/2005
51672-4091-03
51927-1000-00
Q0179
J2271
9/19/2008
9/8/2003
51927-1001-00
J7636
51927-1001-00 KO J7636
51927-1003-00
J1170
51927-1005-00
J2060
51927-1007-00
J1960
9/8/2003
KO
9/8/2003
9/8/2003
9/8/2003
9/8/2003
51927-1012-00
51927-1013-00
51927-1014-00
51927-1017-00
51927-1018-00
51927-1019-00
51927-1026-00
J0592
J0745
J3360
J1230
J2175
J3010
J3140
9/8/2003
9/8/2003
9/8/2003
9/8/2003
9/8/2003
9/8/2003
9/8/2003
51927-1027-00
J3140
9/8/2003
51927-1029-00
J3150
9/8/2003
51927-1046-00
51927-1079-00
51927-1080-00
51927-1082-00
51927-1085-00
51927-1085-00 QR
J2675
J1200
J1240
J2765
J9190
J9190
9/8/2003
9/8/2003
9/8/2003
9/8/2003
9/8/2003
1/28/2005
51927-1090-00
51927-1093-00
51927-1093-00
J3480
J3490
J3415
QR

ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
(1x50ML); (4MG/5ML)
MORPHINE SULFATE (U.S.P.; CII)
HYDROMORPHONE HCL (U.S.P.; CII)
LORAZEPAM (U.S.P.; CIV)
LEVORPHANOL TARTRATE (U.S.P.; CII)
(U.S.P.;CIII)
CODEINE PHOSPHATE (U.S.P.; CII)
DIAZEPAM (U.S.P.; CIV)
METHADONE HCL (U.S.P.; CII)
MEPERIDINE HCL (U.S.P.; CII)
TESTOSTERONE
TESTOSTERONE MICRONIZED (U.S.P.;
SOY; CIII)
MICRONIZED (U.S.P., MICRONIZED)


FLUOROURACIL (U.S.P., -5 FU)
FLUOROURACIL (U.S.P., -5 FU)
POTASSIUM CHLORIDE (USP;
GRANULAR)
PYRIDOXINE HCL (USP)
PYRIDOXINE HCL (USP)
Page 216 of 374
20 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
6 EA NA
PO
EA
5 MG
06/22/2005
99/99/9999
30 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
60 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
12 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
8 EA NA
PO
EA
50 MG
0.5
06/22/2005
99/99/9999
15 EA NA
PO
EA
50 MG
0.5
06/22/2005
99/99/9999
4 EA
40 EA
15 EA
25 EA
40 EA
15 EA
25 EA
NA
NA
NA
NA
NA
NA
NA
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
10 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
1
1
06/22/2005
06/22/2005
06/22/2005
06/22/2005
06/22/2005
06/22/2005
06/22/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
20 EA NA
PO
EA
25 MG
06/22/2005
99/99/9999
50 ML PG
1 EA JR
PO
NA
EA
GM
8 MG
100 MG
1
10
09/19/2008
09/08/2003
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
BO
JR
JR
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 MG
4 MG
2 MG
2 MG
1000
250
500
500
09/08/2003
09/08/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
JR
BO
BO
JR
JR
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
0.1 MG
30 MG
5 MG
10 MG
100 MG
0.1 MG
50 MG
10000
33.33333
200
100
10
10000
20
09/08/2003
09/08/2003
09/08/2003
09/08/2003
09/08/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA JR
NA
GM
50 MG
20
09/08/2003
99/99/9999
1 EA JR
NA
GM
100 MG
10
09/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
JR
JR
BO
BO
JR
JR
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
50 MG
50 MG
50 MG
10 MG
500 MG
500 MG
20
20
20
100
2
2
09/08/2003
09/08/2003
09/08/2003
09/08/2003
09/08/2003
01/28/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
2 MEQ
1 EA
100 MG
6.71141
1
10
12/04/2003
12/04/2003
01/01/2004
99/99/9999
12/31/2003
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
51927-1110-00
J1700
51927-1148-00
51927-1194-00
51927-1202-00
51927-1213-00
51927-1213-00
51927-1225-00
51927-1242-00
51927-1269-00
J7510
J3490
J0706
J2000
J2001
J7799
J3411
J3350
9/8/2003
9/8/2003
12/4/2003
9/8/2003
1/1/2004
9/8/2003
1/1/2004
12/4/2003
51927-1317-00
J3520
51927-1325-00
J2650
51927-1326-00
J7684
51927-1326-00 KO J7684
KO


MICRONIZED (U.S.P.)
PREDNISOLONE MICRONIZED
(ANHYDROUS)
BENZOCAINE
THIAMINE HYDROCHLORIDE (USP)
UREA (USP)
EDETATE DISODIUM (USP; DIHYDRATE)
PREDNISOLONE ACETATE MICRONIZED
(U.S.P.)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
MICRONIZED (U.S.P.)
(U.S.P.)
51927-1332-00
J1030
51927-1347-00
J0500
51927-1370-00
J7669

9/8/2003 12/31/2006 PER 10 MILLIGRAMS
9/8/2003 12/31/2006 PER 10 MILLIGRAMS
51927-1370-00 KO J7669
51927-1370-00
J7670
51927-1370-00 KO J7670
51927-1400-00
J3410
51927-1430-00
51927-1444-00
51927-1449-00
J0280
J3490
51927-1454-00
J7624
51927-1454-00 KO J7624
51927-1510-00
J2810
51927-1565-00
J8610
51927-1571-00
J1245
KO
J7643
51927-1575-00 KO J7643
51927-1597-00
51927-1601-00
J3490
J7699
51927-1601-00
J7604
51927-1601-00 KO J7604
51927-1603-00
J1320
51927-1606-00
J1800
51927-1610-00
J7699
51927-1612-00
J1212
51927-1641-00
KO
J7609
51927-1573-00 KO J7609
51927-1575-00
KO
KO
KO
J7622
51927-1641-00 KO J7622
KO
NA
GM
25 MG
40
09/08/2003
99/99/9999
JR
JR
BO
JR
JR
JR
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
5 MG
1 EA
5 MG
50 ML
10 MG
1 EA
100 MG
40 GM
200
1
200
4
100
1
10
0.025
09/08/2003
09/08/2003
12/04/2003
09/08/2003
01/01/2004
09/08/2003
01/01/2004
12/04/2003
99/99/9999
99/99/9999
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
150 MG
6.66666
12/04/2003
99/99/9999
1 EA JR
NA
GM
1 ML
20
09/08/2003
99/99/9999
1 EA JR
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA JR
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA BO
NA
GM
40 MG
25
09/08/2003
99/99/9999
1 EA BO
NA
GM
20 MG
50
09/08/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/08/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
09/08/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999


PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PREDNISONE MICRONIZED (USP)
ARSENIC TRIOXIDE (TECHNICAL)
1 EA BO
1 EA JR
NA
NA
GM
GM
10 MG
25 MG
100
40
01/01/2007
09/08/2003
99/99/9999
99/99/9999
1 EA JR
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
JR
JR
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 MG
5 MG
5 MG
1 MG
1000
200
200
1000
09/08/2003
09/08/2003
09/08/2003
12/04/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA JR
1 EA JR
NA
NA
GM
GM
250 MG
1 EA
4
1
09/08/2003
09/08/2003
99/99/9999
99/99/9999
1/1/2007
9/8/2003
9/8/2003
9/8/2003
9/8/2003
12/4/2003

9/8/2003 99/99/9999 METHOTREXATE; ORAL, 2.5 MG
AMINOPHYLLINE (U.S.P.; ANHYDROUS)

(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
THEOPHYLLINE (USP, ANHYDROUS)
1 EA JR
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
JR
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 MG
40 MG
2.5 MG
10 MG
1000
25
400
100
09/08/2003
09/08/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/08/2003
99/99/9999
ETHANOLAMINE
(MONOETHANOLAMINE)
1 EA BO
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 EA
1 EA
1
1
12/04/2003
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
DIMETHYL SULFOXIDE (USP)
(U.S.P. (ANHYDROUS))
(U.S.P. (ANHYDROUS))
1 EA
1 EA
1 EA
1 EA
1 ML
BO
JR
BO
JR
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
ML
1 GM
20 MG
1 MG
1 EA
50 %
1
50
1000
1
0.02
01/01/2008
09/08/2003
09/08/2003
09/08/2003
12/04/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/08/2003
99/99/9999
Page 217 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure
1 EA JR
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA

9/8/2003
KO
J7613
51927-1573-00 KO J7613
51927-1573-00
KO
J7638
51927-1430-00 KO J7638
51927-1433-00
J1630
51927-1435-00
J7506
51927-1441-00
J9017
51927-1573-00
KO

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
51927-1706-00
51927-1709-00
51927-1715-00
51927-1722-00
J1110
J1435
J7799
J3430
51927-1726-00
51927-1742-00
51927-1746-00
J0285
J3370
J1160

IPRATROPIUM BROMIDE
9/8/2003 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
9/8/2003 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
9/8/2003 99/99/9999 INJECTION, DYPHYLLINE, UP TO 500 MG
DYPHYLLINE
CYANOCOBALAMIN (USP)
(U.S.P.)
ESTRONE (U.S.P. E-1)
EPINEPHRINE HCL (USP)
12/4/2003 99/99/9999 INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG
MENADIONE (USP)
AMPHOTERICIN B (U.S.P.; ORAL
GRADE)
DIGOXIN (U.S.P.)
51927-1775-00
51927-1776-00
51927-1781-00
51927-1784-00
51927-1788-00
J2440
J3490
J2150
J1940
J3000
9/8/2003
9/8/2003
12/4/2003
9/8/2003
9/8/2003
51927-1794-00
J7641
51927-1648-00
J7644
51927-1648-00 KO J7644
51927-1648-00
KO
J7645
51927-1648-00 KO J7645
51927-1659-00
J1180
51927-1662-00
J3420
51927-1683-00
J3490
51927-1698-00
J0970
51927-1794-00 KO J7641
KO
KO

51927-1829-00
51927-1831-00
51927-1838-00
51927-1865-00
51927-1895-00
51927-1925-00
J3490
J1980
J1165
J1955
J0760
J3430
9/8/2003
9/8/2003
9/8/2003
12/4/2003
9/8/2003
9/8/2003
51927-1940-00
J7659
9/8/2003
51927-1940-00 KO J7659
51927-1940-00
KO
J7660
51927-1940-00 KO J7660
51927-1950-00
J0945
51927-1951-00
J7624
51927-1951-00 KO J7624
9/8/2003
1/1/2007

KO
1/1/2007
KO

NA
GM
1 MG
1000
09/08/2003
12/31/2006
1 EA JR
NA
GM
1 MG
1000
09/08/2003
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
BO
JR
JR
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1000
2
1000
1
25
01/01/2007
09/08/2003
12/04/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA
1 EA
1 EA
1 EA
BO
JR
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 MG
1 MG
1 EA
1 MG
1000
1000
1
1000
09/08/2003
09/08/2003
09/08/2003
12/04/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA JR
1 EA JR
1 EA BO
NA
NA
NA
GM
GM
GM
50 MG
500 MG
0.5 MG
20
2
2000
09/08/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999

AMINOCAPROIC ACID (USP (6))
MANNITOL (USP)
FUROSEMIDE (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
60 MG
1 EA
50 ML
20 MG
1 GM
16.66666
1
0.08
50
1
09/08/2003
09/08/2003
12/04/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
FLUNISOLIDE ANHYDROUS (U.S.P.)
1 EA BO
NA
GM
1 MG
1000
09/08/2003
99/99/9999
FLUNISOLIDE ANHYDROUS (U.S.P.)

CORTISONE ACETATE MICRONIZED
(USP)
LEVOCARNITINE (USP)
COLCHICINE (U.S.P.)
PHYTONADIONE (USP; VITAMIN K1)
1 EA BO
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
JR
BO
BO
BO
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
1 EA
0.25 MG
50 MG
1 GM
1 MG
1 MG
1
4000
20
1
1000
1000
09/08/2003
09/08/2003
09/08/2003
12/04/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
09/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999

PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
MICRONIZED (U.S.P.)
RIFAMPIN (U.S.P.)
BACLOFEN (U.S.P.)
EDETATE CALCIUM DISODIUM (USP,
HYDRATE)
1 EA BO
NA
GM
10 MG
100
09/08/2003
99/99/9999
1 EA JR
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA JR
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1 EA
1 EA
20 MG
200 MG
10 MG
1
1
50
5
100
09/08/2003
09/08/2003
09/08/2003
09/12/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
J3490
J3490
J0360
J3250
J0475
9/8/2003
9/8/2003
9/8/2003
9/12/2003
9/8/2003
51927-2059-00
J0600
51927-2097-00
51927-2099-00
51927-2101-00
J0520
J1330
J0770
51927-2116-00
J0151
51927-2116-00
51927-2118-00
J0152
J2360
51927-2132-00
J0151
51927-2132-00
J0152
51927-2134-00
Q0165

9/8/2003 99/99/9999 MG
ERGONOVINE MALEATE
COLISTIMETHATE SODIUM (USP)
ADENOSINE
ADENOSINE
ORPHENADRINE CITRATE (USP)
ADENOSINE (TRIHYDRATE)
ADENOSINE (TRIHYDRATE)
Page 218 of 374
JR
JR
BO
BO
JR
1 MG
500 MG
1000 MCG
1 EA
40 MG
1 EA BO
NA
GM
1000 MG
12/04/2003
99/99/9999
1 EA JR
1 EA JR
1 EA BO
NA
NA
NA
GM
GM
GM
5 MG
0.2 MG
150 MG
200
5000
6.66666
09/08/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
90 MG
11.11111
12/04/2003
12/31/2003
1 EA BO
1 EA BO
NA
NA
GM
GM
30 MG
60 MG
33.33333
16.66666
01/01/2004
09/08/2003
99/99/9999
99/99/9999
1 EA BO
NA
GM
90 MG
11.11111
12/04/2003
12/31/2003
1 EA BO
NA
GM
30 MG
33.33333
01/01/2004
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/08/2003
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure
1 EA JR
51927-1954-00
51927-1956-00
51927-1979-00
51927-1981-00
51927-2007-00


Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
51927-2140-00
51927-2182-00
J2300
J1790
51927-2196-00
J0270

51927-2206-00
J0780
51927-2231-00
51927-2234-00
51927-2258-00
J1094
J2680
J7501

9/8/2003 99/99/9999 INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG
51927-2298-00
51927-2300-00
J3475
J2730
51927-2303-00
J3490
51927-2303-00
J0364
51927-2316-00
51927-2319-00
51927-2319-00
51927-2351-00
51927-2362-00
Q0178
Q4076
J1265
J3310
J9140
51927-2375-00
J7682
51927-2375-00 KO J7682
51927-2375-00
51927-2692-00
51927-2704-00
51927-2704-00
J0640
J3490
J0278
51927-2706-00
J1070
51927-2732-00
51927-2742-00
J3475
J1730
51927-2762-00
J9340
51927-2765-00
J7681
51927-2765-00 KO J7681
51927-2772-00
J9182
51927-2772-00
J9181
51927-2775-00
J1250

KO
KO
KO
1 EA JR
1 EA BO
1 EA JR
1 EA BO
1 EA BO
100
200
09/08/2003
09/08/2003
GM
GM
10 MG
5 MG
NA
GM
1.25 MCG
800000
09/08/2003
99/99/9999
NA
GM
10 MG
100
09/08/2003
99/99/9999
NA
NA
NA
GM
GM
GM
1 MG
25 MG
100 MG
1000
40
10
09/08/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
500 MG
1 GM
2
1
12/04/2003
12/04/2003
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 EA
09/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999

DOPAMINE HCL
DOPAMINE HCL
DACARBAZINE (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
JR
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
50 MG
40 MG
40 MG
5 MG
200 MG
20
25
25
200
5
09/08/2003
10/01/2003
01/01/2006
08/09/2003
09/08/2003
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
TOBRAMYCIN (USP)
1 EA BO
NA
GM
300 MG
3.33333
09/08/2003
12/31/2006
TOBRAMYCIN (USP)
1 EA BO
NA
GM
300 MG
3.33333
09/08/2003
12/31/2006
TOBRAMYCIN (USP)
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
TOBRAMYCIN (USP)
TRIAMCINOLONE (USP, NONMICRONIZED)
TRIAMCINOLONE (USP, NONMICRONIZED)
TOLAZOLINE HCL
LEUCOVORIN CALCIUM (USP;
ANHYDROUS)
TESTOSTERONE CYPIONATE (U.S.P.;
CIII)
MAGNESIUM SULFATE (USP;
HEPTAHYDRATE)
DIAZOXIDE (U.S.P.)
1 EA
1 EA
1 EA
1 EA
BO
JR
JR
BO
NA
NA
NA
NA
GM
GM
GM
GM
300 MG
1 MG
250 MG
10 ML
3.33333
1000
4
1
01/01/2007
09/08/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA JR
NA
GM
1 MG
1000
09/08/2003
99/99/9999
1 EA JR
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
1 MG
25 MG
5 MG
1000
40
200
09/08/2003
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
1 EA JR
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
50 MG
1 EA
100 MG
20
1
10
09/08/2003
09/08/2003
01/01/2006
99/99/9999
12/31/2005
99/99/9999
1 EA JR
NA
GM
100 MG
10
09/08/2003
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
500 MG
300 MG
2
3.33333
12/04/2003
09/08/2003
99/99/9999
99/99/9999
TRIETHYLENETHIOPHOSPHORAMIDE/T
NA
GM
15 MG
66.66666
09/08/2003
99/99/9999
NA
GM
1 MG
1000
09/08/2003
99/99/9999

ETOPOSIDE (U.S.P.)
ETOPOSIDE (U.S.P.) 1 GM
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 MG
100 MG
10 MG
250 MG
1000
10
100
4
09/08/2003
09/08/2003
01/01/2009
09/08/2003
99/99/9999
12/31/2008
99/99/9999
99/99/9999
BUDESONIDE MICRONIZED
1 EA JR
NA
GM
0.25 MG
2000
09/08/2003
12/31/2005
1 EA JR
NA
GM
0.25 MG
2000
09/08/2003
12/31/2005
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
ALBUTEROL (U.S.P.)
1 EA JR
NA
GM
1 MG
1000
01/01/2005
12/31/2006
ALBUTEROL (U.S.P.)
1 EA JR
NA
GM
1 MG
1000
01/01/2005
12/31/2006
ALBUTEROL (U.S.P.)
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
ALBUTEROL (U.S.P.)
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
9/8/2003
1/1/2006
1/1/2005
1/1/2007
Page 219 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
99/99/9999
1 EA BO
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
PROCHLORPERAZINE EDISYLATE (USP)
MICRONIZED (U.S.P.)
AZATHIOPRINE (USP)
MAGNESIUM SULFATE (ANHYDROUS
REAGENT)
PRALIDOXIME CHLORIDE
APOMORPHINE HCL (U.S.P.,
HEMIHYDRATE)
APOMORPHINE HCL (U.S.P.,
HEMIHYDRATE)
NA
NA
1 EA BO
1/1/2007
KO
1 EA BO
1 EA BO
1/1/2005
KO
NALBUPHINE HCL
DROPERIDOL (USP)
9/8/2003 99/99/9999 INJECTION, THIOTEPA, 15 MG

9/8/2003 12/31/2008 ETOPOSIDE, 100 MG
1/1/2006
J7609
51927-2859-00 KO J7609
1/1/2007 99/99/9999 INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG

8/9/2003 99/99/9999 INJECTION, PERPHENAZINE, UP TO 5 MG
9/8/2003 99/99/9999 DACARBAZINE, 200 MG
9/8/2003 12/31/2006 MILLIGRAMS
9/8/2003 12/31/2006 MILLIGRAMS
9/8/2003 99/99/9999 INJECTION, TETRACYCLINE, UP TO 250 MG
9/8/2003 99/99/9999 INJECTION, TOLAZOLINE HCL, UP TO 25 MG
9/8/2003 99/99/9999 INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG
J7613
51927-2859-00 KO J7613
51927-2859-00
KO
J7627
51927-2834-00 KO J7627
51927-2859-00
KO
J7626
51927-2834-00 KO J7626
51927-2834-00
KO
J7684
51927-2575-00 KO J7684
51927-2593-00
J2670
51927-2669-00
J2760
51927-2834-00
J7685
51927-2375-00 KO J7685
51927-2379-00
J0735
51927-2449-00
J0120
51927-2519-00
J2800
51927-2575-00

NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
51927-2895-00
J1600
9/8/2003 99/99/9999 INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG
GOLD SODIUM THIOMALATE
1 EA BO
NA
GM
50 MG
20
09/08/2003
99/99/9999
51927-2986-00
J3490
BUTORPHANOL TARTRATE (U.S.P.; CIV)
1 EA BO
NA
GM
1 EA
09/08/2003
12/31/2003
51927-2986-00
51927-2994-00
51927-2994-00
51927-3023-00
51927-3098-00
51927-3115-00
51927-3158-00
51927-3163-00
51927-3177-00
51927-3196-00
51927-3213-00
51927-3256-00
51927-3256-00
51927-3258-00
51927-3286-00
51927-3287-00
51927-3306-00
51927-3335-00
51927-3370-00
51927-3408-00
J0595
Q4075
J0133
J2780
J3230
J2690
J1840
J1000
J2010
J7516
J3490
J3490
J1457
J2460
J1644
J1212
J1835
J2310
J3302
J3490
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 ML
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
JR
BO
BO
JR
JR
BO
JR
NA
BO
BO
BO
BO
BO
JR
BO
JR
JR
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
ML
GM
GM
GM
GM
1 MG
5 MG
5 MG
25 MG
50 MG
1 GM
500 MG
5 MG
300 MG
250 MG
1 EA
1 EA
1 MG
50 MG
1000 U
50 %
50 MG
1 MG
5 MG
1 EA
1000
200
200
40
20
1
2
200
3.33333
4
1
1
1000
20
160
0.02
20
1000
200
1
01/01/2004
10/01/2003
01/01/2006
09/08/2003
09/08/2003
09/08/2003
09/08/2003
09/08/2003
09/08/2003
09/08/2003
01/03/2005
12/04/2003
01/01/2005
09/08/2003
09/08/2003
12/04/2003
09/08/2003
09/08/2003
09/08/2003
09/08/2003
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
51927-3422-00
51927-3484-00
J0636
J2725
BUTORPHANOL TARTRATE (U.S.P.; CIV)

ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
CYCLOSPORIN A (USP)
SUFENTANIL CITRATE (U.S.P)
GALLIUM NITRATE (HYDRATE (III))
GALLIUM NITRATE (HYDRATE (III))
HEPARIN SODIUM (USP)
DIMETHYL SULFOXIDE
ITRACONAZOLE MICRONIZED
FAMOTIDINE (U.S.P.)
CALCITRIOL IN ALMOND OIL (NF) 1
MCG/ML
PROTIRELIN
1 ML BO
1 EA BO
NA
NA
ML
GM
0.1 MCG
250 MCG
10
4000
09/08/2003
09/08/2003
99/99/9999
99/99/9999
99/99/9999
1/1/2004
10/1/2003
1/1/2006
9/8/2003
9/8/2003
9/8/2003
9/8/2003
9/8/2003
9/8/2003
9/8/2003
1/3/2005
12/4/2003
1/1/2005
9/8/2003
9/8/2003
12/4/2003
9/8/2003
9/8/2003
9/8/2003
9/8/2003

99/99/9999 INJECTION, GALLIUM NITRATE, 1 MG
99/99/9999 INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG
51927-3489-00
Q0165

9/8/2003 99/99/9999 INJECTION, PROTIRELIN, PER 250 MCG
PROCHLORPERAZINE MESYLATE (BP)
1 EA BO
NA
GM
10 MG
100
09/08/2003
51927-3514-00
J2321
NANDROLONE DECANOATE (U.S.P.; CIII)
1 EA BO
NA
GM
100 MG
10
09/08/2003
99/99/9999
51927-3530-00
J2675
1 EA JR
NA
GM
50 MG
20
09/08/2003
99/99/9999
51927-3536-00
51927-3548-00
J0330
J3490

1 EA BO
1 EA BO
NA
NA
GM
GM
20 MG
1 EA
50
1
09/08/2003
09/08/2003
99/99/9999
99/99/9999
51927-3552-00
51927-3557-00
51927-3557-00
51927-3572-00
51927-3613-00
J2930
J7508
J7507
J3250
J2515
9/8/2003
9/8/2003
1/1/2004
9/8/2003
3/26/2004
1 EA
1 EA
1 EA
1 EA
1 EA
BO
JR
JR
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
125 MG
5 MG
1 MG
200 MG
50 MG
8
200
1000
5
20
09/08/2003
09/08/2003
01/01/2004
09/08/2003
03/26/2004
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
51927-3634-00
51927-3642-00
J3490
J9290

8/19/2004 99/99/9999 MITOMYCIN, 20 MG

(DIHYDRATE; BP)
NALTREXONE
SUCCINATE (BUFFERED)
TACROLIMUS
TACROLIMUS
CIPROFLOXACIN HYDROCHLORIDE
(USP)
MITOMYCIN (USP)
1 EA BO
1 EA BO
NA
NA
GM
GM
1 EA
20 MG
1
50
01/04/2008
08/19/2004
99/99/9999
99/99/9999
51927-3643-00
J7699
GM
1 EA
08/19/2004
12/31/2005
J7640

FORMOTEROL FUMARATE (DIHYDRATE)
1 EA BO
FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
1/1/2006 99/99/9999 THROUGH DME, UNIT DOSE FORM, 12 MICROGRAMS
1 EA BO
1 EA BO
MICRONIZED (USP)
1 EA BO
1/4/2008
1 EA BO
PROGESTERONE (U.S.P.; WETTABLE
POWDER)
1 EA JR
1 EA JR
100 EA BO
10/14/2002
4 MG
21 EA DP
4 MG
21 EA DP
100 EA BO
100 EA BO
PREDNISONE (U.S.P.) 1 MG
100 EA BO
PREDNISONE (U.S.P.) 1 MG
1000 EA BO
100 EA BO
500 EA BO
1/1/2002
100 EA BO
NA
51927-3643-00
NA
GM
12 MCG
83333.33
01/01/2006
99/99/9999
51927-3643-00 KO J7640
51927-3747-00
51927-3760-00
J1094
J0282
51927-9017-00
51927-9018-00
51991-0188-01
J2675
J2550
J7509
51991-0188-21
J7509
51991-0188-31
J7509
51991-0196-01
Q0164
51991-0197-01
51991-0458-01
51991-0458-10
51991-0462-01
51991-0462-05
Q0165
J7506
J7506
J7506
J7506
51991-0625-01
Q0173
KO

Page 220 of 374
NA
GM
12 MCG
83333.33
01/01/2006
99/99/9999
NA
NA
GM
GM
1 MG
30 MG
1000
33.33333
03/11/2005
01/04/2008
99/99/9999
07/01/2008
NA
NA
PO
GM
GM
EA
50 MG
50 MG
4 MG
20
20
1
09/08/2003
09/08/2003
03/10/2003
99/99/9999
99/99/9999
99/99/9999
PO
EA
4 MG
10/14/2002
09/01/2005
PO
EA
4 MG
11/05/2003
99/99/9999
PO
EA
5 MG
10/23/2002
99/99/9999
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
10 MG
5 MG
5 MG
5 MG
5 MG
1
0.2
0.2
4
4
10/23/2002
01/16/2006
01/16/2006
04/13/2006
04/13/2006
99/99/9999
99/99/9999
99/99/9999
11/01/2006
11/01/2006
PO
EA
250 MG
01/01/2002
01/08/2007
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
52152-0166-02
Q0173
1/1/2002
52152-0185-02
Q0173
8/22/2003
52152-0538-30
Q0179
6/25/2007
52152-0539-30
Q0179
6/25/2007
52297-0268-67
Q0163
1/1/2002
52297-0379-26
Q0163
1/1/2002
52297-0462-62
Q0163
1/1/2002
52297-0521-62
Q0163
1/1/2002
52297-0940-26
Q0163
1/1/2002
52297-0941-34
Q0163
1/1/2002
52297-0948-10
52544-0153-02
Q0163
J3315
1/1/2002
12/30/2004
52544-0153-76
52544-0154-02
J3315
J3315
4/1/2005
12/30/2004
52544-0154-76
52544-0335-01
52544-0336-01
52544-0520-16
52544-0520-38
52544-0790-01
J3315
J8499
J8499
J7510
J7510
J7509
4/1/2005
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
52544-0790-21
52544-0797-01
J7509
J7506
1/1/2002
1/1/2002
52544-0800-01
Q0177
1/1/2002
52544-0800-05
Q0177
1/1/2002
52544-0801-01
Q0178
1/1/2002
52544-0801-05
52544-0830-10
52544-0831-10
52544-0832-01
52544-0832-05
Q0178
J7506
J7506
J7506
J7506
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
52544-0922-26
52604-1445-01
J2916
J3490
1/2/2003
1/1/2002

100 EA BO
100 EA BO
(FILM-COATED) 4 MG
30 EA BO
(FILM-COATED) 8 MG
30 EA BO
DIPHEDRYL 25 MG
48 EA BX
DIPHEDRYL CHILDREN'S (AF,CHERRY)
12.5 MG/5 ML
118 ML BO
DIPHEDRYL 25 MG
24 EA BX
DIPHEDRYL 25 MG
24 EA BX
DIPHEDRYL CLEAR ALLERGY RELIEF
118 ML BO
DIPHEDRYL ALLERGY (AF,CHERRY) 12.5
MG/5 ML
236 ML EA
DIPHEDRYL ALLERGY 25 MG
100 EA BO
TRELSTAR DEPOT (SDV) 3.75 MG
1 EA VL
TRELSTAR DEPOT (SDV, CLIP N JECT)
3.75 MG
1 EA VL
TRELSTAR LA (SDV) 11.25 MG
1 EA VL
TRELSTAR LA (SDV, CLIP N JECT) 11.25
MG
1 EA VL
ACYCLOVIR 400 MG
100 EA NA
ACYCLOVIR 800 MG
100 EA BO
473 ML BO
236 ML BO
100 EA BO
4 MG
21 EA DP
PREDNISONE 50 MG
100 EA BO
100 EA BO
500 EA BO
100 EA BO
500 EA BO
PREDNISONE 5 MG
1000 EA BO
PREDNISONE 10 MG
1000 EA BO
PREDNISONE 20 MG
100 EA BO
PREDNISONE 20 MG
500 EA BO
INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 FERRLECIT (SINGLE USE AMP) 62.5
99/99/9999 MG
MG/5 ML
5 ML AM
BREVITAL SODIUM (VIAL) 5 GM
1 EA VL
Page 221 of 374
PO
EA
250 MG
01/01/2002
99/99/9999
PO
EA
250 MG
1.2
08/22/2003
99/99/9999
PO
EA
8 MG
0.5
06/25/2007
99/99/9999
PO
EA
8 MG
06/25/2007
99/99/9999
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
PO
ML
50 MG
0.05
01/01/2002
01/31/2002
PO
ML
50 MG
0.05
01/01/2002
02/01/2002
PO
IM
EA
EA
50 MG
3.75 MG
0.5
1
01/01/2002
12/30/2004
99/99/9999
99/99/9999
IM
IM
EA
EA
3.75 MG
3.75 MG
1
3
04/01/2005
12/30/2004
6/23/2008
99/99/9999
IM
PO
PO
PO
PO
PO
EA
EA
EA
ML
ML
EA
3.75 MG
1 EA
1 EA
5 MG
5 MG
4 MG
3
1
1
0.6
0.6
1
04/01/2005
01/01/2002
01/01/2002
05/15/2003
01/01/2002
01/01/2002
6/23/2008
10/21/2003
07/01/2003
04/12/2004
10/01/2002
08/15/2002
PO
PO
EA
EA
4 MG
5 MG
1
10
01/01/2002
01/01/2002
07/21/2002
10/01/2002
PO
EA
25 MG
01/01/2002
10/01/2002
PO
EA
25 MG
01/01/2002
10/01/2002
PO
EA
50 MG
01/01/2002
07/16/2002
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
1
1
2
4
4
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/04/2002
10/01/2002
10/01/2002
10/01/2002
10/01/2002
IV
IV
ML
EA
12.5 MG
1 EA
1
1
01/02/2003
01/01/2002
99/99/9999
01/09/2003
1/1/2002
10/1/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.6
52604-1446-01
J3490
1/1/2002
52604-1446-05
52604-1448-05
J3490
J3490
1/1/2002
1/1/2002

52604-1465-01
52637-0010-10
J3490
J1940
1/1/2002
1/1/2002

52637-0126-10
52637-0282-10
52637-0312-30
52637-0313-10
52637-0325-10
52637-0332-10
J0725
J3420
J3420
J1435
J2650
J1000
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

52637-0540-05
52637-0756-05
J3301
J1030
1/1/2002
1/1/2002

52637-0926-10
J0945
1/1/2002
52735-0402-41
Q0163
6/18/2003
52735-0404-01
Q0163
6/18/2003
52735-0404-05
Q0163
6/18/2003
52735-0427-05
52769-0268-66
52769-0269-72
Q0163
J1563
J1563
6/18/2003
1/1/2002
1/1/2002

52769-0417-06
Q9941
4/1/2005
52769-0417-06
J1566
1/1/2006
52769-0417-12
J1563
9/1/2003
52769-0418-12
Q9941
4/1/2005
52769-0418-12
J1566
1/1/2006
52769-0460-01
J7190
1/1/2002
52769-0464-02
J7192
5/1/2004
52769-0464-05
52769-0464-10
52769-0470-72
J7192
J7192
Q9942
BREVITAL SODIUM (M.D.V.) 500 MG

BREVITAL SODIUM (M.D.V.,TRAYPACK)
500 MG
BREVITAL SODIUM (VIAL) 2.5 GM
BREVITAL SODIUM (M.D.V. W/DILUENT)
500 MG
CHORIONIC GONADOTROPIN (M.D.V.)
10000 U
VITAMIN B12 (M.D.V.) 1000 MCG/ML
VITAMIN B12 (M.D.V.) 1000 MCG/ML
ESTRO-A (M.D.V.) 2 MG/ML
PRED-JECT-50 (M.D.V.) 50 MG/ML
ESTRO-L.A. (M.D.V.) 5 MG/ML
TRIAMCINOLONE ACETONIDE (M.D.V.)
40 MG/ML
MED-JEC-40 (M.D.V.) 40 MG/ML
BROMPHENIRAMINE MALEATE (M.D.V.)
10 MG/ML
1 EA VL
IV
EA
1 EA
01/01/2002
01/08/2003
1 EA VL
1 EA VL
IV
IV
EA
EA
1 EA
1 EA
1
1
01/01/2002
01/01/2002
01/08/2003
01/08/2003
1 EA VL
2 ML VL
IV
IJ
EA
ML
1 EA
20 MG
1
0.5
01/01/2002
01/01/2002
01/09/2003
8/27/2008
IM
IM
IM
IM
IJ
IM
EA
ML
ML
ML
ML
ML
10
1
1
2
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
8/27/2008
8/27/2008
8/27/2008
8/27/2008
8/27/2008
01/01/2006
5 ML VL
5 ML VL
IJ
IJ
ML
ML
10 MG
40 MG
4
1
01/01/2002
01/01/2002
02/27/2002
01/29/2002
10 ML VL
IJ
ML
10 MG
01/01/2002
03/01/2003
1 EA
10 ML
30 ML
10 ML
30 ML
10 ML
VL
VL
VL
VL
VL
VL
1000 USP Units

1000 MCG
1000 MCG
1 MG
1 ML
5 MG
ALLERGY RELIEF MEDICINE 12.5 MG/5

ML
120 ML BO
PO
ML
50 MG
0.05
06/18/2003
06/23/2005
FAMILY PHARMACY ALLERGY 25 MG
100 EA BO
PO
EA
50 MG
0.5
06/18/2003
99/99/9999
24 EA BX
PO
EA
50 MG
0.5
06/18/2003
04/18/2004
24 EA BX
1 EA VL
1 EA VL
PO
IV
IV
EA
EA
EA
50 MG
1 GM
1 GM
0.5
6
12
06/18/2003
01/01/2002
01/01/2002
06/16/2005
06/17/2003
06/08/2003
ALLERGY RELIEF MEDICINE 25 MG

PANGLOBULIN (IGIV) 6 GM
PANGLOBULIN (IGIV) 12 GM
PANGLOBULIN NF
(S.D.V.,PF,NANOFILTERED) 6 GM
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT PANGLOBULIN NF
PANGLOBULIN NF
PANGLOBULIN NF
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT PANGLOBULIN NF
MONARC-M (APPROX 220-2000 IU/VIAL)
1 IU
GENARC (APPROX. 250 IU/VIAL,LOW) 1
IU
1 EA VL
IV
EA
1 GM
04/01/2005
12/31/2005
1 EA VL
IV
EA
500 MG
12
01/01/2006
99/99/9999
1 EA VL
IV
EA
1 GM
12
09/01/2003
09/01/2003
1 EA VL
IV
EA
1 GM
12
04/01/2005
12/31/2005
1 EA VL
IV
EA
500 MG
24
01/01/2006
99/99/9999
1100 IU
VL
IV
EA
1 IU
01/01/2002
99/99/9999
250 IU
VL
IV
EA
1 IU
05/01/2004
12/31/2004
GENARC (APPROX. 500 IU/VIAL,MID) 1 IU 500 IU VL

GENARC (APPROX.1000 IU/VIAL) 1 IU
1000 IU VL
POLYGAM (W/50 ML DILUENT) 2.5 MG
1 EA NA
IV
IV
IV
EA
EA
EA
1 IU
1 IU
10 MG
1
1
0.25
05/01/2004
05/01/2004
04/01/2005
12/31/2004
12/31/2004
12/31/2005
1 EA NA
IV
EA
500 MG
0.005
01/01/2006
99/99/9999
1 EA VL
IV
EA
1 GM
2.5
01/01/2002
03/31/2005
06/30/2005
52769-0470-72
J1566
5/1/2004 12/31/2004 FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.

4/1/2005 12/31/2005 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED, 10 MG
52769-0471-72
J1563
1/1/2002
52769-0471-72
Q9941
4/1/2005
POLYGAM (W/50 ML DILUENT) 2.5 MG

GM
GM
1 EA VL
IV
EA
1 GM
2.5
04/01/2005
52769-0471-75
J1563
1/1/2002
1 EA VL
IV
EA
1 GM
01/01/2002
03/31/2005
52769-0471-75
Q9941
4/1/2005

POLYGAM S/D (S.D.V. W/DILUENT) 10
GM
POLYGAM S/D (S.D.V. W/DILUENT) 10
GM
1 EA VL
IV
EA
1 GM
04/01/2005
06/30/2005
1 EA VL
IV
EA
1 GM
10
01/01/2002
03/31/2005
1 EA VL
IV
EA
1 GM
10
04/01/2005
06/30/2005
10 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
15 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
30 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
52769-0471-80
J1563
1/1/2002
52769-0471-80
Q9941
4/1/2005
52959-0007-10
G9017
12/1/2004
52959-0007-14
G9017
12/1/2004
52959-0007-15
G9017
12/1/2004
52959-0007-20
G9017
12/1/2004
52959-0007-30
G9017
12/1/2004

Page 222 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

52959-0043-00
Q0163
6/17/2003
52959-0043-04
Q0163
1/1/2002
52959-0043-10
Q0163
1/1/2002
52959-0043-15
Q0163
1/1/2002
52959-0043-20
Q0163
1/1/2002
52959-0043-24
Q0163
5/12/2003
52959-0043-30
Q0163
1/1/2002
52959-0043-50
Q0163
1/1/2002
52959-0043-60
Q0163
1/1/2002
52959-0053-06
Q0163
1/1/2002
52959-0053-10
Q0163
1/1/2002
52959-0053-12
Q0163
1/1/2002
52959-0053-15
Q0163
1/1/2002
52959-0053-20
Q0163
1/1/2002
52959-0053-30
Q0163
1/1/2002
52959-0053-52
52959-0079-00
Q0163
J7500
1/24/2005
1/1/2002
52959-0100-00
J7509
52959-0123-03
Q0163
52959-0123-06
52959-0126-00
52959-0126-05
52959-0126-07
52959-0126-10
52959-0126-12
52959-0126-15
Q0163
J7506
J7506
J7506
J7506
J7506
J7506

100 EA BO
PO
EA
50 MG
0.5
06/17/2003
99/99/9999
4 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
10 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
15 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA BO
PO
EA
50 MG
0.5
05/12/2003
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
50 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
60 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
6 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
10 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
12 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
IMURAN 50 MG
4 MG
52 EA BO
100 EA BO
PO
PO
EA
EA
50 MG
50 MG
1
1
01/24/2005
01/01/2002
99/99/9999
99/99/9999
21 EA DP
PO
EA
4 MG
01/01/2002
99/99/9999
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999

PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
180 ML
100 EA
5 EA
7 EA
10 EA
12 EA
15 EA
PO
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
0.05
2
2
2
2
2
2
01/01/2002
01/01/2002
11/06/2002
11/06/2002
08/19/2003
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 223 of 374
BO
BO
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/15/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
7/18/2007
1/1/2002
1/1/2002
3/1/2004
9/19/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
6/18/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
52959-0134-04
Q0170
1/1/2002
52959-0134-08
Q0170
1/1/2002
52959-0158-06
J7669
1/1/2002
52959-0158-06 KO J7669
52959-0179-06
J2360
52959-0220-00
J7506
52959-0220-10
J7506
52959-0220-20
J7506
52959-0220-21
J7506
52959-0220-30
J7506
52959-0220-36
J7506
52959-0220-40
J7506
52959-0220-60
J7506
52959-0220-75
J7506
KO
1/1/2002
1/1/2002
1/1/2002
8/19/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
52959-0226-10
Q0173
52959-0226-12
Q0173
1/1/2002
52959-0237-12
K0416
3/14/2004
52959-0237-12
52959-0244-00
J8498
None
1/1/2006
10/2/2000
52959-0291-00
52959-0291-00
52959-0313-15
52959-0330-00
52959-0330-25
52959-0330-50
K0416
J8498
Q0144
J8499
J8499
J8499
1/1/2002
1/1/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
52959-0355-06
52959-0355-06
K0416
J8498
1/1/2002
1/1/2006
52959-0355-12
52959-0355-12
K0416
J8498
1/1/2002
1/1/2006
52959-0391-15
52959-0392-12
52959-0392-21
52959-0392-28
Q0165
J8540
J8540
J8540
1/1/2002
1/1/2006
1/1/2006
1/1/2006
1/1/2002
Page 224 of 374
01/15/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
07/18/2007
01/01/2002
01/01/2002
03/01/2004
09/19/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/18/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
ML
25 MG
0.05
01/01/2002
12/02/2004
ML
25 MG
0.05
01/01/2002
12/02/2004
2.5 ML AM IH
ML
10 MG
0.6
01/01/2002
99/99/9999
2.5 ML
2 ML
100 EA
10 EA
20 EA
21 EA
30 EA
36 EA
40 EA
60 EA
75 EA
AM
AM
BO
BO
BO
BO
BO
BO
BO
BO
BO
IH
IJ
PO
PO
PO
PO
PO
PO
PO
PO
PO
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
10 MG
60 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
0.6
0.5
1
1
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
08/19/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 EA BO
PO
EA
250 MG
01/01/2002
02/11/2002
12 EA BO
PO
EA
250 MG
01/01/2002
02/11/2002
12 EA BX
RC
EA
1 MG
25
03/14/2004
12/31/2005
12 EA BX
100 EA BO
RC
PO
EA
EA
1 EA
2.5 MG
1
1
01/01/2006
10/02/2000
99/99/9999
99/99/9999
12 EA
12 EA
15 ML
100 EA
25 EA
50 EA
BX
BX
BO
BO
BO
BO
RC
RC
PO
PO
PO
PO
EA
EA
ML
EA
EA
EA
1 MG
1 EA
1 GM
1 EA
1 EA
1 EA
25
1
0.02
1
1
1
01/01/2002
01/01/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
6 EA BX
6 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
15 EA
12 EA
21 EA
28 EA
PO
PO
PO
PO
EA
EA
EA
EA
10 MG
0.25 MG
0.25 MG
0.25 MG
1
3
3
3
01/01/2002
01/01/2006
01/01/2006
01/01/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
BO
BO
DP
BO
Prior End Date #3
Prior Start Date #3
PO
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
4
4
4
4
Prior End Date #2
240 ML BO
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
Prior Start Date #2
PO
End Date #1
120 ML BO
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Start Date #1
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
CF
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
HCPCS Measure #1
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
18 EA
20 EA
21 EA
25 EA
30 EA
37 EA
40 EA
42 EA
44 EA
45 EA
50 EA
60 EA
100 EA
7 EA
10 EA
12 EA
15 EA
18 EA
20 EA
21 EA
25 EA
30 EA
37 EA
42 EA
HCPCS Amount #1

Package
NDC Label
HCPCS Description

PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
MG/5 ML
MG/5 ML
ALUPENT (VIAL) 0.6%
ALUPENT (VIAL) 0.6%
NORFLEX 30 MG/ML
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
TIGAN 250 MG
TIGAN 250 MG
PRESCRIPTION ANTIEMETIC DRUG, RECTAL, PER 1 MG, FOR USE IN CONJUCTION PROMETHAZINE HYDROCHLORIDE 25
MG
MG
COMPAZINE 25 MG
COMPAZINE 25 MG
ZOVIRAX 200 MG
ZOVIRAX 200 MG
ZOVIRAX 200 MG
COMPAZINE 10 MG
NDC Package Type
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
NDC Package Measure
52959-0126-18
52959-0126-20
52959-0126-21
52959-0126-25
52959-0126-30
52959-0126-37
52959-0126-40
52959-0126-42
52959-0126-44
52959-0126-45
52959-0126-50
52959-0126-60
52959-0127-00
52959-0127-07
52959-0127-10
52959-0127-12
52959-0127-15
52959-0127-18
52959-0127-20
52959-0127-21
52959-0127-25
52959-0127-30
52959-0127-37
52959-0127-42
HCPCS Mod
HCPCS
NDC Mod
NDC
52959-0433-10
Q0177
6/6/2002
52959-0433-15
Q0177
2/28/2002
52959-0433-20
Q0177
12/27/2004
52959-0433-30
Q0177
10/17/2002
52959-0433-40
Q0177
1/1/2002
52959-0433-60
Q0177
12/27/2004
52959-0476-02
Q0165
8/9/2005
52959-0476-10
Q0165
1/1/2002
52959-0476-15
Q0165
1/1/2002
52959-0476-20
Q0165
1/1/2002
52959-0476-24
Q0165
10/27/2004
52959-0476-30
Q0165
11/22/2004
52959-0476-60
Q0165
11/22/2004
52959-0479-10
Q0173
1/1/2002
52959-0479-12
Q0173
1/1/2002
52959-0479-20
Q0173
1/1/2002
52959-0479-30
Q0173
1/1/2002
52959-0490-10
G9036
12/1/2004
52959-0490-14
G9036
12/1/2004
52959-0490-20
52959-0505-06
52959-0517-25
52959-0517-30
52959-0517-35
52959-0544-01
52959-0544-10
52959-0544-12
G9036
Q0144
J8499
J8499
J8499
J8499
J8499
J8499
12/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
FLUMADINE 100 MG
FLUMADINE 100 MG
FLUMADINE 100 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
Page 225 of 374
10 EA BO
PO
EA
25 MG
06/06/2002
99/99/9999
15 EA BO
PO
EA
25 MG
02/28/2002
99/99/9999
20 EA BO
PO
EA
25 MG
12/27/2004
99/99/9999
30 EA BO
PO
EA
25 MG
10/17/2002
99/99/9999
40 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
60 EA BO
PO
EA
25 MG
12/27/2004
99/99/9999
120 EA BO
PO
EA
10 MG
08/09/2005
99/99/9999
10 EA BO
PO
EA
10 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
10 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
10 MG
01/01/2002
99/99/9999
24 EA BO
PO
EA
10 MG
10/27/2004
99/99/9999
30 EA BO
PO
EA
10 MG
11/22/2004
99/99/9999
60 EA BO
PO
EA
10 MG
11/22/2004
99/99/9999
10 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
12 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
10 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
100 MG
1 GM
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
0.25
1
1
1
1
1
1
12/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 EA
6 EA
25 EA
30 EA
35 EA
100 EA
10 EA
12 EA
BO
DP
BO
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002
1/1/2002
1/1/2002
1/1/2002
8/24/2007
1/1/2002
5/16/2007
52959-0547-10
52959-0547-10
Q0181
J8540
1/1/2002
1/1/2006
52959-0547-11
52959-0547-11
Q0181
J8540
1/1/2002
1/1/2006
52959-0547-12
52959-0547-12
Q0181
J8540
1/1/2002
1/1/2006
52959-0547-16
52959-0547-16
Q0181
J8540
1/1/2002
1/1/2006
52959-0547-20
52959-0547-20
Q0181
J8540
1/1/2002
1/1/2006
52959-0547-30
52959-0547-30
Q0181
J8540
1/1/2002
1/1/2006
52959-0547-50
52959-0547-50
Q0181
J8540
1/1/2002
1/1/2006
52959-0561-01
52959-0561-01
K0416
J8498
1/1/2002
1/1/2006
52959-0561-04
52959-0561-04
K0416
J8498
4/4/2003
1/1/2006
52959-0562-01
52959-0562-01
K0416
J8498
1/1/2002
1/1/2006
52959-0562-06
52959-0562-06
K0416
J8498
1/1/2002
1/1/2006
52959-0622-60
52959-0650-01
52959-0657-03
52959-0657-06
52959-0678-30
J7510
J7506
Q0144
Q0144
J8499
1/1/2002
1/1/2002
1/1/2002
1/1/2006
10/7/2003
52959-0741-20
J7602
1/1/2008
52959-0741-20
52959-0748-01
J7611
J8501
4/1/2008
8/22/2007
52959-0801-10
G9035
2/23/2005
52959-0804-04
Q0170
1/1/2002
52959-0804-08
Q0170
1/1/2002
52959-0817-10
Q0173
10/4/2005

PREDNISONE 1 MG
ACYCLOVIR 800 MG
EMEND 40 MG
TAMIFLU 75 MG
Page 226 of 374
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
11 EA BO
11 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
12 EA BO
12 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
16 EA BO
16 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
20 EA BO
20 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
30 EA BO
30 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
50 EA BO
50 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
4 EA BX
4 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
04/04/2003
01/01/2006
12/31/2005
99/99/9999
12 EA NA
12 EA NA
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
6 EA NA
6 EA NA
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
PO
PO
PO
PO
PO
ML
EA
ML
ML
EA
5 MG
5 MG
1 GM
1 GM
1 EA
0.6
0.2
0.04
0.04
1
01/01/2002
01/01/2002
01/01/2002
01/01/2006
10/07/2003
99/99/9999
09/25/2002
99/99/9999
99/99/9999
99/99/9999
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML BO
1 EA BO
IH
PO
ML
EA
1 MG
5 MG
5
8
04/01/2008
08/22/2007
99/99/9999
99/99/9999
10 EA BO
PO
EA
75 MG
02/23/2005
05/31/2005
120 ML BO
PO
ML
25 MG
0.05
01/01/2002
99/99/9999
240 ML BO
PO
ML
25 MG
0.05
01/01/2002
99/99/9999
10 EA BO
PO
EA
250 MG
1.2
10/04/2005
99/99/9999
480 ML
200 EA
15 ML
22.5 ML
30 EA
BO
NA
BO
BO
BO
CF
HCPCS Amount #1
10 EA BO
10 EA BO
Prior End Date #3
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/24/2007
01/01/2002
05/16/2007
1
1
1
1
1
1
16
Prior End Date #2
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
0.25 MG
End Date #1
EA
EA
EA
EA
EA
EA
EA
Start Date #1
PO
PO
PO
PO
PO
PO
PO
HCPCS Measure #1
BO
BO
BO
BO
BO
BO
BO
Billing Units
15 EA
21 EA
25 EA
30 EA
40 EA
50 EA
4 EA
Prior Start Date #2

Package
NDC Label
HCPCS Description

ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 25 MG
PHENERGAN 25 MG
PHENERGAN 25 MG
PHENERGAN 25 MG
NDC Package Type
J8499
J8499
J8499
J8499
J8499
J8499
J8540
NDC Package Measure
52959-0544-15
52959-0544-21
52959-0544-25
52959-0544-30
52959-0544-40
52959-0544-50
52959-0547-04
HCPCS Mod
HCPCS
NDC Mod
NDC
52959-0833-06
Q0178
10/14/2005
52959-0833-20
52959-0838-06
Q0178
Q0144
10/14/2005
11/22/2005
11/26/2007
AZITHROMYCIN 250 MG
52959-0914-30
Q0169
52959-0927-03
52959-0928-30
Q0144
J8999

52959-0932-30
Q0144
53014-0216-04
J9357
1/1/2002
6/30/2004 INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG
53014-0216-24
J9357
1/1/2002
6/30/2004 INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG
53014-0250-01
J7510
53100-0128-22
Q0163
53100-0128-32
Q0163
53100-0128-51
Q0163
53100-0128-70
Q0163
53100-0128-75
Q0163
53100-0128-80
Q0163
53100-1282-20
Q0163
53100-1283-20
Q0163
53100-1285-10
Q0163
53100-1287-00
Q0163
53100-1287-50
Q0163
53100-1288-00
53191-0161-01
53191-0161-05
Q0163
J3350
J3350

53265-0243-12
K0416
53265-0244-12
K0416
53265-0245-12
K0416

AZITHROMYCIN (1X30ML,CHERRY) 200
MG/5 ML
VALSTAR (SINGLE USE VIAL,PF) 40
MG/ML
VALSTAR (SINGLE USE VIAL,PF) 40
MG/ML
PEDIAPRED (SF,DYEFREE,RASPBERRY) 5 MG/5 ML
6 EA BO
PO
EA
50 MG
10/14/2005
99/99/9999
20 EA BO
6 EA BO
PO
PO
EA
EA
50 MG
1 GM
1
0.25
10/14/2005
11/22/2005
99/99/9999
99/99/9999
30 EA BO
PO
EA
12.5 MG
11/26/2007
99/99/9999
3 EA BO
30 EA NA
PO
PO
EA
EA
1 GM
1 EA
0.5
1
04/24/2008
05/15/2008
99/99/9999
99/99/9999
30 ML BO
5 ML VL
5 ML VL
PO
ML
1 GM
0.04
05/23/2008
99/99/9999
IL
ML
200 MG
0.2
01/01/2002
06/30/2004
IL
ML
200 MG
0.2
01/01/2002
06/30/2004
120 ML BO
PO
ML
5 MG
0.2
01/01/2002
99/99/9999
SOMINEX 25 MG
16 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
SOMINEX 25 MG
32 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
SOMINEX 25 MG
72 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
SOMINEX 50 MG
8 EA NA
PO
EA
50 MG
01/01/2002
03/11/2003
SOMINEX 50 MG
16 EA NA
PO
EA
50 MG
01/01/2002
99/99/9999
SOMINEX 50 MG
32 EA NA
PO
EA
50 MG
01/01/2002
10/01/2002
SOMINEX 25 MG
16 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
SOMINEX 25 MG
32 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
SOMINEX 25 MG
72 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
SOMINEX 50 MG
8 EA NA
PO
EA
50 MG
01/01/2002
99/99/9999
SOMINEX 50 MG
16 EA NA
PO
EA
50 MG
01/01/2002
99/99/9999
SOMINEX 50 MG
UREA (U.S.P.)
UREA (U.S.P.)
32 EA NA
1 EA CN
1 EA JR
PO
NA
NA
EA
GM
GM
50 MG
40 GM
40 GM
1
0.025
0.025
Prior End Date #3
Prior Start Date #3
Prior End Date #2
01/01/2002 99/99/9999
01/01/2002 12/31/2008
01/01/2002 99/99/9999
PROCHLORPERAZINE 2.5 MG
12 EA BX
RC
EA
1 MG
2.5
01/01/2002
05/23/2005
12 EA BX
RC
EA
1 MG
01/01/2002
05/23/2005
12 EA BX
RC
EA
1 MG
25
01/01/2002
05/23/2005
Page 227 of 374
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
53265-0301-01
J2680
1/1/2002
53265-0405-10
Q0169
7/1/2004
53265-0406-10
Q0170
7/1/2004
53265-0406-11
Q0170
7/1/2004
53265-0407-10
53265-0444-51
53265-0444-56
Q0170
J1631
J1631
7/1/2004
1/1/2002
1/1/2002
53265-0544-51
J1631
1/1/2002
53265-0544-56
J1631
1/1/2002
53265-0762-12
K0416
4/11/2003
53265-0763-12
K0416
4/11/2003
53265-0764-12
53298-0101-06
53298-0101-06
K0416
A4712
A4216
3/1/2003
1/1/2002
1/1/2004

FLUPHENAZINE DECANOATE 25 MG/ML
HALOPERIDOL DECANOATE 50 MG/ML
53409-0003-06
J3140
11/13/2002
53409-0003-08
J3140
11/13/2002
53409-0003-15
J3140
11/13/2002
53409-0013-06
J1070
11/13/2002
53409-0013-08
53409-1200-07
53409-1200-08
J1070
J2675
J2675
11/13/2002
11/13/2002
11/13/2002

53409-1210-08
J2675
11/13/2002
53409-1220-07
53409-1220-08
53409-1300-05
53409-1300-06
53409-1300-08
53489-0138-01
53489-0138-10
53489-0139-01
53489-0139-05
53489-0139-10
53489-0140-01
53489-0140-05
53489-0140-10
J2675
J2675
J1435
J1435
J1435
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
11/13/2002
11/13/2002
11/13/2002
11/13/2002
11/13/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
53489-0293-01
Q0173
1/1/2002
53489-0376-01
Q0173
8/29/2003
53489-0376-05
Q0173
8/29/2003
53905-0065-01
J7682
1/1/2002
53905-0065-01 KO J7682
53905-0065-04
J7682
KO
1/1/2002
6/17/2005

5 ML VL
IJ
ML
25 MG
01/01/2002
06/05/2002
100 EA BO
PO
EA
12.5 MG
07/01/2004
05/23/2005
100 EA BO
PO
EA
25 MG
07/01/2004
05/23/2005
1000 EA BO
PO
EA
25 MG
07/01/2004
05/23/2005
100 EA BO
1 ML VL
5 ML VL
PO
IM
IM
EA
ML
ML
25 MG
50 MG
50 MG
2
1
1
07/01/2004
01/01/2002
01/01/2002
05/23/2005
06/05/2002
06/05/2002
1 ML VL
IM
ML
50 MG
01/01/2002
06/05/2002
5 ML VL
IM
ML
50 MG
01/01/2002
06/05/2002
12 EA BX
RC
EA
1 MG
12.5
04/11/2003
05/23/2005
12 EA BX
RC
EA
1 MG
25
04/11/2003
05/23/2005
HSA STERILE DILUENT (VIAL)
HSA STERILE DILUENT (VIAL)
TESTOSTERONE MICRONIZED (BULK
FOR COMPOUNDING)
FOR COMPOUNDING)
FOR COMPOUNDING)
TESTOSTERONE CYPIONATE (BULK
FOR COMPOUNDING)
TESTOSTERONE CYPIONATE (BULK
FOR COMPOUNDING)
PROGESTERONE
(WETTABLE,MICRONIZED)
PROGESTERONE (BULK FOR
COMPOUNDING)
PROGESTERONE (USP)
ESTRONE (BULK FOR COMPOUNDING)
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
12 EA BX
1.8 ML VL
1.8 ML VL
RC
IV
IV
EA
ML
ML
1 MG
10 ML
10 ML
50
0.1
0.1
03/01/2003
01/01/2002
01/01/2004
05/23/2005
12/31/2003
01/07/2007
1 EA NA
NA
GM
50 MG
20
11/13/2002
02/01/2003
1 EA NA
NA
GM
50 MG
20
11/13/2002
02/01/2003
1 EA NA
NA
GM
50 MG
20
11/13/2002
02/01/2003
1 EA NA
NA
GM
100 MG
10
11/13/2002
02/01/2003
1 EA NA
1 EA BO
1 EA NA
NA
NA
NA
GM
GM
GM
100 MG
50 MG
50 MG
10
20
20
11/13/2002
11/13/2002
11/13/2002
02/01/2003
02/01/2003
02/01/2003
1 EA NA
NA
GM
50 MG
20
11/13/2002
02/01/2003
NA
NA
NA
NA
NA
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
PO
PO
PO
PO
PO
PO
PO
PO
GM
GM
GM
GM
GM
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
50 MG
1 MG
1 MG
1 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
20
20
1000
1000
1000
1
1
2
2
2
4
4
4
11/13/2002
11/13/2002
11/13/2002
11/13/2002
11/13/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/01/2003
02/01/2003
02/01/2003
02/01/2003
02/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
250 MG
01/01/2002
04/22/2002
100 EA BO
PO
EA
250 MG
1.2
08/29/2003
99/99/9999
500 EA BO
PO
EA
250 MG
1.2
08/29/2003
08/09/2006
1 EA
1 EA
1 EA
1 EA
1 EA
100 EA
1000 EA
100 EA
500 EA
1000 EA
100 EA
500 EA
1000 EA
TOBI (S.D. AMP,4X14) 60 MG/ML
5 ML PC
IH
ML
300 MG
0.2
01/01/2002
02/25/2008
TOBI (S.D. AMP,4X14) 60 MG/ML
5 ML PC
IH
ML
300 MG
0.2
01/01/2002
02/25/2008
TOBI (SINGLE DOSE AMP) 60 MG/ML
5 ML PC
IH
ML
300 MG
0.2
06/17/2005
08/27/2007
Page 228 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
53905-0065-04 KO J7682
53905-0331-01
J9999
53905-0991-01
J9015
54092-0187-01
54092-0541-20
54092-0700-01
54092-0700-01
54396-0328-16
54396-0328-40
54482-0053-01
54482-0146-09
54482-0147-01
Q0173
J3250
J3490
J1743
J3130
J3130
J8999
J1955
J1955
54569-0048-00
J7631
54569-0048-00 KO J7631
54569-0084-02
G9017
54569-0084-03
54569-0091-00
54569-0091-01
54569-0091-02
G9017
J8499
J8499
J8499
54569-0239-00
Q0163
54569-0239-01
Q0163
54569-0239-02
Q0163
54569-0239-03
Q0163
54569-0239-05
Q0163
54569-0239-06
Q0163
54569-0239-08
Q0163
54569-0241-00
Q0163
54569-0241-02
Q0163
54569-0241-03
Q0163
54569-0241-04
Q0163
54569-0241-05
Q0163
54569-0322-00
54569-0322-00
Q0181
J8540
KO
KO
TOBI (SINGLE DOSE AMP) 60 MG/ML
6/17/2005 8/27/2007 MILLIGRAMS
DEPOCYT (S.D.V.) 10 MG/ML
PROLEUKIN (PF) 22 Million IU
TIGAN 250 MG
1/1/2002
TIGAN (VIAL) 100 MG/ML
ELAPRASE (PF) 2 MG/ML
1/1/2008 99/99/9999 INJECTION, IDURSULFASE, 1 MG
ELAPRASE (PF) 2 MG/ML
DELATESTRYL (UNIMATIC) 200 MG/ML
DELATESTRYL (M.D.V.) 200 MG/ML
MATULANE 50 MG
CARNITOR (S.D. AMP) 200 MG/ML
CARNITOR (S.D.V.) 200 MG/ML
INTAL (VIAL) 10 MG/ML
INTAL (VIAL) 10 MG/ML
ZOVIRAX 200 MG
ZOVIRAX 200 MG
1/1/2002
ZOVIRAX 200 MG
1/1/2002 12/31/2005 REGIMEN
Page 229 of 374
5 ML PC
5 ML VL
1 EA VL
IH
IN
IV
ML
ML
EA
300 MG
1 EA
1 VIAL
0.2
1
1
06/17/2005
01/01/2002
01/01/2002
08/27/2007
04/30/2003
12/11/2007
PO
IM
IV
IV
IM
IM
PO
IV
IV
EA
ML
ML
ML
ML
ML
EA
ML
ML
250 MG
200 MG
1 EA
1 MG
200 MG
200 MG
1 EA
1 GM
1 GM
1
0.5
1
2
1
1
1
0.2
0.2
01/01/2002
01/01/2002
07/25/2006
01/01/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
02/08/2002
01/25/2002
12/31/2007
99/99/9999
10/29/2007
4/26/2009
99/99/9999
06/30/2004
99/99/9999
2 ML AM IH
ML
10 MG
01/01/2002
01/31/2003
2 ML AM IH
ML
10 MG
01/01/2002
01/31/2003
100 EA
20 ML
3 ML
3 ML
1 ML
5 ML
100 EA
5 ML
5 ML
BO
VL
VL
VL
SR
VL
BO
AM
VL
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
10 EA
25 EA
50 EA
35 EA
BO
BO
BO
BO
PO
PO
PO
PO
EA
EA
EA
EA
100 MG
1 EA
1 EA
1 EA
1
1
1
1
12/01/2004
01/01/2002
01/01/2002
01/01/2002
05/31/2005
01/31/2003
01/31/2003
06/01/2002
30 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
15 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
21 EA BO
PO
EA
50 MG
0.5
01/01/2002
01/31/2003
4 EA BO
PO
EA
50 MG
0.5
01/01/2002
05/12/2006
6 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
30 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
6 EA BO
PO
EA
50 MG
01/01/2002
01/16/2004
10 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
12 EA BO
12 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54569-0322-03
54569-0322-03
Q0181
J8540
1/1/2002
1/1/2006
54569-0322-05
Q0181
1/1/2002
54569-0324-02
54569-0324-02
Q0181
J8540
12/27/2004
1/1/2006
54569-0324-04
54569-0324-04
Q0181
J8540
1/1/2002
1/1/2006
54569-0324-06
Q0181
1/1/2002
54569-0324-07
Q0181
1/1/2002
54569-0324-09
54569-0327-00
54569-0330-00
54569-0330-01
54569-0330-02
54569-0330-03
54569-0330-04
54569-0330-05
54569-0330-07
54569-0330-08
54569-0330-09
54569-0331-00
54569-0331-01
54569-0331-02
54569-0331-03
54569-0331-04
54569-0331-05
54569-0331-06
54569-0331-07
54569-0331-08
54569-0331-09
54569-0332-00
54569-0332-01
54569-0332-02
54569-0332-03
54569-0332-04
54569-0332-05
54569-0332-08
54569-0332-09
54569-0333-00
54569-0333-04
Q0181
J7509
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
6/26/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-0336-01
54569-0336-01
Q0181
J8540
1/1/2002
1/1/2006
54569-0336-03
Q0181
1/1/2002
54569-0350-00
Q0164
6/26/2002
54569-0350-01
Q0164
1/1/2002

12/31/2005 REGIMEN
3/10/2005 REGIMEN
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
6/10/2003 REGIMEN
DEXAMETHASONE 4 MG
6/10/2003 REGIMEN
DEXAMETHASONE 4 MG
6/10/2003 REGIMEN
MEDROL (UNIT OF USE) 4 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 50 MG
PREDNISONE 50 MG
DEXAMETHASONE 2 MG
12/31/2005 REGIMEN
DEXAMETHASONE 2 MG
DEXAMETHASONE 2 MG
6/1/2002 REGIMEN
Page 230 of 374
20 EA BO
20 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
7 EA BO
PO
EA
1 EA
01/01/2002
03/10/2005
4 EA BO
4 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
12/27/2004
01/01/2006
12/31/2005
01/18/2006
6 EA BO
6 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
12 EA NA
PO
EA
1 EA
01/01/2002
06/10/2003
8 EA NA
PO
EA
1 EA
01/01/2002
06/10/2003
NA
DP
BO
BO
NA
BO
BO
NA
BO
NA
NA
BO
BO
BO
NA
BO
BO
NA
BO
BO
NA
NA
BO
BO
BO
NA
BO
NA
BO
BO
NA
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
4 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
10
10
06/26/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/10/2003
99/99/9999
99/99/9999
99/99/9999
01/31/2003
99/99/9999
99/99/9999
01/31/2003
99/99/9999
01/31/2003
06/10/2003
99/99/9999
99/99/9999
99/99/9999
06/10/2003
99/99/9999
99/99/9999
06/10/2003
99/99/9999
99/99/9999
06/10/2003
06/10/2003
99/99/9999
99/99/9999
99/99/9999
01/31/2003
99/99/9999
06/10/2003
99/99/9999
99/99/9999
06/10/2003
6 EA BO
6 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
8
01/01/2002
01/01/2006
12/31/2005
99/99/9999
15 EA BO
PO
EA
1 EA
01/01/2002
06/01/2002
3 EA NA
PO
EA
5 MG
06/26/2002
10/16/2006
30 EA NA
PO
EA
5 MG
01/01/2002
01/31/2003
10 EA
21 EA
21 EA
50 EA
75 EA
100 EA
30 EA
36 EA
60 EA
6 EA
15 EA
10 EA
15 EA
21 EA
24 EA
50 EA
30 EA
12 EA
100 EA
40 EA
42 EA
8 EA
10 EA
21 EA
30 EA
50 EA
100 EA
27 EA
18 EA
8 EA
5 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54569-0350-02
Q0164
1/1/2002
54569-0350-03
Q0164
1/1/2002
54569-0350-05
Q0164
1/1/2002
54569-0351-00
Q0165
1/1/2002
54569-0351-01
Q0165
1/1/2002
54569-0352-00
Q0164
1/1/2002
54569-0352-01
Q0164
1/1/2002
54569-0352-02
Q0164
1/1/2002
54569-0352-03
Q0164
1/1/2002
54569-0353-00
K0416
1/1/2002
54569-0353-01
54569-0353-01
K0416
J8498
1/1/2002
1/1/2006
54569-0353-02
54569-0353-02
K0416
J8498
1/1/2002
1/1/2006
54569-0355-00
Q0165
1/1/2002
54569-0355-01
Q0165
1/1/2002
54569-0355-02
Q0165
1/1/2002
54569-0355-03
Q0165
1/1/2002
54569-0361-00
54569-0361-00
K0416
J8498
1/1/2002
1/1/2006
54569-0361-01
54569-0361-01
K0416
J8498
1/1/2002
1/1/2006
54569-0361-02
54569-0361-02
K0416
J8498
1/1/2002
1/1/2006
54569-0361-03
K0416
1/1/2002
54569-0362-00
K0416
1/1/2002
54569-0362-01
K0416
1/1/2002
54569-0362-02
K0416
1/1/2002
54569-0362-03
K0416
1/1/2002

COMPAZINE 10 MG
COMPAZINE 10 MG
COMPAZINE 5 MG
COMPAZINE 5 MG
COMPAZINE 5 MG
COMPAZINE 5 MG
COMPAZINE 25 MG
COMPAZINE 25 MG
COMPAZINE 25 MG
COMPAZINE 25 MG
COMPAZINE 25 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 25 MG
PHENERGAN 25 MG
PHENERGAN 25 MG
PHENERGAN 25 MG
Page 231 of 374
20 EA NA
PO
EA
5 MG
01/01/2002
01/31/2003
12 EA NA
PO
EA
5 MG
01/01/2002
06/10/2003
6 EA BO
PO
EA
5 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
10 MG
01/01/2002
01/31/2003
10 EA BO
PO
EA
10 MG
01/01/2002
10/16/2006
30 EA BO
PO
EA
5 MG
01/01/2002
01/31/2003
10 EA BO
PO
EA
5 MG
01/01/2002
01/31/2003
3 EA BO
PO
EA
5 MG
01/01/2002
06/10/2003
12 EA BO
PO
EA
5 MG
01/01/2002
01/31/2003
12 EA BX
RC
EA
1 MG
25
01/01/2002
01/31/2003
6 EA BX
6 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
10/16/2006
3 EA BX
3 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
10/16/2006
30 EA BO
PO
EA
10 MG
12/07/2005
99/99/9999
15 EA NA
PO
EA
10 MG
01/01/2002
06/10/2003
10 EA BO
PO
EA
10 MG
01/01/2002
99/99/9999
4 EA NA
PO
EA
10 MG
01/01/2002
07/01/2002
4 EA BX
4 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
01/01/2002
01/01/2006
12/31/2005
01/20/2006
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
01/01/2002
01/01/2006
12/31/2005
01/20/2006
6 EA BX
6 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
01/01/2002
01/01/2006
12/31/2005
01/20/2006
1 EA BX
RC
EA
1 MG
12.5
01/01/2002
01/31/2003
4 EA BX
RC
EA
1 MG
25
01/01/2002
12/05/2005
12 EA BO
RC
EA
1 MG
25
01/01/2002
12/05/2005
6 EA BX
RC
EA
1 MG
25
01/01/2002
12/05/2005
1 EA BX
RC
EA
1 MG
25
12/27/2004
12/05/2005
1/1/2002
1/31/2003
1/1/2002
1/31/2003
25
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

TIGAN 250 MG
TIGAN 250 MG
TIGAN 250 MG
HYDREA 500 MG
11/20/2002 REGIMEN
PEDIAPRED 5 MG/5 ML
ROCEPHIN (VIAL) 500 MG
54569-0363-03
Q0173
1/1/2002
54569-0363-04
Q0173
1/1/2002
54569-0363-05
54569-0378-00
Q0173
J8999
1/1/2002
1/1/2002
54569-1034-00
54569-1036-00
Q0181
J7509
1/1/2002
1/1/2002
54569-1046-00
54569-1335-00
54569-1377-00
Q0170
J7510
J0696
1/1/2002
1/1/2002
1/1/2002
54569-1381-00
54569-1384-00
54569-1386-00
54569-1387-00
54569-1394-00
54569-1403-00
J3420
J1720
J0696
J2010
J0970
J7051

54569-1409-00
J0560
1/1/2002
54569-1409-01
J0560
1/1/2002
54569-1411-00
54569-1413-00
J1080
J3360

54569-1414-00
54569-1415-00
54569-1415-01
54569-1416-00
54569-1416-00
54569-1416-01
54569-1416-01
54569-1422-00
54569-1469-01
54569-1502-00
54569-1522-00
54569-1522-00
54569-1523-00
54569-1523-01
54569-1524-00
54569-1524-01
54569-1525-00
54569-1529-00
54569-1530-00
J3490
J2000
J2000
J3490
J0592
J3490
J0592
J0170
J7506
J2000
J2912
A4216
J1160
J1160
J2000
J2000
J2000
J0290
J0290
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2003
4/16/2002
1/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
2/19/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-1545-00
54569-1547-00
54569-1555-00
54569-1555-01
J0530
J0170
J2930
J2930
1/1/2002
1/1/2002
1/1/2002
6/5/2002
54569-1572-00
54569-1573-00
54569-1574-00
54569-1575-00
54569-1578-00
J0610
J2310
J1200
J1100
J0170
1/1/2002
9/12/2002
1/1/2002
1/1/2002
1/1/2002
54569-1630-01
54569-1631-01
J0702
J2400
1/1/2002
1/1/2002

3/10/2005 PHOSPHATE 3MG
54569-1660-00
54569-1673-00
54569-1673-01
J3490
J0170
J0170
1/1/2002
1/1/2002
1/1/2002

54569-1675-01
54569-1749-01
A4712
J3410
1/1/2002
1/1/2002


1/31/2003 600,000 UNITS

WATER FOR INHALATION (VIAL)
BICILLIN L-A (TUBEX, 20GX1 1/4) 600000
U/ML
BICILLIN L-A (TUBEX, 20GX1 1/4) 600000
U/ML
MG/ML
MARCAINE HYDROCHLORIDE (M.D.V.)
0.5%
EPINEPHRINE (SRN, TUBEX) 1 MG/ML
PREDNISONE 1 MG
LIDOCAINE HCL 2%
BICILLIN C-R (TUBEX, 20GX1 1/4) 300000
U/ML-300000 U/ML
ADRENALIN (VIAL) 1 MG/ML
CALCIUM GLUCONATE (AMP) 100
MG/ML
NARCAN 0.4 MG/ML
DECADRON (M.D.V.) 4 MG/ML
ADRENALIN (AMP) 1 MG/ML
MG/ML-3 MG/ML
MARCAINE HYDROCHLORIDE (S.D.V.)
0.75%
EPINEPHRINE (SRN) 0.1 MG/ML
EPINEPHRINE (SRN) 0.1 MG/ML
WATER FOR INJECTION
VISTARIL IM 50 MG/ML
Page 232 of 374
4 EA BO
PO
EA
250 MG
01/01/2002
02/12/2002
8 EA BO
PO
EA
250 MG
01/01/2002
02/12/2002
10 EA BO
100 EA BO
PO
PO
EA
EA
250 MG
1 EA
1
1
01/01/2002
01/01/2002
02/12/2002
06/10/2003
100 ML NA
21 EA DP
PO
PO
ML
EA
1 EA
4 MG
1
1
01/01/2002
01/01/2002
11/20/2002
99/99/9999
120 ML BO
120 ML BO
1 EA VL
PO
PO
IJ
ML
ML
EA
25 MG
5 MG
250 MG
0.05
0.2
2
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
IM
IJ
IJ
IJ
IM
IH
ML
EA
EA
ML
ML
ML
1000 MCG
100 MG
250 MG
300 MG
40 MG
5 ML
1
1
1
1
1
0.2
01/01/2002
01/01/2002
01/01/2002
01/15/2004
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
99/99/9999
06/10/2003
01/31/2003
20 ML AM IM
30 ML
1 EA
1 EA
10 ML
5 ML
10 ML
VL
VL
VL
VL
VL
VL
ML
600000 U
01/01/2002
01/31/2003
2 ML SR
IM
ML
600000 U
01/01/2002
01/17/2007
10 ML VL
10 ML VL
IM
IJ
ML
ML
200 MG
5 MG
1
1
01/15/2004
01/01/2002
99/99/9999
01/31/2003
50 ML
50 ML
50 ML
1 ML
1 ML
1 ML
1 ML
1 ML
120 EA
50 ML
10 ML
10 ML
2 ML
2 ML
50 ML
50 ML
50 ML
1 EA
1 EA
VL
VL
VL
AM
AM
AM
AM
SR
NA
VL
AM
AM
AM
AM
VL
NA
VL
VL
VL
IJ
EP
EP
IJ
IJ
IJ
IJ
IJ
PO
EP
IV
IV
IV
IV
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
EA
ML
ML
ML
ML
ML
ML
ML
ML
EA
EA
1 EA
50 ML
50 ML
1 EA
0.1 MG
1 EA
0.1 MG
1 ML
5 MG
50 ML
0.9 %
10 ML
0.5 MG
0.5 MG
50 ML
50 ML
50 ML
500 MG
500 MG
1
0.02
0.02
1
3.24
1
3.24
1
0.2
0.02
0.5
0.1
0.5
0.5
0.02
0.02
0.02
0.5
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2003
04/16/2002
01/01/2003
01/01/2002
01/01/2002
01/01/2002
02/27/2003
01/01/2004
01/01/2002
02/19/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
12/31/2002
01/31/2003
12/31/2002
01/31/2003
01/31/2003
06/10/2003
01/31/2003
12/31/2003
99/99/9999
01/31/2003
01/31/2003
01/31/2003
01/31/2003
01/31/2003
11/16/2002
01/31/2003
2 ML
30 ML
1 EA
1 EA
AM
VL
VL
VL
IM
IJ
IJ
IJ
ML
ML
EA
EA
600000 U
1 ML
125 MG
125 MG
1
1
1
1
01/01/2002
01/01/2002
05/23/2007
06/05/2002
01/31/2003
01/31/2003
99/99/9999
99/99/9999
30 ML
1 ML
1 ML
5 ML
1 ML
AM
AM
AM
VL
AM
IV
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
10 ML
1 MG
50 MG
1 MG
1 ML
0.1
0.4
1
4
1
01/01/2002
09/12/2002
01/01/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
01/31/2003
01/31/2003
5 ML VL
30 ML VL
IJ
IJ
ML
ML
3 MG
30 ML
2
0.03333
01/15/2004
01/01/2002
03/10/2005
01/31/2003
30 ML VL
10 ML SR
10 ML SR
IJ
IJ
IJ
ML
ML
ML
1 EA
1 ML
1 ML
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
30 ML VL
10 ML VL
IV
IM
ML
ML
10 ML
25 MG
0.1
2
01/01/2002
01/01/2002
01/31/2003
01/31/2003
1/1/2002
1/31/2003
01-Jan-02
31-Jan-03
1/1/2002
1/31/2003
0.5
1/1/2002
1/31/2003
1/1/2002
1/31/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54569-1754-00
Q0170
1/1/2002
54569-1754-01
Q0170
1/1/2002
54569-1754-05
Q0170
12/7/2007
54569-1754-06
Q0170
7/2/2002
54569-1754-08
Q0170
11/12/2004
54569-1754-09
54569-1796-01
54569-1802-01
54569-1818-00
54569-1818-03
54569-1818-04
54569-1818-05
54569-1818-06
54569-1818-07
54569-1818-08
54569-1827-01
Q0170
J3250
J0696
None
None
None
None
None
None
None
J3301
1/1/2002
1/1/2002
1/1/2002
9/27/1994
10/25/1995
10/20/2000
10/20/2000
10/20/2000
10/20/2000
10/20/2000
1/1/2002
54569-1850-01
J0530
1/1/2002
54569-1859-00
54569-1878-01
54569-1879-01
54569-1894-01
54569-1901-01
54569-1903-01
54569-1906-01
54569-1917-01
54569-1924-00
54569-1986-00
J0540
J0690
J0780
J2360
J1030
J3070
J2321
J0560
J3410
J0725
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-1989-00
54569-1991-01
54569-2044-00
54569-2044-01
54569-2046-00
J7618
J7799
J2250
J2250
J0500
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-2066-00
J7659
3/1/2002
54569-2066-00 KO J7659
54569-2066-01
KO
J7659
54569-2066-01 KO J7659
54569-2072-00
J2800
54569-2089-00
J3230
3/1/2002
2/25/2002
KO
2/25/2002
1/1/2002
1/1/2002
54569-2091-00
J3490
1/8/2002
54569-2101-00
J2300
1/1/2002
54569-2130-00
54569-2136-00
54569-2184-00
54569-2200-00
54569-2204-00
J3420
J2920
J3303
J0560
J2000
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-2212-00
54569-2213-00
J2912
J1030
1/1/2002
1/1/2002

ROCEPHIN (VIAL) 1 GM
1/31/2003 600,000 UNITS
U/ML
1/31/2003 1,200,000 UNITS
BICILLIN C-R 900/300 (TUBEX)
ANCEF (VIAL) 1 GM
NORFLEX (AMP) 30 MG/ML
TALWIN LACTATE 30 MG/ML
DECA-DURABOLIN (M.D.V.) 100 MG/ML
BICILLIN L-A (TUBEX) 600000 U/ML
PROFASI 10000 U
PROVENTIL 0.5%
DEXTROSE (SRN) 50%
ISUPREL (AMP) 0.2 MG/ML
1/31/2003 MILLIGRAM
ISUPREL (AMP) 0.2 MG/ML
1/31/2003 MILLIGRAM
ISUPREL 0.2 MG/ML
1/31/2003 MILLIGRAM
ISUPREL 0.2 MG/ML
1/31/2003 MILLIGRAM
THORAZINE (AMP) 25 MG/ML
RECOMBIVAX HB (3 DOSE VIAL, TAX
INCL) 10 MCG/ML
NUBAIN (AMP,W/O SULFITE/PARABEN)
10 MG/ML
MCG/ML
(M.D.V.) 0.9%
DEPO-MEDROL (S.D.V.) 40 MG/ML
Page 233 of 374
12 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
10 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
60 EA BO
PO
EA
25 MG
12/07/2007
99/99/9999
20 EA BO
PO
EA
25 MG
07/02/2002
99/99/9999
2 EA BO
PO
EA
25 MG
11/12/2004
4/11/2008
PO
IM
IJ
PO
PO
PO
PO
PO
PO
PO
IJ
EA
ML
EA
EA
EA
EA
EA
EA
EA
EA
ML
25 MG
200 MG
250 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
10 MG
1
0.5
4
1
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
09/27/1994
10/25/1995
10/20/2000
10/20/2000
10/20/2000
10/20/2000
10/20/2000
01/15/2004
99/99/9999
01/31/2003
01/31/2003
01/31/2003
05/17/1999
06/10/2003
06/10/2003
06/10/2003
06/10/2003
99/99/9999
99/99/9999
IM
ML
01/01/2002
01/31/2003
30 EA
20 ML
1 EA
60 EA
18 EA
12 EA
16 EA
20 EA
28 EA
32 EA
5 ML
BO
VL
VL
NA
NA
NA
NA
NA
NA
NA
VL
4 ML SR
600000 U
2 ML
1 EA
10 ML
2 ML
5 ML
10 ML
2 ML
1 ML
10 ML
1 EA
AM
VL
VL
AM
VL
VL
VL
AM
VL
VL
IM
IJ
IJ
IJ
IJ
IJ
IM
IM
IM
IM
ML
EA
ML
ML
ML
ML
ML
ML
ML
EA
1200000 U
500 MG
10 MG
60 MG
40 MG
30 MG
100 MG
600000 U
25 MG
1000 USP Units
0.5
2
0.5
0.5
1
1
1
1
2
10
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/15/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
01/31/2003
99/99/9999
01/31/2003
01/31/2003
01/31/2003
01/31/2003
01/01/2003
20 ML
50 ML
10 ML
10 ML
2 ML
VL
SR
VL
VL
AM
IH
IV
IJ
IJ
IM
ML
ML
ML
ML
ML
1 MG
1 EA
1 MG
1 MG
20 MG
5
1
5
5
0.5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
05/23/2002
05/23/2002
01/31/2003
5 ML AM IV
ML
1 MG
0.2
03/01/2002
01/31/2003
5 ML AM IV
ML
1 MG
0.2
03/01/2002
01/31/2003
5 ML AM IV
ML
1 MG
0.2
02/25/2002
01/31/2003
5 ML AM IV
10 ML VL IJ
1 ML AM IJ
ML
ML
ML
1 MG
10 ML
50 MG
0.2
0.1
0.5
02/25/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
ML
1 EA
01/08/2002
01/31/2003
ML
10 MG
01/01/2002
01/31/2003
1
1
4
1
0.02
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
01/31/2003
01/31/2003
0.5
1
01/01/2002
01/01/2002
01/31/2003
01/31/2003
3 ML VL
IM
1 ML AM IJ
10 ML
1 EA
5 ML
4 ML
50 ML
VL
VL
VL
SR
VL
30 ML VL
1 ML VL
IM
IJ
IJ
IM
EP
ML
EA
ML
ML
ML
IV
IJ
ML
ML
1000 MCG
40 MG
5 MG
600000 U
50 ML
0.9 %
40 MG
1/1/2002
1/31/2003
1/1/2002
1/31/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54569-2222-00
54569-2222-01
54569-2232-01
A4712
A4712
J1800
1/1/2002
2/19/2002
2/11/2002

54569-2236-00
J0460
1/1/2002
54569-2257-00
54569-2262-00
54569-2262-01
54569-2266-00
J3490
J1800
J1800
J2250
1/1/2002
1/9/2002
4/16/2002
1/1/2002
54569-2268-00
54569-2272-00
54569-2306-00
J1200
J2912
J1940
1/1/2002
1/1/2002
1/1/2002
54569-2316-00
54569-2317-00
54569-2318-00
54569-2318-00
54569-2319-00
54569-2319-00
J0530
J3320
J1820
J1815
J1820
J1815
1/1/2002
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2003
54569-2353-02
Q0177
1/1/2002
54569-2353-03
Q0177
1/1/2002
54569-2353-05
54569-2354-00
54569-2356-00
54569-2356-01
Q0177
J2000
J2000
J2000
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-2360-00
54569-2362-00
J2440
J2210
7/2/2002
1/1/2002

1/31/2003 INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG
1/1/2002

1/31/2003 600,000 UNITS
1/31/2003 INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GM
54569-2363-00
J3150
54569-2380-00
54569-2416-00
54569-2431-00
54569-2484-00
54569-2557-00
J2510
J0330
J3490
J0698
J1815
54569-2571-01
Q0178
54569-2571-05
54569-2576-00
54569-2580-00
Q0178
J2910
J1000
54569-2630-00
54569-2646-00
54569-2646-00
J3490
Q2018
J3355

1/1/2002 12/31/2005 INJECTION, UROFOLLITROPIN, 75 IU
1/1/2006 99/99/9999 INJECTION, UROFOLLITROPIN, 75 IU
54569-2660-00
54569-2713-00
54569-2724-00
54569-2775-00
54569-2785-00
J0725
J9217
J2000
J3360
J7506

54569-2790-00
54569-2918-00
54569-2918-00
54569-2918-01
54569-2918-01
J3490
J1820
J1815
J1820
J1815

54569-2918-02
J1815
54569-3040-00
J1100
54569-3040-01
54569-3043-00
54569-3043-01
J1100
J7506
J7506
1/1/2002 1/31/2003 INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS

1/1/2002 1/31/2003 INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG

1/1/2002
9/24/2002

ATROPINE SULFATE (SRN, PREFILLED)
0.1 MG/ML
BRETYLIUM TOSYLATE (S.D.V.) 50
MG/ML
DIPHENHYDRAMINE HCL (TUBEX) 50
MG/ML
BICILLIN C-R (M.D.V.) 150000 U/ML150000 U/ML
TROBICIN (W/DILUENT) 2 GM
5 ML VL IV
5 ML VL IV
1 ML AM IV
10 ML
1 EA
10 ML
10 ML
10 ML
10 ML
VL
VL
VL
VL
VL
VL
ML
ML
ML
10 ML
10 ML
1 MG
0.1
0.1
1
01/01/2002
02/19/2002
02/11/2002
01/31/2003
01/31/2003
03/25/2003
10 ML SR
IJ
ML
0.3 MG
0.33333
01/01/2002
01/31/2003
10 ML
1 ML
1 ML
5 ML
IV
IV
IV
IJ
ML
ML
ML
ML
1 EA
1 MG
1 MG
1 MG
1
1
1
1
01/01/2002
01/09/2002
04/16/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
05/23/2002
1 ML NA IJ
5 ML AM IV
2 ML VL IJ
ML
ML
ML
50 MG
0.9 %
20 MG
1
0.5
0.5
01/01/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
IM
IM
SC
SC
IJ
IJ
ML
EA
ML
ML
ML
ML
600000 U
2 GM
100 U
5U
100 U
5U
0.5
1
1
20
1
20
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/31/2003
01/31/2003
12/31/2002
99/99/9999
12/31/2002
99/99/9999
20 EA NA
PO
EA
25 MG
01/01/2002
06/10/2003
6 EA NA
PO
EA
25 MG
01/01/2002
01/31/2003
PO
IV
EP
EP
EA
ML
ML
ML
25 MG
50 ML
50 ML
50 ML
1
0.02
0.02
0.02
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
01/31/2003
01/31/2003
01/31/2003
10 ML VL IJ
1 ML AM IJ
ML
ML
60 MG
0.2 MG
0.5
1
07/02/2002
01/01/2002
01/01/2003
01/31/2003
BO
SR
VL
VL
10 ML VL
IM
ML
100 MG
01/01/2002
01/31/2003
1 ML
10 ML
1 ML
1 EA
10 ML
SR
VL
VL
NA
EA
IM
IV
IJ
IJ
SC
ML
ML
ML
EA
ML
600000 U
20 MG
1 EA
1 GM
5U
1
1
1
1
20
01/01/2002
01/09/2002
01/01/2002
01/01/2002
06/04/2004
01/31/2003
01/31/2003
12/21/2002
99/99/9999
05/12/2006
20 EA BO
PO
EA
50 MG
09/01/2005
99/99/9999
1/1/2002
6/10/2003
DEPO-ESTRADIOL 5 MG/ML
MCG/ML
METRODIN 75 IU
METRODIN 75 IU
(W/DILUENT) 10000 U
LUPRON DEPOT-PED 7.5 MG
DIAZEPAM (VIAL) 5 MG/ML
PREDNISONE 5 MG
ENGERIX-B (S.D.V.,TAX INCL,PF) 20
MCG/ML
NOVOLIN 70/30 (10X10ML) 70 U/ML-30
U/ML
PREDNISONE 20 MG
PREDNISONE 20 MG
6 EA BO
10 ML VL
5 ML VL
PO
IM
IM
EA
ML
ML
50 MG
50 MG
5 MG
1
1
1
08/20/2003
01/01/2002
01/15/2004
03/10/2005
01/31/2003
99/99/9999
1/1/2002
1/31/2003
1 ML VL
1 EA NA
1 EA NA
IM
IM
IM
ML
EA
EA
1 EA
75 IU
75 IU
1
1
1
07/02/2002
01/01/2002
01/01/2006
01/31/2003
12/31/2005
99/99/9999
10
1
0.02
1
1
01/15/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10/22/2007
01/31/2003
01/31/2003
01/31/2003
06/10/2003
1/1/2002
1/31/2003
10
1/1/2002
1/31/2003
1 EA
1 EA
10 ML
2 ML
28 EA
VL
BX
VL
VL
NA
IM
IM
IJ
IJ
PO
EA
EA
ML
ML
EA
1000 USP Units

7.5 MG
50 ML
5 MG
5 MG
1 ML
10 ML
10 ML
10 ML
10 ML
VL
VL
VL
VL
VL
IM
SC
SC
SC
SC
ML
ML
ML
ML
ML
1 EA
100 U
5U
100 U
5U
1
1
20
1
20
01/22/2004
01/01/2002
01/01/2003
01/01/2002
01/01/2003
06/28/2006
12/31/2002
99/99/9999
12/31/2002
03/10/2005
10 ML VL
SC
ML
5U
20
09/22/2003
99/99/9999
30 ML VL
IJ
ML
1 MG
01/01/2002
01/31/2003
30 ML VL
20 EA BO
12 EA BO
IJ
PO
PO
ML
EA
EA
1 MG
5 MG
5 MG
4
4
4
09/24/2002
01/01/2002
01/01/2002
02/01/2003
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
LIDOCAINE HCL (SRN, 21G) 2%
LIDOCAINE HCL (S.D.V.) 1%
LIDOCAINE HCL (S.D.V.,PF) 1%
PAPAVERINE HYDROCHLORIDE (VIAL)
30 MG/ML
METHERGINE (AMP) 0.2 MG/ML
TESTOSTERONE PROPIONATE (M.D.V.)
100 MG/ML
U/ML
ANECTINE (M.D.V.) 20 MG/ML
THIAMINE HCL (S.D.V.) 100 MG/ML
CLAFORAN 1 GM
Page 234 of 374
30 EA
5 ML
5 ML
5 ML
VL
AM
AM
VL
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54569-3078-00
J7051
54569-3078-00
54569-3080-00
54569-3109-00
54569-3109-00
A4216
J2300
J3490
J0595
54569-3110-00
54569-3130-01
54569-3133-00
54569-3137-00
Q0181
J0280
J1720
Q0136
54569-3142-00
J3490
54569-3149-00
54569-3155-00
J1580
J2250
54569-3200-00
54569-3207-00
54569-3260-00
Q0163
J0696
J3490
54569-3282-00
54569-3302-00
54569-3302-01
54569-3302-02
54569-3302-05
54569-3302-06
54569-3302-07
54569-3302-08
54569-3302-09
54569-3327-00
J2560
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J2000
54569-3377-00
54569-3399-00
J0702
J2000
54569-3407-00
54569-3413-00
54569-3467-00
54569-3467-00
54569-3467-01
54569-3467-01
54569-3477-00
54569-3478-00
54569-3479-00
54569-3500-00
Q0173
J7506
J1820
J1815
J1820
J1815
J0696
J0696
J0696
J2400
54569-3504-00
Q0163
54569-3504-01
Q0163
54569-3519-00
J7643
54569-3519-00 KO J7643
54569-3548-00
J1200
1/1/2002
1/1/2002
1/1/2002

KO

1/1/2002 12/21/2002 PHOSPHATE 3MG
1/1/2002
1/1/2002
J0460
1/1/2002
54569-3589-00
54569-3590-00
54569-3598-00
54569-3626-00
54569-3626-01
J0460
J1940
J2000
J2250
J2250
2/12/2002
1/1/2002
4/23/2002
1/1/2002
1/1/2002


PHENOBARBITAL SODIUM SOLUTION
(TUBEX) 60 MG/ML
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
XYLOCAINE (S.D.V.) 4%
MG/ML-3 MG/ML

PREDNISONE 5 MG
HUMULIN 70/30 70 U/ML-30 U/ML
HUMULIN 70/30 70 U/ML-30 U/ML
5 ML VL
PO
PO
PO
PO
PO
IV
IJ
IJ
EA
EA
EA
EA
EA
ML
ML
ML
5 MG
5 MG
5 MG
5 MG
5 MG
10 U
1 ML
1 ML
4
4
4
4
4
1
1
1
11/17/2003
01/01/2002
01/01/2002
01/01/2002
11/07/2006
01/01/2002
01/01/2002
02/11/2002
99/99/9999
06/10/2003
07/10/2002
99/99/9999
99/99/9999
01/31/2003
01/31/2003
01/31/2003
IH
ML
5 ML
0.2
01/01/2002
01/31/2003
5 ML
10 ML
10 ML
10 ML
VL
VL
VL
VL
IH
IJ
IJ
IJ
ML
ML
ML
ML
10 ML
10 MG
1 EA
1 MG
0.1
1
1
2
01/18/2007
01/01/2002
01/01/2002
01/01/2004
99/99/9999
01/31/2003
12/31/2003
11/10/2004
12 EA
20 ML
1 EA
10 ML
DP
VL
VL
VL
PO
IV
IJ
IJ
EA
ML
EA
ML
1 EA
250 MG
100 MG
1000 U
1
0.1
2.5
10
01/01/2002
01/01/2002
01/01/2002
06/17/2002
09/13/2004
01/31/2003
01/31/2003
01/31/2003
1 ML VL
IM
ML
1 EA
01/22/2004
05/19/2006
2 ML VL
1 ML VL
IJ
IJ
ML
ML
80 MG
1 MG
0.5
5
01/01/2002
01/01/2002
01/31/2003
05/23/2002
PO
IJ
IJ
ML
EA
ML
50 MG
250 MG
1 EA
0.05
8
1
01/01/2002
01/01/2002
01/01/2002
01/31/2003
03/25/2003
99/99/9999
IJ
PO
PO
PO
PO
PO
PO
PO
PO
IV
ML
EA
EA
EA
EA
EA
EA
EA
EA
ML
120 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
50 ML
0.5
2
2
2
2
2
2
2
2
0.02
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/11/2002
06/11/2002
01/01/2002
01/31/2003
99/99/9999
99/99/9999
06/10/2003
06/10/2003
06/10/2003
01/31/2003
06/10/2003
01/31/2003
01/31/2003
5 ML VL IJ
2 ML AM EP
ML
ML
3 MG
50 ML
2
0.02
01/01/2002
01/01/2002
12/21/2002
01/31/2003
120 ML BO
1 EA VL
50 ML VL
1 ML
60 EA
20 EA
45 EA
54 EA
6 EA
4 EA
18 EA
90 EA
50 ML
6/10/2003
1/1/2002
1/31/2003
PO
PO
SC
SC
SC
SC
IJ
IJ
IJ
IJ
EA
EA
ML
ML
ML
ML
EA
EA
EA
ML
250 MG
5 MG
100 U
5U
100 U
5U
250 MG
250 MG
250 MG
30 ML
1
1
1
20
1
20
4
1
2
0.03333
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/25/2004
99/99/9999
12/31/2002
99/99/9999
12/31/2002
06/10/2003
01/31/2003
01/31/2003
01/31/2003
01/31/2003
8 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
10 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
ROBINUL (MDV) 0.2 MG/ML
20 ML VL
IJ
ML
1 MG
0.2
01/15/2004
05/01/2006
1/1/2002
1/31/2003
0.2
20 ML VL
10 ML VL
IJ
IJ
ML
ML
1 MG
50 MG
0.2
1
01/15/2004
01/01/2002
05/01/2006
01/31/2003
1/1/2002
1/31/2003
0.2

ATROPINE SULFATE
(SRN,PREFILL,21GX1 1/2") 0.1 MG/ML
5 ML SR
IJ
ML
0.3 MG
0.33333
01/01/2002
01/31/2003

ATROPINE SULFATE (S.D.V.) 0.4 MG/ML

FUROSEMIDE (AMP) 10 MG/ML
1 ML
4 ML
20 ML
10 ML
10 ML
IJ
IJ
EP
IJ
IJ
ML
ML
ML
ML
ML
0.3 MG
20 MG
50 ML
1 MG
1 MG
1.33333
0.5
0.02
1
1
02/12/2002
01/01/2002
04/23/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
05/23/2002
05/23/2002
AM
AM
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
1/1/2002
BO
DP
VL
VL
VL
VL
VL
VL
VL
VL
Page 235 of 374
12 EA
21 EA
10 ML
10 ML
20 ML
20 ML
1 EA
1 EA
1 EA
30 ML
SR
BO
BO
NA
NA
NA
NA
NA
NA
VL
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
NA
NA
BO
BO
AM
AM
AM
Billing Units
6 EA
9 EA
3 EA
14 EA
25 EA
1 ML
1 ML
1 ML

Package
NDC Label
HCPCS Description
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PITOCIN (AMP) 10 U/ML
SODIUM CHLORIDE/RESPIRATORY
THERAPY 0.9%
SODIUM CHLORIDE/RESPIRATORY
THERAPY 0.9%
NUBAIN (M.D.V.) 10 MG/ML

THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE DEXAMETHASONE (DOSE PACK) 0.75
MG
1/1/2002 9/13/2004 REGIMEN
6/17/2002 1/31/2003 INJECTION, EPOETIN ALPHA, (FOR NON ESRD USE), PER 1000 UNITS
EPOGEN (S.D.V.,S10,PF) 10000 U/ML
MCG/ML
54569-3588-00

NDC Package Type
J7506
J7506
J7506
J7506
J7506
J2590
J0170
J0170
NDC Package Measure
54569-3043-02
54569-3043-03
54569-3043-04
54569-3043-05
54569-3043-06
54569-3056-00
54569-3075-00
54569-3075-01
HCPCS Mod
HCPCS
NDC Mod
NDC
54569-3644-00
J3490
4/23/2002
54569-3701-00
J1055
1/1/2002
54569-3704-00
J3030
1/1/2002
54569-3745-00
54569-3765-00
54569-3765-01
J0150
J8999
J8999
1/1/2002
1/1/2002
10/20/2005
54569-3773-00
54569-3776-01
G9036
J2000
12/1/2004
1/1/2002
54569-3798-00
54569-3799-00
54569-3799-01
54569-3833-00
54569-3833-00
54569-3833-01
54569-3833-01
54569-3833-02
54569-3834-00
54569-3834-00
54569-3835-00
54569-3835-00
54569-3835-01
54569-3835-01
54569-3835-02
54569-3847-00
54569-3882-00
J7506
J3490
J3490
J1820
J1815
J1820
J1815
J1815
J1820
J1815
J1820
J1815
J1820
J1815
J1815
J7506
J2550
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2003
9/22/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/1/2002
1/1/2003
9/22/2003
1/1/2002
1/1/2002
54569-3899-00
J7603
1/1/2008
54569-3899-00 KO J7603
54569-3899-00
KO
J7613
54569-3899-00 KO J7613
1/1/2008
4/1/2008
KO
4/1/2008
54569-3900-00
J7602
1/1/2008
54569-3900-00
54569-3912-00
54569-3914-00
54569-3917-00
54569-3918-00
54569-3922-00
J7611
J3490
J2590
J2000
J0670
J2000
4/1/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-3934-00
54569-3946-00
54569-3947-00
54569-3952-00
54569-3953-00
54569-3953-00
J2920
J1030
J0460
J3490
J1095
J1094
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2003
54569-3955-01
54569-3957-00
54569-3957-00
54569-3958-00
54569-3958-00
J0780
J1050
J1051
J1050
J1051
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2003
54569-3959-00
J7629
54569-3959-00 KO J7629
1/1/2002
KO
1/1/2002
ENGERIX-B PEDIATRIC (S.D.V.,TAX

INCL.,PF) 10 MCG/0.5 ML
99/99/9999 MG
(VIAL) 150 MG/ML
ADENOCARD (S.D.V.) 3 MG/ML
FLUMADINE 100 MG
LIDOCAINE HCL 1%
MG
STADOL (S.D.V.) 2 MG/ML
STADOL (S.D.V.) 2 MG/ML
NOVOLIN R (10X10ML) 100 U/ML
NOVOLIN N (10X10ML) 100 U/ML
STERAPRED DS (UNI-PAK) 10 MG
PITOCIN 10 U/ML
MEPIVACAINE HCL (M.D.V.) 1%
XYLOCAINE (SRN) 2%
SOLU-MEDROL (ACT-O-VIAL 25 PACK)
40 MG
DEPO-MEDROL (VIAL) 40 MG/ML
ATROPINE SULFATE (AMP) 0.4 MG/ML
DALALONE D.P. (VIAL) 16 MG/ML
DALALONE D.P. (VIAL) 16 MG/ML
TORNALATE 0.2%
TORNALATE 0.2%
54569-3965-01
54569-3968-01
54569-4012-00
54569-4012-01
54569-4012-02
54569-4012-03
J2370
J3475
J7510
J7510
J7510
J7510
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

54569-4012-04
J7510
1/1/2002

MAGNESIUM SULFATE 500 MG/ML
PRELONE 15 MG/5 ML
PRELONE 15 MG/5 ML
PRELONE 15 MG/5 ML
PRELONE (2X120 ML) 15 MG/5 ML
PRELONE (4X60 ML,CHERRY) 15 MG/5
ML
Page 236 of 374
0.5 ML VL
IM
ML
1 EA
04/23/2002
01/31/2003
1 ML VL
IM
ML
150 MG
01/15/2004
99/99/9999
0.5 ML VL
SC
ML
6 MG
01/01/2002
99/99/9999
2 ML VL
60 EA BO
60 EA BO
IV
PO
PO
ML
EA
EA
6 MG
1 EA
1 EA
0.5
1
1
01/01/2002
01/01/2002
10/20/2005
01/31/2003
06/13/2005
99/99/9999
14 EA BO
5 ML NA
PO
IV
EA
ML
100 MG
50 ML
1
0.02
12/01/2004
01/01/2002
05/31/2005
01/31/2003
48 EA
1 ML
1 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
21 EA
1 ML
PO
IJ
IJ
IJ
IJ
IJ
IJ
IJ
SC
SC
SC
SC
SC
SC
SC
PO
IJ
EA
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
EA
ML
5 MG
1 EA
1 EA
100 U
5U
100 U
5U
5U
100 U
5U
100 U
5U
100 U
5U
5U
5 MG
50 MG
2
1
1
1
20
1
20
20
1
20
1
20
1
20
20
2
0.5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/26/2004
01/01/2002
01/01/2003
09/22/2003
01/01/2002
01/01/2003
01/01/2002
09/22/2003
01/01/2002
01/01/2003
09/22/2003
01/01/2002
01/01/2002
11/20/2006
01/31/2003
01/31/2003
12/31/2002
99/99/9999
12/31/2002
06/10/2003
4/30/2008
12/31/2002
06/10/2003
12/31/2002
99/99/9999
12/31/2002
06/10/2003
4/11/2008
11/20/2006
01/31/2003
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML
1 EA
25 ML
50 ML
50 ML
50 ML
BO
VL
VL
VL
VL
SR
IH
IV
IV
IJ
IJ
IV
ML
EA
ML
ML
ML
ML
1 MG
1 EA
10 U
50 ML
10 ML
50 ML
5
1
1
0.02
0.1
0.02
04/01/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
01/31/2003
01/31/2003
01/31/2003
01/31/2003
01/31/2003
1 EA
1 ML
25 ML
10 ML
5 ML
5 ML
VL
VL
AM
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
EA
ML
ML
ML
ML
ML
40 MG
40 MG
0.3 MG
1 EA
8 MG
1 MG
1
1
1.33333
1
2
16
01/01/2002
01/22/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/31/2003
99/99/9999
01/31/2003
01/31/2003
12/31/2002
01/31/2003
2 ML
10 ML
10 ML
2.5 ML
2.5 ML
VL
VL
VL
VL
VL
IJ
IM
IM
IM
IM
ML
ML
ML
ML
ML
10 MG
100 MG
50 MG
100 MG
50 MG
0.5
4
8
4
8
01/01/2002
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/31/2003
12/31/2002
01/31/2003
12/31/2002
01/31/2003
30 ML BO
IH
ML
1 MG
01/01/2002
06/17/2002
30 ML BO
IH
ML
1 MG
01/01/2002
06/17/2002
VL
NA
BO
BO
BO
BO
IJ
IJ
PO
PO
PO
PO
ML
ML
ML
ML
ML
ML
1 ML
500 MG
5 MG
5 MG
5 MG
5 MG
1
1
0.6
0.6
0.6
0.6
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/31/2003
01/31/2003
06/10/2003
01/31/2003
01/31/2003
06/10/2003
240 ML BO
PO
ML
5 MG
0.6
01/01/2002
01/31/2003
1 ML
2 ML
240 ML
60 ML
120 ML
120 ML
DP
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
DP
AM
1/1/2002
1/31/2003
1/1/2003
6/10/2003
20
1/1/2003
6/10/2003
20
1/1/2002
1/31/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

1/1/2006
54569-4112-00
54569-4167-00
J2300
J3360
54569-4168-00
54569-4192-00
54569-4192-01
Q0170
J8499
J8499
54569-4197-00
54569-4198-00
Q0163
J2405
54569-4199-00
54569-4212-00
J1060
J2590

ZOVIRAX 400 MG
ZOVIRAX 400 MG
DIPHENHYDRAMINE HCL (AF) 12.5 MG/5
ML
DEPO-TESTADIOL (VIAL) 2 MG/ML-50
1/1/2002 1/31/2003 INJECTION, TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE, UP TO 1 ML MG/ML
OXYTOCIN (M.D.V.) 10 U/ML
54569-4213-00
54569-4223-00
54569-4226-00
54569-4227-00
54569-4230-00
54569-4231-00
54569-4232-00
54569-4265-00
54569-4294-00
54569-4390-00
54569-4395-00
J3490
J3490
J7506
J7506
Q0144
Q0144
Q0144
J1030
J0690
J2300
J2790
1/1/2002
1/1/2002
4/26/2002
2/20/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
9/24/2002
9/24/2002
DELTASONE 20 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
BRONCHO SALINE 0.9%
BRONCHO SALINE 0.9%
(10X1ML) 20 MG/ML

ENGERIX-B PEDIATRIC
(TIPLOK,25GX5/8TAX,PF) 10 MCG/0.5 ML
DOPAMINE HCL 40 MG/ML
DELTASONE 5 MG
BAYRHO-D (SRN)
PO
PO
PO
PO
PO
IH
IH
IV
IV
EA
EA
EA
EA
EA
ML
ML
ML
EA
5 MG
5 MG
5 MG
5 MG
5 MG
5 ML
10 ML
1 EA
1 EA
4
1
1
1
1
0.2
0.1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2006
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
06/10/2003
06/10/2003
12/31/2005
05/08/2007
01/31/2003
01/31/2003
IJ
IJ
ML
ML
10 MG
5 MG
2
1
01/01/2002
01/01/2002
99/99/9999
01/31/2003
5 EA BO
30 EA BO
20 EA BO
PO
PO
PO
EA
EA
EA
25 MG
1 EA
1 EA
1
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
01/31/2003
06/10/2003
120 ML BO
2 ML VL
PO
IJ
ML
ML
50 MG
1 MG
0.05
2
01/01/2002
01/01/2002
99/99/9999
01/31/2003
10 ML VL
10 ML VL
IM
IV
ML
ML
1 ML
10 U
1
1
01/01/2002
01/01/2002
01/31/2003
01/31/2003
IM
IV
PO
PO
PO
PO
PO
IJ
IJ
IJ
IM
ML
ML
EA
EA
ML
ML
ML
ML
EA
ML
ML
1 EA
1 EA
5 MG
5 MG
1 GM
1 GM
1 GM
40 MG
500 MG
10 MG
300 MCG
1
1
1
1
0.04
0.04
0.02
1
2
2
1
01/01/2002
01/01/2002
04/26/2002
02/20/2002
01/01/2002
01/01/2002
01/01/2002
01/15/2004
01/01/2002
09/24/2002
09/24/2002
01/31/2003
01/31/2003
06/10/2003
10/09/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/31/2003
01/31/2003
01/12/2006
1 ML NA
2 ML VL
0.5 ML
5 ML
60 EA
21 EA
15 ML
22.5 ML
15 ML
10 ML
1 EA
10 ML
1 ML
SR
NA
BO
DP
BO
BO
BO
VL
VL
VL
SR
54569-4396-00
J2790
5 ML SR
IM
ML
300 MCG
0.03333
01/01/2002
12/31/2002
54569-4396-00
54569-4398-00
54569-4417-00
J2788
J1670
Q0144

BAYTET (SRN) 250 U
5 ML SR
1 ML SR
30 ML BO
IM
IM
PO
ML
ML
ML
50 MCG
250 U
1 GM
0.2
1
0.04
01/01/2003
01/01/2002
01/01/2002
01/31/2003
01/31/2003
99/99/9999
54569-4423-00
J0275
MUSE 125 MCG
6 EA BX
UR
EA
1 EA
01/01/2002
07/01/2002
54569-4424-00
J0275
MUSE 250 MCG
6 EA BX
UR
EA
1 EA
01/01/2002
07/01/2002
54569-4425-00
J0275
MUSE 500 MCG
6 EA BX
UR
EA
1 EA
01/01/2002
01/31/2003
54569-4426-00
54569-4431-00
54569-4433-00
54569-4433-00
54569-4474-00
54569-4482-00
54569-4482-01
54569-4482-02
54569-4482-03
54569-4482-04
54569-4482-06
54569-4497-00
54569-4516-00
54569-4522-00
54569-4522-01
54569-4522-02
J0275
J0690
J3490
Q3025
J3490
J8499
J8499
J8499
J8499
J8499
J8499
Q0144
J7509
Q0144
Q0144
Q0144
1/1/2002 1/31/2003 INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS
ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE
1/1/2002
1/1/2002
1/1/2003 3/24/2003 INJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR USE
1/1/2002
1/1/2002
5/8/2002
BX
VL
VL
VL
VL
BO
BO
BO
BO
BO
BO
DP
BO
BO
BO
BO
UR
IJ
IM
IM
IV
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
500 MG
1 EA
11 MCG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 GM
4 MG
1 GM
1 GM
1 GM
1
1
1
12
1
1
1
1
1
1
1
0.25
2
0.25
0.25
0.25
01/01/2002
01/01/2002
01/07/2002
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2005
04/26/2005
01/01/2002
05/08/2002
01/01/2002
01/01/2002
01/05/2004
01/31/2003
03/25/2003
12/31/2002
03/24/2003
01/31/2003
99/99/9999
99/99/9999
09/01/2003
09/01/2004
99/99/9999
99/99/9999
99/99/9999
07/01/2002
99/99/9999
99/99/9999
99/99/9999
54569-4526-00
54569-4528-00
J9217
Q2018
5/8/2002
1/1/2002

1 EA SR
1 EA VL
IM
SC
EA
EA
7.5 MG
75 IU
1.5
1
05/08/2002
01/01/2002
01/31/2003
07/01/2002
54569-4547-00
J1950
1/1/2002
IM
EA
3.75 MG
01/01/2002
01/31/2003
J7631
1/1/2002

1 EA SR
54569-4549-00
2 ML VL
IH
ML
10 MG
01/01/2002
01/31/2003
2 ML VL
IH
ML
10 MG
01/01/2002
01/31/2003
54569-4549-00 KO J7631
KO
1/1/2002
MUSE 1000 MCG

AVONEX (S.D.V.) 33 MCG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
MEDROL 8 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
LUPRON DEPOT (SRN,PREFIL,DUAL
CHAMBER) 11.25 MG
FERTINEX 75 IU
LUPRON DEPOT (SRN, PREFILL DUAL
CHAMB) 3.75 MG
Page 237 of 374
6 EA
1 EA
1 EA
1 EA
1 EA
25 EA
50 EA
15 EA
35 EA
40 EA
21 EA
6 EA
10 EA
4 EA
2 EA
30 EA
1/1/2002
1/31/2003
9/11/2002
6/10/2003
8/26/2002
6/10/2003
0.25
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
NA
NA
NA
NA
BO
BO
VL
VL
Billing Units
9 EA
42 EA
24 EA
40 EA
55 EA
240 ML
240 ML
50 ML
1 EA
NDC Package Type
J7506
J7506
J7506
J7506
J7506
J7051
A4216
J3490
J3490
NDC Package Measure
54569-4017-00
54569-4026-00
54569-4026-01
54569-4026-04
54569-4026-05
54569-4037-00
54569-4037-00
54569-4073-00
54569-4100-00

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
IJ
IV
IV
IV
ML
EA
ML
EA
1 MG
500 MG
250 MG
500 MG
4
2
0.1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
01/31/2003
01/31/2003
01/31/2003
54569-4699-00
Q0169
1/1/2002
PO
EA
12.5 MG
01/01/2002
01/31/2003
54569-4702-00
J2760
1/1/2002
IJ
EA
5 MG
01/01/2002
01/31/2003
54569-4720-00
54569-4720-00
K0416
J8498
1/1/2002
1/1/2006
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
6 EA NA
RC
EA
1 MG
25
01/01/2002
01/31/2003
3 EA BX
3 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
1 EA NA
35 EA BO
RC
PO
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2002
07/10/2002
99/99/9999
54569-4720-01
K0416
1/1/2002
54569-4720-02
54569-4720-02
K0416
J8498
1/1/2002
1/1/2006
54569-4720-03
54569-4724-00
K0416
J8499
1/1/2002
1/1/2002
54569-4728-00
J1100
1/1/2002
54569-4729-00
54569-4734-00
54569-4738-00
54569-4739-00
54569-4739-00
J3490
J1610
J1570
J3490
J3590
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2003
54569-4748-00
J7603
1/1/2008
54569-4748-00 KO J7603
54569-4748-00
KO
J7614
54569-4748-00 KO J7614
54569-4751-00
J3490
54569-4752-00
J3490
1/1/2008
4/1/2008
KO
4/1/2008
2/5/2004
1/1/2002
54569-4760-00
54569-4765-00
54569-4765-01
54569-4765-02
54569-4765-03
54569-4765-04
54569-4765-05
54569-4765-06
54569-4765-09
54569-4769-00
J0270
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J3490
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
6/1/2006
1/1/2002
54569-4771-00
J7320
1/1/2002
54569-4772-00
J7631
1/1/2002
54569-4772-00 KO J7631
54569-4782-00
J0670
KO
1/1/2002
1/1/2002
54569-4785-00
J9217
1/1/2002
54569-4807-00
54569-4819-00
54569-4821-00
54569-4824-00
J7510
J2300
J3490
J1440
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-4827-00
54569-4827-01
54569-4827-02
54569-4838-00
54569-4859-00
J7510
J7510
J7510
J2770
J0670

1/1/2002 1/31/2003 INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350)
PREDNISOLONE (2X120 ML) 15 MG/5 ML

PREDNISOLONE (4X60 ML) 15 MG/5 ML
SYNERCID 350 MG-150 MG
Page 238 of 374
30 EA BO
1 EA VL
25 ML VL
CF
HCPCS Amount #1
IJ
ML
1 MG
01/01/2002
01/31/2003
SR
VL
VL
VL
VL
IM
IJ
IV
IM
IM
ML
EA
EA
ML
ML
1 EA
1 MG
500 MG
1 EA
1 EA
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2003
03/14/2002
99/99/9999
01/31/2003
12/31/2002
99/99/9999
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
0.5 MG
0.42
04/01/2008
99/99/9999
3 ML PC
20 ML VL
1 ML VL
IH
IV
IJ
ML
ML
ML
0.5 MG
1 EA
1 EA
0.42
1
1
04/01/2008
02/05/2004
01/01/2002
99/99/9999
11/13/2006
01/31/2003
1 EA
2 EA
14 EA
25 EA
50 EA
15 EA
45 EA
60 EA
45 EA
1 EA
IC
PO
PO
PO
PO
PO
PO
PO
PO
IV
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1.25 MCG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
32
1
1
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/01/2006
01/01/2002
01/31/2003
01/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/31/2003
2 ML SR
IJ
ML
16 MG
0.5
01/01/2002
01/31/2003
2 ML VL
IH
ML
10 MG
01/01/2002
01/31/2003
2 ML VL
50 ML VL
IH
IJ
ML
ML
10 MG
10 ML
1
0.1
01/01/2002
01/01/2002
01/31/2003
03/25/2003
1 EA BX
1 ML
1 EA
1 EA
5 ML
5 ML
VL
NA
BO
BO
BO
BO
BO
BO
BO
VL
IM
EA
7.5 MG
01/01/2002
01/31/2003
120 ML
1 ML
50 ML
1 ML
BO
AM
VL
VL
PO
IJ
IV
IJ
ML
ML
ML
ML
5 MG
10 MG
1 EA
300 MCG
0.2
2
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/10/2003
05/19/2006
01/31/2003
01/31/2003
120 ML
60 ML
240 ML
1 EA
50 ML
BO
BO
BO
VL
VL
PO
PO
PO
IV
IJ
ML
ML
ML
EA
ML
5 MG
5 MG
5 MG
500 MG
10 ML
0.6
0.6
0.6
1
0.1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
10/16/2006
01/31/2003
01/31/2003
NA
VL
VL
VL
Prior End Date #3
5 ML
1 EA
20 ML
1 EA
Prior Start Date #3
1/1/2002
1/1/2002
1/1/2002
1/1/2002
J1100
J3370
J1956
J0456
Prior End Date #2
54569-4648-00
54569-4669-00
54569-4677-00
54569-4681-00
End Date #1
99/99/9999
01/31/2003
01/31/2003
01/31/2003
Start Date #1
01/01/2002
05/08/2002
05/08/2002
01/01/2002
HCPCS Measure #1
1
4
2
1
Billing Units
1 GM
4 MG
15 MG
200 MG

GM/Packet
MEDROL 16 MG
TORADOL IM (S.D.V.) 30 MG/ML
DELATESTRYL (UNIMATIC) 200 MG/ML
VANCOLED 1 GM
1/31/2003 INJECTION, LEVOFLOXACIN, 250 MG
ZITHROMAX 500 MG
PHENERGAN 12.5 MG
PHENTOLAMINE MESYLATE (S.D.V.) 5
MG
ACYCLOVIR 800 MG
PHOSPHATE (S.D.V.) 4 MG/ML
ENGERIX-B (TIPLOK,23GX1,TAX,PF) 20
MCG/ML
GLUCAGON EMERGENCY KIT 1 MG
1/31/2003 INJECTION, GANCICLOVIR SODIUM, 500 MG
CYTOVENE IV (VIAL) 500 MG
NABI-HB
NABI-HB
XOPENEX (PF) 0.021%
XOPENEX (PF) 0.021%
LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG
XOPENEX (PF) 0.021%
XOPENEX (PF) 0.021%
PYRIDOXINE HCL (M.D.V.) 100 MG/ML
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
FLAGYL I.V. (S.D.V.) 500 MG
SYNVISC (3X2ML SRN, PREFILLED) 8
MG/ML
LUPRON DEPOT (SRN PREFIL DUAL
CHAMBER) 7.5 MG
PRELONE (SF,DYE-FREE,CHERRY) 5
MG/5 ML
NUBAIN (AMP) 20 MG/ML
1/31/2003 INJECTION, FILGRASTIM (G-CSF), 300 MCG
NEUPOGEN (S.D.V.,PF) 300 MCG/ML
Prior Start Date #2
NDC Package Type
EA
EA
ML
ML
NDC Label
PO
PO
IM
IM
HCPCS Description
BX
BO
VL
SR
1 EA
21 EA
2 ML
1 ML
HCPCS Mod

HCPCS
Q0144
J7509
J1885
J3130
NDC Mod
54569-4567-00
54569-4580-00
54569-4583-00
54569-4620-00
NDC
NDC Package Measure

Package
54569-4870-00
Q0180
1/1/2002
54569-4871-00
Q0166
1/1/2002
54569-4872-00
Q0179
1/1/2002
54569-4872-01
Q0179
12/7/2005
54569-4888-00
G9035
12/1/2004
54569-4904-00
J1055
1/1/2002
54569-4910-00
J7644
1/1/2002
54569-4910-00 KO J7644
54569-4930-00
J2941
KO
1/1/2002
1/1/2002
54569-4954-00
J1885
1/1/2002
54569-4955-00
54569-4957-00
J1885
J3490
1/1/2002
1/1/2002
54569-4982-00
J9218
1/1/2002
54569-4983-00
J9250
1/1/2002
54569-5116-00
J2250
1/1/2002
54569-5116-01
54569-5128-00
J2250
J3490
1/1/2002
1/1/2002
54569-5162-00
J7626
54569-5162-00 KO J7626
54569-5163-00
KO
J7626
54569-5163-00 KO J7626
KO
5 EA BX
PO
EA
100 MG
01/01/2002
01/31/2003
6 EA PG
PO
EA
1 MG
01/01/2002
07/10/2002
9 EA PG
PO
EA
8 MG
01/01/2002
07/10/2002
4 EA BO
PO
EA
8 MG
12/07/2005
4/30/2008
10 EA BX
PO
EA
75 MG
12/01/2004
05/31/2005
1 ML SR
IM
ML
150 MG
01/15/2004
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
99/99/9999
2.5 ML PC
1 EA VL
IH
SC
ML
EA
1 MG
1 MG
0.2
5
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1 ML VL
IJ
2 ML VL IM
1 EA AM SC
ML
15 MG
01/01/2002
01/31/2003
ML
EA
15 MG
1 EA
2
1
01/01/2002
01/01/2002
01/31/2003
01/31/2003
01/31/2003
2.8 ML VL
SC
EA
1 MG
14
01/01/2002
10 ML VL
IJ
ML
5 MG
01/01/2002
02/09/2005
100 ML VL
IJ
ML
1 MG
01/01/2002
01/31/2003
10 ML VL
1 EA VL
IJ
IJ
ML
EA
1 MG
1 EA
5
1
01/01/2002
01/01/2002
01/31/2003
01/31/2003
1/1/2002
PULMICORT RESPULES 0.25 MG/2 ML
2 ML EA
IH
ML
0.25 MG
0.5
01/01/2002
06/10/2003
1/1/2002
2 ML EA
IH
ML
0.25 MG
0.5
01/01/2002
06/10/2003
1/1/2002
2 ML PC
IH
ML
0.25 MG
0.5
01/01/2002
01/16/2004
1/1/2002
J2765
J3490
J7500
1/1/2002
1/1/2002
1/1/2002
54569-5188-00
J1885
1/1/2002
54569-5189-00
54569-5204-00
54569-5204-01
54569-5246-00
J1885
J7510
J7510
J2000
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-5247-00
J2310
1/1/2002
54569-5254-00
54569-5255-00
54569-5255-01
54569-5260-00
J7699
J2250
J2250
J3490
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54569-5262-00
J9217
6/4/2002
54569-5268-00
J3490
1/1/2002
54569-5272-00
54569-5275-00
54569-5276-00
54569-5281-00
J1056
J1460
J1460
J3490
1/1/2002
1/1/2002
1/1/2002
1/1/2002

MG/ML
ACYCLOVIR SODIUM (VIAL) 500 MG
AZATHIOPRINE 50 MG
ORAPRED 15 MG/5 ML
ORAPRED 15 MG/5 ML
XYLOCAINE-MPF 1%
MG/ML
FORADIL AEROLIZER (BLISTER PACK,
10X6) 0.012 MG
DUAL CHAMBER) 15 MG
TWINRIX (S.D.V., TAX INCL) 720 EL U/ML1/31/2003 UNCLASSIFIED DRUGS
20 MCG/ML
INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG / LUNELLE MONTHLY CONTRACEPTIVE
6/10/2003 25MG
(S.D.V.) 5 MG/0.5 ML-25 MG/0.5 ML
BAYGAM (S.D.V.,PF)
BAYGAM (S.D.V.,PF)
OVIDREL (VIAL W/DILUENT) 0.25 MG
Page 239 of 374
2 ML PC
IH
ML
0.25 MG
0.5
01/01/2002
01/16/2004
2 ML VL
1 EA VL
60 EA NA
IV
IV
PO
ML
EA
EA
10 MG
1 EA
50 MG
0.5
1
1
01/01/2002
01/01/2002
01/01/2002
01/31/2003
01/01/2003
03/25/2003
1 ML NA
2 ML
240 ML
240 ML
10 ML
NA
BO
BO
NA
1 ML VL
IJ
ML
15 MG
01/01/2002
01/31/2003
IM
PO
PO
EP
ML
ML
ML
ML
15 MG
5 MG
5 MG
50 ML
2
0.6
0.6
0.02
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/31/2003
4/30/2008
4/11/2008
03/25/2003
IJ
ML
1 MG
0.4
01/01/2002
99/99/9999
PK
NA
NA
VL
IH
IJ
IJ
IV
EA
ML
ML
ML
1 EA
1 MG
1 MG
1 EA
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
07/01/2002
01/31/2003
01/31/2003
01/31/2003
1 EA CR
IM
EA
7.5 MG
06/04/2002
01/31/2003
1 ML VL
IM
ML
1 EA
01/01/2002
01/31/2003
IM
IM
IM
SC
ML
ML
ML
EA
5 MG
1 ML
1 ML
1 EA
2
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/10/2003
10/03/2006
01/31/2003
01/31/2003
60 EA
100 ML
10 ML
20 ML
0.5 ML
2 ML
10 ML
1 EA
VL
VL
VL
VL
1/1/2002
1/31/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
ANZEMET 100 MG
KYTRIL 1 MG
ZOFRAN 8 MG
ZOFRAN 8 MG
INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150 DEPO-PROVERA (SRN, PREFILLED) 150
99/99/9999 MG
MG/ML
SAIZEN (VIAL, W/DILUENT) 5 MG
30 MG/ML
30 MG/ML
GONAL-F (AMP) 75 IU
MG/ML
METHOTREXATE SODIUM (VIAL) 25
MG/ML
MG/ML
MG/ML
54569-5171-00
54569-5173-00
54569-5177-00
HCPCS Mod
HCPCS
NDC Mod
NDC
54569-5292-00
J3490
1/1/2002
54569-5301-00
54569-5309-00
J1070
J1260
1/9/2002
1/9/2002
54569-5311-00
54569-5312-00
54569-5312-00
54569-5312-01
J3490
J2000
J2001
J2001
1/1/2002
2/6/2002
11/8/2007
11/8/2007
54569-5316-00
J9250
2/12/2002
54569-5318-00
J2710
2/12/2002
54569-5321-00
J1820
2/6/2002
54569-5321-00
54569-5325-00
54569-5335-00
54569-5351-00
J1815
J0715
J2322
J3360
1/1/2003
1/31/2002
2/15/2002
3/7/2002
54569-5408-00
54569-5416-00
54569-5427-00
J3490
J3130
J3490
7/18/2002
7/29/2002
9/9/2002
54569-5432-00
J7699
9/24/2002
54569-5433-00
54569-5444-00
54569-5444-00
J1056
J3490
J3590
9/24/2002
9/13/2002
1/1/2003
54569-5445-00
J7603
1/1/2008
54569-5445-00 KO J7603
54569-5445-00
KO
J7614
54569-5445-00 KO J7614
54569-5448-00
Q0144
1/1/2008
4/1/2008
KO
4/1/2008
9/9/2002
54569-5468-00
54569-5491-00
54569-5492-00
J2250
J3490
J3490
11/4/2002
1/17/2003
1/17/2003
54569-5524-00
J3590
8/12/2003
54569-5524-00
J0135
1/1/2005
54569-5527-00
J1055
8/15/2003
54569-5533-00
54569-5535-00
J3420
J0285
9/19/2003
9/30/2003
54569-5578-00
J3490
7/21/2004
54569-5589-00
Q0173
8/26/2004
54569-5589-01
54569-5605-00
54569-5607-00
Q0173
J1815
J0460
9/2/2005
2/16/2006
9/29/2004
54569-5610-00
J0150
9/30/2004
54569-5615-00
G9035
12/1/2004
54569-5628-00
J3490
11/10/2004
54569-5629-00
J3490
11/10/2004
TWINRIX (TIPLOK,23"GX1",TAX INCL) 720

EL U/ML-20 MCG/ML
1 ML SR
MG/ML
10 ML VL
ANZEMET (AMP) 20 MG/ML
0.625 ML AM
INCL.,PF) 10 MCG/0.5 ML
0.5 ML VL
LIDOCAINE HCL 2%
5 ML SR
LIDOCAINE HCL 2%
5 ML SR
5 ML SR
MG/ML
2 ML VL
(M.D.V.) 1 MG/ML
10 ML VL
U/ML
10 ML VL
U/ML
10 ML VL
CEFIZOX (S,D,V.,PF) 1 GM
1 EA VL
1 ML VL
10 ML VL
ENGERIX-B (TIP-LOK W/O NDL,TAX,PF)
20 MCG/ML
1 ML SR
DELATESTRYL (M.D.V.) 200 MG/ML
5 ML VL
1 EA BX
ML
3 ML VL
INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG / (PREFILLED SRN) 5 MG/0.5 ML-25
MG/0.5 ML
0.5 ML SR
9/1/2003 25MG
NABI-HB (S.D.V.,&GT;312 IU/ML)
1 ML VL
NABI-HB (S.D.V.,&GT;312 IU/ML)
1 ML VL
XOPENEX (PF) 0.042%
3 ML VL
XOPENEX (PF) 0.042%
3 ML VL
XOPENEX (PF) 0.042%
3 ML VL
XOPENEX (PF) 0.042%
3 ML VL
ZITHROMAX TRI-PAK 500 MG
1 EA DP
MIDAZOLAM HCL (FLIPTOP VIAL,LATEX5/15/2003 INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG
FREE) 5 MG/ML
1 ML EA
SYNAGIS (PF) 50 MG
1 EA VL
SYNAGIS (PF) 100 MG
1 EA VL
MG/0.8 ML
0.8 ML CR
3/10/2005 INJECTION, ADALIMUMAB, 20 MG
MG/0.8 ML
0.8 ML CR
INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150 DEPO-PROVERA CONTRACEPTIVE 150
99/99/9999 MG
MG/ML
1 ML VL
MCG/ML
30 ML VL
FUNGIZONE INTRAVENOUS 50 MG
1 EA VL
TWINRIX (TIP-LOK SYRINGE) 720 EL
U/ML-20 MCG/ML
1 ML SR
12 EA BO
6 EA BO
LANTUS 100 U/ML
10 ML VL
ATROPINE SULFATE 1 MG/ML
1 ML NA
ADENOSINE 3 MG/ML
2 ML NA
25 ML BO
RECOMBIVAX HB
0.5 ML VL
RECOMBIVAX HB
0.5 ML VL
Page 240 of 374
IM
ML
1 EA
01/01/2002
03/21/2002
IM
IV
ML
ML
100 MG
10 MG
1
2
01/09/2002
01/09/2002
01/31/2003
01/31/2003
IM
IJ
IJ
IJ
ML
ML
ML
ML
1 EA
50 ML
10 MG
10 MG
1
0.02
2
2
01/01/2002
02/06/2002
11/08/2007
11/08/2007
99/99/9999
01/31/2003
99/99/9999
99/99/9999
IJ
ML
5 MG
02/12/2002
01/31/2003
IJ
ML
0.5 MG
02/12/2002
01/31/2003
SC
ML
100 U
02/06/2002
12/31/2002
SC
IJ
IM
IJ
ML
EA
ML
ML
5U
500 MG
200 MG
5 MG
20
2
1
1
01/01/2003
01/31/2002
02/15/2002
03/07/2002
06/10/2003
11/16/2002
01/31/2003
1/10/2008
IM
IM
MR
ML
ML
EA
1 EA
200 MG
1 EA
1
1
1
07/18/2002
07/29/2002
09/09/2002
99/99/9999
01/31/2003
11/30/2004
IH
ML
1 EA
09/24/2002
06/10/2003
IM
IM
IM
ML
ML
ML
5 MG
1 EA
1 EA
2
1
1
09/24/2002
09/13/2002
01/01/2003
09/01/2003
12/31/2002
01/31/2003
IH
ML
1 MG
0.84
01/01/2008
03/31/2008
IH
ML
1 MG
0.84
01/01/2008
03/31/2008
IH
ML
0.5 MG
0.84
04/01/2008
99/99/9999
IH
PO
ML
EA
0.5 MG
1 GM
0.84
0.5
04/01/2008
09/09/2002
99/99/9999
99/99/9999
IJ
IM
IM
ML
EA
EA
1 MG
1 EA
1 EA
5
1
1
11/04/2002
01/17/2003
01/17/2003
05/15/2003
05/01/2003
05/01/2003
MR
EA
1 EA
08/12/2003
12/31/2004
MR
EA
20 MG
01/01/2005
03/10/2005
IM
ML
150 MG
08/15/2003
99/99/9999
IM
IV
ML
EA
1000 MCG
50 MG
1
1
09/19/2003
09/30/2003
99/99/9999
03/10/2005
IM
ML
1 EA
07/21/2004
99/99/9999
PO
EA
250 MG
1.2
08/26/2004
99/99/9999
PO
SC
IJ
EA
ML
ML
250 MG
5U
0.3 MG
1.2
20
3.33333
09/02/2005
02/16/2006
09/29/2004
99/99/9999
99/99/9999
12/31/2009
IV
ML
6 MG
0.5
09/30/2004
99/99/9999
PO
ML
75 MG
0.16
12/01/2004
05/31/2005
IM
ML
1 EA
11/10/2004
03/21/2007
IM
ML
1 EA
11/10/2004
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54569-5630-00
J3490
G9017
54569-5635-00
54569-5712-00
None
54569-5713-00
None
54569-5715-00
J8999
54569-5716-00
J8999
54569-5717-00
None
54569-5717-00 QR J8521
54569-5718-00
None
54569-5720-00
J0696
54569-5721-00
J0696
54569-5722-00
J0696
54569-5723-00
J0696
54569-5724-00
J0696
54569-5725-00
J0696
54569-5729-00
54569-5729-00
54569-5731-00
54569-5732-00
54569-5741-00
54569-5742-00
Q0181
J8540
J8999
J8999
J8501
J1650
54569-5742-01
J1650
54569-5744-00
K0416
54569-5744-00
J8498
54569-5744-01
K0416
54569-5744-01
J8498
54569-5745-00
54569-5745-00
K0416
J8498
54569-5745-01
K0416
54569-5745-01
J8498
54569-5745-02
K0416
54569-5745-02
J8498
54569-5749-00
54569-5754-00
54569-5755-00
54569-5756-00
J7510
Q0144
Q0144
Q0144
54569-5764-00
J2792
54569-5771-00
54569-5781-00
54569-5781-00
Q0144
J3490
J1324
54569-5789-00
54569-5795-00
54569-5804-00
54569-5806-00
54569-5807-00
54569-5808-00
54569-5809-00
54569-5810-00
Q0167
J2300
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
54569-5815-00
54569-5828-00
54569-5836-00
54569-5837-00
54569-5838-00
54569-5839-00
54569-5840-00
54569-5841-00
54569-5842-00
54569-5843-00
54569-5844-00
J1200
J1460
None
None
None
None
J7506
J7506
None
None
None
QR

MCG/ML
MG/5 ML
7/14/2005 2/27/2007 CYCLOPHOSPHAMIDE, 25 MG, ORAL
7/14/2005 2/27/2007 CYCLOPHOSPHAMIDE, 50 MG, ORAL
HYDROXYUREA 500 MG
7/15/2005 2/27/2007 CAPECITABINE, 500 MG, ORAL
XELODA 500 MG
7/15/2005 2/27/2007 CAPECITABINE, ORAL, 500 MG
XELODA 500 MG
ETOPOSIDE (SOFTGEL) 50 MG
CEFTRIAXONE 250 MG
CEFTRIAXONE 500 MG
CEFTRIAXONE 1 GM
CEFTRIAXONE 250 MG
CEFTRIAXONE 500 MG
CEFTRIAXONE 1 GM
DEXAMETHASONE 4 MG
8/2/2005 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
ARIMIDEX 1 MG
AROMASIN 25 MG
EMEND TRI-FOLD PACK
LOVENOX (2X5 SINGLE DOSE SYRINGE)
80 MG/0.8 ML
PRESCRIPTION ANTIEMETIC DRUG, RECTAL, PER 1 MG, FOR USE IN CONJUCTION PROMETHAZINE HYDROCHLORIDE 12.5
MG
MG
PRESCRIPTION ANTIEMETIC DRUG, RECTAL, PER 1 MG, FOR USE IN CONJUCTION PROMETHAZINE HYDROCHLORIDE 12.5
MG
MG
MG
MG
MG
MG
15 MG/5 ML
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 500 MG
1/12/2006 99/99/9999 DETERGENT, 100 IU
HYPERRHO S/D (FULL DOSE)
1/1/2007 99/99/9999 INJECTION, ENFUVIRTIDE, 1 MG
4/26/2006 4/30/2008 REGIMEN
8/3/2006
9/26/2006
10/9/2006
10/9/2006
10/10/2006
10/10/2006
10/10/2006
10/10/2006
10/10/2006
10/10/2006
10/11/2006

ZMAX (60ML SINGLE-DOSE) 2 GM/60 ML

FUZEON 90 MG
FUZEON 90 MG
MARINOL (SOFT GEL) 2.5 MG

AZITHROMYCIN 600 MG
AZITHROMYCIN 1 GM/Packet
(25X1ML) 50 MG/ML
GAMASTAN S/D (SDV)
TEMODAR 5 MG
TEMODAR 5 MG
TEMODAR 20 MG
TEMODAR 20 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
TEMODAR 100 MG
TEMODAR 100 MG
TEMODAR 250 MG
Page 241 of 374
1 ML VL
IM
ML
1 EA
11/10/2004
99/99/9999
480 ML
100 EA
100 EA
100 EA
90 EA
120 EA
120 EA
20 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BX
VL
VL
VL
VL
VL
VL
PO
PO
PO
PO
PO
PO
PO
PO
IJ
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
100 MG
25 MG
50 MG
1 EA
1 EA
500 MG
500 MG
50 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
0.1
1
1
1
1
1
1
1
1
2
4
1
2
4
12/06/2004
07/14/2005
07/14/2005
07/15/2005
07/15/2005
07/15/2005
07/15/2005
07/20/2005
07/26/2005
07/26/2005
07/26/2005
07/27/2005
07/27/2005
07/27/2005
05/31/2005
02/27/2007
02/27/2007
99/99/9999
10/01/2007
02/27/2007
02/27/2007
02/27/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
28 EA
28 EA
30 EA
30 EA
3 EA
0.8 ML
BO
BO
BO
BO
PG
SR
PO
PO
PO
PO
PO
SC
EA
EA
EA
EA
EA
ML
1 EA
0.25 MG
1 EA
1 EA
5 MG
10 MG
1
16
1
1
19
10
08/02/2005
01/01/2006
08/03/2005
08/03/2005
10/24/2005
10/24/2005
12/31/2005
99/99/9999
99/99/9999
4/11/2008
99/99/9999
4/30/2008
0.8 ML SR
SC
ML
10 MG
10
12/08/2005
02/27/2007
12 EA BX
RC
EA
1 MG
12.5
10/26/2005
12/31/2005
12 EA BX
RC
EA
1 EA
01/01/2006
99/99/9999
6 EA BX
RC
EA
1 MG
12.5
12/27/2005
12/31/2005
6 EA BX
RC
EA
1 EA
01/01/2006
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
10/26/2005
01/01/2006
12/31/2005
99/99/9999
4 EA BX
RC
EA
1 MG
25
12/05/2005
12/31/2005
4 EA BX
RC
EA
1 EA
01/01/2006
99/99/9999
6 EA BX
RC
EA
1 MG
25
12/05/2005
12/31/2005
6 EA BX
RC
EA
1 EA
01/01/2006
99/99/9999
PO
PO
PO
PO
ML
EA
EA
EA
5 MG
1 GM
1 GM
1 GM
0.6
0.25
0.25
0.5
11/04/2005
11/24/2005
11/24/2005
11/24/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
240 ML
4 EA
6 EA
3 EA
BO
BO
DP
DP
1 ML SR
IM
ML
15
01/12/2006
99/99/9999
1 EA BO
60 EA PG
60 EA PG
PO
SC
SC
EA
EA
EA
100 IU
1 GM
1 EA
1 MG
2
1
90
02/14/2006
03/16/2006
01/01/2007
4/30/2008
12/31/2006
99/99/9999
60 EA
1 ML
8 EA
1 EA
15 ML
15 ML
22.5 ML
30 ML
BO
AM
BO
BX
BO
BO
BO
BO
PO
IJ
PO
PO
PO
PO
PO
PO
EA
ML
EA
EA
ML
ML
ML
ML
2.5 MG
10 MG
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1
1
0.6
1
0.02
0.04
0.04
0.04
04/26/2006
05/12/2006
06/30/2006
07/24/2006
07/24/2006
07/24/2006
07/24/2006
07/25/2006
4/30/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML
2 ML
5 EA
20 EA
5 EA
20 EA
21 EA
48 EA
5 EA
20 EA
5 EA
VL
VL
BO
BO
BO
BO
BO
BO
BO
BO
BO
IJ
IM
PO
PO
PO
PO
PO
PO
PO
PO
PO
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
1 ML
5 MG
5 MG
20 MG
20 MG
5 MG
5 MG
100 MG
100 MG
250 MG
1
1
1
1
1
1
2
2
1
1
1
08/03/2006
09/26/2006
10/09/2006
10/09/2006
10/10/2006
10/10/2006
10/10/2006
10/10/2006
10/10/2006
10/10/2006
10/11/2006
99/99/9999
99/99/9999
4/11/2008
4/11/2008
4/11/2008
4/11/2008
99/99/9999
99/99/9999
4/11/2008
4/11/2008
4/11/2008
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54569-5845-00
54569-5857-00
54569-5862-00
None
J8999
J3490
54569-5873-00
54569-5874-00
54569-5876-00
Q0179
J2405
J0560
54569-5877-00
54569-5877-01
J0560
J0560
54569-5910-00
54569-5911-00
J0278
J7506
54569-5946-00
J0170
54569-5949-00
J0170
54569-5957-00
J0540
54569-5958-00
54569-6448-00
J0540
Q0144
54643-1006-00
J1600
54643-1007-00
54643-1043-00
54643-1054-00
54643-1055-00
54643-1056-00
54653-0342-08
54653-0342-53
54746-0001-01
J1600
J3303
J3303
J3303
J3303
J1655
J1655
J9215
54838-0134-40
Q0163
54838-0135-40
Q0163
54838-0135-70
Q0163
54838-0135-80
Q0163
54838-0154-40
Q0163
54838-0154-70
Q0163
54838-0154-80
Q0163
54838-0509-80
54868-0004-00
G9017
J0280
54868-0006-00
54868-0007-00
J0460
J1200
54868-0015-00
J1265
54868-0026-00
Q0163
54868-0026-01
Q0163
10/11/2006 4/11/2008 TEMODAR, 250 MG, ORAL

TEMODAR 250 MG
ONDANSETRON HYDROCHLORIDE 8 MG
ONDANSETRON (5X2ML,SDV) 2 MG/ML
1/17/2007 99/99/9999 INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS
BICILLIN L-A (10X1ML) 600000 U/ML
BICILLIN L-A (10X2ML,1200M U) 600000
U/ML
BICILLIN L-A (1200M U) 600000 U/ML
MG/ML
PREDNISONE (PACK) 5 MG
TWINJECT AUTO-INJECTOR (0.3MG) 1
MG/ML
TWINJECT AUTO-INJECTOR (0.15MG) 1
MG/ML
9/5/2007 12/31/2009 1,200,000 UNITS
BICILLIN C-R (10X2ML)
9/5/2007 12/31/2009 1,200,000 UNITS
BICILLIN C-R 900/300 (10X2ML)
GOLD SODIUM THIOMALATE (M.D.V.) 50
MG/ML
MG/ML
ARISTOSPAN 5 MG/ML
1/1/2002 99/99/9999 INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU
ALFERON N (M.D.V.) 5 Million IU/ML
SILADRYL DAS (AF,SF,DYE-FREE) 12.5
MG/5 ML
SILADRYL ALLERGY (AF,SF) 12.5 MG/5
ML
SILADRYL ALLERGY 12.5 MG/5 ML
SILADRYL ALLERGY (AF,SF) 12.5 MG/5
ML
SILPHEN 12.5 MG/5 ML
AMANTADINE HCL (U.S.P.,RASPBERRY)
50 MG/5 ML
ATROPINE SULFATE (SRN, 21GX1-1/2")
0.1 MG/ML
BENADRYL (VIAL) 50 MG/ML
20 EA BO
30 EA BO
20 ML VL
PO
PO
IV
EA
EA
ML
250 MG
1 EA
1 EA
1
1
1
10/11/2006
11/06/2006
11/13/2006
4/11/2008
99/99/9999
99/99/9999
4 EA BO
2 ML VL
1 ML SR
PO
IJ
IM
EA
ML
ML
8 MG
1 MG
600000 U
1
2
1
01/12/2007
01/12/2007
01/17/2007
99/99/9999
99/99/9999
99/99/9999
2 ML SR
2 ML SR
IM
IM
ML
ML
600000 U
600000 U
1
1
01/17/2007
01/17/2007
99/99/9999
99/99/9999
2 ML VL
48 EA BO
IJ
PO
ML
EA
2.5
1
05/07/2007
05/10/2007
3/13/2008
99/99/9999
100 MG
5 MG
0.3 ML SR
IJ
ML
1 ML
08/13/2007
6/10/2008
0.15 ML SR
IJ
ML
1 ML
08/14/2007
6/10/2008
2 ML SR
IM
ML
1200000 U
0.5
09/05/2007
12/31/2009
2 ML SR
3 EA NA
IM
PO
ML
EA
1200000 U
1 GM
0.5
0.5
09/05/2007
09/24/2002
12/31/2009
01/11/2006
1 ML VL
IM
ML
50 MG
10/01/2003
99/99/9999
VL
VL
VL
VL
VL
VL
VL
VL
IM
IJ
IJ
IJ
IJ
SC
SC
IJ
ML
ML
ML
ML
ML
ML
ML
ML
50 MG
5 MG
5 MG
5 MG
5 MG
1000 IU
1000 IU
250000 IU
1
1
1
4
4
20
20
20
10/01/2003
12/19/2003
03/15/2004
03/15/2004
03/15/2004
04/01/2002
04/01/2002
01/01/2002
99/99/9999
12/31/2004
99/99/9999
99/99/9999
99/99/9999
07/15/2002
07/15/2002
99/99/9999
118 ML BO
PO
ML
50 MG
0.05
01/01/2002
06/30/2005
118 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
237 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
473 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
118 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
237 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
10 ML
5 ML
5 ML
1 ML
5 ML
2 ML
2 ML
1 ML
473 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
480 ML BO
10 ML VL
PO
IV
ML
ML
100 MG
250 MG
0.1
0.1
12/01/2004
01/01/2002
05/31/2005
99/99/9999
ML
ML
0.3 MG
50 MG
0.33333
1
01/01/2002
01/01/2002
12/31/2009
99/99/9999
10 ML SR IJ
10 ML AM IJ
DOPAMINE HYDROCHLORIDE 80 MG/ML
125 ML NA
IV
ML
40 MG
12/11/2006
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
Page 242 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

54868-0026-04
Q0163
1/1/2002
54868-0026-05
Q0163
1/1/2002
54868-0026-06
Q0163
1/1/2002
54868-0026-07
54868-0102-00
54868-0110-01
54868-0110-02
54868-0114-00
Q0163
J7120
J2250
J2250
J2310
6/29/2006
12/11/2006
1/1/2002
1/1/2002
1/1/2002
54868-0115-00
J2270
54868-0116-00
J2912
54868-0116-00
54868-0163-01
54868-0163-02
54868-0163-03
54868-0163-04
54868-0163-05
54868-0163-06
A4216
J8499
J8499
J8499
J8499
J8499
J8499
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

54868-0169-01
Q0177
54868-0173-00
J9250
54868-0173-01
J9250
4/6/2005
54868-0183-00
A4712
54868-0183-00
54868-0186-00
54868-0186-00
A4216
J3490
J0595

1/1/2002 99/99/9999 PHOSPHATE 3MG
54868-0206-00
J0702
54868-0216-00
J1080
54868-0218-00
54868-0218-00
Q0181
J8540
54868-0218-01
54868-0218-01
Q0181
J8540
54868-0218-03
54868-0218-03
Q0181
J8540
54868-0218-04
54868-0218-04
Q0181
J8540
54868-0218-05
54868-0218-05
Q0181
J8540
54868-0218-06
54868-0218-06
Q0181
J8540

1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
10 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
PO
IV
IJ
IJ
IJ
EA
ML
ML
ML
ML
50 MG
1000 ML
1 MG
1 MG
1 MG
0.5
0.001
5
5
0.4
06/29/2006
12/11/2006
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
05/23/2002
05/23/2002
99/99/9999
LACTATED RINGER'S (12X1000ML)
NARCAN (AMP) 0.4 MG/ML
MORPHINE SULFATE (TUBEX,22GX1
1/4") 10 MG/ML
(M.D.V.) 0.9%
(M.D.V.) 0.9%
ZOVIRAX 200 MG
ZOVIRAX 200 MG
ZOVIRAX 200 MG
ZOVIRAX 200 MG
ZOVIRAX 200 MG
ZOVIRAX 200 MG
VISTARIL 25 MG
METHOTREXATE SODIUM (PF) 25
MG/ML
METHOTREXATE SODIUM (PF) 25
MG/ML
WATER FOR INJECTION
WATER FOR INJECTION
MG/ML-3 MG/ML
MG/ML

DEXAMETHASONE 4 MG
6/30/2005 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
7/7/2005 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
7/22/2005 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
8/15/2005 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
8/15/2005 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
Page 243 of 374
60 EA
1000 ML
1 ML
1 ML
1 ML
BO
PC
VL
VL
AM
1 ML SR
IJ
ML
10 MG
01/01/2002
99/99/9999
30 ML VL
IV
ML
0.9 %
0.5
01/01/2002
12/31/2003
IV
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
10 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
0.1
1
1
1
1
1
1
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
9/30/2008
11/19/2003
99/99/9999
11/19/2003
11/19/2003
04/15/2002
11/19/2003
30 ML
50 EA
25 EA
30 EA
100 EA
120 EA
40 EA
VL
BO
BO
BO
BO
BO
BO
100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
2 ML EA
IJ
ML
5 MG
03/26/2003
99/99/9999
20 ML VL
IJ
ML
5 MG
04/06/2005
5/8/2008
30 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
30 ML VL
10 ML VL
10 ML VL
IV
IJ
IJ
ML
ML
ML
10 ML
1 EA
1 MG
0.1
1
2
01/01/2004
01/01/2002
01/01/2004
99/99/9999
12/31/2003
99/99/9999
5 ML VL
IJ
ML
3 MG
01/01/2002
99/99/9999
10 ML VL
IM
ML
200 MG
09/20/2007
99/99/9999
20 EA BO
20 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
06/30/2005
01/01/2006
12/31/2005
99/99/9999
10 EA BO
10 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
3 EA BO
3 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
07/07/2005
01/01/2006
12/31/2005
99/99/9999
30 EA BO
30 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
07/22/2005
01/01/2006
12/31/2005
99/99/9999
16 EA BO
16 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
08/15/2005
01/01/2006
12/31/2005
99/99/9999
100 EA BO
100 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
08/15/2005
01/01/2006
12/31/2005
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
12/16/2005
1/1/2006
9/11/2006
4/3/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
3/14/2002
54868-0261-00
J0780
1/1/2002
54868-0262-00
J2550
54868-0262-01
J2550
54868-0284-00
54868-0296-00
54868-0296-01
54868-0296-02
54868-0296-04
54868-0554-00
54868-0559-00
54868-0597-00
J3301
J7060
J7060
J7060
J7060
J1200
J0690
J2550

54868-0601-00
K0416
2/18/2003
54868-0601-01
54868-0601-01
K0416
J8498
4/28/2003
1/1/2006
54868-0601-02
54868-0601-02
54868-0605-00
54868-0608-00
K0416
J8498
J1720
J3250
7/8/2003
1/1/2006
1/1/2002
1/1/2002
54868-0616-00
54868-0617-00
54868-0617-01
54868-0617-02
J2175
J3360
J3360
J3360
54868-0622-00
54868-0622-00
K0416
J8498
54868-0622-02
54868-0622-02
54868-0710-00
54868-0710-01
K0416
J8498
J7030
J7040

1/1/2002
PROMETHAZINE HCL (M.D.V.) 50 MG/ML

PROMETHAZINE HCL (10X25ML,MDV) 50
MG/ML
TRIAMCINOLONE ACETONIDE (VIAL) 40
MG/ML
DEXTROSE 5%
DEXTROSE 5%
DEXTROSE 5%
PO
PO
PO
PO
IM
IJ
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
0.25 MG
0.25 MG
0.25 MG
25 MG
10 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
16
16
16
2
1
1
1
1
1
1
1
1
1
12/16/2005
01/01/2006
09/11/2006
04/03/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/14/2002
10 ML VL
IJ
ML
10 MG
0.5
01/01/2002
99/99/9999
IJ
ML
50 MG
0.5
01/01/2002
99/99/9999
10 ML VL
IJ
ML
50 MG
09/29/2005
99/99/9999
IJ
IV
IV
IV
IV
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
EA
ML
10 MG
500 ML
500 ML
500 ML
500 ML
50 MG
500 MG
50 MG
4
0.002
0.002
0.002
0.002
1
2
0.5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/12/2006
01/01/2002
01/01/2002
01/01/2002
02/28/2002
04/15/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
VL
NA
FC
FC
FC
VL
VL
AM
6 EA BX
RC
EA
1 MG
25
02/18/2003
05/23/2005
2 EA BX
2 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
04/28/2003
01/01/2006
12/31/2005
99/99/9999
SOLU-CORTEF (S.D.V.) 100 MG
TRIMETHOBENZAMIDE HCL 100 MG/ML
DEMEROL HYDROCHLORIDE (M.D.V.) 50
MG/ML
DIAZEPAM (M.D.V.,FLIPTOP) 5 MG/ML
DIAZEPAM (10X10ML,M.D.V) 5 MG/ML
12 EA
12 EA
1 EA
2 ML
BX
BX
VL
VL
RC
RC
IJ
IM
EA
EA
EA
ML
1 MG
1 EA
100 MG
200 MG
25
1
1
0.5
07/08/2003
01/01/2006
01/01/2002
01/01/2002
12/31/2005
99/99/9999
99/99/9999
99/99/9999
30 ML
10 ML
10 ML
10 ML
VL
VL
VL
VL
IJ
IJ
IJ
IJ
ML
ML
ML
ML
100 MG
5 MG
5 MG
5 MG
0.5
1
1
1
01/01/2002
01/01/2002
03/07/2002
04/03/2008
99/99/9999
09/01/2006
99/99/9999
99/99/9999
COMPAZINE 25 MG
COMPAZINE 25 MG
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
RC
RC
IV
IV
EA
EA
ML
ML
1 MG
1 EA
1000 ML
500 ML
25
1
0.001
0.002
01/01/2002
01/01/2006
01/01/2002
01/01/2002
12/31/2005
99/99/9999
99/99/9999
99/99/9999
500 ML PC
IR
ML
1000 ML
0.001
05/22/2003
12/31/2003
500 ML PC
IR
ML
500 ML
0.002
01/01/2004
99/99/9999
100 ML PC
IV
ML
250 ML
0.004
12/12/2006
99/99/9999
1000 ML FC
IV
ML
1000 ML
0.001
12/15/2006
99/99/9999
50 ML FC
IV
ML
10 ML
0.1
12/15/2006
99/99/9999
250 ML FC
10 ML VL
IV
IJ
ML
ML
250 ML
5 MG
0.004
1
01/02/2007
01/01/2002
99/99/9999
99/99/9999
12 EA BO
1 ML VL
PO
IM
EA
ML
12.5 MG
1 EA
1
1
01/01/2002
08/27/2002
99/99/9999
99/99/9999
12/31/2009
COMPAZINE 25 MG
COMPAZINE 25 MG
0.9%
0.9%
SODIUM CHLORIDE (NORMAL
SALINE,48X100ML) 0.9%
VALIUM (VIAL) 5 MG/ML
PHENERGAN 12.5 MG
ENGERIX-B (S.D.V.,PF) 20 MCG/ML
6 EA
6 EA
1000 ML
500 ML
BX
BX
FC
FC
54868-0710-02
A4323
5/22/2003
54868-0710-02
A4217
1/1/2004
54868-0710-03
J7050
12/12/2006
54868-0710-04
J7030
12/15/2006
54868-0710-05
A4216
12/15/2006
54868-0710-06
54868-0716-00
J7050
J3360
1/2/2007
1/1/2002
54868-0721-00
54868-0734-00
Q0169
J3490
1/1/2002
8/27/2002
54868-0740-00
J0460
20 ML VL
IJ
ML
0.3 MG
1.33333
01/01/2002
54868-0740-01
J0460
20 ML VL
IJ
ML
0.3 MG
1.33333
01/01/2002
12/31/2009
54868-0748-00
54868-0753-00
54868-0753-01
J2310
J0560
J0560


NALOXONE HCL (SRN,PREFILLED,MIN-IJET) 0.4 MG/ML
IJ
IM
IM
ML
ML
ML
1 MG
600000 U
600000 U
0.4
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
Page 244 of 374
1 ML SR
2 ML SR
2 ML SR
Prior End Date #3
Prior Start Date #3
Prior End Date #2
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 ML VL
5 ML
1000 ML
500 ML
250 ML
100 ML
1 ML
1 EA
1 ML
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
BO
BO
BO
VL
VL
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
40 EA
40 EA
50 EA
5 EA
10 ML
5 ML
30 EA
100 EA
50 EA
20 EA
36 EA
55 EA
60 EA
15 EA

Package
NDC Package Type
Q0181
J8540
J8540
J8540
J3410
J3301
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
NDC Package Measure

DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE (USP) 4 MG
DEXAMETHASONE 4 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
(M.D.V.) 5 MG/ML
54868-0218-07
54868-0218-07
54868-0218-08
54868-0218-09
54868-0231-00
54868-0234-00
54868-0258-01
54868-0258-02
54868-0258-03
54868-0258-04
54868-0258-05
54868-0258-06
54868-0258-08
54868-0258-09
1/1/2002
1/1/2002
1/1/2002
1/1/2002
12/12/2006
1/1/2002
1/1/2002
1/1/2002
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54868-0756-00
54868-0762-00
54868-0762-01
J3250
J3420
J3420
54868-0767-00
54868-0767-01
54868-0768-00
54868-0776-01
54868-0796-00
J3480
J3480
J2920
J7509
J1070

1/1/2002
3/16/2007
1/1/2002
1/1/2002
10/21/2004

54868-0800-00
G9017
12/1/2004
54868-0800-01
G9017
12/1/2004
54868-0800-02
G9017
12/1/2004
54868-0800-03
G9017
12/1/2004
54868-0800-04
G9017
12/1/2004
54868-0800-07
54868-0821-00
54868-0836-00
54868-0836-02
54868-0836-03
54868-0836-04
54868-0836-05
54868-0836-07
54868-0836-08
54868-0858-00
G9017
J7510
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J3410
12/1/2004
4/11/2007
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54868-0871-00
J1100
54868-0871-01
J1100
54868-0871-06
54868-0908-00
54868-0908-01
54868-0908-02
54868-0908-03
54868-0908-04
J1100
J7506
J7506
J7506
J7506
J7506
1/1/2002
1/1/2002
11/10/2005
2/16/2006
5/16/2006
2/6/2007
54868-0916-00
54868-0916-00
54868-0921-01
54868-0921-02
54868-0921-04
54868-0923-01
54868-0934-00
54868-0934-01
Q0181
J8540
J7500
J7500
J7500
J7506
J0696
J0696
1/1/2002
1/1/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
6/11/2003
54868-0948-00
J7616
9/19/2005
54868-0948-00
J7620
54868-0954-00
J7510
54868-1050-00
Q0163
54868-1050-01
Q0163
54868-1050-03
Q0163
54868-1050-04
Q0163
54868-1050-05
Q0163

CYANOCOBALAMIN 1000 MCG/ML
POTASSIUM CHLORIDE (VIAL) 2 MEQ/ML
POTASSIUM CHLORIDE 2 MEQ/ML
SOLU-MEDROL (S.D.V.) 40 MG
MEDROL (DOSE PACK) 4 MG
20 ML VL
30 ML VL
1 ML VL
10 ML
250 ML
1 EA
21 EA
10 ML
VL
VL
VL
DP
VL
IM
IM
IM
ML
ML
ML
200 MG
1000 MCG
1000 MCG
0.5
1
1
01/01/2002
01/01/2002
09/18/2003
99/99/9999
99/99/9999
99/99/9999
IV
IV
IJ
PO
IM
ML
ML
EA
EA
ML
2 MEQ
2 MEQ
40 MG
4 MG
100 MG
1
1
1
1
1
01/01/2002
03/16/2007
01/01/2002
01/01/2002
10/21/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
60 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
10 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
30 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005

ORAPRED ODT 15 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 50 MG
PREDNISONE 50 MG
PREDNISONE 50 MG
15 EA
48 EA
40 EA
100 EA
50 EA
15 EA
60 EA
30 EA
20 EA
1 ML
PO
PO
PO
PO
PO
PO
PO
PO
PO
IM
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
100 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
25 MG
1
3
2
2
2
2
2
2
2
1
12/01/2004
04/11/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999

12/31/2005 REGIMEN
IMURAN 50 MG
IMURAN 50 MG
IMURAN 50 MG
DELTASONE 5 MG
ROCEPHIN 250 MG
12/31/2005 COMPOUNDED INHALATION SOLUTION, ADMINISTERED THROUGH DME
DUONEB 3 MG/3 ML-0.5 MG/3 ML
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA1/1/2006 99/99/9999 APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME DUONEB 3 MG/3 ML-0.5 MG/3 ML
ORAPRED (DYE-FREE,GRAPE) 15 MG/5
ML
Page 245 of 374
BO
BX
BO
BO
BO
BO
BO
BO
BO
VL
5 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
125 ML NA
IJ
ML
1 MG
07/21/2003
99/99/9999
30 ML
30 EA
10 EA
3 EA
50 EA
60 EA
VL
BO
BO
BO
BO
BO
IJ
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
1 MG
5 MG
5 MG
5 MG
5 MG
5 MG
4
10
10
10
10
10
01/01/2002
01/01/2002
11/10/2005
02/16/2006
05/16/2006
02/06/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 EA
30 EA
30 EA
20 EA
50 EA
30 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
VL
NA
PO
PO
PO
PO
PO
PO
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
0.25 MG
50 MG
50 MG
50 MG
5 MG
250 MG
250 MG
1
3
1
1
1
1
1
1
01/01/2002
01/01/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/11/2003
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
IH
ML
5 MG
0.16666
09/19/2005
12/31/2005
3 ML PC
IH
ML
2.5 MG
0.33333
01/01/2006
99/99/9999
237 ML BO
3 ML PC
PO
ML
5 MG
0.6
12/16/2003
99/99/9999
20 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
1000 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
40 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54868-1050-06
Q0163
4/15/2002
54868-1081-02
Q0165
1/1/2002
54868-1082-00
Q0165
1/1/2002
54868-1082-01
Q0165
1/29/2004
54868-1082-02
Q0165
6/3/2005
54868-1082-03
Q0165
8/24/2007
54868-1082-04
Q0165
2/10/2005
54868-1082-05
Q0165
6/9/2005
54868-1082-06
54868-1119-01
54868-1119-02
54868-1119-03
54868-1119-04
54868-1119-05
54868-1126-00
54868-1126-01
54868-1126-02
54868-1126-03
54868-1126-04
54868-1126-05
54868-1133-00
54868-1183-00
54868-1183-01
54868-1183-02
54868-1183-03
54868-1183-07
54868-1183-08
54868-1183-09
Q0165
J7506
J7506
J7506
J7506
J7506
J8999
J8999
J8999
J8999
J8999
J8999
J2910
J7506
J7506
J7506
J7506
J7506
J7506
J7506
4/16/2007
1/1/2002
12/9/2002
12/9/2002
6/1/2004
10/5/2004
8/11/2003
11/22/2005
11/22/2005
11/22/2005
5/23/2006
10/17/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
8/19/2003
8/15/2005
54868-1227-00
Q0163
2/23/2006
54868-1227-02
Q0163
10/22/2002
54868-1284-02
Q0164
1/1/2002
54868-1323-00
Q0170
1/1/2002
54868-1323-01
Q0170
1/1/2002
54868-1323-02
Q0170
1/1/2002

COMPAZINE 10 MG
PREDNISONE 1 MG
PREDNISONE 1 MG
PREDNISONE 1 MG
PREDNISONE 1 MG
PREDNISONE 1 MG
LEUKERAN 2 MG
LEUKERAN 2 MG
LEUKERAN 2 MG
LEUKERAN 2 MG
LEUKERAN 2 MG
LEUKERAN 2 MG
10/20/2004 INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
DIPHENHYDRAMINE (AF) 12.5 MG/5 ML
GENAHIST (AF,SF,CHERRY) 12.5 MG/5
ML
COMPAZINE 5 MG
Page 246 of 374
15 EA NA
PO
EA
50 MG
04/15/2002
99/99/9999
20 EA BO
PO
EA
10 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
10 MG
01/01/2002
99/99/9999
10 EA BO
PO
EA
10 MG
01/29/2004
99/99/9999
20 EA BO
PO
EA
10 MG
06/03/2005
99/99/9999
100 EA BO
PO
EA
10 MG
08/24/2007
99/99/9999
30 EA BO
PO
EA
10 MG
02/10/2005
99/99/9999
60 EA BO
PO
EA
10 MG
06/09/2005
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
VL
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
IM
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
EA
EA
EA
EA
EA
EA
EA
10 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
0.2
0.2
0.2
0.2
0.2
1
1
1
1
1
1
1
4
4
4
4
4
4
4
04/16/2007
01/01/2002
12/09/2002
12/09/2002
06/01/2004
10/05/2004
08/11/2003
11/22/2005
11/22/2005
11/22/2005
05/23/2006
10/17/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/19/2003
08/15/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/20/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
473 ML BO
PO
ML
50 MG
0.05
02/23/2006
99/99/9999
120 ML BO
PO
ML
50 MG
0.05
10/22/2002
99/99/9999
30 EA BO
PO
EA
5 MG
01/01/2002
99/99/9999
100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
10 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
12 EA BO
PO
EA
25 MG
07/02/2003
99/99/9999
90 EA
100 EA
90 EA
30 EA
15 EA
60 EA
50 EA
30 EA
10 EA
25 EA
5 EA
100 EA
10 ML
100 EA
15 EA
60 EA
30 EA
20 EA
10 EA
25 EA
1/1/2002
4/15/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54868-1323-04
Q0170
1/1/2002
54868-1323-05
Q0170
1/1/2002
54868-1323-06
Q0170
1/1/2002
54868-1323-07
Q0170
6/15/2005
54868-1323-08
54868-1363-00
54868-1366-00
54868-1367-00
54868-1429-01
54868-1429-01
Q0170
J0170
J8999
J8999
J1820
J1815
9/21/2005
1/1/2002
4/6/2006
8/8/2003
1/1/2002
1/1/2003
54868-1485-01
54868-1613-02
54868-1629-00
54868-1629-01
54868-1629-02
54868-1720-00
54868-1729-00
Q0173
J8498
J8999
J8999
J8999
J7510
J1000
1/1/2002
9/11/2006
10/3/2005
10/3/2005
7/6/2007
1/1/2002
1/1/2002
54868-1744-00
54868-1744-00
54868-1795-00
54868-1795-00
54868-1798-01
54868-1798-01
Q0181
J8540
J2000
J2001
J2000
J2001
1/1/2002
1/1/2006
1/1/2002
1/1/2004
1/1/2002
1/1/2004
54868-1854-00
Q0178
1/1/2002
54868-1854-01
Q0178
1/1/2002
54868-1854-03
Q0178
1/1/2002
54868-1854-04
Q0178
1/1/2002
54868-1867-00
Q0170
1/1/2002
54868-1932-00
54868-1932-00
K0416
J8498
1/1/2002
1/1/2006
54868-1932-01
54868-1932-01
K0416
J8498
1/1/2002
1/1/2006
54868-1932-02
54868-1932-02
K0416
J8498
9/30/2002
1/1/2006
54868-1963-00
Q0174
2/11/2003
54868-1963-01
Q0174
2/11/2003

MATULANE 50 MG
HYDREA 500 MG
HUMULIN N 100 U/ML
HUMULIN N 100 U/ML
TIGAN 100 MG
PROMETHAZINE (USP) 50 MG
PEDIAPRED 5 MG/5 ML
DEPO-ESTRADIOL (VIAL) 5 MG/ML
12/31/2005 REGIMEN
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
TORECAN 10 MG
TORECAN 10 MG
Page 247 of 374
15 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
60 EA BO
PO
EA
25 MG
06/15/2005
99/99/9999
50 EA
1 ML
100 EA
100 EA
10 ML
10 ML
BO
AM
BO
BO
VL
VL
PO
IJ
PO
PO
SC
SC
EA
ML
EA
EA
ML
ML
25 MG
1 ML
1 EA
1 EA
100 U
5U
1
1
1
1
1
20
09/21/2005
01/01/2002
04/06/2006
08/08/2003
01/01/2002
01/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2002
99/99/9999
15 EA
6 EA
100 EA
14 EA
30 EA
120 ML
5 ML
BO
BX
BO
BO
BO
BO
VL
PO
RC
PO
PO
PO
PO
IM
EA
EA
EA
EA
EA
ML
ML
250 MG
1 EA
1 EA
1 EA
1 EA
5 MG
5 MG
0.4
1
1
1
1
0.2
1
01/01/2002
09/11/2006
10/03/2005
10/03/2005
07/06/2007
01/01/2002
01/01/2002
02/12/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA
100 EA
50 ML
50 ML
10 ML
10 ML
BO
BO
VL
VL
VL
VL
PO
PO
EP
EP
IJ
IJ
EA
EA
ML
ML
ML
ML
1 EA
0.25 MG
50 ML
10 MG
50 ML
10 MG
1
6
0.02
1
0.02
2
01/01/2002
01/01/2006
01/01/2002
01/01/2004
01/01/2002
01/01/2004
12/31/2005
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
60 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
500 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
120 ML BO
PO
ML
25 MG
0.05
01/01/2002
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
1 EA BX
1 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
6 EA BX
6 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
09/30/2002
01/01/2006
12/31/2005
99/99/9999
15 EA BO
PO
EA
10 MG
02/11/2003
99/99/9999
10 EA BO
PO
EA
10 MG
02/11/2003
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54868-1994-00
J1040
1/1/2002
54868-2048-00
J1200
54868-2048-01
54868-2062-00
54868-2064-00
54868-2064-00
54868-2064-01
54868-2065-00
54868-2065-01
54868-2088-00
54868-2184-00
54868-2184-02
54868-2184-03
54868-2184-04
J1200
J2310
J2000
J2001
J2001
J0170
J0170
J2550
J8499
J8499
J8499
J8499
54868-2219-00
J3490
54868-2219-01
54868-2289-01
54868-2289-01
54868-2299-00
J3490
J3490
J3590
J1940
1/1/2002
1/1/2002
1/1/2003
9/29/2005
54868-2302-00
Q0172
1/1/2002
54868-2302-02
54868-2320-01
54868-2320-02
54868-2331-00
54868-2331-00
54868-2331-01
54868-2331-01
Q0172
J3360
J3360
J2000
J2001
J2000
J2001
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2004
6/23/2006
1/1/2002
1/1/2002
9/29/2005
1/1/2002
1/1/2002
1/1/2002
1/1/2002
Q0172
1/1/2002
54868-2362-01
54868-2380-01
54868-2407-01
54868-2429-01
J1990
J1815
J2060
J0515
1/1/2002
7/16/2007
1/1/2002
1/1/2002
54868-2464-00
Q0172
1/1/2002
54868-2464-02
54868-2466-00
Q0172
J0560
8/8/2007
6/12/2006
54868-2472-00
J7603
1/1/2008
54868-2472-00
KO
J7613
54868-2472-00 KO J7613
1/1/2008
4/1/2008
KO
4/1/2008
54868-2472-01
J7602
1/1/2008
54868-2472-01
54868-2488-01
54868-2489-01
54868-2489-01
54868-2522-00
54868-2523-00
54868-2523-00
54868-2523-01
J7611
J0696
J3490
J3411
J1440
Q0136
J0885
Q0136
4/1/2008
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2006
1/1/2002

54868-2347-00
54868-2472-00 KO J7603

10/14/2004 INJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MG
12/31/2005 INJECTION, EPOETIN ALPHA, (FOR NON ESRD USE), PER 1000 UNITS
99/99/9999 INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS
METHYLPREDNISOLONE ACETATE 80
MG/ML
DIPHENHYDRAMINE HCL (VIAL) 50
MG/ML
DIPHENHYDRAMINE HCL (VIAL) 50
MG/ML
NALOXONE HCL (AMP) 0.4 MG/ML
LIDOCAINE HCL 2%
EPINEPHRINE HCL 1 MG/ML
EPINEPHRINE HCL 1 MG/ML
ZOVIRAX 800 MG
ZOVIRAX 800 MG
ZOVIRAX 800 MG
ZOVIRAX 800 MG
INCL) 10 MCG/ML
MCG/ML
5 ML VL
IJ
ML
80 MG
01/01/2002
04/16/2002
1 ML VL
IJ
ML
50 MG
01/01/2002
99/99/9999
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
PO
PO
PO
PO
ML
ML
ML
ML
ML
ML
ML
ML
EA
EA
EA
EA
50 MG
1 MG
50 ML
10 MG
10 MG
1 ML
1 ML
50 MG
1 EA
1 EA
1 EA
1 EA
1
0.4
0.02
2
2
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2004
06/23/2006
01/01/2002
01/01/2002
09/29/2005
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
IM
ML
1 EA
01/01/2002
99/99/9999
IM
IM
IM
IJ
ML
ML
ML
ML
1 EA
1 EA
1 EA
20 MG
1
1
1
0.5
01/01/2002
01/01/2002
01/01/2003
09/29/2005
99/99/9999
12/31/2002
99/99/9999
99/99/9999
PO
EA
25 MG
01/01/2002
99/99/9999
PO
IJ
IJ
EP
EP
EP
EP
EA
ML
ML
ML
ML
ML
ML
25 MG
5 MG
5 MG
50 ML
10 MG
50 ML
10 MG
2
1
1
0.02
1
0.02
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
99/99/9999
99/99/9999
99/99/9999
12/31/2003
12/31/2007
12/31/2003
12/31/2007
1 ML
1 ML
50 ML
50 ML
1250 ML
1 ML
1 ML
25 ML
100 EA
30 EA
25 EA
50 EA
VL
AM
VL
VL
VL
AM
AM
AM
BO
BO
BO
BO
3 ML VL
1 ML
1 ML
1 ML
250 ML
VL
VL
VL
VL
10 EA BO
DIAZEPAM 5 MG/ML
DIAZEPAM (AMP) 5 MG/ML
100 EA
2 ML
2 ML
50 ML
50 ML
30 ML
30 ML
BO
SR
AM
VL
VL
VL
VL

LIBRIUM (DUPLEX AMP W/DILUENT) 100
MG
NOVOLIN N 100 U/ML
ATIVAN 2 MG/ML
100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
AM
VL
VL
AM
IJ
SC
IJ
IJ
EA
ML
ML
ML
100 MG
5U
2 MG
1 MG
1
20
1
1
01/01/2002
07/16/2007
01/01/2002
01/01/2002
10/14/2004
99/99/9999
99/99/9999
99/99/9999
30 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
60 EA NA
4 ML SR
PO
IM
EA
ML
25 MG
600000 U
1
1
08/08/2007
06/12/2006
99/99/9999
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
01/01/2008
03/31/2008

THIAMINE HCL 100 MG/ML
THIAMINE HCL 100 MG/ML
PROCRIT (S.D.V.) 10000 U/ML
3 ML
1 EA
2 ML
2 ML
1 ML
1 ML
1 ML
1 ML
IH
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
EA
ML
ML
ML
ML
ML
ML
5
4
1
1
1
10
10
10
04/01/2008
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2006
01/01/2002
99/99/9999
99/99/9999
12/31/2003
99/99/9999
99/99/9999
12/31/2005
99/99/9999
12/31/2005
Page 248 of 374
1 EA
10 ML
10 ML
2 ML
PC
VL
VL
VL
VL
VL
VL
VL
1 MG
250 MG
1 EA
100 MG
300 MCG
1000 U
1000 U
1000 U
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54868-2523-01
54868-2526-00
54868-2527-00
J0885
J1642
A4216
54868-2528-00
54868-2530-00
J2545
J3070
54868-2652-00
J3030
54868-2652-01
J3030
54868-2684-01
Q0171
54868-2686-00
Q0175
54868-2687-01
Q0176
54868-2687-02
Q0176
54868-2695-00
54868-2746-00
54868-2746-00
J2550
J1820
J1815
54868-2777-00
54868-2825-00
J1817
J1950
54868-2844-00
Q0170
54868-2844-01
54868-2889-00
54868-2889-01
Q0170
J1631
J1631
54868-2892-00
Q0177
54868-2892-02
Q0177
54868-2892-03
Q0177
54868-2892-04
54868-2913-00
54868-2913-01
54868-2913-02
Q0177
J7509
J7509
J7509
54868-2973-00
Q0173
54868-2973-02
Q0173
54868-2973-03
Q0173
54868-2973-04
54868-3004-01
Q0173
J8999
1/1/2006 99/99/9999 INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS
HEP-LOCK (VIAL,DOSETTE) 100 U/ML
SODIUM CHLORIDE (150X5ML) 0.9%
NEBUPENT (S.D.V.,PF) 300 MG
TALWIN LACTATE (VIAL) 30 MG/ML
IMITREX (SDV) 6 MG/0.5 ML
CHLORPROMAZINE 10 MG
PERPHENAZINE 4 MG
1/1/2002 99/99/9999 REGIMEN
PERPHENAZINE 8 MG
1/1/2002 99/99/9999 REGIMEN
PERPHENAZINE 8 MG
6/12/2007 99/99/9999 REGIMEN

5/7/2007 99/99/9999 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS NOVOLOG 100 U/ML
3/10/2003 99/99/9999 INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG
LUPRON DEPOT 3.75 MG
Page 249 of 374
1 ML VL
1 ML VL
5 ML SR
IJ
IV
IV
ML
ML
ML
1000 U
10 U
10 ML
10
10
0.1
01/01/2006
01/01/2002
06/28/2007
99/99/9999
99/99/9999
99/99/9999
1 EA VL
10 ML VL
IH
IJ
EA
ML
300 MG
30 MG
1
1
1/1/2007
01/01/2002
99/99/9999
99/99/9999
0.5 ML VL
SC
ML
6 MG
01/01/2002
99/99/9999
5 ML VL
SC
ML
6 MG
08/28/2006
99/99/9999
30 EA BO
PO
EA
10 MG
02/01/2007
99/99/9999
30 EA BO
PO
EA
4 MG
01/01/2002
99/99/9999
100 EA BO
PO
EA
8 MG
01/01/2002
99/99/9999
60 EA BO
PO
EA
8 MG
06/12/2007
99/99/9999
10 ML VL
10 ML VL
10 ML VL
IJ
SC
SC
ML
ML
ML
50 MG
100 U
5U
0.5
1
20
01/01/2002
01/01/2002
01/01/2003
99/99/9999
12/31/2002
99/99/9999
10 ML VL
1 EA BX
SC
IM
ML
EA
50 U
3.75 MG
2
1
05/07/2007
03/10/2003
99/99/9999
99/99/9999
60 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
30 EA BO PO
1 ML AM IM
1 ML AM IM
EA
ML
ML
25 MG
50 MG
50 MG
2
1
1
04/21/2008
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
500 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
25 MG
09/19/2005
99/99/9999
BO
BO
BO
BO
PO
PO
PO
PO
EA
EA
EA
EA
25 MG
4 MG
4 MG
4 MG
1
1
1
1
10/11/2005
01/01/2002
01/01/2002
07/29/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
15 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
100 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
10 EA BO
120 EA BO
PO
PO
EA
EA
250 MG
1 EA
1
1
05/26/2004
01/01/2002
99/99/9999
99/99/9999
15 EA
100 EA
30 EA
60 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
MARCAINE HCL 0.5%
PROCAINAMIDE HCL (VIAL,FLIPTOP) 100
MG/ML
1/27/2006
12/11/2006
12/5/2007
1/1/2002
54868-3112-00
54868-3112-00
K0416
J8498
1/1/2002
1/1/2006
54868-3112-01
54868-3112-01
54868-3134-00
54868-3134-01
K0416
J8498
J3490
J3490
4/12/2004
1/1/2006
1/1/2002
2/2/2007
54868-3136-00
J2690
54868-3157-00
54868-3157-00
Q0181
J8540
54868-3157-01
J8540
54868-3179-00
J7669

DEXAMETHASONE 2 MG
6/21/2005 12/31/2005 REGIMEN
DEXAMETHASONE 2 MG
DEXAMETHASONE (USP,GLUTEN-FREE)
2 MG
ALUPENT (VIAL) 0.6%
1/1/2002 99/99/9999 PER 10 MILLIGRAMS
ALUPENT (VIAL) 0.6%
1/1/2002 99/99/9999 PER 10 MILLIGRAMS
IMITREX (SRN) 6 MG/0.5 ML
LEUKINE 500 MCG/ML
54868-3181-00
54868-3188-00
J3030
J2820
54868-3189-00
Q0168
54868-3189-01
54868-3189-02

6/7/2005 99/99/9999 OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN MARINOL (SOFTGEL) 5 MG
99/99/9999
EA
2.5 MG
02/11/2004
99/99/9999
PO
IV
IV
PO
EA
ML
ML
ML
2.5 MG
1 EA
1 EA
1 EA
1
1
1
1
01/27/2006
12/11/2006
12/05/2007
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
6 EA
6 EA
30 ML
50 ML
RC
RC
IJ
IJ
EA
EA
ML
ML
1 MG
1 EA
1 EA
1 EA
25
1
1
1
04/12/2004
01/01/2006
01/01/2002
02/02/2007
12/31/2005
99/99/9999
99/99/9999
99/99/9999
10 ML VL
IV
ML
1 GM
0.1
02/18/2004
99/99/9999
10 EA BO
10 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
8
06/21/2005
01/01/2006
12/31/2005
99/99/9999
48 EA BO
PO
EA
0.25 MG
05/10/2007
99/99/9999
2.5 ML VL
IH
ML
10 MG
0.6
01/01/2002
99/99/9999
2.5 ML VL
IH
ML
10 MG
0.6
01/01/2002
99/99/9999
2 ML BX
5 ML VL
SC
IV
ML
ML
6 MG
50 MCG
2
10
01/01/2002
05/23/2006
99/99/9999
99/99/9999
90 EA
50 ML
1250 ML
240 ML
BX
BX
VL
VL
25 EA BO
PO
EA
5 MG
06/07/2005
99/99/9999
Q0168

1/30/2006 99/99/9999 OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN MARINOL 5 MG
100 EA BO
PO
EA
5 MG
01/30/2006
99/99/9999
Q0168

2/7/2006 99/99/9999 OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN MARINOL 5 MG
60 EA BO
PO
EA
5 MG
02/07/2006
99/99/9999
54868-3189-03
Q0168
6/6/2006
54868-3216-00
54868-3220-00
54868-3221-00
54868-3221-01
G9017
J7510
J0696
J0696
2/23/2005
1/1/2002
1/1/2002
1/1/2002
54868-3230-01
J2175
1/1/2002
54868-3231-01
J7643
1/1/2002
54868-3231-01 KO J7643
54868-3234-00
54868-3236-00
54868-3244-00
54868-3277-00
MARINOL (SOFTGEL) 2.5 MG

MEGACE 40 MG/ML
HCPCS Amount #1
NDC Label
Q0167
J7799
J7799
J8999
01/01/2002
J7506
J3490
Q0144
J1950
KO
1/1/2002
1/1/2002
1/2/2003
6/8/2004
1/1/2002

99/99/9999 OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN MARINOL 5 MG
MG/5 ML
DEMEROL HYDROCHLORIDE (UNI-AMP)
50 MG/ML
MG
ENGERIX-B PEDIATRIC 10 MCG/0.5 ML
LUPRON DEPOT (S.D.V.) 3.75 MG
Page 250 of 374
15 EA NA
473 ML
240 ML
1 EA
1 EA
BO
BO
VL
VL
PO
EA
5 MG
06/06/2006
99/99/9999
PO
PO
IJ
IJ
ML
ML
EA
EA
100 MG
5 MG
250 MG
250 MG
0.1
0.6
2
2
02/23/2005
01/01/2002
01/01/2002
01/01/2002
05/31/2005
99/99/9999
99/99/9999
99/99/9999
25 ML AM IJ
ML
100 MG
0.5
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1 MG
0.2
01/01/2002
99/99/9999
PO
IM
PO
IM
EA
ML
EA
EA
5 MG
1 EA
1 GM
3.75 MG
2
1
0.5
1
01/01/2002
01/02/2003
06/08/2004
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
48 EA
0.5 ML
3 EA
1 EA
DP
VL
DP
BX
BO
SR
GC
BO
54868-3084-02
54868-3089-00
54868-3089-01
54868-3099-01
Prior End Date #3
PO
2/11/2004
2.5 MG
Prior Start Date #3
30 EA BO
Q0167
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
MARINOL 2.5 MG
54868-3084-01
01/01/2002
02/02/2006
04/10/2006
04/13/2006
01/01/2002
08/14/2006
01/13/2006
Prior End Date #2
EA
1
1
1
1
1
1.25
1
Prior Start Date #2
PO
1/1/2002
End Date #1
60 EA BO
Q0167
Start Date #1
MARINOL (SOFTGEL) 2.5 MG
54868-3084-00
CF
1 EA
1 EA
1 EA
1 EA
1 EA
480 MCG
50 MG
ZOVIRAX 400 MG
NEUPOGEN 480 MCG/0.8 ML
BENADRYL 50 MG/ML
HCPCS Measure #1
EA
EA
EA
EA
EA
ML
ML
1/1/2002
2/2/2006
4/10/2006
4/13/2006
1/1/2002
8/14/2006
1/13/2006
Billing Units
NDC Package Type
PO
PO
PO
PO
PO
IJ
IJ
J8999
J8999
J8999
J8999
J8499
J1441
J1200
KO
NDC Package Measure
BO
BO
BO
BO
BO
SR
VL
54868-3004-02
54868-3004-03
54868-3004-04
54868-3004-05
54868-3025-00
54868-3050-00
54868-3053-00
54868-3179-00 KO J7669

99/99/9999 REGIMEN
99/99/9999 REGIMEN
99/99/9999 REGIMEN

Package
60 EA
180 EA
100 EA
30 EA
15 EA
10 ML
25 ML
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54868-3341-00
54868-3344-00
54868-3348-01
54868-3348-01
54868-3349-00
54868-3392-00
54868-3392-00
J9214
J3303
J1050
J1051
J0560
J2000
J2001
7/2/2003
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2002
1/1/2004
54868-3407-00
J7602
1/1/2008
54868-3407-00
54868-3429-00
54868-3429-01
54868-3437-00
J7611
J0698
J0698
J3490
4/1/2008
1/1/2002
1/1/2002
2/2/2007
54868-3441-00
G9036
12/1/2004
54868-3459-00
54868-3471-00
54868-3474-00
54868-3474-00
J1630
J2300
J1820
J1815
1/1/2002
1/1/2002
1/1/2002
1/1/2003
54868-3479-00
J7602
54868-3479-00
J7611
54868-3480-00
54868-3481-00
J2540
J0290
54868-3508-00
Q0179
54868-3508-01
Q0179
54868-3508-02
Q0179
54868-3509-00
Q0179
54868-3509-01
Q0179
54868-3509-02
Q0179
54868-3509-03
Q0179
54868-3555-00
J7631
54868-3555-00 KO J7631
54868-3559-00
J2175
54868-3566-00
J2060
54868-3566-01
J2060
54868-3566-02
J2060
54868-3583-00
J3490
54868-3583-00
Q4076
54868-3598-00
J1815
54868-3608-00
J2300
54868-3608-01
J2300
54868-3609-00
J2300
54868-3610-00
54868-3611-00
J2175
J2175
54868-3613-00
J1055
54868-3615-00
J1642


1/1/2008 3/31/2008 (LEVALBUTEROL)
KO
INTRON A 50 Million IU
ARISTOSPAN (M.D.V.) 20 MG/ML
BICILLIN L-A (M.D.V.) 300000 U/ML
XYLOCAINE (VIAL) 0.5%
XYLOCAINE (VIAL) 0.5%
1 EA
1 ML
2.5 ML
2.5 ML
10 ML
50 ML
50 ML
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IM
IM
IM
IJ
IJ
EA
ML
ML
ML
ML
ML
ML
1 MU
5 MG
100 MG
50 MG
600000 U
50 ML
10 MG
50
4
4
8
0.5
0.02
0.5
07/02/2003
01/01/2002
01/01/2002
01/01/2003
01/01/2002
01/01/2002
01/01/2004
99/99/9999
99/99/9999
12/31/2002
99/99/9999
99/99/9999
12/31/2003
99/99/9999
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008

MARCAINE 0.25%
20 ML
1 EA
1 EA
50 ML
IH
IJ
IJ
IJ
ML
EA
EA
ML
1 MG
1 GM
1 GM
1 EA
5
1
1
1
04/01/2008
01/01/2002
01/01/2002
02/02/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
FLUMADINE 100 MG
MG/ML
20 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
1 ML
10 ML
10 ML
10 ML
IM
IJ
SC
SC
ML
ML
ML
ML
5 MG
10 MG
100 U
5U
1
1
1
20
01/01/2002
01/01/2002
01/01/2002
01/01/2003
99/99/9999
99/99/9999
12/31/2002
99/99/9999
VENTOLIN 0.5%
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
VENTOLIN 0.5%
PENICILLIN G POTASSIUM (VIAL) 5 Million
U
AMPICILLIN SODIUM 1 GM
20 ML BO
IH
ML
1 MG
04/01/2008
99/99/9999
1 EA VL
1 EA VL
IV
IJ
EA
EA
600000 U
500 MG
8.33333
2
01/01/2002
01/01/2002
12/08/2004
99/99/9999
3 EA BX
PO
EA
8 MG
0.5
01/01/2002
99/99/9999
30 EA BO
PO
EA
8 MG
0.5
01/01/2002
99/99/9999
10 EA BO
PO
EA
8 MG
0.5
10/20/2003
99/99/9999
3 EA BX
PO
EA
8 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
8 MG
06/28/2005
99/99/9999
10 EA BO
PO
EA
8 MG
07/07/2005
99/99/9999

ZOFRAN 4 MG
ZOFRAN 4 MG
ZOFRAN 8 MG
ZOFRAN 8 MG
ZOFRAN 8 MG
CROMOLYN SODIUM 10 MG/ML
CROMOLYN SODIUM 10 MG/ML
LORAZEPAM 2 MG/ML
DOPAMINE HCL (SRN) 40 MG/ML
10/1/2003
DOPAMINE HCL (SRN) 40 MG/ML
NOVOLIN R 100 U/ML
NALBUPHINE HCL 10 MG/ML
DEMEROL HYDROCHLORIDE (M.D.V.)
100 MG/ML
MEPERIDINE HCL (VIAL) 100 MG/ML
1/1/2002 99/99/9999 MG
(SRN,PREFILLED) 150 MG/ML
HEP-LOCK U/P (VIAL,DOSETTE,PF) 100
U/ML
Page 251 of 374
BO
VL
VL
VL
VL
VL
VL
VL
20 EA BO
PO
EA
8 MG
10/19/2005
99/99/9999
2 ML PC
IH
ML
10 MG
03/24/2003
99/99/9999
PC
VL
VL
VL
VL
SR
SR
VL
AM
AM
AM
IH
IJ
IJ
IJ
IJ
IV
IV
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
10 MG
100 MG
2 MG
2 MG
2 MG
1 EA
40 MG
5U
10 MG
10 MG
10 MG
1
0.5
1
1
1
1
1
20
1
1
2
03/24/2003
01/01/2002
01/01/2002
01/01/2002
01/10/2007
01/01/2002
10/01/2003
06/30/2005
01/01/2002
05/24/2007
01/01/2002
99/99/9999
09/30/2005
99/99/9999
99/99/9999
99/99/9999
09/30/2003
07/09/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 ML VL
20 ML VL
IJ
IJ
ML
ML
100 MG
100 MG
1
1
01/01/2002
01/01/2002
99/99/9999
09/30/2005
1 ML VL
IM
ML
150 MG
01/01/2002
99/99/9999
1 ML VL
IV
ML
10 U
10
01/01/2002
99/99/9999
2 ML
30 ML
10 ML
1 ML
25 ML
10 ML
10 ML
10 ML
1 ML
1 ML
10 ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54868-3618-00
J1080
54868-3618-01
54868-3619-00
54868-3619-00
54868-3623-00
54868-3637-00
54868-3637-01
54868-3641-00
J1080
J1820
J1815
J2930
J2930
J2930
J0170
8/10/2007
1/1/2002
1/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54868-3644-00
54868-3645-00
54868-3648-00
54868-3670-00
J1200
J1940
Q0144
J3360
1/1/2002
1/1/2002
11/16/2005
1/1/2002
54868-3682-00
J7649
54868-3682-00 KO J7649

TESTOSTERONE CYPIONATE (M.D.V.)

200 MG/ML
TESTOSTERONE CYPIONATE 200
MG/ML
HUMULIN R 100 U/ML
HUMULIN R 100 U/ML
SOLU-MEDROL (W/DILUENT) 500 MG
EPINEPHRINE HCL (M.D.V.) 1 MG/ML
DIPHENHYDRAMINE HCL (M.D.V.) 10
MG/ML
FUROSEMIDE (CARPUJECT) 10 MG/ML
AZITHROMYCIN (TRI-PACK) 500 MG
VALIUM 5 MG/ML
ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON1/1/2002 10/29/2004 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMISOETHARINE HCL (W/DROPPER) 1%
KO
1/1/2002
J2300
1/1/2002
54868-3686-01
54868-3692-00
54868-3694-00
J2300
J0380
J3490
1/1/2002
1/1/2002
1/1/2002
54868-3695-00
54868-3703-00
54868-3727-00
54868-3738-00
54868-3738-01
54868-3826-00
54868-3826-01
54868-3826-02
54868-3826-03
54868-3826-04
54868-3826-05
54868-3826-06
54868-3826-07
J3490
J7799
J3490
J3010
J3010
None
None
None
None
None
None
None
None
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
12/4/2002
12/4/2002
12/9/2002
8/25/2003
8/25/2003
7/20/2004
11/22/2004
11/4/2005
54868-3843-00
54868-3847-00
54868-3851-00
J1885
J3490
J3490
6/21/2002
1/1/2002
1/1/2002
54868-3859-01
J2560
1/1/2002
54868-3873-00
54868-3889-00
54868-3890-00
54868-3893-00
54868-3894-00
54868-3894-00
54868-3896-00
54868-3896-01
54868-3896-02
54868-3905-00
54868-3905-00
54868-3910-00
54868-3975-00
54868-3975-00
J1800
J2597
J1790
J0460
J2000
J2001
J1030
J1030
J1030
A4712
A4217
J0725
A4712
A4216
12/11/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
5/3/2005
2/2/2007
1/1/2002
1/1/2004
5/2/2003
1/1/2002
1/1/2004
54868-3977-00
J1095
1/1/2002
54868-3977-00
54868-3979-00
54868-3996-00
54868-3996-01
54868-3996-02
54868-3996-03
54868-3996-04
54868-3996-05
54868-3997-00
54868-3997-01
54868-3997-02
54868-3997-03
54868-3997-04
54868-3997-05
54868-3998-00
54868-3998-01
J1094
J0740
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
1/1/2003
4/12/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
6/17/2004
8/6/2007
1/1/2002
6/12/2003
9/25/2003
10/20/2003
11/3/2003
8/1/2005
1/1/2002
1/1/2002
ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON10/29/2004 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAMISOETHARINE HCL (W/DROPPER) 1%
10 MG/ML
10 MG/ML
99/99/9999 INJECTION, METARAMINOL BITARTRATE, PER 10 MG
ARAMINE 10 MG/ML
CLINDAMYCIN PHOSPHATE (S.D.V.) 150
MG/ML
DEXTROSE (18GX1-1/2") 50%
FENTANYL CITRATE (AMP) 0.05 MG/ML
FENTANYL CITRATE (AMP) 0.05 MG/ML
METHOTREXATE 2.5 MG
METHOTREXATE 2.5 MG
METHOTREXATE 2.5 MG
METHOTREXATE 2.5 MG
TORADOL IV/IM (TUBEX, 22GX1/2") 30
MG/ML
CEFOTAN (VIAL) 1 GM
CEFOTAN (VIAL) 2 GM
PHENOBARBITAL SODIUM (TUBEX) 30
MG/ML
PROPRANOLOL (S.D.V.,10X1ML) 1
MG/ML
DDAVP (VIAL) 4 MCG/ML
DROPERIDOL (AMP) 2.5 MG/ML
ATROPINE SULFATE (S.D.V.) 1 MG/ML
XYLOCAINE (AMP) 2%
XYLOCAINE (AMP) 2%
WATER FOR INJECTION
WATER FOR INJECTION
PROFASI 10000 U
MG/ML
MG/ML
99/99/9999 INJECTION, CIDOFOVIR, 375 MG
VISTIDE 75 MG/ML
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
Page 252 of 374
10 ML VL
IM
ML
200 MG
04/14/2005
99/99/9999
1 ML
10 ML
10 ML
1 EA
1 EA
1 EA
30 ML
VL
VL
VL
VL
VL
VL
VL
IM
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
EA
EA
EA
ML
200 MG
100 U
5U
125 MG
125 MG
125 MG
1 ML
1
1
20
4
1
1
1
08/10/2007
01/01/2002
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 ML
2 ML
3 EA
2 ML
VL
SR
DP
AM
IJ
IJ
PO
IJ
ML
ML
EA
ML
50 MG
20 MG
1 GM
5 MG
0.2
0.5
0.5
1
01/01/2002
01/01/2002
11/16/2005
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 ML BO
IH
ML
1 MG
10
01/01/2002
10/29/2004
30 ML BO
IH
ML
1 MG
10
01/01/2002
10/29/2004
1 ML AM IJ
ML
10 MG
01/01/2002
99/99/9999
1 ML AM IJ
10 ML VL IJ
1 EA VL IV
ML
ML
EA
10 MG
10 MG
1 EA
1
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
IJ
IV
IV
IJ
IJ
PO
PO
PO
PO
PO
PO
PO
PO
ML
ML
EA
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
1 EA
1 EA
0.1 MG
0.1 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
2.5 MG
1
1
1
0.5
0.5
1
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/04/2002
12/04/2002
12/09/2002
08/25/2003
08/25/2003
07/20/2004
11/22/2004
11/04/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
IJ
IJ
IJ
ML
EA
EA
15 MG
1 EA
1 EA
2
1
1
06/21/2002
01/01/2002
01/01/2002
08/06/2007
99/99/9999
99/99/9999
120 MG
0.25
01/01/2002
99/99/9999
1
4
0.5
3.33333
0.02
2
1
1
1
0.1
0.002
10
0.1
0.1
12/11/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
05/03/2005
02/02/2007
01/01/2002
01/01/2004
05/02/2003
01/01/2002
01/01/2004
99/99/9999
99/99/9999
99/99/9999
12/31/2009
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2003
99/99/9999
12/13/2005
12/31/2003
99/99/9999
2 ML
50 ML
1 EA
2 ML
2 ML
16 EA
12 EA
24 EA
20 EA
28 EA
100 EA
50 EA
30 EA
VL
VL
VL
AM
AM
DP
DP
DP
BO
BO
BO
BO
BO
1 ML SR
1 EA VL
1 EA VL
1 ML SR
1 ML
10 ML
1 ML
1 ML
5 ML
5 ML
10 ML
25 ML
5 ML
6000 ML
6000 ML
1 EA
5 ML
5 ML
VL
VL
AM
VL
AM
AM
VL
VL
VL
FC
FC
VL
VL
VL
5 ML VL
5 ML
5 ML
25 EA
40 EA
30 EA
50 EA
100 EA
60 EA
30 EA
100 EA
20 EA
10 EA
40 EA
60 EA
30 EA
50 EA
VL
VL
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
IJ
ML
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IV
IV
IM
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
EA
ML
ML
IJ
ML
8 MG
01/01/2002
12/31/2002
IJ
IV
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 MG
375 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
8
0.2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
01/01/2003
04/12/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
06/17/2004
08/06/2007
01/01/2002
06/12/2003
09/25/2003
10/20/2003
11/03/2003
08/01/2005
01/01/2002
01/01/2002
07/27/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 MG
1 MCG
5 MG
0.3 MG
50 ML
10 MG
40 MG
40 MG
40 MG
10 ML
500 ML
1000 USP Units
10 ML
10 ML
1/1/2002
11/8/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
54868-3686-00
HCPCS Mod
HCPCS
NDC Mod
NDC
3/5/2003
12/8/2003
1/28/2004
6/9/2004
7/6/2004
7/23/2004
4/22/2005
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54868-4082-00
J7644
1/1/2002
54868-4082-00 KO J7644
54868-4082-01
J7644
54868-4082-01 KO J7644
54868-4095-00
54868-4096-00
KO
J7506
J7506
1/1/2002
1/1/2002
KO
1/1/2002
4/23/2002
11/27/2002
54868-4100-00
J1055
1/1/2002
54868-4100-01
J1055
2/11/2002
54868-4103-00
J1580
2/12/2003
54868-4106-00
J3260
1/1/2002
54868-4109-00
54868-4121-00
54868-4123-00
Q0178
J0725
J0585
1/1/2002
7/13/2007
1/1/2002
54868-4136-00
J2180
1/1/2002
54868-4137-00
J0780
1/1/2002
54868-4138-00
Q0180
2/10/2005
54868-4138-01
Q0180
9/22/2005
54868-4139-00
Q0166
6/3/2005
54868-4139-01
Q0166
6/28/2005
54868-4139-02
Q0166
9/7/2005
54868-4139-03
Q0166
10/14/2005
54868-4139-04
Q0166
9/22/2005
54868-4139-05
Q0166
1/5/2006
Page 253 of 374
PO
PO
PO
PO
PO
PO
PO
IJ
IJ
NA
IJ
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
ML
EA
GM
ML
ML
ML
ML
ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
50 MG
500 MG
100 MG
5 MG
1 GM
1 GM
1 GM
1 GM
1
1
1
1
1
1
1
0.5
1
10
1
0.02
0.04
0.04
0.04
03/05/2003
12/08/2003
01/28/2004
06/09/2004
07/06/2004
07/23/2004
04/22/2005
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
07/21/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
99/99/9999
48 EA DP
21 EA BX
PO
PO
EA
EA
5 MG
5 MG
2
1
04/23/2002
11/27/2002
99/99/9999
99/99/9999
1 ML SR
IM
ML
150 MG
01/01/2002
99/99/9999
1 ML SR
IM
ML
150 MG
02/11/2002
99/99/9999
2 ML VL
IJ
ML
80 MG
0.5
02/12/2003
99/99/9999
2 ML VL
IJ
ML
80 MG
0.5
01/01/2002
99/99/9999
PO
IM
IM
EA
EA
EA
2
10
100
01/01/2002
07/13/2007
01/01/2002
99/99/9999
99/99/9999
99/99/9999
100 EA BO
1 EA VL
1 EA VL
50 MG
1000 USP Units
1U
2 ML SR
IJ
ML
50 MG
01/01/2002
99/99/9999
2 ML SR
IJ
ML
10 MG
0.5
01/01/2002
99/99/9999
5 EA BO
PO
EA
100 MG
02/10/2005
99/99/9999
1 EA BO
PO
EA
100 MG
09/22/2005
99/99/9999
2 EA BO
PO
EA
1 MG
06/03/2005
99/99/9999
10 EA BO
PO
EA
1 MG
06/28/2005
99/99/9999
6 EA BO
PO
EA
1 MG
09/07/2005
99/99/9999
8 EA BO
PO
EA
1 MG
10/14/2005
99/99/9999
3 EA BO
PO
EA
1 MG
09/22/2005
99/99/9999
20 EA BO
PO
EA
1 MG
01/05/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
BO
BO
BO
BO
BO
BO
AM
VL
JR
VL
BO
BO
BO
BO
Billing Units
15 EA
20 EA
40 EA
100 EA
35 EA
500 EA
60 EA
1 ML
1 EA
1 EA
1 ML
15 ML
22.5 ML
15 ML
30 ML

Package
NDC Label
HCPCS Description

ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
PROMETHAZINE HCL (AMP) 25 MG/ML
MORPHINE SULFATE
PREDNISONE (12 DAY DOSE PACK) 10
MG
PREDNISONE (6 DAY DOSEPAK) 5 MG
99/99/9999 MG
99/99/9999 MG
GENTAMICIN SULFATE (FLIPTOP VIAL)
40 MG/ML
MG/ML
CHORIONIC GONADOTROP 10000 U
99/99/9999 INJECTION, ONABOTULINUMTOXINA, 1 UNIT
BOTOX 100 U
MEPERGAN (TUBEX,22GX1 1/4") 25
99/99/9999 INJECTION, MEPERIDINE AND PROMETHAZINE HCL, UP TO 50 MG
MG/ML-25 MG/ML
(CARPUJECT) 5 MG/ML
ANZEMET 100 MG
ANZEMET 100 MG
KYTRIL 1 MG
KYTRIL 1 MG
KYTRIL 1 MG
KYTRIL 1 MG
KYTRIL 1 MG
KYTRIL 1 MG
NDC Package Type
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J2550
J0290
J2271
J3360
Q0144
Q0144
Q0144
Q0144
NDC Package Measure
54868-3998-02
54868-3998-03
54868-3998-04
54868-3998-05
54868-3998-06
54868-3998-07
54868-3998-08
54868-4021-00
54868-4047-00
54868-4050-00
54868-4061-00
54868-4076-00
54868-4078-00
54868-4078-01
54868-4078-02
HCPCS Mod
HCPCS
NDC Mod
NDC
QR
QR
QR
QR
QR
QR
54868-4154-00
J3490
1/1/2002
54868-4167-00
J2765
1/1/2002
54868-4169-00
54868-4183-00
J3490
Q0144
3/2/2004
1/1/2002
54868-4189-00
J2270
1/1/2002
54868-4193-00
54868-4194-00
J1460
J3490
1/1/2002 10/3/2006 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC

1/1/2007 12/31/2007 DOSE
1/1/2008 12/31/2009 DOSE
54868-4219-00
Q4084
54868-4219-00
J7322
54868-4287-00
J8999
54868-4287-01
J8999
54868-4287-02
J8999
54868-4287-03
J8999
54868-4287-04
54868-4296-00
54868-4296-00
54868-4298-00
54868-4298-00
54868-4311-00
54868-4311-00
54868-4319-00
54868-4319-00
54868-4339-00
54868-4339-01
54868-4339-02
54868-4339-03
54868-4339-04
J8999
A4319
A4217
J2000
J2001
A4712
A4217
Q4098
J1750
None
None
None
None
None
54868-4377-00
G9034
54868-4380-00
J0330
54868-4381-00
J1820
54868-4381-00
J1815
54868-4409-00
J7603
54868-4409-00 KO J7603
54868-4409-00

12/31/2008 INJECTION, IRON DEXTRAN, 50 MG
ZANAMIVIR, INHALATION POWDER ADMINISTERED THROUGH INHALER, BRAND,
12/1/2004 5/31/2005 PER 10 MG (FOR USE IN A MEDICARE APPROVED DEMONSTRATION PROJECT)
J1885
KO
J7614
54868-4409-00 KO J7614
54868-4419-00
1/18/2008
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
4/1/2008
1/1/2009
8/16/2005
11/22/2005
2/3/2006
4/3/2006
2/5/2008
1/1/2002
KO

1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON4/1/2008 99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 MG
20 MG
20 MG
20 MG
20 MG
20 MG
20 MG
20 MG
150 MG
150 MG
150 MG
150 MG
150 MG
150 MG
150 MG
150 MG
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
06/07/2006
06/29/2005
08/03/2006
01/26/2006
03/16/2006
03/23/2006
03/23/2006
05/16/2006
02/10/2005
02/10/2005
08/08/2007
08/08/2007
10/19/2005
10/19/2005
05/19/2006
05/19/2006
IJ
ML
1 EA
01/01/2002
99/99/9999
2 ML VL
IV
ML
10 MG
0.5
01/01/2002
99/99/9999
2 ML VL
6 EA DP
IJ
PO
ML
EA
1 EA
1 GM
1
0.25
03/02/2004
01/01/2002
99/99/9999
99/99/9999
1 ML AM IJ
ML
10 MG
01/01/2002
99/99/9999
BAYGAM (S.D.V.,PF) 15%-18% (DF & C)

2 ML VL
1 EA VL
IM
IV
ML
EA
1 ML
1 EA
1
1
01/01/2002
01/01/2002
10/03/2006
99/99/9999
SYNVISC 8 MG/ML
2 ML NA
IJ
ML
1 DOSE
0.5
01/01/2007
12/31/2007
SYNVISC 8 MG/ML
MG
MG
MG
MG
MG
XYLOCAINE 0.5%
XYLOCAINE 0.5%
WATER FOR INJECTION
WATER FOR INJECTION
INFED (2MLX10) 50 MG/ML
INFED (2MLX10) 50 MG/ML
ALKERAN 2 MG
ALKERAN 2 MG
ALKERAN 2 MG
ALKERAN 2 MG
RELENZA (5X4,W/DISKHALER) 5
MG/Actuation
SUCCINYLCHOLINE CHLORIDE (VIAL) 20
MG/ML
U/ML
U/ML
2 ML NA
IJ
ML
1 DOSE
0.5
01/01/2008
12/31/2009
30 EA BO
PO
EA
1 EA
01/17/2005
99/99/9999
10 EA BO
PO
EA
1 EA
01/17/2005
99/99/9999
100 EA BO
PO
EA
1 EA
02/14/2005
99/99/9999
90 EA BO
PO
EA
1 EA
09/22/2005
99/99/9999
PO
IR
IR
IJ
IJ
IV
IV
IJ
IJ
PO
PO
PO
PO
PO
EA
ML
ML
ML
ML
ML
ML
ML
ML
EA
EA
EA
EA
EA
1 EA
1000 ML
500 ML
50 ML
10 MG
10 ML
500 ML
50 MG
50 MG
2 MG
2 MG
2 MG
2 MG
2 MG
1
0.001
0.002
0.02
0.5
0.1
0.002
1
1
1
1
1
1
1
01/18/2008
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
04/01/2008
01/01/2009
08/16/2005
11/22/2005
02/03/2006
04/03/2006
02/05/2008
99/99/9999
12/31/2003
99/99/9999
12/31/2003
12/31/2007
12/31/2003
99/99/9999
12/31/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 EA IH
IH
EA
10 MG
0.5
12/01/2004
05/31/2005
10 ML VL
IV
ML
20 MG
01/01/2002
06/21/2005
10 ML VL
SC
ML
100 U
06/14/2002
12/31/2002
10 ML VL
SC
ML
5U
20
01/01/2003
99/99/9999
1 MG
0.42
01/01/2008
03/31/2008
BO
VL
VL
VL
VL
NA
NA
VL
VL
BO
BO
BO
BO
BO
XOPENEX (PF) 0.021%
3 ML PC
IH
ML
XOPENEX (PF) 0.021%
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
XOPENEX (PF) 0.021%
3 ML PC
IH
ML
0.5 MG
0.42
04/01/2008
99/99/9999
XOPENEX (PF) 0.021%

30 MG/ML
3 ML PC
IH
ML
0.5 MG
0.42
04/01/2008
99/99/9999
2 ML VL
IM
ML
15 MG
01/01/2002
99/99/9999
Page 254 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
4 ML VL
60 EA
500 ML
500 ML
50 ML
50 ML
500 ML
500 ML
2 ML
2 ML
4 EA
50 EA
24 EA
28 EA
32 EA
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
30 EA
5 EA
25 EA
10 EA
60 EA
40 EA
30 EA
20 EA
60 EA
60 EA
120 EA
120 EA
30 EA
30 EA
28 EA
28 EA

Package
NDC Label
HCPCS Description
HCPCS
HCPCS Mod
QR
6/7/2006
6/29/2005
8/3/2006
1/26/2006
3/16/2006
3/23/2006
3/23/2006
5/16/2006
2/10/2005
2/10/2005
8/8/2007
8/8/2007
10/19/2005
10/19/2005
5/19/2006
5/19/2006
NDC Package Type
QR
Q0166
None
None
None
None
None
None
None
None
J8520
None
J8520
None
J8520
None
J8520

KYTRIL 1 MG
TEMODAR 20 MG
TEMODAR 20 MG
TEMODAR 20 MG
TEMODAR 20 MG
TEMODAR 20 MG
TEMODAR 20 MG
TEMODAR 20 MG
XELODA 150 MG
XELODA 150 MG
XELODA 150 MG
XELODA 150 MG
XELODA 150 MG
XELODA 150 MG
XELODA 150 MG
XELODA 150 MG
CLEOCIN PHOSPHATE (S.D.V.) 150
MG/ML
MG/ML
CLEOCIN PHOSPHATE (S.D.V.) 150
MG/ML
MORPHINE SULFATE (AMP,DOSETTE)
10 MG/ML
NDC Package Measure
54868-4139-06
54868-4142-00
54868-4142-01
54868-4142-02
54868-4142-03
54868-4142-04
54868-4142-05
54868-4142-06
54868-4143-00
54868-4143-00
54868-4143-01
54868-4143-01
54868-4143-02
54868-4143-02
54868-4143-03
54868-4143-03
NDC Mod
NDC
54868-4419-01
54868-4464-00
54868-4464-00
J1885
J2912
A4216
54868-4476-00
54868-4484-00
G9035
J3490
54868-4488-00
54868-4508-00
54868-4509-00
54868-4527-00
54868-4547-00
54868-4579-00
54868-4580-00
J2540
J1720
J2405
J0456
J0744
J3280
J2250
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
54868-4586-00
54868-4626-00
54868-4626-00
54868-4628-00
54868-4629-00
54868-4644-00
54868-4644-01
54868-4644-02
54868-4651-00
J3360
J1820
J1815
J8999
J3490
Q0144
Q0144
Q0144
J0690
1/23/2002
6/14/2002
1/1/2003
6/12/2002
10/7/2003
7/26/2002
2/21/2005
6/1/2005
9/15/2003


EA
EA
75 MG
1 EA
1
1
12/01/2004
01/01/2002
05/31/2005
10/24/2003
1 EA
1 EA
2 ML
1 EA
40 ML
2 ML
5 ML
VL
VL
VL
VL
VL
AM
VL
IV
IJ
IJ
IV
IV
IM
IJ
EA
EA
ML
EA
ML
ML
ML
600000 U
100 MG
1 MG
500 MG
200 MG
10 MG
1 MG
33.33333
10
2
1
0.05
0.5
5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML
10 ML
10 ML
180 EA
20 ML
4 EA
6 EA
30 EA
1 EA
SR
VL
VL
BO
VL
BO
BO
BO
VL
IJ
SC
SC
PO
IV
PO
PO
PO
IJ
ML
ML
ML
EA
ML
EA
EA
EA
EA
5 MG
100 U
5U
1 EA
1 EA
1 GM
1 GM
1 GM
500 MG
1
1
20
1
1
0.25
0.25
0.25
1
01/23/2002
06/14/2002
01/01/2003
06/12/2002
10/07/2003
07/26/2002
02/21/2005
06/01/2005
09/15/2003
99/99/9999
12/31/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
0.5 ML VL
IM
ML
5 MG
09/17/2002
10/01/2004
25 ML BO
PO
ML
75 MG
0.16
12/01/2004
05/31/2005
6 EA
6 EA
12 EA
20 ML
20 ML
RC
RC
RC
IJ
IJ
EA
EA
EA
ML
ML
1 MG
1 EA
1 EA
50 MG
50 MG
25
1
1
1
1
09/30/2002
01/01/2006
04/26/2006
04/01/2008
01/01/2009
12/31/2005
99/99/9999
99/99/9999
12/31/2008
99/99/9999
10 ML VL
IJ
ML
5 MG
12/16/2002
99/99/9999
30 EA BO
PO
EA
5 MG
02/10/2003
99/99/9999
15 EA BO
PO
EA
5 MG
04/08/2003
99/99/9999
60 EA BO
PO
EA
5 MG
06/09/2005
99/99/9999
100 EA BO
120 ML BO
240 ML BO
PO
PO
PO
EA
ML
ML
5 MG
5 MG
5 MG
1
0.2
0.6
06/04/2007
02/28/2003
02/28/2003
99/99/9999
99/99/9999
99/99/9999

480 ML BO
PO
ML
5 MG
0.6
05/25/2004
99/99/9999
ML
100 MG
03/11/2003
99/99/9999
DEMEROL HYDROCHLORIDE 100 MG/ML

HYDROXYUREA 500 MG
HYDROXYUREA 500 MG
HYDROXYUREA 500 MG
HYDROXYUREA 500 MG
ENGERIX-B PEDIATRIC (PEDIATRIC,PF)
10 MCG/0.5 ML
1 ML
1 ML
1 ML
30 EA
100 EA
50 EA
60 EA
IJ
IJ
IJ
PO
PO
PO
PO
ML
ML
ML
EA
EA
EA
EA
100 MG
10 MG
10 MG
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
1
1
07/03/2003
03/11/2003
05/26/2004
04/10/2003
08/06/2003
07/07/2005
07/14/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
0.5 ML VL
IM
ML
1 EA
04/24/2003
99/99/9999
4 EA BX
SC
EA
25 MG
04/30/2003
99/99/9999
12 EA BX
2 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
05/20/2003
08/08/2007
05/23/2005
99/99/9999
2 ML VL
IJ
ML
5 MG
1 ML EA
IJ
ML
10 MG
05/30/2003
99/99/9999
10 ML EA
IJ
ML
5 MG
06/03/2003
99/99/9999
9/30/2002
1/1/2006
4/26/2006
4/1/2008
1/1/2009
54868-4716-00
J9250
12/16/2002
54868-4721-00
Q0164
2/10/2003
54868-4721-01
Q0164
4/8/2003
54868-4721-02
Q0164
6/9/2005
54868-4721-03
54868-4748-00
54868-4749-00
Q0164
J7510
J7510
6/4/2007
2/28/2003
2/28/2003
54868-4749-01
J7510
54868-4751-00
J2175
54868-4751-01
54868-4752-00
54868-4752-01
54868-4773-00
54868-4773-01
54868-4773-02
54868-4773-03
J2175
J2270
J2270
J8999
J8999
J8999
J8999
7/3/2003
3/11/2003
5/26/2004
4/10/2003
8/6/2003
7/7/2005
7/14/2005
54868-4781-00
J3490

INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN
ENBREL (PF) 25 MG
METHOTREXATE SODIUM (VIAL, L.P.P.)
25 MG/ML
25 MG/ML
54868-4809-00
J9250
Page 255 of 374
BX
BX
NA
VL
VL
1 ML AM IJ
AM
VL
VL
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
PO
IV
K0416
J8498
J8498
Q4098
J1750
J2270
Start Date #1
10 EA BO
1 EA VL
54868-4686-00
54868-4686-00
54868-4686-01
54868-4715-00
54868-4715-00
J9250
CF
99/99/9999
12/31/2003
99/99/9999
12/1/2004
54868-4804-00
HCPCS Measure #1
10/17/2005
01/01/2002
01/01/2004
9/17/2002
54868-4796-00
HCPCS Amount #1
2
0.5
0.1
G9035
K0416
J8498
Billing Units
15 MG
0.9 %
10 ML
J1056
J1438
ML
ML
ML
54868-4660-00
54868-4782-00
NDC Package Type
IM
IV
IV
54868-4684-00
54868-4794-00
54868-4794-02
NDC Package Measure
2 ML VL
10 ML VL
10 ML VL
TAMIFLU 75 MG
FLAGYL I.V. (S.D.V.) 500 MG
(VIAL,PHARMACY BOTTLE) 20 Million U
SOLU-CORTEF (ACT-O-VIAL) 1 GM
ZITHROMAX (VIAL) 500 MG
99/99/9999 INJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MG
MIDAZOLAM HCL (VIAL,PF) 5 MG/ML
DIAZEPAM (22GX1 1/4",CARPUJECT) 5
MG/ML
LANTUS (VIAL) 100 U/ML
LANTUS (VIAL) 100 U/ML
FLUTAMIDE 125 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
CEFAZOLIN SODIUM (VIAL,PF) 500 MG
INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG / LUNELLE MONTHLY CONTRACEPTIVE
10/1/2004 25MG
(S.D.V.) 5 MG/0.5 ML-25 MG/0.5 ML
PROMETHEGAN 25 MG
PROMETHEGAN 25 MG
PROMETHEGAN 25 MG
IRON DEXTRAN 50 MG/ML
IRON DEXTRAN 50 MG/ML
METHOTREXATE SODIUM (P.F.V.,PF) 25
MG/ML


Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
05/21/2003 11/30/2008
J2322
8/13/2003
54868-4893-01
54868-4925-00
54868-4952-00
54868-4952-01
54868-4972-00
54868-4972-01
54868-4997-00
J2322
J2400
J7509
J7509
J7699
J7699
J0725
8/14/2003
9/25/2003
10/30/2003
10/30/2003
1/8/2004
5/28/2004
2/18/2004
54868-4998-00
54868-5000-00
54868-5005-00
54868-5005-01
54868-5016-00
J1940
J8999
None
None
J3130
2/18/2004
2/19/2004
1/18/2006
4/13/2006
3/9/2004

54868-5020-00
54868-5026-00
54868-5026-00
54868-5036-00
54868-5036-01
54868-5070-00
J1440
J7051
A4216
J3490
J3490
J1610
3/11/2004
3/17/2004
1/1/2006
3/31/2004
6/29/2006
5/24/2004
54868-5089-00
Q0179
6/9/2004
54868-5089-01
Q0179
6/29/2005
54868-5089-02
Q0179
9/28/2005
54868-5089-03
Q0179
9/22/2005
54868-5089-04
Q0179
12/20/2005
54868-5089-05
Q0179
8/25/2006
54868-5108-00
54868-5112-00
54868-5112-01
54868-5137-00
J1817
J1650
J1650
J1170
7/15/2004
7/28/2004
9/8/2004
8/13/2004
54868-5181-00
54868-5201-00
54868-5213-00
54868-5218-00
54868-5218-01
54868-5218-02
54868-5229-00
54868-5230-00
54868-5231-00
54868-5231-01
54868-5231-02
Q0173
J1815
J7506
None
None
None
J2505
J7506
J8501
J8501
J8501
11/18/2004
12/28/2004
1/25/2005
2/10/2005
12/22/2005
12/22/2005
2/23/2006
2/25/2005
6/29/2005
8/3/2006
3/4/2008
54868-5242-00
J7510
3/3/2005
J1055
54868-5257-00
54868-5260-00
None
54868-5260-00 QR J8521
54868-5260-01
None
54868-5260-01 QR J8521
54868-5260-02
None
54868-5260-02 QR J8521
3/30/2005
6/28/2005
6/28/2005
6/29/2005
6/29/2005
6/29/2005
6/29/2005
QR
QR
QR

CAVERJECT IMPULSE 20 MCG
1 EA BX
NANDROLONE DECANOATE 200 MG/ML
1 ML VL
NANDROLONE DECANOATE 200 MG/ML

MEDROL 2 MG
MEDROL 2 MG
FORADIL AEROLIZER 0.012 MG
PREGNYL (W/DILUENT) 10000 U
FUROSEMIDE
ARIMIDEX 1 MG
DELATESTRYL 200 MG/ML
NEUPOGEN (PF,SINGLEJECT) 300
MCG/0.5 ML
SODIUM CHLORIDE (AMP,PF) 0.9%
PEG INTRON RP 150 MCG
GLUCAGON EMERGENCY KIT 1 MG
1 EA
20 MG
1
4
IC
EA
1.25 MCG
IM
ML
200 MG
06/23/2003
01/01/2005
12/31/2004
99/99/9999
16
08/28/2003
99/99/9999
08/13/2003
8/18/2007
1
0.03333
0.5
0.5
1
1
10
08/14/2003
09/25/2003
10/30/2003
10/30/2003
01/08/2004
05/28/2004
02/18/2004
8/18/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML
30 ML
30 EA
10 EA
12 EA
60 EA
1 EA
VL
VL
BO
BO
BX
BX
VL
IM
IJ
PO
PO
IH
IH
IM
ML
ML
EA
EA
EA
EA
EA
2 ML
30 EA
100 EA
50 EA
5 ML
VL
BO
BO
BO
VL
IJ
PO
PO
PO
IM
ML
EA
EA
EA
ML
20 MG
1 EA
50 MG
50 MG
200 MG
0.5
1
1
1
1
02/18/2004
02/19/2004
01/18/2006
04/13/2006
03/09/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999

ZOFRAN ODT 8 MG
ZOFRAN ODT 8 MG
ZOFRAN ODT 8 MG
ZOFRAN ODT 8 MG
ZOFRAN ODT 8 MG
ZOFRAN ODT 8 MG
0.5 ML
3 ML
3 ML
1 EA
4 EA
1 EA
SR
PC
PC
BX
BX
BX
IJ
IH
IH
MR
MR
IJ
ML
ML
ML
EA
EA
EA
300 MCG
5 ML
10 ML
1 EA
1 EA
1 MG
2
0.2
0.1
1
1
1
03/11/2004
03/17/2004
01/01/2006
03/31/2004
06/29/2006
05/24/2004
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 EA BO
PO
EA
8 MG
06/09/2004
99/99/9999
15 EA BO
PO
EA
8 MG
06/29/2005
99/99/9999
10 EA BX
PO
EA
8 MG
09/28/2005
99/99/9999
3 EA BO
PO
EA
8 MG
09/22/2005
99/99/9999
20 EA BO
PO
EA
8 MG
12/20/2005
99/99/9999
30 EA BX
PO
EA
8 MG
08/25/2006
99/99/9999
99/99/9999 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS
99/99/9999 INJECTION, PEGFILGRASTIM, 6 MG
10 ML
0.8 ML
0.8 ML
10 ML
VL
SR
SR
AM
SC
SC
SC
IJ
ML
ML
ML
ML
50 U
10 MG
10 MG
4 MG
2
10
10
1
07/15/2004
07/28/2004
09/08/2004
08/13/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA
10 ML
48 EA
100 EA
10 EA
30 EA
0.6 ML
21 EA
5 EA
6 EA
2 EA
BO
VL
DP
BO
BO
BO
SR
BO
BO
BX
DP
PO
SC
PO
PO
PO
PO
SC
PO
PO
PO
PO
EA
ML
EA
EA
EA
EA
ML
EA
EA
EA
EA
250 MG
5U
5 MG
25 MG
25 MG
25 MG
6 MG
5 MG
5 MG
5 MG
5 MG
1.2
20
1
1
1
1
1.66666
2
16
16
16
11/18/2004
12/28/2004
01/25/2005
02/10/2005
12/22/2005
12/22/2005
02/23/2006
02/25/2005
06/29/2005
08/03/2006
03/04/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
HUMALOG 100 U/ML

TIGAN 300 MG
NOVOLOG MIX 70/30 70 U/ML-30 U/ML
PREDNISONE 5 MG
NEULASTA (PF) 6 MG/0.6 ML
EMEND 80 MG
EMEND 80 MG
EMEND 80 MG
INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150 MEDROXYPROGESTERONE ACETATE
99/99/9999 MG
150 MG/ML
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
Page 256 of 374
200 MG
30 ML
4 MG
4 MG
1 EA
1 EA
1000 USP Units
237 ML BO
PO
ML
5 MG
0.6
03/03/2005
99/99/9999
1 ML
30 EA
30 EA
60 EA
60 EA
120 EA
120 EA
IM
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
150 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
1
1
1
1
1
1
1
03/30/2005
06/28/2005
06/28/2005
06/29/2005
06/29/2005
06/29/2005
06/29/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
VL
BO
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
EA
EA
HCPCS Measure #1
MR
MR
NDC Package Measure
0.8 ML BX
0.8 ML BX
HUMIRA (KIT,PF) 40 MG/0.8 ML

HUMIRA (KIT,PF) 40 MG/0.8 ML
HCPCS Amount #1

Package
Billing Units
J0270
54868-4893-00
NDC Label
HCPCS Description
54868-4890-00

J3590
J0135
NDC Package Type
54868-4822-00
54868-4822-00
HCPCS Mod
HCPCS
NDC Mod
NDC
J1170
54868-5325-00
J8501
54868-5327-00
J1815
54868-5334-00
54868-5334-00
54868-5334-01
54868-5348-00
54868-5348-01
54868-5350-00
54868-5350-01
54868-5350-02
54868-5350-03
54868-5350-04
54868-5354-00
54868-5355-00
54868-5355-01
54868-5355-02
54868-5389-00
54868-5389-01
54868-5404-00
54868-5406-00
54868-5428-00
Q0181
J8540
J8540
None
None
None
None
None
None
None
None
None
None
None
J8999
J8999
Q0144
J3110
J0881
54868-5429-00
54868-5440-00
54868-5440-01
J0881
J1650
J1650
54868-5444-00
J1438
54868-5459-00
J7603
54868-5459-00 KO J7603
54868-5459-00
QR
QR
QR
QR
KO
J7614
54868-5459-00 KO J7614
54868-5471-00
Q0144
54868-5478-00
Q0144
54868-5478-01
Q0144
54868-5478-02
Q0144
54868-5487-00
Q0144
54868-5487-01
Q0144
54868-5501-00
J1652
54868-5501-01
J1652
54868-5501-02
J1652
54868-5511-00
54868-5522-00
QR
J3535
J7502
KO
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
XELODA 500 MG
AROMASIN 25 MG
AZATHIOPRINE 50 MG
AZATHIOPRINE 50 MG
AZATHIOPRINE 50 MG
HYDROMORPHONE HCL (25X1ML) 2
MG/ML
EMEND (COMBO PACK 1 125MG/2
80MG)
NOVOLOG MIX 70/30 (PREFILLED
SYRINGE) 70 U/ML-30 U/ML

DEXPAK 1.5 MG
6/13/2005 12/31/2005 REGIMEN
DEXPAK 1.5 MG
DEXPAK 1.5 MG
10/20/2005 99/99/9999 TEMODAR, 5 MG, ORAL
TEMODAR 5 MG
4/13/2006 99/99/9999 TEMODAR, 5 MG, ORAL
TEMODAR 5 MG
10/31/2007 99/99/9999 TEMODAR, 100 MG, ORAL
TEMODAR 100 MG
10/20/2005 99/99/9999 TEMODAR, 100 MG, ORAL
TEMODAR 100 MG
11/22/2005 99/99/9999 TEMODAR, 100 MG, ORAL
TEMODAR 100 MG
2/8/2006 99/99/9999 TEMODAR, 100 MG, ORAL
TEMODAR 100 MG
3/23/2006 99/99/9999 TEMODAR, 100 MG, ORAL
TEMODAR 100 MG
4/13/2006 99/99/9999 TEMODAR, 250 MG, ORAL
TEMODAR 250 MG
ETOPOSIDE 50 MG
ETOPOSIDE 50 MG
ETOPOSIDE 50 MG
ZMAX (CHERRY-BANANA) 2 GM/60 ML
9/6/2005 99/99/9999 INJECTION, TERIPARATIDE, 10 MCG
FORTEO (RDNA ORIGIN) 250 MCG/ML
8/10/2007 99/99/9999 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)
ARANESP 0.2 MG/0.4 ML
ARANESP (1X0.6ML, PREFILLED,PF) 0.3
MG/0.6 ML
ENBREL (4X0.98ML,PF) 50 MG/ML
XOPENEX (PF) 0.042%
1/1/2008 3/31/2008 (LEVALBUTEROL)
XOPENEX (PF) 0.042%
1/1/2008 3/31/2008 (LEVALBUTEROL)
XOPENEX (PF) 0.042%
XOPENEX (PF) 0.042%
AZITHROMYCIN (PAK) 250 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 500 MG
AZITHROMYCIN 500 MG
ARIXTRA 7.5 MG/0.6 ML
IPRATROPIUM BROMIDE (0.017
10/21/2008 99/99/9999 DRUG ADMINISTERED THROUGH A METERED DOSE INHALER
MG/ACTUATION)
CYCLOSPORINE 100 MG
Page 257 of 374
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
1 EA
1 EA
1 EA
50 MG
50 MG
50 MG
50 MG
50 MG
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
10/07/2005
10/07/2005
01/12/2006
01/12/2006
01/12/2006
01/12/2006
01/11/2006
01/11/2006
01/12/2006
01/12/2006
01/20/2006
01/20/2006
08/16/2006
08/16/2006
06/29/2005
05/23/2005
05/23/2005
05/23/2005
05/23/2005
09/22/2005
02/23/2006
02/28/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
IJ
ML
4 MG
0.5
05/31/2005
3 EA PG
PO
EA
5 MG
19
06/24/2005
99/99/9999
3 ML SR
SC
ML
5U
20
06/09/2005
99/99/9999
DP
DP
NA
NA
BO
BO
BO
BO
BO
BO
BO
BX
NA
BO
BO
BO
BO
SR
SR
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
SC
IJ
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
ML
EA
ML
ML
1 EA
0.25 MG
0.25 MG
5 MG
5 MG
100 MG
100 MG
100 MG
100 MG
100 MG
250 MG
50 MG
50 MG
50 MG
1 EA
1 EA
1 GM
10 MCG
1 MCG
1
6
6
1
1
1
1
1
1
1
1
1
1
1
1
1
2
25
500
06/13/2005
01/01/2006
08/31/2007
10/20/2005
04/13/2006
10/31/2007
10/20/2005
11/22/2005
02/08/2006
03/23/2006
04/13/2006
12/20/2005
01/30/2006
01/30/2006
09/01/2005
12/14/2005
09/02/2005
09/06/2005
08/10/2007
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
0.6 ML SR
0.4 ML SR
0.4 ML SR
IJ
SC
SC
ML
ML
ML
1 MCG
10 MG
10 MG
500
10
10
03/20/2008
09/29/2005
11/01/2005
99/99/9999
99/99/9999
99/99/9999
0.98 ML SR
SC
ML
25 MG
03/18/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.84
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.84
01/01/2008
03/31/2008
3 ML PC
IH
ML
0.5 MG
0.84
04/01/2008
99/99/9999
PC
DP
BO
BO
BO
BO
BO
SR
SR
SR
IH
PO
PO
PO
PO
PO
PO
SC
SC
SC
ML
EA
EA
EA
EA
EA
EA
ML
ML
ML
0.5 MG
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
0.5 MG
0.5 MG
0.5 MG
0.84
0.25
0.25
0.25
0.25
0.5
0.5
25
25
25
04/01/2008
11/16/2005
11/23/2005
12/13/2005
02/07/2006
12/13/2005
08/10/2007
01/11/2006
01/11/2006
11/13/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12.9 GM PC
30 EA BO
IH
PO
GM
EA
1 MG
100 MG
0.017
1
10/21/2008
02/10/2006
99/99/9999
99/99/9999
51 EA
51 EA
35 EA
25 EA
5 EA
15 EA
25 EA
5 EA
10 EA
30 EA
5 EA
20 EA
7 EA
1 EA
240 ML
480 ML
1 EA
3 ML
0.4 ML
3 ML
6 EA
6 EA
30 EA
10 EA
6 EA
60 EA
0.6 ML
0.6 ML
0.6 ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
90 EA
90 EA
14 EA
14 EA
28 EA
28 EA
42 EA
42 EA
70 EA
70 EA
80 EA
80 EA
20 EA
20 EA
30 EA
60 EA
25 EA
30 EA
120 EA
100 EA
60 EA
90 EA

Package
NDC Package Type
54868-5319-00
QR

NDC Package Measure
None
QR J8521
None
QR J8521
None
QR J8521
None
QR J8521
None
QR J8521
None
QR J8521
None
QR J8521
J8999
J8999
J8999
J7500
J7500
J7500
J7500
J7500
NDC Label
HCPCS Description
54868-5260-03
54868-5260-03
54868-5260-04
54868-5260-04
54868-5260-05
54868-5260-05
54868-5260-06
54868-5260-06
54868-5260-07
54868-5260-07
54868-5260-08
54868-5260-08
54868-5260-09
54868-5260-09
54868-5261-00
54868-5282-00
54868-5282-01
54868-5310-00
54868-5310-01
54868-5310-02
54868-5310-03
54868-5310-04
QR
10/7/2005
10/7/2005
1/12/2006
1/12/2006
1/12/2006
1/12/2006
1/11/2006
1/11/2006
1/12/2006
1/12/2006
1/20/2006
1/20/2006
8/16/2006
8/16/2006
6/29/2005
5/23/2005
5/23/2005
5/23/2005
5/23/2005
9/22/2005
2/23/2006
2/28/2006
HCPCS Mod
HCPCS
NDC Mod
NDC
J0696
J0150
J2321
J9217
J2355
J1650
J1650
J0696
J9015
J2941
J0770

4/13/2006 99/99/9999 INJECTION, OPRELVEKIN, 5 MG
ADENOSINE 3 MG/ML
NANDROLONE DEC 100 MG/ML
LUPRON DEPOT 30 MG
NEUMEGA 5 MG
CEFTRIAXONE 250 MG
PROLEUKIN 22 Million IU
GENOTROPIN MINIQUICK 0.2 MG
COLISTIMETHATE 150 MG
2 ML
20 ML
1 EA
1 EA
0.6 ML
6 ML
1 EA
1 EA
7 EA
1 EA
54868-5621-00
J7626

ARIXTRA 5 MG/0.4 ML
ACETYLCYSTEINE 20%
ACETYLCYSTEINE 20%
54868-5670-00
J7608
54868-5670-00 KO J7608
54868-5670-01
54868-5709-00
KO
4/1/2008
12/27/2006
12/11/2006
8/10/2007
3/24/2008
1/1/2008
KO
J7613
54868-5709-00 KO J7613
54868-5711-00
J2250
54868-5714-00
A4216
8/10/2007
8/10/2007
J7603
54868-5709-00 KO J7603
7/17/2007
6/30/2006
8/1/2006
8/1/2006
8/1/2006
8/3/2006
8/4/2006
8/10/2007
KO
J7608
54868-5670-01 KO J7608
54868-5673-01
J0885
54868-5709-00
KO
1/1/2008
4/1/2008
KO
EA
250 MG
02/17/2006
99/99/9999
IV
IM
IM
SC
SC
SC
IJ
IV
SC
IJ
ML
ML
EA
EA
ML
ML
EA
EA
EA
EA
6 MG
100 MG
7.5 MG
5 MG
10 MG
10 MG
250 MG
1 VIAL
1 MG
150 MG
0.5
1
4
1
10
10
1
1
0.2
1
03/16/2006
04/11/2006
04/12/2006
04/13/2006
05/17/2006
09/25/2007
05/12/2006
05/22/2006
05/22/2006
06/12/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
60 ML PC
IH
ML
0.25 MG
0.5
07/17/2007
99/99/9999
60 ML
7 EA
15 ML
30 ML
23 ML
15 ML
10 ML
IH
SC
PO
PO
PO
PO
SC
ML
EA
ML
ML
ML
ML
ML
0.25 MG
1 MG
1 GM
1 GM
1 GM
1 GM
0.5 MG
0.5
0.4
0.02
0.04
0.04
0.04
25
07/17/2007
06/30/2006
08/01/2006
08/01/2006
08/01/2006
08/03/2006
08/04/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 ML VL
IH
ML
1 GM
0.2
08/10/2007
99/99/9999
30 ML VL
IH
ML
1 GM
0.2
08/10/2007
99/99/9999
30 ML VL
IH
ML
1 GM
0.2
08/10/2007
99/99/9999

PROCRIT (M.D.V,1X4ML) 20000 U/ML
30 ML VL
4 ML VL
IH
IJ
ML
ML
1 GM
1000 U
0.2
20
08/10/2007
03/24/2008
99/99/9999
99/99/9999
ALBUTEROL (30X3ML) 0.042%
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.42
04/01/2008
99/99/9999
3 ML PC
2 ML VL
20 ML VL
IH
IJ
IV
ML
ML
ML
1 MG
1 MG
10 ML
0.42
1
0.1
04/01/2008
12/27/2006
12/11/2006
99/99/9999
99/99/9999
99/99/9999
PC
CT
BO
BO
BO
BO
SR
54868-5716-00
54868-5717-00
54868-5717-01
54868-5717-02
54868-5719-00
J2370
J1250
J1250
J1250
J2001
12/11/2006
12/11/2006
1/2/2007
6/28/2007
12/11/2006

VL
VL
VL
VL
SR
IJ
IV
IV
IV
IV
ML
ML
ML
ML
ML
1 ML
250 MG
250 MG
250 MG
10 MG
1
0.05
0.05
0.05
2
12/11/2006
12/11/2006
01/02/2007
06/28/2007
12/11/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
54868-5722-00
54868-5724-00
54868-5725-00
54868-5727-00
J0282
J3475
J0170
J7799
12/11/2006
12/12/2006
12/11/2006
12/12/2006
IV
IJ
IJ
IV
ML
ML
ML
ML
30 MG
500 MG
1 ML
1 EA
1.66666
1
1
1
12/11/2006
12/12/2006
12/11/2006
12/12/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
54868-5738-00
Q0179
12/29/2006
PO
EA
8 MG
12/29/2006
99/99/9999
54868-5741-00
54868-5745-00
Q0173
J2270
1/5/2007
1/10/2007
PO
IJ
EA
ML
250 MG
10 MG
1.2
0.4
01/05/2007
01/10/2007
99/99/9999
99/99/9999
54868-5749-00
Q0179
1/16/2007
PO
EA
8 MG
01/16/2007
99/99/9999
54868-5749-01
54868-5752-00
54868-5760-00
54868-5765-00
Q0179
J0285
J2941
J1815
10/18/2007
1/25/2007
8/17/2007
4/4/2007

AMIODARONE (SDV,10X3ML) 50 MG/ML
3 ML VL
MAGNES SULF (25X10ML) 500 MG/ML
10 ML SR
EPINEPHRINE (10X10ML) 0.1 MG/ML
10 ML SR
1000 ML FC
10 EA BO
100 EA BO
MORPHINE SULF (10X1ML) 4 MG/ML
1 ML CR
10 EA BX
15 EA BO
AMPHOTERICIN B 50 MG
1 EA VL
1 EA CT
LANTUS 100 U/ML
15 ML CT
PO
IV
SC
SC
EA
EA
EA
ML
8 MG
50 MG
1 MG
5U
1
1
0.8
20
10/18/2007
01/25/2007
08/17/2007
04/04/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
54868-5774-00
J7626
IH
ML
0.25 MG
0.5
06/01/2007
99/99/9999
Page 258 of 374
1 ML
20 ML
40 ML
200 ML
5 ML
VL
VL
BX
VL
SR
SR
VL
VL
CT
VL
2 ML PC
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
IJ

MIDAZOLAM (10X2ML) 1 MG/ML
SODIUM CHLORIDE (20X25ML) 0.9%
PHENYLEPHRINE HYDROCHLORIDE
(SDV,25X1ML) 10 MG/ML
DOBUTAMINE 12.5 MG/ML
DOBUTAMINE (10X40ML) 12.5 MG/ML
DOBUTAMINE 12.5 MG/ML
LIDOCAINE (10X5ML) 2%
1 EA VL
Billing Units
NDC Package Type
NDC Package Measure
54868-5533-00
54868-5551-00
54868-5555-00
54868-5568-00
54868-5569-00
54868-5587-00
54868-5587-01
54868-5589-00
54868-5596-00
54868-5601-00
54868-5612-00
54868-5621-00 KO J7626
54868-5634-00
J2941
54868-5647-00
Q0144
54868-5648-00
Q0144
54868-5648-01
Q0144
54868-5648-02
Q0144
54868-5652-00
J1652
CEFTRIAXONE 500 MG

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
54868-5774-00 KO J7626
54868-5775-00
J2780
54868-5801-00
Q0179
54868-5801-01
54868-5802-00
Q0179
J0885
54868-5808-00
54868-5823-00
J2175
J1740
54868-5824-00
J1815
54868-5825-00
J0152
54868-5825-01
54868-5835-00
J0152
J1650
54868-5836-00
54868-5837-00
J1817
J1650
54868-5867-00
J0881
54868-5887-00
54868-5888-00
54868-5899-00
Q0179
J2405
J1815
54868-6624-01
J7509
54888-1082-03
Q0165
55045-1124-00
Q0163
55045-1124-01
Q0163
55045-1124-02
Q0163
55045-1124-03
Q0163
55045-1124-04
Q0163
55045-1124-05
Q0163
55045-1124-06
Q0163
55045-1124-07
Q0163
55045-1124-08
Q0163
55045-1124-09
Q0163
KO
BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON6/1/2007 99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG PULMICORT RESPULES 0.25 MG/2 ML
ZANTAC 25 MG/ML
ONDANSETRON 4 MG
ONDANSETRON 4 MG
PROCRIT (SDV,1MLX4) 40000 U/ML
DEMEROL HYDROCHLORIDE (1MLX10)
50 MG/ML
10/16/2007 99/99/9999 INJECTION, IBANDRONATE SODIUM, 1 MG
BONIVA (PFS) 1 MG/ML
INSULIN HUMULIN 50/50 50 U/ML-50
U/ML
ADENOSCAN 3 MG/ML
ADENOSCAN 3 MG/ML
LOVENOX (10X1ML) 100 MG/ML
12/3/2007 99/99/9999 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS INSULIN-HUMALOG (1X15ML) 100 U/ML
ARANESP (1X1ML, PREFILLED,PF) 0.5
MG/ML
ONDANSETRON (1X10ML) 2 MG/ML
HUMALOG PEN (1X15ML) 100 U/ML
4 MG
Page 259 of 374
2 ML PC
40 ML VL
IH
IJ
ML
ML
0.25 MG
25 MG
0.5
1
06/01/2007
06/06/2007
99/99/9999
99/99/9999
30 EA BO
PO
EA
8 MG
0.5
07/30/2007
99/99/9999
15 EA BO
1 ML VL
PO
IJ
EA
ML
8 MG
1000 U
0.5
40
10/25/2007
08/13/2007
99/99/9999
99/99/9999
IJ
IV
ML
EA
100 MG
1 MG
0.5
1
08/21/2007
10/16/2007
99/99/9999
99/99/9999
10 ML VL
1 ML SR
1 EA BX
SC
ML
5U
20
10/16/2007
99/99/9999
30 ML VL
IV
ML
30 MG
0.1
10/18/2007
99/99/9999
20 ML VL
1 ML SR
IV
IJ
ML
ML
30 MG
10 MG
0.1
10
10/18/2007
11/29/2007
99/99/9999
99/99/9999
15 ML CT
0.8 ML SR
SC
IJ
ML
ML
50 U
10 MG
2
15
12/03/2007
12/04/2007
99/99/9999
99/99/9999
IJ
ML
1 MCG
500
03/20/2008
99/99/9999
10 EA BX
10 ML NA
15 ML CT
PO
IJ
SC
EA
ML
ML
8 MG
1 MG
5U
0.5
2
20
05/12/2008
05/09/2008
05/12/2008
99/99/9999
99/99/9999
99/99/9999
21 EA DP
PO
EA
4 MG
01/01/2002
99/99/9999
100 EA NA
PO
EA
10 MG
10/20/2004
99/99/9999
100 EA BO
PO
EA
50 MG
05/01/2004
99/99/9999
3 EA BO
PO
EA
50 MG
12/06/2004
99/99/9999
60 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
90 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
120 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
15 EA BO
PO
EA
50 MG
01/01/2003
99/99/9999
6 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
20 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
30 EA BO
PO
EA
50 MG
01/01/2003
99/99/9999
50 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
1 ML SR
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55045-1125-00
Q0163
12/6/2004
55045-1125-01
Q0163
7/1/2004
55045-1125-02
Q0163
2/1/2004
55045-1125-03
Q0163
12/6/2004
55045-1125-04
Q0163
1/1/2003
55045-1125-05
Q0163
1/2/2004
55045-1125-06
Q0163
1/1/2003
55045-1125-08
Q0163
1/1/2003
55045-1125-09
Q0163
2/1/2004
55045-1126-02
Q0165
4/1/2005
55045-1126-03
Q0165
7/1/2003
55045-1126-04
Q0165
1/1/2003
55045-1126-06
Q0165
11/10/2005
55045-1126-07
Q0165
7/1/2005
55045-1126-08
Q0165
7/1/2003
55045-1252-02
Q0163
1/1/2003
55045-1259-09
55045-1260-00
55045-1260-09
J7509
J7506
J7506
1/1/2003
12/6/2004
1/1/2003
55045-1297-02
G9017
12/1/2004
55045-1297-03
G9033
12/1/2004
55045-1297-05
G9017
12/6/2004
55045-1308-01
55045-1308-01
Q0181
J8540
12/6/2004
1/1/2006

DIPHENHYDRAMINE HCL (AF) 12.5 MG/5
ML
METHYLPREDNISOLONE (DOSEPAK) 4
MG
PREDNISONE (DOSEPACK) 5 MG
AMANTADINE HYDROCHLORIDE, ORAL, BRAND, PER 100 MG (FOR USE IN A
AMANTADINE 100 MG
12/31/2005 REGIMEN
Page 260 of 374
120 EA NA
PO
EA
50 MG
0.5
12/06/2004
99/99/9999
100 EA NA
PO
EA
50 MG
0.5
07/01/2004
99/99/9999
6 EA NA
PO
EA
50 MG
0.5
02/01/2004
99/99/9999
90 EA NA
PO
EA
50 MG
0.5
12/06/2004
99/99/9999
12 EA BO
PO
EA
50 MG
0.5
01/01/2003
99/99/9999
15 EA NA
PO
EA
50 MG
0.5
01/02/2004
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
01/01/2003
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
01/01/2003
99/99/9999
60 EA NA
PO
EA
50 MG
0.5
02/01/2004
99/99/9999
10 EA BO
PO
EA
10 MG
04/01/2005
99/99/9999
5 EA BO
PO
EA
10 MG
07/01/2003
99/99/9999
12 EA BO
PO
EA
10 MG
01/01/2003
99/99/9999
60 EA BO
PO
EA
10 MG
11/10/2005
99/99/9999
20 EA BO
PO
EA
10 MG
07/01/2005
99/99/9999
30 EA BO
PO
EA
10 MG
07/01/2003
99/99/9999
118 ML BO
PO
ML
50 MG
0.05
01/01/2003
99/99/9999
21 EA DP
48 EA DP
21 EA DP
PO
PO
PO
EA
EA
EA
4 MG
5 MG
5 MG
1
1
1
01/01/2003
12/06/2004
01/01/2003
99/99/9999
99/99/9999
99/99/9999
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
10 EA NA
PO
EA
100 MG
12/01/2004
05/31/2005
50 EA BO
PO
EA
100 MG
12/06/2004
05/31/2005
100 EA BO
100 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
12/06/2004
01/01/2006
12/31/2005
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55045-1308-02
55045-1308-02
Q0181
J8540
12/6/2004
1/1/2006
55045-1308-03
55045-1308-03
Q0181
J8540
12/6/2004
1/1/2006
55045-1308-06
55045-1308-06
Q0181
J8540
3/1/2004
1/1/2006
55045-1308-07
55045-1308-07
Q0181
J8540
12/6/2004
1/1/2006
55045-1308-08
55045-1308-08
Q0181
J8540
12/6/2004
1/1/2006
55045-1308-09
55045-1308-09
55045-1444-01
55045-1444-02
55045-1444-03
55045-1444-04
55045-1444-07
55045-1444-08
55045-1480-01
55045-1480-02
55045-1480-05
55045-1480-06
55045-1480-07
55045-1480-08
55045-1480-09
55045-1533-01
55045-1533-03
55045-1533-06
55045-1533-07
55045-1533-08
55045-1533-09
Q0181
J8540
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
1/1/2004
1/1/2006
12/6/2004
5/1/2005
1/1/2004
1/1/2003
1/1/2003
1/1/2003
1/1/2003
12/6/2004
12/6/2004
12/6/2004
1/1/2003
1/1/2003
1/1/2003
5/1/2004
1/1/2003
1/1/2003
1/1/2003
1/1/2003
1/1/2003
55045-1596-00
Q0170
12/6/2004
55045-1596-01
Q0170
12/6/2004
55045-1596-02
Q0170
8/9/2004
55045-1596-03
Q0170
1/1/2003
55045-1596-04
Q0170
2/9/2003
55045-1596-05
Q0170
1/1/2003
55045-1596-06
Q0170
1/1/2003
55045-1596-08
Q0170
1/1/2004

12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
Page 261 of 374
60 EA BO
60 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
12/06/2004
01/01/2006
12/31/2005
99/99/9999
90 EA BO
90 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
12/06/2004
01/01/2006
12/31/2005
99/99/9999
6 EA BO
6 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
03/01/2004
01/01/2006
12/31/2005
99/99/9999
20 EA BO
20 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
12/06/2004
01/01/2006
12/31/2005
99/99/9999
30 EA BO
30 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
12/06/2004
01/01/2006
12/31/2005
99/99/9999
BO
BO
NA
BO
BO
BO
BO
BO
BO
NA
NA
NA
BO
BO
BO
NA
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
0.25 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
3
4
4
4
4
4
4
1
1
1
1
1
1
1
2
2
2
2
2
2
01/01/2004
01/01/2006
12/06/2004
05/01/2005
01/01/2004
01/01/2003
01/01/2003
01/01/2003
01/01/2003
12/06/2004
12/06/2004
12/06/2004
01/01/2003
01/01/2003
01/01/2003
05/01/2004
01/01/2003
01/01/2003
01/01/2003
01/01/2003
01/01/2003
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
25 MG
12/06/2004
99/99/9999
120 EA BO
PO
EA
25 MG
12/06/2004
99/99/9999
12 EA NA
PO
EA
25 MG
08/09/2004
99/99/9999
10 EA BO
PO
EA
25 MG
01/01/2003
99/99/9999
60 EA NA
PO
EA
25 MG
02/09/2003
99/99/9999
15 EA BO
PO
EA
25 MG
01/01/2003
99/99/9999
20 EA BO
PO
EA
25 MG
01/01/2003
99/99/9999
30 EA BO
PO
EA
25 MG
05/23/2005
99/99/9999
36 EA
36 EA
35 EA
42 EA
18 EA
12 EA
21 EA
30 EA
100 EA
60 EA
15 EA
20 EA
21 EA
30 EA
40 EA
100 EA
20 EA
42 EA
21 EA
30 EA
40 EA
1/1/2004
5/22/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55045-1596-09
Q0170
12/6/2004
55045-1628-03
Q0173
1/1/2003
55045-1643-09
Q0170
1/1/2003
55045-1661-00
Q0178
12/6/2004
55045-1661-01
Q0178
12/6/2004
55045-1661-02
Q0178
12/6/2004
55045-1661-03
Q0178
9/1/2004
55045-1661-06
Q0178
9/1/2004
55045-1661-08
Q0178
6/1/2003
55045-1661-09
Q0178
12/6/2004
55045-1696-02
Q0164
12/6/2004
55045-1749-02
55045-1749-02
55045-1811-03
55045-1811-08
K0416
J8498
J7509
J7509
1/1/2003
1/1/2006
12/6/2004
12/6/2004
55045-1970-05
55045-1970-05
Q0181
J8540
5/1/2005
1/1/2006
55045-2043-07
J7603
1/1/2008
55045-2043-07 KO J7603
55045-2043-07
KO
J7613
55045-2043-07 KO J7613
55045-2133-03
J3360
1/1/2008
4/1/2008
KO
4/1/2008
3/24/2003
55045-2195-02
Q0177
12/6/2004
55045-2195-04
Q0177
7/1/2004
55045-2195-05
Q0177
3/24/2003

ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE HCL (FRUIT,TROPICAL)
6.25 MG/5 ML
PHENERGAN 25 MG
PHENERGAN 25 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DIAZEPAM 5 MG/ML
Page 262 of 374
90 EA BO
PO
EA
25 MG
12/06/2004
99/99/9999
10 EA BO
PO
EA
250 MG
01/01/2003
99/99/9999
118 ML BO
PO
ML
25 MG
0.05
01/01/2003
99/99/9999
100 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
120 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
20 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
40 EA NA
PO
EA
50 MG
09/01/2004
99/99/9999
60 EA NA
PO
EA
50 MG
09/01/2004
99/99/9999
30 EA BO
PO
EA
50 MG
06/01/2003
99/99/9999
90 EA NA
PO
EA
50 MG
12/06/2004
99/99/9999
10 EA NA
PO
EA
5 MG
12/06/2004
99/99/9999
4 EA
4 EA
40 EA
30 EA
BO
BO
NA
NA
RC
RC
PO
PO
EA
EA
EA
EA
1 MG
1 EA
4 MG
4 MG
25
1
1
1
01/01/2003
01/01/2006
12/06/2004
12/06/2004
12/31/2005
99/99/9999
99/99/9999
99/99/9999
8 EA BO
8 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
05/01/2005
01/01/2006
12/31/2005
99/99/9999
3 ML NA
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML NA
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML NA
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML NA
10 ML VL
IH
IJ
ML
ML
1 MG
5 MG
0.83
1
04/01/2008
03/24/2003
99/99/9999
99/99/9999
120 EA NA
PO
EA
25 MG
12/06/2004
99/99/9999
9 EA BO
PO
EA
25 MG
07/01/2004
99/99/9999
15 EA BO
PO
EA
25 MG
03/24/2003
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55045-2195-06
Q0177
12/6/2004
55045-2195-07
Q0177
3/1/2004
55045-2195-08
Q0177
2/1/2004
55045-2195-09
55045-2372-05
55045-2373-05
55045-2373-06
55045-2373-08
Q0177
Q0144
Q0144
Q0144
Q0144
12/6/2004
1/19/2005
1/19/2005
1/1/2003
1/19/2005
55045-2400-02
55045-2400-02
K0416
J8498
5/1/2003
1/1/2006
55045-2470-02
J7602
1/1/2008
55045-2470-02
55045-2492-06
55045-2533-00
55045-2533-00
55045-2565-00
55045-2565-02
55045-2565-04
55045-2565-05
55045-2565-08
55045-2571-00
55045-2571-02
55045-2571-04
55045-2571-05
55045-2571-06
55045-2571-08
55045-2648-00
55045-2648-02
55045-2648-03
55045-2648-05
55045-2648-06
J7611
Q0144
J3490
J0595
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
4/1/2008
7/3/2006
3/24/2003
1/1/2004
1/1/2005
12/6/2004
1/1/2005
1/1/2005
1/1/2005
1/1/2005
1/1/2005
1/1/2003
1/1/2005
3/1/2005
1/1/2005
1/1/2005
7/1/2003
1/1/2005
1/1/2005
1/1/2005
55045-2665-02
55045-2665-02
Q0181
J8540
1/1/2003
1/1/2006
55045-2759-01
G9035
1/1/2005
55045-2781-06
Q0163
7/1/2004
55045-2815-08
Q0169
2/23/2005
STADOL 2 MG/ML
STADOL 2 MG/ML
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
12/31/2005 REGIMEN
TAMIFLU 75 MG
55045-2857-01
55045-2885-00
55045-2885-08
55045-2887-02
55045-2942-06
55045-2963-01
55045-2963-02
J2250
J7510
J7510
J2250
Q0144
J7506
J7506
12/1/2005
1/2/2006
7/5/2006
8/27/2003
1/1/2003
12/6/2004
12/6/2004

55045-2968-01
55045-2968-02
J0595
J0595
55045-3011-02
55045-3011-02
K0416
J8498
55045-3011-03
K0416

55045-3011-03
J8498

ORAPRED (10X20ML) 15 MG/5 ML
ORAPRED 15 MG/5 ML
ZITHROMAX Z-PAK (Z-PAK) 250 MG
MG/ML
BUTORPHANOL TARTRATE 2 MG/ML
MG
MG
Page 263 of 374
60 EA NA
PO
EA
25 MG
12/06/2004
99/99/9999
20 EA NA
PO
EA
25 MG
03/01/2004
99/99/9999
30 EA NA
PO
EA
25 MG
02/01/2004
99/99/9999
NA
BO
BO
BO
BO
PO
PO
PO
PO
PO
EA
ML
ML
ML
ML
25 MG
1 GM
1 GM
1 GM
1 GM
1
0.02
0.04
0.04
0.04
12/06/2004
01/19/2005
01/19/2005
01/01/2003
01/19/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
05/01/2003
01/01/2006
12/31/2005
99/99/9999
20 ML NA
90 EA
15 ML
15 ML
22.5 ML
30 ML
IH
ML
1 MG
01/01/2008
03/31/2008
NA
BX
VL
VL
NA
BO
NA
NA
NA
NA
NA
BO
NA
NA
NA
NA
BO
NA
NA
NA
IH
PO
IJ
IJ
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
ML
EA
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 MG
1 GM
1 EA
1 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
5
0.25
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
04/01/2008
07/03/2006
03/24/2003
01/01/2004
01/01/2005
12/06/2004
01/01/2005
01/01/2005
01/01/2005
01/01/2005
01/01/2005
01/01/2003
01/01/2005
03/01/2005
01/01/2005
01/01/2005
07/01/2003
01/01/2005
01/01/2005
01/01/2005
99/99/9999
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA BO
12 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
01/01/2003
01/01/2006
12/31/2005
99/99/9999
10 EA DP
PO
EA
75 MG
01/01/2005
05/31/2005
24 EA NA
PO
EA
50 MG
0.5
07/01/2004
99/99/9999
20 ML
6 EA
10 ML
10 ML
100 EA
25 EA
50 EA
15 EA
30 EA
100 EA
25 EA
15 EA
50 EA
60 EA
30 EA
100 EA
15 EA
25 EA
50 EA
60 EA
30 EA NA
PO
EA
12.5 MG
02/23/2005
05/23/2005
IJ
PO
PO
IJ
PO
PO
PO
ML
ML
ML
ML
EA
EA
EA
1 MG
5 MG
5 MG
1 MG
1 GM
5 MG
5 MG
5
0.6
0.6
1
0.25
2
2
12/01/2005
01/02/2006
07/05/2006
08/27/2003
01/01/2003
12/06/2004
12/06/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/19/2005
99/99/9999
99/99/9999
1 ML NA
1 ML NA
IJ
IJ
ML
ML
1 MG
1 MG
2
2
01/01/2005
04/11/2006
99/99/9999
99/99/9999
4 EA BX
4 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
03/01/2003
01/01/2006
12/31/2005
99/99/9999
12 EA NA
RC
EA
1 MG
25
05/01/2005
12/31/2005
12 EA NA
RC
EA
1 EA
01/01/2006
99/99/9999
1 ML
20 ML
237 ML
2 ML
18 EA
21 EA
48 EA
VL
BO
BO
EA
NA
DP
DP
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55045-3029-02
J1080
55045-3203-03
55045-3212-03
55045-3231-01
55045-3232-01
55045-3242-02
55045-3242-05
55045-3243-01
55045-3248-01
55045-3249-05
55045-3251-05
55045-3252-02
55045-3281-03
55045-3281-04
55045-3298-01
Q0173
J1100
J2001
J0690
J1030
J1030
J1040
J3301
J2001
J3490
J3490
J7506
J7506
J1200
55045-3339-04
55045-3442-05
55045-3442-06
55045-3471-01
55045-3503-01
G9020
Q0144
Q0144
J7500
J0696
55045-3505-01
55045-3506-01
55045-3508-01
55045-3509-01
55045-3511-01
55045-3511-02
J1055
J1815
J1815
J2930
J0696
J0696
55045-3512-01
55045-3513-01
J3030
J7509
55045-3514-01
J2550
55045-3515-01
55045-3516-01
55045-3532-01
55045-3565-01
J2310
J0696
J1956
J3250
55045-3684-02
55045-3685-01
55045-3693-01
55045-3696-03
55045-3698-03
55045-3710-01
55045-3710-01
55045-3725-01
55045-3726-02
55045-3727-01
J0540
J1815
Q0144
J0170
Q0144
J2912
A4216
Q0144
Q0144
Q0144
55045-3729-03
55045-3773-05
Q0179
J3490
55045-3815-01
Q0179
55045-9903-03
J0170
55111-0153-13
Q0179
55111-0153-30
Q0179
55111-0154-13
Q0179
55111-0154-30
Q0179

DEXAMETHASONE 4 MG/ML
LIDOCAINE HYDROCHLORIDE 1%
DEPO MEDROL 40 MG/ML
KENALOG 40 40 MG/ML
LIDOCAINE HYDROCHLORIDE 2%
MARCAINE HYDROCHLORIDE 0.5%
MARCAINE HYDROCHLORIDE 0.25%
PREDNISONE 10 MG
PREDNISONE 10 MG
BENADRYL 50 MG/ML
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
AZATHIOPRINE 50 MG
CEFTRIAXONE 500 MG
6/28/2006 99/99/9999 MG
DEPO PROVERA 150 MG/ML
HUMULIN R U-100 100 U/ML
NOVOLIN 70/30 70 U/ML-30 U/ML
SOLU MEDROL 125 MG
CEFTRIAXONE 1 GM
CEFTRIAXONE 1 GM
IMITREX (5X0.5ML) 6 MG/0.5 ML
PROMETHAZINE HYDROCHLORIDE
(25X1ML) 25 MG/ML
NALOXONE HYDROCHLORIDE 0.4
MG/ML
CEFTRIAXONE 250 MG
LEVAQUIN 25 MG/ML
TIGAN 100 MG/ML
11/15/2005 12/31/2009 1,200,000 UNITS
BICILLIN CR 900/300 (10X2ML)
LANTUS 100 U/ML
AZITHROMYCIN 500 MG
ADRENALIN CHLORIDE 1 MG/ML
SODIUM CHLORIDE (10MLX25) 0.9%
BACITRACIN 50000 U
ONDANSETRON 8 MG
EPINEPHRINE HCL (SYRINGE,LATEX3/15/2003 99/99/9999 INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE
FREE) 0.1 MG/ML
(FILM-COATED) 4 MG
(FILM-COATED) 8 MG
Page 264 of 374
10 ML VL
IM
ML
200 MG
01/01/2003
99/99/9999
10 EA
30 ML
50 ML
1 EA
10 ML
5 ML
1 ML
1 ML
50 ML
50 ML
50 ML
15 EA
18 EA
10 ML
NA
NA
NA
NA
NA
NA
VL
VL
NA
NA
NA
NA
NA
NA
PO
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
PO
PO
IJ
EA
ML
ML
EA
ML
ML
ML
ML
ML
ML
ML
EA
EA
ML
250 MG
1 MG
10 MG
500 MG
40 MG
40 MG
80 MG
10 MG
10 MG
1 EA
1 EA
5 MG
5 MG
50 MG
1.2
4
1
2
1
1
1
4
2
1
1
2
2
1
05/01/2005
07/01/2006
07/01/2006
09/01/2004
07/01/2006
07/01/2006
07/20/2006
07/21/2006
07/01/2006
07/01/2006
07/01/2006
12/20/2004
02/11/2005
01/01/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
14 EA
6 EA
6 EA
100 EA
1 EA
NA
NA
NA
BO
VL
PO
PO
PO
PO
IJ
EA
EA
EA
EA
EA
100 MG
1 GM
1 GM
50 MG
250 MG
1
0.25
0.25
1
2
03/21/2005
12/05/2005
12/05/2005
03/01/2006
06/28/2006
05/31/2005
12/05/2005
99/99/9999
99/99/9999
99/99/9999
1 ML
10 ML
10 ML
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
IM
IJ
SC
IJ
IJ
IJ
ML
ML
ML
EA
EA
EA
150 MG
5U
5U
125 MG
250 MG
250 MG
1
20
20
1
4
4
06/28/2006
06/28/2006
06/30/2006
07/10/2006
07/11/2006
07/14/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
0.5 ML VL
25 EA BO
SC
PO
ML
EA
6 MG
4 MG
2
2
07/11/2006
06/23/2006
99/99/9999
99/99/9999
1 ML AM IJ
ML
50 MG
0.5
07/12/2006
99/99/9999
1 ML
1 EA
20 ML
20 ML
AM
VL
NA
NA
IJ
IJ
IV
IM
ML
EA
ML
ML
1 MG
250 MG
250 MG
200 MG
0.4
1
0.1
0.5
07/12/2006
07/12/2006
01/02/2007
07/01/2006
99/99/9999
99/99/9999
99/99/9999
07/31/2008
2 ML
10 ML
3 EA
30 ML
30 ML
10 ML
10 ML
15 ML
22.5 ML
15 ML
SR
VL
NA
NA
BO
NA
NA
BO
BO
BO
IM
SC
PO
IJ
PO
IJ
IJ
PO
PO
PO
ML
ML
EA
ML
ML
ML
ML
ML
ML
ML
1200000 U
5U
1 GM
1 ML
1 GM
0.9 %
10 ML
1 GM
1 GM
1 GM
0.5
20
0.5
1
0.04
0.5
0.1
0.02
0.04
0.04
11/15/2005
11/15/2006
12/06/2006
08/17/2006
12/26/2006
07/24/2006
01/01/2007
12/26/2006
12/26/2006
12/26/2006
12/31/2009
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 EA BO
1 EA NA
PO
IM
EA
EA
8 MG
1 EA
0.5
1
02/01/2007
04/06/2007
99/99/9999
99/99/9999
10 EA BX
PO
EA
8 MG
07/26/2007
99/99/9999
10 ML SR
IJ
ML
1 ML
03/15/2003
99/99/9999
3 EA BX
PO
EA
8 MG
0.5
12/26/2006
99/99/9999
30 EA BO
PO
EA
8 MG
0.5
12/26/2006
99/99/9999
3 EA BX
PO
EA
8 MG
12/26/2006
99/99/9999
30 EA BO
PO
EA
8 MG
12/26/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
12/26/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
55289-0012-10
G9017
12/1/2004
55289-0012-14
G9017
12/1/2004
55289-0012-20
G9017
12/1/2004
55289-0033-04
Q0165
1/1/2002
55289-0033-10
Q0165
1/1/2002
55289-0033-97
Q0165
1/1/2002
55289-0100-01
Q0163
1/1/2002
55289-0100-10
Q0163
1/1/2002
55289-0100-15
Q0163
1/1/2002
55289-0100-20
Q0163
1/1/2002
55289-0100-30
Q0163
1/1/2002
55289-0100-40
Q0163
9/9/2002
55289-0119-02
55289-0119-02
K0416
J8498
10/1/2002
1/1/2006
55289-0119-06
55289-0119-06
K0416
J8498
1/1/2002
1/1/2006
55289-0195-10
Q0178
1/1/2002
55289-0219-20
Q0173
1/1/2002
55289-0224-04
Q0165
5/21/2002
55289-0224-06
Q0165
3/7/2008
55289-0224-12
Q0165
4/2/2008
55289-0226-10
Q0177
1/1/2002
PO
EA
100 MG
12/01/2004
05/31/2005
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
4 EA BO
PO
EA
10 MG
01/01/2002
05/21/2003
10 EA BO
PO
EA
10 MG
01/01/2002
05/21/2003
25 EA BX
PO
EA
10 MG
01/01/2002
10/01/2002
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
10 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
40 EA BO
PO
EA
50 MG
09/09/2002
99/99/9999
2 EA BX
2 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
10/01/2002
01/01/2006
12/31/2005
99/99/9999
6 EA BX
6 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
10 EA BO
PO
EA
50 MG
01/01/2002
12/23/2002
20 EA BO
PO
EA
250 MG
01/01/2002
10/09/2006
4 EA BO
PO
EA
10 MG
05/21/2002
99/99/9999
10 EA BO
PO
EA
10 MG
03/07/2008
99/99/9999
12 EA BO
PO
EA
10 MG
04/02/2008
99/99/9999
10 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
CF
HCPCS Amount #1
10 EA BO
Prior End Date #3
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
12/26/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
3
1
1
1
1
Prior End Date #2
8 MG
1 EA
1 EA
1 EA
1 EA
End Date #1
EA
EA
EA
EA
EA
Start Date #1
PO
PO
PO
PO
PO
HCPCS Measure #1
BX
BO
BO
BO
BO
Billing Units
1 EA
10 EA
25 EA
35 EA
50 EA
Prior Start Date #2

Package
HCPCS Description
NDC Label
Page 265 of 374
NDC Package Type
Q0179
J8499
J8499
J8499
J8499

ZOVIRAX 200 MG
ZOVIRAX 200 MG
ZOVIRAX 200 MG
ZOVIRAX 200 MG
COMPAZINE 10 MG
COMPAZINE 10 MG
COMPAZINE 10 MG
NDC Package Measure
55111-0156-11
55289-0006-10
55289-0006-25
55289-0006-35
55289-0006-50
HCPCS Mod
HCPCS
NDC Mod
NDC
3/6/2008
1/1/2002
1/1/2002
8/1/2006
1/1/2002
1/1/2002
10/16/2007
55289-0274-03
55289-0310-04
55289-0310-06
55289-0310-14
55289-0330-05
55289-0330-07
55289-0330-10
55289-0352-05
55289-0352-07
55289-0352-09
55289-0352-10
55289-0352-12
55289-0352-14
55289-0352-15
55289-0352-20
55289-0352-21
55289-0352-30
Q0144
Q0144
Q0144
Q0144
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
4/2/2008
1/1/2002
1/15/2004
1/1/2002
4/25/2008
9/16/2008
1/1/2002
5/1/2008
3/1/2004
1/1/2002
1/1/2002
5/1/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
55289-0354-10
55289-0373-01
55289-0373-12
55289-0373-30
55289-0373-36
55289-0373-42
55289-0373-46
55289-0373-55
55289-0373-60
55289-0373-72
Q0178
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
10/1/2002
1/1/2002
12/13/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
55289-0414-04
55289-0414-04
K0416
J8498
1/1/2002
1/1/2006
55289-0414-06
55289-0414-06
K0416
J8498
1/1/2002
1/1/2006
55289-0417-14
G9036
12/1/2004
55289-0428-10
Q0173
1/1/2002
55289-0428-17
55289-0438-01
55289-0438-20
55289-0438-21
55289-0438-30
55289-0438-36
55289-0438-38
55289-0438-40
55289-0438-42
55289-0438-50
55289-0438-60
55289-0462-05
55289-0462-12
55289-0462-15
55289-0462-21
55289-0462-25
55289-0462-30
55289-0462-35
55289-0462-60
Q0173
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
3/18/2008
1/1/2002
3/5/2002
1/15/2004
1/1/2002
1/1/2002
8/17/2006
1/1/2002
1/1/2002
4/21/2008
3/1/2006
55289-0464-15
Q0170
12/1/2003

ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
PREDNISONE 50 MG
PREDNISONE 50 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
FLUMADINE 100 MG
TIGAN 250 MG
TIGAN 250 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
Page 266 of 374
3 EA
4 EA
6 EA
14 EA
5 EA
7 EA
10 EA
5 EA
7 EA
9 EA
10 EA
12 EA
14 EA
15 EA
20 EA
21 EA
30 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 GM
1 GM
1 GM
1 GM
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
0.5
0.25
0.25
0.25
10
10
10
4
4
4
4
4
4
4
4
4
4
04/02/2008
01/01/2002
01/15/2004
01/01/2002
04/25/2008
09/16/2008
01/01/2002
05/01/2008
03/01/2004
01/01/2002
01/01/2002
05/01/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 EA
100 EA
12 EA
30 EA
36 EA
42 EA
46 EA
50 EA
60 EA
72 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
1
1
1
1
1
1
1
1
1
10/01/2002
01/01/2002
12/13/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
10/09/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
4 EA BX
4 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
01/01/2002
01/01/2006
12/31/2005
10/09/2006
6 EA BX
6 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
01/01/2002
01/01/2006
12/31/2005
10/09/2006
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
10 EA BO
PO
EA
250 MG
02/12/2002
06/29/2006
1/1/2002
2/11/2002
BX
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
250 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
02/12/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
03/18/2008
01/01/2002
03/05/2002
01/15/2004
01/01/2002
01/01/2002
08/17/2006
01/01/2002
01/01/2002
04/21/2008
03/01/2006
10/09/2006
09/17/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1/1/2002
2/11/2002
15 EA BO
PO
EA
25 MG
12/01/2003
99/99/9999
100 EA
100 EA
20 EA
21 EA
30 EA
36 EA
38 EA
40 EA
42 EA
50 EA
60 EA
5 EA
12 EA
15 EA
21 EA
25 EA
30 EA
35 EA
60 EA
CF
HCPCS Amount #1
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
03/06/2008
01/01/2002
01/01/2002
08/01/2006
01/01/2002
01/01/2002
10/16/2007
Prior End Date #2
1
1
1
1
1
1
0.5
Prior Start Date #2
25 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 GM
End Date #1
EA
EA
EA
EA
EA
EA
EA
Start Date #1
PO
PO
PO
PO
PO
PO
PO
HCPCS Measure #1
BO
BO
BO
BO
BO
BO
BO
Billing Units
15 EA
10 EA
25 EA
30 EA
35 EA
50 EA
2 EA
Prior End Date #3

Package
HCPCS Description
NDC Label
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
AZITHROMYCIN 500 MG
NDC Package Type
Q0177
J8499
J8499
J8499
J8499
J8499
Q0144
NDC Package Measure
55289-0226-15
55289-0273-10
55289-0273-25
55289-0273-30
55289-0273-35
55289-0273-50
55289-0274-02
HCPCS Mod
HCPCS
NDC Mod
NDC
55289-0464-79
Q0170
2/1/2005
55289-0479-01
Q0163
1/1/2002
55289-0479-10
Q0163
1/1/2002
55289-0479-12
Q0163
7/1/2006
55289-0479-15
Q0163
1/1/2002
55289-0479-20
Q0163
1/1/2002
55289-0479-24
Q0163
1/1/2002
55289-0479-30
Q0163
1/1/2002
55289-0531-04
Q0170
2/26/2008
55289-0559-03
Q0179
4/25/2008
55289-0559-05
Q0179
6/3/2008
55289-0559-06
55289-0564-15
55289-0564-20
55289-0564-48
Q0179
J8499
J8499
J8499
4/25/2008
1/1/2002
1/1/2002
1/1/2002
55289-0568-10
Q0164
7/1/2005
55289-0568-12
Q0164
10/1/2002
55289-0568-30
55289-0582-04
55289-0582-10
55289-0585-30
55289-0629-10
55289-0629-30
55289-0629-50
55289-0649-30
55289-0649-98
55289-0691-12
55289-0691-15
55289-0691-25
Q0164
J8540
J8540
J8999
J8499
J8499
J8499
J7509
J7509
J8499
J8499
J8499
11/15/2007
10/1/2007
4/10/2008
1/1/2002
8/26/2002
6/5/2007
4/23/2008
10/15/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
55289-0832-14
55289-0924-30
55289-0928-02
55289-0928-04
G9020
None
J8498
J8498
12/1/2004
11/1/2005
3/1/2006
5/9/2006
55289-0928-06
K0416
11/1/2005

(USP) 50 MG
MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 ONDANSETRON (USP, STRAWBERRY 4
MG
MG
ZOVIRAX 800 MG
ZOVIRAX 800 MG
ZOVIRAX 800 MG
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
NOLVADEX 10 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ZOVIRAX 400 MG
ZOVIRAX 400 MG
ZOVIRAX 400 MG
METHOTREXATE 2.5 MG
PROMETHAZINE (USP) 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
Page 267 of 374
1 EA BO
PO
EA
25 MG
05/24/2005
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
10 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
12 EA BO
PO
EA
50 MG
0.5
07/01/2006
99/99/9999
15 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
4 EA BO
PO
EA
25 MG
02/26/2008
99/99/9999
3 EA BO
PO
EA
8 MG
0.5
04/25/2008
99/99/9999
5 EA BO
PO
EA
8 MG
0.5
06/03/2008
99/99/9999
BO
BO
BO
BO
PO
PO
PO
PO
EA
EA
EA
EA
8 MG
1 EA
1 EA
1 EA
0.5
1
1
1
04/25/2008
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 EA BO
PO
EA
5 MG
07/01/2005
99/99/9999
12 EA BO
PO
EA
5 MG
10/01/2002
99/99/9999
6 EA
15 EA
20 EA
48 EA
30 EA
4 EA
10 EA
30 EA
10 EA
30 EA
50 EA
30 EA
120 EA
12 EA
15 EA
25 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
5 MG
0.25 MG
0.25 MG
1 EA
1 EA
1 EA
1 EA
4 MG
4 MG
1 EA
1 EA
1 EA
1
16
16
1
1
1
1
1
1
1
1
1
11/15/2007
10/01/2007
04/10/2008
01/01/2002
08/26/2002
06/05/2007
04/23/2008
10/15/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
11/14/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
14 EA
30 EA
2 EA
4 EA
BO
BO
BX
BX
PO
PO
RC
RC
EA
EA
EA
EA
100 MG
2.5 MG
1 EA
1 EA
1
1
1
1
12/01/2004
11/01/2005
03/01/2006
05/09/2006
05/31/2005
99/99/9999
99/99/9999
99/99/9999
6 EA BX
RC
EA
1 MG
25
11/01/2005
12/31/2005
2/1/2005
5/23/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55289-0928-06
J8498
55289-0928-79
55289-0928-79
K0416
J8498
55289-0940-02
J8498
55289-0940-06
J8498
55289-0948-02
Q0169
55289-0953-06
55289-0964-04
55289-0964-14
55370-0202-02
55370-0202-04
55370-0555-07
55370-0555-09
55370-0556-07
55370-0556-08
55370-0557-07
55370-0557-09
55390-0003-10
Q0173
Q0144
Q0144
J3490
J3490
J8499
J8499
J8499
J8499
J8499
J8499
J1800
55390-0004-01
55390-0004-10
J1610
J1610

PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE HYDROCHLORIDE
(USP) 12.5 MG
MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
CIMETIDINE HCL (VIAL) 150 MG/ML
1/1/2002
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
1/1/2002
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
PROPRANOLOL HCL (S.D.V.) 1 MG/ML
GLUCAGEN DIAGNOSTIC KIT (VIAL
W/STERILE WATER) 1 MG
GLUCAGEN (VIAL) 1 MG
6 EA BX
RC
EA
1 EA
01/01/2006
99/99/9999
1 EA BX
1 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
11/01/2005
01/01/2006
12/31/2005
99/99/9999
2 EA BX
RC
EA
1 EA
03/01/2006
99/99/9999
6 EA BX
RC
EA
1 EA
05/09/2006
99/99/9999
2 EA BO
PO
EA
12.5 MG
05/09/2006
99/99/9999
PO
PO
PO
IV
IV
PO
PO
PO
PO
PO
PO
IV
EA
EA
EA
ML
ML
EA
EA
EA
EA
EA
EA
ML
250 MG
1 GM
1 GM
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 MG
1.2
0.25
0.25
1
1
1
1
1
1
1
1
1
05/09/2006
11/01/2005
02/01/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
09/29/2005
09/29/2005
09/01/2006
07/14/2003
07/14/2003
07/14/2003
09/01/2006
07/14/2003
99/99/9999
1 EA VL
1 EA VL
IJ
IJ
EA
EA
1 MG
1 MG
1
1
01/01/2002
01/01/2002
99/99/9999
99/99/9999
6 EA
4 EA
14 EA
2 ML
8 ML
100 EA
1000 EA
100 EA
500 EA
100 EA
1000 EA
1 ML
BO
BO
BO
VL
VL
BO
BO
BO
BO
BO
BO
VL
55390-0005-01
J9040
BLEOMYCIN SULFATE (S.D.V.,USP) 15 U
1 EA VL
IJ
EA
15 U
03/10/2003
99/99/9999
55390-0006-01
J9040
1 EA VL
IJ
EA
15 U
03/10/2003
99/99/9999
55390-0009-01
55390-0012-01
J0640
J1450

50 ML VL
100 ML VL
IJ
IV
ML
ML
50 MG
200 MG
0.2
0.01
01/01/2002
07/29/2004
99/99/9999
99/99/9999
55390-0013-10
55390-0014-02
55390-0019-10
55390-0020-10
55390-0021-01
55390-0026-01
55390-0027-01
55390-0028-10
55390-0029-10
55390-0030-10
J1110
J1190
J2260
J2260
J2260
J3490
J3490
J3490
J3490
J9340
9/3/2003
4/8/2005
5/31/2002
5/31/2002
5/31/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
IV
IV
IV
IV
IJ
ML
EA
ML
ML
ML
ML
ML
ML
ML
EA
1 MG
250 MG
5 MG
5 MG
5 MG
1 EA
1 EA
1 EA
1 EA
15 MG
1
1
0.2
0.2
0.2
1
1
1
1
1
09/03/2003
04/08/2005
05/31/2002
05/31/2002
05/31/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
55390-0031-10
J9250
2 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
55390-0032-10
J9250
4 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
55390-0033-10
J9250
8 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
55390-0034-10
J9250
BLEOMYCIN SULFATE (S.D.V.,USP) 30 U

MG/ML
(VIAL) 1 MG/ML
DEXRAZOXANE 250 MG
FAMOTIDINE (BULK VIAL) 10 MG/ML
FAMOTIDINE (M.D.V.,PF) 10 MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
10 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
55390-0042-10
55390-0045-01
55390-0046-01
55390-0051-10
55390-0052-10
55390-0053-01
J3490
J9209
J1450
J0640
J0640
J0640
IV
IV
IV
IJ
IJ
IJ
ML
ML
ML
EA
EA
EA
1 EA
200 MG
200 MG
50 MG
50 MG
50 MG
1
0.5
0.01
1
2
4
01/01/2002
02/24/2004
07/29/2004
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
55390-0054-01
J0640
55390-0057-01
J0282
1/1/2002
2/24/2004
7/29/2004
1/1/2002
1/1/2002
1/1/2002



55390-0057-10
J0282
55390-0058-10
J0282
55390-0059-10
55390-0060-02
55390-0066-10
J2360
J1190
J0500
55390-0067-10
J0150
55390-0068-01
J0150
55390-0069-01
J9390

4/8/2005 99/99/9999 INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG
INAMRINONE LACTATE (S.D.V.) 5 MG/ML

LEUCOVORIN CALCIUM (VIAL) 50 MG
MG
AMIODARONE HCL (20ML MULTIPLE
USE VIAL) 50 MG/ML
1 ML
1 EA
10 ML
20 ML
50 ML
50 ML
20 ML
4 ML
2 ML
1 EA
20 ML
10 ML
200 ML
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
1 EA VL
IJ
EA
50 MG
01/01/2002
99/99/9999
18 ML VL
IV
ML
30 MG
1.66666
10/25/2002
99/99/9999
3 ML VL
AMIODARONE HCL (S.D.V.,PF) 50 MG/ML

AMIODARONE HCL (5ML AMPULE,PF) 50
MG/ML
ORPHENADRINE CITRATE (S.D.V) 30
MG/ML
DEXRAZOXANE 500 MG
DICYCLOMINE HCL (U.S.P.) 10 MG/ML
IV
ML
30 MG
1.66666
12/01/2003
99/99/9999
3 ML VL
IV
ML
30 MG
1.66666
10/18/2002
11/30/2003
2 ML VL
1 EA VL
2 ML VL
IJ
IV
IM
ML
EA
ML
60 MG
250 MG
20 MG
0.5
2
0.5
04/28/2003
04/08/2005
07/14/2003
99/99/9999
99/99/9999
99/99/9999
ADENOSINE (S.D.V.) 3 MG/ML
2 ML VL
IV
ML
6 MG
0.5
06/16/2004
99/99/9999
ADENOSINE (S.D.V.) 3 MG/ML

MG/ML
4 ML VL
IV
ML
6 MG
0.5
09/01/2004
99/99/9999
1 ML VL
IV
ML
10 MG
02/03/2004
99/99/9999
Page 268 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55390-0070-01
J9390
55390-0074-10
J2260
55390-0075-10
J2260
55390-0076-01
J2260
55390-0077-01
J0780
55390-0077-10
J0780
55390-0083-01
J9293
55390-0084-01
J9293
55390-0085-01
55390-0090-10
55390-0091-10
J9293
J9140
J9360

1/1/2002 99/99/9999 DACARBAZINE, 200 MG
55390-0097-10
55390-0099-01
J0282
J9060

55390-0100-10
55390-0101-10
55390-0104-20
55390-0104-50
55390-0104-99
55390-0105-01
J0592
J3105
J3490
J3490
J3490
J0282

6/23/2005
6/23/2005
6/23/2005
55390-0106-01
J9999
55390-0107-10
J2440
1/1/2002
55390-0108-01
J9150
55390-0108-10
55390-0109-01
55390-0112-50
55390-0112-99
J9150
J3490
J9060
J9060
1/1/2002
4/8/2005
1/1/2002
1/1/2002
99/99/9999 INJECTION, DAUNORUBICIN, 10 MG

55390-0113-01
55390-0114-05
55390-0114-20
55390-0114-50
J2760
J9265
J9265
J9265
1/1/2002
1/1/2002
1/1/2002
1/1/2002

55390-0115-01
55390-0121-01
J9065
J2405
1/1/2002 99/99/9999 INJECTION, CLADRIBINE, PER 1 MG

55390-0121-10
55390-0122-10
55390-0123-01
55390-0124-01
55390-0125-10
55390-0126-05
55390-0126-10
J2405
J7516
J3490
J9065
J2250
J2250
J2250
12/26/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
55390-0127-01
J2430
55390-0129-01
55390-0131-10
55390-0132-10
55390-0133-01
55390-0134-01
55390-0135-01
55390-0136-05
55390-0137-02
55390-0137-05
55390-0138-01
55390-0138-02
J2430
J9100
J9110
J9110
J9110
J9200
J1955
J2250
J2250
J2250
J2250
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

99/99/9999 INJECTION, CLADRIBINE, PER 1 MG

99/99/9999 INJECTION, FLOXURIDINE, 500 MG
55390-0142-10
J9150
55390-0143-01
J9260
55390-0147-01
J1630
55390-0147-10
55390-0150-01
J1630
J9045


MG/ML
MILRINONE LACTATE NOVAPLUS
(S.D.V.) 1 MG/ML
(S.D.V.) 1 MG/ML
(S.D.V.) 1 MG/ML
(U.S.P., M.D.V.) 5 MG/ML
(U.S.P.,M.D.V.) 5 MG/ML
MITOXANTRONE
(USP,CONCENTRATE,PF) 2 MG/ML
MITOXANTRONE
MITOXANTRONE
VINBLASTINE SULFATE (VIAL) 10 MG
NOVAPLUS AMIODARONE
HYDROCHLORIDE (10X3ML,S.D.V) 50
MG/ML
CISPLATIN 1 MG/ML
BUPRENORPHINE HYDROCHLORIDE 0.3
MG/ML
PROPOFOL 10 MG/ML
PROPOFOL 10 MG/ML
PROPOFOL 10 MG/ML
AMIODARONE HCL (M.D.V.) 50 MG/ML
ALLOPURINOL SODIUM (S.D.V.,PF) 500
MG
PAPAVERINE HYDROCHLORIDE (M.D.V.)
30 MG/ML
MG/ML
MG/ML
CLINDAMYCIN (USP) 150 MG/ML
PHENTOLAMINE MESYLATE (S.D.V.) 5
MG
CLADRIBINE NOVAPLUS (S.D.V.,PF) 1
MG/ML
MG/ML
CYCLOSPORINE (S.D.V.) 50 MG/ML
RIFAMPIN (VIAL,30 ML) 600 MG
CLADRIBINE (S.D.V.,PF) 1 MG/ML
5 ML VL
IV
ML
10 MG
02/03/2004
99/99/9999
10 ML VL
IV
ML
5 MG
0.2
05/31/2002
99/99/9999
20 ML VL
IV
ML
5 MG
0.2
05/31/2002
99/99/9999
50 ML VL
IV
ML
5 MG
0.2
05/31/2002
99/99/9999
10 ML VL
IJ
ML
10 MG
0.5
07/22/2004
99/99/9999
2 ML VL
IJ
ML
10 MG
0.5
07/22/2004
99/99/9999
10 ML VL
IV
ML
5 MG
0.4
04/11/2006
99/99/9999
12.5 ML VL
IV
ML
5 MG
0.4
04/11/2006
99/99/9999
15 ML VL
1 EA VL
1 EA VL
IV
IV
IV
ML
EA
EA
5 MG
200 MG
1 MG
0.4
1
10
04/11/2006
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
3 ML VL
200 ML VL
IV
IV
ML
ML
30 MG
10 MG
1.66666
0.1
03/05/2008
10/01/2004
99/99/9999
99/99/9999
1 ML
2 ML
20 ML
50 ML
100 ML
9 ML
IJ
SC
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
0.1 MG
1 MG
1 EA
1 EA
1 EA
30 MG
3.24
1
1
1
1
1.66666
06/03/2005
04/28/2004
06/23/2005
06/23/2005
06/23/2005
09/07/2005
99/99/9999
99/99/9999
1/1/2008
1/1/2008
1/1/2008
99/99/9999
VL
VL
VL
VL
VL
VL
1 EA VL
IV
EA
1 EA
09/01/2004
99/99/9999
10 ML VL
IJ
ML
60 MG
0.5
01/01/2002
02/25/2008
10 ML VL
IV
ML
10 MG
0.5
01/01/2002
99/99/9999
4 ML
60 ML
50 ML
100 ML
VL
VL
VL
VL
IV
IJ
IV
IV
ML
ML
ML
ML
10 MG
1 EA
10 MG
10 MG
0.5
1
0.1
0.1
01/01/2002
04/08/2005
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA
5 ML
16.7 ML
50 ML
VL
VL
VL
VL
IJ
IV
IV
IV
EA
ML
ML
ML
5 MG
30 MG
30 MG
30 MG
1
0.2
0.2
0.2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 ML VL
20 ML VL
IV
IJ
ML
ML
1 MG
1 MG
1
2
01/01/2002
12/26/2006
99/99/9999
99/99/9999
2 ML
5 ML
1 EA
10 ML
10 ML
5 ML
10 ML
VL
VL
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IJ
IJ
IJ
ML
ML
EA
ML
ML
ML
ML
1 MG
250 MG
1 EA
1 MG
1 MG
1 MG
1 MG
2
0.2
1
1
1
5
5
12/26/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
PAMIDRONATE DISODIUM (VIAL) 30 MG
1 EA VL
IV
EA
30 MG
01/01/2002
99/99/9999
PAMIDRONATE DISODIUM (VIAL) 90 MG

CYTARABINE (VIAL) 100 MG
CYTARABINE (VIAL) 500 MG
CYTARABINE (VIAL) 1 GM
CYTARABINE (VIAL) 2 GM
FLOXURIDINE (VIAL) 0.5 GM
LEVOCARNITINE (S.D.V.) 200 MG/ML
DAUNORUBICIN HCL NOVAPLUS
(S.D.V.,PF) 5 MG/ML
METHOTREXATE SODIUM (S.D.V.,30ML
VIAL,PF) 1 GM
MG/ML
MG/ML
CARBOPLATIN 50 MG
1
1
1
1
1
1
5
2
5
1
2
IV
IJ
IJ
IJ
IJ
IJ
IV
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
ML
ML
ML
ML
ML
30 MG
100 MG
500 MG
500 MG
500 MG
500 MG
1 GM
1 MG
1 MG
1 MG
1 MG
3
1
1
2
4
1
0.2
1
1
5
5
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 269 of 374
EA
EA
EA
EA
EA
EA
ML
ML
ML
ML
ML
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
4 ML VL
IV
ML
10 MG
0.5
01/01/2002
99/99/9999
1 EA VL
IJ
EA
50 MG
20
09/07/2005
99/99/9999
10 ML VL
IM
ML
5 MG
01/01/2002
99/99/9999
1 ML VL
1 EA VL
IM
IV
ML
EA
5 MG
50 MG
1
1
01/01/2002
01/17/2006
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55390-0151-01
55390-0152-01
55390-0153-01
55390-0154-01
55390-0155-01
55390-0156-01
J9045
J9045
J9045
J9045
J9045
J9045
55390-0157-01
J2430
55390-0159-01
J2430
55390-0160-10
J2354
55390-0161-10
J2354
1/17/2006
1/17/2006
10/15/2004
10/15/2004
10/15/2004
3/1/2006

55390-0164-01
J2354

55390-0168-10
J2060
55390-0169-10
J2060
55390-0170-10
J2060
55390-0171-10
J2060
55390-0175-10
Q2009
55390-0176-10
Q2009
55390-0183-01
J3490
55390-0183-01
J0595
55390-0184-01
J3490
55390-0184-01
J0595
55390-0184-02
J3490
55390-0184-02
J0595
55390-0185-10
J3490
55390-0185-10
55390-0187-01
J0595
J9060
55390-0193-10
55390-0197-01
55390-0198-01
J3105
J0744
J0744

55390-0199-01
J0744
55390-0204-01
J2430
55390-0207-01
J9178
55390-0162-10
J2354
55390-0163-01
J2354

55390-0208-01
J9178
55390-0209-10
J2920
55390-0210-10
J2930
55390-0211-03
J7608

55390-0211-03 KO J7608
55390-0212-03
KO
J7608
55390-0213-03 KO J7608
55390-0214-03
KO
J7608
55390-0212-03 KO J7608
55390-0213-03
KO
J7608
55390-0214-03 KO J7608
KO
CARBOPLATIN 150 MG
CARBOPLATIN 450 MG
CARBOPLATIN (S.D.V.,PF) 10 MG/ML
PAMIDRONATE DISODIUM
(LYOPHILIZED) 30 MG
(LYOPHILIZED) 90 MG
IV
IV
IV
IV
IV
IV
EA
EA
ML
ML
ML
ML
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
3
9
0.2
0.2
0.2
0.2
01/17/2006
01/17/2006
10/15/2004
10/15/2004
10/15/2004
03/01/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IV
EA
30 MG
01/01/2003
99/99/9999
1 EA VL
IV
EA
30 MG
01/01/2003
99/99/9999
OCTREOTIDE 50 MCG/ML
1 ML VL
IJ
ML
25 MCG
05/04/2005
99/99/9999
1 ML VL
IJ
ML
25 MCG
04/04/2005
99/99/9999
1 ML VL
IJ
ML
25 MCG
20
04/04/2005
99/99/9999
5 ML VL
IJ
ML
25 MCG
05/25/2005
99/99/9999
5 ML VL
IJ
ML
25 MCG
40
05/25/2005
99/99/9999
1 ML VL
IJ
ML
2 MG
09/13/2006
99/99/9999
1 ML VL
IJ
ML
2 MG
09/13/2006
99/99/9999
10 ML VL
IJ
ML
2 MG
09/13/2006
99/99/9999
10 ML VL
IJ
ML
2 MG
09/13/2006
99/99/9999
20 ML VL
IJ
ML
50 MG
1.5
08/06/2007
99/99/9999
100 ML VL
IJ
ML
50 MG
1.5
08/06/2007
99/99/9999
1 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
1 ML VL
IJ
ML
1 MG
01/01/2004
99/99/9999
1 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
1 ML VL
IJ
ML
1 MG
01/01/2004
99/99/9999
2 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
2 ML VL
IJ
ML
1 MG
01/01/2004
99/99/9999
10 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
10 ML VL
200 ML VL
IJ
IV
ML
ML
1 MG
10 MG
2
0.1
01/01/2004
10/01/2004
99/99/9999
99/99/9999
1 ML VL
20 ML VL
40 ML VL
SC
IV
IV
ML
ML
ML
1 MG
200 MG
200 MG
1
0.05
0.05
11/19/2004
08/28/2006
08/28/2006
99/99/9999
99/99/9999
99/99/9999
120 ML VL
IV
ML
200 MG
0.05
11/06/2006
99/99/9999
10 ML VL
IV
ML
30 MG
0.1
04/02/2002
99/99/9999
25 ML VL
IV
ML
2 MG
08/07/2007
99/99/9999
100 ML VL
IV
ML
2 MG
08/07/2007
99/99/9999
1 EA VL
IJ
EA
40 MG
02/22/2007
99/99/9999
1 EA VL
IJ
EA
125 MG
02/22/2007
99/99/9999
ACETYLCYSTEINE (VIAL,PF) 10%
10 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/11/2002
10 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/11/2002
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/11/2002
30 ML VL
IH
ML
1 GM
0.1
01/01/2002
03/11/2002
10 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/11/2002
10 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/11/2002
30 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/11/2002
30 ML VL
IH
ML
1 GM
0.2
01/01/2002
03/11/2002
Page 270 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
VL
VL
VL
VL
VL
VL

OCTREOTIDE ACETATE (MDV) 200
MCG/ML
MCG/ML
LORAZEPAM (USP,SDV,1MLX10,PF) 2
MG/ML
LORAZEPAM (USP,SDV,1MLX10,PF) 4
MG/ML
LORAZEPAM (USP,MDV,10MLX10) 2
MG/ML
LORAZEPAM (USP,MDV,10MLX10) 4
MG/ML
FOSPHENYTOIN SODIUM
FOSPHENYTOIN SODIUM
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
BUTORPHANOL TARTRATE (M.D.V.) 2
MG/ML
MG/ML
CISPLATIN NOVAPLUS 1 MG/ML
TERBUTALINE SULFATE NOVAPLUS 1
MG/ML
CIPROFLOXACIN (USP,SDV) 10 MG/ML
CIPROFLOXACIN (USP,SDV) 10 MG/ML
CIPROFLOXACIN (PHARMACY BULK
PACKAGE) 10 MG/ML
(S.D.V.,FLIPTOP) 3 MG/ML
EPIRUBICIN HYDROCHLORIDE (SINGLEDOSE,PF) 2 MG/ML
EPIRUBICIN HYDROCHLORIDE (SINGLEDOSE,PF) 2 MG/ML
SUCCINATE (SDV) 40 MG
1 EA
1 EA
5 ML
15 ML
45 ML
60 ML
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55390-0215-01
J9211
55390-0216-01
J9211
55390-0217-01
J9211
55390-0218-01
J2930
2/22/2007
55390-0219-01
J2930
2/22/2007
55390-0220-01
J9045
55390-0221-01
J9045
55390-0222-01
J9045
55390-0223-02
J3490
55390-0223-02
J0278
55390-0224-02
J3490
55390-0224-02
J0278
55390-0224-04
J3490
55390-0224-04
J0278
55390-0225-02
J3490
55390-0225-02
J0278
55390-0226-02
J3490
55390-0226-02
55390-0226-04
55390-0226-04
55390-0231-10
55390-0232-10
55390-0233-01
55390-0235-10
55390-0236-10
55390-0237-01
55390-0238-01
J0278
J3490
J0278
J9000
J9000
J9000
J9000
J9000
J9000
J9000
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

55390-0241-10
J9000
55390-0242-10
J9000
1/1/2002
55390-0243-01
55390-0244-01
J9000
J9268

8/8/2007 99/99/9999 INJECTION, PENTOSTATIN, 10 MG
55390-0245-10
J9000
55390-0246-10
J9000
55390-0247-01
J9000
55390-0248-01
J9000
55390-0250-10
55390-0251-01
55390-0252-01
55390-0253-01
J1626
J9280
J9290
J9291
55390-0258-01
J2930
55390-0259-01
J2930
55390-0263-10
J0895
55390-0265-01
J0895
55390-0266-01
J9209
55390-0267-01
J9390
55390-0268-01
J9390
7/29/2008
1/1/2002
1/1/2002
1/1/2002

IDARUBICIN HYDROCHLORIDE (SINGLEDOSE,PF) 1 MG/ML

SUCCINATE (SDV) 1 GM
CARBOPLATIN AMERINET CHOICE
(M.D.V.,PF) 10 MG/ML
AMIKACIN SULFATE PEDIATRIC
NOVAPLUS (S.D.V.,PF) 50 MG/ML
NOVAPLUS (S.D.V.,PF) 50 MG/ML
AMIKACIN SULFATE NOVAPLUS
(S.D.V.,PF) 250 MG/ML
AMIKACIN SULFATE NOVAPLUS
AMIKACIN SULFATE NOVAPLUS (PF) 250
MG/ML
AMIKACIN SULFATE NOVAPLUS (PF) 250
MG/ML
AMIKACIN SULFATE (S.D.V.,PF) 250
MG/ML
AMIKACIN SULFATE (S.D.V.,PF) 250
MG/ML
AMIKACIN SULFATE (PF) 250 MG/ML
AMIKACIN SULFATE (PF) 250 MG/ML
ADRIAMYCIN (S.D.V.,PF) 10 MG
ADRIAMYCIN (S.D.V.) 2 MG/ML
ADRIAMYCIN (S.D.V.,PF) 2 MG/ML
ADRIAMYCIN (S.D.V.) 2 MG/ML
ADRIAMYCIN (M.D.V.) 2 MG/ML
DOXORUBICIN HCL NOVAPLUS
(S.D.V.,PF) 10 MG
(S.D.V.,PF) 20 MG
(S.D.V.,PF) 50 MG
PENTOSTATIN (SDV) 10 MG
(S.D.V.,PF) 2 MG/ML
(S.D.V.,PF) 2 MG/ML
(S.D.V.,PF) 2 MG/ML
DOXORUBICIN HCL NOVAPLUS (M.D.V.)
2 MG/ML
(10X1ML,SDV) 0.1 MG/ML
MITOMYCIN (S.D.V.,PF) 5 MG
SUCCINATE (USP,MDV,LYOPHILIZED)
500 MG
SUCCINATE (USP,MDV,LYOPHILIZED) 1
GM
DEFEROXAMINE MESYLATE (USP) 500
MG
DEFEROXAMINE MESYLATE (USP) 2 GM
MESNA AMERINET CHOICE (M.D.V.) 100
MG/ML
VINORELBINE TARTRATE AMERINET
CHOICE (S.D.V.,PF) 10 MG/ML
VINORELBINE TARTRATE AMERINET
CHOICE (S.D.V.,PF) 10 MG/ML
Page 271 of 374
5 ML VL
IV
ML
5 MG
0.2
08/07/2007
99/99/9999
10 ML VL
IV
ML
5 MG
0.2
08/07/2007
99/99/9999
20 ML VL
IV
ML
5 MG
0.2
08/07/2007
99/99/9999
1 EA VL
IJ
EA
125 MG
02/22/2007
8/1/2008
1 EA VL
IJ
EA
125 MG
02/22/2007
8/1/2008
5 ML VL
IV
ML
50 MG
0.2
11/19/2004
99/99/9999
15 ML VL
IV
ML
50 MG
0.2
11/19/2004
99/99/9999
45 ML VL
IV
ML
50 MG
0.2
11/19/2004
99/99/9999
2 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2005
2 ML VL
IJ
ML
100 MG
0.5
01/01/2006
99/99/9999
2 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2005
2 ML VL
IJ
ML
100 MG
2.5
01/01/2006
99/99/9999
4 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2005
4 ML VL
IJ
ML
100 MG
2.5
01/01/2006
99/99/9999
2 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2005
2 ML VL
IJ
ML
100 MG
0.5
01/01/2006
99/99/9999
2 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2005
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
EA
EA
EA
ML
ML
ML
ML
100 MG
1 EA
100 MG
10 MG
10 MG
10 MG
10 MG
10 MG
10 MG
10 MG
2.5
1
2.5
1
2
5
0.2
0.2
0.2
0.2
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IV
EA
10 MG
01/01/2002
99/99/9999
1 EA VL
IV
EA
10 MG
01/01/2002
01/01/2004
1 EA VL
1 EA VL
IV
IV
EA
EA
10 MG
10 MG
5
1
01/01/2002
08/08/2007
99/99/9999
99/99/9999
2 ML
4 ML
4 ML
1 EA
1 EA
1 EA
5 ML
10 ML
25 ML
100 ML
5 ML VL
IV
ML
10 MG
0.2
01/01/2002
99/99/9999
10 ML VL
IV
ML
10 MG
0.2
01/01/2002
99/99/9999
25 ML VL
IV
ML
10 MG
0.2
01/01/2002
99/99/9999
100 ML VL
IV
ML
10 MG
0.2
01/01/2002
99/99/9999
VL
VL
VL
VL
IV
IV
IV
IV
ML
EA
EA
EA
100 MCG
5 MG
20 MG
40 MG
1
1
1
1
07/29/2008
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
125 MG
02/01/2008
99/99/9999
1 EA VL
IJ
EA
125 MG
02/01/2008
99/99/9999
1 EA VL
IJ
EA
500 MG
06/18/2007
99/99/9999
1 EA VL
IJ
EA
500 MG
06/18/2007
99/99/9999
10 ML VL
IV
ML
200 MG
0.5
09/21/2005
99/99/9999
1 ML VL
IV
ML
10 MG
09/21/2005
99/99/9999
5 ML VL
IV
ML
10 MG
09/21/2005
99/99/9999
1 ML
1 EA
1 EA
1 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002
1/1/2002
1/1/2002
1/1/2002
99/99/9999 INJECTION, DAUNORUBICIN, 10 MG

55390-0281-10
55390-0291-01
55390-0292-01
55390-0293-01
J9150
J9181
J9181
J9181
55390-0304-05
J9265
55390-0304-20
J9265
55390-0304-50
J9265
55390-0307-01
J2405
55390-0307-10
J2405
55390-0308-03
J0207
55390-0314-05
J9265
55390-0314-20
J9265
55390-0314-50
J9265
55390-0339-10
J9140
3/5/2008 99/99/9999 DACARBAZINE, 200 MG
55390-0347-01
J9209
CERUBIDINE (S.D.V.) 20 MG
NOVAPLUS PACLITAXEL (MDV,USP) 6
MG/ML
NOVAPLUS PACLITAXEL (MDV,USP) 6
MG/ML
NOVAPLUS PACLITAXEL (MULTIPLEDOSE,USP) 6 MG/ML
NOVAPLUS ONDANSETRON (MDV,USP)
2 MG/ML
NOVAPLUS ONDANSETRON
AMIFOSTINE (3X10ML,LYOPHILIZED) 500
MG
PACLITAXEL AMERINET CHOICE
(M.D.V.) 6 MG/ML
(M.D.V.) 6 MG/ML
(M.D.V.) 6 MG/ML
NOVAPLUS DACARBAZINE (USP) 200
MG
NOVAPLUS MESNA (1X10ML,M.D.V) 100
MG/ML
10 ML VL
55390-0403-20
J2400
CHLOROPROCAINE HCL (S.D.V.,PF) 2%
20 ML VL
55390-0404-20
J2400
20 ML VL
55390-0412-01
J1631
4/8/2008 99/99/9999 INJECTION, AMIFOSTINE, 500 MG
1 EA
5 ML
25 ML
50 ML
VL
VL
VL
VL
IV
IV
IV
IV
EA
ML
ML
ML
10 MG
10 MG
10 MG
10 MG
2
2
2
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
5 ML VL
IV
ML
30 MG
0.2
12/04/2006
99/99/9999
16.7 ML VL
IV
ML
30 MG
0.2
12/04/2006
99/99/9999
99/99/9999
50 ML VL
IV
ML
30 MG
0.2
12/04/2006
20 ML VL
IJ
ML
1 MG
12/26/2006
99/99/9999
2 ML VL
IJ
ML
1 MG
12/26/2006
99/99/9999
1 EA VL
IV
EA
500 MG
04/08/2008
99/99/9999
5 ML VL
IV
ML
30 MG
0.2
01/14/2004
99/99/9999
16.7 ML VL
IV
ML
30 MG
0.2
01/14/2004
99/99/9999
50 ML VL
IV
ML
30 MG
0.2
01/14/2004
99/99/9999
1 EA VL
IV
EA
200 MG
03/05/2008
99/99/9999
IV
ML
200 MG
0.5
03/05/2008
99/99/9999
IJ
ML
30 ML
0.03333
01/01/2002
99/99/9999
IJ
ML
30 ML
0.03333
01/01/2002
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
5 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
5 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
55390-0412-05
J1631
55390-0413-01
J1631
55390-0413-05
J1631
55390-0414-50
J9060
CISPLATIN NOVAPLUS (M.D.V.) 1 MG/ML
50 ML VL
IV
ML
10 MG
0.1
01/01/2002
99/99/9999
CISPLATIN NOVAPLUS (M.D.V.) 1 MG/ML

HALOPERIDOL DECANOATE NOVAPLUS
(S.D.V.) 50 MG/ML
(M.D.V.) 50 MG/ML
(S.D.V.) 100 MG/ML
(M.D.V.) 100 MG/ML
100 ML VL
IV
ML
10 MG
0.1
01/01/2002
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
01/01/2006
5 ML VL
IM
ML
50 MG
01/01/2002
04/01/2006
1 ML VL
IM
ML
50 MG
01/01/2002
04/01/2006
5 ML VL
IM
ML
50 MG
01/01/2002
04/01/2006
FLOXURIDINE NOVAPLUS (VIAL) 0.5 GM

LEVOCARNITINE NOVAPLUS (S.D.V.) 200
MG/ML
HALOPERIDOL LACTATE NOVAPLUS
(M.D.V.) 5 MG/ML
HALOPERIDOL LACTATE NOVAPLUS
(S.D.V.) 5 MG/ML
MITOMYCIN NOVAPLUS (S.D.V.,PF) 5
MG
MG
MG
ACETAZOLAMIDE SODIUM (S.D.V.,PF)
500 MG
FLUPHENAZINE DECANOATE (VIAL) 25
MG/ML
15 MG/ML
30 MG/ML
30 MG/ML
KETOROLAC TROMETHAMINE (M.D.V.)
30 MG/ML
ETOPOSIDE NOVAPLUS (M.D.V.) 20
MG/ML
MG/ML
1 EA VL
IJ
EA
500 MG
01/01/2002
11/1/2008
5 ML VL
IV
ML
1 GM
0.2
01/01/2002
11/1/2008
10 ML VL
IM
ML
5 MG
01/01/2002
99/99/9999
J9060
55390-0422-01
J1631
1/1/2002
55390-0422-05
J1631
1/1/2002
55390-0423-01
J1631
1/1/2002
55390-0423-05
J1631
1/1/2002
55390-0435-01
J9200
1/1/2002
55390-0436-05
J1955
1/1/2002
55390-0447-01
J1630
55390-0447-10
J1630
55390-0451-01
J9280
1/1/2002 99/99/9999 MITOMYCIN, 5 MG
55390-0452-01
J9290
1/1/2002 99/99/9999 MITOMYCIN, 20 MG
55390-0453-01
J9291
1/1/2002 99/99/9999 MITOMYCIN, 40 MG
55390-0460-01
J1120
1/1/2002 99/99/9999 INJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MG
55390-0465-05
J2680
55390-0480-01
J1885
55390-0481-01
J1885
55390-0481-02
J1885
55390-0481-10
J1885
55390-0491-01
J9181
55390-0492-01
J9181
Page 272 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
99/99/9999
99/99/9999
99/99/9999
CHLOROPROCAINE HCL (S.D.V.,PF) 3%

HALOPERIDOL DECANOATE (S.D.V.) 50
MG/ML
MG/ML
HALOPERIDOL DECANOATE (S.D.V.) 100
MG/ML
MG/ML
55390-0414-99
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1 ML VL
IM
ML
5 MG
01/01/2002
99/99/9999
1 EA VL
IV
EA
5 MG
01/01/2002
99/99/9999
1 EA VL
IV
EA
20 MG
01/01/2002
99/99/9999
1 EA VL
IV
EA
40 MG
01/01/2002
99/99/9999
1 EA VL
IV
EA
500 MG
01/01/2002
99/99/9999
5 ML VL
IJ
ML
25 MG
01/01/2002
99/99/9999
1 ML VL
IJ
ML
15 MG
01/01/2002
99/99/9999
1 ML VL
IJ
ML
15 MG
01/01/2002
99/99/9999
2 ML VL
IM
ML
15 MG
01/01/2002
99/99/9999
10 ML VL
IJ
ML
15 MG
01/01/2002
99/99/9999
5 ML VL
IV
ML
10 MG
01/01/2002
99/99/9999
25 ML VL
IV
ML
10 MG
01/01/2002
99/99/9999
55390-0493-01
55390-0500-02
55390-0500-05
55390-0500-10
J9181
J3490
J3490
J3490
1/1/2002
1/1/2002
1/1/2002
1/1/2002
55390-0501-02
J3490
1/1/2002
55390-0501-05
J3490
1/1/2002
55390-0501-10
J3490
1/1/2002
55390-0503-10
J0270
1/1/2002
55390-0506-05
J0270
1/1/2002
55390-0506-10
55390-0514-05
55390-0514-20
55390-0514-50
55390-0555-01
55390-0555-10
55390-0555-90
J0270
J9265
J9265
J9265
J1245
J1245
J1245
1/1/2002
1/25/2005
1/25/2005
1/25/2005
1/1/2002
1/1/2002
4/8/2005
55390-0560-90
55390-0600-20
J1250
J7501
55390-0604-01
55390-0605-02
55390-0612-10
55390-0612-10
55390-0613-20
55390-0613-20
55390-0616-01
55390-0616-10
J2430
J0760
Q4075
J0133
Q4075
J0133
J2780
J2780



MG/ML
BUMETANIDE (M.D.V.) 0.25 MG/ML
BUMETANIDE NOVAPLUS (S.D.V.) 0.25
MG/ML
BUMETANIDE NOVAPLUS (S.D.V.) 0.25
MG/ML
BUMETANIDE NOVAPLUS (M.D.V.) 0.25
MG/ML
2 ML VL
IJ
ML
1 EA
01/01/2002
11/1/2008
4 ML VL
IJ
ML
1 EA
01/01/2002
11/1/2008
10 ML VL
IJ
ML
1 EA
01/01/2002
11/1/2008
ALPROSTADIL NOVAPLUS (VIAL) 0.5

MG/ML
1 ML VL
IV
ML
1.25 MCG
400
01/01/2002
99/99/9999
ALPROSTADIL (AMP) 0.5 MG/ML
1 ML AM IV
ML
1.25 MCG
400
01/01/2002
01/01/2005
J9100
55390-0807-10
55390-0808-01
55390-0809-01
J9110
J9110
J9110

55390-0818-10
J0640
55390-0824-01
J0640
55390-0825-01
J0640
55390-0826-01
55513-0002-01
55513-0002-04
55513-0003-01
55513-0003-04
55513-0004-01
55513-0004-04
55513-0005-01
55513-0005-04
55513-0006-01
J0640
J0881
J0881
J0881
J0881
J0881
J0881
J0881
J0881
J0881
55513-0010-01
Q0137
1/1/2004 12/31/2005 INJECTION, DARBEPOETIN ALFA, 1 MCG (NON-ESRD USE)
55513-0010-01
J0881
55513-0010-04
Q0137
55513-0010-04
J0881
55513-0011-01
Q0137
55513-0011-01
J0881
55513-0011-04
Q0137
55513-0011-04
J0881
1 ML
5 ML
16.7 ML
50 ML
10 ML
2 ML
10 ML
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
1.25 MCG
30 MG
30 MG
30 MG
10 MG
10 MG
10 MG
400
0.2
0.2
0.2
0.5
0.5
0.5
01/01/2002
01/25/2005
01/25/2005
01/25/2005
01/01/2002
02/01/2008
04/08/2005
99/99/9999
5/1/2008
5/1/2008
5/1/2008
4/1/2005
99/99/9999
99/99/9999
20 ML VL
1 EA VL
IV
IV
ML
EA
250 MG
100 MG
0.05
1
01/01/2002
01/01/2002
99/99/9999
99/99/9999
10 ML
2 ML
1 EA
1 EA
1 EA
1 EA
6 ML
2 ML
IV
IV
IV
IV
IV
IV
IJ
IJ
ML
ML
EA
EA
EA
EA
ML
ML
30 MG
1 MG
5 MG
5 MG
5 MG
5 MG
25 MG
25 MG
0.1
0.5
100
100
200
200
1
1
04/02/2002
01/01/2002
10/01/2003
01/01/2006
10/01/2003
01/01/2006
11/22/2004
11/22/2004
99/99/9999
02/25/2008
12/31/2005
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
VL
VL
VL
VL
40 ML VL
IJ
ML
25 MG
03/29/2006
1 EA VL
IV
EA
10 MG
01/01/2002
99/99/9999
CYTARABINE NOVAPLUS (VIAL) 100 MG
1 EA VL
IJ
EA
100 MG
01/01/2002
99/99/9999
CYTARABINE NOVAPLUS (VIAL) 500 MG

CYTARABINE NOVAPLUS (VIAL) 1 GM
CYTARABINE NOVAPLUS (VIAL) 2 GM
LEUCOVORIN CALCIUM NOVAPLUS
(VIAL) 100 MG
(VIAL) 200 MG
(S.D.V.,PF) 350 MG
ARANESP (PF) 0.025 MG/ML
ARANESP (4X1ML,PF) 0.025 MG/ML
ARANESP (1MLX4,PF) 0.04 MG/ML
ARANESP (S.D.V.,ALBUMIN SOL,PF)
0.025 MG/ML
0.025 MG/ML
0.025 MG/ML
0.025 MG/ML
ARANESP (S.D.V.,ALBUMIN SOL,PF) 0.04
MG/ML
MG/ML
MG/ML
MG/ML
1 EA VL
1 EA VL
1 EA VL
IJ
IJ
IJ
EA
EA
EA
500 MG
500 MG
500 MG
1
2
4
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
50 MG
01/01/2002
99/99/9999
1 EA VL
IJ
EA
50 MG
01/01/2002
99/99/9999
1 EA VL
IJ
EA
50 MG
01/01/2002
99/99/9999
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
50 MG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
0.2
25
25
40
40
60
60
100
100
200
01/01/2002
09/11/2006
09/11/2006
09/11/2006
09/11/2006
09/11/2006
09/11/2006
09/11/2006
09/11/2006
09/11/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
IJ
ML
1 MCG
25
01/01/2004
12/31/2005
1 ML VL
IJ
ML
1 MCG
25
02/08/2008
99/99/9999
1 ML VL
IJ
ML
1 MCG
25
01/01/2004
12/31/2005
1 ML VL
IJ
ML
1 MCG
25
02/08/2008
99/99/9999
1 ML VL
IJ
ML
1 MCG
40
01/01/2004
12/31/2005
1 ML VL
IJ
ML
1 MCG
40
02/08/2008
99/99/9999
1 ML VL
IJ
ML
1 MCG
40
01/01/2004
12/31/2005
1 ML VL
IJ
ML
1 MCG
40
02/08/2008
99/99/9999
Page 273 of 374
50 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1/1/2002
1/1/2005
0.5
1/1/2006
3/28/2006
25
1/1/2006
3/28/2006
25
1/1/2006
2/16/2006
40
1/1/2006
2/16/2006
40
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
99/99/9999
99/99/9999
99/99/9999
99/99/9999
55390-0806-10
HCPCS Measure #1
01/01/2002
01/01/2002
01/01/2002
01/01/2002

99/99/9999 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)
HCPCS Amount #1
2
1
1
1
J2780
1/1/2002
9/11/2006
9/11/2006
9/11/2006
9/11/2006
9/11/2006
9/11/2006
9/11/2006
9/11/2006
9/11/2006
Billing Units
10 MG
1 EA
1 EA
1 EA
J9150
ML
ML
ML
ML
55390-0805-10

50 ML
2 ML
4 ML
10 ML
NDC Package Type
IV
IJ
IJ
IJ
55390-0618-01
4/2/2002
1/1/2002
10/1/2003
1/1/2006
10/1/2003
1/1/2006
11/22/2004
11/22/2004
NDC Package Measure
VL
VL
VL
VL
ALPROSTADIL (VIAL) 0.5 MG/ML

PACLITAXEL OTN (M.D.V.) 6 MG/ML
DIPYRIDAMOLE 5 MG/ML
DOBUTAMINE HCL (S.D.V.,PF) 12.5
MG/ML
AZATHIOPRINE SODIUM (PF) 100 MG
PAMIDRONATE DISODIUM (SDV) 3
MG/ML
COLCHICINE (S.D.V.,PF) 0.5 MG/ML
ACYCLOVIR SODIUM (PF) 500 MG
RANITIDINE (M.D.V.) 25 MG/ML
RANITIDINE (S.D.V.) 25 MG/ML
RANITIDINE (PHARMACY BULK
PACKAGE) 25 MG/ML
DAUNORUBICIN HCL NOVAPLUS (S.D.V.)
20 MG


Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55513-0012-01
Q0137
55513-0012-01
J0881
55513-0012-04
Q0137
55513-0012-04
J0881
55513-0013-01
Q0137
55513-0013-01
J0881
55513-0013-04
Q0137
55513-0013-04
J0881
55513-0014-01
Q0137
55513-0014-01
J0881
55513-0014-04
Q0137
55513-0014-04
J0881
55513-0015-01
Q0137
55513-0015-01
55513-0021-01
55513-0021-04
55513-0023-01
55513-0023-04
55513-0025-01
55513-0025-04
55513-0027-01
J0881
J0881
J0881
J0881
J0881
J0881
J0881
J0881
1/1/2006
8/14/2006
8/14/2006
8/14/2006
8/14/2006
8/14/2006
8/14/2006
9/11/2006
55513-0027-04
55513-0028-01
J0881
J0881

55513-0032-01
J0881
55513-0037-01
Q0137


MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
ARANESP (PF) 0.04 MG/0.4 ML
1 ML VL
IJ
ML
1 MCG
60
01/01/2004
12/31/2005
1 ML VL
IJ
ML
1 MCG
60
02/08/2008
99/99/9999
1 ML VL
IJ
ML
1 MCG
60
01/01/2004
12/31/2005
1 ML VL
IJ
ML
1 MCG
60
02/08/2008
99/99/9999
1 ML VL
IJ
ML
1 MCG
100
01/01/2004
12/31/2005
1 ML VL
IJ
ML
1 MCG
100
02/08/2008
99/99/9999
1 ML VL
IJ
ML
1 MCG
100
01/01/2004
12/31/2005
1 ML VL
IJ
ML
1 MCG
100
02/08/2008
99/99/9999
1 ML VL
IJ
ML
1 MCG
200
01/01/2004
12/31/2005
1 ML VL
IJ
ML
1 MCG
200
02/08/2008
99/99/9999
1 ML VL
IJ
ML
1 MCG
200
01/01/2004
12/13/2004
1 ML VL
IJ
ML
1 MCG
200
02/08/2008
99/99/9999
1 ML VL
IJ
ML
1 MCG
300
01/01/2004
12/31/2005
VL
SR
SR
SR
SR
SR
SR
SR
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
300
100
100
200
200
200
200
500
02/08/2008
08/14/2006
08/14/2006
08/14/2006
08/14/2006
08/14/2006
08/14/2006
09/11/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
0.3 ML SR
0.4 ML SR
IJ
IJ
ML
ML
1 MCG
1 MCG
500
500
09/11/2006
08/14/2006
99/99/9999
99/99/9999
1 ML
0.4 ML
0.4 ML
0.3 ML
0.3 ML
0.5 ML
0.5 ML
0.3 ML
55513-0037-01
J0881
55513-0037-04
Q0137
55513-0037-04
J0881
55513-0039-01
Q0137
55513-0039-01
J0881
55513-0039-04
Q0137
55513-0039-04
J0881
55513-0041-01
Q0137
55513-0041-01
J0881
55513-0041-04
Q0137
55513-0041-04
55513-0043-01
55513-0043-01
55513-0043-04
55513-0043-04
J0881
Q0137
J0881
Q0137
J0881
1/1/2006
6/7/2004
1/1/2006
6/7/2004
1/1/2006
55513-0044-01
Q0137
55513-0044-01
J0881
55513-0046-01
Q0137
55513-0046-01
J0881
ARANESP (0.3MLX4,PF) 0.15 MG/0.3 ML

ARANESP (SINGLEJECT,G27,1/2",PF) 0.5
MG/ML
ARANESP (SINGLEJECT,PF) 0.04 MG/0.4
ML
ML
ML
ML
ARANESP (PF,PREFILLED SYRINGE)
0.06 MG/0.3 ML
0.06 MG/0.3 ML
0.06 MG/0.3 ML
0.06 MG/0.3 ML
ARANESP (PF,PREFILLED SYRINGE) 0.1
MG/0.5 ML
MG/0.5 ML
MG/0.5 ML
MG/0.5 ML
ARANESP (PF,PFS) 0.15 MG/0.3 ML
MG/0.4 ML
MG/0.4 ML
MG/0.6 ML
MG/0.6 ML
0.6 ML SR
IJ
ML
1 MCG
55513-0048-01
Q0137
ARANESP (SINGLEJECT,PF) 0.5 MG/ML
1 ML SR
IJ
ML
1 MCG
55513-0048-01
55513-0053-01
J0881
J0881
ARANESP (SINGLEJECT,PF) 0.5 MG/ML

1 ML SR
1 ML VL
IJ
IJ
ML
ML
1 MCG
1 MCG
500
200

12/31/2005 INJECTION, DARBEPOETIN ALFA, 1 MCG (NON-ESRD USE)
12/31/2005 INJECTION, DARBEPOETIN ALFA, 1 MCG (NON-ESRD USE)

Page 274 of 374
1 ML SR
IJ
ML
1 MCG
500
06/07/2006
99/99/9999
0.4 ML SR
IJ
ML
1 MCG
100
02/09/2004
11/30/2005
0.4 ML SR
IJ
ML
1 MCG
100
02/08/2008
99/99/9999
0.4 ML SR
IJ
ML
1 MCG
100
02/09/2004
11/30/2005
0.4 ML SR
IJ
ML
1 MCG
100
02/08/2008
99/99/9999
0.3 ML SR
IJ
ML
1 MCG
200
01/01/2004
12/31/2005
0.3 ML SR
IJ
ML
1 MCG
200
02/08/2008
99/99/9999
0.3 ML SR
IJ
ML
1 MCG
200
01/01/2004
12/31/2005
0.3 ML SR
IJ
ML
1 MCG
200
02/08/2008
99/99/9999
0.5 ML SR
IJ
ML
1 MCG
200
01/01/2004
12/31/2005
0.5 ML SR
IJ
ML
1 MCG
200
02/08/2008
99/99/9999
0.5 ML SR
IJ
ML
1 MCG
200
01/01/2004
12/31/2005
0.5 ML
0.3 ML
0.3 ML
0.3 ML
0.3 ML
SR
SR
SR
SR
SR
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
1
1
1
1
1
MCG
MCG
MCG
MCG
MCG
200
500
500
500
500
02/08/2008
06/07/2004
02/08/2008
06/07/2004
02/08/2008
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
0.4 ML SR
IJ
ML
1 MCG
500
01/01/2004
12/31/2005
0.4 ML SR
IJ
ML
1 MCG
500
02/08/2008
99/99/9999
0.6 ML SR
IJ
ML
1 MCG
500
01/01/2004
12/31/2005
500
02/08/2008
99/99/9999
500
02/09/2004
12/31/2005
02/08/2008
09/11/2006
99/99/9999
99/99/9999
1/1/2006
3/10/2006
60
1/1/2006
3/10/2006
60
1/1/2006
4/25/2006
100
1/1/2006
4/25/2006
100
1/1/2006
4/29/2006
200
1/1/2006
4/7/2006
300
1/1/2006
2/6/2006
200
1/1/2006
2/6/2006
200
1/1/2006
3/2/2006
200
1/1/2006
3/2/2006
200
1/1/2006
12/7/2006
500
1/1/2006
12/7/2006
500
1/1/2006
2/21/2006
500
1/1/2006
4/7/2006
500
1/1/2006
2/21/2006
500
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55513-0053-04
J0881
55513-0054-01
Q0137

55513-0054-01
J0881
55513-0054-04
Q0137
55513-0054-04
55513-0057-01
55513-0057-04
J0881
J0881
J0881
55513-0058-01
Q0137
55513-0058-01
J0881
55513-0058-04
Q0137
55513-0058-04
55513-0090-01
55513-0091-01
55513-0092-01
55513-0093-01
55513-0094-01
55513-0095-01
55513-0096-01
55513-0097-01
55513-0110-01
55513-0111-01
55513-0126-01
55513-0126-01
55513-0126-10
55513-0126-10
55513-0144-01
55513-0144-01
55513-0144-10
55513-0144-10
55513-0148-01
55513-0148-01
55513-0148-10
55513-0148-10
J0881
J0881
J0881
J0881
J0881
J0881
J0881
J0881
J0881
J0881
J0881
Q0136
J0885
Q0136
J0885
Q0136
J0885
Q0136
J0885
Q0136
J0885
Q0136
J0885

1/1/2006
9/25/2006
9/25/2006
9/25/2006
9/25/2006
9/25/2006
9/25/2006
9/25/2006
9/25/2006
8/14/2006
8/14/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006

55513-0177-01
J3490
55513-0177-07
J3490
55513-0177-28
J3490
55513-0190-01
Q4053
7/1/2003 12/31/2003 INJECTION, PEGFILGRASTIM, 1 MG
55513-0190-01
J2505
1/1/2004 99/99/9999 INJECTION, PEGFILGRASTIM, 6 MG
ARANESP (1MLX4,PF) 0.15 MG/0.75 ML

MG/0.75 ML
MG/0.75 ML
ARANESP (SDV,ALBUMIN SOLN,PF) 0.15
MG/0.75 ML
ARANESP (SDV,ALBUMIN SOLN,PF) 0.15
MG/0.75 ML
ARANESP (SINGLEJECT,PF) 0.025
MG/0.42 ML
MG/0.42 ML
MG/0.42 ML
MG/0.42 ML
ARANESP (PF,STERILE) 0.5 MG/ML
ARANESP (PF,STERILE) 0.3 MG/ML
KINERET (SRN,W/27G NDL,PF) 100
MG/0.67 ML
MG/0.67 ML
MG/0.67 ML
NEULASTA
(SRN,PREFILLED,PF,4X0.6ML) 6 MG/0.6
ML
NEULASTA
(SRN,PREFILLED,PF,4X0.6ML) 6 MG/0.6
ML
55513-0209-01
J1441
55513-0209-10
55513-0267-01
55513-0267-01
55513-0267-10
55513-0267-10
55513-0283-01
55513-0283-01
55513-0283-10
55513-0283-10
55513-0478-01
55513-0478-01
55513-0478-10
55513-0478-10
55513-0520-01
55513-0520-01
55513-0520-06
55513-0520-06
55513-0530-01
J1441
Q0136
J0885
Q0136
J0885
Q0136
J0885
Q0136
J0885
Q0136
J0885
Q0136
J0885
J3490
J2425
J3490
J2425
J1440
55513-0530-10
J1440
1/1/2002 99/99/9999 INJECTION, FILGRASTIM (G-CSF), 300 MCG
NEUPOGEN (26GX5/8",PF,SINGLEJECT)
480 MCG/0.8 ML
NEUPOGEN
(26GX5/8",10X0.8ML,PF,SINGLEJECT)
480 MCG/0.8 ML
EPOGEN (M.D.V.,M10) 10000 U/ML
KEPIVANCE (PF) 6.25 MG
NEUPOGEN (S.D.V.,1MLX10,PF) 300
MCG/ML
55513-0546-01
J1441
NEUPOGEN (S.D.V.,PF) 480 MCG/1.6 ML
1/1/2002
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/1/2002
1/1/2006
1/24/2005
1/1/2006
1/24/2005
1/1/2006
1/1/2002

99/99/9999 INJECTION, PALIFERMIN, 50 MICROGRAMS
99/99/9999 INJECTION, PALIFERMIN, 50 MICROGRAMS
Page 275 of 374
1 ML VL
IJ
ML
1 MCG
200
09/11/2006
99/99/9999
0.75 ML VL
IJ
ML
1 MCG
200
01/01/2004
12/17/2005
0.75 ML VL
IJ
ML
1 MCG
200
02/08/2008
99/99/9999
0.75 ML VL
IJ
ML
1 MCG
200
01/01/2004
12/17/2005
0.75 ML VL
0.42 ML SR
0.42 ML SR
IJ
IJ
IJ
ML
ML
ML
1 MCG
1 MCG
1 MCG
200
59.52381
59.52381
02/08/2008
08/14/2006
08/14/2006
99/99/9999
99/99/9999
99/99/9999
1 EA SR
IJ
ML
1 MCG
59.52381
02/09/2004
12/31/2005
1 EA SR
IJ
ML
1 MCG
59.52381
02/08/2008
99/99/9999
4 EA SR
IJ
ML
1 MCG
59.52381
02/09/2004
12/31/2005
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1 MCG
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
59.52381
59.52381
100
200
200
500
500
500
500
300
500
2
2
2
2
10
10
10
10
4
4
4
4
02/08/2008
09/25/2006
09/25/2006
09/25/2006
09/25/2006
09/25/2006
09/25/2006
09/25/2006
09/25/2006
08/14/2006
08/14/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
99/99/9999
2/28/2009
2/28/2009
2/28/2009
2/28/2009
2/28/2009
2/28/2009
2/28/2009
2/28/2009
99/99/9999
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
4 EA
0.42 ML
0.4 ML
0.3 ML
0.5 ML
0.3 ML
0.4 ML
0.6 ML
1 ML
1 ML
0.6 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
SR
SR
SR
SR
SR
SR
SR
SR
SR
VL
SR
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
0.67 ML SR
SC
ML
1 EA
01/01/2002
99/99/9999
0.67 ML SR
SC
ML
1 EA
09/01/2006
99/99/9999
0.67 ML SR
SC
ML
1 EA
02/23/2004
99/99/9999
0.6 ML SR
SC
ML
1 MG
10
07/01/2003
12/31/2003
0.6 ML SR
SC
ML
6 MG
1.66666
01/01/2004
99/99/9999
0.8 ML SR
IJ
ML
480 MCG
1.25
01/01/2002
99/99/9999
0.8 ML
1 ML
1 ML
1 ML
1 ML
2 ML
2 ML
2 ML
2 ML
1 ML
1 ML
1 ML
1 ML
1 EA
1 EA
1 EA
1 EA
1 ML
SR
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IV
IV
IV
IV
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
EA
EA
EA
EA
ML
480 MCG
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1 EA
50 MCG
1 EA
50 MCG
300 MCG
1.25
3
3
3
3
10
10
10
10
20
20
20
20
1
125
1
125
1
01/01/2002
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/01/2002
01/01/2006
01/24/2005
01/01/2006
01/24/2005
01/01/2006
01/01/2002
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
99/99/9999
1 ML VL
IJ
ML
300 MCG
01/01/2002
99/99/9999
1.6 ML VL
IJ
ML
480 MCG
0.625
01/01/2002
99/99/9999
1/1/2006
3/1/2006 59.5238
1/1/2006
3/1/2006 59.5238
1/1/2002
7/31/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55513-0546-10
J1441
55513-0554-01
J9212
1/1/2002
55513-0554-06
J9212
1/1/2002
55513-0562-01
J9212
1/1/2002
55513-0562-06
55513-0823-01
55513-0823-01
55513-0823-10
55513-0823-10
J9212
Q0136
J0885
Q0136
J0885
1/1/2002
1/1/2002
1/1/2006
1/1/2002
1/1/2006
55513-0924-01
J1440
1/1/2002
55513-0924-10
55513-0954-01
55513-0954-01
55513-0955-01
55513-0955-01
55513-0956-01
55513-0956-01
55553-0041-10
55553-0042-05
55553-0055-50
55553-0055-50
55553-0056-50
55553-0056-50
55553-0091-10
55553-0091-30
55553-0092-05
55553-0092-05
55553-0129-10
55553-0171-10
55553-0249-10
55553-0661-10
55553-0807-05
55553-0827-10
55553-0908-10
55566-0081-05
55566-0302-01
55566-0302-01
55566-1501-01
J1440
J3490
J9303
J3490
J9303
J3490
J9303
J1435
J3302
J2000
J2001
J2000
J2001
J3420
J3420
J1095
J1094
J2360
J3410
J2650
J1100
J1100
J1200
J2010
J2725
Q2005
J0795
J0725
1/1/2002
10/10/2006
1/1/2008
10/10/2006
1/1/2008
10/10/2006
1/1/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2006
1/1/2002
55566-4100-01
Q4085
1/1/2007
55566-4100-01
J7323
1/1/2008
55566-5030-01
J2597
1/1/2002
55566-5040-01
55566-8505-02
55566-8505-02
55566-8505-06
55566-8505-06
55592-0500-01
55592-0500-01
55688-0106-02
J2597
Q2018
J3355
Q2018
J3355
J3490
J9225
J7191
1/1/2002
5/14/2002
1/1/2006
1/3/2005
1/1/2006
10/12/2004
1/1/2006
1/1/2002
55887-0033-15
Q0144
4/1/2008
55887-0078-03
Q0179
4/1/2007
55887-0081-06
55887-0165-30
55887-0165-60
55887-0165-90
55887-0220-12
55887-0246-15
55887-0246-21
55887-0246-25
55887-0246-30
55887-0246-40
55887-0246-50
55887-0246-60
Q0173
J8540
J8540
J8540
J8498
J8499
J8499
J8499
J8499
J8499
J8499
J8499
4/1/2007
4/1/2007
4/1/2007
4/1/2007
4/1/2007
4/1/2007
2/1/2005
2/1/2005
2/1/2005
4/1/2007
2/1/2005
3/23/2007
NEUPOGEN (S.D.V.,1.6MLX10,PF) 480

MCG/1.6 ML
INFERGEN (9MCG,S.D.V.,PF) 30 MCG/ML

INFERGEN (6X9MCG,S.D.V.,PF) 30
MCG/ML
INFERGEN (15 MCG,S.D.V.,PF) 30
MCG/ML
MCG/ML
NEUPOGEN (26GX5/8",SINGLE USE) 300
MCG/0.5 ML
NEUPOGEN ((26GX5/8"),0.5MLX10,PF)
300 MCG/0.5 ML
VECTIBIX 20 MG/ML
99/99/9999 INJECTION, PANITUMUMAB, 10 MG
VECTIBIX 20 MG/ML
VECTIBIX 20 MG/ML
VECTIBIX 20 MG/ML
VECTIBIX 20 MG/ML
VECTIBIX 20 MG/ML
ESTRAGYN 5 (VIAL) 5 MG/ML
CLINACORT (VIAL) 40 MG/ML
ANESTACAINE (VIAL) 1%
VITA #12 (VIAL) 1000 MCG/ML
VITA #12 (VIAL) 1000 MCG/ML
CORTASTAT LA (VIAL) 8 MG/ML
CORTASTAT LA (VIAL) 8 MG/ML
ANTIFLEX (AMP) 30 MG/ML
RESTALL (VIAL) 50 MG/ML
PREDACORT 50 (VIAL) 50 MG/ML
CORTASTAT 10 (VIAL) 10 MG/ML
CORTASTAT (VIAL) 4 MG/ML
BANARIL (VIAL) 50 MG/ML
BACTRAMYCIN (VIAL) 300 MG/ML
5/1/2002 INJECTION, PROTIRELIN, PER 250 MCG
THYREL TRH (AMP) 500 MCG/ML
12/31/2005 INJECTION, CORTICORELIN OVINE TRIFLUTATE, PER DOSE
ACTHREL (S.D.V.) 0.1 MG
99/99/9999 INJECTION, CORTICORELIN OVINE TRIFLUTATE, 1 MICROGRAM
ACTHREL (S.D.V.) 0.1 MG
NOVAREL (M.D.V.) 10000 U
HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PEREUFLEXXA (3 SYRINGES X 2ML) 10
12/31/2007 DOSE
MG/ML
HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PEREUFLEXXA (3 SYRINGES X 2ML) 10
MG/ML
99/99/9999 DOSE
DESMOPRESSIN ACETATE (AMP,PF) 4
MCG/ML
DESMOPRESSIN ACETATE (M.D.V.) 4
MCG/ML
BRAVELLE (S.D.V. W/DILUENT) 75 IU
BRAVELLE (S.D.V. W/DILUENT) 75 IU
BRAVELLE (SDV W/Q-CAP) 75 IU
BRAVELLE (SDV W/Q-CAP) 75 IU
VANTAS 50 MG
7/25/2007 HISTRELIN IMPLANT, 50 MG
VANTAS 50 MG
6/20/2005 FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U.
HYATE:C (APPR. 400-700 U/VIAL) 1 U
AZITHROMYCIN (1X15ML,CHERRY) 100
MG/5 ML
ONDANSETRON 4 MG
TRIMETHOBENZAMIDE
HYDROCHLORIDE 300 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
Page 276 of 374
1.6 ML VL
IJ
ML
480 MCG
0.625
01/01/2002
0.3 ML VL
SC
ML
1 MCG
30
01/01/2002
04/17/2003
0.3 ML VL
SC
ML
1 MCG
30
01/01/2002
04/17/2003
0.5 ML VL
SC
ML
1 MCG
30
01/01/2002
10/31/2002
0.5 ML
1 ML
1 ML
1 ML
1 ML
SC
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
1 MCG
1000 U
1000 U
1000 U
1000 U
30
40
40
40
40
01/01/2002
01/01/2002
01/01/2006
01/01/2002
01/01/2006
10/31/2002
12/31/2005
99/99/9999
12/31/2005
99/99/9999
VL
VL
VL
VL
VL
0.5 ML SR
IJ
ML
01/01/2002
99/99/9999
IJ
IV
IV
IV
IV
IV
IV
IM
IJ
EP
EP
IJ
IJ
IM
IM
IJ
IJ
IJ
IM
IJ
IJ
IJ
IJ
IJ
IV
IV
IV
IM
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
EA
EA
EA
300 MCG
1 EA
10 MG
1 EA
10 MG
1 EA
10 MG
1 MG
5 MG
50 ML
10 MG
50 ML
10 MG
1000 MCG
1000 MCG
8 MG
1 MG
60 MG
25 MG
1 ML
1 MG
1 MG
50 MG
300 MG
250 MCG
1 DOSE
1 MCG
1000 USP Units
2
1
2
1
2
1
2
5
8
0.02
1
0.02
2
1
1
1
8
0.5
2
1
10
4
1
1
2
1
100
10
01/01/2002
10/10/2006
01/01/2008
10/10/2006
01/01/2008
10/10/2006
01/01/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2006
01/01/2002
99/99/9999
12/31/2007
99/99/9999
12/31/2007
99/99/9999
12/31/2007
99/99/9999
99/99/9999
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
12/31/2002
99/99/9999
99/99/9999
99/99/9999
09/25/2006
99/99/9999
99/99/9999
99/99/9999
01/25/2002
05/01/2002
12/31/2005
99/99/9999
99/99/9999
2 ML SR
IJ
ML
1 DOSE
0.5
01/01/2007
12/31/2007
2 ML SR
IJ
ML
1 DOSE
0.5
01/01/2008
99/99/9999
1 ML AM IJ
ML
1 MCG
01/01/2002
99/99/9999
4
1
1
1
1
1
1
1
01/01/2002
05/14/2002
01/01/2006
01/03/2005
01/01/2006
10/12/2004
01/01/2006
01/01/2002
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
07/25/2007
06/20/2005
10 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
300 MCG
VL
VL
VL
VL
VL
BX
BX
VL
IJ
IJ
IJ
IJ
IJ
SC
SC
IV
ML
EA
EA
EA
EA
EA
EA
EA
1 MCG
75 IU
75 IU
75 IU
75 IU
1 EA
50 MG
1 IU
15 ML BO
PO
ML
1 GM
0.02
04/01/2008
99/99/9999
3 EA BO
PO
EA
8 MG
0.5
04/01/2007
99/99/9999
PO
PO
PO
PO
RC
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
250 MG
0.25 MG
0.25 MG
0.25 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1.2
2
2
2
1
1
1
1
1
1
1
1
04/01/2007
04/01/2007
04/01/2007
04/01/2007
04/01/2007
04/01/2007
02/01/2005
02/01/2005
02/01/2005
04/01/2007
02/01/2005
03/23/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
05/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
6 EA
30 EA
60 EA
90 EA
12 EA
15 EA
21 EA
25 EA
30 EA
40 EA
50 EA
60 EA
BO
NA
NA
NA
BX
BO
BO
BO
BO
BO
BO
NA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
0.5 ML
5 ML
5 ML
10 ML
10 ML
20 ML
20 ML
10 ML
5 ML
50 ML
50 ML
50 ML
50 ML
10 ML
30 ML
5 ML
5 ML
10 ML
10 ML
10 ML
10 ML
5 ML
10 ML
10 ML
1 ML
1 EA
1 EA
1 EA
SR
VL
VL
VL
VL
VL
VL
EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
AM
VL
EA
VL
VL
VL
VL
AM
VL
VL
VL
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55887-0311-30
Q0144
55887-0332-24
J7603
55887-0332-24 KO J7603
55887-0332-24
KO
J7614
55887-0332-24 KO J7614
55887-0332-30
Q0144
55887-0333-03
Q0144
55887-0333-10
Q0144
55887-0373-08
J7510
55887-0377-12
J8540
55887-0377-30
55887-0377-30
Q0181
J8540
55887-0382-20
J7602
55887-0382-20
J7611
55887-0395-30
Q0164
55887-0395-60
Q0164
55887-0395-90
Q0164
55887-0422-30
Q0177
55887-0422-60
55887-0544-25
55887-0554-50
Q0177
J7509
J7509
55887-0561-12
K0416
55887-0619-12
Q0165
55887-0619-30
55887-0621-03
Q0165
J8498
55887-0621-12
55887-0621-12
55887-0643-15
55887-0643-21
55887-0643-30
55887-0643-40
55887-0643-42
55887-0643-50
55887-0643-60
55887-0643-90
K0416
J8498
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
55887-0644-14
G9020
55887-0644-28
G9020
55887-0675-04
Q0170
KO

XOPENEX (24X3ML) 0.63 MG/3 ML
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
11/1/2004
ZITHROMAX 600 MG
11/1/2004
ZITHROMAX 500 MG
11/1/2004
ZITHROMAX 500 MG
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
4/1/2004 12/31/2005 REGIMEN
1/1/2006
DEXAMETHASONE 4 MG
ALBUTEROL 0.5%
1/1/2008 3/31/2008 (LEVALBUTEROL)
ALBUTEROL 0.5%
4/1/2004
4/1/2004
9/1/2003
MEDROL 8 MG
5/31/2003
MEDROL 16 MG
4/1/2004
PROMETHAZINE 25 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
6.25 MG/5 ML
Page 277 of 374
30 ML NA
PO
ML
1 GM
0.04
01/01/2007
99/99/9999
3 ML NA
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML NA
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML NA
IH
ML
0.5 MG
0.42
04/01/2008
99/99/9999
NA
BO
BO
BO
BO
NA
IH
PO
PO
PO
PO
PO
ML
EA
EA
EA
ML
EA
0.5 MG
1 GM
1 GM
1 GM
5 MG
0.25 MG
0.42
0.6
0.5
0.5
0.6
16
04/01/2008
11/01/2004
11/01/2004
11/01/2004
04/01/2004
03/23/2007
99/99/9999
07/01/2006
07/01/2006
07/01/2006
99/99/9999
99/99/9999
30 EA BO
30 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
04/01/2004
01/01/2006
12/31/2005
07/01/2006
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML BO
IH
ML
1 MG
04/01/2008
99/99/9999
30 EA BO
PO
EA
5 MG
04/01/2004
99/99/9999
60 EA BO
PO
EA
5 MG
04/01/2004
07/01/2006
90 EA BO
PO
EA
5 MG
04/01/2004
07/01/2006
30 EA BO
PO
EA
25 MG
04/01/2004
99/99/9999
60 EA NA
25 EA BO
50 EA BO
PO
PO
PO
EA
EA
EA
25 MG
4 MG
4 MG
1
2
4
03/23/2007
09/01/2003
05/31/2003
99/99/9999
07/01/2006
07/01/2006
12 EA BX
RC
EA
1 MG
12.5
04/01/2004
05/23/2005
12 EA BO
PO
EA
10 MG
04/01/2004
07/01/2006
30 EA BO
3 EA BX
PO
RC
EA
EA
10 MG
1 EA
1
1
04/01/2004
01/01/2006
99/99/9999
99/99/9999
12 EA
12 EA
15 EA
21 EA
30 EA
40 EA
42 EA
50 EA
60 EA
90 EA
BX
BX
BO
DP
BO
BO
BO
BO
BO
BO
RC
RC
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 MG
1 EA
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
25
1
2
2
2
2
2
2
2
2
04/01/2004
04/01/2007
04/01/2004
01/01/2006
04/01/2004
01/01/2006
04/01/2007
04/01/2007
06/01/2007
06/01/2007
05/23/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
28 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
120 ML BO
PO
ML
25 MG
0.05
06/01/2007
99/99/9999
3 ML
30 EA
3 EA
10 EA
8 ML
12 EA
01-Apr-04
4/1/2004
01-Jul-06
7/1/2006
2
2
4/1/2004
5/1/2007
0.05
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55887-0696-21
55887-0696-48
J7506
J7506
55887-0755-10
G9035
55887-0767-10
G9017
55887-0767-14
G9017
55887-0767-20
G9017
55887-0767-30
55887-0770-01
55887-0770-15
55887-0770-20
55887-0770-21
55887-0770-30
55887-0770-39
55887-0770-50
55887-0770-60
55887-0785-06
55887-0796-18
55887-0796-20
55887-0796-21
55887-0796-30
55887-0796-90
55887-0853-25
55887-0853-30
55887-0853-35
55887-0853-50
55887-0853-60
55887-0853-90
G9017
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
Q0144
J7506
J7506
J7506
J7506
J7506
J8499
J8499
J8499
J8499
J8499
J8499
55887-0885-20
Q0163
55887-0885-28
Q0163
55887-0885-30
55887-0933-06
Q0163
Q0144
55887-0936-10
Q0170
55887-0936-12
Q0170
55887-0936-15
Q0170
55887-0936-20
Q0170
55887-0936-25
Q0170
55887-0936-28
Q0170
55887-0936-30
Q0170
55887-0936-60
Q0170
55887-0936-90
Q0170

1/1/2002
TAMIFLU 75 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
6/30/2003
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
AZITHROMYCIN 250 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
1/1/2002
4/1/2004
ZITHROMAX 250 MG
PROMETHAZINE 25 MG
7/1/2003
Page 278 of 374
21 EA DP
48 EA DP
PO
PO
EA
EA
5 MG
5 MG
2
2
01/01/2002
01/01/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
07/01/2006
10 EA BO
PO
EA
75 MG
12/01/2004
05/31/2005
10 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
BO
NA
BO
BO
DP
BO
BO
BO
BO
BO
NA
BO
BO
BO
NA
BO
BO
NA
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
100 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1 GM
5 MG
5 MG
5 MG
5 MG
5 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
1
1
1
1
0.25
4
4
4
4
4
1
1
1
1
1
1
12/01/2004
01/01/2007
04/01/2007
04/01/2007
06/30/2003
04/01/2007
04/01/2007
04/01/2007
04/01/2007
06/01/2007
01/01/2007
01/01/2006
04/01/2004
04/01/2004
01/01/2007
04/01/2004
04/01/2004
04/01/2007
04/01/2007
04/01/2004
04/01/2004
05/31/2005
99/99/9999
99/99/9999
99/99/9999
05/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
20 EA BO
PO
EA
50 MG
01/01/2002
05/01/2007
28 EA BO
PO
EA
50 MG
04/01/2004
07/01/2006
30 EA BO
6 EA DP
PO
PO
EA
EA
50 MG
1 GM
1
0.25
04/01/2004
01/01/2002
99/99/9999
99/99/9999
10 EA BO
PO
EA
25 MG
07/01/2003
99/99/9999
12 EA BO
PO
EA
25 MG
07/01/2003
99/99/9999
15 EA BO
PO
EA
25 MG
04/01/2004
99/99/9999
20 EA BO
PO
EA
25 MG
07/01/2003
99/99/9999
25 EA BO
PO
EA
25 MG
01/01/2006
99/99/9999
28 EA BO
PO
EA
25 MG
07/01/2003
05/01/2007
30 EA BO
PO
EA
25 MG
07/01/2003
99/99/9999
60 EA BO
PO
EA
25 MG
01/01/2005
99/99/9999
90 EA BO
PO
EA
25 MG
01/01/2005
99/99/9999
30 EA
100 EA
15 EA
20 EA
21 EA
30 EA
39 EA
50 EA
60 EA
6 EA
18 EA
20 EA
21 EA
30 EA
90 EA
25 EA
30 EA
35 EA
50 EA
60 EA
90 EA
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
55887-0953-21
J7509
55887-0973-20
Q0163
55887-0973-28
Q0163
55887-0973-30
55887-0977-30
55887-0977-40
Q0163
J8499
J8499
55966-0115-01
Q0163
55966-0998-05
Q0163
57394-0240-24
Q0163
57394-0240-40
Q0163
57394-0262-24
Q0163
57394-0262-52
Q0163
57394-0334-24
Q0163
57394-0334-52
57665-0001-01
57665-0001-01
57665-0002-02
Q0163
Q2012
J2504
J9266
57665-0101-41
57665-0331-01
57665-0331-01
57844-0522-06
57844-0522-07
57844-0713-19
57844-0713-41
J0287
J9999
J9098
J8999
J8999
J2941
J2941
1/1/2004
5/1/2003
1/1/2004
5/14/2004
9/11/2003
1/18/2005
1/18/2005
57866-0215-01
57866-0446-07
57866-3136-01
Q0170
Q0144
Q0144
2/1/2004
4/15/2002
5/1/2006
57866-3594-01
Q0163
4/15/2002
57866-3594-02
Q0163
4/15/2002
57866-3594-05
Q0163
4/15/2002
57866-3594-06
Q0163
4/15/2002

4/1/2004
1/1/2002 12/31/2005 INJECTION, PEGADEMASE BOVINE, 25 IU
1/1/2006 99/99/9999 INJECTION, PEGADEMASE BOVINE, 25 IU
4/1/2002 99/99/9999 INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL
METHYLPRED DP 4 MG
21 EA BO
PO
EA
4 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
28 EA BO
PO
EA
50 MG
0.5
04/01/2004
05/01/2007
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
30 EA BO
30 EA BO
40 EA BO
PO
PO
PO
EA
EA
EA
50 MG
1 EA
1 EA
0.5
1
1
04/01/2004
04/01/2007
11/29/2005
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
08/28/2007
NIGHT TIME SLEEP-AID (CAPLET) 25 MG
16 EA NA
PO
EA
50 MG
0.5
01/01/2002
08/28/2007
NITE-TIME SLEEP AID (12X24) 25 MG
12 EA NA
PO
EA
50 MG
0.5
01/01/2002
12/31/2002
NITE-TIME SLEEP AID (12X48) 25 MG
12 EA NA
PO
EA
50 MG
0.5
01/01/2002
12/31/2002
HAYFEVER & ALLERGY RELIEF (12X24)

25 MG
12 EA NA
PO
EA
50 MG
0.5
01/01/2002
12/31/2002
HAYFEVER & ALLERGY RELIEF 25 MG
600 EA NA
PO
EA
50 MG
0.5
01/01/2002
12/31/2002

25 MG
12 EA NA
PO
EA
50 MG
0.5
01/01/2002
12/31/2002
COMPLETE ALLERGY RELIEF 25 MG

25 MG
ADAGEN (VIAL) 250 U/ML
ADAGEN (VIAL) 250 U/ML
ONCASPAR (S.D.V.,PF) 750 IU/ML
99/99/9999 INJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MG

ABELCET (W/FILTER NEEDLE) 5 MG/ML
99/99/9999 INJECTION, CYTARABINE LIPOSOME, 10 MG
PURINETHOL 50 MG
PURINETHOL 50 MG
TEV-TROPIN (VIAL W/DILUENT) 5 MG
TEV-TROPIN (VIAL W/DILUENT) 5 MG
PROMETHAZINE 25 MG
ZITHROMAX 250 MG
AZITHROMYCIN 500 MG
Page 279 of 374
100 EA
1.5 ML
1.5 ML
5 ML
NA
VL
VL
VL
PO
IM
IM
IJ
EA
ML
ML
ML
50 MG
25 IU
25 IU
1 VIAL
0.5
10
10
0.2
01/01/2002
01/01/2002
01/01/2006
04/01/2002
12/31/2002
12/31/2005
99/99/9999
99/99/9999
20 ML
5 ML
5 ML
60 EA
25 EA
1 EA
1 EA
VL
VL
VL
BO
BO
VL
VL
IV
IN
IN
PO
PO
SC
SC
ML
ML
ML
EA
EA
EA
EA
10 MG
1 EA
10 MG
1 EA
1 EA
1 MG
1 MG
0.5
1
1
1
1
5
5
11/15/2004
05/01/2003
01/01/2004
05/14/2004
09/11/2003
01/18/2005
01/18/2005
99/99/9999
12/31/2003
99/99/9999
99/99/9999
05/13/2004
99/99/9999
08/01/2007
12 EA BO
18 EA BX
3 EA BO
PO
PO
PO
EA
EA
EA
25 MG
1 GM
1 GM
1
0.25
0.5
02/01/2004
04/15/2002
05/01/2006
99/99/9999
1/1/2008
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
04/15/2002
99/99/9999
12 EA BO
PO
EA
50 MG
0.5
04/15/2002
99/99/9999
90 EA BO
PO
EA
50 MG
0.5
04/15/2002
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
04/15/2002
99/99/9999
1/1/2004
1/1/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.5
57866-3762-01
Q0163
4/15/2002
57866-3762-02
Q0163
4/15/2002
57866-3762-04
Q0163
4/15/2002
57866-3762-05
Q0163
3/22/2006
57866-3893-01
Q0177
4/15/2002
57866-3893-02
Q0177
4/15/2002
57866-3893-03
Q0177
4/15/2002
57866-3894-01
Q0178
4/15/2002
57866-3894-02
Q0178
4/15/2002
57866-3894-03
57866-4037-01
Q0178
J7509
4/15/2002
4/15/2002
57866-4132-01
Q0175
4/15/2002
57866-4132-02
Q0175
4/15/2002
57866-4132-03
Q0175
4/15/2002
57866-4133-01
Q0176
4/15/2002
57866-4133-02
Q0176
4/15/2002
57866-4133-03
57866-4324-01
57866-4324-04
57866-4324-05
57866-4325-01
57866-4325-02
57866-4325-03
57866-4325-07
57866-4325-08
57866-4326-01
57866-4326-02
57866-4326-04
57866-4326-05
57866-4326-07
57866-4326-08
57866-4327-01
57866-4327-02
Q0176
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7510
J7506
4/15/2002
4/15/2002
4/15/2002
10/1/2003
4/15/2002
4/15/2002
4/15/2002
11/1/2005
1/2/2006
10/1/2003
4/15/2002
4/15/2002
10/1/2003
10/1/2003
11/1/2005
4/15/2002
10/1/2003

99/99/9999 REGIMEN
99/99/9999 REGIMEN
99/99/9999 REGIMEN
99/99/9999 REGIMEN
99/99/9999 REGIMEN
99/99/9999 REGIMEN
30 EA BO
PO
EA
50 MG
04/15/2002
99/99/9999
20 EA BO
PO
EA
50 MG
04/15/2002
99/99/9999
90 EA BO
PO
EA
50 MG
04/15/2002
99/99/9999
15 EA BO
PO
EA
50 MG
03/22/2006
99/99/9999
30 EA BO
PO
EA
25 MG
04/15/2002
99/99/9999
60 EA BO
PO
EA
25 MG
04/15/2002
99/99/9999
90 EA BO
PO
EA
25 MG
04/15/2002
99/99/9999
30 EA BO
PO
EA
50 MG
04/15/2002
99/99/9999
60 EA BO
PO
EA
50 MG
04/15/2002
99/99/9999
90 EA BO
21 EA DP
PO
PO
EA
EA
50 MG
4 MG
1
1
04/15/2002
04/15/2002
99/99/9999
99/99/9999
PERPHENAZINE 4 MG
30 EA BO
PO
EA
4 MG
04/15/2002
99/99/9999
PERPHENAZINE 4 MG
60 EA BO
PO
EA
4 MG
04/15/2002
99/99/9999
PERPHENAZINE 4 MG
90 EA BO
PO
EA
4 MG
04/15/2002
99/99/9999
PERPHENAZINE 8 MG
30 EA BO
PO
EA
8 MG
04/15/2002
99/99/9999
PERPHENAZINE 8 MG
60 EA BO
PO
EA
8 MG
04/15/2002
99/99/9999
PERPHENAZINE 8 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISOLONE 5 MG
PREDNISONE 5 MG
90 EA
30 EA
21 EA
50 EA
30 EA
21 EA
40 EA
90 EA
60 EA
20 EA
30 EA
21 EA
15 EA
5 EA
18 EA
90 EA
20 EA
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
8 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
1
1
1
2
2
2
2
2
4
4
4
4
4
4
1
1
04/15/2002
04/15/2002
04/15/2002
10/01/2003
04/15/2002
04/15/2002
04/15/2002
11/01/2005
01/02/2006
10/01/2003
04/15/2002
04/15/2002
10/01/2003
10/01/2003
11/01/2005
04/15/2002
10/01/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 280 of 374
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

PROMETHAZINE 25 MG
AZITHROMYCIN 250 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
HYDROXYUREA 500 MG
NOLVADEX 10 MG
NOLVADEX 20 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
TAMIFLU 75 MG
AZATHIOPRINE 50 MG
PURINETHOL 50 MG
99/99/9999 INJECTION INFLIXIMAB, 10 MG
REMICADE (S.D.V.,PF) 100 MG
57866-4328-03
57866-4356-01
Q0170
Q0144
10/1/2003
3/28/2006
57866-4379-01
Q0170
11/1/2005
57866-4379-02
Q0170
4/15/2002
57866-4379-04
Q0170
4/15/2002
57866-4379-06
Q0170
1/2/2006
57866-4379-07
Q0170
1/2/2006
57866-4379-08
57866-4436-01
57866-4822-01
Q0170
J8999
J8999
4/11/2006
4/15/2002
4/15/2002
57866-6298-01
Q0165
4/15/2002
57866-6299-01
Q0164
4/15/2002
57866-6299-02
57866-6615-01
57866-6618-01
57866-6950-02
57866-6950-03
57866-7100-01
Q0164
J8999
J8999
J8499
J8499
J7509
10/1/2003
4/15/2002
4/15/2002
4/15/2002
4/15/2002
1/22/2008
57866-8002-01
57866-9021-01
57884-0522-07
57894-0030-01
G9035
J7500
J8999
J1745
12/1/2004
4/15/2002
9/10/2003
1/1/2002
57894-0040-01
J2993
1/1/2002 11/29/2005 INJECTION, RETEPLASE, 18.1 MG
RETAVASE (2X18.1 MG VIALS,PF) 10.4 U
57894-0040-02
J2993
57896-0351-01
Q0163
57896-0352-01
Q0163
57896-0781-01
Q0163
57896-0782-01
Q0163
58016-0084-00
Q0179
58016-0084-10
Q0179
1/1/2002 11/29/2005 INJECTION, RETEPLASE, 18.1 MG

GERIDRYL 25 MG
GERIDRYL (CAPLET) 25 MG
GERIDRYL 25 MG
GERIDRYL (CAPLET) 25 MG
ZOFRAN 8 MG
ZOFRAN 8 MG
Page 281 of 374
20 EA BO
6 EA BO
PO
PO
EA
EA
25 MG
1 GM
1
0.25
10/01/2003
03/28/2006
99/99/9999
99/99/9999
30 EA BO
PO
EA
25 MG
11/01/2005
99/99/9999
12 EA BO
PO
EA
25 MG
04/15/2002
99/99/9999
10 EA BO
PO
EA
25 MG
04/15/2002
99/99/9999
5 EA BO
PO
EA
25 MG
01/02/2006
99/99/9999
60 EA BO
PO
EA
25 MG
01/02/2006
99/99/9999
90 EA BO
30 EA BO
30 EA BO
PO
PO
PO
EA
EA
EA
25 MG
1 EA
1 EA
1
1
1
04/11/2006
04/15/2002
04/15/2002
99/99/9999
1/1/2008
99/99/9999
30 EA BO
PO
EA
10 MG
04/15/2002
99/99/9999
30 EA BO
PO
EA
5 MG
04/15/2002
99/99/9999
10 EA
60 EA
60 EA
25 EA
50 EA
25 EA
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
5 MG
1 EA
1 EA
1 EA
1 EA
4 MG
1
1
1
1
1
2
10/01/2003
04/15/2002
04/15/2002
04/15/2002
04/15/2002
01/22/2008
99/99/9999
09/01/2006
09/01/2006
99/99/9999
99/99/9999
99/99/9999
10 EA
30 EA
25 EA
1 EA
BO
BO
BO
VL
PO
PO
PO
IV
EA
EA
EA
EA
75 MG
50 MG
1 EA
10 MG
1
1
1
10
12/01/2004
04/15/2002
09/10/2003
01/01/2002
05/31/2005
99/99/9999
09/10/2003
99/99/9999
2 EA BX
IV
EA
18.1 MG
01/01/2002
11/29/2005
1 EA BX
IV
EA
18.1 MG
01/01/2002
11/29/2005
100 EA NA
PO
EA
50 MG
0.5
01/01/2002
07/31/2002
100 EA NA
PO
EA
50 MG
0.5
01/01/2002
07/31/2002
100 EA NA
PO
EA
50 MG
0.5
08/01/2002
99/99/9999
100 EA NA
PO
EA
50 MG
0.5
08/01/2002
99/99/9999
100 EA BO
PO
EA
8 MG
02/01/2006
99/99/9999
10 EA BO
PO
EA
8 MG
02/01/2006
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
58016-0084-30
Q0179
2/1/2006
58016-0084-60
Q0179
2/1/2006
58016-0084-90
58016-0086-00
58016-0086-30
58016-0086-60
58016-0086-90
58016-0111-00
58016-0111-15
58016-0111-20
58016-0111-25
58016-0111-30
58016-0111-60
58016-0111-90
58016-0112-00
58016-0112-20
58016-0112-30
58016-0112-60
58016-0112-90
58016-0126-12
Q0179
Q0144
Q0144
Q0144
Q0144
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J7506
2/1/2006
2/1/2006
2/1/2006
2/1/2006
2/1/2006
9/1/2006
9/1/2006
9/1/2006
9/1/2006
9/1/2006
9/1/2006
9/1/2006
5/31/2005
5/31/2005
5/31/2005
8/9/2002
5/31/2005
1/1/2002
58016-0153-00
G9017
12/1/2004
58016-0153-10
G9017
12/1/2004
58016-0153-14
G9017
12/1/2004
58016-0153-15
G9017
12/1/2004
58016-0153-20
G9017
12/1/2004
58016-0153-30
58016-0170-00
58016-0170-30
58016-0170-60
58016-0170-90
58016-0170-99
58016-0216-00
58016-0216-10
58016-0216-12
58016-0216-14
58016-0216-15
58016-0216-20
58016-0216-21
58016-0216-22
58016-0216-24
58016-0216-28
58016-0216-30
58016-0216-32
58016-0216-40
58016-0216-42
58016-0216-50
58016-0216-60
58016-0216-84
58016-0216-90
58016-0217-00
58016-0217-05
58016-0217-07
58016-0217-10
58016-0217-12
58016-0217-15
58016-0217-16
58016-0217-18
58016-0217-20
58016-0217-21
58016-0217-22
58016-0217-23
58016-0217-24
58016-0217-28
58016-0217-30
58016-0217-40
58016-0217-60
G9017
J8999
J8999
J8999
J8999
J8999
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
12/1/2004
2/1/2006
2/1/2006
2/1/2006
2/1/2006
2/1/2006
1/1/2002
1/1/2007
3/22/2002
3/22/2002
1/1/2002
3/22/2002
1/1/2002
1/1/2007
3/22/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2007
1/1/2002
1/1/2002
1/1/2007
1/1/2007
1/1/2002
1/1/2007
1/1/2007
3/21/2002
1/1/2007
3/21/2002
3/21/2002
3/21/2002
1/1/2002
1/1/2002
3/21/2002
1/1/2007
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

ZOFRAN 8 MG
ZOFRAN 8 MG
ZOFRAN 8 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
PREDNISONE 10 MG
FLUTAMIDE 125 MG
FLUTAMIDE 125 MG
FLUTAMIDE 125 MG
FLUTAMIDE 125 MG
FLUTAMIDE 125 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
Page 282 of 374
30 EA BO
PO
EA
8 MG
02/01/2006
99/99/9999
60 EA BO
PO
EA
8 MG
02/01/2006
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
8 MG
1 GM
1 GM
1 GM
1 GM
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
5 MG
1
0.25
0.25
0.25
0.25
1
1
1
1
1
1
1
1
1
1
1
1
2
02/01/2006
02/01/2006
02/01/2006
02/01/2006
02/01/2006
09/01/2006
09/01/2006
09/01/2006
09/01/2006
09/01/2006
09/01/2006
09/01/2006
05/31/2005
05/31/2005
05/31/2005
08/09/2002
05/31/2005
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
10 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
15 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
100 MG
1 EA
1 EA
1 EA
1 EA
1 EA
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
12/01/2004
02/01/2006
02/01/2006
02/01/2006
02/01/2006
02/01/2006
01/01/2002
01/01/2007
03/22/2002
03/22/2002
01/01/2002
03/22/2002
01/01/2002
01/01/2007
03/22/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2007
01/01/2002
01/01/2002
01/01/2007
01/01/2007
01/01/2002
01/01/2007
01/01/2007
03/21/2002
01/01/2007
03/21/2002
03/21/2002
03/21/2002
01/01/2002
01/01/2002
03/21/2002
01/01/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
90 EA
100 EA
30 EA
60 EA
90 EA
100 EA
15 EA
20 EA
25 EA
30 EA
60 EA
90 EA
100 EA
20 EA
30 EA
60 EA
90 EA
12 EA
30 EA
100 EA
30 EA
60 EA
90 EA
180 EA
100 EA
10 EA
12 EA
14 EA
15 EA
20 EA
21 EA
22 EA
24 EA
28 EA
30 EA
32 EA
40 EA
42 EA
50 EA
60 EA
84 EA
90 EA
100 EA
5 EA
7 EA
10 EA
12 EA
15 EA
16 EA
18 EA
20 EA
21 EA
22 EA
23 EA
24 EA
28 EA
30 EA
40 EA
60 EA
BO
BO
BO
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
NA
BO
BO
NA
BO
BO
NA
NA
BO
NA
BO
BO
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002
3/22/2002
1/1/2002
3/22/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2007
5/31/2005
58016-0259-00
Q0177
1/1/2002
58016-0259-02
Q0177
1/1/2007
58016-0259-10
Q0177
1/1/2002
58016-0259-20
Q0177
1/1/2002
58016-0259-30
Q0177
1/1/2002
58016-0259-50
Q0177
1/1/2002
58016-0259-60
Q0177
1/1/2002
58016-0259-90
Q0177
1/1/2007
58016-0283-00
Q0169
8/1/2004
58016-0283-02
Q0169
8/1/2004
58016-0283-30
Q0169
8/1/2004
58016-0283-60
Q0169
8/1/2004
58016-0283-90
Q0169
8/1/2004
58016-0290-00
58016-0290-00
Q0181
J8540
1/1/2002
1/1/2006
58016-0290-02
58016-0290-02
Q0181
J8540
9/15/2003
1/1/2006
58016-0290-03
58016-0290-03
Q0181
J8540
9/15/2003
1/1/2006
Page 283 of 374
1
1
1
1
1
1
1
1
1
1
1
1
1
01/01/2002
03/22/2002
01/01/2002
03/22/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2007
05/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
EA
25 MG
01/01/2002
99/99/9999
PO
EA
25 MG
01/01/2007
99/99/9999
10 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
50 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
60 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
90 EA NA
PO
EA
25 MG
01/01/2007
99/99/9999
100 EA BO
PO
EA
12.5 MG
08/01/2004
05/23/2005
120 EA BO
PO
EA
12.5 MG
08/01/2004
05/23/2005
30 EA BO
PO
EA
12.5 MG
08/01/2004
05/23/2005
60 EA BO
PO
EA
12.5 MG
08/01/2004
05/23/2005
90 EA BO
PO
EA
12.5 MG
08/01/2004
05/23/2005
100 EA BO
100 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
01/01/2002
01/01/2006
12/31/2005
99/99/9999
120 EA BO
120 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
09/15/2003
01/01/2006
12/31/2005
99/99/9999
150 EA BO
150 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
09/15/2003
01/01/2006
12/31/2005
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
120 EA NA
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
Prior Start Date #2
PO
End Date #1
100 EA BO
5
5
5
5
5
5
5
5
5
5
5
5
5
Start Date #1
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
CF
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
HCPCS Measure #1
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
BO
Billing Units
100 EA
20 EA
21 EA
24 EA
30 EA
33 EA
36 EA
40 EA
50 EA
55 EA
60 EA
69 EA
90 EA
HCPCS Amount #1

Package
NDC Label
HCPCS Description

PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
NDC Package Type
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
NDC Package Measure
58016-0218-00
58016-0218-20
58016-0218-21
58016-0218-24
58016-0218-30
58016-0218-33
58016-0218-36
58016-0218-40
58016-0218-50
58016-0218-55
58016-0218-60
58016-0218-69
58016-0218-90
HCPCS Mod
HCPCS
NDC Mod
NDC
58016-0290-12
58016-0290-12
Q0181
J8540
1/1/2002
1/1/2006
58016-0290-15
58016-0290-15
Q0181
J8540
1/1/2002
1/1/2006
58016-0290-20
58016-0290-20
Q0181
J8540
1/1/2002
1/1/2006
58016-0290-30
58016-0290-30
Q0181
J8540
1/1/2002
1/1/2006
58016-0290-73
58016-0290-73
Q0181
J8540
9/15/2003
1/1/2006
58016-0290-89
58016-0290-89
58016-0291-60
Q0181
J8540
J8540
9/15/2003
1/1/2006
1/1/2007
58016-0293-00
58016-0293-00
58016-0293-06
Q0181
J8540
J8540
1/1/2002
1/1/2006
1/1/2007
58016-0293-12
58016-0293-12
Q0181
J8540
1/1/2002
1/1/2006
58016-0293-15
58016-0293-15
Q0181
J8540
1/1/2002
1/1/2006
58016-0293-20
58016-0293-20
Q0181
J8540
1/1/2002
1/1/2006
58016-0293-30
58016-0293-30
Q0181
J8540
1/1/2002
1/1/2006
58016-0326-00
Q0164
3/1/2007
58016-0326-12
Q0164
9/15/2003
58016-0326-30
Q0164
3/1/2007
58016-0326-60
Q0164
3/1/2007
58016-0326-90
Q0164
3/1/2007
58016-0350-20
Q0181
1/1/2002

12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
12/31/2005 REGIMEN
Page 284 of 374
12 EA BO
12 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
01/01/2002
01/01/2006
12/31/2005
99/99/9999
15 EA BO
15 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
01/01/2002
01/01/2006
12/31/2005
99/99/9999
20 EA BO
20 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
01/01/2002
01/01/2006
12/31/2005
99/99/9999
30 EA BO
30 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
01/01/2002
01/01/2006
12/31/2005
99/99/9999
300 EA BO
300 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
2
09/15/2003
01/01/2006
12/31/2005
99/99/9999
200 EA BO
200 EA BO
60 EA BO
PO
PO
PO
EA
EA
EA
1 EA
0.25 MG
0.25 MG
1
2
2
09/15/2003
01/01/2006
01/01/2007
12/31/2005
99/99/9999
99/99/9999
100 EA BO
100 EA BO
6 EA NA
PO
PO
PO
EA
EA
EA
1 EA
0.25 MG
0.25 MG
1
3
3
01/01/2002
01/01/2006
01/01/2007
12/31/2005
99/99/9999
99/99/9999
12 EA BO
12 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
15 EA BO
15 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
20 EA BO
20 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
30 EA BO
30 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA BO
PO
EA
5 MG
03/01/2007
99/99/9999
12 EA BO
PO
EA
5 MG
09/15/2003
99/99/9999
30 EA BO
PO
EA
5 MG
03/01/2007
99/99/9999
60 EA BO
PO
EA
5 MG
03/01/2007
99/99/9999
90 EA BO
PO
EA
5 MG
03/01/2007
99/99/9999
100 ML BO
PO
ML
1 EA
01/01/2002
12/31/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2006
1/15/2004
4/3/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/15/2004
1/15/2004
58016-0408-00
Q0163
1/1/2002
58016-0408-06
Q0163
1/1/2002
58016-0408-09
Q0163
1/1/2002
58016-0408-10
Q0163
1/1/2002
58016-0408-12
Q0163
1/1/2002
58016-0408-14
Q0163
1/1/2002
58016-0408-15
Q0163
1/1/2002
58016-0408-20
Q0163
1/1/2002
58016-0408-21
Q0163
1/1/2002
58016-0408-24
Q0163
1/1/2007
58016-0408-25
Q0163
1/1/2007
58016-0408-28
Q0163
1/1/2002
58016-0408-30
Q0163
1/1/2002
58016-0408-40
Q0163
1/1/2002
58016-0408-60
Q0163
1/1/2002
58016-0409-00
Q0163
1/1/2002
58016-0409-10
Q0163
1/1/2002
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
6 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
9 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
10 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
12 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
14 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
15 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
21 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
24 EA NA
PO
EA
50 MG
0.5
01/01/2007
99/99/9999
25 EA NA
PO
EA
50 MG
0.5
01/01/2007
99/99/9999
28 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
40 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
60 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
10 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
Page 285 of 374
CF
HCPCS Amount #1
Prior End Date #3
12/31/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
01/01/2006
01/15/2004
04/03/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/15/2004
01/15/2004
0.4
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
0.25
Prior End Date #2
0.25 MG
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
End Date #1
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
Start Date #1
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
HCPCS Measure #1
BO
BO
BX
BO
BO
BO
BX
BO
BO
BO
BO
BO
Billing Units
100 ML
100 EA
6 EA
6 EA
10 EA
15 EA
18 EA
20 EA
28 EA
30 EA
60 EA
90 EA
Prior Start Date #2

Package

ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
NDC Label
HCPCS Description

NDC Package Type
J8540
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
NDC Package Measure
58016-0350-20
58016-0391-00
58016-0391-01
58016-0391-06
58016-0391-10
58016-0391-15
58016-0391-18
58016-0391-20
58016-0391-28
58016-0391-30
58016-0391-60
58016-0391-90
HCPCS Mod
HCPCS
NDC Mod
NDC
58016-0409-12
Q0163
1/1/2002
58016-0409-15
Q0163
1/1/2002
58016-0409-20
Q0163
1/1/2002
58016-0409-21
Q0163
1/1/2007
58016-0409-24
Q0163
3/26/2002
58016-0409-30
Q0163
1/1/2002
58016-0409-40
Q0163
1/1/2007
58016-0409-60
Q0163
8/1/2006
58016-0409-90
Q0163
8/1/2006
58016-0424-00
Q0170
1/1/2002
58016-0424-02
Q0170
9/15/2003
58016-0424-03
Q0170
9/15/2003
58016-0424-10
Q0170
3/26/2002
58016-0424-12
Q0170
1/1/2002
58016-0424-15
Q0170
1/1/2002
58016-0424-20
Q0170
1/1/2002
58016-0424-30
Q0170
1/1/2002
58016-0424-40
Q0170
1/1/2007
58016-0424-48
Q0170
1/1/2007
58016-0424-50
Q0170
1/1/2002

Page 286 of 374
12 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
21 EA BO
PO
EA
50 MG
01/01/2007
99/99/9999
24 EA BO
PO
EA
50 MG
03/26/2002
99/99/9999
30 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
40 EA NA
PO
EA
50 MG
01/01/2007
99/99/9999
60 EA BO
PO
EA
50 MG
08/01/2006
99/99/9999
90 EA BO
PO
EA
50 MG
08/01/2006
99/99/9999
100 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
120 EA BO
PO
EA
25 MG
09/15/2003
99/99/9999
150 EA BO
PO
EA
25 MG
09/15/2003
99/99/9999
10 EA BO
PO
EA
25 MG
03/26/2002
99/99/9999
12 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
40 EA NA
PO
EA
25 MG
01/01/2007
99/99/9999
48 EA NA
PO
EA
25 MG
01/01/2007
99/99/9999
50 EA BO
PO
EA
25 MG
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
58016-0424-60
Q0170
7/13/2003
58016-0424-73
Q0170
9/15/2003
58016-0424-89
Q0170
9/15/2003
58016-0424-90
Q0170
9/15/2003
58016-0464-10
Q0178
1/1/2002
58016-0464-15
Q0178
1/1/2002
58016-0464-20
Q0178
1/1/2002
58016-0464-30
58016-0603-01
58016-0603-01
58016-0627-00
58016-0627-20
58016-0627-30
58016-0627-60
58016-0627-90
58016-0657-60
58016-0673-12
58016-0673-24
58016-0673-48
Q0178
J7051
A4216
J8499
J8499
J8499
J8499
J8499
J8999
J7510
J7510
J7510
1/1/2002
1/1/2002
1/1/2006
1/29/2002
1/29/2002
1/29/2002
1/29/2002
1/29/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
58016-0706-00
Q0165
9/23/2004
58016-0706-02
Q0165
9/23/2004
58016-0706-03
Q0165
9/23/2004
58016-0706-08
Q0165
1/1/2007
58016-0706-30
Q0165
9/23/2004
58016-0706-60
Q0165
9/23/2004
58016-0706-90
Q0165
9/23/2004
58016-0781-00
58016-0781-00
58016-0781-08
Q0181
J8540
J8540
1/1/2002
1/1/2006
1/1/2007
58016-0781-10
Q0181
1/1/2002

ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
NOLVADEX 10 MG
PRELONE 15 MG/5 ML
PRELONE 15 MG/5 ML
PRELONE 15 MG/5 ML
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
Page 287 of 374
60 EA BO
PO
EA
25 MG
07/13/2003
99/99/9999
300 EA BO
PO
EA
25 MG
09/15/2003
99/99/9999
200 EA BO
PO
EA
25 MG
09/15/2003
99/99/9999
90 EA BO
PO
EA
25 MG
09/15/2003
99/99/9999
10 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
BO
EA
EA
BO
BO
BO
BO
BO
BO
EA
EA
EA
PO
IH
IH
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
ML
ML
EA
EA
EA
EA
EA
EA
ML
ML
ML
50 MG
5 ML
10 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
5 MG
5 MG
5 MG
1
0.2
0.1
1
1
1
1
1
1
0.6
0.6
0.6
01/01/2002
01/01/2002
01/01/2006
01/29/2002
01/29/2002
01/29/2002
01/29/2002
01/29/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
09/01/2006
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
10 MG
09/23/2004
99/99/9999
120 EA BO
PO
EA
10 MG
09/23/2004
99/99/9999
150 EA BO
PO
EA
10 MG
09/23/2004
99/99/9999
8 EA NA
PO
EA
10 MG
01/01/2007
99/99/9999
30 EA BO
PO
EA
10 MG
09/23/2004
99/99/9999
60 EA BO
PO
EA
10 MG
09/23/2004
99/99/9999
90 EA BO
PO
EA
10 MG
09/23/2004
99/99/9999
100 EA BO
100 EA BO
8 EA NA
PO
PO
PO
EA
EA
EA
1 EA
0.25 MG
0.25 MG
1
16
16
01/01/2002
01/01/2006
01/01/2007
12/31/2005
99/99/9999
99/99/9999
10 EA BO
PO
EA
1 EA
01/01/2002
12/31/2005
30 EA
3 ML
3 ML
100 EA
20 EA
30 EA
60 EA
90 EA
60 EA
60 ML
120 ML
240 ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
58016-0781-10
J8540
58016-0781-12
58016-0781-12
Q0181
J8540
58016-0781-14
58016-0781-14
Q0181
J8540
58016-0781-15
58016-0781-15
Q0181
J8540
58016-0781-20
58016-0781-20
Q0181
J8540
58016-0781-21
58016-0781-21
Q0181
J8540
58016-0781-24
58016-0781-24
Q0181
J8540
58016-0781-28
58016-0781-28
Q0181
J8540
58016-0781-30
58016-0781-30
Q0181
J8540
58016-0781-40
58016-0781-40
Q0181
J8540
58016-0781-50
58016-0781-50
Q0181
J8540
58016-0826-00
Q0179
58016-0826-30
Q0179
58016-0826-60
Q0179
58016-0826-90
Q0179
58016-0951-00
58016-0951-30
58016-0951-60

DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
ZOFRAN 4 MG
ZOFRAN 4 MG
ZOFRAN 4 MG
ZOFRAN 4 MG
10 EA BO
PO
EA
0.25 MG
16
01/01/2006
99/99/9999
12 EA BO
12 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
14 EA BO
14 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
15 EA BO
15 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
20 EA BO
20 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
21 EA BO
21 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
24 EA BO
24 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
28 EA BO
28 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
30 EA BO
30 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
40 EA BO
40 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
50 EA BO
50 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/01/2002
01/01/2006
12/31/2005
99/99/9999
100 EA BO
PO
EA
8 MG
0.5
01/15/2004
99/99/9999
30 EA BO
PO
EA
8 MG
0.5
01/15/2004
99/99/9999
60 EA BO
PO
EA
8 MG
0.5
01/15/2004
99/99/9999
90 EA BO
PO
EA
8 MG
0.5
01/15/2004
99/99/9999
Q0168

100 EA BO
PO
EA
5 MG
04/01/2004
99/99/9999
Q0168

30 EA BO
PO
EA
5 MG
04/01/2004
99/99/9999
Q0168

60 EA BO
PO
EA
5 MG
04/01/2004
99/99/9999
Page 288 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
58016-0951-90
Q0168
58016-0973-00
Q0173
58016-0973-02
Q0173
58016-0973-03
Q0173
58016-0973-08
Q0173
58016-0973-10
Q0173
58016-0973-12
Q0173
58016-0973-15
Q0173
58016-0973-20
Q0173
58016-0973-24
Q0173
58016-0973-30
Q0173
58016-0973-50
Q0173
58016-0973-60
Q0173
58016-0973-73
Q0173
58016-0973-89
Q0173
58016-0973-90
58016-2001-01
Q0173
J7509
58016-2004-01
J7509
58016-3018-03
58016-3018-03
K0416
J8498
58016-3066-01
58016-3066-01
K0416
J8498
58016-3067-01
58016-3067-01
K0416
J8498
58016-3222-01
58016-3222-01
K0416
J8498

4 MG
COMPAZINE 25 MG
COMPAZINE 25 MG
PHENERGAN 12.5 MG
PHENERGAN 12.5 MG
PHENERGAN 25 MG
PHENERGAN 25 MG
COMPAZINE 5 MG
COMPAZINE 5 MG
Page 289 of 374
90 EA BO
PO
EA
5 MG
04/01/2004
99/99/9999
100 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
120 EA BO
PO
EA
250 MG
09/15/2003
99/99/9999
150 EA BO
PO
EA
250 MG
09/15/2003
99/99/9999
8 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
10 EA BO
PO
EA
250 MG
09/15/2003
99/99/9999
12 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
15 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
24 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
30 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
50 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
60 EA BO
PO
EA
250 MG
09/15/2003
99/99/9999
300 EA BO
PO
EA
250 MG
09/15/2003
99/99/9999
200 EA BO
PO
EA
250 MG
09/15/2003
99/99/9999
90 EA BO
21 EA DP
PO
PO
EA
EA
250 MG
4 MG
1
1
09/15/2003
10/01/2006
99/99/9999
99/99/9999
21 EA DP
PO
EA
4 MG
01/01/2002
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
12.5
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
5
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
58016-4008-01
58016-4144-01
58016-4719-01
Q0170
J7510
J7509
1/1/2002
1/1/2002
2/16/2005
58016-4770-01
58016-4771-01
58016-4786-01
58016-4788-01
58016-4790-01
58016-4811-01
58016-4814-01
58016-4832-01
58016-4834-01
J2300
J2941
J0696
J1815
J0696
J2765
Q0144
J7506
J0696
2/1/2006
2/1/2006
2/1/2006
2/1/2006
2/1/2006
2/1/2006
12/20/2005
2/1/2006
2/1/2006
58016-4838-01
58016-4840-01
58016-4843-01
A4216
J2001
J7510
58016-4849-01
J7644
58016-4849-01 KO J7644
58016-4855-01
J3303
58016-4868-01
58016-4872-01
J0595
J1650
58016-4893-01
58016-4897-01
58016-4995-01
58016-4995-01
J1040
J2920
J2912
A4216
58016-5009-01
58016-5009-01
K0416
J8498
KO
J7602
J7611
58016-6506-01
58016-6506-01
K0416
J8498
58016-9191-01
58016-9299-01
58016-9331-01
58016-9343-01
58016-9384-01
J0702
J3410
J2001
J3490
J2300
58016-9413-01
58016-9438-01
58016-9452-01
58016-9453-01
58016-9464-01
58016-9464-01
58016-9551-01
58063-0457-01
58063-0600-50
58063-0600-50
J1885
J0696
J2930
J0696
A4712
A4216
J0696
J1436
J3490
J0894
58063-0797-25
58063-0797-25
K0415
J2469
58063-0797-37
J2469
7/2/2008
58063-0979-09
J8999
1/1/2002
58160-0815-11
J3490
58160-0815-46
J3490
58160-0820-11
J3490
58160-0820-46
J3490
3/31/2009 INJECTION, PALONOSETRON HCL, 25 MCG

25 MG
5 MG
4 MG
0.05
0.2
2
01/01/2002
01/01/2002
02/16/2005
99/99/9999
99/99/9999
99/99/9999
IJ
SC
IJ
SC
IJ
IV
PO
PO
IJ
ML
EA
EA
ML
EA
ML
EA
EA
EA
10 MG
1 MG
250 MG
5U
250 MG
10 MG
1 GM
5 MG
250 MG
1
13.8
4
20
1
0.5
0.25
1
8
02/01/2006
02/01/2006
02/01/2006
02/01/2006
02/01/2006
02/01/2006
12/20/2005
02/01/2006
02/01/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
240 ML BO IH
5 ML AM EP
240 ML BO PO
ML
ML
ML
10 ML
10 MG
5 MG
0.1
1
0.6
02/01/2006
02/01/2006
02/01/2006
99/99/9999
99/99/9999
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
02/01/2006
99/99/9999
2.5 ML PC
5 ML VL
IH
IJ
ML
ML
1 MG
5 MG
0.2
4
02/01/2006
02/01/2006
99/99/9999
99/99/9999
1 ML VL
0.4 ML SR
IJ
SC
ML
ML
1 MG
10 MG
2
10
03/15/2006
04/01/2006
99/99/9999
99/99/9999
1 ML
1 EA
10 ML
10 ML
IJ
IJ
IJ
IJ
ML
EA
ML
ML
80 MG
40 MG
0.9 %
10 ML
1
1
0.5
0.1
06/01/2006
07/01/2006
07/01/2006
01/01/2007
99/99/9999
99/99/9999
12/31/2006
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2005
01/01/2006
12/31/2005
99/99/9999
20 ML NA
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML NA
IH
ML
1 MG
04/01/2008
99/99/9999
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
01/01/2002
01/01/2006
12/31/2005
99/99/9999
5 ML
10 ML
50 ML
50 ML
10 ML
VL
VL
VL
VL
VL
IJ
IM
EP
IJ
IJ
ML
ML
ML
ML
ML
3 MG
25 MG
10 MG
1 EA
10 MG
1
2
1
1
1
01/01/2002
01/01/2002
08/01/2004
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML
1 EA
1 EA
1 EA
50 ML
50 ML
1 EA
6 ML
1 EA
1 EA
VL
VL
VL
VL
VL
VL
VL
AM
VL
VL
IM
IJ
IJ
IJ
IV
IV
IJ
IV
IV
IV
ML
EA
EA
EA
ML
ML
EA
ML
EA
EA
15 MG
250 MG
125 MG
250 MG
10 ML
10 ML
250 MG
300 MG
1 EA
1 MG
2
4
1
1
0.1
0.1
2
0.16666
1
50
01/01/2002
02/22/2002
01/01/2002
01/01/2002
01/03/2002
01/01/2004
01/01/2002
01/01/2002
05/22/2006
01/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2003
99/99/9999
99/99/9999
10/04/2004
12/31/2006
99/99/9999
5 ML VL
5 ML VL
IV
IV
ML
ML
1 MG
25 MCG
0.05
2
08/06/2003
01/01/2005
12/31/2004
4/26/2009
ALOXI (Single-Use, 1.5ml 5s) 0.05 MG/ML
1.5 ML VL
IV
ML
25 MCG
7/2/2008
3/31/2009
MYLOCEL (UNIT OF USE,CAPLET) 1 GM

TWINRIX (TAX INCLUDED,1MLX10,PF)
720 EL U/ML-20 MCG/ML
TWINRIX (TPLOK,SNGLE DSE,TAXINCL)
ENGERIX-B PEDIATRIC
(10X0.5ML,SDV,TAXINCL,PF) 10 MCG/0.5
ML
ENGERIX-B PEDIATRIC
(0.5X5,SD,TIPLOK,TAXINCL) 10 MCG/0.5
ML
60 EA BO
PO
EA
1 EA
01/01/2002
04/01/2002
1 ML VL
IM
ML
1 EA
08/06/2007
99/99/9999
1 ML SR
IM
ML
1 EA
06/25/2007
99/99/9999
0.5 ML VL
IM
ML
1 EA
02/01/2007
99/99/9999
0.5 ML SR
IM
ML
1 EA
02/01/2007
99/99/9999
1 ML
1 EA
1 EA
10 ML
1 EA
2 ML
6 EA
21 EA
1 EA
AM
CT
VL
VL
VL
VL
DP
DP
VL
VL
VL
SR
SR
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
ML
ML
EA
Page 290 of 374
120 ML NA
120 ML BO
25 EA BO
Billing Units
NDC Package Type
NDC Package Measure
PO
PO
PO

BRONCHO SALINE 0.9% AEROSAL 0.9%
LIDOCAINE (SDA) 1%
2/1/2006 99/99/9999 MILLIGRAM
IPRATROPIUM (2.5MLX25) 0.02%
2/1/2006 99/99/9999 MILLIGRAM
IPRATROPIUM (2.5MLX25) 0.02%
ARISTOSPAN 20 MG/ML
MG/ML
METHYLPREDNISOLONE ACETATE 80
MG/ML
SOLU-MEDROL (SDV) 40 MG
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2002 99/99/9999 PHOSPHATE 3MG
MG/ML-3 MG/ML
HYDROXYZINE HCL 50 MG/ML
NALBUPHINE HCL (M.D.V.) 10 MG/ML
KETOROLAC TROMETHAMINE (SDV) 30
MG/ML
ROCEPHIN 1 GM
SOLU-MEDROL 125 MG
ROCEPHIN 250 MG
WATER FOR INJECTION
WATER FOR INJECTION
ROCEPHIN 500 MG
1/1/2002 10/4/2004 INJECTION, ETIDRONATE DISODIUM, PER 300 MG
DIDRONEL I.V. (AMP) 50 MG/ML
DACOGEN 50 MG
1/1/2007 99/99/9999 INJECTION, DECITABINE, 1 MG
DACOGEN 50 MG
ALOXI (S.D.V.,PF) 0.05 MG/ML
1/1/2005 4/26/2009 INJECTION, PALONOSETRON HCL, 25 MCG
ALOXI (S.D.V.,PF) 0.05 MG/ML
58016-6404-01

Package
NDC Label

PEDIAPRED 5 MG/5 ML
NALBUPHINE HCL (10X1ML AMPS) 10
MG/ML
GENOTROPIN 13.8 MG
CEFTRIAXONE 1 GM
HUMULIN N 100 U/ML
CEFTRIAXONE 250 MG
REGLAN (25X2ML) 5 MG/ML
AZITHROMYCIN 250 MG
PREDNISONE 5 MG
CEFTRIAXONE 2 GM
58016-6404-01
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
ENGERIX-B (SDV,TAXINCL,PF) 20
MCG/ML
ENGERIX-B (5X1ML,PF) 20 MCG/ML
TWINRIX (S.D.V.,TAX INCL) 720 EL U/ML20 MCG/ML
TWINRIX (S.D.V.,TAX INCL) 720 EL U/ML20 MCG/ML
TWINRIX (TIPLOK,23GX1",TAX INCL) 720
EL U/ML-20 MCG/ML
TWINRIX (TIPLOK W/O NDL,TAX INCL)
ENGERIX-B PEDIATRIC (TIPLOK,23GX1,TX INC,PF) 10 MCG/0.5 ML
ENGERIX-B PEDIATRIC (TIPLOK,25GX5/8,TAX,PF) 10 MCG/0.5 ML
ENGERIX-B PEDIATRIC
(TIPLOK,23GX1,TAX INC,PF) 10 MCG/0.5
ML
ENGERIX-B PEDIATRIC (TIPLOK,25GX5/8,TAX,PF) 10 MCG/0.5 ML
ENGERIX-B PEDIATRIC (TIP-LOK W/O
NDL,TAX,PF) 10 MCG/0.5 ML
ENGERIX-B PEDIATRIC (TIP-LOK W/O
NDL,TAX,PF) 10 MCG/0.5 ML
ENGERIX-B PEDIATRIC W/SAFETYGLIDE
(TIP-LOK,23GX1.TX INC,PF) 10 MCG/0.5
ML
(TIP-LOK,25GX5/8,TAX,PF) 10 MCG/0.5
ML
(TIP-LOK,23GX1.TX INC,PF) 10 MCG/0.5
ML
MCG/ML
ENGERIX-B (TAX INCLUDED,SDV,PF) 20
MCG/ML
MCG/ML
ENGERIX-B (TIPLOK,23GX1,TAX INC,PF)
20 MCG/ML
ENGERIX-B (TIPLOK,23GX1,TAX INC,PF)
20 MCG/ML
20 MCG/ML
20 MCG/ML
J3490
J3490
58160-0850-01
J3490
1/1/2002
58160-0850-11
J3490
1/1/2002
58160-0850-35
J3490
1/1/2002
58160-0850-46
J3490
3/20/2002
58160-0856-01
J3490
1/1/2002
58160-0856-11
J3490
1/1/2002
58160-0856-26
J3490
1/1/2002
58160-0856-27
J3490
1/1/2002
58160-0856-35
J3490
58160-0856-36
J3490
1/1/2002
58160-0856-46
J3490
1/17/2002
58160-0856-50
J3490
1/17/2002
58160-0856-56
J3490
5/10/2002
58160-0856-57
J3490
1/1/2002
58160-0856-58
J3490
1/1/2002
58160-0857-01
J3490
1/1/2002
58160-0857-11
J3490
3/30/2006
58160-0857-16
J3490
1/1/2002
58160-0857-26
J3490
1/1/2002
58160-0857-35
J3490
1/1/2002
58160-0857-46
J3490
2/1/2002
58160-0857-50
J3490
2/1/2002
58177-0037-04
Q0173
1/1/2002
58177-0363-22
Q0179
6/27/2007
58177-0364-22
Q0179
6/27/2007
58177-0364-56
Q0179
6/27/2007

ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 ONDANSETRON
(USP,10X3,STRAWBERRY) 4 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 ONDANSETRON
(USP,3X10,STRAWBERRY) 8 MG
MG
10 EA BX
PO
EA
8 MG
06/27/2007
2/18/2009
58177-0910-05
J7510
4/16/2002
240 ML BO
PO
ML
5 MG
0.6
04/16/2002
2/18/2009
58177-0910-07
58177-0912-03
J7510
J7510

480 ML BO
120 ML BO
PO
PO
ML
ML
5 MG
5 MG
0.6
0.2
04/16/2002
01/01/2002
2/18/2009
99/99/9999
58177-0932-05
58178-0017-01
58178-0017-03
J7510
J0207
J0207

237 ML BO
1 EA VL
1 EA VL
PO
IV
IV
ML
EA
EA
5 MG
500 MG
500 MG
0.6
1
1
05/25/2005
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
58178-0020-10
58178-0020-50
58178-0021-01
J3305
J3305
J3305

ETHYOL (S.D.V.) 500 MG
ETHYOL (S.D.V.,10MLX3) 500 MG
NEUTREXIN (S.D.V.,2 TRAYS OF 25) 25
MG
NEUTREXIN (S.D.V.) 25 MG
NEUTREXIN (M.D.V.) 200 MG
IV
IV
IV
EA
EA
EA
25 MG
25 MG
25 MG
1
1
8
01/01/2002
01/01/2002
01/01/2002
01/31/2007
01/08/2004
01/31/2007
1/1/2002
1/1/2002
1/1/2002
1/31/2007 INJECTION, TRIMETREXATE GLUCURONATE, PER 25 MG

Page 291 of 374
1 ML VL
1 ML SR
IM
IM
ML
ML
1 EA
1 EA
1
1
02/01/2007
03/28/2007
99/99/9999
99/99/9999
1 ML VL
IM
ML
1 EA
01/01/2002
09/30/2005
1 ML VL
IM
ML
1 EA
01/01/2002
08/05/2007
1 ML SR
IM
ML
1 EA
01/01/2002
06/10/2002
06/24/2007
1 ML SR
IM
ML
1 EA
03/20/2002
0.5 ML VL
IM
ML
1 EA
01/01/2002
5/3/2006
0.5 ML VL
IM
ML
1 EA
01/01/2002
01/31/2007
0.5 ML SR
IM
ML
1 EA
01/01/2002
06/10/2002
0.5 ML SR
IM
ML
1 EA
01/01/2002
06/10/2002
0.5 ML SR
IM
ML
1 EA
01/01/2002
99/99/9999
0.5 ML SR
IM
ML
1 EA
01/01/2002
06/10/2002
0.5 ML SR
IM
ML
1 EA
01/17/2002
01/31/2007
0.5 ML SR
IM
ML
1 EA
01/17/2002
12/09/2005
0.5 ML SR
IM
ML
1 EA
05/10/2002
05/11/2004
0.5 ML SR
IM
ML
1 EA
01/01/2002
03/16/2004
0.5 ML SR
IM
ML
1 EA
01/01/2002
05/11/2004
1 ML VL
IM
ML
1 EA
01/01/2002
05/24/2006
1 ML VL
IM
ML
1 EA
03/30/2006
01/31/2007
1 ML VL
IM
ML
1 EA
01/01/2002
04/06/2006
1 ML SR
IM
ML
1 EA
01/01/2002
06/10/2002
1 ML SR
IM
ML
1 EA
01/01/2002
06/10/2002
1 ML SR
IM
ML
1 EA
02/01/2002
03/27/2007
1 ML SR
IM
ML
1 EA
02/01/2002
11/07/2005
100 EA BO
PO
EA
250 MG
01/01/2002
03/09/2004
30 EA BX
PO
EA
8 MG
0.5
06/27/2007
2/18/2009
30 EA BX
PO
EA
8 MG
06/27/2007
2/18/2009
1 EA VL
1 EA VL
1 EA VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
58160-0821-11
58160-0821-46

NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
58281-0560-01
J0475
58281-0560-02
J0475
58281-0561-02
J0475
58281-0561-04
J0475
58281-0562-01
J0476
1/1/2002 99/99/9999 INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL
58281-0563-01
J0475
58281-0563-02
58298-0525-02
58298-0525-05
J0475
J3010
J3010

4/3/2006
4/3/2006
58298-0534-02
J1170
4/3/2006
58298-0534-03
58298-0543-25
58298-0545-01
58298-0545-02
J1170
J2175
J2271
J2271
4/3/2006
4/3/2006
4/3/2006
58394-0001-01
58394-0001-06
J7195
J7195
1/1/2002 99/99/9999 FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.

58394-0002-01
58394-0002-06
J7195
J7195

58394-0003-01
58394-0003-06
58394-0004-01
58394-0004-02
58394-0005-01
58394-0005-02
J7195
J7195
J2355
J2355
J7192
J7192
58394-0005-04
58394-0006-01
J7192
J7192
58394-0006-02
58394-0007-01
J7192
J7192
58394-0007-02
58394-0008-02
58394-0011-01
58394-0011-02
J7192
J7195
J7192
J7192
58394-0011-04
58406-0002-33
58406-0050-30
J7192
J2820
J2820
58406-0425-34
J1438
58406-0425-41
J1438
58406-0435-01
J1438
58406-0435-04
J1438
58406-0445-01
J1438
58406-0445-04
J1438
58406-0455-01
J1438
58406-0455-04
58406-0640-03
58406-0640-05
58406-0640-07
58406-0662-01
58406-0662-36
58468-0040-01
J1438
J9293
J9293
J9293
J9340
J9340
J3490
LIORESAL INTRATHECAL REFILL KIT

(1X20 ML AMP) 0.5 MG/ML
(2X20ML AMP) 0.5 MG/ML
(2X5 ML AMP) 2 MG/ML
(4X5 ML AMP) 2 MG/ML
LIORESAL INTRATHECAL SCREENING
KIT (1X1 ML AMP) 0.05 MG/ML
(1X20ML AMP) 2 MG/ML
(2X20ML AMP) 2 MG/ML
FENTANYL CITRATE (USP)
FENTANYL CITRATE (USP)
(USP)
(USP)
MEPERIDINE HYDROCHLORIDE (USP)
MORPHINE SULFATE (USP)
MORPHINE SULFATE (USP)
20 ML BX
IN
EA
10 MG
01/01/2002
99/99/9999
20 ML BX
MR
EA
10 MG
04/02/2004
99/99/9999
5 ML BX
IN
EA
10 MG
01/01/2002
99/99/9999
5 ML AM IN
EA
10 MG
01/01/2002
10/20/2003
1 ML AM IN
EA
50 MCG
01/01/2002
99/99/9999
20 ML BX
MR
EA
10 MG
10/21/2003
99/99/9999
20 ML BX
1 EA NA
1 EA NA
MR
NA
NA
EA
GM
GM
10 MG
0.1 MG
0.1 MG
8
10000
10000
04/02/2004
04/03/2006
04/03/2006
99/99/9999
5/1/2008
5/1/2008
1 EA NA
NA
GM
4 MG
250
04/03/2006
5/1/2008
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
GM
GM
GM
GM
4 MG
100 MG
100 MG
100 MG
250
10
10
10
04/03/2006
04/03/2006
04/03/2006
04/03/2006
5/1/2008
5/1/2008
5/1/2008
99/99/9999
BENEFIX (S.D.V.,W/DILUENT,1000IU) 1 IU 1000 IU VL

BENEFIX (1000IU,PF) 1 IU
1 EA VL
IV
IV
EA
EA
1 IU
1 IU
1
1
01/01/2002
06/28/2007
99/99/9999
99/99/9999
BENEFIX (S.D.V.,W/DILUENT,500 IU) 1 IU

IV
IV
EA
EA
1 IU
1 IU
1
1
01/01/2002
06/28/2007
99/99/9999
99/99/9999
IV
IV
SC
SC
IV
IV
EA
EA
EA
EA
EA
EA
1
1
5
5
1
1
1
1
1
1
1
1
01/01/2002
06/28/2007
01/01/2002
01/01/2002
01/01/2002
11/02/2004
99/99/9999
99/99/9999
9/2/2009
06/15/2007
11/01/2004
4/9/2009
1 EA VL
500 IU VL
IV
IV
EA
EA
1 IU
1 IU
1
1
03/26/2008
01/01/2002
99/99/9999
11/01/2004
500 IU
250 IU
VL
VL
IV
IV
EA
EA
1 IU
1 IU
1
1
11/02/2004
01/01/2002
99/99/9999
11/01/2004
250 IU
1 EA
2000 IU
2000 IU
VL
VL
VL
VL
IV
IV
IV
IV
EA
EA
EA
EA
1
1
1
1
IU
IU
IU
IU
1
1
1
1
11/02/2004
06/28/2007
10/01/2002
11/02/2004
99/99/9999
99/99/9999
11/01/2004
4/9/2009
1 EA VL
1 EA VL
1 ML VL
IV
IV
IV
EA
EA
ML
1 IU
50 MCG
50 MCG
1
5
10
03/26/2008
01/01/2002
01/01/2002
99/99/9999
10/22/2003
10/22/2003
4 EA BX
SC
EA
25 MG
01/01/2002
99/99/9999
1 EA BX
SC
EA
25 MG
01/01/2002
99/99/9999
0.98 ML SR
SC
ML
25 MG
11/17/2004
99/99/9999
0.98 ML SR
SC
ML
25 MG
11/17/2004
99/99/9999
0.98 ML SR
SC
ML
25 MG
07/17/2006
99/99/9999
0.98 ML SR
SC
ML
25 MG
07/17/2006
99/99/9999
0.51 ML SR
SC
ML
25 MG
04/30/2007
99/99/9999
0.51 ML
10 ML
12.5 ML
15 ML
1 EA
1 EA
1 EA
SC
IV
IV
IV
IJ
IJ
IV
ML
ML
ML
ML
EA
EA
EA
25 MG
5 MG
5 MG
5 MG
15 MG
15 MG
1 EA
2
0.4
0.4
0.4
1
1
1
04/30/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/02/2003
99/99/9999
06/10/2003
06/10/2003
06/10/2003
12/13/2002
12/13/2002
12/31/2004

BENEFIX (S.D.V.,W/DILUENT,250 IU) 1 IU
1/1/2002
9/2/2009 INJECTION, OPRELVEKIN, 5 MG
NEUMEGA (VIAL,PF) 5 MG
1/1/2002 6/15/2007 INJECTION, OPRELVEKIN, 5 MG
NEUMEGA (VIAL,PF) 5 MG
REFACTO (APPROX 1000 IU/VIAL) 1 IU
11/2/2004
3/26/2008 99/99/9999 SPECIFIED
REFACTO (1000IU,LYOPHILIZED) 1 IU
11/2/2004 99/99/9999 SPECIFIED
11/2/2004 99/99/9999 SPECIFIED
11/2/2004
3/26/2008 99/99/9999 SPECIFIED
REFACTO (2000IU,LYOPHILIZED) 1 IU
LEUKINE (VIAL) 250 MCG
LEUKINE (M.D.V.) 500 MCG/ML
ENBREL (S.D. TRAY,PF) 25 MG
ENBREL (S.D. TRAY,PF) 25 MG
ENBREL (ACTUAL FILL 50MG/0.98ML) 50
MG/ML
ENBREL (ACTUAL FILL 50MG/0.98ML) 50
MG/ML
ENBREL (SURECLICK AUTOINJECTOR)
50 MG/ML
ENBREL (SURECLICK AUTOINJECTOR)
50 MG/ML
ENBREL (27G,1/2",PF) 50 MG/ML
ENBREL (4X0.51ML,27G,1/2",PF) 50
MG/ML
THIOPLEX (S.D.V.) 15 MG
THIOPLEX (S.D.V.) 15 MG
FABRAZYME (PF) 35 MG
Page 292 of 374
BO
NA
BO
NA
500 IU VL
1 EA VL
250 IU
1 EA
1 EA
1 EA
1000 IU
1000 IU
VL
VL
VL
VL
VL
VL
SR
VL
VL
VL
VL
VL
VL
IU
IU
MG
MG
IU
IU
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
58468-0040-01
58468-0041-01
58468-0041-01
58468-0070-01
58468-0070-01
J0180
J3490
J0180
J3590
J1931
58468-0080-01
J7511
58468-0090-01
Q4084
1/1/2005
5/14/2004
1/1/2005
5/12/2003
1/1/2005
58468-0090-01
J7322
J9027
58468-0100-02
58468-0122-01
58468-0150-01
58468-0150-01
J9027
J1270
J3490
J0220
1/1/2006
6/1/2006
5/11/2006
1/1/2008
58468-0218-02
58468-0218-02
58468-1060-01
Q0181
J8540
J0205
6/30/2005
1/1/2006
1/1/2002
58468-1849-04
58468-1983-01
58468-4663-01
58469-0399-83
58469-3998-30
J3240
J1785
J1785
None
None
1/1/2002
1/1/2002
1/1/2002
1/1/1994
1/1/1994
58634-0020-02
Q0163
1/1/2002
58634-0020-04
Q0163
1/1/2002
58634-0020-08
Q0163
1/1/2002
58634-0021-02
Q0163
1/1/2002
58634-0021-04
Q0163
1/1/2002
58634-0021-08
Q0163
1/1/2002
58634-0022-02
Q0163
1/1/2002
58634-0022-04
Q0163
1/1/2002
58634-0022-08
Q0163
1/1/2002
58634-0023-02
Q0163
1/1/2002
58634-0023-04
Q0163
1/1/2002
58634-0023-08
Q0163
1/1/2002
1/1/2006 99/99/9999 INJECTION, CLOFARABINE, 1 MG
FABRAZYME (PF) 35 MG
FABRAZYME (PF) 5 MG
FABRAZYME (PF) 5 MG
ALDURAZYME (PF) 0.58 MG/ML
ALDURAZYME (PF) 0.58 MG/ML
1 EA
1 EA
1 EA
5 ML
5 ML
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
EA
EA
EA
ML
ML
1 MG
1 EA
1 MG
1 EA
0.1 MG
THYMOGLOBULIN (VIAL,DILUENT) 25 MG
MG/ML
MG/ML
1 EA VL
IV
EA
25 MG
2 ML SR
IJ
ML
2 ML SR
IJ
CLOLAR (SINGLE-USE VIAL,PF) 1 MG/ML
20 ML VL
IV
20 ML
2 ML
1 EA
1 EA
IV
IV
IV
IV
ML
ML
EA
EA
PO
PO
IV
EA
EA
ML
VL
VL
VL
NA
NA
IJ
IV
IV
PO
PO
60 ML BO
99/99/9999 INJECTION, CLOFARABINE, 1 MG

CLOLAR (SINGLE-USE VIAL,PF) 1 MG/ML
99/99/9999 INJECTION, DOXERCALCIFEROL, 1 MCG
HECTOROL (50X2ML) 2 MCG/ML
MYOZYME (PF) 50 MG
99/99/9999 INJECTION, AGLUCOSIDASE ALFA, 10 MG
MYOZYME (PF) 50 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
99/99/9999 INJECTION, ALGLUCERASE, PER 10 UNITS
CEREDASE 80 U/ML
THYROGEN (W/2 VIALS DILUENT) 1.1
99/99/9999 INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG VIAL
MG
99/99/9999 INJECTION, IMIGLUCERASE, PER UNIT
CEREZYME (VIAL) 200 U
99/99/9999 INJECTION, IMIGLUCERASE, PER UNIT
CEREZYME (VIAL) 400 U
POLYDRYL (AF) 12.5 MG/5 ML
POLYDRYL (SF) 12.5 MG/5 ML
POLYDRYL (AF,SF) 12.5 MG/5 ML
POLYDRYL ALLERGY MEDICATION
Page 293 of 374
35
1
5
1
5.8
01/01/2005
05/14/2004
01/01/2005
05/12/2003
01/01/2005
12/01/2005
99/99/9999
0.5
01/01/2007
12/31/2007
ML
1 DOSE
0.5
01/01/2008
12/31/2009
ML
1 MG
01/01/2006
99/99/9999
1 MG
1 MCG
1 EA
10 MG
1
2
1
5
01/01/2006
06/01/2006
05/11/2006
01/01/2008
99/99/9999
99/99/9999
12/31/2007
99/99/9999
1 EA
0.25 MG
10 U
1
16
8
06/30/2005
01/01/2006
01/01/2002
12/31/2005
99/99/9999
99/99/9999
EA
EA
EA
EA
EA
1.1 MG
1U
1U
2.5 MG
2.5 MG
1
200
400
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/1994
01/01/1994
99/99/9999
99/99/9999
99/99/9999
03/07/1994
03/07/1994
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
240 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
60 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
240 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
60 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
240 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
60 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
240 ML BO
PO
ML
50 MG
0.05
01/01/2002
08/06/2003
120 EA NA
120 EA NA
5 ML VL
1 EA
1 EA
1 EA
30 EA
30 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
12/31/2004
99/99/9999
12/31/2004
99/99/9999
1 DOSE
VL
AM
VL
VL
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
99/99/9999 INJECTION, AGALSIDASE BETA, 1 MG

99/99/9999 INJECTION, AGALSIDASE BETA, 1 MG
99/99/9999 INJECTION, LARONIDASE, 0.1 MG
LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT,
12/1/2005 99/99/9999 PARENTERAL, 25MG
1/1/2007 12/31/2007 DOSE
1/1/2008 12/31/2009 DOSE
58468-0100-01
HCPCS Mod
HCPCS
NDC Mod
NDC
58634-0027-02
Q0163
1/1/2002
58634-0027-04
Q0163
1/1/2002
58634-0027-08
58768-0150-15
58768-0150-15
Q0163
J3395
J3396
1/1/2002
1/1/2002
1/1/2005
58768-0902-35
J1452
1/1/2002
58864-0100-40
Q0163
1/1/2002
58864-0162-30
Q0163
1/1/2002
58864-0162-56
Q0163
3/1/2004
58864-0162-60
Q0163
1/1/2002
58864-0163-01
Q0163
7/9/2002
58864-0163-30
Q0163
1/1/2002

12/31/2004 INJECTION, VERTEPORFIN, 15MG
10/17/2005 INJECTION, VERTEPORFIN, 0.1 MG
3/31/2004 INJECTION, FOMIVIRSEN SODIUM, INTRAOCULAR, 1.65 MG
58864-0163-60
58864-0191-25
58864-0191-35
Q0163
J8499
J8499
1/1/2002
3/1/2004
3/1/2004
58864-0362-20
J7506
58864-0362-56
58864-0423-15
58864-0423-20
58864-0423-30
58864-0423-40
58864-0424-09
58864-0424-14
58864-0424-20
58864-0424-30
58864-0602-01
58864-0602-30
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J8499
J8499
3/1/2004
1/1/2005
6/1/2005
1/1/2002
7/1/2004
1/1/2002
3/2/2004
1/1/2005
3/2/2004
6/1/2004
3/2/2004
58864-0644-42
58864-0655-04
58864-0655-06
58864-0655-14
58864-0655-30
Q0165
Q0144
Q0144
Q0144
Q0144
3/1/2004
7/1/2005
9/10/2003
2/1/2005
6/1/2006
58864-0702-01
Q0164
6/15/2006
58864-0702-15
Q0164
3/1/2004
58864-0761-10
Q0170
8/1/2004
POLYDRYL DYE-FREE MEDICATION

60 ML BO
PO
ML
50 MG
0.025
01/01/2002
08/06/2003

120 ML BO
PO
ML
50 MG
0.025
01/01/2002
08/06/2003
240 ML BO
1 EA VL
1 EA VL
PO
IV
IV
ML
EA
EA
50 MG
15 MG
0.1 MG
0.025
1
150
01/01/2002
04/01/2004
01/01/2005
08/06/2003
12/31/2004
10/17/2005
0.25 ML VL
IO
ML
1.65 MG
01/01/2002
03/31/2004

VISUDYNE 15 MG
VISUDYNE 15 MG
VITRAVENE (SINGLE USE VIAL,PF) 6.6
MG/ML
DIPHENHYDRAMINE HCL (REDI-SCRIPT)

50 MG
40 EA BO
PO
EA
50 MG
01/01/2002
09/10/2003

25 MG
30 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999

25 MG
56 EA BO
PO
EA
50 MG
0.5
03/01/2004
99/99/9999

25 MG
60 EA BO
PO
EA
50 MG
0.5
01/01/2002
08/11/2004
100 EA BO
PO
EA
50 MG
07/09/2002
08/11/2004
30 EA BO
PO
EA
50 MG
01/01/2002
10/27/2006
60 EA BO
25 EA BO
35 EA BO
PO
PO
PO
EA
EA
EA
50 MG
1 EA
1 EA
1
1
1
01/01/2002
03/01/2004
03/01/2004
08/11/2004
99/99/9999
99/99/9999
20 EA BO

50 MG

50 MG
ACYCLOVIR (REDI-SCRIPT) 800 MG
PREDNISONE (U.S.P.,REDI-SCRIPT) 5
MG
PREDNISONE (U.S.P.,REDI-SCRIPT) 5
MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE (REDI-SCRIPT) 10 MG
PREDNISONE 20 MG

ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROCHLORPERAZINE MALEATE (REDISCRIPT) 10 MG
ZITHROMAX 250 MG
ZITHROMAX (REDI-SCRIPT) 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
PROCHLORPERAZINE MALEATE (REDISCRIPT) 5 MG
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 PROMETHAZINE HCL (REDI-SCRIPT) 25
MG
Page 294 of 374
PO
EA
5 MG
03/01/2004
99/99/9999
56 EA
15 EA
20 EA
30 EA
40 EA
9 EA
14 EA
20 EA
30 EA
100 EA
30 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1 EA
1 EA
1
2
2
2
2
4
4
4
4
1
1
03/01/2004
01/01/2005
06/01/2005
01/01/2002
07/01/2004
01/01/2002
03/02/2004
01/01/2005
03/02/2004
06/01/2004
03/02/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/27/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
42 EA
4 EA
6 EA
14 EA
6 EA
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
10 MG
1 GM
1 GM
1 GM
1 GM
1
0.25
0.25
0.25
0.25
03/01/2004
07/01/2005
09/10/2003
02/01/2005
06/01/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
15 EA BO
PO
EA
5 MG
06/15/2006
99/99/9999
15 EA BO
PO
EA
5 MG
03/01/2004
10/27/2006
10 EA BO
PO
EA
25 MG
08/01/2004
99/99/9999
01-Jan-02
31-Mar-04
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
58864-0761-25
Q0170
11/1/2004
58864-0761-30
Q0170
5/1/2004
58864-0761-42
58864-0791-06
Q0170
Q0144
8/1/2004
7/1/2004
58864-0795-10
58864-0876-35
58914-0080-52
58914-0155-75
G9017
J8499
J0500
J9600
12/1/2004
1/1/2005
6/22/2004
1/1/2002
58948-0024-73
Q0163
1/1/2002
58948-0379-26
Q0163
1/1/2002
58948-0462-62
Q0163
1/1/2002
58948-0479-62
Q0163
1/1/2002
58948-0479-78
59060-1833-02
59060-1833-02
59060-1834-02
59060-1834-02
59060-1837-02
59060-1837-02
Q0163
J1820
J1815
J1820
J1815
J1820
J1815
1/1/2002
10/14/2002
1/1/2003
10/14/2002
1/1/2003
10/14/2002
1/1/2003
59060-2314-04
J1815
12/19/2003
59060-2317-04
59075-0710-10
59075-0711-10
59075-0712-10
59075-0720-10
59075-0720-10
59075-0722-10
59075-0722-10
59075-0723-10
59075-0723-10
59075-0730-15
59075-0730-15
59148-0016-65
59148-0016-65
59196-0010-24
59196-0010-48
59196-0012-24
J1815
J0587
J0587
J0587
J3490
J2278
J3490
J2278
J3490
J2278
Q4079
J2323
J3490
J0400
J7510
J7510
J7510
12/19/2003
1/1/2002
1/1/2002
1/1/2002
12/28/2004
1/1/2006
12/28/2004
1/1/2006
12/28/2004
1/1/2006
1/1/2005
1/1/2008
12/8/2006
1/1/2008
1/1/2002
1/1/2002
7/12/2002
59390-0065-35
Q0163
1/1/2002
59390-0065-46
Q0163
1/1/2002
59390-0065-47
Q0163
1/1/2002
59439-0455-02
59572-0301-01
59572-0302-50
J7510
J9245
None
1/1/2002
3/15/2004
4/22/2004

25 EA BO
30 EA BO
42 EA BO
AZITHROMYCIN DIHYDRATE 250 MG
6 EA BO
10 EA BO
ACYCLOVIR 200 MG
35 EA BO
2 ML AM
99/99/9999 INJECTION, PORFIMER SODIUM, 75 MG
PHOTOFRIN (VIAL) 75 MG
1 EA VL
NIGHTTIME SLEEP AID (MAX.
STR.,LIQUIGEL) 50 MG
16 EA BO
ANTIHISTAMINE (AF,CHERRY) 12.5 MG/5
ML
120 ML EA
ANTIHISTAMINE ALLERGY RELIEF 25 MG
24 EA NA
ANTIHISTAMINE ALLERGY RELIEF 25 MG
24 EA NA
ANTIHISTAMINE ALLERGY RELIEF 25 MG 100 EA NA
10 ML VL
10 ML VL
10 ML VL
10 ML VL
10 ML VL
10 ML VL
RELION NOVOLIN N INNOLET
(SRN,PREFILLED,INNOLET) 100 U/ML
3 ML CT
RELION NOVOLIN 70/30 INNOLET
(SRN,PREFILLED,INNOLET) 70 U/ML-30
U/ML
3 ML CT
1/27/2005 BOTULINUM TOXIN TYPE B, PER 100 UNITS
MYOBLOC (PF) 2500 U/0.5 ML
0.5 ML VL
1 ML VL
2 ML VL
PRIALT (PF) 100 MCG/ML
1 ML VL
99/99/9999 INJECTION, ZICONOTIDE, 1 MICROGRAM
1 ML VL
5 ML VL
5 ML VL
20 ML VL
20 ML VL
12/31/2007 INJECTION, NATALIZUMAB, 1 MG
TYSABRI 20 MG/ML
15 ML VL
99/99/9999 INJECTION, NATALIZUMAB, 1 MG
TYSABRI 20 MG/ML
15 ML VL
ABILIFY (SDV) 9.75 MG/1.3 ML
1.3 ML VL
99/99/9999 INJECTION, ARIPIPRAZOLE, INTRAMUSCULAR, 0.25 MG
ABILIFY (SDV) 9.75 MG/1.3 ML
1.3 ML VL
240 ML BO
480 ML BO
240 ML BO
ALTARYL CHILDREN'S (AF,CHERRY)
12.5 MG/5 ML
118 ML BO
ALTARYL 12.5 MG/5 ML
473 ML BO
ALTARYL 12.5 MG/5 ML
3785 ML BO
ML
237 ML BO
99/99/9999 INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG
ALKERAN IV 50 MG
1 EA VL
50 EA BO
Page 295 of 374
PO
EA
25 MG
11/01/2004
06/13/2006
PO
EA
25 MG
05/01/2004
99/99/9999
PO
PO
EA
EA
25 MG
1 GM
1
0.25
08/01/2004
07/01/2004
99/99/9999
99/99/9999
PO
PO
IM
IV
EA
EA
ML
EA
100 MG
1 EA
20 MG
75 MG
1
1
0.5
1
12/01/2004
01/01/2005
03/23/2007
01/01/2002
05/31/2005
99/99/9999
99/99/9999
99/99/9999
PO
EA
50 MG
01/01/2002
01/13/2004
PO
ML
50 MG
0.05
01/01/2002
01/13/2004
PO
EA
50 MG
0.5
01/01/2002
01/13/2004
PO
EA
50 MG
0.5
01/01/2002
01/13/2004
PO
IJ
IJ
SC
SC
SC
SC
EA
ML
ML
ML
ML
ML
ML
50 MG
100 U
5U
100 U
5U
100 U
5U
0.5
1
20
1
20
1
20
01/01/2002
10/14/2002
01/01/2003
10/14/2002
01/01/2003
10/14/2002
01/01/2003
01/13/2004
12/31/2002
07/12/2005
12/31/2002
07/12/2005
12/31/2002
07/12/2005
SC
ML
5U
20
12/19/2003
2/28/2006
SC
IM
IM
IM
IN
IN
IN
IN
IN
IN
IV
IV
IM
IM
PO
PO
PO
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
5U
100 U
100 U
100 U
1 EA
1 MCG
1 EA
1 MCG
1 EA
1 MCG
1 MG
1 MG
1 EA
0.25 MG
5 MG
5 MG
5 MG
20
50
50
50
1
100
1
100
1
25
20
20
1
30
0.6
0.6
0.6
12/19/2003
01/01/2002
01/01/2002
08/01/2005
12/28/2004
01/01/2006
12/28/2004
01/01/2006
12/28/2004
01/01/2006
06/12/2006
01/01/2008
12/08/2006
01/01/2008
01/01/2002
01/01/2002
07/12/2002
6/30/2006
01/27/2005
01/27/2005
06/29/2006
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2007
99/99/9999
12/31/2007
99/99/9999
99/99/9999
99/99/9999
09/15/2002
PO
ML
50 MG
0.05
01/01/2002
9/30/2008
PO
ML
50 MG
0.05
01/01/2002
9/30/2008
PO
ML
50 MG
0.05
01/01/2002
9/30/2008
PO
IV
PO
ML
EA
EA
5 MG
50 MG
2 MG
0.6
1
1
01/01/2002
03/15/2004
04/22/2004
05/18/2004
99/99/9999
99/99/9999
6/22/2004 11/14/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.5
1/1/2002
1/27/2005
50
1/1/2005
2/28/2005
20

99/99/9999 INJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR USE
99/99/9999 INJECTION, INTERFERON BETA-1A, 33 MCG
59618-0199-33
Q0163
1/1/2002
59618-0200-06
59627-0001-03
59627-0001-03
59627-0002-05
Q0163
J3490
Q3025
J1825
1/1/2002
1/1/2002
1/1/2003
8/4/2003
59627-0020-01
J3590
59627-0020-01
59627-0020-02
59627-0020-02
J0215
J3590
J0215
1/1/2004
1/1/2004 INJECTION, ALEFACEPT, 0.5 MG
1/1/2004
59627-0021-03
J3590
59627-0021-03
59627-0021-04
59627-0021-04
59676-0101-01
59676-0201-01
59676-0302-01
59676-0302-01
J0215
J3590
J0215
J7505
J9065
Q0136
J0885
1/1/2004
1/31/2003
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2006

99/99/9999 MUROMONAB-CD3, PARENTERAL, 5 MG
59676-0302-02
Q0136
59676-0302-02
59676-0303-01
59676-0303-01
J0885
Q0136
J0885
59676-0303-02
Q0136
59676-0303-02
59676-0304-01
59676-0304-01
J0885
Q0136
J0885
59676-0304-02
Q0136
59676-0304-02
59676-0310-01
59676-0310-01
J0885
Q0136
J0885
59676-0310-02
Q0136
59676-0310-02
59676-0312-01
59676-0312-01
59676-0312-04
59676-0320-01
59676-0320-01
59676-0320-04
59676-0340-01
59676-0340-01
J0885
Q0136
J0885
J0885
Q0136
J0885
J0885
Q0136
J0885
1/1/2006
1/1/2002
1/1/2006
1/18/2008
1/1/2002
1/1/2006
10/15/2007
1/1/2002
1/1/2006
59676-0360-01
Q4086
1/1/2007
59676-0360-01
59730-4202-01
59730-4202-01
59730-4203-01
59730-4203-01
59730-4204-01
59730-4205-01
59730-4402-01
59730-4403-01
59730-5601-01
59730-6059-07
J7324
J3490
J3590
J3490
J3590
J3590
J3590
J3490
J3490
J9999
J7198
1/1/2008
1/1/2002
1/1/2003
1/1/2002
1/1/2003
1/3/2005
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
59741-0119-04
Q0163
1/1/2002
59741-0119-08
Q0163
1/1/2002

HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION,
12/31/2007 PER DOSE
HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION,
99/99/9999 PER DOSE
5/11/2004 ANTI-INHIBITOR, PER I.U.
DIPHENYL ELIXIR 12.5 MG/5 ML
DIPHENYL 25 MG
AVONEX 30 MCG/0.5 ML
AMEVIVE (4 VIALS W/ADMIN. SET,PF)
7.5 MG
AMEVIVE (4 VIALS W/ADMIN. SET,PF)
7.5 MG
AMEVIVE (PF) 7.5 MG
AMEVIVE (PF) 7.5 MG
AMEVIVE (4 VIALS, SRN, W/DILUENT) 15
MG
AMEVIVE (4 VIALS, SRN, W/DILUENT) 15
MG
AMEVIVE (PF) 15 MG
AMEVIVE (PF) 15 MG
ORTHOCLONE OKT 3 (AMP) 1 MG/ML
LEUSTATIN (S.D.V.) 1 MG/ML
PROCRIT (VIAL) 2000 U/ML
PROCRIT (VOLUME PACK VIAL) 2000
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
U/ML
PROCRIT (M.D.V.) 10000 U/ML
PROCRIT (4X2ML,MDV) 10000 U/ML
PROCRIT (MULTIDOSE) 20000 U/ML
PROCRIT (PF) 40000 U/ML
PROCRIT (PF) 40000 U/ML
ORTHOVISC (PREFILLED SYRINGE) 15
MG/ML
ORTHOVISC (PREFILLED SYRINGE) 15
MG/ML
NABI-HB NOVAPLUS (312 IU/ML)
NABI-HB NOVAPLUS (312 IU/ML)
ALOPRIM (S.D.V.,PF) 500 MG
AUTOPLEX T (390-1050 FECU) 1 IU
120 ML EA
PO
ML
50 MG
PO
IM
IM
MR
EA
EA
EA
EA
50 MG
1 EA
11 MCG
33 MCG
1 EA VL
IV
EA
1 EA VL
1 EA VL
1 EA VL
IV
IV
IV
EA
EA
EA
1 EA VL
IM
EA
1 EA
01/31/2003
12/31/2003
IM
IM
IM
IV
IV
IJ
IJ
EA
EA
EA
ML
ML
ML
ML
0.5 MG
1 EA
0.5 MG
5 MG
1 MG
1000 U
1000 U
120
1
30
0.2
1
2
2
01/01/2004
01/31/2003
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2006
02/27/2008
12/31/2003
12/30/2007
99/99/9999
99/99/9999
12/31/2005
99/99/9999
1 ML VL
IJ
ML
1000 U
01/01/2002
12/31/2005
1 ML VL
1 ML VL
1 ML VL
IJ
IJ
IJ
ML
ML
ML
1000 U
1000 U
1000 U
2
3
3
01/01/2006
01/01/2002
01/01/2006
99/99/9999
12/31/2005
99/99/9999
1 ML VL
IJ
ML
1000 U
01/01/2002
12/31/2005
1 ML VL
1 ML VL
1 ML VL
IJ
IJ
IJ
ML
ML
ML
1000 U
1000 U
1000 U
3
4
4
01/01/2006
01/01/2002
01/01/2006
99/99/9999
12/31/2005
99/99/9999
1 ML VL
IJ
ML
1000 U
01/01/2002
12/31/2005
1 ML VL
1 ML VL
1 ML VL
IJ
IJ
IJ
ML
ML
ML
1000 U
1000 U
1000 U
4
10
10
01/01/2006
01/01/2002
01/01/2006
99/99/9999
12/31/2005
99/99/9999
1 ML VL
IJ
ML
1000 U
10
01/01/2002
12/31/2005
1 ML
2 ML
2 ML
2 ML
1 ML
1 ML
1 ML
1 ML
1 ML
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
1000 U
10
10
10
10
20
20
20
40
40
01/01/2006
01/01/2002
01/01/2006
01/18/2008
01/01/2002
01/01/2006
10/15/2007
01/01/2002
01/01/2006
99/99/9999
12/31/2005
7/3/2008
99/99/9999
12/31/2005
7/3/2008
99/99/9999
12/31/2005
99/99/9999
24 EA
1 EA
1 EA
4 EA
1 EA
1 EA
1 EA
5 ML
10 ML
1 ML
1 ML
NA
BX
BX
BX
VL
VL
VL
AM
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
2 ML SR
2 ML
1 ML
1 ML
5 ML
5 ML
1 ML
5 ML
1 ML
5 ML
1 EA
1050 IU
SR
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
0.05
01/01/2002
99/99/9999
0.5
1
12
3.63636
01/01/2002
01/01/2002
02/17/2004
08/04/2003
99/99/9999
12/31/2002
99/99/9999
99/99/9999
1 EA
01/31/2003
12/31/2003
0.5 MG
1 EA
0.5 MG
60
1
15
01/01/2004
01/31/2003
01/01/2004
01/01/2004
12/31/2003
01/01/2004
IJ
ML
1 DOSE
0.5
01/01/2007
12/31/2007
IJ
IM
IM
IM
IM
IM
IM
IM
IM
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
EA
EA
1 DOSE
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 IU
0.5
1
1
1
1
1
1
1
1
1
1
01/01/2008
01/01/2002
01/01/2003
01/01/2002
01/01/2003
01/03/2005
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2002
99/99/9999
12/31/2002
99/99/9999
09/30/2007
9/30/2007
06/24/2002
06/24/2002
1/8/2008
05/11/2004
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
240 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
Page 296 of 374
1/1/2003
8/3/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
12
59741-0119-16
Q0163
1/1/2002
59741-0119-20
59746-0001-03
59746-0001-06
59746-0001-09
59746-0002-04
59746-0003-14
59746-0007-06
59746-0007-10
59746-0008-06
59746-0008-10
59746-0015-04
Q0163
J7509
J7509
J7509
J7509
J7509
J7506
J7506
J7506
J7506
J7509
1/1/2002
1/1/2002
1/1/2002
1/1/2002
9/24/2007
7/20/2007
1/1/2002
1/1/2002
1/1/2002
1/1/2002
7/20/2007
59746-0113-06
Q0164
1/1/2002
59746-0113-10
Q0164
1/1/2002
59746-0115-06
Q0165
1/1/2002
59746-0115-10
59746-0171-06
59746-0171-10
59746-0172-06
59746-0172-10
59746-0173-06
59746-0173-09
59746-0173-10
59746-0175-06
59746-0175-09
59746-0175-10
59762-0100-01
59762-0100-01
Q0165
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
Q2001
J8515
1/1/2002
10/21/2005
10/21/2005
8/3/2007
8/3/2007
8/3/2007
8/3/2007
8/3/2007
8/3/2007
8/3/2007
8/3/2007
12/30/2005
1/1/2006
59762-2576-01
J9211
8/27/2007
59762-2586-01
J9211
8/27/2007
59762-2596-01
59762-3051-01
59762-3051-02
J9211
Q0144
Q0144
8/27/2007
7/7/2006
7/7/2006

METHYLPREDNISOLONE (USP) 8 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 1 MG
PREDNISONE 1 MG
12/31/2005 ORAL, CABERGOLINE, 0.5 MG
CABERGOLINE 0.5 MG
CABERGOLINE 0.5 MG
IDARUBICIN HYDROCHLORIDE (PF) 1
MG/ML
MG/ML
MG/ML
480 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
BO
DP
BO
BO
BO
BO
NA
NA
NA
NA
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
4 MG
4 MG
4 MG
4 MG
4 MG
5 MG
5 MG
5 MG
5 MG
4 MG
0.05
1
1
1
2
4
1
1
2
2
8
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/24/2007
07/20/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2002
07/20/2007
99/99/9999
99/99/9999
99/99/9999
10/21/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
5 MG
01/01/2002
99/99/9999
1000 EA BO
PO
EA
5 MG
01/01/2002
10/22/2006
100 EA BO
PO
EA
10 MG
01/01/2002
99/99/9999
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
10 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
0.5 MG
0.25 MG
1
0.2
0.2
1
1
2
2
2
4
4
4
1
2
01/01/2002
10/21/2005
10/21/2005
08/03/2007
08/03/2007
08/03/2007
08/03/2007
08/03/2007
08/03/2007
08/03/2007
08/03/2007
12/30/2005
01/01/2006
10/22/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2005
99/99/9999
3840 ML
21 EA
100 EA
500 EA
25 EA
50 EA
100 EA
1000 EA
100 EA
1000 EA
25 EA
1000 EA
100 EA
1000 EA
100 EA
1000 EA
100 EA
500 EA
1000 EA
100 EA
500 EA
1000 EA
8 EA
8 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
5 ML VL
IV
ML
5 MG
0.2
08/27/2007
99/99/9999
10 ML VL
IV
ML
5 MG
0.2
08/27/2007
99/99/9999
20 ML VL
10 EA BX
3 EA BX
IV
PO
PO
ML
EA
EA
5 MG
1 GM
1 GM
0.2
1
1
08/27/2007
07/07/2006
07/07/2006
99/99/9999
99/99/9999
99/99/9999
59762-3060-01
Q0144
6 EA DP
PO
EA
1 GM
0.25
11/14/2005
99/99/9999
59762-3060-02
Q0144
30 EA BO
PO
EA
1 GM
0.25
11/14/2005
99/99/9999
99/99/9999
59762-3060-03
Q0144
50 EA BX
PO
EA
1 GM
0.25
11/14/2005
59762-3070-01
Q0144
3 EA DP
PO
EA
1 GM
0.5
11/14/2005
99/99/9999
59762-3070-02
Q0144
30 EA BO
PO
EA
1 GM
0.5
11/14/2005
99/99/9999
59762-3080-01
Q0144
30 EA BO
PO
EA
1 GM
0.6
11/14/2005
99/99/9999
59762-3110-01
Q0144
AZITHROMYCIN (CHERRY) 100 MG/5 ML
15 ML BO
PO
ML
1 GM
0.02
07/07/2006
99/99/9999
59762-3120-01
Q0144
15 ML BO
PO
ML
1 GM
0.04
07/07/2006
99/99/9999
59762-3130-01
Q0144
22.5 ML BO
PO
ML
1 GM
0.04
07/07/2006
99/99/9999
59762-3140-01
Q0144
PO
ML
1 GM
0.04
07/07/2006
99/99/9999
J7509
1/1/2002
21 EA DP
PO
EA
4 MG
01/01/2002
05/15/2007
59762-3327-02
J7509
59762-4537-01
J1055

4 MG
4 MG
9/27/2004 99/99/9999 MG
150 MG/ML
30 ML BO
59762-3327-01
Page 297 of 374
100 EA BO
1 ML VL
PO
EA
4 MG
01/01/2002
05/15/2007
IM
ML
150 MG
09/27/2004
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
59762-4537-02
59762-4538-01
J1055
J1450
59762-5035-02
J1450
59762-5036-02
J1450
59762-5037-02
J1450
59762-5091-01
J9178
59762-5093-01
J9178
59762-7529-01
J9206
59762-7529-01 QR J9206
QR
Q0173
None
59911-5900-01
J0295
59911-5901-02
J0295
59911-5902-02
J0295
59911-5905-02
J2260
59911-5906-02
J2260
59911-5907-02
J2260
59911-5908-02
J2260
59911-5911-02
59911-5912-02
59911-5913-02
J2250
J2250
J2250
59911-5914-02
J2250
59911-5915-02
59911-5916-02
59911-5950-02
J2250
J2250
J3490
59911-5950-04
59911-5951-02
J3490
J3490
59911-5951-04
59911-5952-02
J3490
J3490
59911-5952-04
J3490
59911-5958-01
J9390
59911-5959-01
59911-5963-02
59911-5964-02
J9390
J0694
J0694
59911-5965-02
J0694
59930-1500-06
J7619
59930-1500-06 KO J7619
59930-1500-08
QR
J9206
59762-7529-02 QR J9206
59879-0115-01
59911-5874-01
J7619
KO

5/26/2006 99/99/9999 MG
(PREFILLED SYRINGE,USP) 150 MG/ML
FLUCONAZOLE IV (VIAFLEX,SODIUM
FLUCONAZOLE IV (VIAFLEX,SODIUM
FLUCONAZOLE IV (VIAFLEX,
DEXTROSE) 200 MG/100 ML
FLUCONAZOLE IV (VIAFLEX,
DEXTROSE) 400 MG/200 ML
USE,PF) 2 MG/ML
USE,PF) 2 MG/ML
(1X2ML,SDV) 20 MG/ML
PACKAGE) 10 GM-5 GM
AMPICILLIN/SULBACTAM (VIAL) 1 GM-0.5
GM
AMPICILLIN/SULBACTAM (VIAL) 2 GM-1
GM
MILRINONE LACTATE (S.D.V.,PF) 1
MG/ML
MILRINONE LACTATE (S.D.V.,PF) 1
MG/ML
(S.D.V.,REDI-INFUSION,PF) 5%-20
MG/100 ML
9/26/2002
MG/100 ML
MIDAZOLAM HCL (DOSETTE VIAL) 1
MG/ML
MIDAZOLAM HCL (VIAL) 1 MG/ML
MG/ML
MG/ML
FAMOTIDINE NOVAPLUS (S.D.V.,PF) 10
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
1/1/2002 11/30/2003 INJECTION, CEFOXITIN SODIUM, 1 GM
CEFOXITIN SODIUM (BULK PACKAGE)
10 GM
Page 298 of 374
1 ML VL
IM
ML
150 MG
09/27/2004
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
1 ML SR
IM
ML
150 MG
05/26/2006
99/99/9999
100 ML PC
IV
ML
200 MG
0.01
09/09/2004
12/22/2006
200 ML PC
IV
ML
200 MG
0.01
09/09/2004
12/22/2006
100 ML PC
IV
ML
200 MG
0.01
09/09/2004
12/22/2006
200 ML PC
IV
ML
200 MG
0.01
09/09/2004
12/22/2006
25 ML VL
IV
ML
2 MG
08/08/2007
99/99/9999
100 ML VL
IV
ML
2 MG
08/08/2007
99/99/9999
2 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
2 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
PO
PO
EA
EA
250 MG
2.5 MG
1
1
01/01/2002
03/12/1996
12/31/2002
09/27/2001
100 EA BO
100 EA BO
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

9/27/2004 99/99/9999 MG
150 MG/ML
J1055
59762-5034-02
59762-7529-02
HCPCS Mod
HCPCS
NDC Mod
NDC
1 EA VL
IV
EA
1.5 GM
10
03/14/2002
12/14/2003
1 EA VL
IJ
EA
1.5 GM
03/14/2002
12/14/2003
1 EA VL
IJ
EA
1.5 GM
03/14/2002
12/14/2003
10 ML VL
IV
ML
5 MG
0.2
05/31/2002
12/14/2006
20 ML VL
IV
ML
5 MG
0.2
05/31/2002
12/14/2006
100 ML FC
IV
ML
5 MG
0.04
05/31/2002
12/14/2006
100 ML FC
IV
ML
5 MG
0.04
09/26/2002
02/06/2004
2 ML VL
5 ML VL
10 ML VL
IJ
IJ
IJ
ML
ML
ML
1 MG
1 MG
1 MG
1
1
1
01/01/2002
01/01/2002
01/01/2002
12/14/2006
10/05/2003
10/05/2003
1 ML VL
IJ
ML
1 MG
01/01/2002
12/14/2006
2 ML VL
10 ML VL
2 ML VL
IJ
IJ
IV
ML
ML
ML
1 MG
1 MG
1 EA
5
5
1
01/01/2002
01/01/2002
01/01/2002
12/14/2006
10/05/2003
10/31/2003
2 ML VL
4 ML VL
IV
IV
ML
ML
1 EA
1 EA
1
1
01/01/2002
01/01/2002
10/31/2003
10/31/2003
4 ML VL
20 ML VL
IV
IV
ML
ML
1 EA
1 EA
1
1
01/01/2002
01/01/2002
10/31/2003
10/31/2003
20 ML VL
IV
ML
1 EA
01/01/2002
12/31/2003
1 ML VL
IV
ML
10 MG
06/16/2003
12/30/2003
5 ML VL
1 EA VL
1 EA VL
IV
IJ
IJ
ML
EA
EA
10 MG
1 GM
1 GM
1
1
2
06/16/2003
01/01/2002
01/01/2002
12/30/2003
11/30/2003
11/30/2003
1 EA VL
IJ
EA
1 GM
10
01/01/2002
11/30/2003
3 ML PC
IH
ML
1 MG
0.83
01/01/2002
06/13/2002
3 ML PC
IH
ML
1 MG
0.83
01/01/2002
06/13/2002
3 ML PC
IH
ML
1 MG
0.83
01/01/2002
06/13/2002
1/1/2002
59930-1515-04
J7618
1/1/2002
59930-1517-01
J7619
1/1/2002
59930-1517-01 KO J7619
59930-1517-01
59930-1517-01 KO J7613
59930-1517-02
KO
1/1/2005
1/1/2002
KO
J7613
59930-1517-02 KO J7613
1/1/2002
1/1/2005
J7619
59930-1517-02 KO J7619
59930-1517-02
KO
J7613
1/1/2002
1/1/2005
KO
1/1/2005
59930-1600-01
Q0175
1/1/2002
59930-1603-01
Q0175
1/1/2002
59930-1605-01
59930-1609-01
59930-1609-01
59930-1609-02
59930-1609-02
Q0176
J7051
A4216
J7051
A4216
1/1/2002
1/1/2002
1/1/2006
1/1/2002
1/1/2006
59930-1610-01
Q0176
1/1/2002
59930-1647-02
J7618
1/1/2002
59930-1647-02
J7611
1/1/2005
60242-0202-01
Q0163
7/6/2007
60242-0202-10
Q0163
7/6/2007
60346-0045-15
Q0163
5/30/2002
60346-0045-20
Q0163
5/30/2002
60346-0045-30
Q0163
5/30/2002
60346-0045-44
Q0163
5/30/2002
60346-0045-60
60346-0058-15
60346-0058-30
Q0163
J7506
J7506
5/30/2002
7/11/2002
7/15/2002

ALBUTEROL SULFATE (MDV) 0.5%
PERPHENAZINE 2 MG
11/9/2003 REGIMEN
PERPHENAZINE 4 MG
10/16/2003 REGIMEN
PERPHENAZINE 8 MG
10/16/2003 REGIMEN
PERPHENAZINE 16 MG
10/16/2003 REGIMEN
50 MG
50 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
Page 299 of 374
3 ML PC
IH
ML
1 MG
0.83
01/01/2002
06/13/2002
20 ML BO
IH
ML
1 MG
01/01/2002
06/13/2002
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
12/31/2004
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
12/31/2004
3 ML VL
IH
ML
1 MG
0.83
01/01/2005
01/01/2007
3 ML VL
IH
ML
1 MG
0.83
01/01/2005
01/01/2007
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
12/31/2004
3 ML VL
IH
ML
1 MG
0.83
01/01/2002
12/31/2004
3 ML VL
IH
ML
1 MG
0.83
01/01/2005
01/01/2007
3 ML VL
IH
ML
1 MG
0.83
01/01/2005
01/01/2007
100 EA BO
PO
EA
4 MG
0.5
01/01/2002
11/09/2003
100 EA BO
PO
EA
4 MG
01/01/2002
10/16/2003
100 EA
3 ML
3 ML
5 ML
5 ML
BO
PC
PC
PC
PC
PO
IH
IH
IH
IH
EA
ML
ML
ML
ML
8 MG
5 ML
10 ML
5 ML
10 ML
1
0.2
0.1
0.2
0.1
01/01/2002
01/01/2002
01/01/2006
01/01/2002
01/01/2006
10/16/2003
12/31/2005
01/01/2007
12/31/2005
01/01/2007
100 EA BO
PO
EA
8 MG
01/01/2002
10/16/2003
20 ML BO
IH
ML
1 MG
01/01/2002
12/31/2004
20 ML BO
IH
ML
1 MG
01/01/2005
01/01/2007
100 EA BO
PO
EA
50 MG
07/06/2007
99/99/9999
1000 EA BO
PO
EA
50 MG
07/06/2007
99/99/9999
15 EA NA
PO
EA
50 MG
05/30/2002
03/25/2003
20 EA NA
PO
EA
50 MG
05/30/2002
10/15/2003
30 EA NA
PO
EA
50 MG
05/30/2002
05/06/2003
4 EA NA
PO
EA
50 MG
05/30/2002
05/06/2003
60 EA NA
15 EA NA
30 EA NA
PO
PO
PO
EA
EA
EA
50 MG
5 MG
5 MG
1
2
2
05/30/2002
07/11/2002
07/15/2002
05/06/2003
01/01/2006
10/15/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
59930-1500-08 KO J7619
NDC
HCPCS
60346-0058-40
60346-0058-60
J7506
J7506
60346-0085-10
60346-0094-25
60346-0094-30
Q0170
J7506
J7506
60346-0493-02
60346-0493-02
K0416
J8498
60346-0493-03
60346-0493-03
60346-0515-55
K0416
J8498
J7506
60346-0550-15
60346-0550-15
Q0181
J8540
60346-0550-30
60346-0550-30
Q0181
J8540
60346-0589-06
Q0163
60346-0589-12
Q0163
60346-0589-30
Q0163
60346-0589-60
Q0163
60346-0860-10
Q0165
60429-0153-60
Q0175
60429-0154-60
60429-0711-50
60429-0713-50
Q0176
J8499
J8499
60432-0033-04
Q0163
60432-0033-08
Q0163
60432-0033-16
Q0163
60432-0033-28
Q0163
60432-0089-04
J7510
60432-0093-16
G9017
60432-0126-08
J8999
60432-0126-16
J8999
60432-0137-08
J7510

PREDNISONE 10 MG
7/15/2002
PREDNISONE 10 MG
7/11/2002
7/15/2002
PREDNISONE 20 MG
PREDNISONE 20 MG
COMPAZINE 25 MG
1/1/2006
COMPAZINE 25 MG
COMPAZINE 25 MG
1/1/2006
COMPAZINE 25 MG
PREDNISONE 5 MG
6/18/2002 12/31/2005 REGIMEN
1/1/2006
6/18/2002 12/31/2005 REGIMEN
1/1/2006
5/30/2002
5/30/2002
5/30/2002
5/30/2002
COMPAZINE 10 MG
6/18/2002
PERPHENAZINE (UNIT OF USE) 4 MG
10/22/2002 99/99/9999 REGIMEN
PERPHENAZINE (UNIT OF USE) 8 MG
10/22/2002 99/99/9999 REGIMEN
ACYCLOVIR (UNIT OF USE) 200 MG
ACYCLOVIR (UNIT OF USE) 800 MG
DIPHEN AF (CHERRY) 12.5 MG/5 ML
1/1/2002
(AF,SF,DYE-FREE) 5 MG/5 ML
MG/5 ML
MEGESTROL ACETATE (LEMON-LIME)
40 MG/ML
MEGESTROL ACETATE (LEMON-LIME)
40 MG/ML
Page 300 of 374
40 EA NA
60 EA NA
PO
PO
EA
EA
5 MG
5 MG
2
2
07/15/2002
07/15/2002
10/15/2003
01/01/2006
10 EA NA
25 EA NA
30 EA NA
PO
PO
PO
EA
EA
EA
25 MG
5 MG
5 MG
1
4
4
07/11/2002
07/15/2002
07/15/2002
01/01/2006
01/01/2006
03/25/2003
1 EA BX
1 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
06/18/2002
01/01/2006
12/31/2005
01/01/2006
3 EA BX
3 EA BX
55 EA NA
RC
RC
PO
EA
EA
EA
1 MG
1 EA
5 MG
25
1
1
06/18/2002
01/01/2006
07/11/2002
12/31/2005
01/01/2006
08/27/2002
15 EA NA
15 EA NA
PO
PO
EA
EA
1 EA
0.25 MG
1
3
06/18/2002
01/01/2006
12/31/2005
01/01/2006
30 EA NA
30 EA NA
PO
PO
EA
EA
1 EA
0.25 MG
1
3
06/18/2002
01/01/2006
12/31/2005
01/01/2006
6 EA NA
PO
EA
50 MG
0.5
05/30/2002
01/01/2006
12 EA NA
PO
EA
50 MG
0.5
05/30/2002
01/01/2006
30 EA NA
PO
EA
50 MG
0.5
05/30/2002
01/01/2006
60 EA NA
PO
EA
50 MG
0.5
05/30/2002
06/01/2005
10 EA BO
PO
EA
10 MG
06/18/2002
01/01/2006
60 EA BO
PO
EA
4 MG
10/22/2002
99/99/9999
60 EA BO
50 EA BO
50 EA BO
PO
PO
PO
EA
EA
EA
8 MG
1 EA
1 EA
1
1
1
10/22/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
120 ML BO
PO
ML
50 MG
0.05
01/01/2002
06/26/2007
240 ML BO
PO
ML
50 MG
0.05
01/01/2002
06/27/2007
480 ML BO
PO
ML
50 MG
0.05
01/01/2002
04/02/2007
3840 ML BO
PO
ML
50 MG
0.05
01/01/2002
12/16/2002
118 ML BO
PO
ML
5 MG
0.2
07/18/2002
99/99/9999
473 ML BO
PO
ML
100 MG
0.1
12/01/2004
05/31/2005
240 ML BO
PO
ML
1 EA
11/17/2004
99/99/9999
480 ML BO
PO
ML
1 EA
12/01/2006
99/99/9999
240 ML BO
PO
ML
5 MG
0.6
08/16/2004
11/23/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
60432-0137-16
60432-0140-50
J7510
J7502
60432-0212-08
J7510
60432-0466-08
Q0181
60432-0466-08
J8540
60432-0608-04
Q0170
60432-0608-16
Q0170
60432-0676-01
J7668
60432-0676-30
J7668
60492-0021-01
J2792
60492-0023-01
J2792
60492-0024-01
J2792
60492-0051-01
Q4090
60492-0051-01
J1571
60492-0051-02
J3590


ML
5 MG
0.6
10/25/2004
99/99/9999
240 ML BO
PO
ML
1 EA
01/01/2002
12/31/2005
240 ML BO
PO
ML
0.25 MG
0.4
01/01/2006
99/99/9999
120 ML BO
PO
ML
25 MG
0.05
01/01/2002
99/99/9999
480 ML BO
PO
ML
25 MG
0.05
01/01/2002
99/99/9999
10 ML BO
IH
ML
10 MG
01/01/2002
05/21/2002
30 ML BO
IH
ML
10 MG
01/01/2002
05/21/2002
1 EA VL
IV
EA
100 IU
01/01/2002
03/24/2005
1 EA VL
IV
EA
100 IU
15
01/01/2002
03/24/2005
1 EA VL
IV
EA
100 IU
50
01/01/2002
03/24/2005
5 ML VL
IM
ML
0.5 ML
07/01/2007
12/31/2007
5 ML VL
IM
ML
0.5 ML
01/01/2008
99/99/9999
NOVAPLUS HEPAGAM B (>1560/5ML,PF)
5 ML VL
IJ
ML
1 EA
10/01/2007
12/31/2007
1/1/2008 99/99/9999 INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVENOUS, 0.5 ML NOVAPLUS HEPAGAM B (>1560/5ML,PF)
INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5
7/1/2007 12/31/2007 ML
HEPAGAM B (SDV,PF)
1/1/2008 99/99/9999 ML
HEPAGAM B (SDV,PF)
5 ML VL
IJ
ML
0.5 ML
01/01/2008
99/99/9999
1 ML VL
IM
ML
0.5 ML
07/01/2007
12/31/2007
1 ML VL
IM
ML
0.5 ML
01/01/2008
99/99/9999
1 ML VL
NOVAPLUS HEPAGAM B (>312IU/ML,PF)
J1573
J8499
J7515
J7502
J7502
1/1/2008
3/1/2006
5/17/2002
5/17/2002
8/1/2005
60505-0368-01
J8999
NOVAPLUS HEPAGAM B (>312IU/ML,PF)

CYCLOSPORINE 25 MG
CYCLOSPORINE 100 MG
CYCLOSPORINE (U.S.P.) 100 MG/ML
MEGESTROL ACETATE (USP,LEMONLIME) 40 MG/ML

ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 ONDANSETRON (USP,1X50ML) 4 MG/5
ML
BUTORPHANOL TARTRATE (VIAL) 1
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
CEFTRIAXONE (1X100ML,BULK PKG) 10
GM
CEFTRIAXONE (1X100ML,PIGGYBACK) 1
GM
CEFEPIME (USP) 2 GM
J0595
60505-0659-01
J3490
60505-0660-00
J3490
60505-0660-00
J0595
60505-0664-02
J2680
60505-0679-05
J0696
60505-0679-08
60505-0679-09
60505-0680-02
60505-0680-05
60505-0681-00
J0696
J0696
J0690
J0690
J0692
99/99/9999 INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVENOUS, 0.5 ML

Page 301 of 374
IJ
ML
1 EA
10/01/2007
12/31/2007
VL
BO
BO
BO
BO
IJ
PO
PO
PO
PO
ML
EA
EA
EA
ML
0.5 ML
1 EA
25 MG
100 MG
100 MG
2
1
1
1
1
01/01/2008
03/01/2006
05/17/2002
05/17/2002
08/01/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
240 ML BO
PO
ML
1 EA
06/23/2006
99/99/9999
50 ML BO
1 ML
100 EA
30 EA
30 EA
50 ML
PO
ML
8 MG
0.1
03/10/2008
99/99/9999
1 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
1 ML VL
IJ
ML
1 MG
01/01/2004
99/99/9999
1 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
1 ML VL
IJ
ML
1 MG
01/01/2004
99/99/9999
2 ML VL
IJ
ML
1 EA
01/01/2002
06/26/2002
10 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
10 ML VL
IJ
ML
1 MG
01/01/2004
99/99/9999
5 ML VL
IJ
ML
25 MG
01/01/2002
10/1/2008
1 EA VL
IV
EA
250 MG
40
09/01/2005
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
250 MG
250 MG
500 MG
500 MG
500 MG
4
8
20
20
4
09/01/2005
09/01/2005
09/19/2005
09/19/2005
06/19/2007
99/99/9999
99/99/9999
09/20/2005
09/20/2005
99/99/9999
VL
VL
NA
NA
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
PO
J3590
60505-0659-00
Start Date #1
237 ML BO

THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE DEXAMETHASONE (RASPBERRY) 0.5
MG/5 ML
1/1/2002 12/31/2005 REGIMEN
DEXAMETHASONE (RASPBERRY) 0.5
MG/5 ML
6.25 MG/5 ML
6.25 MG/5 ML
PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED
METAPROTERENOL SULFATE 5%
1/1/2002 5/21/2002 FORM, PER 10 MILLIGRAMS
PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED
METAPROTERENOL SULFATE 5%
1/1/2002 5/21/2002 FORM, PER 10 MILLIGRAMS
1/1/2002 3/24/2005 DETERGENT, 100 IU
WINRHO SDF (S.D.V.) 600 IU
1/1/2002 3/24/2005 DETERGENT, 100 IU
WINRHO SDF (S.D.V.) 1500 IU
1/1/2002 3/24/2005 DETERGENT, 100 IU
WINRHO SDF (VIAL) 5000 IU
7/1/2007 12/31/2007 ML
HEPAGAM B (SDV,PF)
1/1/2008 99/99/9999 ML
HEPAGAM B (SDV,PF)
60492-0052-02
60505-0042-06
60505-0133-00
60505-0134-00
60505-0354-01
J3490
CF
07/22/2005
99/99/9999
60492-0052-02
60505-0659-00
HCPCS Measure #1
08/16/2004
09/28/2004
J1571
J0595
HCPCS Amount #1
0.6
1
60492-0052-01
60505-0658-00
Billing Units
5 MG
100 MG
J1573
J3490
ML
ML
Q4090
Q0179
NDC Package Type
PO
PO
60492-0051-02
60505-0381-05
NDC Package Measure
480 ML BO
50 ML BO
60492-0052-01
60505-0658-00

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
60505-0681-04
J0692
60505-0692-00
J1626
60505-0693-00
J1626
60505-0702-01
J1631
60505-0703-01
J1631
60505-0705-00
J1885
60505-0706-00
J1885
60505-0706-01
60505-0711-01
60505-0711-02
60505-0711-03
60505-0712-01
60505-0712-02
60505-0712-03
60505-0712-04
60505-0715-00
60505-0715-01
60505-0718-00
60505-0718-01
60505-0722-00
J1885
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J1245
J1245
J2260
J2260
J0282
2/28/2005
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
8/1/2004
8/1/2004
2/28/2005
2/28/2005
6/1/2003
60505-0722-01
J0282
60505-0725-01
J1885


CEFEPIME (USP) 2 GM
(1X4ML,MULTI-USE) 1 MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
30 MG/ML
DIPYRIDAMOLE 5 MG/ML
DIPYRIDAMOLE (10X10) 5 MG/ML
MILRINONE LACTATE (PF) 1 MG/ML
MILRINONE LACTATE (PF) 1 MG/ML
AMIODARONE HCL (SDS,10X3ML) 50
MG/ML
10 EA VL
IJ
EA
500 MG
06/19/2007
99/99/9999
1 ML VL
IV
ML
100 MCG
10
8/14/2008
99/99/9999
4 ML VL
IV
ML
100 MCG
10
8/14/2008
99/99/9999
5 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
5 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
1 ML VL
IJ
ML
15 MG
02/28/2005
99/99/9999
1 ML VL
2 ML
2 ML
5 ML
10 ML
1 ML
2 ML
5 ML
10 ML
2 ML
10 ML
10 ML
20 ML
3 ML
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
ML
15 MG
02/28/2005
99/99/9999
IM
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
15 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
10 MG
10 MG
5 MG
5 MG
30 MG
2
1
1
1
5
5
5
5
0.5
0.5
0.2
0.2
1.66666
02/28/2005
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
08/01/2004
08/01/2004
02/28/2005
02/28/2005
06/01/2003
99/99/9999
11/17/2003
12/09/2002
03/06/2003
11/17/2003
03/07/2003
06/18/2003
05/21/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
3 ML SR
IV
ML
30 MG
1.66666
12/20/2005
99/99/9999
1 ML SR
IJ
ML
15 MG
11/01/2004
99/99/9999
60505-0726-01
J1885
1 ML SR
IJ
ML
15 MG
11/01/2004
99/99/9999
60505-0726-02
60505-0727-03
J1885
J1630

2 ML SR
1 ML SR
IJ
IM
ML
ML
15 MG
5 MG
2
1
11/01/2004
01/24/2005
99/99/9999
99/99/9999
60505-0733-01
J1450
100 ML PC
IV
ML
200 MG
0.01
05/25/2005
99/99/9999
60505-0733-02
J1450
200 ML PC
IV
ML
200 MG
0.01
05/25/2005
99/99/9999
60505-0734-01
J1450
100 ML PC
IV
ML
200 MG
0.01
05/25/2005
99/99/9999
60505-0734-02
J1450
200 ML PC
IV
ML
200 MG
0.01
05/25/2005
99/99/9999
60505-0744-01
60505-0744-06
J2405
J2405

2 ML VL
20 ML VL
IJ
IJ
ML
ML
1 MG
1 MG
2
2
12/26/2006
12/26/2006
99/99/9999
99/99/9999
60505-0746-05
60505-0748-04
60505-0748-05
60505-0749-04
60505-0749-05
60505-0750-00
60505-0750-04
60505-0751-00
60505-0751-04
60505-0752-00
60505-0752-04
60505-0753-00
60505-0753-04
60505-0759-05
60505-0760-05
60505-0761-04
J1165
J0690
J0690
J0690
J0690
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J0694
J0694
J0694
10/24/2007
9/19/2005
9/19/2005
9/19/2005
9/16/2005
8/2/2005
8/2/2005
8/2/2005
8/2/2005
8/2/2005
8/2/2005
8/2/2005
8/2/2005
1/23/2006
1/23/2006
2/13/2006
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IV
IV
IV
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
500 MG
500 MG
500 MG
500 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
1 GM
1 GM
1 GM
1
1
1
2
2
1
1
2
2
4
4
8
8
1
2
10
10/24/2007
09/19/2005
09/19/2005
09/19/2005
09/16/2005
08/02/2005
08/02/2005
08/02/2005
08/02/2005
08/02/2005
08/02/2005
08/02/2005
08/02/2005
01/23/2006
01/23/2006
02/13/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
60505-0764-02
J1626
60505-0765-04
60505-0769-00
J1165
J0690

HALOPERIDOL (PF) 5 MG/ML
FLUCONAZOLE (FLEXBAG) 200 MG/100
ML
FLUCONAZOLE (FLEXBAG) 400 MG/200
ML
FLUCONAZOLE (FLEXBAG,DEXTROSE)
200 MG/100 ML
FLUCONAZOLE (FLEXBAG,DEXTROSE)
400 MG/200 ML
MG/ML
FOSPHENYTOIN SODIUM (25X2ML) 50
MG/ML
CEFTRIAXONE (1X10ML) 250 MG
CEFOXITIN 1 GM
CEFOXITIN 2 GM
CEFOXITIN (BULK PACKAGE) 10 GM
(5X1ML,SINGLE-USE,PF) 0.1 MG/ML
FOSPHENYTOIN SODIUM (10X10ML) 50
MG/ML
CEFAZOLIN 10 GM
60505-0802-01
J7631

5/31/2002
5/31/2002
IPRATROPIUM BROMIDE (AMP) 0.02%
1/1/2002 99/99/9999 MILLIGRAM
60505-0802-01 KO J7631
60505-0802-02
KO
J7631
60505-0802-02 KO J7631
60505-0806-01
J7644
KO

Page 302 of 374
2 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
1 ML VL
IV
ML
100 MCG
12/31/2007
99/99/9999
10 ML VL
1 EA VL
IV
IV
ML
EA
50 MG
500 MG
1
20
10/24/2007
06/13/2006
99/99/9999
99/99/9999
2 ML PC
IH
ML
10 MG
05/31/2002
99/99/9999
2 ML PC
IH
ML
10 MG
05/31/2002
99/99/9999
2 ML PC
IH
ML
10 MG
05/31/2002
07/02/2002
2 ML PC
IH
ML
10 MG
05/31/2002
07/02/2002
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
60505-0807-01
J7669
60505-0807-01 KO J7669
60505-0808-01
J7669
60505-0808-01 KO J7669
60505-0834-00
J0692
60505-0834-04
J0692
60505-5306-01
J8499
60505-5306-08
J8499
60505-5307-01
J8499
60505-5307-05
J8499
60505-6020-02
J1631
60505-6021-02
60505-6025-05
60505-6026-05
60505-6030-04
60505-6031-04
60553-0111-10
J1631
J0694
J0694
J0692
J0692
J9017
60574-2101-01
J1565
60574-3101-01
J0850
60574-4111-01
J3490
60574-4112-01
60760-0002-21
60760-0138-30
J3490
J7506
J7506
60760-0330-30
60760-0630-28
Q0163
J7506
60760-0830-20
60763-2041-00
60763-2041-04
Q0170
J8499
J8499
60793-0010-12
J7631
60793-0010-12 KO J7631
60793-0010-60
KO
KO
60793-0130-10
J2510
60793-0131-10
J2510
60793-0225-01
J2440
60793-0225-10
J2440
60793-0401-11
J0170
60793-0405-71
60793-0416-05
J0720
J2590
60793-0600-10
J0540
60793-0601-10
J0540
60793-0602-10
60793-0700-10
60793-0701-10
60793-0702-10
J0540
J0560
J0560
J0560
KO
KO
SYNAGIS (SINGLE USE VIAL,PF) 100 MG

SYNAGIS (SINGLE USE VIAL,PF) 50 MG
PREDNISONE 20 MG
1/1/2002
PREDNISONE 5 MG
1/1/2002
PREDNISONE 10 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
INTAL 10 MG/ML
INTAL 10 MG/ML
INTAL 10 MG/ML
INTAL 10 MG/ML
PENICILLIN G PROCAINE
(21GX1&1/2,1MLX10) 600000 U/ML
PENICILLIN G PROCAINE
(21GX1&1/4,2MLX10) 600000 U/ML
PAPAVERINE HYDROCHLORIDE (SRN,
PREFILLED) 30 MG/ML
PAPAVERINE HYDROCHLORIDE (SRN,
PREFILLED) 30 MG/ML
EPINEPHRINE HCL (M.D. STERI-VIAL) 1
MG/ML
CHLORAMPHENICOL SODIUM
1/1/2002 9/24/2003 INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM
SUCCINATE (STERI-VIAL) 1 GM
OXYTOCIN (STERI-VIAL) 10 U/ML
8/15/2007 12/31/2009 1,200,000 UNITS
BICILLIN C-R (2MLX10,21GX1&1/2")
8/15/2007 12/31/2009 1,200,000 UNITS
BICILLIN C-R (2MLX10,21GX1",PEDIA)
BICILLIN C-R 900/300
8/15/2007 12/31/2009 1,200,000 UNITS
(2MLX10,21GX1",PEDIA)
BICILLIN L-A 600000 U/ML
BICILLIN L-A 600000 U/ML
Page 303 of 374
2.5 ML PC
IH
ML
1 MG
0.2
01/01/2002
99/99/9999
2.5 ML PC
IH
ML
10 MG
0.4
01/01/2002
99/99/9999
2.5 ML PC
IH
ML
10 MG
0.4
01/01/2002
99/99/9999
2.5 ML PC
IH
ML
10 MG
0.6
01/01/2002
99/99/9999
IH
IJ
IJ
PO
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
10 MG
500 MG
500 MG
1 EA
1 EA
1 EA
1 EA
0.6
2
2
1
1
1
1
01/01/2002
06/19/2007
06/19/2007
03/01/2006
05/21/2007
03/01/2006
05/21/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2.5 ML
1 EA
10 EA
100 EA
1000 EA
100 EA
500 EA
PC
VL
VL
BO
BO
BO
BO
5 ML VL
IM
ML
50 MG
01/30/2008
99/99/9999
VL
VL
VL
VL
VL
AM
IM
IV
IV
IJ
IJ
IV
ML
EA
EA
EA
EA
ML
50 MG
1 GM
1 GM
500 MG
500 MG
1 MG
2
1
2
2
4
1
12/14/2007
02/27/2008
02/27/2008
04/11/2008
04/11/2008
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
07/14/2006
50 ML VL
IV
ML
50 MG
01/01/2002
03/01/2004
50 ML VL
IV
ML
1 EA
0.02
01/01/2002
01/31/2007
1 EA VL
IM
EA
1 EA
01/01/2002
09/19/2006
1 EA VL
21 EA BO
30 EA BO
IM
PO
PO
EA
EA
EA
1 EA
5 MG
5 MG
1
4
1
01/01/2002
5/15/2009
03/01/2006
09/19/2006
99/99/9999
09/01/2007
30 EA BO
28 EA BO
PO
PO
EA
EA
50 MG
5 MG
0.5
2
01/01/2002
01/01/2002
99/99/9999
09/01/2007
20 EA BO
100 EA BO
400 EA BO
PO
PO
PO
EA
EA
EA
25 MG
1 EA
1 EA
1
1
1
06/01/2005
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
2 ML PC
IH
ML
10 MG
12/15/2005
8/14/2008
2 ML PC
IH
ML
10 MG
12/15/2005
8/14/2008
2 ML PC
IH
ML
10 MG
12/15/2005
8/14/2008
5 ML
1 EA
1 EA
1 EA
1 EA
10 ML
2 ML PC
IH
ML
1 ML SR
IM
ML
600000 U
2 ML SR
IM
ML
600000 U
2 ML SR
IJ
ML
60 MG
2 ML SR
IJ
ML
60 MG
30 ML VL
IJ
ML
1 EA VL
1 ML VL
IV
IV
EA
ML
2 ML SR
IM
ML
2 ML SR
IM
ML
2 ML
1 ML
2 ML
4 ML
IM
IM
IM
IM
ML
ML
ML
ML
SR
SR
SR
SR
10 MG
12/15/2005
8/14/2008
09/14/2007
99/99/9999
09/14/2007
99/99/9999
0.5
01/01/2002
09/24/2003
0.5
01/01/2002
09/24/2003
1 ML
01/01/2002
09/24/2003
1 GM
10 U
1
1
01/01/2002
01/01/2002
09/24/2003
09/24/2003
1200000 U
0.5
08/15/2007
12/31/2009
1200000 U
0.5
08/15/2007
12/31/2009
1200000 U
600000 U
600000 U
600000 U
0.5
1
1
1
08/15/2007
11/21/2006
11/21/2006
11/21/2006
12/31/2009
99/99/9999
99/99/9999
99/99/9999
1/1/2002
1/1/2002
9/26/2002
9/26/2002
4 03/01/2006 09/01/2007
1
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

IPRATROPIUM BROMIDE (AMP) 0.02%
1/1/2002 99/99/9999 MILLIGRAM
PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM METAPROTERENOL SULFATE (AMP)
0.4%
1/1/2002 99/99/9999 PER 10 MILLIGRAMS
0.4%
1/1/2002 99/99/9999 PER 10 MILLIGRAMS
0.6%
1/1/2002 99/99/9999 PER 10 MILLIGRAMS
0.6%
1/1/2002 99/99/9999 PER 10 MILLIGRAMS
CEFEPIME (USP) 1 GM
CEFEPIME (USP) 1 GM
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
NOVAPLUS HALOPERIDOL DECANOATE
NOVAPLUS HALOPERIDOL DECANOATE
NOVAPLUS CEFOXITIN (USP) 1 GM
NOVAPLUS CEFOXITIN (USP) 2 GM
CEFEPIME (USP) 1 GM
CEFEPIME (USP) 2 GM
TRISENOX (AMP,10X10) 1 MG/ML
INJECTION, RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN, INTRAVENOUS,
1/1/2002
3/1/2004 50 MG
RESPIGAM (S.D.V.,PF)
INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER
1/1/2002 1/31/2007 VIAL
CYTOGAM (S.D.V.,PF)
1/1/2002
J7631
60793-0010-60 KO J7631
HCPCS Mod
KO
NDC Mod
60505-0806-01 KO J7644
NDC
HCPCS
IJ
IJ
IJ
IJ
ML
ML
ML
ML
50 MG
50 MG
50 MG
50 MG
0.5
0.5
0.5
1
10/21/2004
05/05/2007
05/05/2007
01/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
60977-0002-04
60977-0002-43
60977-0002-44
J2550
J2550
J2550
10/21/2004
5/5/2007
5/5/2007
1 ML VL IJ
1 ML AM IJ
1 ML VL IJ
ML
ML
ML
50 MG
50 MG
50 MG
1
1
1
10/21/2004
05/05/2007
05/05/2007
99/99/9999
99/99/9999
99/99/9999
60977-0016-02
J2275
1/15/2004
60977-0016-73
J2275
5/5/2007
60977-0017-01
J2275
1/15/2004
60977-0017-73
60977-0112-01
60977-0112-02
60977-0112-71
60977-0112-81
60977-0113-01
60977-0113-02
60977-0113-71
60977-0113-81
J2275
J2060
J2060
J2060
J2060
J2060
J2060
J2060
J2060
5/5/2007
2/13/2004
2/13/2004
5/5/2007
5/5/2007
2/13/2004
2/13/2004
5/5/2007
5/5/2007
60977-0114-01
J2275
1/1/2004
60977-0114-74
J2275
5/5/2007
60977-0115-01
J2275
1/1/2004
60977-0115-74
60977-0141-01
60977-0141-27
60977-0150-01
60977-0150-71
J2275
J2730
J2730
J2800
J2800
5/5/2007
12/20/2004
5/5/2007
1/1/2004
5/5/2007
60977-0155-01
J7643
60977-0155-01 KO J7643
60977-0155-02
J7643
60977-0155-02 KO J7643
60977-0155-03
60977-0155-05
60977-0155-17
60977-0155-63
J7643
7/19/2004
2/13/2004
KO
2/13/2004
3/2/2006
KO
3/2/2006
5/5/2007
KO
5/5/2007
5/5/2007
KO
J7643
60977-0155-63 KO J7643
60977-0155-81
KO
J7643
60977-0155-54 KO J7643
2/13/2004
7/19/2004
J7643
60977-0155-17 KO J7643
60977-0155-54
KO
J7643
60977-0155-06 KO J7643
2/13/2004
2/13/2004
J7643
60977-0155-05 KO J7643
60977-0155-06
KO
J7643
60977-0155-04 KO J7643
2/13/2004
2/13/2004
J7643
60977-0155-03 KO J7643
60977-0155-04
2/13/2004
KO
5/5/2007
5/5/2007
KO
5/5/2007
5/5/2007
Page 304 of 374
CF
HCPCS Amount #1
10 ML AM IJ
ML
10 MG
0.05
01/15/2004
99/99/9999
10 ML AM IJ
ML
10 MG
0.05
05/05/2007
99/99/9999
10 ML AM IJ
ML
10 MG
0.1
01/15/2004
99/99/9999
10 ML
1 ML
10 ML
10 ML
1 ML
1 ML
10 ML
10 ML
1 ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
10 MG
2 MG
2 MG
2 MG
2 MG
2 MG
2 MG
2 MG
2 MG
0.1
1
1
1
1
2
2
2
2
05/05/2007
02/13/2004
02/13/2004
05/05/2007
05/05/2007
02/13/2004
02/13/2004
05/05/2007
05/05/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
AM
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
20 ML AM IJ
1 ML NA
IJ
20 ML AM IJ
1 ML
1 EA
1 EA
10 ML
10 ML
ML
10 MG
01/01/2004
99/99/9999
ML
10 MG
05/05/2007
99/99/9999
ML
10 MG
2.5
01/01/2004
99/99/9999
NA
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
ML
ML
10 MG
1 GM
1 GM
10 ML
10 ML
2.5
1
1
0.1
0.1
05/05/2007
12/20/2004
05/05/2007
01/01/2004
05/05/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
IJ
ML
1 MG
0.2
02/13/2004
99/99/9999
1 ML VL
IJ
ML
1 MG
0.2
02/13/2004
99/99/9999
2 ML VL
IJ
ML
1 MG
0.2
02/13/2004
99/99/9999
2 ML VL
IJ
ML
1 MG
0.2
02/13/2004
99/99/9999
5 ML VL
IJ
ML
1 MG
0.2
02/13/2004
99/99/9999
5 ML VL
IJ
ML
1 MG
0.2
02/13/2004
99/99/9999
20 ML VL
IJ
ML
1 MG
0.2
07/19/2004
03/01/2006
20 ML VL
IJ
ML
1 MG
0.2
07/19/2004
03/01/2006
20 ML VL
IJ
ML
1 MG
0.2
02/13/2004
02/22/2006
20 ML VL
IJ
ML
1 MG
0.2
02/13/2004
02/22/2006
20 ML VL
IJ
ML
1 MG
0.2
03/02/2006
99/99/9999
20 ML VL
IJ
ML
1 MG
0.2
03/02/2006
99/99/9999
2 ML VL
IJ
ML
1 MG
0.2
05/05/2007
99/99/9999
2 ML VL
IJ
ML
1 MG
0.2
05/05/2007
99/99/9999
5 ML VL
IJ
ML
1 MG
0.2
05/05/2007
99/99/9999
5 ML VL
IJ
ML
1 MG
0.2
05/05/2007
99/99/9999
20 ML VL
IJ
ML
1 MG
0.2
05/05/2007
99/99/9999
20 ML VL
IJ
ML
1 MG
0.2
05/05/2007
99/99/9999
1 ML VL
IJ
ML
1 MG
0.2
05/05/2007
99/99/9999
VL
AM
VL
AM
Prior End Date #3
1 ML
1 ML
1 ML
1 ML
Prior Start Date #3
10/21/2004
5/5/2007
5/5/2007
1/1/2004
J2550
J2550
J2550
J2550
Prior End Date #2
60977-0001-03
60977-0001-43
60977-0001-44
60977-0002-02
End Date #1
03/25/2007
03/25/2007
10/04/2002
01/21/2002
03/26/2002
99/99/9999
Start Date #1
12/19/2005
12/19/2005
01/01/2002
01/01/2002
01/01/2002
01/01/2004
HCPCS Measure #1
1
1
1
1
1
0.5
Billing Units
10 MG
10 MG
1 EA
1 EA
1 EA
50 MG
NAVELBINE (SDV,PF) 10 MG/ML

CIMETIDINE HCL (M.D.V.) 150 MG/ML
PHENERGAN (25X1ML,DOSETTE) 25
MG/ML
PHENERGAN 25 MG/ML
PHENERGAN 25 MG/ML
PHENERGAN (1X25ML,DOSETTE) 50
MG/ML
PHENERGAN 50 MG/ML
PHENERGAN 50 MG/ML
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER DURAMORPH (AMP,DOSETTE,PF) 0.5
99/99/9999 10 MG
MG/ML
99/99/9999 10 MG
DURAMORPH (PF) 0.5 MG/ML
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER DURAMORPH (AMP,DOSETTE,PF) 1
99/99/9999 10 MG
MG/ML
99/99/9999 10 MG
DURAMORPH (PF) 1 MG/ML
ATIVAN (MDV) 2 MG/ML
ATIVAN (SDV) 2 MG/ML
ATIVAN (MDV) 4 MG/ML
ATIVAN 4 MG/ML
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER INFUMORPH 200 (AMP, DOSETTE,PF) 10
99/99/9999 10 MG
MG/ML
99/99/9999 10 MG
INFUMORPH 200 (PF) 10 MG/ML
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER INFUMORPH 500 (AMP, DOSETTE,PF) 25
99/99/9999 10 MG
MG/ML
99/99/9999 10 MG
INFUMORPH 500 (PF) 25 MG/ML
PROTOPAM CHLORIDE 1 GM
ROBAXIN (SDV) 100 MG/ML
ROBINUL (S.D.V.) 0.2 MG/ML
ROBINUL (S.D.V.) 0.2 MG/ML
ROBINUL (S.D.V) 0.2 MG/ML
ROBINUL (S.D.V) 0.2 MG/ML
ROBINUL (M.D.V.) 0.2 MG/ML
ROBINUL 0.2 MG/ML
ROBINUL 0.2 MG/ML
ROBINUL (10X20ML,MDV) 0.2 MG/ML
ROBINUL (10X20ML,MDV) 0.2 MG/ML
ROBINUL 0.2 MG/ML
ROBINUL 0.2 MG/ML
ROBINUL 0.2 MG/ML
ROBINUL 0.2 MG/ML
ROBINUL 0.2 MG/ML
Prior Start Date #2
NDC Package Type
ML
ML
ML
ML
ML
ML
NDC Label
IV
IV
IV
IV
IV
IJ
HCPCS Description
VL
VL
VL
VL
VL
AM
1 ML
5 ML
8 ML
2 ML
2 ML
1 ML
HCPCS Mod

HCPCS
J9390
J9390
J3490
J3490
J3490
J2550
NDC Mod
60831-3086-01
60831-3086-02
60951-0637-27
60951-0637-53
60951-0637-57
60977-0001-01
NDC
NDC Package Measure

Package
60977-0155-81 KO J7643
60977-0319-03
J3470
60977-0319-03
J3473
60977-0319-44
J3473
60977-0451-01
J2765
60977-0451-02
J2765
60977-0451-03
J2765
60977-0451-17
J2765
60977-0451-71
J2765
60977-0451-82
J2765
KO
5/5/2007
3/30/2006
1/1/2007
4/27/2007
1/1/2004
1/1/2004
1/1/2004
5/5/2007
5/5/2007
5/5/2007
61073-0005-01
Q0163
1/1/2002
61073-0005-10
Q0163
1/1/2002
61073-0006-01
Q0163
1/1/2002
61073-0006-10
Q0163
1/1/2002
61073-0026-04
Q0163
9/19/2002
61073-0026-08
Q0163
9/19/2002
61379-0120-01
J3245
5/1/2004
61379-0120-01
J3246
10/1/2005
61379-0120-02
J3245
5/1/2004
61379-0120-02
61379-0120-05
61379-0120-05
J3246
J3245
J3246
61392-0010-15
Q0178
61392-0010-30
Q0178
61392-0010-31
Q0178
61392-0010-32
Q0178
61392-0010-39
Q0178
61392-0010-45
Q0178
61392-0010-51
Q0178
61392-0010-54
Q0178
61392-0010-56
Q0178

12/31/2006 INJECTION, HYALURONIDASE, UP TO 150 UNITS
99/99/9999 INJECTION, HYALURONIDASE, RECOMBINANT, 1 USP UNIT
99/99/9999 INJECTION, HYALURONIDASE, RECOMBINANT, 1 USP UNIT
11/1/2005 3/31/2008 INJECTION, TIROFIBAN HCL, 0.25MG

1/1/2005
ROBINUL 0.2 MG/ML

HYLENEX (4X1ML VIALS,PF) 150 U/ML
HYLENEX (4X1ML VIALS,PF) 150 U/ML
HYLENEX (PF) 150 U/ML
REGLAN (S.D.V.,PF) 5 MG/ML
REGLAN (PF) 5 MG/ML
REGLAN (PF) 5 MG/ML
REGLAN (PF) 5 MG/ML
1 ML
1 ML
1 ML
1 ML
2 ML
10 ML
30 ML
2 ML
10 ML
30 ML
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 MG
150 U
1 USP UNIT
1 USP UNIT
10 MG
10 MG
10 MG
10 MG
10 MG
10 MG
0.2
1
150
150
0.5
0.5
0.5
0.5
0.5
0.5
05/05/2007
03/30/2006
01/01/2007
04/27/2007
01/01/2004
01/01/2004
01/01/2004
05/05/2007
05/05/2007
05/05/2007
99/99/9999
12/31/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
11/03/2006
1000 EA BO
PO
EA
50 MG
0.5
01/01/2002
11/03/2006
100 EA BO
PO
EA
50 MG
01/01/2002
11/03/2006
1000 EA BO
PO
EA
50 MG
01/01/2002
11/03/2006
118 ML BO
PO
ML
50 MG
0.05
09/19/2002
11/03/2006
DIPHENHYDRAMINE HCL
(AF,SF,CHERRY) 12.5 MG/5 ML
DIPHENHYDRAMINE HCL
(AF,SF,CHERRY) 12.5 MG/5 ML
MG/ML
MG/ML
MG/ML
MG/ML
AGGRASTAT (PF) 0.25 MG/ML
AGGRASTAT (PF) 0.25 MG/ML
236 ML BO
PO
ML
50 MG
0.05
09/19/2002
11/03/2006
100 ML PC
IV
ML
12.5 MG
0.004
05/01/2004
05/02/2004
100 ML PC
IV
ML
0.25 MG
0.2
10/01/2005
03/31/2008
250 ML PC
IV
ML
12.5 MG
0.004
05/01/2004
05/02/2004
250 ML PC
50 ML VL
50 ML VL
IV
IV
IV
ML
ML
ML
0.25 MG
12.5 MG
0.25 MG
0.2
0.02
1
11/01/2005
05/01/2004
01/01/2005
03/31/2008
12/31/2004
04/01/2008
15 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
30 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
31 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
32 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
HYDROXYZINE PAMOATE (BLISTER

PACK) 50 MG
30 EA BP
PO
EA
50 MG
01/01/2002
7/27/2006
45 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
500 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
2000 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
3000 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
Page 305 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
61392-0010-60
Q0178
1/1/2002
61392-0010-90
Q0178
1/1/2002
61392-0010-91
Q0178
1/1/2002
61392-0039-30
Q0171
1/1/2002
61392-0039-31
Q0171
1/1/2002
61392-0039-32
Q0171
1/1/2002
61392-0039-39
Q0171
1/1/2002
61392-0039-45
Q0171
1/1/2002
61392-0039-51
Q0171
1/1/2002
61392-0039-54
Q0171
1/1/2002
61392-0039-56
Q0171
1/1/2002
61392-0039-60
Q0171
1/1/2002
61392-0039-90
Q0171
1/1/2002
61392-0039-91
Q0171
1/1/2002
61392-0040-30
Q0172
1/1/2002
61392-0040-31
Q0172
1/1/2002
61392-0040-32
Q0172
1/1/2002
61392-0040-39
Q0172
1/1/2002
61392-0040-45
Q0172
1/1/2002
61392-0040-51
Q0172
1/1/2002
60 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
90 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
10000 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
30 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
31 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
32 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
CHLORPROMAZINE HCL (BLISTER

PACK) 10 MG
30 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
45 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
500 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
2000 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
3000 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
60 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
90 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
10000 EA NA
PO
EA
10 MG
01/01/2002
7/27/2006
30 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
31 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
32 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
CHLORPROMAZINE HCL (BLISTER

PACK) 25 MG
30 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
45 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
500 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
Page 306 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
61392-0040-54
Q0172
1/1/2002
61392-0040-56
Q0172
1/1/2002
61392-0040-60
Q0172
1/1/2002
61392-0040-90
Q0172
1/1/2002
61392-0040-91
Q0172
1/1/2002
61392-0081-30
Q0175
1/1/2002
61392-0081-31
Q0175
1/1/2002
61392-0081-32
Q0175
1/1/2002
61392-0081-39
Q0175
1/1/2002
61392-0081-45
Q0175
1/1/2002
61392-0081-51
Q0175
1/1/2002
61392-0081-54
Q0175
1/1/2002
61392-0081-56
Q0175
1/1/2002
61392-0081-60
Q0175
1/1/2002
61392-0081-90
Q0175
1/1/2002
61392-0081-91
Q0175
1/1/2002
61392-0082-30
Q0175
1/1/2002
61392-0082-31
Q0175
1/1/2002
61392-0082-32
Q0175
1/1/2002
61392-0082-39
Q0175
1/1/2002

7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
2000 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
3000 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
60 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
90 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
10000 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
30 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
31 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
32 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE (BLISTER PACK) 4 MG
30 EA BP
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
45 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
500 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
2000 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
3000 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
60 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
90 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 4 MG
10000 EA NA
PO
EA
4 MG
01/01/2002
7/27/2006
PERPHENAZINE 2 MG
30 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
PERPHENAZINE 2 MG
31 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
PERPHENAZINE 2 MG
32 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
30 EA BP
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
Page 307 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
61392-0082-45
Q0175
1/1/2002
61392-0082-51
Q0175
1/1/2002
61392-0082-54
Q0175
1/1/2002
61392-0082-56
Q0175
1/1/2002
61392-0082-60
Q0175
1/1/2002
61392-0082-90
Q0175
1/1/2002
61392-0082-91
Q0175
1/1/2002
61392-0105-30
G9017
12/1/2004
61392-0105-31
G9017
12/1/2004
61392-0105-32
G9017
12/1/2004
61392-0105-39
G9017
12/1/2004
61392-0105-45
G9017
12/1/2004
61392-0105-51
G9017
12/1/2004
61392-0105-54
G9017
12/1/2004
61392-0105-60
G9017
12/1/2004
61392-0105-90
G9017
12/1/2004
61392-0105-91
G9017
12/1/2004
61392-0123-30
Q0177
1/1/2002
61392-0123-31
Q0177
1/1/2002
61392-0123-32
Q0177
1/1/2002
61392-0123-39
Q0177
1/1/2002
61392-0123-45
Q0177
1/1/2002
61392-0123-51
Q0177
1/1/2002
61392-0123-54
Q0177
1/1/2002
61392-0123-60
Q0177
1/1/2002

7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
PERPHENAZINE 2 MG
45 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
PERPHENAZINE 2 MG
500 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
PERPHENAZINE 2 MG
2000 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
PERPHENAZINE 2 MG
3000 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
PERPHENAZINE 2 MG
60 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
PERPHENAZINE 2 MG
90 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
PERPHENAZINE 2 MG
10000 EA NA
PO
EA
4 MG
0.5
01/01/2002
7/27/2006
30 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
31 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005

AMANTADINE HCL (BLISTER PACK) 100
MG
32 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
30 EA PK
PO
EA
100 MG
12/01/2004
05/31/2005
45 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
500 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
2000 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
60 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
90 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
10000 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
30 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
31 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
32 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
HYDROXYZINE PAMOATE (BLISTER

PACK) 25 MG
30 EA BP
PO
EA
25 MG
01/01/2002
7/27/2006
45 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
500 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
2000 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
60 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
Page 308 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
61392-0123-90
Q0177
1/1/2002
61392-0123-91
61392-0136-30
61392-0136-31
61392-0136-32
Q0177
J7509
J7509
J7509
1/1/2002
1/1/2002
1/1/2002
1/1/2002
61392-0136-39
61392-0136-45
61392-0136-51
61392-0136-54
61392-0136-60
61392-0136-90
61392-0136-91
J7509
J7509
J7509
J7509
J7509
J7509
J7509
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
61392-0142-30
Q0176
1/1/2002
61392-0142-31
Q0176
1/1/2002
61392-0142-32
Q0176
1/1/2002
61392-0142-39
Q0176
1/1/2002
61392-0142-45
Q0176
1/1/2002
61392-0142-51
Q0176
1/1/2002
61392-0142-54
Q0176
1/1/2002
61392-0142-60
Q0176
1/1/2002
61392-0142-90
Q0176
1/1/2002
61392-0142-91
Q0176
1/1/2002
61392-0220-15
Q0163
1/1/2002
61392-0220-30
Q0163
1/1/2002
61392-0220-31
Q0163
1/1/2002
61392-0220-32
Q0163
1/1/2002
61392-0220-39
Q0163
1/1/2002
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
7/27/2006 REGIMEN
METHYLPREDNISOLONE (BLISTER
PACK) 4 MG
90 EA NA
PO
EA
25 MG
01/01/2002
7/27/2006
10000 EA
30 EA
31 EA
32 EA
NA
NA
NA
NA
PO
PO
PO
PO
EA
EA
EA
EA
25 MG
4 MG
4 MG
4 MG
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
7/27/2006
7/27/2006
7/27/2006
7/27/2006
30 EA
45 EA
500 EA
2000 EA
60 EA
90 EA
10000 EA
BP
NA
NA
NA
NA
NA
NA
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
4 MG
4 MG
4 MG
4 MG
4 MG
4 MG
4 MG
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
PERPHENAZINE 8 MG
30 EA NA
PO
EA
8 MG
01/01/2002
7/27/2006
PERPHENAZINE 8 MG
31 EA NA
PO
EA
8 MG
01/01/2002
7/27/2006
PERPHENAZINE 8 MG
32 EA NA
PO
EA
8 MG
01/01/2002
7/27/2006
30 EA BP
PO
EA
8 MG
01/01/2002
7/27/2006
PERPHENAZINE 8 MG
45 EA NA
PO
EA
8 MG
01/01/2002
7/27/2006
PERPHENAZINE 8 MG
500 EA NA
PO
EA
8 MG
01/01/2002
7/27/2006
PERPHENAZINE 8 MG
2000 EA NA
PO
EA
8 MG
01/01/2002
7/27/2006
PERPHENAZINE 8 MG
60 EA NA
PO
EA
8 MG
01/01/2002
7/27/2006
PERPHENAZINE 8 MG
90 EA NA
PO
EA
8 MG
01/01/2002
7/27/2006
PERPHENAZINE 8 MG
10000 EA NA
PO
EA
8 MG
01/01/2002
7/27/2006
15 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
30 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
31 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
32 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006

PACK) 25 MG
30 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
Page 309 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
61392-0220-45
Q0163
1/1/2002
61392-0220-51
Q0163
1/1/2002
61392-0220-54
Q0163
1/1/2002
61392-0220-56
Q0163
1/1/2002
61392-0220-60
Q0163
1/1/2002
61392-0220-90
Q0163
1/1/2002
61392-0220-91
Q0163
1/1/2002
61392-0223-30
Q0163
1/1/2002
61392-0223-31
Q0163
1/1/2002
61392-0223-32
Q0163
1/1/2002
61392-0223-39
Q0163
1/1/2002
61392-0223-45
Q0163
1/1/2002
61392-0223-51
Q0163
1/1/2002
61392-0223-54
Q0163
1/1/2002
61392-0223-56
Q0163
1/1/2002
61392-0223-60
Q0163
1/1/2002
61392-0223-90
Q0163
1/1/2002
61392-0223-91
61392-0408-15
61392-0408-30
61392-0408-31
61392-0408-32
61392-0408-39
61392-0408-45
61392-0408-51
61392-0408-54
61392-0408-56
Q0163
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

45 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
500 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
2000 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
3000 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
60 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
90 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
10000 EA NA
PO
EA
50 MG
0.5
01/01/2002
7/27/2006
30 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
31 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
32 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006

PACK) 50 MG
30 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
45 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
500 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
2000 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
3000 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
60 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
90 EA NA
PO
EA
50 MG
01/01/2002
7/27/2006
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
1
1
1
1
1
1
1
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE (BLISTER PACK) 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
Page 310 of 374
10000 EA
15 EA
30 EA
31 EA
32 EA
30 EA
45 EA
500 EA
2000 EA
3000 EA
NA
NA
NA
NA
NA
BP
NA
NA
NA
NA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
61553-0107-02
J3010


(SRN,12 ML) 0.5 MG/100 ML-0.9%


61553-0111-48
61553-0112-48
J3010
J3010
J3010
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
61553-0113-02
J3010

61553-0114-02
J3010

61553-0116-48
J3010
61553-0118-41
J3010
61553-0161-41
J1170

FENTANYL CITRATE (INTRAVIA) 0.05
MG/ML
61553-0162-67
J1170
61553-0163-75
J1170
61553-0165-41
J1170
61553-0166-67
J1170
61553-0167-75
J1170
61553-0170-41
J2175
61553-0172-48
J2175
61553-0173-48
J2175
61553-0177-41
J2270
61553-0178-48
J2270
61553-0179-48
J2270
(INTRAVIA) 1 GM/100 ML-0.9%
(IPUMP BAG) 1 GM/100 ML-0.9%
Page 311 of 374
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
250 ML BG
IV
10 ML SR
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
MG
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
4
4
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
7/27/2006
ML
0.1 MG
0.05
02/02/2004
99/99/9999
IV
ML
0.1 MG
0.05
02/02/2004
99/99/9999
100 ML BG
IV
ML
0.1 MG
0.1
02/02/2004
99/99/9999
100 ML BG
IV
ML
0.1 MG
0.1
02/02/2004
99/99/9999
250 ML BG
IV
ML
0.1 MG
0.1
02/02/2004
99/99/9999
250 ML BG
IV
ML
0.1 MG
0.1
02/02/2004
99/99/9999
100 ML BG
IV
ML
0.1 MG
0.2
02/02/2004
99/99/9999
50 ML NA
IV
ML
0.1 MG
0.5
02/02/2004
99/99/9999
50 ML BG
IV
ML
4 MG
0.05
02/02/2004
99/99/9999
25 ML SR
IV
ML
4 MG
0.05
02/02/2004
99/99/9999
50 ML SR
IV
ML
4 MG
0.05
02/02/2004
99/99/9999
50 ML BG
IV
ML
4 MG
0.25
02/02/2004
99/99/9999
25 ML SR
IV
ML
4 MG
0.25
02/02/2004
99/99/9999
50 ML SR
IV
ML
4 MG
0.25
02/02/2004
99/99/9999
50 ML BG
IV
ML
100 MG
0.1
02/02/2004
99/99/9999
100 ML BG
IV
ML
100 MG
0.1
02/02/2004
99/99/9999
100 ML BG
IV
ML
100 MG
0.1
02/02/2004
99/99/9999
50 ML BG
IV
ML
10 MG
0.1
02/02/2004
99/99/9999
100 ML BG
IV
ML
10 MG
0.1
02/02/2004
99/99/9999
150 ML BG
IV
ML
10 MG
0.1
02/02/2004
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
NA
NA
NA
NA
NA
NA
NA
BP
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
BP
NA
NA
NA
NA
NA
NA
Billing Units
60 EA
90 EA
10000 EA
15 EA
30 EA
31 EA
32 EA
30 EA
45 EA
500 EA
2000 EA
3000 EA
60 EA
90 EA
10000 EA
30 EA
31 EA
32 EA
30 EA
45 EA
500 EA
2000 EA
60 EA
90 EA
10000 EA

Package
NDC Package Type
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
NDC Package Measure
61392-0408-60
61392-0408-90
61392-0408-91
61392-0417-15
61392-0417-30
61392-0417-31
61392-0417-32
61392-0417-39
61392-0417-45
61392-0417-51
61392-0417-54
61392-0417-56
61392-0417-60
61392-0417-90
61392-0417-91
61392-0761-30
61392-0761-31
61392-0761-32
61392-0761-39
61392-0761-45
61392-0761-51
61392-0761-54
61392-0761-60
61392-0761-90
61392-0761-91
61553-0109-72

NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
61553-0181-02
J2270
61553-0183-48
J2270
61553-0185-02
J2270
61553-0186-67
J2270
61553-0187-75
J2270
61553-0189-48
J3490
61553-0190-48
J3490
61553-0191-48
J3490
61553-0192-02
J3490
61553-0193-41
J3490
61553-0194-48
J3490
61553-0228-02
J3490
61553-0421-04
J3475
61553-0423-02
J3475
61553-0602-48
J3010
61553-0624-48
J1170
61553-0649-75
J2271
61553-0651-76
J2271
61553-0681-76
J1170
61553-0701-68
J1170
61553-0702-68
J1170
61553-0704-68
J1170
61553-0705-68
J1170
61553-0706-68
J1170
61553-0710-68
J1170
61553-0712-68
J1170
02/02/2004
99/99/9999
02/02/2004
99/99/9999
250 ML NA
IV
ML
10 MG
0.1
02/02/2004
99/99/9999
25 ML NA
IV
ML
10 MG
0.2
02/02/2004
99/99/9999
50 ML NA
IV
ML
10 MG
0.2
02/02/2004
99/99/9999
100 ML BG
IV
ML
1 EA
02/02/2004
99/99/9999
100 ML BG
IV
ML
1 EA
02/02/2004
99/99/9999
100 ML BG
IV
ML
1 EA
02/02/2004
99/99/9999
250 ML BG
IV
ML
1 EA
02/02/2004
99/99/9999
50 ML BG
IV
ML
1 EA
02/02/2004
99/99/9999
100 ML BG
IV
ML
1 EA
02/02/2004
99/99/9999
99/99/9999
250 ML NA
EP
ML
1 EA
11/21/2007
1000 ML NA
IV
ML
500 MG
0.04
02/01/2005
99/99/9999
250 ML NA
IV
ML
500 MG
0.16
07/11/2005
99/99/9999
100 ML BG
IV
ML
0.1 MG
0.02
02/02/2004
99/99/9999
100 ML BG
IV
ML
4 MG
0.05
02/02/2004
99/99/9999
50 ML EA
IJ
ML
100 MG
0.5
3/3/2005
99/99/9999
55 ML EA
IJ
ML
100 MG
0.5
3/3/2005
99/99/9999
60 ML SR
IV
ML
4 MG
0.05
11/21/2007
99/99/9999
30 ML VL
IV
ML
4 MG
0.025
12/01/2006
99/99/9999
30 ML VL
IV
ML
4 MG
0.05
12/01/2006
99/99/9999
30 ML VL
IV
ML
4 MG
0.1
12/01/2006
99/99/9999
30 ML VL
IV
ML
4 MG
0.125
12/01/2006
99/99/9999
30 ML VL
IV
ML
4 MG
0.15
12/01/2006
99/99/9999
30 ML VL
IV
ML
4 MG
0.25
12/01/2006
99/99/9999
30 ML VL
IV
ML
4 MG
0.3
12/01/2006
99/99/9999
0.25
11/21/2007
99/99/9999
02/06/2004
99/99/9999
4 MG
0.5
12/01/2006
99/99/9999
30 ML VL
IV
ML
0.1 MG
100
12/01/2006
99/99/9999
FENTANYL CITRATE-SODIUM CHLORIDE

(10X30ML, PCA VIAL) 20 MCG/ML-0.9%
30 ML VL
IV
ML
0.1 MG
200
12/01/2006
99/99/9999

30 ML VL
IV
ML
0.1 MG
300
12/01/2006
99/99/9999
Page 312 of 374
30 ML VL
IV
ML
0.1 MG
500 ML NA
IV
ML
10 U
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
0.1
0.1
ML
J1170
J3010
10 MG
10 MG
IV
61553-0780-68
61553-0793-68
ML
ML
30 ML VL
J3010
IV
IV

J2590
61553-0792-68

MORPHINE SULFATE (5X50ML,LATEXFREE) 50 MG/ML
MORPHINE SULFATE (5X55ML) 50
MG/ML
HYDROMORPHONE HYDROCHLORIDESODIUM CHLORIDE (5X60ML, BD
SYRINGES) 0.2 MG/ML-0.9%
HYDROMORPHONE HYDROCHLORIDESODIUM CHLORIDE (10X30ML, PCA
VIAL) 0.1 MG/ML-0.9%
VIAL) 1 MG/ML-0.9%
250 ML BG
100 ML NA
J3010
61553-0732-03
J3010
(INTRAVIA) 0.0625%-0.9%
(IPUMP BAG) 0.0625%-0.9%
(INTRAVIA) 0.125%-0.9%
(INTRAVIA) 0.125%-0.9%
(INTRAVIA) 0.25%-0.9%
(IPUMP BAG) 0.125%-0.9%
ROPIVACAINE HYDROCHLORIDESODIUM CHLORIDE 0.2%-0.9%
DEXTROSE-MAGNESIUM SULFATE
(6X1000ML, VIAFLEX BAG) 5%-20 GM
MAGNESIUM SULFATE IN DEXTROSE
(24X250ML) 5%-8 GM/100 ML

OXYTOCIN-SODIUM CHLORIDE
(12X500ML, VIAFLEX BAG) 10 U-0.9%
(10X30ML, PCA VIAL) 2 MG/ML
61553-0730-68
61553-0791-68
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
61553-0794-68
J3010
61553-0795-68
J3010
61570-0054-10
J3490
1/1/2002
61570-0055-10
J3490
1/1/2002
61570-0079-01
Q0173
61570-0079-05
Q0173

9/25/2002
61570-0085-10
J2510
12/4/2002
61570-0086-10
61570-0095-01
61570-0095-25
61570-0096-25
J2510
J3490
J3490
J3490
12/6/2002
1/9/2003
1/9/2003
1/9/2003

61570-0139-10
J0530
1/19/2002
61570-0140-10
J0530
1/1/2002
61570-0141-10
J0540
5/29/2002
61570-0142-10
J0530
1/1/2002
61570-0143-10
J0540
1/1/2002
61570-0144-10
J0540
1/1/2002

8/22/2007 600,000 UNITS
8/14/2007 600,000 UNITS
8/14/2007 1,200,000 UNITS
10/11/2007 600,000 UNITS
8/22/2007 1,200,000 UNITS
8/14/2007 1,200,000 UNITS
61570-0146-10
J0560
61570-0147-10
61570-0148-10
J0560
J0560

61570-0149-10
J2510
1/10/2002
61570-0150-10
61570-0180-01
61570-0181-01
61570-0182-01
J2510
J1380
J1390
J0970
1/1/2002
10/24/2002
8/29/2002
10/24/2002
61570-0186-01
Q0173
1/1/2002
61570-0187-05
61570-0260-10
61570-0261-10
61570-0301-41
61570-0401-11
Q0173
J2770
J2770
J7699
J0170
1/1/2002
6/27/2003
9/9/2003
1/1/2002
9/7/2002
61570-0405-71
J0720
1/1/2002
61570-0414-51
61570-0416-01
61570-0416-03
61570-0416-05
61570-0418-81
61570-0540-02
61570-0541-20
61570-0543-25
J0770
J2590
J2590
J2590
J0170
J3250
J3250
J3250
61646-0308-01
61703-0201-07
61703-0202-04
61703-0202-07
61703-0202-08
Q0173
J3490
J3490
J3490
J3490

3/1/2006 INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM

9/7/2002
1/1/2002

FENTANYL CITRATE (10X30ML, PCA
VIAL) 50 MCG/ML
SEPTRA INFUSION (M.D.V.) 80 MG/ML-16
MG/ML
SEPTRA INFUSION (M.D.V.) 80 MG/ML-16
MG/ML
TIGAN 300 MG
IV
ML
0.1 MG
400
12/01/2006
99/99/9999
30 ML VL
IV
ML
0.1 MG
500
12/01/2006
99/99/9999
10 ML VL
IV
ML
1 EA
01/01/2002
01/09/2003
20 ML VL
IV
ML
1 EA
01/01/2002
01/09/2003
100 EA BO
PO
EA
250 MG
1.2
02/13/2002
99/99/9999
250 MG
BO
PO
EA
1.2
09/25/2002
03/04/2004
SR
IM
ML
600000 U
12/04/2002
09/13/2007
SR
VL
VL
VL
IM
IV
IV
IV
ML
EA
EA
EA
600000 U
1 EA
1 EA
1 EA
1
1
1
1
12/06/2002
01/09/2003
01/09/2003
01/09/2003
09/13/2007
7/30/2008
9/30/2008
03/30/2008
SR
IM
ML
600000 U
01/19/2002
08/22/2007
SR
IM
ML
600000 U
01/01/2002
08/14/2007
08/14/2007
SR
IM
ML
1200000 U
0.5
05/29/2002
SR
IM
ML
600000 U
01/01/2002
10/11/2007
SR
IM
ML
1200000 U
0.5
01/01/2002
08/22/2007
SR
IM
ML
1200000 U
0.5
01/01/2002
08/14/2007
1 ML SR
IM
ML
600000 U
01/01/2002
11/20/2006
2 ML SR
4 ML SR
IM
IM
ML
ML
600000 U
600000 U
1
1
01/01/2002
01/01/2002
11/20/2006
11/20/2006
1 ML SR
IM
ML
600000 U
01/10/2002
12/03/2002
2
5
5
5
IM
IM
IM
IM
ML
ML
ML
ML
600000 U
10 MG
20 MG
40 MG
1
1
1
1
01/01/2002
10/24/2002
08/29/2002
10/24/2002
12/05/2002
12/09/2007
02/04/2008
03/30/2008
ML
ML
ML
ML
SR
VL
VL
VL
TIGAN 100 MG
100 EA BO
PO
EA
250 MG
0.4
01/01/2002
02/08/2002
TIGAN 250 MG
SYNERCID (PF) 350 MG-150 MG
SYNERCID 420 MG-180 MG
ADRENALIN 1:100
ADRENALIN (VIAL) 1 MG/ML
CHLOROMYCETIN SODIUM SUCCINATE
(VIAL) 1 GM
500 EA
1 EA
1 EA
7.5 ML
30 ML
PO
IV
IV
IH
IJ
EA
EA
EA
ML
ML
250 MG
500 MG
500 MG
1 EA
1 ML
1
1
1.2
1
1
01/01/2002
06/27/2003
09/09/2003
01/01/2002
09/07/2002
02/08/2002
99/99/9999
03/08/2005
03/08/2005
02/27/2008
IV
EA
1 GM
01/01/2002
03/01/2006
COLY-MYCIN M (PARENTERAL) 150 MG

PITOCIN (AMP) 10 U/ML
PITOCIN (SRN STERI-DOSE) 10 U/ML
PITOCIN (STERI-VIAL) 10 U/ML
TIGAN (AMP) 100 MG/ML
TIGAN (SDV,2X25) 100 MG/ML
1 EA
1 ML
1 ML
1 ML
1 ML
2 ML
20 ML
2 ML
VL
AM
SR
VL
AM
AM
VL
VL
IJ
IV
IV
IV
IJ
IM
IM
IM
EA
ML
ML
ML
ML
ML
ML
ML
150 MG
10 U
10 U
10 U
1 ML
200 MG
200 MG
200 MG
1
1
1
1
1
0.5
0.5
0.5
100 EA
2 ML
4 ML
2 ML
3 ML
BO
VL
VL
VL
VL
PO
IJ
IJ
IJ
IJ
EA
ML
ML
ML
ML
250 MG
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1

Page 313 of 374
BO
VL
VL
BO
VL
1 EA VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
30 ML VL
TIGAN 300 MG
12000 EA
PENICILLIN G PROCAINE (TUBEX, 21GX1
1/4) 600000 U/ML
1 ML
PENICILLIN G PROCAINE (TUBEX, 21GX1
1/4) 600000 U/ML
2 ML
1 EA
1 EA
1 EA
BICILLIN C-R
(TUBEX,21GX1",PEDIATRIC) 300000 U/ML
300000 U/ML
1 ML
BICILLIN C-R (TUBEX,21GX1 1/4") 300000
U/ML-300000 U/ML
2 ML
BICILLIN C-R
(TUBEX,21GX1",PEDIATRIC)
2 ML
U/ML
4 ML
BICILLIN C-R 900/300 PEDIATRIC
(TUBEX,21GX1 1/4")
2 ML
BICILLIN C-R 900/300 PEDIATRIC
(TUBEX,21GX1")
2 ML
BICILLIN L-A (TUBEX,21GX1",PEDIATRIC)
600000 U/ML
BICILLIN L-A (TUBEX,21GX1 1/4") 600000
U/ML
U/ML
U/ML
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
01/01/2002 11/24/2008
09/07/2002 08/04/2004
01/01/2002 04/02/2004
01/01/2002 03/31/2008
01/01/2002
5/31/2008
01/01/2002
4/24/2006
01/01/2002
7/31/2008
04/25/2006
7/21/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/23/2003
05/24/2002
05/24/2002
05/24/2002
05/24/2002
61703-0203-04
J7608
61703-0203-04 KO J7608
61703-0203-31
KO
KO
KO
1/1/2002
1/1/2002
KO
1/1/2002

ACETYLCYSTEINE (VIAL) 10%
4 ML VL
IH
ML
1 GM
0.1
01/01/2002
4 ML VL
IH
ML
1 GM
0.1
01/01/2002
05/24/2002
30 ML VL
IH
ML
1 GM
0.1
04/01/2007
99/99/9999
1/1/2002
8/1/2006
0.1
30 ML VL
IH
ML
1 GM
0.1
04/01/2007
99/99/9999
1/1/2002
8/1/2006
0.1
4 ML VL
IH
ML
1 GM
0.2
01/01/2002
05/24/2002
4 ML VL
IH
ML
1 GM
0.2
01/01/2002
05/24/2002
30 ML VL
IH
ML
1 GM
0.2
04/01/2007
99/99/9999
1/1/2002
8/1/2006
0.2
30 ML VL
IH
ML
1 GM
0.2
04/01/2007
99/99/9999
1/1/2002
8/1/2006
0.2
0.5
J2765
1/1/2002
METOCLOPRAMIDE (S.D.V.,PF) 5 MG/ML
2 ML VL
IV
ML
10 MG
0.5
09/04/2007
9/5/2007
1/1/2002
8/1/2006
61703-0210-11
J2765
1/1/2002
10 ML VL
IV
ML
10 MG
0.5
09/04/2007
9/5/2007
1/1/2002
8/1/2006
0.5
61703-0210-21
J2765
20 ML VL
IV
ML
10 MG
0.5
09/04/2007
99/99/9999
1/1/2002
8/1/2006
0.5
5/1/2003
8/1/2006
0.5
61703-0210-31
J2765
61703-0210-35
J2765
61703-0219-75
J2270
1/1/2002
61703-0219-80
J2270
1/1/2002
61703-0219-85
J2270
1/1/2002
61703-0221-75
J2270
1/1/2002
61703-0221-85
J2270
1/1/2002

METOCLOPRAMIDE (150MG/30ML,PF) 5
MG/ML
MORPHINE SULFATE (LUER LOCK
SRN,RAPI-JECT) 1 MG/ML
MORPHINE SULFATE (UNIT OF
USE,RAPI-JECT) 1 MG/ML
MORPHINE SULFATE (VIAL FOR
S.P.A.R.) 1 MG/ML
MORPHINE SULFATE (LUER LOCK
SRN,RAPI-JECT) 5 MG/ML
MORPHINE SULFATE (VIAL FOR
S.P.A.R.) 5 MG/ML
30 ML VL
IJ
ML
10 MG
0.5
01/01/2002
05/24/2002
61703-0223-21
J2270
1/1/2002
20 ML VL
IJ
ML
10 MG
2.5
01/01/2002
05/08/2007
61703-0223-43
J2270
1/1/2002
IJ
ML
10 MG
2.5
01/01/2002
05/24/2002
J2275
1/1/2002
4 ML SR
IJ
ML
10 MG
2.5
01/01/2002
09/30/2005
61703-0224-72
J2275
1/1/2002
20 ML SR
IJ
ML
10 MG
2.5
01/01/2002
09/30/2005
61703-0224-76
J2275
1/1/2002
50 ML SR
IJ
ML
10 MG
2.5
01/01/2002
05/24/2002
61703-0224-80
J2275
1/1/2002
10 ML SR
IJ
ML
10 MG
2.5
01/01/2002
09/30/2005
61703-0224-86
J2275
1/1/2002

LOCK,PF,RAPI-JECT) 25 MG/ML
LOCK,P.F,RAPI-JECT) 25 MG/ML
40 ML VL
61703-0224-71
30 ML SR
IJ
ML
10 MG
2.5
01/01/2002
05/24/2002
61703-0225-21
J2271
1/1/2002
20 ML VL
IJ
ML
100 MG
0.5
01/01/2002
05/08/2007
61703-0225-43
J2271
1/1/2002
ML
100 MG
0.5
01/01/2002
05/08/2007
1/1/2002
20 ML SR
IJ
ML
10 MG
01/01/2002
09/30/2005
61703-0226-76
J2275
1/1/2002
50 ML SR
IJ
ML
10 MG
01/01/2002
09/30/2005
61703-0226-80
J2275
1/1/2002
10 ML SR
IJ
ML
10 MG
01/01/2002
09/30/2005
61703-0226-86
J2275
1/1/2002

IJ
J2275

9/30/2005 10 MG
9/30/2005 10 MG
9/30/2005 10 MG
5/24/2002 10 MG
40 ML VL
61703-0226-72
30 ML SR
IJ
ML
10 MG
01/01/2002
05/24/2002
61703-0231-32
J2270
1/1/2002
IJ
ML
10 MG
01/01/2002
05/24/2002
J2275
J0636
30 ML SR IJ
1 ML AM IV
ML
ML
10 MG
0.1 MCG
1
10
01/01/2002
04/02/2004
05/24/2002
99/99/9999
61703-0236-75
61703-0236-85
61703-0238-07
61703-0239-21
61703-0239-22
61703-0239-26
61703-0241-03
J2175
J2175
J3490
J3490
J3490
J3490
J0282

30 ML
30 ML
2 ML
20 ML
20 ML
4 ML
3 ML
61703-0242-21
J2260
61703-0242-32
J2260
61703-0242-50
J2260

CALCITRIOL 1 MCG/ML
MEPERIDINE HCL (S.D.V.,RAPI-JECT) 10
MG/ML
MILRINONE LACTATE (PF,LATEX-FREE)
1 MG/ML
1 MG/ML
1 MG/ML
10 ML VL
61703-0232-86
61703-0234-29

1/1/2002 5/24/2002 10 MG
Page 314 of 374
05/24/2002
61703-0210-07

9/30/2005 10 MG
9/30/2005 10 MG
5/24/2002 10 MG
9/30/2005 10 MG
5/24/2002 10 MG
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

1/1/2002
1/1/2002
J7608
61703-0204-31 KO J7608
1/1/2002
1/1/2002
J7608
61703-0204-04 KO J7608
61703-0204-31
1/1/2002
J7608
61703-0203-31 KO J7608
61703-0204-04
HCPCS Mod
HCPCS
NDC Mod
NDC
30 ML VL
IV
ML
10 MG
0.5
01/01/2002
99/99/9999
30 ML VL
IV
ML
10 MG
0.5
09/04/2007
99/99/9999
30 ML SR
IV
ML
10 MG
0.1
01/01/2002
05/24/2002
10 ML NA
IV
ML
10 MG
0.1
01/01/2002
05/24/2002
30 ML VL
IV
ML
10 MG
0.1
01/01/2002
05/24/2002
30 ML SR
IJ
ML
10 MG
0.5
01/01/2002
05/24/2002
VL
VL
VL
VL
VL
VL
AM
IJ
IJ
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
100 MG
100 MG
1 EA
1 EA
1 EA
1 EA
30 MG
0.1
0.1
1
1
1
1
1.66666
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/01/2007
05/24/2002
05/24/2002
05/24/2002
05/24/2002
05/24/2002
05/24/2002
99/99/9999
2/12/2003
8/1/2006 1.66666
20 ML VL
IV
ML
5 MG
0.2
09/04/2007
99/99/9999
9/23/2002
8/1/2006
0.2
10 ML VL
IV
ML
5 MG
0.2
09/04/2007
99/99/9999
9/23/2002
8/1/2006
0.2
50 ML VL
IV
ML
5 MG
0.2
09/04/2007
99/99/9999
9/23/2002
8/1/2006
0.2
61703-0243-45
61703-0243-50
J1170
J1170
61703-0243-53
J1170
61703-0244-07
61703-0245-22
61703-0246-15
J2405
J2405
J1170
61703-0303-46
J9110
61703-0303-50
61703-0304-25
J9110
J9110

61703-0304-36
61703-0305-09
61703-0305-38
61703-0306-50
J9110
J9100
J9100
J9290

1/1/2002 5/24/2002 MITOMYCIN, 20 MG
61703-0309-06
J9370
61703-0309-16
61703-0310-18
61703-0311-21
61703-0311-21
61703-0311-43
61703-0311-43
J9370
J9360
Q4075
J0133
Q4075
J0133

1/1/2002
61703-0317-45
J0595
61703-0318-45
61703-0319-22
61703-0320-07
61703-0320-32
61703-0320-53
61703-0321-07
61703-0321-32
61703-0321-42
61703-0321-53
J0595
J9110
J2250
J2250
J2250
J2250
J2250
J2250
J2250
6/25/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
61703-0321-73
61703-0323-22
J2250
J9040
61703-0324-18
61703-0324-39
J2430
J2430

61703-0325-18
61703-0326-18
J2430
J2430

61703-0327-22
61703-0329-11
J9140
J0690
9/23/2002 99/99/9999 DACARBAZINE, 200 MG

61703-0330-60
61703-0331-09
61703-0332-18
J0690
J9200
J9040

9/23/2002 99/99/9999 INJECTION, FLOXURIDINE, 500 MG
61703-0333-11
J0697
1/1/2002
61703-0334-33
61703-0339-18
61703-0339-22
61703-0339-50
61703-0339-56
J0697
J9045
J9045
J9045
J9045
1/1/2002
4/14/2004
4/14/2004
4/14/2004
2/9/2005

61703-0341-06
J9390
61703-0341-09
61703-0342-09
61703-0342-22
61703-0342-50
J9390
J9265
J9265
J9265
11/7/2005
4/21/2004
4/21/2004
4/21/2004
61703-0343-18
J9293
61703-0343-65
61703-0343-66
J9293
J9293
5/15/2003
5/15/2003

5/15/2003

10/8/2003


HYDROMORPHONE HCL (S.D.V.) 10

MG/ML
HYDROMORPHONE HCL 10 MG/ML
HYDROMORPHONE HCL (S.D.V.) 10
MG/ML
ONDANSETRON (2MLX10,SDV,USP) 2
MG/ML
ONDANSETRON (M.D.V.,USP) 2 MG/ML
HYDROMORPHONE HCL 2 MG/ML
1 ML VL
50 ML VL
IJ
IJ
ML
ML
4 MG
4 MG
2.5
2.5
05/15/2003
05/15/2003
05/08/2007
05/08/2007
5 ML VL
IJ
ML
4 MG
2.5
05/15/2003
05/08/2007
2 ML VL
20 ML VL
1 ML VL
IJ
IJ
IJ
ML
ML
ML
1 MG
1 MG
4 MG
2
2
0.5
12/26/2006
12/26/2006
10/08/2003
99/99/9999
99/99/9999
05/08/2007
CYTARABINE (1GM/50ML,PF) 20 MG/ML

CYTARABINE (BULK PACKAGE,PF) 20
MG/ML
CYTARABINE (M.D.V.) 20 MG/ML
CYTARABINE (500MG/25ML,PF) 20
MG/ML
CYTARABINE (S.D.V.,PF) 20 MG/ML
CYTARABINE (S.D.V. X 5,PF) 20 MG/ML
MITOMYCIN 20 MG
VINCRISTINE SULFATE (S.D.V.,PF) 1
MG/ML
VINCRISTINE SULFATE (S.D.V.,PF) 1
MG/ML
VINBLASTINE SULFATE (VIAL) 10 MG
ACYCLOVIR SODIUM (VIAL) 25 MG/ML
MG/ML
MG/ML
CYTARABINE (S.D.V.,PF) 100 MG/ML
MIDAZOLAM HCL (SRN,RAPI-JECT) 5
MG/ML
BLEOMYCIN SULFATE 30 U
PAMIDRONATE DISODIUM (SDV) 3
MG/ML
50 ML VL
IJ
ML
500 MG
0.04
05/01/2003
99/99/9999
50 ML VL
25 ML VL
IJ
IJ
ML
ML
500 MG
500 MG
0.04
0.04
01/01/2002
01/01/2002
99/99/9999
99/99/9999
25 ML
5 ML
5 ML
1 EA
VL
VL
VL
VL
IJ
IJ
IJ
IV
ML
ML
ML
EA
500 MG
100 MG
100 MG
20 MG
0.04
0.2
0.2
1
05/01/2003
01/01/2002
05/01/2003
01/01/2002
99/99/9999
04/30/2003
99/99/9999
05/24/2002
1 ML VL
PAMIDRONATE DISODIUM (PF) 6 MG/ML

DACARBAZINE (SINGLE DOSE VIAL,PF)
200 MG
10 GM
FUDR 0.5 GM
BLEOMYCIN SULFATE 15 U
CEFUROXIME SODIUM
(VIAL,TRAYPACK) 750 MG
CEFUROXIME SODIUM
(VIAL,TRAYPACK) 1.5 GM
MG/ML
MG/ML
IV
ML
1 MG
01/01/2002
99/99/9999
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
ML
EA
ML
ML
ML
ML
1 MG
1 MG
5 MG
5 MG
5 MG
5 MG
1
10
5
5
5
5
01/01/2002
01/01/2002
10/01/2003
01/01/2006
10/01/2003
01/01/2006
99/99/9999
09/03/2003
12/31/2005
4/24/2006
12/31/2005
4/24/2006
1 ML VL
2 ML
1 EA
20 ML
20 ML
40 ML
40 ML
IJ
ML
1 MG
06/25/2004
99/99/9999
VL
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 MG
500 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
2
0.2
1
1
1
5
5
5
5
06/25/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/01/2007
04/01/2007
04/01/2007
04/01/2007
99/99/9999
99/99/9999
05/24/2002
05/24/2002
05/24/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML SR
1 EA VL
IJ
IJ
ML
EA
1 MG
15 U
5
2
01/01/2002
01/01/2002
05/24/2002
99/99/9999
10 ML VL
10 ML VL
IV
IV
ML
ML
30 MG
30 MG
0.1
0.1
12/15/2006
09/15/2005
99/99/9999
99/99/9999
10 ML VL
10 ML VL
IV
IV
ML
ML
30 MG
30 MG
0.2
0.3
01/27/2003
09/15/2005
99/99/9999
99/99/9999
1 EA VL
1 EA VL
IV
IJ
EA
EA
200 MG
500 MG
1
2
09/23/2002
01/01/2002
99/99/9999
05/24/2002
1 EA VL
1 EA VL
1 EA VL
IJ
IJ
IJ
EA
EA
EA
500 MG
500 MG
15 U
20
1
1
01/01/2002
09/23/2002
01/01/2002
05/24/2002
99/99/9999
99/99/9999
1 EA VL
1 ML
20 ML
2 ML
10 ML
5 ML
2 ML
10 ML
1 ML
5 ML
IJ
EA
750 MG
01/01/2002
05/24/2002
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
EA
ML
ML
ML
ML
750 MG
50 MG
50 MG
50 MG
50 MG
2
0.2
0.2
0.2
0.2
01/01/2002
04/14/2004
04/14/2004
04/14/2004
02/09/2005
05/24/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
1 EA
5 ML
15 ML
45 ML
60 ML
IV
ML
10 MG
09/07/2005
99/99/9999
VL
VL
VL
VL
IV
IV
IV
IV
ML
ML
ML
ML
10 MG
30 MG
30 MG
30 MG
1
0.2
0.2
0.2
11/07/2005
04/21/2004
04/21/2004
04/21/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
MITOXANTRONE
(USP,CONCENTRATE,MDV,PF) 2 MG/ML
10 ML VL
IV
ML
5 MG
0.4
04/11/2006
99/99/9999
MITOXANTRONE
12.5 ML VL
IV
ML
5 MG
0.4
04/11/2006
99/99/9999
MITOXANTRONE
15 ML VL
IV
ML
5 MG
0.4
04/11/2006
99/99/9999

Page 315 of 374
5 ML
5 ML
16.7 ML
50 ML
1/1/2002
1/1/2002
1/1/2002
1/1/2002
12/7/2006
12/7/2006
12/7/2006
12/7/2006
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
5
5
5
5
61703-0347-35
61703-0348-59
J9178
J9178
61703-0349-09
J9206
61703-0349-09 QR J9206
61703-0349-16

QR

QR
61703-0350-38
J9250
61703-0356-18
J2430
61703-0359-01
J9178
61703-0359-02
J9178
61703-0359-59
J9178
61703-0359-91
J9178
61703-0359-92
J9178
61703-0359-93
J9178
61703-0360-18
J9045
61703-0360-22
J9045
61703-0360-50
J9045
61703-0407-07
J9250
1/1/2002
61703-0407-32
J9250
1/1/2002
61703-0408-04
J9250
1/1/2002
61703-0408-07
J9250
1/1/2002
61703-0408-13
J9250
1/1/2002
61703-0408-22
J9250
4/9/2004
61703-0408-32
J9250
1/1/2002
61703-0408-41
J9250
61703-0408-58
61703-0409-32
61703-0409-53
61703-0409-67
J9250
J9190
J9190
J9190
4/9/2004
1/1/2002
4/9/2004
4/9/2004

61703-0410-50
J0640
1/1/2002
61703-0414-63
J1450
61703-0414-64
J1450
61703-0415-49
J2405
61703-0425-94
J1170
3/7/2006
61703-0425-95
61772-0002-01
J1170
J7310
3/7/2006
1/1/2002
61787-0578-04
61799-0101-31
61799-0101-31
61799-0101-41
61799-0101-41
Q0163
J0286
J0287
J0286
J0287
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2003


7/25/2005 GANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANT
12/31/2002 INJECTION, AMPHOTERICIN B, ANY LIPID FORMULATION, 50 MG
EPIRUBICIN HYDROCHLORIDE (S.D.V.)

50 MG
EPIRUBICIN HYDROCHLORIDE 200 MG
20 MG/ML
20 MG/ML
20 MG/ML
20 MG/ML
METHOTREXATE SODIUM (MDV,5X2ML)
25 MG/ML
NOVAPLUS PAMIDRONATE DISODIUM
(SDV) 9 MG/ML
NOVAPLUS EPIRUBICIN
HYDROCHLORIDE (1X25ML,SINGLE
USE,PF) 2 MG/ML
NOVAPLUS EPIRUBICIN
HYDROCHLORIDE (1X100ML,SINGLE
USE,PF) 2 MG/ML
MG/ML
EPIRUBICIN HYDROCHLORIDE
(1X75ML,SINGLE USE,PF) 2 MG/ML
(1X5ML,SINGLE USE,PF) 2 MG/ML
MG/ML
NOVAPLUS CARBOPLATIN (MDV) 10
MG/ML
MG/ML
MG/ML
METHOTREXATE SODIUM (S.D.V.) 25
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
METHOTREXATE SODIUM (SDV,PF) 25
MG/ML
MG/ML
MG
FLUCONAZOLE (PVC FLEXIBLE BAGS)
200 MG/100 ML
FLUCONAZOLE (PVC FLEXIBLE BAGS)
400 MG/200 ML
ONDANSETRON AND DEXTROSE
(SINGLE-USE,6X50ML,PF) 32 MG/50 ML
(USP,25X1ML UNIAMP,PF) 10 MG/ML
(USP,SDA,10X5ML,PF) 10 MG/ML
VITRASERT 4.5 MG
KOSHER CARE ALLERGY RELIEF 12.5

MG/5 ML
ABELCET 5 MG/ML
ABELCET 5 MG/ML
ABELCET 5 MG/ML
ABELCET 5 MG/ML
Page 316 of 374
1 EA VL
1 EA VL
IV
IV
EA
EA
2 MG
2 MG
25
100
11/06/2006
11/06/2006
99/99/9999
99/99/9999
5 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
2 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
2 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
25 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
25 ML VL
IV
ML
20 MG
02/27/2008
99/99/9999
2 ML VL
IJ
ML
5 MG
06/27/2005
99/99/9999
10 ML VL
IV
ML
30 MG
0.3
12/15/2006
99/99/9999
25 ML VL
IV
ML
2 MG
04/10/2008
99/99/9999
100 ML VL
IV
ML
2 MG
04/10/2008
99/99/9999
100 ML VL
IV
ML
2 MG
08/08/2007
99/99/9999
75 ML VL
IV
ML
2 MG
03/13/2008
99/99/9999
5 ML VL
IV
ML
2 MG
03/13/2008
99/99/9999
25 ML VL
IV
ML
2 MG
08/08/2007
99/99/9999
5 ML VL
IV
ML
50 MG
0.2
06/28/2006
99/99/9999
15 ML VL
IV
ML
50 MG
0.2
06/28/2006
99/99/9999
45 ML VL
IV
ML
50 MG
0.2
06/28/2006
99/99/9999
2 ML VL
IJ
ML
5 MG
01/01/2002
05/24/2002
10 ML VL
IJ
ML
5 MG
01/01/2002
05/24/2002
4 ML VL
IJ
ML
5 MG
01/01/2002
05/24/2002
2 ML VL
IJ
ML
5 MG
01/01/2002
05/24/2002
8 ML VL
IJ
ML
5 MG
01/01/2002
05/24/2002
20 ML VL
IJ
ML
5 MG
04/09/2004
01/17/2005
10 ML VL
IJ
ML
5 MG
01/01/2002
05/24/2002
40 ML VL
IJ
ML
5 MG
06/27/2005
99/99/9999
IJ
IV
IV
IV
ML
ML
ML
ML
5 MG
500 MG
500 MG
500 MG
5
0.1
0.1
0.1
04/09/2004
04/09/2004
04/09/2004
04/09/2004
01/17/2005
01/17/2005
01/17/2005
01/17/2005
8 ML
10 ML
5 ML
100 ML
VL
VL
VL
VL
1 EA VL
IJ
EA
50 MG
04/09/2004
01/17/2005
100 ML PC
IV
ML
200 MG
0.01
06/09/2004
99/99/9999
200 ML PC
IV
ML
200 MG
0.01
06/09/2004
99/99/9999
50 ML NA
IV
ML
1 MG
0.64
12/26/2006
99/99/9999
1 ML AM IJ
ML
4 MG
2.5
03/07/2006
05/08/2007
5 ML AM IJ
1 EA BX IO
ML
EA
4 MG
4.5 MG
2.5
1
03/07/2006
01/01/2002
05/08/2007
07/25/2005
ML
ML
ML
ML
ML
50 MG
50 MG
10 MG
50 MG
10 MG
0.05
0.1
0.5
0.1
0.5
01/01/2002
01/01/2002
01/01/2003
01/01/2002
12/16/2003
02/03/2003
12/31/2002
01/02/2003
12/31/2002
11/14/2004
120 ML
10 ML
10 ML
20 ML
20 ML
BO
VL
VL
VL
VL
PO
IV
IV
IV
IV
4/9/2004
1/17/2005
1/1/2002
5/24/2002
0.1
1/1/2002
5/24/2002
1/1/2003 12/15/2003
0.5
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

QR
J9206
61703-0349-36 QR J9206

J9206
61703-0349-16 QR J9206
61703-0349-36
HCPCS Mod
HCPCS
NDC Mod
NDC
61953-0003-02
Q4091
61953-0003-02
J1572
61953-0003-03
Q4091
61953-0003-03
J1572
61953-0003-04
Q4091
61953-0003-04
J1572
61953-0004-01
Q4091
61953-0004-01
J1572
61953-0004-02
Q4091
61953-0004-02
J1572
61953-0004-03
Q4091
61953-0004-03
J1572
61953-0004-04
Q4091
61953-0004-04
J1572
61953-0004-05
Q4091
61953-0004-05
61958-0101-01
61958-0301-01
62033-0204-10
62033-0204-14
J1572
J0740
J9151
J8499
J8499
62053-0534-25
62086-0145-50
J7511
J1212
INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED FLEBOGAMMA 5% (0.5 GM/VIAL,PF) 50

7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
MG/ML
INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZEDFLEBOGAMMA 5% (0.5 GM/VIAL,PF) 50
MG/ML
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED FLEBOGAMMA 5% (2.5 GM/VIAL,PF) 50
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
MG/ML
INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZEDFLEBOGAMMA 5% (2.5 GM/VIAL,PF) 50
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
MG/ML
INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED FLEBOGAMMA 5% (5 GM/VIAL,PF) 50
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
MG/ML
INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZEDFLEBOGAMMA 5% (5 GM/VIAL,PF) 50
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
MG/ML
INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED FLEBOGAMMA 5% (10 GM/VIAL,PF) 50
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
MG/ML
INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZEDFLEBOGAMMA 5% (10 GM/VIAL,PF) 50
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
MG/ML
INJECTION, IMMUNE GLOBULIN (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
FLEBOGAMMA (DIF,PF) 5 GM/100 ML
INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G. LIQUID), 500 MG
1/1/2002 99/99/9999 INJECTION, CIDOFOVIR, 375 MG
VISTIDE (S.D.V.,PF) 75 MG/ML
1/1/2002 99/99/9999 INJECTION, DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG
DAUNOXOME (S.D.V.,PF) 2 MG/ML
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT,
1/1/2002 11/30/2005 PARENTERAL, 25MG
THYMOGLOBULIN (VIAL,DILUENT) 25 MG
DIMETHYL SULFOXIDE 50%
62086-0147-20
62086-0153-03
J3520
J0282
10/30/2003
10/30/2003
62086-0154-10
62161-0003-34
62161-0003-34
62161-0005-38
J2550
Q2008
J1451
J9999

1/1/2002 12/31/2005 INJECTION, FOMEPIZOLE, 15 MG
1/1/2006 99/99/9999 INJECTION, FOMEPIZOLE, 15 MG
1/1/2002
62161-0007-10
62263-0414-11
Q2002
J0285
62269-0275-24
Q0164
61953-0003-01
Q4091
61953-0003-01
J1572
62269-0276-24
Q0165
62269-0351-21
62269-0351-24
J7509
J7509
62541-0110-01
J0275
62541-0110-06
J0275
62541-0120-01
J0275
62541-0120-06
J0275
62541-0130-01
J0275

10 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
10 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
50 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
50 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
100 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
100 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
200 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
200 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
10 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
10 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
50 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
50 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
100 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
100 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
200 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
200 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
400 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
400 ML
5 ML
25 ML
100 EA
400 EA
IV
IV
IV
PO
PO
ML
ML
ML
EA
EA
500 MG
375 MG
10 MG
1 EA
1 EA
0.1
0.2
0.2
1
1
01/01/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
50 ML VL
IV
IL
EA
ML
25 MG
50 %
1
0.02
01/01/2002
10/30/2003
11/30/2005
06/30/2005
EDETATE DISODIUM (S.D.V.) 150 MG/ML

20 ML VL
3 ML VL
IV
IV
ML
ML
150 MG
30 MG
1
1.66666
10/30/2003
10/30/2003
06/30/2005
06/30/2005

ANTIZOL (PF) 1 GM/ML
ANTIZOL (PF) 1 GM/ML
BUSULFEX (AMP) 6 MG/ML
10 ML
1.5 ML
1.5 ML
10 ML
IJ
IV
IV
IV
ML
ML
ML
ML
50 MG
15 MG
15 MG
1 EA
0.5
66.66666
66.66666
1
10/30/2003
01/01/2002
01/01/2006
06/03/2003
06/30/2005
12/31/2005
99/99/9999
06/09/2004
ML
GM
1 ML
50 MG
1
20
EA
5 MG
01/01/2002
07/24/2002
1/1/2002 5/27/2003 INJECTION, ELLIOTTS B SOLUTION, PER ML

ELLIOTS B (FOR INTRATHECAL USE,P.F)
AMPHOTERICIN B
1/1/2002
4 MG
1/1/2002
MUSE 125 MCG
MUSE 125 MCG
MUSE 250 MCG
MUSE 250 MCG
MUSE 500 MCG
Page 317 of 374
VL
VL
VL
BO
BO
VL
VL
VL
AM
10 ML AM IV
1 EA BO NA
100 EA BO
PO
1/1/2002
6/2/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
01/01/2002 05/27/2003
09/07/2004 10/28/2008
100 EA BO
PO
EA
10 MG
01/01/2002
07/24/2002
21 EA DP
100 EA BO
PO
PO
EA
EA
4 MG
4 MG
1
1
01/01/2002
01/01/2002
04/03/2003
04/03/2003
1 EA BX
UR
EA
1 EA
01/01/2002
99/99/9999
6 EA BX
UR
EA
1 EA
01/01/2002
99/99/9999
1 EA BX
UR
EA
1 EA
01/01/2002
99/99/9999
6 EA BX
UR
EA
1 EA
01/01/2002
99/99/9999
1 EA BX
UR
EA
1 EA
01/01/2002
99/99/9999
62541-0130-06
J0275
62541-0140-01
J0275
62541-0140-06
62584-0782-01
62584-0827-21
62682-1021-02
62701-0010-01
62701-0011-01
62701-0800-01
62701-0940-36
62701-0940-99
J0275
None
J7502
J8499
J9280
J9290
J9268
None
None
62756-0130-01
Q0179

MUSE 500 MCG
MUSE 1000 MCG
MUSE 1000 MCG
4/3/1997
CYCLOSPORINE (USP,3X10) 100 MG
4/30/2002
ACYCLOVIR 200 MG
1/1/2002
MITOMYCIN (VIAL) 5 MG
1/1/2002 99/99/9999 MITOMYCIN, 20 MG
1/1/2002 8/15/2007 INJECTION, PENTOSTATIN, 10 MG
NIPENT (S.D.V.) 10 MG
(FILM-COATED) 4 MG
(FILM-COATED) 8 MG
ONDANSETRON (5X2ML,SDA,USP) 2
MG/ML
ONDANSETRON 4 MG
ONDANSETRON 8 MG
ONDANSETRON 8 MG
AMIFOSTINE (USP) 500 MG
AMIFOSTINE (USP) 500 MG
APOKYN (CARTRIDGE) 10 MG/ML
APOKYN (CARTRIDGE) 10 MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
UR
EA
1 EA
01/01/2002
99/99/9999
1 EA BX
UR
EA
1 EA
01/01/2002
99/99/9999
BX
BO
BX
NA
VL
VL
VL
BO
BO
UR
PO
PO
PO
IV
IV
IV
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
2.5 MG
100 MG
1 EA
5 MG
20 MG
10 MG
2.5 MG
2.5 MG
1
1
1
1
1
1
1
1
1
01/01/2002
04/03/1997
10/19/2006
04/30/2002
01/01/2002
01/01/2002
01/01/2002
09/11/1996
09/11/1996
99/99/9999
04/07/1998
99/99/9999
01/01/2006
1/1/2007
99/99/9999
08/15/2007
12/23/1998
12/23/1998
30 EA BO
PO
EA
8 MG
0.5
06/25/2007
99/99/9999
30 EA BO
PO
6 EA
100 EA
30 EA
25 EA
1 EA
1 EA
1 EA
36 EA
100 EA
EA
8 MG
06/25/2007
99/99/9999
ML
ML
1 MG
1 MG
2
2
12/27/2006
12/27/2006
99/99/9999
99/99/9999
30 EA BX
PO
EA
8 MG
0.5
06/25/2007
99/99/9999
30 EA BX
PO
EA
8 MG
06/25/2007
99/99/9999
10 EA
1 EA
1 EA
3 ML
3 ML
PO
IV
IV
SC
SC
EA
EA
EA
ML
ML
8 MG
500 MG
500 MG
1 EA
1 EA
1
1
1
1
1
06/25/2007
03/26/2008
03/26/2008
06/21/2004
06/21/2004
99/99/9999
99/99/9999
99/99/9999
12/14/2006
12/14/2006
1 ML VL
IJ
ML
1 EA
01/01/2002
06/30/2002
1 ML VL
IJ
ML
1 EA
01/01/2002
06/30/2002
1 ML VL
IJ
ML
1 EA
01/01/2002
06/30/2002
1 ML VL
IJ
ML
1 EA
01/01/2002
06/30/2002
2 ML VL
IJ
ML
1 EA
01/01/2002
06/30/2002
2 ML VL
IJ
ML
1 EA
01/01/2002
06/30/2002
ACYCLOVIR SODIUM (S.D.V.) 50 MG/ML
10 ML VL
IV
ML
1 EA
01/01/2002
06/30/2002
10 ML VL
IV
ML
1 EA
01/01/2002
06/30/2002
20 ML VL
IV
ML
1 EA
01/01/2002
06/30/2002

FRAGMIN (27GX1/2"W/NDLGUARD)
10000 IU/ML
FRAGMIN (MDV) 10000 IU/ML
FRAGMIN (SINGLE DOSE,PF) 12500
IU/0.5 ML
IU/0.6 ML
IU/0.72 ML
FRAGMIN (10X0.2ML,PF) 2500 IU/0.2 ML
FRAGMIN (MDV) 25000 IU/ML
FRAGMIN (27GX1/2",10X0.2ML,PF) 5000
IU/0.2 ML
20 ML VL
IV
ML
1 EA
01/01/2002
06/30/2002
1 ML SR
9.5 ML VL
SC
SC
ML
ML
2500 IU
2500 IU
4
4
11/20/2006
07/10/2006
99/99/9999
99/99/9999
0.5 ML SR
SC
ML
2500 IU
10
08/25/2007
99/99/9999
0.6 ML SR
SC
ML
2500 IU
10.66666
08/25/2007
99/99/9999
0.72 ML SR
0.2 ML SR
3.8 ML VL
SC
SC
SC
ML
ML
ML
2500 IU
2500 IU
2500 IU
10
5
10
08/25/2007
06/26/2007
11/20/2006
99/99/9999
99/99/9999
99/99/9999
Q0179
J2405
J2405
62756-0240-64
Q0179
62756-0356-64
Q0179
62756-0356-66
62756-0581-40
62756-0581-42
62794-0255-13
62794-0255-37
Q0179
J0207
J0207
J3490
J3490
62794-0311-31
J3490
62794-0311-97
J3490
62794-0313-31
J3490
62794-0313-97
J3490
62794-0315-31
J3490
62794-0315-97
J3490
62794-0401-31
J3490
1/1/2002
62794-0401-97
J3490
1/1/2002
62794-0403-31
J3490
1/1/2002
62794-0403-97
J3490
1/1/2002
62856-0101-10
62856-0102-01
J1645
J1645

62856-0125-10
J1645
62856-0150-10
J1645
62856-0180-10
62856-0250-10
62856-0251-01
J1645
J1645
J1645

62856-0500-10
J1645
62856-0603-01
62856-0750-10
62856-0798-01
J9160
J1645
J2469
1/17/2008 99/99/9999 INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS

4/1/2009 99/99/9999 INJECTION, PALONOSETRON HCL, 25 MCG
ONTAK (2ML,SINGLE USE) 150 MCG/ML

FRAGMIN (PREFILLED) 7500 IU/0.3 ML
ALOXI (SINGLE-USE) 0.05 MG/ML
Page 318 of 374
BX
VL
VL
CT
CT
0.2 ML SR
SC
ML
2500 IU
10
10/10/2006
99/99/9999
2 ML VL
0.3 ML SR
1.5 ML EA
IV
SC
IV
ML
ML
ML
300 MCG
2500 IU
25 MCG
0.5
10
2
01/17/2008
02/06/2007
4/1/2009
99/99/9999
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
6 EA BX
2 ML AM IJ
20 ML VL IJ
62756-0131-01
62756-0181-01
62756-0182-01
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
62927-0621-04
Q0177
1/1/2002
62927-0621-16
Q0177
1/1/2002
62991-1003-01
J7608
1/1/2002
62991-1003-01 KO J7608
62991-1003-02
J7699
62991-1003-02
J7604
62991-1003-02 KO J7604
62991-1003-03
J7699
62991-1003-03
62991-1003-05
62991-1006-01
62991-1006-01
62991-1006-02
62991-1006-03
62991-1006-03
62991-1006-04
62991-1012-02
J7636
1/1/2007
1/1/2005
KO
1/1/2005
1/1/2007
KO
1/1/2007
1/1/2005
KO
1/1/2005
1/1/2007
KO
1/1/2007
1/1/2002
KO
J7636
62991-1012-02 KO J7636
62991-1012-03
KO
J7636
62991-1012-01 KO J7636
1/1/2005
1/1/2007
J7609
62991-1006-04 KO J7609
62991-1012-01
KO
J7613
62991-1006-04 KO J7613
1/1/2007
1/1/2005
J7609
62991-1006-03 KO J7609
62991-1006-04
KO
J7613
62991-1006-03 KO J7613
1/1/2005
1/1/2007
J7609
62991-1006-02 KO J7609
9/15/2003
1/1/2007
10/1/2003
1/1/2006
10/1/2003
1/1/2006
9/15/2003
10/1/2003
1/1/2005
KO
J7613
62991-1006-02 KO J7613
62991-1006-02
KO
J7609
62991-1006-01 KO J7609
1/1/2008
9/15/2003
J7613
62991-1006-01 KO J7613
1/1/2008
1/1/2007
1/1/2008
KO
J7608
62991-1003-05 KO J7608
62991-1003-05
J7699
62991-1004-01
Q4075
62991-1004-01
J0133
62991-1004-02
Q4075
62991-1004-02
J0133
62991-1004-03
J7799
62991-1004-03
Q4075
1/1/2008
1/1/2007
1/1/2008
KO
J7604
62991-1003-04 KO J7604
1/1/2002
1/1/2007
1/1/2008
KO
J7604
62991-1003-03 KO J7604
62991-1003-04
J7699
62991-1003-04
KO
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
HYDROXYZINE PAMOATE (BANANA) 25

MG/5 ML
120 ML EA
PO
ML
25 MG
0.2
01/01/2002
99/99/9999
HYDROXYZINE PAMOATE (BANANA) 25

MG/5 ML
480 ML EA
PO
ML
25 MG
0.2
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 GM
01/01/2002
11/01/2005
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2002
01/01/2007
11/01/2005
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
NA
GM
1 GM
09/15/2003
12/31/2006
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
1 GM
1 EA
5 MG
5 MG
5 MG
5 MG
1 EA
5 MG
1
1
200
200
200
200
1
200
09/15/2003
01/01/2007
10/01/2003
01/01/2006
10/01/2003
01/01/2006
09/15/2003
10/01/2003
12/31/2006
10/01/2007
12/31/2005
99/99/9999
12/31/2005
99/99/9999
09/30/2003
11/01/2005
1 EA JR
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA JR
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999

ALBUTEROL SULFATE (U.S.P.,
MICRONIZED)
MICRONIZED)
MICRONIZED)
MICRONIZED)
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/01/2005
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/01/2005
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/01/2005
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/01/2005
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/01/2005
Page 319 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
J7622
62991-1020-01 KO J7622
62991-1020-02
62991-1020-03
62991-1023-02
62991-1024-01
62991-1024-04
62991-1024-05
62991-1038-02
62991-1038-04
62991-1041-02
KO
KO
KO
9/15/2003
1/1/2007
1/1/2008
KO
1/1/2008
1/1/2007
1/1/2008
KO
1/1/2008
1/1/2007
1/1/2008
KO
1/1/2008
1/1/2007
1/1/2008
KO
1/1/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
KO
1/1/2002

1 EA BO
NA
GM
1 MG
1000
01/01/2002
10/01/2007
1 EA BO
NA
GM
1 MG
1000
01/01/2002
10/01/2007
1 EA BO
NA
GM
1 MG
1000
01/01/2002
10/01/2007
MICRONIZED
MICRONIZED
BENZOCAINE (U.S.P./N.F.)
BENZOCAINE (U.S.P./N.F.)
BENZOCAINE (U.S.P.)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P., 25)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
10/01/2007
1 EA NA
NA
GM
1 MG
1000
09/15/2003
10/01/2007
1 EA
1 EA
1 EA
1 EA
NA
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 MG
1 EA
1 EA
1 EA
1000
1
1
1
09/15/2003
01/01/2002
01/01/2002
09/15/2003
10/01/2007
11/01/2005
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
10/01/2007
1 EA BO
NA
GM
1 MG
1000
01/01/2002
10/01/2007
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
CF
HCPCS Amount #1
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/15/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/15/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/15/2003
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 MG
1 EA
1000
1
09/15/2003
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
GM
GM
GM
GM
10 MG
1000 MCG
1000 MCG
1000 MCG
100
1000
1000
1000
01/01/2008
01/01/2002
01/01/2002
01/01/2002
99/99/9999
10/01/2007
99/99/9999
99/99/9999
Page 320 of 374
BO
BO
BO
BO
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/01/2005
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/01/2005
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
Prior End Date #3
11/01/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/15/2003
1000
100
100
100
100
Prior End Date #2
1 MG
10 MG
10 MG
10 MG
10 MG
End Date #1
GM
GM
GM
GM
GM
Start Date #1
NA
NA
NA
NA
NA
HCPCS Measure #1
BO
BO
BO
BO
BO
Billing Units
1 EA
1 EA
1 EA
1 EA
1 EA
Prior Start Date #2

Package

BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
BACLOFEN
BACLOFEN (U.S.P.)
NDC Label
HCPCS Description

9/15/2003
9/15/2003
J7638
62991-1041-02 KO J7638
1/1/2002
9/15/2003
J7638
62991-1041-01 KO J7638
1/1/2002
1/1/2002
J7632
62991-1038-04 KO J7632
62991-1039-01
J3420
62991-1039-02
J3420
62991-1039-03
J3420
62991-1041-01
KO
J7632
62991-1038-03 KO J7632
62991-1038-04
J7699
1/1/2002
1/1/2002
J7632
62991-1038-02 KO J7632
62991-1038-03
J7699
62991-1038-03
KO
J7632
62991-1038-01 KO J7632
62991-1038-02
J7699
1/1/2002
1/1/2002
J7624
62991-1024-05 KO J7624
62991-1038-01
J7699
62991-1038-01
KO
J7624
62991-1024-04 KO J7624
1/1/2002
1/1/2002
J7624
62991-1024-02 KO J7624
9/15/2003
1/1/2002
1/1/2002
9/15/2003
1/1/2002
KO
J7624
62991-1024-01 KO J7624
62991-1024-02
KO
J7624
62991-1023-03 KO J7624
1/1/2002
9/15/2003
J7624
62991-1023-02 KO J7624
62991-1023-03
KO
J7624
62991-1023-01 KO J7624
1/1/2002
1/1/2002
J7622
62991-1020-03 KO J7622
62991-1021-01
J3490
62991-1021-02
J3490
62991-1021-04
J3490
62991-1023-01
1/1/2002
KO
J7622
62991-1020-02 KO J7622
1/1/2002
1/1/2002
1/1/2002
1/1/2002
9/15/2003
NDC Package Type
62991-1020-01
KO
NDC Package Measure
62991-1012-03 KO J7636
62991-1013-01
J0475
62991-1013-02
J0475
62991-1013-03
J0475
62991-1013-04
J0475
HCPCS Mod
HCPCS
NDC Mod
NDC
62991-1041-03
J7638
62991-1041-03 KO J7638
62991-1041-04
KO
J7638
62991-1041-04 KO J7638
62991-1041-05
KO
J7638
62991-1041-05 KO J7638
62991-1047-02
J1200
62991-1051-01
J1435
62991-1051-02
J1435
62991-1051-03
J1435
62991-1051-04
J1435
62991-1072-01
J7699
62991-1072-02
J7699
62991-1072-03
J7699
KO

62991-1078-01
J1700
1/1/2002
62991-1078-02
J1700
62991-1078-03
J1700
62991-1078-04
J1700
62991-1078-05
J1700
62991-1085-01
J7644
62991-1085-01 KO J7644
62991-1085-01
62991-1085-01 KO J7645
62991-1085-02
KO
J7644
62991-1085-05 KO J7644
62991-1085-05
KO
J7645
62991-1085-04 KO J7645
62991-1085-05
KO
J7644
62991-1085-04 KO J7644
62991-1085-04
KO
J7645
62991-1085-03 KO J7645
62991-1085-04
KO
J7644
62991-1085-03 KO J7644
62991-1085-03
KO
J7645
62991-1085-02 KO J7645
62991-1085-03
KO
J7644
62991-1085-02 KO J7644
62991-1085-02
KO
J7645
KO
J7645
62991-1085-05 KO J7645
KO
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)
(U.S.P.,MICRONIZED)

IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
1/1/2002 12/31/2006 MILLIGRAM
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE MICRONIZED
(PH. EUR)
9/15/2003 12/31/2006 MILLIGRAM
(PH. EUR)
9/15/2003 12/31/2006 MILLIGRAM
(PH. EUR)
(PH. EUR)
(PH. EUR)
9/15/2003 12/31/2006 MILLIGRAM
(PH. EUR)
9/15/2003 12/31/2006 MILLIGRAM
(PH. EUR)
(PH. EUR)
(PH. EUR)
9/15/2003 12/31/2006 MILLIGRAM
(PH. EUR)
9/15/2003 12/31/2006 MILLIGRAM
(PH. EUR)
(PH. EUR)
Page 321 of 374
1 EA BO
NA
GM
1 MG
1000
01/01/2002
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/15/2003
11/01/2005
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
VL
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
50 MG
1 MG
1 MG
1 MG
1 MG
1 EA
1 EA
1 EA
1000
20
1000
1000
1000
1000
1
1
1
09/15/2003
01/01/2002
01/01/2002
01/01/2002
09/15/2003
09/15/2003
09/01/2002
09/01/2002
09/01/2002
11/01/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/01/2007
1 EA BO
NA
GM
25 MG
40
01/01/2002
10/01/2007
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
25 MG
40
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/15/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
09/15/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/15/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
09/15/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/15/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
09/15/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
10/01/2007
1 EA BO
NA
GM
1 MG
1000
01/01/2007
10/01/2007
62991-1085-06
J7644
62991-1085-06 KO J7644
62991-1085-06
62991-1099-04
KO
KO
KO
J7669
62991-1099-04 KO J7669
62991-1108-01
J2760
62991-1108-02
J2760
62991-1108-03
J2760
62991-1108-04
J2760
9/15/2003
1/1/2002
1/1/2002
9/15/2003
9/15/2003
62991-1122-01
Q0165
1/1/2002
62991-1122-02
62991-1122-03
Q0165
J2675
1/1/2002
9/15/2003
62991-1122-04
62991-1122-05
Q0165
J2675
9/15/2003
9/15/2003
62991-1124-01
J2675
1/1/2002
62991-1124-02
62991-1124-03
62991-1124-05
62991-1125-01
62991-1125-02
J2675
J2675
J2675
J2550
J2550
1/1/2002
10/1/2007
10/1/2007
1/1/2002
1/1/2002

PROGESTERONE MICRONIZED (YAM)
1 EA BO
NA
GM
1 MG
1000
09/15/2003
1 EA BO
NA
GM
1 MG
1000
09/15/2003
12/31/2006
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
10 MG
1000
4
100
4
100
4
100
4
100
100
01/01/2007
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
04/01/2008
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
11/01/2005
1 EA BO
NA
GM
10 MG
100
01/01/2002
11/01/2005
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2002
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
09/15/2003
11/01/2005
1
1
1
1
1
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
10 MG
5 MG
5 MG
5 MG
5 MG
100
200
200
200
200
09/15/2003
01/01/2002
01/01/2002
09/15/2003
09/15/2003
11/01/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2002
09/01/2004
1 EA BO
1 EA NA
NA
NA
GM
GM
10 MG
50 MG
100
20
01/01/2002
09/15/2003
99/99/9999
09/30/2007
1 EA BO
1 EA NA
NA
NA
GM
GM
10 MG
50 MG
100
20
09/15/2003
09/15/2003
99/99/9999
09/30/2007
1 EA BO
NA
GM
50 MG
20
01/01/2002
11/01/2005
PROGESTERONE MICRONIZED
1
1
1
1
1
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
50 MG
50 MG
50 MG
50 MG
50 MG
20
20
20
20
20
01/01/2002
10/01/2007
10/01/2007
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 322 of 374
EA
EA
EA
EA
EA
BO
BO
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
12/31/2006
1 EA BO
EA
EA
EA
EA
EA
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

1/1/2007
9/15/2003
KO

1/1/2002 12/31/2006 PER 10 MILLIGRAMS
1/1/2002 12/31/2006 PER 10 MILLIGRAMS
J7670
62991-1099-03 KO J7670

(PH. EUR)
9/15/2003 12/31/2006 MILLIGRAM
(PH. EUR)
9/15/2003 12/31/2006 MILLIGRAM
(PH. EUR)
(PH. EUR)
LIDOCAINE HCL (U.S.P., B.P.)
LIDOCAINE HCL (USP)
1/1/2002 11/1/2005 PER 10 MILLIGRAMS
1/1/2002 11/1/2005 PER 10 MILLIGRAMS
1/1/2002 12/31/2006 PER 10 MILLIGRAMS
1/1/2002 12/31/2006 PER 10 MILLIGRAMS
J7669
62991-1099-03 KO J7669
62991-1099-03
KO
J7670
62991-1099-02 KO J7670
62991-1099-03
KO
J7669
62991-1099-02 KO J7669
62991-1099-02
KO
J7669
62991-1099-01 KO J7669
62991-1099-02
KO
J7645
62991-1085-06 KO J7645
62991-1095-01
J2000
62991-1095-01
J2001
62991-1095-02
J2000
62991-1095-02
J2001
62991-1095-03
J2000
62991-1095-03
J2001
62991-1095-04
J2000
62991-1095-04
J2001
62991-1095-06
J2001
62991-1099-01
HCPCS Mod
HCPCS
NDC Mod
NDC
62991-1125-04
J2550
62991-1128-02
J0270
62991-1128-06
J0270
62991-1128-07
J0270
62991-1128-08
62991-1130-01
62991-1130-01
62991-1130-02
62991-1130-02
62991-1130-03
62991-1130-03
62991-1132-01
62991-1132-02
62991-1132-03
62991-1132-04
62991-1133-01
62991-1133-02
62991-1133-03
62991-1133-04
J0270
J3490
J3415
J3490
J3415
J3490
J3415
J2780
J2780
J2780
J2780
J3490
J3490
J3490
J3490
62991-1152-01
J7681
62991-1152-01 KO J7681
62991-1152-02
KO
J7684
62991-1156-02 KO J7684
62991-1156-03
KO
J7684
62991-1156-01 KO J7684
62991-1156-02
KO
J7681
62991-1152-02 KO J7681
62991-1156-01
KO
J7684
62991-1156-03 KO J7684
KO

1 EA BO
NA
GM
50 MG
1 EA BO
NA
GM
1 EA BO
NA
1 EA BO
RIFAMPIN (U.S.P.)
RIFAMPIN (U.S.P.)
RIFAMPIN (U.S.P.)
RIFAMPIN (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
20
01/01/2002
99/99/9999
1.25 MCG
800000
09/15/2003
99/99/9999
GM
1.25 MCG
800000
09/15/2003
99/99/9999
NA
GM
1.25 MCG
800000
09/15/2003
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1.25 MCG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
25 MG
25 MG
25 MG
25 MG
1 EA
1 EA
1 EA
1 EA
800000
1
10
1
10
1
10
40
40
40
40
1
1
1
1
09/15/2003
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
09/15/2003
09/15/2003
09/15/2003
09/15/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
12/31/2003
11/01/2005
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999

(U.S.P.,BP,EP,MICRONIZED)
AMPHOTERICIN B (U.S.P., ORAL
GRADE)
GRADE)
GRADE)
AMPHOTERICIN B (USP)
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
50 MG
20
01/01/2002
09/01/2004
1 EA BO
NA
GM
50 MG
20
01/01/2008
99/99/9999
1/1/2002
9/1/2004
20
1 EA BO
1 EA BO
NA
NA
GM
GM
50 MG
50 MG
20
20
01/01/2008
01/01/2008
99/99/9999
99/99/9999
1/1/2002
9/1/2004
20
BUDESONIDE MICRONIZED (EP)
1 EA JR
NA
GM
0.25 MG
2000
05/30/2002
12/31/2005
1 EA JR
NA
GM
0.25 MG
2000
05/30/2002
12/31/2005
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA JR
NA
GM
0.25 MG
2000
05/30/2002
12/31/2005
1 EA JR
NA
GM
0.25 MG
2000
05/30/2002
12/31/2005
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
J7626
1 EA JR
NA
GM
0.25 MG
2000
05/30/2002
12/31/2005
62991-1179-03 KO J7626
1 EA JR
NA
GM
0.25 MG
2000
05/30/2002
12/31/2005
62991-1173-01
J0285
1/1/2002
62991-1173-02
J0285
62991-1173-04
62991-1173-05
J0285
J0285

62991-1179-01
J7626
62991-1179-01 KO J7626
62991-1179-01
KO
J7627
62991-1179-02 KO J7627
62991-1179-03
KO
J7626
62991-1179-02 KO J7626
62991-1179-02
KO
J7627
62991-1179-01 KO J7627
62991-1179-02
KO
KO
Page 323 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
62991-1179-03
J7627
62991-1179-03 KO J7627
62991-1179-05
KO
KO
J7627
62991-1179-05 KO J7627
KO
62991-1189-01
J1110
1/1/2002
62991-1189-02
62991-1200-01
62991-1200-02
J1110
J8610
J8610
1/1/2002
1/1/2002
1/1/2002

1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA JR
NA
GM
0.25 MG
2000
09/15/2003
12/31/2005
1 EA JR
NA
GM
0.25 MG
2000
09/15/2003
12/31/2005
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999

(U.S.P.)
(U.S.P.)
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
09/01/2004
1 EA BO
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
1 MG
2.5 MG
2.5 MG
1000
400
400
01/01/2002
01/01/2002
01/01/2002
09/01/2004
09/01/2004
09/01/2004
11/01/2005
62991-1203-01
J2440
1/1/2002
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
62991-1203-02
J2440
1/1/2002
1 EA BO
NA
GM
60 MG
16.66666
01/01/2002
10/01/2007
62991-1203-04
62991-1206-01
62991-1206-02
62991-1229-01
62991-1229-02
62991-1229-03
62991-1236-01
62991-1236-02
62991-1254-01
62991-1254-02
62991-1254-03
62991-1257-01
J2440
J7506
J7506
J0760
J0760
J0760
J1330
J1330
J1165
J1165
J1165
J7510

1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
60 MG
5 MG
5 MG
1 MG
1 MG
1 MG
0.2 MG
0.2 MG
50 MG
50 MG
50 MG
5 MG
16.66666
200
200
1000
1000
1000
5000
5000
20
20
20
200
09/15/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/15/2003
09/15/2003
09/15/2003
01/01/2002
10/01/2007
99/99/9999
99/99/9999
09/01/2004
09/01/2004
09/01/2004
09/01/2003
09/01/2003
10/01/2007
10/01/2007
10/01/2007
99/99/9999
62991-1257-02
J7510
1 EA NA
NA
GM
5 MG
200
09/15/2003
99/99/9999
62991-1351-01
J7682

1/1/2002 12/31/2006 MILLIGRAMS
1/1/2002 12/31/2006 MILLIGRAMS
1/1/2002 12/31/2006 MILLIGRAMS
1/1/2002 12/31/2006 MILLIGRAMS
1/1/2002 12/31/2006 MILLIGRAMS
1/1/2002 12/31/2006 MILLIGRAMS
9/15/2003 12/31/2006 MILLIGRAMS
9/15/2003 12/31/2006 MILLIGRAMS

COLCHICINE (U.S.P.)
COLCHICINE (U.S.P.)
COLCHICINE
PHENYTOIN SODIUM (BP)
PREDNISOLONE ANHYDROUS (U.S.P.,
MICRO)
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2002
12/31/2006
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
TOBRAMYCIN SULFATE
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
09/15/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
09/15/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
62991-1351-01 KO J7682
62991-1351-01
62991-1351-01 KO J7685
62991-1351-02
KO
J7682
62991-1351-04 KO J7682
62991-1351-04
KO
J7685
62991-1351-03 KO J7685
62991-1351-04
KO
J7682
62991-1351-03 KO J7682
62991-1351-03
KO
J7685
62991-1351-02 KO J7685
62991-1351-03
KO
J7682
62991-1351-02 KO J7682
62991-1351-02
KO
J7685
KO
J7685
62991-1351-04 KO J7685
KO
Page 324 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

J7626
62991-1179-05 KO J7626
62991-1179-05
HCPCS Mod
HCPCS
NDC Mod
NDC
62991-1351-05
J7682
62991-1351-05 KO J7682
62991-1351-05
KO
J7685
62991-1351-05 KO J7685
KO
9/15/2003 12/31/2006 MILLIGRAMS
9/15/2003 12/31/2006 MILLIGRAMS
1/1/2003 12/31/2006 INJECTION
1/1/2003 12/31/2006 INJECTION
9/15/2003 12/31/2006 INJECTION
62991-1352-01
62991-1352-01
J7317
J3490
62991-1352-02
62991-1352-02
J7317
J3490
62991-1352-04
62991-1352-04
62991-1382-01
J7317
J3490
J3350
62991-1412-01
J3150
62991-1412-02
J3150
J3150
62991-1412-03
62991-1422-01
J0735
62991-1422-02
J0735
62991-1486-01
J9190
62991-1486-01 QR J9190
62991-1486-02
J9190
62991-1486-02 QR J9190
62991-1486-03
J9190
62991-1486-03 QR J9190
62991-1509-01
J0706
62991-1509-02
J0706
62991-1513-01
J3490
62991-1513-01
J0364
62991-1513-02
J3490
62991-1513-02
J0364
62991-1513-03
J3490
62991-1513-03
J0364
QR
QR
QR
9/1/2002
9/15/2003
9/15/2003
9/15/2003
1/28/2005
9/15/2003
1/28/2005
9/15/2003
1/28/2005
9/15/2003
9/15/2003
9/15/2003
1/1/2007
9/15/2003
1/1/2007
9/15/2003
1/1/2007
62991-1530-02
J0520
9/15/2003
62991-1530-03
62991-1533-01
62991-1533-02
62991-1533-05
62991-1536-01
62991-1536-02
J0520
J7516
J7516
J7516
J1212
J1212
9/15/2003
9/15/2003
9/15/2003
1/1/2008
9/15/2003
9/15/2003
62991-1549-01
J3480
9/15/2003
62991-1549-02
62991-1568-01
62991-1583-01
62991-1583-02
62991-1583-03
J3480
J2150
J0592
J0592
J0592
9/15/2003
9/15/2003
9/15/2003
9/15/2003
9/15/2003
62991-1590-01
J7641
62991-1590-01 KO J7641
62991-1590-02
J7641
62991-1590-02 KO J7641
62991-1590-03
9/15/2003
KO
9/15/2003
KO
J7641
62991-1590-03 KO J7641
9/15/2003
9/15/2003
9/15/2003
KO
9/15/2003

99/99/9999 MG
99/99/9999 MG
62991-1635-01
J1030
9/1/2002
62991-1635-02
J1030
62991-1635-03
J1030
62991-1635-04
J1030
62991-1635-05
J1030
1 EA BO
NA
GM
300 MG
3.33333
09/15/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
09/15/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
HYALURONIC ACID
HYALURONIC ACID
1 EA BO
1 EA BO
NA
NA
GM
GM
20 MG
1 EA
40
1
01/01/2003
01/01/2007
12/31/2006
99/99/9999
HYALURONIC ACID
HYALURONIC ACID
1 EA NA
1 EA NA
NA
NA
GM
GM
20 MG
1 EA
40
1
01/01/2003
01/01/2007
12/31/2006
99/99/9999
HYALURONIC ACID
HYALURONIC ACID
UREA (U.S.P./N.F.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
1 EA BO
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
20 MG
1 EA
40 GM
40
1
0.025
09/15/2003
01/01/2007
01/01/2002
12/31/2006
99/99/9999
99/99/9999
1 EA BO
NA
GM
100 MG
10
09/01/2002
99/99/9999
1 EA BO
NA
GM
100 MG
10
09/01/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
100 MG
1 MG
1 MG
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
5 MG
5 MG
1 EA
1 MG
1 EA
1 MG
1 EA
1 MG
10
1000
1000
2
2
2
2
2
2
200
200
1
1000
1
1000
1
1000
09/01/2002
09/15/2003
09/15/2003
09/15/2003
01/28/2005
09/15/2003
01/28/2005
09/15/2003
01/28/2005
09/15/2003
09/15/2003
09/15/2003
01/01/2007
09/15/2003
01/01/2007
09/15/2003
01/01/2007
99/99/9999
99/99/9999
99/99/9999
11/01/2005
11/01/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/01/2007
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
1 EA BO

CYCLOSPORINE (U.S.P.,A)
DIMETHYL SULFOXIDE (DMSO, U.S.P.)
DIMETHYL SULFOXIDE (DMSO, U.S.P.)
POTASSIUM CHLORIDE
(U.S.P.,GRANULAR)
POTASSIUM CHLORIDE
(U.S.P.,GRANULAR)
MANNITOL (U.S.P.)
FLUNISOLIDE MICRONIZED
(U.S.P.,ANHYDROUS)
(U.S.P.,ANHYDROUS)
(U.S.P.,ANHYDROUS)
(U.S.P.,ANHYDROUS)
(U.S.P.,ANHYDROUS)
(U.S.P.,ANHYDROUS)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
Page 325 of 374
NA
GM
5 MG
200
09/15/2003
99/99/9999
BO
BO
BO
NA
EA
EA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
ML
ML
5 MG
250 MG
250 MG
250 MG
50 %
50 %
200
4
4
4
0.02
0.02
09/15/2003
09/15/2003
09/15/2003
01/01/2008
09/15/2003
09/15/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
2 MEQ
6.71141
09/15/2003
10/01/2007
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
2 MEQ
50 ML
0.1 MG
0.1 MG
0.1 MG
6.71141
0.08
10000
10000
10000
09/15/2003
01/01/2008
09/15/2003
09/15/2003
09/15/2003
10/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
09/15/2003
10/01/2007
1 EA BO
NA
GM
1 MG
1000
09/15/2003
10/01/2007
1 EA BO
NA
GM
1 MG
1000
09/15/2003
10/01/2007
1 EA BO
NA
GM
1 MG
1000
09/15/2003
10/01/2007
1 EA BO
NA
GM
1 MG
1000
09/15/2003
10/01/2007
1 EA BO
NA
GM
1 MG
1000
09/15/2003
10/01/2007
1 EA BO
NA
GM
40 MG
25
09/01/2002
11/01/2005
1 EA BO
NA
GM
40 MG
25
09/01/2002
99/99/9999
1 EA BO
NA
GM
40 MG
25
09/01/2002
99/99/9999
1 EA BO
NA
GM
40 MG
25
09/15/2003
99/99/9999
1 EA BO
NA
GM
40 MG
25
09/15/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
500 ML
3840 ML
9/15/2003
10/1/2007
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.08
62991-1692-01
J2650
62991-1692-02
J2650
62991-1692-03
62991-1707-01
62991-1707-02
62991-1707-03
62991-1707-04
62991-1707-05
62991-1738-01
62991-1738-02
62991-1738-03
62991-2002-01
62991-2002-01
62991-2002-02
62991-2002-02
62991-2002-03
62991-2002-03
62991-2003-01
62991-2003-02
62991-2003-03
62991-2004-01
62991-2004-02
62991-2004-03
62991-2012-01
J2650
J1070
J1070
J1070
J1070
J1070
J1800
J1800
J1800
J3490
J0278
J3490
J0278
J3490
J0278
J0280
J0280
J0280
J1320
J1320
J1320
J0515
62991-2022-01
J7638
62991-2022-01 KO J7638
62991-2022-02
62991-2022-03
62991-2022-04
99/99/9999
09/01/2002
99/99/9999

PROPRANOLOL HCL
PROPRANOLOL HCL
PROPRANOLOL HCL
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 ML
100 MG
100 MG
100 MG
100 MG
100 MG
1 MG
1 MG
1 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
250 MG
250 MG
250 MG
20 MG
20 MG
20 MG
1 MG
20
10
10
10
10
10
1000
1000
1000
1
10
1
10
1
10
4
4
4
50
50
50
1000
09/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2006
01/01/2002
01/01/2006
09/15/2003
01/01/2006
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
09/01/2004
99/99/9999
09/01/2004
09/01/2004
09/01/2004
12/31/2005
10/01/2007
12/31/2005
10/01/2007
12/31/2005
10/01/2007
10/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
09/01/2004
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/01/2005
1 EA BO
NA
GM
1 MG
1000
01/01/2002
11/01/2005
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1/1/2002
1/1/2002
1/1/2002
1/1/2002
KO
1/1/2002
1/1/2002
1/1/2002
1/1/2002
9/15/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

62991-2068-02
J3411
62991-2068-03
J3411
62991-2068-04
62991-2150-01
62991-2150-02
62991-2150-03
62991-2150-04
J3411
J3140
J3140
J3140
J3140
10/1/2007
9/1/2002
9/1/2002
9/1/2002
9/1/2002

CF
HCPCS Amount #1
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2002
99/99/9999
EDETATE DISODIUM (U.S.P./N.F.)
EDETATE DISODIUM (DIHYDRATE)
HYDROXYZINE HCL (U.S.P./N.F.)
HYDROXYZINE HCL (U.S.P./N.F.)
THIAMINE HYDROCHLORIDE (1X100GM,
USP)
THIAMINE HYDROCHLORIDE (1X500GM,
USP)
THIAMINE HYDROCHLORIDE
(1X1000GM,USP)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
150 MG
150 MG
150 MG
150 MG
5 MG
5 MG
5 MG
5 MG
25 MG
25 MG
0.25 MG
0.25 MG
0.25 MG
10 MG
10 MG
10 MG
1 EA
1 EA
1000
6.66666
6.66666
6.66666
6.66666
200
200
200
200
40
40
4000
4000
4000
100
100
100
1
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
09/15/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
11/01/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/01/2007
10/01/2007
09/01/2004
09/01/2004
09/01/2004
99/99/9999
99/99/9999
99/99/9999
09/01/2004
09/01/2004
1 EA BO
NA
GM
100 MG
10
10/01/2007
99/99/9999
1/1/2004
9/1/2004
10
1 EA BO
NA
GM
100 MG
10
10/01/2007
99/99/9999
1/1/2004
9/1/2004
10
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
100 MG
50 MG
50 MG
50 MG
50 MG
10
20
20
20
20
10/01/2007
09/01/2002
09/01/2002
09/01/2002
09/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 326 of 374
NA
BO
BO
BO
BO
09/01/2002
20
Prior End Date #3
20
1 ML
Prior Start Date #3
1 ML
GM
GM
NA
Prior End Date #2
NA
1 EA BO
Prior Start Date #2
1 EA BO
End Date #1
Start Date #1
HCPCS Measure #1
99/99/9999
99/99/9999
99/99/9999
99/99/9999
07/02/2008
10/01/2007
99/99/9999
99/99/9999
99/99/9999
Billing Units
09/15/2003
11/01/2005
11/01/2005
11/01/2005
10/01/2002
10/01/2002
09/01/2002
09/01/2002
09/01/2002
1/1/2002
KO
25
25
25
25
500
500
1
1
1

NDC Label
40 MG
40 MG
40 MG
40 MG
2 MG
2 MG
1 EA
1 EA
1 EA
HCPCS Description
GM
GM
GM
GM
GM
GM
GM
GM
GM
NA
NA
NA
NA
NA
NA
NA
NA
NA
1/1/2002
KO

Package
BO
BO
BO
NA
BO
BO
BO
BO
BO
1/1/2002
KO
J7638
62991-2022-04 KO J7638
62991-2026-01
J3520
62991-2026-02
J3520
62991-2026-03
J3520
62991-2026-04
J3520
62991-2031-01
J1630
62991-2031-02
J1630
62991-2031-03
J1630
62991-2031-04
J1630
62991-2035-01
J3410
62991-2035-02
J3410
62991-2036-01
J1980
J1980
62991-2036-02
62991-2036-03
J1980
62991-2042-01
J2765
62991-2042-02
J2765
62991-2042-03
J2765
62991-2046-01
J7799
62991-2046-02
J7799
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
9/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2006
1/1/2002
1/1/2006
9/15/2003
1/1/2006
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
J7638
62991-2022-03 KO J7638
MICRONIZED (U.S.P.)
ESTRADIOL VALERATE
ESTRADIOL VALERATE
ESTRADIOL VALERATE
LORAZEPAM
LORAZEPAM
9/15/2003
11/1/2005
11/1/2005
11/1/2005
10/1/2002
10/1/2002
9/1/2002
9/1/2002
9/1/2002
J7638
62991-2022-02 KO J7638
NDC Package Type
J1030
J0970
J0970
J0970
J2060
J2060
J3490
J3490
J3490
NDC Package Measure
62991-1635-06
62991-1662-02
62991-1662-03
62991-1662-04
62991-1682-01
62991-1682-02
62991-1685-01
62991-1685-02
62991-1685-03
HCPCS Mod
HCPCS
NDC Mod
NDC
9/1/2002
9/1/2002
9/1/2002
9/1/2002

62991-2186-02
62991-2186-03
62991-2186-04
62991-2186-05
J2321
J2321
J2321
J2321
1/1/2008
1/1/2008
1/1/2008
1/1/2008

62991-2501-01
J3490
62991-2501-02
J3490
62991-2504-02
J2675
62991-2504-03
J2675
62991-2504-04
62991-2516-01
J2675
J7699
62991-2516-01
J7640

FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
FORMOTEROL FUMARATE
LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON- LEVALBUTEROL HYDROCHLORIDE
1/1/2006 12/31/2006 COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG
100%
100%
LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTEREDLEVALBUTEROL HYDROCHLORIDE
100%
1/1/2007 99/99/9999 THROUGH DME, UNIT DOSE, 0.5 MG
100%
100%
100%
100%
100%
ITRACONAZOLE
ITRACONAZOLE
ITRACONAZOLE
AZITHROMYCIN DIHYDRATE
(1X1000GM,USP)
(1X100GM,USP)
(1X500GM,USP)
(1X100GM)
(1X1000GM)
TACROLIMUS (1X100MG)
TACROLIMUS (1X500MG)
TACROLIMUS (1X1GM)
TACROLIMUS (1X5GM)
TESTOSTERONE ENANTHATE (USP,
1X1000GM)
CEFTAZIDIME (USP, 1X1000GM)
LEVOFLOXACIN
LEVOFLOXACIN
1/1/2002 10/17/2005 INJECTION, ETHANOLAMINE OLEATE, 100 MG
ETHAMOLIN (AMP) 50 MG/ML
GLOFIL-125 (VIAL)
1/1/2002 99/99/9999 INJECTION, CORTICOTROPIN, UP TO 40 UNITS
H.P. ACTHAR (M.D.V.) 80 U/ML
VELCADE (10ML SDV,LYOPHILIZED) 3.5
MG
62991-2516-01 KO J7640
62991-2516-02
J7699
62991-2516-02
J7640
62991-2516-02 KO J7640
62991-2516-03
J7699
62991-2516-03
KO
J7614
62991-2549-02 KO J7614
62991-2549-02
KO
J7615
62991-2549-01 KO J7615
62991-2549-02
KO
J7614
62991-2549-01 KO J7614
62991-2549-01
KO
J7640
62991-2516-03 KO J7640
62991-2522-01
J3370
62991-2522-02
J3370
62991-2522-03
J3370
62991-2522-04
J3370
62991-2549-01
KO
KO
J7615
62991-2549-02 KO J7615
62991-2562-01
J1835
62991-2562-02
J1835
62991-2562-03
J1835
62991-2577-01
J0456
62991-2577-02
J0456
62991-2577-03
J0456
62991-2599-01
J2405
62991-2599-02
62991-2664-01
62991-2664-02
62991-2664-03
62991-2664-04
J2405
J7507
J7507
J7507
J7507
62991-2700-01
62991-2703-01
62991-2707-02
62991-2707-03
63004-4790-06
63004-7729-02
63004-7731-01
J3130
J0713
J1956
J1956
Q2007
J3490
J0800
63020-0049-01
J9999
KO
NANDROLONE DECANOATE (USP,
1X1000GM)
NANDROLONE DECANOATE (USP)
MICRONIZED (U.S.P., 24)
MICRONIZED (U.S.P., 24)
PROGESTERONE MICRONIZED (SOY,
U.S.P. 23)
U.S.P. 23)
U.S.P. 23)
FORMOTEROL FUMARATE
Page 327 of 374
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
100 MG
100 MG
100 MG
100 MG
10
10
10
10
01/01/2008
01/01/2008
01/01/2008
01/01/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 EA
09/15/2003
99/99/9999
1 EA BO
NA
GM
1 EA
09/15/2003
99/99/9999
1 EA BO
NA
GM
50 MG
20
01/01/2008
99/99/9999
9/15/2003
10/1/2007
20
1 EA BO
NA
GM
50 MG
20
01/01/2008
99/99/9999
9/15/2003
10/1/2007
20
1 EA BO
1 EA BO
NA
NA
GM
GM
50 MG
1 EA
20
1
01/01/2008
01/13/2003
99/99/9999
12/31/2005
9/15/2003
10/1/2007
20
1 EA BO
NA
GM
12 MCG
83333.33
01/01/2006
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
12 MCG
1 EA
83333.33
1
01/01/2006
01/13/2003
99/99/9999
12/31/2005
1 EA BO
NA
GM
12 MCG
83333.33
01/01/2006
10/01/2007
1 EA BO
1 EA BO
NA
NA
GM
GM
12 MCG
1 EA
83333.33
1
01/01/2006
01/13/2003
10/01/2007
12/31/2005
1 EA BO
NA
GM
12 MCG
83333.33
01/01/2006
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
12 MCG
500 MG
500 MG
500 MG
500 MG
83333.33
2
2
2
2
01/01/2006
09/15/2003
09/15/2003
09/15/2003
09/15/2003
99/99/9999
10/01/2007
10/01/2007
10/01/2007
10/01/2007
BO
BO
BO
BO
BO
CF
HCPCS Amount #1
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
12/31/2006
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
12/31/2006
1 EA BO
NA
GM
0.5 MG
2000
01/01/2007
99/99/9999
1 EA BO
NA
GM
0.5 MG
2000
01/01/2007
99/99/9999
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
12/31/2006
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
12/31/2006
1 EA BO
NA
GM
0.5 MG
2000
01/01/2007
99/99/9999
1
1
1
1
BO
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
0.5 MG
50 MG
50 MG
50 MG
2000
20
20
20
01/01/2007
11/01/2005
11/01/2005
11/01/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA NA
NA
GM
500 MG
10/01/2007
99/99/9999
1 EA NA
NA
GM
500 MG
10/01/2007
99/99/9999
1 EA NA
NA
GM
500 MG
10/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2006
99/99/9999
EA
EA
EA
EA
1 EA
100 ML
500 ML
1 EA
1 EA
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
ML
ML
GM
GM
1 MG
1 MG
1 MG
1 MG
1 MG
1000
1000
1000
1000
1000
01/01/2006
10/01/2007
10/01/2007
10/01/2007
10/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA
1 EA
1 EA
1 EA
2 ML
4 ML
5 ML
BO
BO
BO
BO
AM
VL
VL
NA
NA
NA
NA
IV
IV
IJ
GM
GM
GM
GM
ML
ML
ML
200 MG
500 MG
250 MG
250 MG
100 MG
1 EA
40 U
5
2
4
4
0.5
1
2
01/01/2008
01/01/2008
01/01/2008
01/01/2008
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/17/2005
10/17/2005
99/99/9999
IV
EA
1 EA
05/14/2003
12/31/2004
1 EA VL
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
09/01/2002
09/01/2002
09/01/2002
09/01/2002
Prior End Date #2
20
20
20
20
Prior Start Date #2
50 MG
50 MG
50 MG
50 MG
End Date #1
GM
GM
GM
GM
Start Date #1
NA
NA
NA
NA
HCPCS Measure #1
BO
BO
BO
BO
Billing Units
EA
EA
EA
EA
1
1
1
1
Prior End Date #3
NDC Package Type
J2675
J2675
J2675
J2675
NDC Package Measure
62991-2184-01
62991-2184-02
62991-2184-03
62991-2184-04

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
J1320
63275-9936-04
J1320
63275-9936-05
J1320
63275-9936-08
63275-9955-01
63275-9955-06
63275-9955-07
63275-9958-01
63275-9958-02
63275-9958-06
63275-9958-07
63275-9960-01
63275-9960-02
63275-9960-04
63275-9960-05
63275-9960-09
63275-9963-02
63275-9963-04
63275-9963-05
63275-9963-09
J1320
J2405
J2405
J2405
J7507
J7507
J7507
J7507
J1450
J1450
J1450
J1450
J1450
J1835
J1835
J1835
J1835
63275-9965-02
J0456
63275-9965-03
J0456
63275-9965-04
J0456
63275-9965-05
63275-9974-01
63275-9974-02
63275-9974-03
63275-9979-02
63275-9979-04
63275-9979-05
63275-9981-05
63275-9981-08
63275-9981-09
63275-9982-04
63275-9982-05
63275-9982-09
63275-9983-04
63275-9983-05
63275-9983-08
63275-9983-09
63275-9986-01
63275-9986-02
63275-9986-04
J0456
J0735
J0735
J0735
J2060
J2060
J2060
J2675
J2675
J2675
J1070
J1070
J1070
J3140
J3140
J3140
J3140
J1435
J1435
J1435
63275-9988-09
J0270
1/1/2007
1/1/2003
1/1/2003
1/1/2003
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002
12/4/2002


VELCADE (10ML SDV,LYOPHILIZED) 3.5

MG
AMITRIPTYLINE HYDROCHLORIDE
(1X5GM, USP)
(1X25GM, USP)
(1X100GM, USP)
(1X500GM, USP)
ONDANSETRON HCL
ONDANSETRON HCL
ONDANSETRON HCL
TACROLIMUS
TACROLIMUS
TACROLIMUS
TACROLIMUS
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
ITRACONAZOLE
ITRACONAZOLE
ITRACONAZOLE
ITRACONAZOLE
AZITHROMYCIN DIHYDRATE (1X5GM,
USP)
USP)
USP)
USP)
CLONIDINE HCL (BULK COMPOUND)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
TESTOSTERONE MICRONIZED
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
ESTRONE (U.S.P.)
Page 328 of 374
IV
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
EA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
0.1 MG
100 MG
100 MG
2 MG
2 MG
2 MG
2 MG
4 MG
4 MG
4 MG
4 MG
4 MG
0.1 MG
0.1 MG
0.1 MG
1 EA
1 EA
1 EA
1 EA
100 MG
100 MG
30 MG
30 MG
30 MG
10 MG
10 MG
35
10
10
500
500
500
500
250
250
250
250
250
10000
10000
10000
1
1
1
1
10
10
33.33333
33.33333
33.33333
100
100
01/01/2005
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
09/01/2003
12/03/2002
09/01/2002
12/03/2002
01/01/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
12/03/2002
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
VL
BO
BO
BO
BO
BO
BO
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA

Package
NDC Package Type
63275-9936-02
1/1/2007
1/27/2005
1/27/2005
1/27/2005
9/1/2004
9/1/2004
9/1/2004
9/1/2004
5/1/2004
5/1/2004
5/1/2004
5/1/2004
5/1/2004
6/4/2004
6/4/2004
6/4/2004
6/4/2004
99/99/9999 INJECTION, BORTEZOMIB, 0.1 MG

NDC Package Measure
J9041
J2271
J2271
J1960
J1960
J1960
J1960
J1170
J1170
J1170
J1170
J1170
J3010
J3010
J3010
J3490
J3490
J3490
J3490
J2175
J2175
J0745
J0745
J0745
J1230
J1230
NDC Label
HCPCS Description
63020-0049-01
63275-1025-04
63275-1100-05
63275-1200-01
63275-1200-02
63275-1200-04
63275-1200-07
63275-2001-01
63275-2005-02
63275-2010-03
63275-2100-05
63275-2100-09
63275-5100-01
63275-5100-02
63275-5100-06
63275-6200-01
63275-6200-06
63275-6200-07
63275-6200-09
63275-7100-04
63275-7100-05
63275-8100-03
63275-8100-04
63275-8100-05
63275-9100-04
63275-9100-05
1/1/2005
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
9/1/2003
12/3/2002
9/1/2002
12/3/2002
1/1/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
12/3/2002
HCPCS Mod
HCPCS
NDC Mod
NDC
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
20 MG
50
01/01/2007
99/99/9999
1 EA BO
NA
GM
20 MG
50
01/01/2007
99/99/9999
1 EA BO
NA
GM
20 MG
50
01/01/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
20 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
200 MG
200 MG
200 MG
200 MG
200 MG
50 MG
50 MG
50 MG
50 MG
50
1000
1000
1000
1000
1000
1000
1000
5
5
5
5
5
20
20
20
20
01/01/2007
01/27/2005
01/27/2005
01/27/2005
09/01/2004
09/01/2004
09/01/2004
09/01/2004
05/01/2004
05/01/2004
05/01/2004
05/01/2004
05/01/2004
06/04/2004
06/04/2004
06/04/2004
06/04/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
500 MG
01/01/2007
99/99/9999
1 EA BO
NA
GM
500 MG
01/01/2007
99/99/9999
1 EA BO
NA
GM
500 MG
01/01/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
JR
JR
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
JR
JR
JR
JR
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
500 MG
1 MG
1 MG
1 MG
2 MG
2 MG
2 MG
50 MG
50 MG
50 MG
100 MG
100 MG
100 MG
50 MG
50 MG
50 MG
50 MG
1 MG
1 MG
1 MG
2
1000
1000
1000
500
500
500
20
20
20
10
10
10
20
20
20
20
1000
1000
1000
01/01/2007
01/01/2003
01/01/2003
01/01/2003
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
12/04/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1.25 MCG
800000
12/04/2002
99/99/9999
63275-9989-01
63275-9989-06
63275-9989-07
J2760
J2760
J2760


1 EA BO
1 EA BO
1 EA BO
NA
NA
NA
GM
GM
GM
5 MG
5 MG
5 MG
200
200
200
12/04/2002
12/04/2002
12/04/2002
99/99/9999
99/99/9999
99/99/9999
63275-9990-02
J2440
1 EA BO
NA
GM
60 MG
16.66666
12/04/2002
99/99/9999
63275-9990-04
J2440
1 EA BO
NA
GM
60 MG
16.66666
12/04/2002
99/99/9999
63275-9990-05
63275-9991-04
63275-9991-04
63275-9991-05
63275-9991-05
63275-9991-08
63275-9991-08
63275-9992-02
63275-9992-04
63275-9992-05
J2440
J2000
J2001
J2000
J2001
J2000
J2001
J0475
J0475
J0475
12/4/2002
12/4/2002
1/1/2004
12/4/2002
1/1/2004
12/4/2002
1/1/2004
12/4/2002
12/4/2002
12/4/2002
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
60 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
10 MG
10 MG
10 MG
16.66666
4
100
4
100
4
100
100
100
100
12/04/2002
12/04/2002
01/01/2004
12/04/2002
01/01/2004
12/04/2002
01/01/2004
12/04/2002
12/04/2002
12/04/2002
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
63275-9998-01
J7644
12/4/2002
1 EA BO
NA
GM
1 MG
1000
12/04/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
12/04/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
12/04/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
12/04/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
12/04/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
12/04/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
12/04/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
12/04/2002
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
1 EA VL
1 EA VL
NA
IJ
IJ
GM
EA
EA
1 MG
125 MG
125 MG
1000
4
4
01/01/2007
01/01/2002
01/01/2002
99/99/9999
1/11/2009
3/10/2006
30 EA BO
PO
EA
8 MG
0.5
06/25/2007
99/99/9999
63275-9998-01 KO J7644
63275-9998-01
63275-9998-01 KO J7645
63275-9998-02
63275-9998-04
63275-9998-05
63275-9999-04
63275-9999-05
63304-0458-30
KO
Q0179
1/1/2007
12/4/2002
KO
12/4/2002
1/1/2007
KO
1/1/2007
1/1/2005
KO
1/1/2005
1/1/2007
KO
1/1/2007
1/1/2005
KO
J7609
63275-9999-05 KO J7609
63304-0303-10
J0300
63304-0303-25
J0300
12/4/2002
1/1/2007
J7613
63275-9999-05 KO J7613
63275-9999-05
KO
J7609
63275-9999-04 KO J7609
1/1/2007
12/4/2002
J7613
63275-9999-04 KO J7613
63275-9999-04
KO
J7645
63275-9998-05 KO J7645
12/4/2002
1/1/2007
J7644
63275-9998-05 KO J7644
63275-9998-05
KO
J7645
63275-9998-04 KO J7645
1/1/2007
12/4/2002
J7644
63275-9998-04 KO J7644
63275-9998-04
KO
J7645
63275-9998-02 KO J7645
12/4/2002
1/1/2007
J7644
63275-9998-02 KO J7644
63275-9998-02
KO
J7645
1/1/2005
1/1/2007
KO
1/1/2007
1/1/2002
1/1/2002
6/25/2007

LIDOCAINE HCL
LIDOCAINE HCL
LIDOCAINE HCL
LIDOCAINE HCL
LIDOCAINE HCL
LIDOCAINE HCL
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
IPRATROPIUM BROMIDE (U.S.P.)
AMYTAL SODIUM 0.5 GM
AMYTAL SODIUM 0.5 GM
(FILM-COATED) 4 MG
Page 329 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63304-0459-30
63304-0504-01
63304-0505-01
Q0179
J8499
J8499
6/25/2007
1/1/2002
1/1/2002
63304-0591-22
63304-0652-01
63304-0652-05
63304-0748-01
63304-0749-01
63304-0940-25
J7509
J8499
J8499
J0745
J0745
J0690
6/12/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
12/7/2004
63304-0941-10
J0690
4/13/2005
63323-0010-02
J1580
1/1/2002
63323-0010-20
J1580
1/1/2002
63323-0011-15
63323-0012-01
63323-0012-10
J0720
J2590
J2590
1/1/2002
1/1/2002
1/1/2002
63323-0012-12
63323-0012-30
63323-0013-02
63323-0013-02
63323-0017-10
63323-0021-01
63323-0024-25
63323-0024-50
J2590
J2590
J3490
J3411
J1642
J3410
J2150
J2150
1/28/2008
9/24/2007
1/1/2002
1/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
63323-0025-10
63323-0038-10
63323-0038-30
J0725
J1644
J1644
1/1/2002
1/1/2002
1/1/2002
63323-0044-01
63323-0047-10
63323-0051-01
63323-0051-02
J3420
J1644
J3410
J3410
1/1/2002
1/1/2002
1/1/2002
1/1/2002
63323-0064-02
J3475
1/1/2002
63323-0064-10
J3475
1/1/2002
63323-0064-20
J3475
1/1/2002
63323-0064-50
J3475
1/1/2002
63323-0088-61
J7799
1/1/2002
63323-0088-63
J7799
1/1/2002
63323-0101-61
63323-0103-51
63323-0103-64
63323-0103-65
J9000
J9060
J9060
J9060
8/6/2007
1/1/2002
1/1/2002
1/1/2002
63323-0103-91
J9060
1/1/2002
63323-0103-95
63323-0104-05
63323-0104-25
63323-0104-50
63323-0105-10
63323-0105-10
63323-0113-10
J9060
J9181
J9181
J9181
Q4075
J0133
J7699
1/1/2002
1/1/2002
1/1/2002
1/1/2002
10/1/2003
1/1/2006
1/1/2007
63323-0113-10
J7676
63323-0113-10 KO J7676
63323-0117-10
J9190
63323-0117-10 QR J9190
63323-0117-20
J9190
63323-0117-20 QR J9190
63323-0117-51
1/1/2008
KO
QR
1/1/2008
1/1/2002
1/28/2005
1/1/2002
1/28/2005
QR
1/28/2005
QR
J9190
63323-0117-51 QR J9190
1/1/2002

(FILM-COATED) 8 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
4 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
CODEINE PHOSPHATE 30 MG
CODEINE PHOSPHATE 60 MG
CEFAZOLIN 1 GM
10 GM
MG/ML
MG/ML
CHLORAMPHENICOL SODIUM
99/99/9999 INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM
SUCCINATE (VIAL,PF) 1 GM
OXYTOCIN (VIAL,P.C.) 10 U/ML
OXYTOCIN (M.D.V.) 10 U/ML
NOVAPLUS OXYTOCIN (25X1ML,USP) 10
U/ML
OXYTOCIN (10X30ML,MDV) 10 U/ML
THIAMINE HCL (M.D.V.) 100 MG/ML
THIAMINE HCL (M.D.V.) 100 MG/ML
HEPFLUSH-10 (S.D.V.,PF) 10 U/ML
MANNITOL (FLIPOFF TOP,PF) 25%
MANNITOL (S.D.V.,TEARTOP,PF) 25%
CHORIONIC GONADOTROPIN (M.D.V.
W/DILUENT) 10000 U
MCG/ML
MAGNESIUM SULFATE (S.D.V.,P.C.) 500
MG/ML
MAGNESIUM SULFATE (S.D.V.,P.C.,PF)
500 MG/ML
MG/ML
MG/ML
(MAXIVIAL,BULK PACK,PF) 23.4%
(MAXIVIAL,BULK PACK,PF) 23.4%
DOXORUBICIN HYDROCHLORIDE
(USP,STERILE,MDV,PF) 2 MG/ML
CISPLATIN (M.D.V.,PF) 1 MG/ML
CISPLATIN AMERINET CHOICE (M.D.V.)
1 MG/ML
CISPLATIN AMERINET CHOICE (M.D.V.)
1 MG/ML
ACYCLOVIR SODIUM (VIAL,PF) 500 MG
ACYCLOVIR SODIUM (VIAL,PF) 500 MG
PENTAM (S.D.V.,PF) 300 MG
99/99/9999 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG
99/99/9999 ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG
FLUOROURACIL (S.D.V.,PF) 50 MG/ML
FLUOROURACIL (BULK PACKAGE,PF) 50
MG/ML
MG/ML
Page 330 of 374
30 EA BO
100 EA BO
100 EA BO
PO
PO
PO
EA
EA
EA
8 MG
1 EA
1 EA
1
1
1
06/25/2007
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
21 EA
100 EA
500 EA
100 EA
100 EA
1 EA
PO
PO
PO
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
4 MG
1 EA
1 EA
30 MG
30 MG
500 MG
1
1
1
1
2
2
06/12/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/07/2004
04/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
8/6/2008
1 EA VL
IJ
EA
500 MG
20
04/13/2005
8/6/2008
2 ML VL
IJ
ML
80 MG
0.5
01/01/2002
99/99/9999
20 ML VL
IJ
ML
80 MG
0.5
01/01/2002
99/99/9999
1 EA VL
1 ML VL
10 ML VL
IV
IV
IV
GM
ML
ML
1 GM
10 U
10 U
1
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
1 ML
30 ML
2 ML
2 ML
10 ML
1 ML
50 ML
50 ML
VL
VL
VL
VL
VL
VL
VL
VL
IJ
IV
IJ
IJ
IV
IM
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
10 U
10 U
1 EA
100 MG
10 U
25 MG
50 ML
50 ML
1
1
1
1
1
1
0.02
0.02
01/28/2008
09/24/2007
01/01/2002
01/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
12/31/2003
99/99/9999
99/99/9999
8/14/2009
99/99/9999
01/01/2002
1 EA VL
10 ML VL
30 ML VL
IM
IJ
IJ
EA
ML
ML
1000 USP Units

1000 U
1000 U
10
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
09/30/2002
09/30/2002
1 ML
10 ML
1 ML
2 ML
IM
IJ
IM
IM
ML
ML
ML
ML
1000 MCG
1000 U
25 MG
25 MG
1
5
2
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
8/14/2009
8/14/2009
DP
BO
BO
BO
BO
VL
VL
VL
VL
VL
2 ML VL
IJ
ML
500 MG
01/01/2002
99/99/9999
10 ML VL
IJ
ML
500 MG
01/01/2002
99/99/9999
20 ML VL
IJ
ML
500 MG
01/01/2002
99/99/9999
50 ML VL
IJ
ML
500 MG
01/01/2002
99/99/9999
100 ML VL
IV
ML
1 EA
01/01/2002
99/99/9999
200 ML VL
IV
ML
1 EA
01/01/2002
99/99/9999
100 ML
50 ML
200 ML
100 ML
IV
IV
IV
IV
ML
ML
ML
ML
10 MG
10 MG
10 MG
10 MG
0.2
0.1
0.1
0.1
08/06/2007
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
50 ML VL
IV
ML
10 MG
0.1
01/01/2002
99/99/9999
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
IJ
ML
ML
ML
ML
EA
EA
EA
10 MG
10 MG
10 MG
10 MG
5 MG
5 MG
1 EA
0.1
2
2
2
100
100
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
10/01/2003
01/01/2006
01/01/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2005
99/99/9999
12/31/2007
1 EA VL
100 ML
5 ML
25 ML
50 ML
1 EA
1 EA
1 EA
IJ
EA
300 MG
01/01/2008
99/99/9999
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
EA
ML
ML
ML
ML
300 MG
500 MG
500 MG
500 MG
500 MG
1
0.1
0.1
0.1
0.1
01/01/2008
01/01/2002
01/28/2005
01/01/2002
01/28/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
50 ML VL
IV
ML
500 MG
0.1
01/01/2002
99/99/9999
50 ML VL
IV
ML
500 MG
0.1
01/28/2005
99/99/9999
1 EA
10 ML
10 ML
20 ML
20 ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63323-0117-61
J9190
63323-0117-61 QR J9190
63323-0119-08
J9150

QR

63323-0120-20
J9110
63323-0121-02
J9250
63323-0121-04
J9250
63323-0121-08
J9250
63323-0121-10
J9250
63323-0121-40
J9250
63323-0122-50
J9260
63323-0123-02
J9250
63323-0123-10
J9250
63323-0124-04
63323-0127-10
J9150
J9130
63323-0128-12
63323-0128-20
J9140
J9140
63323-0132-10
J9293
63323-0132-12
J9293
63323-0132-15
63323-0139-20
63323-0139-40
63323-0140-10
63323-0142-10
63323-0142-12
63323-0145-07
J9293
J7799
J7799
J9065
J9208
J9208
J9200
63323-0148-01
J9390
63323-0148-05
J9390
63323-0151-00
J9178
63323-0151-05
J9178
12/7/2007
63323-0151-25
J9178
63323-0151-75
J9178
12/7/2007
63323-0161-01
J1885
63323-0162-01
J1885
63323-0162-02
J1885
63323-0165-01
J1100
63323-0165-05
J1100
63323-0165-30
63323-0166-10
63323-0167-20
63323-0167-21
63323-0168-00
J1100
J9045
J9045
J9045
J9045
1/1/2002
4/1/2004
4/1/2004
4/1/2004
4/1/2004
63323-0172-45
J9045
63323-0172-60
J9045
63323-0173-02
J1580
63323-0180-01
J3490
63323-0180-01
J3415
63323-0185-00
A4712

1/1/2002 99/99/9999 DACARBAZINE, 100 MG
1/1/2002 11/21/2007 DACARBAZINE, 200 MG
1/1/2002 99/99/9999 DACARBAZINE, 200 MG
3/17/2006
1/1/2002
1/1/2002
9/13/2004
7/25/2002
11/18/2002
1/1/2002



MG/ML
MG/ML
DAUNORUBICIN HCL (S.D.V.,PF) 20 MG
CYTARABINE (S.D.V.,LATEX-FREE) 100
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
METHOTREXATE SODIUM (VIAL,PF) 25
MG/ML
GM
MG/ML
MG/ML
DAUNORUBICIN HCL (S.D.V.,PF,LATEXFREE) 5 MG/ML
DACARBAZINE NOVA PLUS (S.D.V.) 200
MG
MITOXANTRONE (USP,PF,LATEX-FREE)
2 MG/ML
2 MG/ML
2 MG/ML
CLADRIBINE (S.D.V.,PF) 1 MG/ML
IFOSFAMIDE (S.D.V.) 1 GM
IFOSFAMIDE (SDV) 1 GM
FLOXURIDINE 0.5 GM
VINORELBINE TARTRATE (USP,PF) 10
MG/ML
VINORELBINE TARTRATE (USP,PF) 10
MG/ML
(1X5ML,PF) 2 MG/ML
(1X25ML,PF) 2 MG/ML
(1X75ML,PF) 2 MG/ML
15 MG/ML
30 MG/ML
30 MG/ML
CARBOPLATIN 50 MG
CARBOPLATIN 150 MG
CARBOPLATIN 150 MG
CARBOPLATIN (STERILE) 450 MG
CARBOPLATIN (MDV,LATEX-FREE) 10
MG/ML
CARBOPLATIN (600MG/60ML,LATEXFREE) 10 MG/ML
GENTAMICIN SULFATE PEDIATRIC
(PEDIATRIC S.D.V.,PF) 10 MG/ML
PYRIDOXINE HCL (M.D.V.,AMBER) 100
MG/ML
PYRIDOXINE HCL (M.D.V.,AMBER) 100
MG/ML
WATER FOR INJECTION (S.D.V.,TEAR
TOP)
Page 331 of 374
100 ML VL
IV
ML
500 MG
0.1
01/01/2002
99/99/9999
100 ML VL
1 EA VL
IV
IV
ML
EA
500 MG
10 MG
0.1
2
01/28/2005
01/01/2002
99/99/9999
99/99/9999
20 ML VL
IJ
ML
500 MG
0.2
03/05/2004
99/99/9999
2 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
4 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
8 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
10 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
40 ML VL
IJ
ML
5 MG
03/08/2002
99/99/9999
1 EA VL
IJ
EA
50 MG
20
01/01/2002
99/99/9999
2 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
10 ML VL
IJ
ML
5 MG
01/01/2002
99/99/9999
4 ML VL
1 EA VL
IV
IV
ML
EA
10 MG
100 MG
0.5
1
02/18/2004
01/01/2002
99/99/9999
99/99/9999
1 EA VL
1 EA VL
IV
IV
EA
EA
200 MG
200 MG
1
1
01/01/2002
01/01/2002
11/21/2007
99/99/9999
10 ML VL
IV
ML
5 MG
0.4
03/17/2006
99/99/9999
12.5 ML VL
IV
ML
5 MG
0.4
03/17/2006
99/99/9999
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
IJ
ML
ML
ML
ML
EA
EA
EA
5 MG
1 EA
1 EA
1 MG
1 GM
1 GM
500 MG
0.4
1
1
1
1
1
1
03/17/2006
01/01/2002
01/01/2002
09/13/2004
07/25/2002
11/18/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 ML VL
IV
ML
10 MG
06/22/2005
99/99/9999
5 ML VL
IV
ML
10 MG
06/22/2005
99/99/9999
100 ML VL
IV
ML
2 MG
12/07/2007
99/99/9999
15 ML
20 ML
40 ML
10 ML
1 EA
1 EA
1 EA
5 ML VL
IV
ML
2 MG
12/07/2007
9/11/2009
25 ML VL
IV
ML
2 MG
12/07/2007
99/99/9999
75 ML VL
IV
ML
2 MG
12/07/2007
9/11/2009
1 ML VL
IJ
ML
15 MG
01/01/2002
99/99/9999
1 ML VL
IJ
ML
15 MG
01/01/2002
99/99/9999
2 ML VL
IM
ML
15 MG
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
5 ML VL
IJ
ML
1 MG
01/01/2002
99/99/9999
VL
VL
VL
VL
VL
IJ
IV
IV
IV
IV
ML
EA
EA
EA
EA
1 MG
50 MG
50 MG
50 MG
50 MG
4
1
3
3
9
01/01/2002
04/01/2004
04/01/2004
04/01/2004
04/01/2004
99/99/9999
99/99/9999
02/10/2006
99/99/9999
99/99/9999
50 ML VL
IV
ML
50 MG
0.2
04/28/2006
99/99/9999
60 ML VL
IV
ML
50 MG
0.2
04/07/2006
99/99/9999
2 ML VL
IJ
ML
80 MG
0.125
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1 EA
01/01/2002
12/31/2003
30 ML
1 EA
1 EA
1 EA
1 EA
1 ML VL
IJ
ML
100 MG
01/01/2004
99/99/9999
100 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63323-0185-00
63323-0185-05
63323-0185-05
63323-0185-10
63323-0185-10
63323-0185-20
63323-0185-20
A4216
A4712
A4216
A4712
A4216
A4712
A4216
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004

WATER FOR INJECTION (S.D.V.,TEAR

TOP)
WATER FOR INJECTION (S.D.V.,P.C.)
100 ML
5 ML
5 ML
10 ML
10 ML
20 ML
20 ML
VL
VL
VL
VL
VL
VL
VL
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
0.1
0.1
0.1
0.1
0.1
0.1
0.1
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
63323-0185-50
A4712
WATER FOR INJECTION (S.D.V.,P.C.,PF)
50 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
A4216
50 ML VL
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
63323-0186-00
63323-0186-02
63323-0186-02
63323-0186-10
63323-0186-10
63323-0186-20
63323-0186-20
J7050
J2912
A4216
J2912
A4216
J2912
A4216
1/1/2002
1/1/2002
1/1/2007
1/1/2002
1/1/2004
1/1/2002
1/1/2004
IV
IV
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
250 ML
0.9 %
10 ML
0.9 %
10 ML
0.9 %
10 ML
0.004
0.5
0.1
0.5
0.1
0.5
0.1
01/01/2002
01/01/2002
01/01/2007
01/01/2002
01/01/2004
01/01/2002
01/01/2004
99/99/9999
12/31/2006
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
63323-0187-30
J7799
63323-0190-02
63323-0190-20
63323-0191-20
63323-0191-40
J9185
J9280
J9280
J9290
63323-0193-02
J9206
WATER FOR INJECTION (S.D.V.,P.C.,PF)

SODIUM CHLORIDE (S.D.V.,TEAR TOP)
0.9%
SODIUM CHLORIDE (S.D.V.,P.C.) 0.9%
(S.D.V.,PF) 23.4%
FLUDARABINE PHOSPHATE (SINGLEDOSE) 25 MG/ML
MITOMYCIN 5 MG
MITOMYCIN 5 MG
FLUDARABINE PHOSPHATE (USP) 50
MG
LIDOCAINE HCL (S.D.V.,P.C.) 1%
LIDOCAINE HCL (S.D.V.,P.C.) 1%
VANCOMYCIN HCL (VIAL,PF) 500 MG
63323-0193-02 QR J9206
63323-0193-05
10/31/2007
7/1/2004
2/21/2002
2/4/2002

QR
J9206
63323-0193-05 QR J9206


QR
63323-0196-06
63323-0201-02
63323-0201-02
63323-0201-10
63323-0201-10
63323-0202-02
63323-0202-02
63323-0208-05
63323-0208-05
63323-0221-10
J9185
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J3370
12/7/2007
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002
1/1/2004
1/1/2002

63323-0229-05
J2720
1/1/2002 99/99/9999 INJECTION, PROTAMINE SULFATE, PER 10 MG
63323-0229-15
J2720
63323-0229-30
J2720
ML
1 EA
01/01/2002
99/99/9999
IV
IV
IV
IV
ML
EA
EA
EA
50 MG
5 MG
5 MG
20 MG
0.5
1
1
1
10/31/2007
07/01/2004
02/21/2002
02/04/2002
12/2/2008
04/02/2007
06/30/2004
04/02/2007
2 ML VL
IV
ML
20 MG
02/05/2008
99/99/9999
2 ML VL
IV
ML
20 MG
02/05/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/05/2008
99/99/9999
5 ML VL
IV
ML
20 MG
02/05/2008
99/99/9999
IV
EP
EP
EP
EP
IJ
IJ
IV
IV
IV
EA
ML
ML
ML
ML
ML
ML
ML
ML
EA
50 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
500 MG
1
0.02
1
0.02
1
0.02
2
0.02
2
1
12/07/2007
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
01/01/2004
01/01/2002
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
1 EA
2 ML
2 ML
10 ML
10 ML
2 ML
2 ML
5 ML
5 ML
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
IV
ML
10 MG
01/01/2002
IV
ML
10 MG
01/07/2008
99/99/9999
25 ML VL
IV
ML
10 MG
01/01/2002
99/99/9999
25 ML VL
IV
ML
10 MG
01/07/2008
99/99/9999
1 ML VL
IJ
ML
0.3 MG
1.33333
01/01/2002
12/31/2007
VL
VL
VL
VL
IJ
IJ
IJ
IJ
ML
EA
EA
EA
0.3 MG
500 MG
500 MG
500 MG
1.33333
1
2
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
12/31/2007
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
500 MG
20
01/01/2002
99/99/9999
1 ML VL
1 ML VL
IJ
IJ
ML
ML
0.3 MG
0.3 MG
1.66666
3.33333
01/01/2002
01/01/2002
04/19/2005
12/31/2007
10 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
10 ML VL
IV
ML
10 ML
0.1
01/01/2004
02/10/2006
30 ML VL
IV
ML
10 ML
0.1
01/01/2002
12/31/2003
30 ML VL
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
1 EA VL
IJ
EA
40 MG
09/22/2004
99/99/9999
IJ
IV
IV
IV
EA
ML
ML
ML
125 MG
0.9 %
10 ML
0.9 %
1
0.5
0.1
0.5
08/23/2004
01/01/2002
01/01/2004
01/01/2002
99/99/9999
12/31/2003
12/31/2007
12/31/2003
J2720
J0460
63323-0234-20
63323-0236-10
63323-0237-10
63323-0237-65
J0460
J0690
J0690
J0690
1/1/2002
1/1/2002
1/1/2002
1/1/2002
63323-0238-61
J0690

CEFAZOLIN SODIUM (VIAL,PF) 500 MG
CEFAZOLIN SODIUM (P.B.,PF) 1 GM
CEFAZOLIN SODIUM (BULK
PACKAGE,PF) 10 GM
63323-0243-01
63323-0246-01
J0460
J0460

63323-0249-10
A4712
63323-0249-10
A4216
1/1/2004
63323-0249-30
A4712
63323-0249-30
A4216
63323-0255-03
J2920
63323-0258-03
63323-0259-10
63323-0259-10
63323-0259-30
J2930
J2912
A4216
J2912
8/23/2004
1/1/2002
1/1/2004
1/1/2002
IV
NA
VL
VL
VL
2 ML
1 EA
1 EA
1 EA
5 ML VL
63323-0229-35

30 ML VL
5 ML VL
63323-0234-01
VL
VL
VL
VL
VL
VL
VL
PROTAMINE SULFATE (S.D.V.) 10 MG/ML

NOVAPLUS PROTAMINE SULFATE
(25X5ML,SDV,FLIPTOP,USP) 10 MG/ML
PROTAMINE SULFATE (S.D.V.) 10 MG/ML
NOVAPLUS PROTAMINE SULFATE
(1X25ML,SDV,FLIPTOP,USP) 10 MG/ML

100 ML
2 ML
2 ML
10 ML
10 ML
20 ML
20 ML

ATROPINE SULFATE (M.D.V.) 1 MG/ML
STERILE WATER BACTERIOSTATIC
(M.D.V.)
(M.D.V.)
(M.D.V.)
(M.D.V.)
SUCCINATE 40 MG
SUCCINATE 125 MG
Page 332 of 374
20 ML
1 EA
1 EA
1 EA
1 EA
10 ML
10 ML
30 ML
VL
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
63323-0185-50

Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63323-0259-30
A4216
63323-0261-10
J2675
63323-0262-01
J1644
63323-0265-30
63323-0269-20
J2930
J3490
63323-0269-27
63323-0269-50
J3490
J3490

63323-0269-57
63323-0269-65
J3490
J3490

63323-0269-67
J3490
63323-0272-05
J2680
63323-0272-55
63323-0276-02
J2680
J1644

63323-0278-10
J9360

PROGESTERONE IN SESAME OIL
(M.D.V.) 50 MG/ML
HEPARIN SODIUM (M.D.V.,P.C.) 5000
U/ML
SUCCINATE (PF) 1 GM
DIPRIVAN (20X25ML) 10 MG/ML
NOVAPLUS DIPRIVAN (25X20ML) 10
MG/ML
NOVAPLUS DIPRIVAN (20X50ML) 10
MG/ML
NOVAPLUS DIPRIVAN (10X100ML,
INFUSION) 10 MG/ML
MG/ML
MG/ML
HEPARIN SODIUM (S.D.V.) 1000 U/ML
VINBLASTINE SULFATE (M.D.V.) 1
MG/ML
63323-0280-02
J1940
FUROSEMIDE (S.D.V.,AMBER) 10 MG/ML
63323-0280-04
J1940
4 ML VL
IJ
ML
20 MG
0.5
01/01/2002
99/99/9999
63323-0280-10
J1940
10 ML VL
IJ
ML
20 MG
0.5
01/01/2002
99/99/9999
2 ML VL
IJ
ML
1 EA
05/11/2007
99/99/9999
4 ML VL
IJ
ML
1 EA
05/11/2007
99/99/9999
6 ML VL
60 ML VL
1 EA VL
IJ
IV
IV
ML
ML
EA
1 EA
1 EA
500 MG
1
1
2
05/11/2007
05/11/2007
01/01/2002
99/99/9999
99/99/9999
99/99/9999

30 ML VL
IV
ML
10 ML
0.1
01/01/2004
99/99/9999
10 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
1 ML VL
IJ
ML
01/01/2002
99/99/9999
1 EA VL
20 ML VL
IJ
IV
EA
ML
125 MG
1 EA
8
1
10/27/2004
02/21/2008
99/99/9999
99/99/9999
20 ML VL
50 ML VL
IV
IV
ML
ML
1 EA
1 EA
1
1
01/15/2008
04/28/2008
99/99/9999
99/99/9999
50 ML VL
100 ML VL
IV
IV
ML
ML
1 EA
1 EA
1
1
03/05/2008
03/06/2008
99/99/9999
99/99/9999
100 ML VL
IV
ML
1 EA
02/01/2008
99/99/9999
5 ML VL
IJ
ML
25 MG
01/01/2002
99/99/9999
5 ML VL
2 ML VL
IJ
IJ
ML
ML
25 MG
1000 U
1
1
01/01/2002
01/01/2002
07/15/2003
99/99/9999
10 ML VL
IV
ML
1 MG
01/01/2002
99/99/9999
2 ML VL
IJ
ML
20 MG
0.5
01/01/2002
99/99/9999
1000 U
63323-0282-02
J3490
63323-0282-04
J3490
63323-0282-06
63323-0282-60
63323-0284-20
J3490
J3490
J3370

63323-0295-61
J3370

CLINDAMYCIN (SDV,USP,2MLX25) 150
MG/ML
MG/ML
MG/ML
CLINDAMYCIN (USP) 150 MG/ML
VANCOMYCIN HCL (VIAL,PF) 1 GM
VANCOMYCIN HCL (BULK PACKAGE,PF)
5 GM
1 EA VL
IV
GM
500 MG
01/01/2002
99/99/9999
63323-0301-10
J0697
1/1/2002
CEFUROXIME SODIUM (VIAL,PF) 750 MG
1 EA VL
IJ
EA
750 MG
01/01/2002
03/14/2002

VIAL,PF,LATEX-FREE) 1.2 GM
1 EA VL
IV
EA
300 MG
06/21/2004
12/31/2006
12/31/2006
63323-0303-51
J7682
63323-0303-51 KO J7682
63323-0303-51
KO
1/1/2007
12/17/2004
KO
J7685
63323-0303-55 KO J7685
6/21/2004
1/1/2007
J7682
63323-0303-55 KO J7682
63323-0303-55
KO
J7685
63323-0303-51 KO J7685
63323-0303-55
6/21/2004
12/17/2004
1/1/2007
KO
1/1/2007

63323-0305-02
J3260
63323-0306-02
J3260
63323-0306-30
J3260
63323-0307-51
J3260
63323-0308-61
J1450
63323-0308-63
J1450
63323-0311-10
J0610
63323-0311-50
J0610
63323-0311-61
J0610
63323-0311-63
J0610

1 EA VL
IV
EA
300 MG
06/21/2004
1 EA VL
IV
EA
300 MG
01/01/2007
99/99/9999
1 EA VL
IV
EA
300 MG
01/01/2007
99/99/9999
TOBRAMYCIN SULFATE NOVAPLUS

(BULK PKG,50ML VIAL X 6) 1.2 GM
1 EA VL
IV
EA
300 MG
12/17/2004
12/31/2006

TOBRAMYCIN SULFATE (PEDIATRIC
M.D.V.) 10 MG/ML
TOBRAMYCIN SULFATE (M.D.V.,LATEXFREE) 40 MG/ML
TOBRAMYCIN SULFATE (M.D.V.,LATEXFREE) 40 MG/ML
TOBRAMYCIN SULFATE (PHARMACY
BULK PACKAGE) 40 MG/ML
FLUCONAZOLE (GLASS BOTTLE) 200
MG/100 ML
FLUCONAZOLE (GLASS BOTTLE) 400
MG/200 ML
MG/ML
MG/ML
CALCIUM GLUCONATE (MAXIVIAL,BULK
PACK,PF) 100 MG/ML
CALCIUM GLUCONATE (MAXIVIAL,BULK
PACK) 100 MG/ML
Page 333 of 374
1 EA VL
IV
EA
300 MG
12/17/2004
12/31/2006
1 EA VL
IV
EA
300 MG
01/01/2007
99/99/9999
1 EA VL
IV
EA
300 MG
01/01/2007
99/99/9999
2 ML VL
IJ
ML
80 MG
0.125
04/05/2004
99/99/9999
2 ML VL
IJ
ML
80 MG
0.5
04/05/2004
99/99/9999
30 ML VL
IJ
ML
80 MG
0.5
04/05/2004
99/99/9999
50 ML VL
IJ
ML
80 MG
0.5
04/05/2004
99/99/9999
100 ML VL
IV
ML
200 MG
0.01
07/08/2004
99/99/9999
200 ML VL
IV
ML
200 MG
0.01
07/08/2004
99/99/9999
10 ML VL
IV
ML
10 ML
0.1
01/01/2002
99/99/9999
50 ML VL
IV
ML
10 ML
0.1
01/01/2002
99/99/9999
100 ML VL
IV
ML
10 ML
0.1
01/01/2002
99/99/9999
200 ML VL
IV
ML
10 ML
0.1
01/01/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63323-0312-20
J0697
1/1/2002
63323-0313-61
J0697
1/1/2002
63323-0314-61
J3370
63323-0317-01
J1626

CEFUROXIME SODIUM (VIAL,PF) 1.5 GM

PACKAGE,PF) 7.5 GM
VANCOMYCIN HCL (BULK PACKAGE,PF)
10 GM
(10X1ML,S.D.V,PF) 0.1 MG/ML
(1X1ML,SDV,PF) 1 MG/ML
(1X4ML,MDV) 1 MG/ML
ACYCLOVIR SODIUM (S.D.V.,PF) 50
MG/ML
MG/ML
MG/ML
MG/ML
CEFEPIME (USP,10X1GM) 1 GM
BACITRACIN (LATEX-FREE) 50000 U
CEFOTAXIME SODIUM (S.D.V.) 1 GM
CEFOTAXIME SODIUM (S.D.V.) 2 GM
CEFOTAXIME SODIUM (BULK PAKAGE)
10 GM
CEFOTAXIME SODIUM (BULK PACKAGE)
20 GM
CEFOTAXIME SODIUM (S.D.V.) 500 MG
CEFEPIME (USP,10X2GM) 2 GM
CEFOXITIN SODIUM (VIAL,PF) 1 GM
CEFOXITIN SODIUM (P.B.,P.F) 1 GM
CEFOXITIN SODIUM (VIAL,PF) 2 GM
CEFOXITIN SODIUM (P.B.,PF) 2 GM
CEFOXITIN SODIUM (BULK
PACKAGE,PF) 10 GM
CEFTRIAXONE (S.D.V.) 250 MG
CEFTRIAXONE (S.D.V.) 500 MG
CEFTRIAXONE (S.D.V.) 1 GM
CEFTRIAXONE (S.D.V.) 2 GM
CEFTRIAXONE (BULK
PACKAGE,1X100ML) 10 GM
63323-0318-01
J1626
63323-0319-04
J1626
63323-0325-10
Q4075
63323-0325-10
J0133
63323-0325-20
Q4075
63323-0325-20
63323-0326-20
63323-0329-30
63323-0331-15
63323-0332-15
J0133
J0692
J3490
J0698
J0698
1/1/2006
3/17/2008
4/23/2004
1/29/2002
1/29/2002
63323-0333-61
J0698
63323-0334-61
63323-0335-10
63323-0340-50
63323-0341-20
63323-0341-65
63323-0342-20
63323-0342-65
J0698
J0698
J0692
J0694
J0694
J0694
J0694
1/29/2002
1/29/2002
3/17/2008
1/1/2002
1/1/2002
1/1/2002
1/1/2002

63323-0343-61
63323-0344-10
63323-0345-10
63323-0346-10
63323-0347-20
J0694
J0696
J0696
J0696
J0696
1/1/2002
2/16/2006
2/16/2006
2/16/2006
2/16/2006

63323-0348-61
J0696
63323-0352-10
J0697
CEFUROXIME SODIUM (VIAL,PF) 750 MG
63323-0353-20
J0697
63323-0354-61
63323-0359-03
J0697
J1840
63323-0365-01
63323-0366-01
63323-0368-20
63323-0369-20
J2354
J1240
J0295
J0295
63323-0370-62
J0295
63323-0373-02
63323-0374-20
J2405
J2405
CEFUROXIME SODIUM (VIAL,PF) 1.5 GM

PACKAGE,PF) 7.5 GM
KANAMYCIN SULFATE 1 GM/3 ML
OCTREOTIDE ACETATE
(SDV,1MLX10,PF) 50 MCG/ML
AMPICILLIN/SULBACTAM 2 GM-1 GM
AMPICILLIN AND SULBACTAM
(USP,PHARMACY BULK PKG) 10 GM-5
GM
ONDANSETRON (SDV,25X2ML,PF) 2
MG/ML
ONDANSETRON (MDV) 2 MG/ML
OCTREOTIDE ACETATE
OCTREOTIDE ACETATE
MCG/ML
MCG/ML
PIPERACILLIN (VIAL) 2 GM
(M.D.V.,AMBER) 0.5 MG/ML
(M.D.V.,AMBER) 1 MG/ML
CEFOTETAN 1 GM
CEFOTETAN 2 GM
63323-0376-01
J2354
63323-0377-01
J2354
63323-0378-05
J2354
63323-0379-05
63323-0380-20
63323-0381-20
J2354
J3490
J3490
63323-0382-10
J2710
63323-0383-10
63323-0385-10
63323-0386-20
63323-0387-10
63323-0388-10
63323-0389-10
63323-0390-50
J2710
J3490
J3490
J0290
J0290
J0290
J3490



1/1/2002
8/13/2007
8/13/2007
1/1/2002
1/1/2002
1/1/2002
1/12/2004

Page 334 of 374
1 EA VL
IJ
EA
750 MG
01/01/2002
04/05/2002
1 EA VL
IJ
EA
750 MG
10
01/01/2002
01/12/2003
1 EA VL
IV
GM
500 MG
01/01/2002
99/99/9999
1 ML VL
IV
ML
100 MCG
12/14/2007
99/99/9999
1 ML VL
IV
ML
100 MCG
10
06/25/2008
99/99/9999
4 ML VL
IV
ML
100 MCG
10
06/25/2008
99/99/9999
10 ML VL
IV
ML
5 MG
10
10/01/2003
12/31/2005
10 ML VL
IV
ML
5 MG
10
01/01/2006
99/99/9999
20 ML VL
IV
ML
5 MG
10
10/01/2003
12/31/2005
20 ML
1 EA
1 EA
1 EA
1 EA
IV
IJ
IM
IJ
IJ
ML
EA
EA
EA
EA
5 MG
500 MG
1 EA
1 GM
1 GM
10
2
1
1
2
01/01/2006
03/17/2008
04/23/2004
01/29/2002
01/29/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
1 GM
10
01/29/2002
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
GC
VL
GC
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
1 GM
1 GM
500 MG
1 GM
1 GM
1 GM
1 GM
20
0.5
4
1
1
2
2
01/29/2002
01/29/2002
03/17/2008
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
01/01/2002
99/99/9999
01/01/2002
1
1
1
1
1
VL
VL
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
1 GM
250 MG
250 MG
250 MG
250 MG
10
1
2
4
8
01/01/2002
02/16/2006
02/16/2006
02/16/2006
02/16/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IV
EA
250 MG
40
02/16/2006
99/99/9999
1 EA VL
IJ
EA
750 MG
01/01/2002
99/99/9999
1 EA VL
IJ
EA
750 MG
01/01/2002
99/99/9999
1 EA VL
3 ML VL
IJ
IJ
EA
ML
750 MG
500 MG
10
0.666
01/13/2003
01/03/2003
99/99/9999
99/99/9999
1 ML
1 ML
1 EA
1 EA
IJ
IJ
IJ
IJ
ML
ML
EA
EA
25 MCG
50 MG
1.5 GM
1.5 GM
2
1
1
2
04/13/2006
07/01/2004
11/30/2005
11/30/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
EA
EA
EA
EA
EA
VL
VL
VL
VL
VL
VL
VL
VL
VL
1 EA VL
IV
EA
1.5 GM
10
11/08/2006
99/99/9999
2 ML VL
20 ML VL
IJ
IJ
ML
ML
1 MG
1 MG
2
2
12/27/2006
12/27/2006
99/99/9999
99/99/9999
1 ML VL
IJ
ML
25 MCG
04/13/2006
99/99/9999
1 ML VL
IJ
ML
25 MCG
20
04/13/2006
99/99/9999
5 ML VL
IJ
ML
25 MCG
05/12/2006
99/99/9999
5 ML VL
1 EA VL
1 EA VL
IJ
IJ
IJ
ML
EA
EA
25 MCG
1 EA
1 EA
40
1
1
05/12/2006
01/12/2004
01/12/2004
99/99/9999
99/99/9999
99/99/9999
10 ML VL
IJ
ML
0.5 MG
01/01/2002
99/99/9999
10 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
EA
EA
0.5 MG
1 EA
1 EA
500 MG
500 MG
500 MG
1 EA
2
1
1
0.5
1
2
1
01/01/2002
08/13/2007
08/13/2007
01/01/2002
01/01/2002
01/01/2002
01/12/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
COLISTIMETHATE (USP,LYOPHILIZED
CAKE) 150 MG
AZITHROMYCIN (10X10ML,LATEX-FREE)
500 MG
NOVAPLUS AZITHROMYCIN (10X10ML)
500 MG
FOSPHENYTOIN SODIUM (USP,25X2ML)
75 MG/ML
FOSPHENYTOIN SODIUM
CAFFEINE CITRATE (USP,SDV,PF) 20
MG/ML
CEFAZOLIN SODIUM (BULK
PACKAGE,PF) 20 GM
MG/ML
MG/ML
HALOPERIDOL AMERINET CHOICE
(VIAL,FLIP-TOP) 50 MG/ML
MG/ML
MG/ML
(VIAL,FLIP-TOP) 100 MG/ML
(M.D.V.,FLIP-TOP) 100 MG/ML
63323-0393-06
J0770
63323-0398-10
J0456
63323-0398-12
63323-0399-23
J0456
J0290

63323-0403-02
Q2009
63323-0403-10
Q2009
63323-0407-03
63323-0411-05
63323-0411-10
63323-0411-12
63323-0411-25
63323-0412-01
63323-0412-02
63323-0412-05
63323-0412-10
63323-0412-25
J0706
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
J2250
8/3/2007
1/1/2002
1/1/2002
1/1/2002
12/8/2003
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/7/2004
63323-0446-61
J0690
63323-0469-01
J1631
63323-0469-05
J1631
63323-0469-51
J1631
63323-0471-01
J1631
63323-0471-05
J1631
63323-0471-51
J1631
63323-0471-55
J1631
63323-0474-01
J1630
63323-0474-10
J1630
63323-0474-91
J1630
63323-0506-01
J1100
63323-0513-02
J1580
63323-0516-10
J1100
63323-0540-01
63323-0540-11
63323-0540-31
J1644
J1644
J1644

63323-0542-01
63323-0542-07
J1644
J1644

63323-0544-01
J1642
HALOPERIDOL LACTATE (VIAL) 5 MG/ML

MG/ML
(VIAL) 5 MG/ML
PHOSPHATE (LATEX-FREE) 10 MG/ML
GENTAMICIN SULFATE PEDIATRIC
(PEDIATRIC M.D.V.,PF) 10 MG/ML
PHOSPHATE 10 MG/ML
U/ML
U/ML
HEPARIN LOCK FLUSH (M.D.V.,P.C.) 10
U/ML
63323-0544-11
J1642
HEPARIN LOCK FLUSH (M.D.V.) 10 U/ML
63323-0544-31
J1642
1/1/2002
63323-0545-01
J1642
63323-0545-05
63323-0604-01
63323-0613-02
63323-0613-10
63323-0614-01
J1642
J1800
J1245
J1245
J0360
63323-0614-55
63323-0616-03
63323-0616-09
J0360
J0282
J0282
63323-0616-13
63323-0617-10
63323-0617-20
63323-0617-50
J0282
J2260
J2260
J2260
HEPARIN LOCK FLUSH (M.D.V.) 10 U/ML

HEPARIN LOCK FLUSH (M.D.V.,P.C.) 100
U/ML
HEPARIN LOCK FLUSH (M.D.V.) 100
U/ML
PROPRANOLOL HCL (S.D.V.) 1 MG/ML
HYDRALAZINE HCL (S.D.V.) 20 MG/ML
NOVAPLUS HYDRALAZINE
HYDROCHLORIDE (USP,SDV,LATEXFREE) 20 MG/ML
AMIODARONE HCL (S.D.V.) 50 MG/ML
AMIODARONE HCL (S.D.V.) 50 MG/ML
AMIODARONE HCL NOVAPLUS (S.D.V.)
50 MG/ML



1/6/2003
5/14/2002
5/14/2002
5/14/2002

Page 335 of 374
1 EA VL
IJ
EA
150 MG
03/10/2008
99/99/9999
1 EA VL
IV
EA
500 MG
02/27/2006
99/99/9999
1 EA VL
1 EA VL
IV
IJ
EA
EA
500 MG
500 MG
1
4
02/27/2006
01/01/2002
99/99/9999
99/99/9999
2 ML VL
IJ
ML
50 MG
1.5
08/16/2007
99/99/9999
10 ML VL
IJ
ML
50 MG
1.5
08/16/2007
99/99/9999
3 ML
5 ML
10 ML
2 ML
5 ML
1 ML
2 ML
5 ML
10 ML
1 ML
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
5 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
4
1
1
1
1
5
5
5
5
5
08/03/2007
01/01/2002
01/01/2002
01/01/2002
12/08/2003
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/07/2004
99/99/9999
12/07/2003
99/99/9999
99/99/9999
99/99/9999
01/07/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
1 EA VL
IJ
EA
500 MG
40
01/01/2002
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
5 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
5 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
1 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
5 ML VL
IM
ML
50 MG
01/01/2002
99/99/9999
1 ML VL
IM
ML
5 MG
01/01/2002
99/99/9999
10 ML VL
IM
ML
5 MG
01/01/2002
99/99/9999
1 ML VL
IM
ML
5 MG
01/01/2002
99/99/9999
1 ML VL
IJ
ML
1 MG
10
05/30/2003
99/99/9999
2 ML VL
IJ
ML
80 MG
0.125
01/01/2002
99/99/9999
10 ML VL
IJ
ML
1 MG
10
08/23/2005
99/99/9999
1 ML VL
10 ML VL
30 ML VL
IJ
IJ
IJ
ML
ML
ML
1000 U
1000 U
1000 U
1
1
1
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
1 ML VL
5 ML VL
IJ
IJ
ML
ML
1000 U
1000 U
10
10
01/01/2002
01/01/2002
99/99/9999
99/99/9999
1 ML VL
IV
ML
10 U
01/01/2002
99/99/9999
10 ML VL
IV
ML
10 U
01/01/2002
99/99/9999
30 ML VL
IV
ML
10 U
01/01/2002
02/10/2006
1 ML VL
IV
ML
10 U
10
01/01/2002
99/99/9999
VL
VL
VL
VL
VL
IV
IV
IV
IV
IJ
ML
ML
ML
ML
ML
10 U
1 MG
10 MG
10 MG
20 MG
10
1
0.5
0.5
1
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
99/99/9999
99/99/9999
05/18/2006
05/18/2006
99/99/9999
1 ML VL
3 ML VL
9 ML VL
IJ
IV
IV
ML
ML
ML
20 MG
30 MG
30 MG
1
1.66666
1.66666
03/26/2007
08/02/2002
12/16/2003
99/99/9999
99/99/9999
99/99/9999
IV
IV
IV
IV
ML
ML
ML
ML
30 MG
5 MG
5 MG
5 MG
1.66666
0.2
0.2
0.2
01/06/2003
05/14/2002
05/14/2002
05/14/2002
11/21/2007
99/99/9999
99/99/9999
99/99/9999
5 ML
1 ML
2 ML
10 ML
1 ML
3 ML
10 ML
20 ML
50 ML
VL
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63323-0651-02
J0150
63323-0651-04
63323-0664-01
63323-0665-01
J0150
J1200
J3105

63323-0711-00
63323-0731-01
63323-0733-10
63323-0733-11
J0640
J0636
J9209
J9209
1/1/2002
3/17/2003
1/1/2002
1/1/2002
63323-0733-12
J9209
63323-0734-10
J2430
63323-0734-35
J2430
63323-0735-10
J2430
63323-0735-35
63323-0738-04
63323-0738-20
63323-0739-02
63323-0739-12
J2430
J3490
J3490
J3490
J3490
9/11/2003
1/1/2002
1/1/2002
1/1/2002
5/14/2002

99/99/9999 INJECTION, CALCITRIOL, 0.1 MCG
63323-0877-15
J2545

63323-0883-05
J9000
63323-0883-10
J9000
63323-0883-30
J9000
63323-0915-01
63323-0924-10
63323-0924-10
63323-0924-30
63323-0924-30
J1644
J2912
A4216
J2912
A4216
1/1/2002
1/1/2002
1/1/2004
1/1/2002
1/1/2004

63323-0929-05
J1642
1/23/2002
63323-0965-05
63323-0965-10
63323-0965-15
63323-0965-20
J3480
J3480
J3480
J3480
63323-0967-30
63370-0005-25
J3480
J7699
63370-0005-25
J7604
63370-0005-25 KO J7604
63370-0005-35
J7699
63370-0005-35
J7604
63370-0005-35 KO J7604
63370-0005-45
J7699
63370-0005-45
KO
J7604
63370-0005-50 KO J7604
63370-0005-55
J7699
63370-0005-55
KO
J7604
63370-0005-45 KO J7604
63370-0005-50
J7699
63370-0005-50
KO
KO
J7604
63370-0005-55 KO J7604
KO
2 ML VL
IV
ML
6 MG
0.5
06/27/2005
99/99/9999

DIPHENHYDRAMINE HCL 50 MG/ML
MG
CALCITRIOL 1 MCG/ML
4 ML VL
1 ML VL
1 ML VL
IV
IJ
SC
ML
ML
ML
6 MG
50 MG
1 MG
0.5
1
1
06/27/2005
06/12/2002
06/21/2004
99/99/9999
99/99/9999
99/99/9999
VL
AM
VL
VL
IJ
IV
IV
IV
EA
ML
ML
ML
50 MG
0.1 MCG
200 MG
200 MG
10
10
0.5
0.5
01/01/2002
03/17/2003
01/01/2002
01/01/2002
12/31/2006
99/99/9999
99/99/9999
99/99/9999
10 ML VL
IV
ML
200 MG
0.5
01/01/2002
11/21/2007
10 ML VL
IV
ML
30 MG
0.1
04/25/2002
99/99/9999
10 ML VL
IV
ML
30 MG
0.1
07/20/2004
99/99/9999
10 ML VL
IV
ML
30 MG
0.3
04/25/2002
99/99/9999
10 ML
4 ML
20 ML
2 ML
2 ML
IV
IV
IV
IV
IV
ML
ML
ML
ML
ML
30 MG
1 EA
1 EA
1 EA
1 EA
0.3
1
1
1
1
09/11/2003
01/01/2002
01/01/2002
01/01/2002
05/14/2002
99/99/9999
99/99/9999
99/99/9999
05/13/2002
99/99/9999
MESNA NOVAPLUS (M.D.V.) 100 MG/ML

PAMIDRONATE DISODIUM (S.D.V.) 3
MG/ML
PAMIDRONATE DISODIUM OTN
(S.D.V.,LATEX-FREE) 3 MG/ML
PAMIDRONATE DISODIUM (S.D.V.) 9
MG/ML
PAMIDRONATE DISODIUM OTN (S.D.V.)
9 MG/ML
FAMOTIDINE (S.D.V.) 10 MG/ML
FAMOTIDINE (S.D.V.) 10 MG/ML
NEBUPENT (S.D.V.,PF) 300 MG
(USP,STERILE,SDV,PF) 2 MG/ML
U/ML
SODIUM CHLORIDE (M.D.V.,P.C.) 0.9%
SMARTAMP HEPARIN LOCK FLUSH
(AMP,PF) 10 U/ML
1 EA
1 ML
10 ML
10 ML
VL
VL
VL
VL
VL
1 EA VL
IH
EA
300 MG
1/1/2007
99/99/9999
5 ML VL
IV
ML
10 MG
0.2
08/06/2007
99/99/9999
10 ML VL
IV
ML
10 MG
0.2
08/06/2007
99/99/9999
25 ML VL
IV
ML
10 MG
0.2
08/06/2007
99/99/9999
1 ML
10 ML
10 ML
30 ML
30 ML
IJ
IV
IV
IV
IV
ML
ML
ML
ML
ML
1000 U
0.9 %
10 ML
0.9 %
10 ML
20
0.5
0.1
0.5
0.1
01/01/2002
01/01/2002
01/01/2004
01/01/2002
01/01/2004
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
10 U
01/23/2002
07/09/2003
VL
VL
VL
VL
VL
5 ML AM IV
ML
POTASSIUM CHLORIDE CONCENTRATE

(S.D.V.,P.C.) 2 MEQ/ML
5 ML VL
IV
ML
2 MEQ
01/01/2002
99/99/9999

10 ML VL
IV
ML
2 MEQ
01/01/2002
99/99/9999

15 ML VL
IV
ML
2 MEQ
01/01/2002
99/99/9999

20 ML VL
IV
ML
2 MEQ
01/01/2002
99/99/9999

(M.D.V.,P.C.) 2 MEQ/ML
30 ML VL
1 EA BO
IV
NA
ML
GM
2 MEQ
1 EA
1
1
01/01/2002
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
1 EA BO
NA
NA
GM
GM
1 GM
1 EA
1
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999

Page 336 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63370-0005-62
J7699
63370-0005-62
J7604
63370-0005-62 KO J7604
63370-0007-25
Q4075
63370-0007-25
J0133
63370-0007-35
Q4075
63370-0007-35
J0133
63370-0007-50
Q4075
63370-0007-50
J0133
63370-0010-25
KO
J7622
63370-0027-10 KO J7622
63370-0027-15
KO
J7609
63370-0010-50 KO J7609
63370-0016-15
J3490
63370-0016-15
J0278
63370-0016-25
J3490
63370-0016-25
J0278
63370-0016-35
J3490
63370-0016-35
J0278
63370-0016-50
J3490
63370-0016-50
J0278
63370-0018-15
J1320
63370-0018-25
J1320
63370-0018-35
J1320
63370-0020-10
J0285
63370-0020-15
J0285
63370-0020-25
J0285
63370-0020-35
J0285
63370-0020-50
J0285
63370-0022-06
J3490
63370-0022-06
J0364
63370-0022-09
J3490
63370-0022-09
J0364
J3490
63370-0022-15
63370-0022-15
J0364
63370-0025-10
J7501
63370-0025-15
J7501
63370-0025-25
J7501
63370-0025-35
J7501
63370-0026-15
J0475
63370-0026-25
J0475
63370-0026-35
J0475
63370-0026-45
J0475
63370-0027-10
KO
J7613
63370-0010-50 KO J7613
63370-0010-50
KO
J7609
63370-0010-45 KO J7609
63370-0010-50
KO
J7613
63370-0010-45 KO J7613
63370-0010-45
KO
J7609
63370-0010-35 KO J7609
63370-0010-45
KO
J7613
63370-0010-35 KO J7613
63370-0010-35
KO
J7609
63370-0010-25 KO J7609
63370-0010-35
KO
J7613
63370-0010-25 KO J7613
63370-0010-25
KO
J7622
63370-0027-15 KO J7622
KO

1 EA BO
NA
GM
1 EA
01/01/2007
12/31/2007
1 EA BO
NA
GM
1 GM
01/01/2008
99/99/9999
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
ACYCLOVIR (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
1 GM
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
200
200
200
200
200
200
01/01/2008
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2005
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999

AMPHOTERICIN B (U.S.P.,ORAL)
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
BACLOFEN (U.S.P.)
BECLOMETHASONE DIPROP
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
JR
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
1 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
1 EA
100 MG
20 MG
20 MG
20 MG
50 MG
50 MG
50 MG
50 MG
50 MG
1 EA
1 MG
1 EA
1 MG
1 EA
1 MG
100 MG
100 MG
100 MG
100 MG
10 MG
10 MG
10 MG
10 MG
1000
1
10
1
10
1
10
1
10
50
50
50
20
20
20
20
20
1
1000
1
1000
1
1000
10
10
10
10
100
100
100
100
01/01/2007
07/08/2003
01/01/2006
07/08/2003
01/01/2006
07/08/2003
01/01/2006
07/08/2003
01/01/2006
07/08/2003
07/08/2003
07/08/2003
07/08/2003
09/04/2002
09/04/2002
09/04/2002
09/04/2002
12/19/2003
01/01/2007
12/19/2003
01/01/2007
12/19/2003
01/01/2007
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
08/29/2003
1 EA BO
NA
GM
1 MG
1000
07/08/2003
08/29/2003
1 EA BO
NA
GM
1 MG
1000
07/08/2003
08/29/2003
1 EA BO
NA
GM
1 MG
1000
07/08/2003
08/29/2003
Page 337 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63370-0027-25
J7622
63370-0027-25 KO J7622
63370-0027-35
63370-0028-25
KO
KO
7/8/2003
7/8/2003
KO
7/8/2003
7/8/2003
KO
7/8/2003
7/8/2003
KO
7/8/2003
7/8/2003
7/8/2003
7/8/2003

63370-0032-10
J3490
63370-0032-15
J3490
63370-0032-25
J3490
63370-0032-35
63370-0034-35
63370-0034-45
63370-0034-50
J3490
J3490
J3490
J3490
63370-0035-09
J7626
63370-0035-09 KO J7626
63370-0035-09
63370-0035-10
63370-0035-25
KO
J7627
KO
KO
J7626
63370-0035-25 KO J7626
63370-0035-25
KO
J7627
63370-0035-15 KO J7627
J7626
63370-0035-15 KO J7626
63370-0035-15
KO
J7627
63370-0035-10 KO J7627
63370-0035-15
KO
J7626
63370-0035-10 KO J7626

J7627
63370-0035-09 KO J7627
63370-0035-10
7/8/2003
7/12/2004
7/12/2004
7/12/2004
KO
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
BENZOCAINE (U.S.P.)
BENZOCAINE (U.S.P.)
BENZOCAINE (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
MICRONIZED (U.S.P.)
CIPROFLOXACIN HCL (USP)
1 EA BO
NA
GM
1 MG
1000
07/08/2003
1 EA BO
NA
GM
1 MG
1000
07/08/2003
08/29/2003
1 EA BO
NA
GM
1 MG
1000
07/08/2003
08/29/2003
1 EA BO
NA
GM
1 MG
1000
07/08/2003
08/29/2003
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
08/29/2003
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 MG
1 EA
1 EA
1 EA
1000
1
1
1
07/08/2003
07/08/2003
07/08/2003
07/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 EA
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 EA
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 EA
07/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
1 EA
1 EA
1 EA
1 EA
1
1
1
1
07/08/2003
07/12/2004
07/12/2004
07/12/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
0.25 MG
2000
07/08/2003
12/31/2005
1 EA BO
NA
GM
0.25 MG
2000
07/08/2003
12/31/2005
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA JR
NA
GM
0.25 MG
2000
07/08/2003
12/31/2005
1 EA JR
NA
GM
0.25 MG
2000
07/08/2003
12/31/2005
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA JR
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.25 MG
2000
07/08/2003
12/31/2005
1 EA BO
NA
GM
0.25 MG
2000
07/08/2003
12/31/2005
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
1 EA BO
NA
GM
0.25 MG
2000
07/08/2003
12/31/2005
1 EA BO
NA
GM
0.25 MG
2000
07/08/2003
12/31/2005
1 EA BO
NA
GM
0.5 MG
2000
01/01/2006
99/99/9999
Page 338 of 374
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description

7/8/2003
7/8/2003
J7624
63370-0028-35 KO J7624
63370-0031-25
J3490
63370-0031-35
J3490
63370-0031-45
J3490
7/8/2003
7/8/2003
J7624
63370-0028-25 KO J7624
63370-0028-35
KO
J7624
63370-0028-15 KO J7624
7/8/2003
7/8/2003
J7624
63370-0028-10 KO J7624
63370-0028-15
KO
J7624
63370-0028-06 KO J7624
63370-0028-10
7/8/2003
J7622
63370-0027-35 KO J7622
63370-0028-06
HCPCS Mod
HCPCS
NDC Mod
NDC
63370-0035-25 KO J7627
63370-0050-15
J7699
63370-0050-15
KO
J7632
63370-0050-45 KO J7632
63370-0050-50
J7699
63370-0050-50
KO
J7632
63370-0050-35 KO J7632
63370-0050-45
J7699
63370-0050-45
KO
J7632
63370-0050-25 KO J7632
63370-0050-35
J7699
63370-0050-35
KO
J7632
63370-0050-15 KO J7632
63370-0050-25
J7699
63370-0050-25
KO
J7632
63370-0050-50 KO J7632
63370-0052-10
J0735
63370-0052-15
J0735
63370-0052-25
J0735
63370-0057-10
J7516
63370-0057-15
J7516
63370-0057-25
J7516
63370-0057-35
J7516
63370-0057-45
J7516
KO

1 EA BO
1 EA BO
NA
NA
GM
GM
0.5 MG
1 EA
2000
1
01/01/2006
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

1 EA BO
1 EA BO
NA
NA
GM
GM
10 MG
1 EA
100
1
01/01/2008
01/01/2007
99/99/9999
12/31/2007
1 EA BO
NA
GM
10 MG
100
01/01/2008
99/99/9999

CLONIDINE HCL (USP)
CLONIDINE HCL (USP)
CLONIDINE HCL (USP)
CYCLOSPORIN A (U.S.P.)
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
JR
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
10 MG
1 MG
1 MG
1 MG
250 MG
250 MG
250 MG
250 MG
250 MG
100
1000
1000
1000
4
4
4
4
4
01/01/2008
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
12/19/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
63370-0060-15
J1094
1 EA BO
NA
GM
1 MG
1000
07/08/2003
63370-0060-20
J1095
1 EA BO
NA
GM
8 MG
125
01/01/2002
12/31/2002
63370-0060-20
J1094
1 EA BO
NA
GM
1 MG
1000
01/01/2003
99/99/9999
63370-0060-25
J1094
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
63370-0060-35
J1094
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
63370-0060-50
J1094
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
63370-0069-09
J7640

FORMOTEROL FUMARATE DIHYDRATE
(1X0.5GM)
(1X0.5GM)
(1X1GM)
(1X1GM)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
PHOSPHATE (U.S.P.)
1 EA NA
NA
GM
12 MCG
83333.33
10/24/2006
99/99/9999
63370-0069-09 KO J7640
63370-0069-10
63370-0069-10 KO J7640
63370-0070-10
KO
J7638
63370-0070-45 KO J7638
63370-0070-50
KO
J7638
63370-0070-35 KO J7638
63370-0070-45
KO
J7638
63370-0070-25 KO J7638
63370-0070-35
KO
J7638
63370-0070-20 KO J7638
63370-0070-25
KO
J7638
63370-0070-15 KO J7638
63370-0070-20
KO
J7638
63370-0070-10 KO J7638
63370-0070-15
KO
J7640
J7638
KO

Page 339 of 374
1 EA NA
NA
GM
12 MCG
83333.33
10/24/2006
99/99/9999
1 EA NA
NA
GM
12 MCG
83333.33
10/24/2006
99/99/9999
1 EA NA
NA
GM
12 MCG
83333.33
10/24/2006
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
J1700
63370-0108-35
J1700
63370-0108-45
J1700
63370-0108-50
J1700
63370-0109-10
63370-0109-10
J7317
J3490
63370-0109-16
63370-0109-16
J7317
J3490
63370-0120-10
J7644
63370-0120-10
63370-0120-10 KO J7645
63370-0120-15
KO
J7644
63370-0120-15 KO J7644
63370-0120-15
KO
J7645
KO
J7645
63370-0120-15 KO J7645
KO

10/24/2006 12/31/2006 INJECTION
SODIUM HYALURONATE (1X1GM)
SODIUM HYALURONATE (1X1GM)
10/24/2006 12/31/2006 INJECTION
SODIUM HYALURONATE (1X0.2GM)
SODIUM HYALURONATE (1X0.2GM)
IPRATROPIUM BROMIDE (EP)
7/8/2003 12/31/2006 MILLIGRAM
7/8/2003 12/31/2006 MILLIGRAM
7/8/2003 12/31/2006 MILLIGRAM
7/8/2003 12/31/2006 MILLIGRAM
Page 340 of 374
NA
GM
25 MG
40
07/12/2004
99/99/9999
1 EA BO
NA
GM
25 MG
40
07/12/2004
99/99/9999
1 EA BO
NA
GM
25 MG
40
07/12/2004
99/99/9999
1 EA BO
NA
GM
25 MG
40
07/12/2004
99/99/9999
1 EA BO
NA
GM
25 MG
40
07/12/2004
99/99/9999
1 EA NA
1 EA NA
NA
NA
GM
GM
20 MG
1 EA
40
1
10/24/2006
01/01/2007
12/31/2006
99/99/9999
1 EA NA
1 EA NA
NA
NA
GM
GM
20 MG
1 EA
40
1
10/24/2006
01/01/2007
12/31/2006
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
CF
HCPCS Amount #1
1 EA BO
Prior End Date #3
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
12/19/2003
12/19/2003
12/19/2003
07/12/2004
07/12/2004
07/12/2004
07/12/2004
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/12/2004
07/12/2004
07/12/2004
07/08/2003
01/28/2005
07/08/2003
01/28/2005
07/08/2003
01/28/2005
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
1000
20
20
20
20
200
200
200
25
25
25
1
1
1
5
5
5
5
1000
1000
1000
1000
1
1
1
2
2
2
2
2
2
1
1
1
1
1
200
200
200
40
40
40
40
Prior End Date #2
1 MG
50 MG
50 MG
50 MG
50 MG
5 MG
5 MG
5 MG
40 MG
40 MG
40 MG
1 EA
1 EA
1 EA
200 MG
200 MG
200 MG
200 MG
1 MG
1 MG
1 MG
1 MG
1 EA
1 EA
1 EA
500 MG
500 MG
500 MG
500 MG
500 MG
500 MG
1 EA
1 EA
1 EA
1 EA
1 EA
5 MG
5 MG
5 MG
25 MG
25 MG
25 MG
25 MG
End Date #1
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
Start Date #1
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
HCPCS Measure #1
BO
BO
BO
BO
BO
JR
JR
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
JR
BO
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
Prior Start Date #2

Package
NDC Package Type
J1700
63370-0108-25
QR
PHOSPHATE (U.S.P.)
DIPHENHYDRAMINE HCL (USP)
ESTRADIOL CYPIONATE (USP)
FLUCONAZOLE (USP)
FLUCONAZOLE (USP)
FLUCONAZOLE (USP)
FLUCONAZOLE (USP)
ESTRONE (USP,1X1GM)
ESTRONE (USP,1X5GM)
ESTRONE (USP,1X25GM)
ESTRONE (USP,1X100GM)
FAMOTIDINE (USP)
FAMOTIDINE (USP)
FAMOTIDINE (USP)
HALOPERIDOL (U.S.P.,BASE)
MICRONIZED (USP)
MICRONIZED (USP)
MICRONIZED (USP)
MICRONIZED (USP)
MICRONIZED (USP)
NDC Package Measure
63370-0108-15
QR
NDC Label
HCPCS Description
KO J7638
J1200
J1200
J1200
J1200
J1000
J1000
J1000
J0970
J0970
J0970
J7799
J7799
J7799
J1450
J1450
J1450
J1450
J1435
J1435
J1435
J1435
J3490
J3490
J3490
J9190
QR J9190
J9190
QR J9190
J9190
QR J9190
J7699
J7699
J7699
J7699
J7699
J1630
J1630
J1630
J3410
J3410
J3410
J3410
QR
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
12/19/2003
12/19/2003
12/19/2003
7/12/2004
7/12/2004
7/12/2004
7/12/2004
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/12/2004
7/12/2004
7/12/2004
7/8/2003
1/28/2005
7/8/2003
1/28/2005
7/8/2003
1/28/2005
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003

63370-0070-50
63370-0071-25
63370-0071-35
63370-0071-45
63370-0071-50
63370-0084-10
63370-0084-15
63370-0084-25
63370-0086-10
63370-0086-15
63370-0086-25
63370-0088-07
63370-0088-15
63370-0088-25
63370-0089-25
63370-0089-35
63370-0089-45
63370-0089-50
63370-0090-10
63370-0090-15
63370-0090-25
63370-0090-35
63370-0091-25
63370-0091-35
63370-0091-45
63370-0095-15
63370-0095-15
63370-0095-25
63370-0095-25
63370-0095-35
63370-0095-35
63370-0098-15
63370-0098-25
63370-0098-35
63370-0098-50
63370-0098-55
63370-0102-15
63370-0102-25
63370-0102-35
63370-0107-25
63370-0107-35
63370-0107-50
63370-0107-55
63370-0120-10 KO J7644
KO
HCPCS Mod
HCPCS
NDC Mod
NDC
63370-0120-25
J7644
63370-0120-25 KO J7644
63370-0120-25
KO
J7644
63370-0120-50 KO J7644
63370-0120-50
KO
J7645
63370-0120-35 KO J7645
63370-0120-50
KO
J7644
63370-0120-35 KO J7644
63370-0120-35
KO
J7645
63370-0120-25 KO J7645
63370-0120-35
KO
J7645
63370-0120-50 KO J7645
63370-0122-15
J1835
63370-0122-25
J1835
63370-0122-35
J1835
63370-0124-20
J1840
63370-0124-25
J1840
63370-0124-35
J1840
63370-0138-10
J1030
63370-0138-15
J1030
63370-0138-25
J1030
63370-0138-35
J1030
63370-0138-50
J1030
63370-0141-15
J2765
63370-0141-25
J2765
63370-0141-35
63370-0143-35
63370-0143-45
63370-0143-50
63370-0145-14
63370-0145-14
63370-0145-25
63370-0145-25
63370-0145-35
63370-0145-35
63370-0145-50
63370-0145-50
63370-0145-55
63370-0145-55
63370-0152-25
63370-0152-35
63370-0152-45
J2765
J2800
J2800
J2800
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J2000
J2001
J3490
J3490
J3490
63370-0153-20
J7669
63370-0153-20 KO J7669
KO
KO

7/8/2003 12/31/2006 MILLIGRAM
7/8/2003 12/31/2006 MILLIGRAM
7/8/2003 12/31/2006 MILLIGRAM
7/8/2003 12/31/2006 MILLIGRAM
7/8/2003 12/31/2006 MILLIGRAM
7/8/2003 12/31/2006 MILLIGRAM
MICRO (1X1GM,USP)
MICRO (1X5GM,USP)
MICRO (1X25GM,USP)
MICRO (1X100GM,USP)
MICRO (1X1000GM,USP)
METOCLOPRAMIDE HCL (U.S.P.,
MONOHYDRATE)
MONOHYDRATE)
MONOHYDRATE)
7/8/2003 12/31/2006 PER 10 MILLIGRAMS
7/8/2003 12/31/2006 PER 10 MILLIGRAMS
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
07/08/2003
12/31/2006
1 EA BO
NA
GM
1 MG
1000
01/01/2007
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
JR
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
1 MG
50 MG
50 MG
50 MG
500 MG
500 MG
500 MG
1000
20
20
20
2
2
2
01/01/2007
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA NA
NA
GM
40 MG
25
10/25/2006
99/99/9999
1 EA NA
NA
GM
40 MG
25
10/25/2006
99/99/9999
1 EA NA
NA
GM
40 MG
25
10/25/2006
99/99/9999
1 EA NA
NA
GM
40 MG
25
10/25/2006
99/99/9999
1 EA NA
NA
GM
40 MG
25
10/25/2006
99/99/9999
1 EA BO
NA
GM
10 MG
100
07/08/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
07/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
10 MG
10 ML
10 ML
10 ML
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
50 ML
10 MG
1 EA
1 EA
1 EA
100
1
1
1
4
100
4
100
4
100
4
100
4
100
1
1
1
07/08/2003
07/08/2003
07/08/2003
07/08/2003
12/19/2003
01/01/2004
07/08/2003
01/01/2004
07/08/2003
01/01/2004
07/08/2003
01/01/2004
07/08/2003
01/01/2004
07/08/2003
07/08/2003
07/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
12/31/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
10 MG
100
07/08/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
07/08/2003
12/31/2006
J7670

1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
63370-0153-20 KO J7670

1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
63370-0153-20
KO
Page 341 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63370-0153-25
J7669
63370-0153-25 KO J7669
63370-0153-25
63370-0153-45
KO
KO
KO
J7669
63370-0153-45 KO J7669
KO

7/8/2003 12/31/2006 PER 10 MILLIGRAMS
7/8/2003 12/31/2006 PER 10 MILLIGRAMS
1 EA BO
NA
GM
10 MG
100
07/08/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
07/08/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
07/08/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
07/08/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
07/08/2003
12/31/2006
1 EA BO
NA
GM
10 MG
100
07/08/2003
12/31/2006
J7670

1 EA BO
NA
GM
10 MG
100
01/01/2007
99/99/9999
63370-0153-45 KO J7670
63370-0154-10
J8610
63370-0154-15
J8610
63370-0154-25
J8610


1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
NA
NA
NA
NA
GM
GM
GM
GM
10 MG
2.5 MG
2.5 MG
2.5 MG
100
400
400
400
01/01/2007
07/08/2003
07/08/2003
07/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
63370-0153-45
KO
1/1/2007
7/8/2003
7/8/2003
7/8/2003
63370-0165-15
J2440
1 EA BO
NA
GM
60 MG
16.66666
07/08/2003
99/99/9999
63370-0165-25
J2440
1 EA BO
NA
GM
60 MG
16.66666
07/08/2003
99/99/9999
63370-0165-35
63370-0170-06
63370-0170-09
63370-0170-10
63370-0170-15
63370-0176-25
63370-0176-35
63370-0176-45
63370-0176-53
63370-0194-15
63370-0194-25
63370-0194-35
63370-0194-45
63370-0194-50
J2440
J2760
J2760
J2760
J2760
J1165
J1165
J1165
J1165
J7506
J7506
J7506
J7506
J7506
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
60 MG
5 MG
5 MG
5 MG
5 MG
50 MG
50 MG
50 MG
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
16.66666
200
200
200
200
20
20
20
20
200
200
200
200
200
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/12/2004
07/12/2004
07/12/2004
07/12/2004
07/12/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
63370-0195-15
J2650
1 EA BO
NA
GM
1 ML
20
07/08/2003
99/99/9999
63370-0195-25
J2650
1 EA BO
NA
GM
1 ML
20
07/08/2003
99/99/9999
63370-0195-35
J2650
1 EA BO
NA
GM
1 ML
20
07/08/2003
99/99/9999
63370-0195-50
J2650
1 EA BO
NA
GM
1 ML
20
07/08/2003
99/99/9999
63370-0195-55
J2650

PREDNISONE MICRONIZED (U.S.P)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
(U.S.P.)
1 EA BO
NA
GM
1 ML
20
07/08/2003
99/99/9999
63370-0198-25
Q0165
1 EA BO
NA
GM
10 MG
100
12/19/2003
99/99/9999
63370-0198-35
Q0165
1 EA BO
NA
GM
10 MG
100
12/19/2003
99/99/9999
63370-0198-45
Q0165
1 EA BO
NA
GM
10 MG
100
12/19/2003
99/99/9999
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/12/2004
7/12/2004
7/12/2004
7/12/2004
7/12/2004


PROCHLORPERAZINE MALEATE (USP)
Page 342 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
HCPCS Description
NDC Label

7/8/2003 12/31/2006 PER 10 MILLIGRAMS
7/8/2003 12/31/2006 PER 10 MILLIGRAMS
J7670
63370-0153-35 KO J7670

7/8/2003 12/31/2006 PER 10 MILLIGRAMS
7/8/2003 12/31/2006 PER 10 MILLIGRAMS
J7669
63370-0153-35 KO J7669
63370-0153-35
KO
J7670
63370-0153-25 KO J7670
63370-0153-35
HCPCS Mod
HCPCS
NDC Mod
NDC
63370-0199-35
J2675
63370-0199-45
J2675
63370-0199-50
J2675
63370-0199-55
J2675
63370-0199-62
63370-0200-35
63370-0200-45
63370-0200-50
63370-0200-55
63370-0200-62
J2675
J2675
J2675
J2675
J2675
J2675
63370-0202-35
J2675
63370-0202-45
J2675
63370-0202-50
63370-0203-25
63370-0203-35
63370-0203-45
63370-0203-50
63370-0204-35
63370-0204-45
63370-0204-50
63370-0204-55
63370-0204-62
63370-0205-25
63370-0205-35
63370-0205-45
J2675
J2550
J2550
J2550
J2550
J2675
J2675
J2675
J2675
J2675
J1800
J1800
J1800
7/12/2004
7/8/2003
7/8/2003
7/8/2003
7/8/2003
2/25/2004
2/25/2004
2/25/2004
2/25/2004
2/25/2004
7/8/2003
7/8/2003
7/8/2003
63370-0210-04
J0270
7/8/2003
63370-0210-06
J0270
7/8/2003
63370-0210-10
63370-0218-25
63370-0218-35
63370-0218-45
63370-0218-50
J0270
J2780
J2780
J2780
J2780
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
63370-0233-35
J3000
63370-0233-50
J3000
63370-0250-15
J7681

7/8/2003 12/31/2006 MILLIGRAMS
7/8/2003 12/31/2006 MILLIGRAMS
7/8/2003 12/31/2006 MILLIGRAMS
63370-0250-15 KO J7681
63370-0250-20
KO
J7685
63370-0275-10 KO J7685
63370-0275-15
KO
J7682
63370-0275-10 KO J7682
63370-0275-10
KO
J7681
63370-0250-35 KO J7681
63370-0275-10
KO
J7681
63370-0250-25 KO J7681
63370-0250-35
KO
J7681
63370-0250-20 KO J7681
63370-0250-25
2/25/2004
12/19/2003
12/19/2003
7/8/2003
12/19/2003
7/8/2003
J7682
KO


(USP,SOY)
(USP,SOY)
(USP,SOY)
(USP,SOY)
(USP,SOY)
PROGESTERONE (USP,YAM)
(U.S.P.,YAM)
(U.S.P.,YAM)
(U.S.P.,YAM)
1 EA BO
NA
GM
50 MG
20
02/25/2004
99/99/9999
1 EA BO
NA
GM
50 MG
20
02/25/2004
99/99/9999
1 EA BO
NA
GM
50 MG
20
02/25/2004
99/99/9999
1 EA BO
NA
GM
50 MG
20
02/25/2004
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
20
20
20
20
20
20
02/25/2004
12/19/2003
12/19/2003
07/08/2003
12/19/2003
07/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
07/08/2003
1 EA BO
NA
GM
50 MG
20
07/12/2004
99/99/9999
1 EA BO
NA
GM
50 MG
20
07/12/2004
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
50 MG
1 MG
1 MG
1 MG
20
20
20
20
20
20
20
20
20
20
1000
1000
1000
07/12/2004
07/08/2003
07/08/2003
07/08/2003
07/08/2003
02/25/2004
02/25/2004
02/25/2004
02/25/2004
02/25/2004
07/08/2003
07/08/2003
07/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1.25 MCG
800000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1.25 MCG
800000
07/08/2003
99/99/9999
STREPTOMYCIN SULFATE (U.S.P., NONSTERILE)
STREPTOMYCIN SULFATE (U.S.P., NONSTERILE)
1 EA
1 EA
1 EA
1 EA
1 EA
BO
JR
JR
BO
BO
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
1.25 MCG
25 MG
25 MG
25 MG
25 MG
800000
40
40
40
40
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
1 GM
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 GM
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
1 MG
1000
07/08/2003
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
07/08/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
07/08/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
07/08/2003
12/31/2006
Page 343 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63370-0275-15
J7685
63370-0275-15 KO J7685
63370-0275-25
J7682
63370-0275-25 KO J7682
63370-0275-25
KO
J7682
63370-0275-35 KO J7682
63370-0275-35
KO
J7685
63370-0275-25 KO J7685
63370-0275-35
KO
KO
J7685
63370-0275-35 KO J7685
KO
7/8/2003 12/31/2006 MILLIGRAMS
7/8/2003 12/31/2006 MILLIGRAMS
7/8/2003 12/31/2006 MILLIGRAMS
7/8/2003 12/31/2006 MILLIGRAMS
7/8/2003 12/31/2006 MILLIGRAMS
63370-0300-15
J3301
63370-0300-20
J3301
63370-0300-25
J3301
63370-0300-35
63370-0350-10
63370-0350-15
63370-0350-25
63370-0350-35
63370-0414-35
63370-0414-45
63370-0414-50
63370-0414-53
63370-0432-35
63370-0432-50
63370-0462-10
63370-0462-15
63370-0462-25
J3301
J3370
J3370
J3370
J3370
J1955
J1955
J1955
J1955
J3520
J3520
J3430
J3430
J3430
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
10/24/2006
10/24/2006
10/24/2006
10/24/2006
10/24/2006
10/24/2006
10/25/2006
10/25/2006
10/25/2006

63370-0472-35
J3415
63370-0472-45
J3415
63370-0472-50
J3415
63370-0472-53
J3415
63370-0485-35
J3411
63370-0485-45
J3411
63370-0485-50
J3411
63370-0485-53
J3411
63370-0905-06
J0592
63370-0905-09
J0592
63370-0905-10
J0592
63370-0905-15
63370-0910-15
63370-0910-25
63370-0910-35
63370-0920-06
63370-0920-09
63370-0920-10
63370-0920-15
63370-0930-10
63370-0930-15
J0592
J0745
J0745
J0745
J3010
J3010
J3010
J3010
J1170
J1170
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003

1 EA BO
NA
GM
300 MG
3.33333
07/08/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
07/08/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
07/08/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
300 MG
3.33333
07/08/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
07/08/2003
12/31/2006
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999

MICRONIZED
MICRONIZED
MICRONIZED
MICRONIZED
LEVOCARNITINE (1X100GM,USP)
EDETATE DISODIUM (1X100GM,USP)
EDETATE DISODIUM (1X1000GM,USP)
PHYTONADIONE (1X1GM,USP)
PYRIDOXINE HYDROCHLORIDE
(1X100GM,USP)
(1X500GM,USP)
(1X1000GM,USP)
(1X25000GM,USP)
(1X100GM,USP)
(1X500GM,USP)
(1X1000GM,USP)
(1X2500GM,USP)
(USP)
(USP)
(USP)
(USP)
1 EA BO
NA
GM
300 MG
3.33333
01/01/2007
99/99/9999
1 EA BO
NA
GM
10 MG
100
07/08/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
07/08/2003
99/99/9999
1 EA BO
NA
GM
10 MG
100
07/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
BO
BO
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
10 MG
500 MG
500 MG
500 MG
500 MG
1 GM
1 GM
1 GM
1 GM
150 MG
150 MG
1 MG
1 MG
1 MG
100
2
2
2
2
1
1
1
1
6.66666
6.66666
1000
1000
1000
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
10/24/2006
10/24/2006
10/24/2006
10/24/2006
10/24/2006
10/24/2006
10/25/2006
10/25/2006
10/25/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA BO
NA
GM
100 MG
10
10/26/2006
99/99/9999
1 EA BO
NA
GM
100 MG
10
10/26/2006
99/99/9999
1 EA BO
NA
GM
100 MG
10
10/26/2006
99/99/9999
1 EA NA
NA
GM
100 MG
10
10/26/2006
99/99/9999
1 EA BO
NA
GM
100 MG
10
10/26/2006
99/99/9999
1 EA BO
NA
GM
100 MG
10
10/26/2006
99/99/9999
1 EA BO
NA
GM
100 MG
10
10/26/2006
99/99/9999
1 EA NA
NA
GM
100 MG
10
10/26/2006
99/99/9999
1 EA JR
NA
GM
0.1 MG
10000
07/08/2003
99/99/9999
1 EA JR
NA
GM
0.1 MG
10000
07/08/2003
99/99/9999
1 EA JR
NA
GM
0.1 MG
10000
07/08/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
0.1 MG
30 MG
30 MG
30 MG
0.1 MG
0.1 MG
0.1 MG
0.1 MG
4 MG
4 MG
10000
33.33333
33.33333
33.33333
10000
10000
10000
10000
250
250
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Page 344 of 374
JR
BO
BO
BO
BO
JR
BO
JR
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
63370-0275-15 KO J7682
NDC
HCPCS


LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
LORAZEPAM (U.S.P.)
(USP,YAM)
(USP,YAM)
(USP,YAM)
(USP,YAM)
NA
GM
50 MG
20
12/19/2003
99/99/9999
1 EA BO
NA
GM
50 MG
20
12/19/2003
99/99/9999
1 EA BO
NA
GM
50 MG
20
12/19/2003
99/99/9999
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
BO
BO
JR
JR
BO
BO
BO
BO
NA
NA
NA
NA
NA
NA
NA
NA
GM
GM
GM
GM
GM
GM
GM
GM
50 MG
100 MG
100 MG
100 MG
200 MG
200 MG
200 MG
200 MG
20
10
10
10
5
5
5
5
12/19/2003
07/08/2003
07/08/2003
07/08/2003
01/19/2004
01/19/2004
01/19/2004
01/19/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
CF
HCPCS Amount #1
J3140
J3140
63370-0971-45
J3140
63370-0971-50
63370-0980-25
63370-0980-35
63370-0980-50
63370-0983-15
63370-0983-25
63370-0983-35
63370-0983-50
J3140
J1070
J1070
J1070
J3130
J3130
J3130
J3130
12/19/2003
7/8/2003
7/8/2003
7/8/2003
1/19/2004
1/19/2004
1/19/2004
1/19/2004
63370-0985-25
J3150
1 EA BO
NA
GM
100 MG
10
07/08/2003
99/99/9999
63370-0985-35
J3150
1 EA BO
NA
GM
100 MG
10
07/08/2003
99/99/9999
63370-0985-45
J3150
1 EA BO
NA
GM
100 MG
10
07/08/2003
99/99/9999
63370-0985-50
J3150
1 EA BO
NA
GM
100 MG
10
07/08/2003
99/99/9999
63402-0511-24
J7603

1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
1/1/2008 3/31/2008 (LEVALBUTEROL)
XOPENEX PEDIATRIC 0.31 MG/3 ML
3 ML PC
IH
ML
1 MG
0.20666
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.20666
01/01/2008
03/31/2008
3 ML PC
IH
ML
0.5 MG
0.20666
04/01/2008
99/99/9999
3 ML PC
IH
ML
0.5 MG
0.20666
04/01/2008
99/99/9999
XOPENEX (PF) 0.63 MG/3 ML
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
1 MG
0.42
01/01/2008
03/31/2008
3 ML PC
IH
ML
0.5 MG
0.42
04/01/2008
99/99/9999
3 ML PC
IH
ML
0.5 MG
0.42
04/01/2008
99/99/9999
3 ML PC
IH
ML
1 MG
0.83333
01/01/2008
03/31/2008
63402-0511-24 KO J7603
63402-0511-24
63402-0511-24 KO J7614
63402-0512-24
KO
J7614
63402-0512-24 KO J7614
63402-0513-24
KO
J7603
63402-0512-24 KO J7603
63402-0512-24
KO
J7614
J7603
KO

Page 345 of 374
1 EA BO
63370-0971-25
63370-0971-35
Prior End Date #3
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
07/08/2003
01/31/2002
01/31/2002
01/31/2002
01/31/2002
250
250
250
500
500
500
500
10
10
10
100
100
100
10
10
10
10
10
10
10
10
10
1
1
20
20
20
20
Prior End Date #2
4 MG
4 MG
4 MG
2 MG
2 MG
2 MG
2 MG
100 MG
100 MG
100 MG
10 MG
10 MG
10 MG
100 MG
100 MG
100 MG
100 MG
100 MG
100 MG
100 MG
100 MG
100 MG
1 EA
1 EA
50 MG
50 MG
50 MG
50 MG
End Date #1
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
Start Date #1
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
HCPCS Measure #1
BO
JR
JR
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
JR
JR
JR
JR
JR
NA
BO
BO
BO
JR
JR
Billing Units
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
Prior Start Date #2

Package
NDC Label
HCPCS Description

7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
7/8/2003
1/31/2002
1/31/2002
1/31/2002
1/31/2002
NDC Package Type
J1170
J1170
J1170
J2060
J2060
J2060
J2060
J2175
J2175
J2175
J1230
J1230
J1230
J2271
J2271
J2271
J2271
J2321
J2321
J2321
J2321
J2321
J3490
J3490
J3140
J3140
J3140
J3140
NDC Package Measure
63370-0930-20
63370-0930-25
63370-0930-35
63370-0935-10
63370-0935-15
63370-0935-25
63370-0935-35
63370-0937-15
63370-0937-25
63370-0937-35
63370-0939-15
63370-0939-25
63370-0939-35
63370-0950-25
63370-0950-35
63370-0950-45
63370-0950-50
63370-0955-10
63370-0955-15
63370-0955-25
63370-0955-35
63370-0955-45
63370-0968-04
63370-0968-06
63370-0970-25
63370-0970-35
63370-0970-45
63370-0970-50
HCPCS Mod
HCPCS
NDC Mod
NDC
63402-0513-24 KO J7603
63402-0513-24
KO
J7614
63402-0513-24 KO J7614
63402-0515-30
1/1/2008
4/1/2008
KO
J7602
4/1/2008
1/1/2008
63402-0515-30
J7612
63402-0911-30 KO J7699
KO
4/1/2008
4/4/2007
63402-0911-30 KO J7605
63402-0911-64 KO J7699
KO
KO
1/1/2008
1/31/2007
63402-0911-64 KO J7605
63459-0300-42
J3490
63459-0300-42
J2315
63459-0391-20
J3490
63459-0600-10
J9017
KO
1/1/2008
6/12/2006
1/1/2007
3/31/2008
7/15/2006

LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON99/99/9999 COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG
ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15
ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15
5/1/2009 INJECTION, NALTREXONE, DEPOT FORM, 1 MG
63481-0108-70
G9033
12/1/2004
63481-0205-16
63481-0358-10
63481-0359-10
63481-0365-05
63481-0368-05
63481-0377-10
G9033
J2310
J2310
J2310
J2310
J2310
12/1/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002
63481-0432-10
J2300
1/1/2002
63481-0433-10
63481-0444-10
63481-0445-01
63481-0508-05
63481-0509-05
J2300
J2410
J2410
J2300
J2300
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2002

7/19/2007 INJECTION, OXYMORPHONE HCL, UP TO 1 MG
9/30/2005 INJECTION, OXYMORPHONE HCL, UP TO 1 MG
63481-0624-10
63629-1262-01
J2410
J8999
63629-1335-01
Q0165
63629-1335-02
Q0165
63629-1335-03
Q0165
63629-1343-01
Q0163
63629-1343-02
Q0163
63629-1343-03
Q0163
63629-1343-04
Q0163
63629-1349-01
Q0163
3 ML PC
IH
ML
1 MG
0.83333
01/01/2008
03/31/2008
3 ML PC
IH
ML
0.5 MG
0.83333
04/01/2008
99/99/9999
3 ML PC
IH
ML
0.5 MG
0.83333
04/01/2008
99/99/9999
XOPENEX (PF) 1.25 MG/0.5 ML
0.5 ML PC
IH
ML
1 MG
01/01/2008
03/31/2008
XOPENEX (PF) 1.25 MG/0.5 ML

BROVANA 15 MCG/2 ML
0.5 ML PC
2 ML PC
IH
IH
ML
ML
0.5 MG
1 EA
5
1
04/01/2008
04/04/2007
99/99/9999
12/31/2007
2 ML PC
2 ML VL
IH
IH
ML
ML
15 MCG
1 EA
0.5
1
01/01/2008
01/31/2007
99/99/9999
12/31/2007
IH
IM
IM
IV
IV
ML
EA
EA
EA
ML
15 MCG
1 EA
1 MG
1 EA
1 MG
0.5
1
380
1
1
01/01/2008
06/12/2006
01/01/2007
03/31/2008
07/15/2006
99/99/9999
12/31/2006
5/1/2009
99/99/9999
99/99/9999
BROVANA 15 MCG/2 ML
BROVANA (60X2ML) 15 MCG/2 ML
BROVANA (60X2ML) 15 MCG/2 ML

VIVITROL (W/DILUENT) 380 MG
VIVITROL (W/DILUENT) 380 MG
TREANDA
TRISENOX (10X10 AMP,PF) 1 MG/ML
2 ML
1 EA
1 EA
1 EA
10 ML
VL
VL
VL
VL
AM
SYMMETREL 100 MG
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
SYMMETREL 50 MG/5 ML
NARCAN (M.D.V.) 0.4 MG/ML
NARCAN (M.D.V) 1 MG/ML
NARCAN (AMP) 1 MG/ML
10 MG/ML
20 MG/ML
NUMORPHAN HCL (AMP) 1 MG/ML
NUMORPHAN HCL (VIAL) 1.5 MG/ML
OPANA (1MLX10,PARABEN-FREE) 1
MG/ML
AROMASIN 25 MG
480 ML
1 ML
2 ML
10 ML
10 ML
2 ML
PO
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
100 MG
1 MG
1 MG
1 MG
1 MG
1 MG
0.1
0.4
0.02
0.4
1
1
12/01/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/18/2005
05/21/2007
06/24/2003
01/06/2005
01/06/2005
02/16/2005
ML
10 MG
01/01/2002
05/21/2007
ML
ML
ML
ML
ML
10 MG
1 MG
1 MG
10 MG
10 MG
2
1
1.5
1
2
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
05/21/2007
07/19/2007
09/30/2005
09/16/2005
05/21/2007
1 ML AM IJ
30 EA NA PO
ML
EA
1 MG
1 EA
1
1
05/07/2007
11/01/2004
99/99/9999
99/99/9999
10 EA NA
PO
EA
10 MG
11/01/2004
99/99/9999
30 EA NA
PO
EA
10 MG
11/01/2004
99/99/9999
20 EA NA
PO
EA
10 MG
11/01/2004
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
11/01/2004
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
11/01/2004
99/99/9999
42 EA BO
PO
EA
50 MG
0.5
11/01/2004
99/99/9999
24 EA BO
PO
EA
50 MG
0.5
11/01/2004
99/99/9999
15 EA BO
PO
EA
50 MG
11/01/2004
99/99/9999
5/7/2007 99/99/9999 INJECTION, OXYMORPHONE HCL, UP TO 1 MG

Page 346 of 374
BO
AM
AM
VL
VL
AM
1 ML AM IJ
1 ML
1 ML
10 ML
10 ML
10 ML
AM
AM
VL
VL
VL
IJ
IJ
IJ
IJ
IJ
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63629-1349-02
Q0163
11/1/2004
63629-1349-03
63629-1472-01
Q0163
None
11/1/2004
11/1/2004
63629-1533-01
Q0177
11/1/2004
63629-1533-02
63629-1579-01
63629-1579-02
63629-1579-03
63629-1587-01
63629-1587-02
63629-1587-03
63629-1587-04
Q0177
J7506
J7506
J7506
J7506
J7506
J7506
J7506
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
63629-1591-01
Q0169
11/1/2004
63629-1591-02
Q0169
11/1/2004
63629-1591-03
Q0169
11/1/2004
63629-1591-04
63629-1605-01
63629-1605-02
63629-1605-03
63629-1605-04
63629-1605-05
63629-1676-01
63629-1676-02
63629-1676-03
63629-1677-01
63629-1677-02
63629-1677-03
63629-1678-01
63629-1678-02
63629-1678-03
Q0169
J7506
J7506
J7506
J7506
J7506
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
11/1/2004
63629-1742-01
Q0170
11/1/2004
63629-1742-02
Q0170
11/1/2004
63629-1742-03
Q0170
11/1/2004
63629-1742-04
Q0170
11/1/2004
63629-1841-01
Q0164
11/1/2004
63629-1856-01
Q0177
11/1/2004

METHOTREXATE 2.5 MG
HYDROXYYZINE PAMOATE 25 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
Page 347 of 374
20 EA BO
PO
EA
50 MG
11/01/2004
99/99/9999
30 EA BO
30 EA NA
PO
PO
EA
EA
50 MG
2.5 MG
1
1
11/01/2004
11/01/2004
99/99/9999
99/99/9999
20 EA NA
PO
EA
25 MG
11/01/2004
99/99/9999
30 EA
21 EA
40 EA
30 EA
20 EA
30 EA
40 EA
15 EA
NA
NA
NA
NA
NA
NA
NA
NA
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
25 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
2
2
2
4
4
4
4
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA NA
PO
EA
12.5 MG
11/01/2004
99/99/9999
4 EA NA
PO
EA
12.5 MG
11/01/2004
99/99/9999
2 EA NA
PO
EA
12.5 MG
11/01/2004
99/99/9999
NA
NA
NA
NA
NA
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
12.5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
11/01/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
15 EA NA
PO
EA
25 MG
11/01/2004
99/99/9999
30 EA NA
PO
EA
25 MG
11/01/2004
99/99/9999
10 EA NA
PO
EA
25 MG
11/01/2004
99/99/9999
20 EA NA
PO
EA
25 MG
11/01/2004
99/99/9999
20 EA NA
PO
EA
5 MG
11/01/2004
99/99/9999
30 EA NA
PO
EA
25 MG
11/01/2004
99/99/9999
30 EA
30 EA
78 EA
36 EA
21 EA
15 EA
30 EA
25 EA
35 EA
20 EA
28 EA
30 EA
25 EA
35 EA
30 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
ERGOTRATE (AMP) 0.2 MG/ML
ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 GRANISOL (1X30ML,AMBER GLASS) 2
MG/10 ML
PACK) 25 MG
DIPHENHYDRAMINE HCL (PUNCH CARD
25X30) 25 MG
PACK) 50 MG
DIPHENHYDRAMINE HCL (PUNCH CARD
25X30) 50 MG
MEGESTROL ACETATE (BLISTER PACK)
40 MG
MEGESTROL ACETATE (PUNCH CARD
25X30) 40 MG
PREDNISONE 5 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
(USP) 25 MG
(USP) 25 MG
MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
SYREX (SRN,PF) 0.9%
SYREX (SRN,PF) 0.9%
SYREX (SRN,PF) 0.9%
SYREX (PF,LATEX-FREE) 0.9%
SYREX (30X10ML,PF) 0.9%
SYREX (SRN,PF) 0.9%
SYREX (SRN,PF) 0.9%
63629-1856-02
63629-1862-01
Q0177
J7510
11/1/2004
11/1/2004
63629-1870-01
Q0170
11/1/2004
63629-1870-02
63704-0002-01
Q0170
J1330
11/1/2004
1/1/2006
63717-0801-30
Q0166
3/3/2008
63739-0082-01
Q0163
1/1/2002
63739-0082-03
Q0163
1/1/2002
63739-0083-01
Q0163
1/1/2002
63739-0083-03
63739-0161-10
63739-0161-15
Q0163
J7509
J7509
1/1/2002
2/27/2007
8/4/2003
63739-0165-01
J8999
1/1/2002
63739-0165-03
63739-0165-10
63739-0165-15
63739-0207-10
63739-0207-15
63739-0208-10
63739-0208-15
63739-0209-10
63739-0209-15
J8999
J8999
J8999
J7506
J7506
J7506
J7506
J7506
J7506
1/1/2002
2/27/2007
6/9/2004
3/1/2007
6/9/2004
3/1/2007
6/9/2004
3/1/2007
6/9/2004
63739-0213-10
Q0170
2/27/2007
63739-0213-15
63739-0269-10
Q0170
J8999
3/1/2006
2/27/2007
63739-0269-15
63739-0314-10
63739-0314-15
63739-0315-10
63739-0315-15
63739-0316-10
63739-0316-15
63807-0100-03
63807-0100-05
63807-0100-10
63807-0100-11
63807-0100-11
63807-0100-20
63807-0100-30
63807-0100-30
63807-0100-33
63807-0100-33
J8999
J8499
J8499
J8499
J8499
J8499
J8499
J2912
J2912
J2912
J2912
A4216
A4216
J2912
A4216
J2912
A4216
2/15/2005
2/27/2007
6/9/2004
2/27/2007
6/9/2004
2/27/2007
6/9/2004
1/1/2002
1/1/2002
1/1/2002
1/1/2002
1/1/2007
4/1/2007
1/1/2002
1/1/2007
1/1/2002
1/1/2007
63807-0100-35
J2912
63807-0100-35
63807-0100-50
63807-0100-50
A4216
J2912
A4216

60 EA NA
60 ML NA
PO
PO
EA
ML
25 MG
5 MG
1
0.6
11/01/2004
11/01/2004
99/99/9999
99/99/9999
120 ML NA
PO
ML
25 MG
0.05
11/01/2004
99/99/9999
240 ML NA PO
1 ML AM IJ
ML
ML
25 MG
0.2 MG
0.05
1
11/01/2004
01/01/2006
99/99/9999
99/99/9999
30 ML BO
PO
ML
1 MG
0.2
03/03/2008
99/99/9999
750 EA BX
PO
EA
50 MG
0.5
01/01/2002
04/14/2005
25 EA BX
PO
EA
50 MG
0.5
01/01/2002
04/14/2005
750 EA BX
PO
EA
50 MG
01/01/2002
04/14/2005
25 EA BX
100 EA BX
150 EA BX
PO
PO
PO
EA
EA
EA
50 MG
4 MG
4 MG
1
1
1
01/01/2002
02/27/2007
08/04/2003
04/14/2005
99/99/9999
10/3/2008
25 EA BX
PO
EA
1 EA
01/01/2002
06/30/2007
BX
BX
BX
BX
BX
BX
BX
BX
BX
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
1 EA
1 EA
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
1
1
1
1
2
2
4
4
01/01/2002
02/27/2007
06/09/2004
03/01/2007
06/09/2004
03/01/2007
06/09/2004
03/01/2007
06/09/2004
06/30/2007
99/99/9999
10/3/2008
99/99/9999
10/3/2008
99/99/9999
10/3/2008
99/99/9999
10/3/2008
100 EA BX
PO
EA
25 MG
02/27/2007
99/99/9999
150 EA BX
100 EA BX
PO
PO
EA
EA
25 MG
1 EA
1
1
03/01/2006
02/27/2007
10/3/2008
99/99/9999
150 EA
100 EA
150 EA
100 EA
150 EA
100 EA
150 EA
2.5 ML
5 ML
10 ML
10 ML
10 ML
10 ML
2.5 ML
2.5 ML
2.5 ML
2.5 ML
PO
PO
PO
PO
PO
PO
PO
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
0.9 %
0.9 %
0.9 %
0.9 %
10 ML
10 ML
0.9 %
10 ML
0.9 %
10 ML
1
1
1
1
1
1
1
0.5
0.5
0.5
0.5
0.1
0.1
0.5
0.1
0.5
0.1
02/15/2005
02/27/2007
06/09/2004
02/27/2007
06/09/2004
02/27/2007
06/09/2004
01/01/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2007
04/01/2007
01/01/2002
01/01/2007
01/01/2002
01/01/2007
10/3/2008
99/99/9999
10/3/2008
99/99/9999
10/3/2008
99/99/9999
10/3/2008
07/01/2002
07/01/2002
07/01/2002
12/31/2006
99/99/9999
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
25 EA
100 EA
150 EA
100 EA
150 EA
100 EA
150 EA
100 EA
150 EA
BX
BX
BX
BX
BX
BX
BX
SR
SR
SR
BX
BX
SR
SR
SR
BX
BX
SYREX (USP,10X3ML SYRINGE,PF) 0.9%
3 ML SR
IJ
ML
0.9 %
0.5
05/25/2006
12/31/2006
SYREX (USP,10X3ML SYRINGE,PF) 0.9%

SYREX (SRN,PF) 0.9%
SYREX (SRN,PF) 0.9%
3 ML SR
5 ML SR
5 ML SR
IJ
IJ
IJ
ML
ML
ML
10 ML
0.9 %
10 ML
0.1
0.5
0.1
01/01/2007
01/01/2002
01/01/2007
99/99/9999
12/31/2006
99/99/9999
Page 348 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63807-0300-31
J1642
63807-0300-35
J1642
63807-0400-31
J1642
63807-0400-35
J1642
63807-0500-31
J1642
63807-0500-51
J1642
63807-0600-31
J1642
63807-0600-51
63807-0600-55
J1642
J1642
63868-0087-01
Q0163
63868-0087-24
Q0163
63868-0500-01
Q0163
63868-0611-32
Q0163
63868-0612-32
Q0163
63868-0751-24
Q0163
63868-0789-24
Q0163
63868-0823-54
Q0163
63868-0995-01
Q0163
63868-0995-24
Q0163
63874-0005-01
Q0163
63874-0005-02
Q0163
63874-0005-06
Q0163

SYREX (100X5ML,PF) 0.9%
SYREX (SRN,PF) 0.9%
SYREX (SRN,PF) 0.9%
SYREX (2X10ML,PF,LATEX-FREE) 0.9%
SYREX (2X10ML,PF,LATEX-FREE) 0.9%
HEPARIN LOCK FLUSH (LATEX-FREE) 1
U/ML
HEPARIN LOCK FLUSH
(USP,3MLX100,PF) 1 U/ML
U/ML
HEPARIN LOCK FLUSH
(USP,3MLX100,PF) 2 U/ML
U/ML
U/ML
HEPARIN LOCK FLUSH (LATEX-FREE)
100 U/ML
HEPARIN LOCK FLUSH (LATEX-FREE)
100 U/ML
HEPARIN LOCK FLUSH 100 U/ML
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
0.9 %
10 ML
10 ML
0.9 %
10 ML
0.9 %
10 ML
0.9 %
10 ML
0.9 %
10 ML
0.5
0.1
0.1
0.5
0.1
0.5
0.1
0.5
0.1
0.5
0.1
01/01/2002
01/01/2007
04/01/2007
01/01/2002
01/01/2007
01/01/2002
01/01/2007
01/01/2002
01/01/2007
01/01/2002
01/01/2007
3 ML SR
IV
ML
10 U
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
10 U
0.1
04/12/2007
99/99/9999
5 ML SR
IV
ML
10 U
0.2
01/01/2007
99/99/9999
3 ML SR
IV
ML
10 U
0.2
04/12/2007
99/99/9999
3 ML SR
IV
ML
10 U
01/01/2007
99/99/9999
5 ML SR
IV
ML
10 U
01/01/2007
99/99/9999
3 ML SR
IV
ML
10 U
10
01/01/2007
99/99/9999
5 ML SR
5 ML SR
IV
IV
ML
ML
10 U
10 U
10
10
01/01/2007
05/10/2005
99/99/9999
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
MEDIPHEDRYL 25 MG
24 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
NIGHT TIME SLEEP AID 25 MG
32 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
QUALITY CHOICE SLEEP AID (SOFTGEL)

50 MG
32 EA BO
PO
EA
50 MG
04/01/2006
99/99/9999
ALLERGY RELIEF INTENSE STRENGTH

(CAPLET) 50 MG
24 EA BX
PO
EA
50 MG
04/15/2003
99/99/9999
QUALITY CHOICE REST SIMPLY

(CAPLET) 25 MG
24 EA BX
PO
EA
50 MG
0.5
11/01/2003
99/99/9999
ALLERGY CHILDREN'S (AF,CHERRY)

12.5 MG/5 ML
118 ML BO
PO
ML
50 MG
0.05
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
0.5
01/01/2003
11/10/2005
QUALITY CHOICE DYE-FREE ALLERGY

MEDICINE (DYE-FREE,SOFTGEL) 25 MG
24 EA BX
PO
EA
50 MG
0.5
09/12/2003
99/99/9999
100 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
1000 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
6 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
Page 349 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
12/31/2006
99/99/9999
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
12/31/2006
99/99/9999
MEDIPHEDRYL 25 MG
MEDIPHEDRYL (MINITAB) 25 MG
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
BX
BX
SR
BX
BX
SR
SR
SR
SR
SR
SR
Billing Units
5 ML
5 ML
5 ML
5 ML
5 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML

Package
NDC Label
HCPCS Description

NDC Package Type
1/1/2002
1/1/2007
4/1/2007
1/1/2002
1/1/2007
1/1/2002
1/1/2007
1/1/2002
1/1/2007
1/1/2002
1/1/2007
HCPCS Mod
HCPCS
J2912
A4216
A4216
J2912
A4216
J2912
A4216
J2912
A4216
J2912
A4216
NDC Package Measure
63807-0100-51
63807-0100-51
63807-0100-55
63807-0100-56
63807-0100-56
63807-0100-75
63807-0100-75
63807-0100-92
63807-0100-92
63807-0102-11
63807-0102-11
NDC Mod
NDC
63874-0005-09
Q0163
5/10/2004
63874-0005-10
Q0163
5/10/2004
63874-0005-12
Q0163
5/10/2004
63874-0005-14
Q0163
5/10/2004
63874-0005-15
Q0163
1/1/2002
63874-0005-20
Q0163
1/1/2002
63874-0005-21
Q0163
5/10/2004
63874-0005-24
Q0163
5/10/2004
63874-0005-25
Q0163
5/10/2004
63874-0005-28
Q0163
5/10/2004
63874-0005-30
Q0163
1/1/2002
63874-0005-40
Q0163
5/10/2004
63874-0005-45
Q0163
5/10/2004
63874-0005-60
Q0163
5/10/2004
63874-0005-90
Q0163
5/10/2004
63874-0006-01
Q0163
1/1/2002
63874-0006-02
Q0163
1/1/2002
63874-0006-07
Q0163
5/10/2004
63874-0006-10
Q0163
5/10/2004
63874-0006-12
Q0163
5/10/2004

9 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
10 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
12 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
14 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
15 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
20 EA NA
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
21 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
24 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
25 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
28 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
30 EA BX
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
40 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
45 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
60 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
90 EA BO
PO
EA
50 MG
0.5
05/10/2004
99/99/9999
100 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
1000 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
7 EA BO
PO
EA
50 MG
05/10/2004
99/99/9999
10 EA BO
PO
EA
50 MG
05/10/2004
99/99/9999
12 EA BO
PO
EA
50 MG
05/10/2004
99/99/9999
Page 350 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63874-0006-14
Q0163
5/10/2004
63874-0006-15
Q0163
1/1/2002
63874-0006-20
Q0163
1/1/2002
63874-0006-25
Q0163
5/10/2004
63874-0006-28
Q0163
5/10/2004
63874-0006-30
Q0163
1/1/2002
63874-0006-60
Q0163
5/10/2004
63874-0098-10
63874-0229-01
63874-0229-10
63874-0246-00
63874-0246-04
63874-0246-06
63874-0246-10
63874-0246-15
63874-0327-01
63874-0327-02
63874-0327-10
63874-0327-12
63874-0327-14
63874-0327-15
63874-0327-18
63874-0327-19
63874-0327-20
63874-0327-21
63874-0327-24
63874-0327-25
63874-0327-28
63874-0327-30
63874-0327-32
63874-0327-40
63874-0327-42
63874-0327-50
63874-0327-60
G9035
J3360
J3360
Q0144
Q0144
Q0144
Q0144
Q0144
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
12/1/2004
4/4/2008
4/4/2008
3/15/2006
3/15/2006
3/15/2006
3/15/2006
3/15/2006
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
5/10/2004
63874-0370-01
Q0170
5/7/2004
63874-0370-08
Q0170
5/7/2004
63874-0370-10
Q0170
5/7/2004
63874-0370-12
Q0170
5/7/2004
63874-0370-15
Q0170
5/7/2004
63874-0370-20
Q0170
5/7/2004

DIAZEPAM (1X10ML) 5 MG/ML
DIAZEPAM (5X10ML) 5 MG/ML
ZITHROMAX (Z-PACK) 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
Page 351 of 374
14 EA BO
PO
EA
50 MG
05/10/2004
99/99/9999
15 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
25 EA BO
PO
EA
50 MG
05/10/2004
99/99/9999
28 EA BO
PO
EA
50 MG
05/10/2004
99/99/9999
30 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
60 EA BO
PO
EA
50 MG
05/10/2004
99/99/9999
BO
VL
VL
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
IJ
IJ
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
75 MG
5 MG
5 MG
1 GM
1 GM
1 GM
1 GM
1 GM
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
1
1
0.25
0.25
0.25
0.25
0.25
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
12/01/2004
04/04/2008
04/04/2008
03/15/2006
03/15/2006
03/15/2006
03/15/2006
03/15/2006
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/10/2004
05/31/2005
04/05/2008
04/05/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
25 MG
05/07/2004
99/99/9999
8 EA BO
PO
EA
25 MG
05/07/2004
99/99/9999
10 EA BO
PO
EA
25 MG
05/07/2004
99/99/9999
12 EA BO
PO
EA
25 MG
05/07/2004
99/99/9999
15 EA BO
PO
EA
25 MG
05/07/2004
99/99/9999
20 EA BO
PO
EA
25 MG
05/07/2004
99/99/9999
10 EA
10 ML
10 ML
6 EA
4 EA
6 EA
10 EA
15 EA
100 EA
1000 EA
10 EA
12 EA
14 EA
15 EA
18 EA
19 EA
20 EA
21 EA
24 EA
25 EA
28 EA
30 EA
32 EA
40 EA
42 EA
50 EA
60 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63874-0370-24
Q0170
5/7/2004
63874-0370-30
Q0170
5/7/2004
63874-0370-40
Q0170
5/7/2004
63874-0370-60
63874-0373-01
63874-0373-02
63874-0373-10
63874-0373-15
63874-0373-20
63874-0373-21
63874-0373-30
63874-0373-33
63874-0373-36
63874-0373-40
63874-0373-50
63874-0373-60
63874-0392-01
63874-0392-02
63874-0392-06
63874-0392-10
63874-0392-14
63874-0392-15
63874-0392-20
63874-0392-21
63874-0392-24
63874-0392-28
63874-0392-30
63874-0392-40
63874-0404-01
63874-0404-10
63874-0404-14
63874-0404-15
63874-0404-20
63874-0404-24
63874-0404-25
63874-0404-30
63874-0404-35
63874-0404-40
63874-0404-50
63874-0404-60
63874-0405-01
63874-0405-10
63874-0405-20
63874-0405-25
63874-0405-30
63874-0405-35
63874-0413-21
Q0170
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J7509
3/2/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/23/2002
1/23/2002
1/23/2002
1/23/2002
1/23/2002
1/23/2002
1/23/2002
1/23/2002
1/15/2006
1/23/2002
1/23/2002
1/23/2002
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/15/2006
1/1/2002
63874-0442-02
Q0177
5/11/2004
63874-0442-03
Q0177
5/11/2004
63874-0442-04
Q0177
5/11/2004
63874-0442-05
Q0177
5/11/2004
63874-0442-09
Q0177
5/11/2004

MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
Page 352 of 374
24 EA BO
PO
EA
25 MG
05/07/2004
99/99/9999
30 EA BO
PO
EA
25 MG
05/07/2004
99/99/9999
40 EA BO
PO
EA
25 MG
05/07/2004
99/99/9999
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
DP
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
25 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
4 MG
1
1
1
1
1
1
1
1
1
1
1
1
1
4
4
4
4
4
4
4
4
4
4
4
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
03/02/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/23/2002
01/23/2002
01/23/2002
01/23/2002
01/23/2002
01/23/2002
01/23/2002
01/23/2002
01/15/2006
01/23/2002
01/23/2002
01/23/2002
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/15/2006
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1000 EA NA
PO
EA
25 MG
05/11/2004
99/99/9999
500 EA NA
PO
EA
25 MG
05/11/2004
99/99/9999
120 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
5 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
9 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
60 EA
100 EA
1000 EA
10 EA
15 EA
20 EA
21 EA
30 EA
33 EA
36 EA
40 EA
50 EA
60 EA
100 EA
1000 EA
60 EA
10 EA
14 EA
15 EA
20 EA
21 EA
24 EA
28 EA
30 EA
40 EA
100 EA
10 EA
14 EA
15 EA
20 EA
24 EA
25 EA
30 EA
35 EA
40 EA
50 EA
60 EA
100 EA
10 EA
20 EA
25 EA
30 EA
35 EA
21 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63874-0442-10
Q0177
5/11/2004
63874-0442-14
Q0177
5/11/2004
63874-0442-15
Q0177
5/11/2004
63874-0442-20
Q0177
5/11/2004
63874-0442-25
Q0177
5/11/2004
63874-0442-28
Q0177
5/11/2004
63874-0442-30
Q0177
5/11/2004
63874-0442-40
Q0177
5/11/2004
63874-0442-45
Q0177
5/11/2004
63874-0442-60
Q0177
5/11/2004
63874-0442-90
Q0177
5/11/2004
DEXAMETHASONE (DOSE PAK) 0.75 MG
12/31/2005 REGIMEN
10 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
14 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
15 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
20 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
25 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
28 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
30 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
40 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
45 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
60 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
90 EA BO
PO
EA
25 MG
05/11/2004
99/99/9999
63874-0444-01
Q0181
5/7/2004
100 EA BO
PO
EA
1 EA
05/07/2004
12/31/2005
63874-0444-01
J8540
100 EA BO
PO
EA
0.25 MG
01/01/2006
99/99/9999
63874-0444-12
Q0181

5/7/2004 12/31/2005 REGIMEN
12 EA BO
PO
EA
1 EA
05/07/2004
12/31/2005
63874-0444-12
J8540

5/7/2004 12/31/2005 REGIMEN
12 EA BO
PO
EA
0.25 MG
01/01/2006
99/99/9999
15 EA BO
PO
EA
1 EA
05/07/2004
12/31/2005

5/7/2004 12/31/2005 REGIMEN
15 EA BO
PO
EA
0.25 MG
01/01/2006
99/99/9999
20 EA BO
PO
EA
1 EA
05/07/2004
12/31/2005

5/7/2004 12/31/2005 REGIMEN
20 EA BO
PO
EA
0.25 MG
01/01/2006
99/99/9999
12 EA BO
PO
EA
1 EA
05/07/2004
12/31/2005
12 EA BO
PO
EA
0.25 MG
01/01/2006
99/99/9999
30 EA BO
PO
EA
1 EA
05/07/2004
12/31/2005
30 EA BO
PO
EA
0.25 MG
01/01/2006
99/99/9999
63874-0444-15
Q0181
63874-0444-15
J8540
63874-0444-20
Q0181
63874-0444-20
J8540
63874-0444-21
Q0181
63874-0444-21
J8540
63874-0444-30
Q0181

5/7/2004 12/31/2005 REGIMEN
63874-0444-30
J8540
Page 353 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63874-0490-01
Q0165
5/10/2004
63874-0490-06
Q0165
5/10/2004
63874-0490-08
Q0165
5/10/2004
63874-0490-10
Q0165
5/10/2004
63874-0490-12
Q0165
5/10/2004
63874-0490-15
Q0165
5/10/2004
63874-0490-20
Q0165
5/10/2004
63874-0490-28
Q0165
5/10/2004
63874-0490-30
Q0165
5/10/2004
63874-0490-60
63874-0500-01
63874-0500-15
63874-0500-20
63874-0500-21
63874-0500-25
63874-0500-30
63874-0500-40
63874-0500-60
Q0165
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
5/10/2004
3/15/2006
1/23/2002
3/15/2006
3/15/2006
3/15/2006
3/15/2006
3/15/2006
3/15/2006
63874-0529-01
G9017
12/1/2004
63874-0529-10
G9017
12/1/2004
63874-0529-14
G9017
12/1/2004
63874-0529-20
G9017
12/1/2004
63874-0529-30
G9017
12/1/2004
63874-0708-20
J7602
1/1/2008
63874-0708-20
J7611
4/1/2008
63874-0712-12
Q0170
1/1/2002
63874-0757-01
Q0178
1/15/2006
63874-0757-04
Q0178
1/15/2006
63874-0757-10
Q0178
1/15/2006

ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
Page 354 of 374
100 EA BO
PO
EA
10 MG
05/10/2004
99/99/9999
6 EA BO
PO
EA
10 MG
05/10/2004
99/99/9999
8 EA BO
PO
EA
10 MG
05/10/2004
99/99/9999
10 EA BO
PO
EA
10 MG
05/10/2004
99/99/9999
12 EA BO
PO
EA
10 MG
05/10/2004
99/99/9999
15 EA BO
PO
EA
10 MG
05/10/2004
99/99/9999
20 EA BO
PO
EA
10 MG
05/10/2004
99/99/9999
28 EA BO
PO
EA
10 MG
05/10/2004
99/99/9999
30 EA BO
PO
EA
10 MG
05/10/2004
99/99/9999
BO
BO
BO
BO
BO
BO
BO
BO
NA
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
10 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
1
1
1
1
05/10/2004
03/15/2006
01/23/2002
03/15/2006
03/15/2006
03/15/2006
03/15/2006
03/15/2006
03/15/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
10 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
30 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 ML NA
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML NA
IH
ML
1 MG
04/01/2008
99/99/9999
120 ML NA
PO
ML
25 MG
0.05
01/01/2002
99/99/9999
100 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
120 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
10 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
60 EA
100 EA
15 EA
20 EA
21 EA
25 EA
30 EA
40 EA
60 EA
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
63874-0757-15
Q0178
1/15/2006
63874-0757-20
Q0178
1/15/2006
63874-0757-21
Q0178
1/15/2006
63874-0757-24
Q0178
1/15/2006
63874-0757-28
Q0178
1/15/2006
63874-0757-30
Q0178
1/15/2006
63874-0757-60
Q0178
1/15/2006
63874-0757-90
63874-0806-12
63874-1061-01
64019-0750-85
64019-0750-88
Q0178
J8498
J1080
J1230
J1230
1/15/2006
1/15/2006
1/1/2008
1/1/2002
1/1/2002
64054-0902-03
A4216
64054-0903-02
A4216
64054-0903-06
A4216
64054-0905-02
A4216
64054-0905-06
A4216
64054-0910-02
A4216
64054-1003-01
J1642
64054-1003-02
J1642
64054-3003-02
J1642
64054-3005-02
64116-0011-01
64116-0011-12
64116-0021-01
64116-0021-01
64116-0025-01
64116-0025-01
J1642
J9216
J9216
J0286
J0288
J0286
J0288
1/1/2007
1/1/2002
1/1/2002
1/1/2002
1/1/2003
1/1/2002
1/1/2003
15 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
20 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
21 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
24 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
28 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
30 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
60 EA BO
PO
EA
50 MG
01/15/2006
99/99/9999
90 EA
12 EA
10 ML
1 EA
1 EA
PO
RC
IM
NA
NA
EA
EA
ML
GM
GM
50 MG
1 EA
200 MG
10 MG
10 MG
1
1
1
100
100
01/15/2006
01/15/2006
01/01/2008
01/01/2002
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
10 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
10 U
10
01/01/2007
99/99/9999
5 ML SR
IV
ML
10 U
10
01/01/2007
99/99/9999
3 ML BX
IV
ML
10 U
01/01/2007
99/99/9999
IV
SC
SC
IV
IV
IV
IV
ML
ML
ML
EA
EA
EA
EA
10 U
3 MU
3 MU
50 MG
10 MG
50 MG
10 MG
1
1.33333
1.33333
2
10
1
5
01/01/2007
01/01/2002
01/01/2002
01/01/2002
01/01/2003
01/01/2002
01/01/2003
99/99/9999
3/13/2006
99/99/9999
12/31/2002
8/13/2008
12/31/2002
05/01/2005
64116-0031-01
J9212
4/18/2003
METHADONE HCL
METHADONE HCL
NORMAL SALINE IV FLUSH SYRINGE
(2X2ML,PF) 0.9%
(3X3ML,PF) 0.9%
(3X3ML,PF) 0.9%
(5X5ML,PF) 0.9%
(5X5ML,PF) 0.9%
(10X10ML,PF) 0.9%
HEPARIN LOCK FLUSH
(3X3ML,PF,LATEX-FREE) 100 U/ML
HEPARIN LOCK FLUSH
(3X5ML,PF,LATEX-FREE) 100 U/ML
HEPARIN LOCK FLUSH
(1X3ML,USP,PF,LATEX-FREE) 10 U/ML
HEPARIN LOCK FLUSH
(1X5ML,USP,PF,LATEX-FREE) 10 U/ML
ACTIMMUNE (VIAL) 2 Million IU/0.5 ML
ACTIMMUNE (VIAL) 2 Million IU/0.5 ML
AMPHOTEC (S.D.V.) 100 MG
INFERGEN (15MCG,PF,SINGLEJECT) 30
MCG/ML
0.5 ML VL
SC
ML
1 MCG
30
04/18/2003
02/08/2006
64116-0031-06
J9212
4/18/2003
INFERGEN (PF,SINGLEJECT) 30 MCG/ML
0.5 ML VL
SC
ML
1 MCG
30
04/18/2003
01/17/2008
64116-0031-24
J9212
2/12/2004
INFERGEN (PF,SINGLEJECT) 30 MCG/ML
0.5 ML VL
SC
ML
1 MCG
30
02/12/2004
02/08/2006
64116-0039-01
J9212
4/18/2003
VL
SC
ML
1 MCG
30
04/18/2003
02/08/2006
VL
SC
ML
1 MCG
30
04/18/2003
01/17/2008
VL
VL
VL
VL
SC
IV
IV
IV
ML
EA
EA
EA
1 MCG
1 IU
1 IU
1 IU
30
1
1
1
02/12/2004
08/20/2004
01/01/2002
02/01/2006
02/08/2006
99/99/9999
99/99/9999
99/99/9999
VL
IV
EA
1 IU
01/01/2002
99/99/9999
1 EA VL
IV
EA
1 GM
04/01/2005
12/31/2005

3/13/2006 INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS
99/99/9999 INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS
8/13/2008 INJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MG
5 ML
0.5 ML
0.5 ML
1 EA
1 EA
1 EA
1 EA
64116-0039-06
J9212
4/18/2003
64116-0039-24
64193-0222-03
64193-0222-04
64193-0222-05
J9212
J7198
J7198
J7198
2/12/2004
8/20/2004 99/99/9999 ANTI-INHIBITOR, PER I.U.
64193-0244-02
J7194
1/1/2002 99/99/9999 FACTOR IX, COMPLEX, PER I.U.
INFERGEN (9MCG,S.D.V.,PF) 30 MCG/ML

0.3 ML
MCG/ML
0.3 ML
MCG/ML
0.3 ML
FEIBA-VH IMMUNO (400-650IU) 1 IU
650 IU
1200 IU
3250 IU
BEBULIN VH (VAPOR HEATED) (200-1200
IU) 1 IU
1200 IU
64193-0250-50
Q9941
IVEEGAM EN (IGIV,W/DILUENT,PF) 5 GM
Page 355 of 374
BO
NA
VL
BO
BO
BX
VL
VL
VL
VL
VL
VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
64193-0250-50
J1566
1/1/2006
64253-0111-11
J2912
1/1/2002
64253-0111-12
J2912
1/1/2002
64253-0111-21
J2912
1/1/2002
64253-0111-21
A4216
1/1/2007
64253-0111-22
J2912
1/1/2002
64253-0111-22
A4216
1/1/2007
64253-0111-23
J2912
1/1/2002
64253-0111-23
A4216
1/1/2007
64253-0111-25
J2912
1/1/2002
64253-0111-25
A4216
1/1/2007
64253-0111-30
J2912
1/1/2002
64253-0111-30
A4216
1/1/2007
64253-0111-33
J2912
1/1/2002
64253-0111-33
A4216
1/1/2007
64253-0111-35
J2912
1/1/2002
64253-0111-35
A4216
1/1/2007
64253-0222-11
J1642
1/1/2002
64253-0222-12
J1642
1/1/2002
64253-0222-21
J1642
1/1/2002
64253-0222-22
J1642
1/1/2002
64253-0222-23
J1642
1/1/2002
64253-0222-25
J1642
1/1/2002
64253-0222-30
J1642
1/1/2002
64253-0222-33
J1642
1/1/2002
64253-0222-35
J1642
1/1/2002
64253-0333-11
J1642
1/1/2002
64253-0333-12
J1642
1/1/2002
64253-0333-21
J1642
1/1/2002
64253-0333-22
J1642
1/1/2002
64253-0333-23
J1642
1/1/2002
64253-0333-25
J1642
1/1/2002
64253-0333-30
J1642
1/1/2002
64253-0333-33
J1642
1/1/2002
64253-0333-35
J1642
1/1/2002
64253-0444-21
J1642
10/10/2003
64253-0444-22
J1642
10/10/2003
64253-0444-23
J1642
10/10/2003
64253-0444-25
J1642
10/10/2003
64253-0444-30
J1642
10/10/2003

IVEEGAM EN (IGIV,W/DILUENT,PF) 5 GM
W/LUER LOCK,PF) 0.9%
NORMAL SALINE FLUSH (SRN W/LUER
LOCK,PF) 0.9%
NORMAL SALINE FLUSH (SRN W/LUER
LOCK,PF) 0.9%
W/LUER LOK,PF) 0.9%
W/LUER LOK,PF) 0.9%
W/LUER LOK,PF) 0.9%
W/LUER LOK,PF) 0.9%
HEPARIN LOCK FLUSH (SRN,3 ML
W/LUER LOCK) 10 U/ML-0.9%
HEPARIN LOCK FLUSH (SRN W/LUER
LOCK) 10 U/ML-0.9%
HEPARIN LOCK FLUSH (SRN W/LUER
LOCK) 100 U/ML-0.9%
HEPARIN LOCK FLUSH (6ML PRE-FILLED
SYRINGE) 1 U/ML
SYRINGE) 1 U/ML
SYRINGE) 1 U/ML
SYRINGE) 1 U/ML
HEPARIN LOCK FLUSH (12ML PRE99/99/9999 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS
FILLED SYRINGE) 1 U/ML
Page 356 of 374
1 EA VL
IV
EA
500 MG
10
01/01/2006
5/31/2006
3 ML SR
IV
ML
0.9 %
0.5
01/01/2002
07/31/2002
3 ML SR
IV
ML
0.9 %
0.5
01/01/2002
07/31/2002
1 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
1 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
2 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
2 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
10 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
10 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
0.9 %
0.5
01/01/2002
12/31/2006
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
1 ML SR
IV
ML
10 U
01/01/2002
07/31/2002
2 ML SR
IV
ML
10 U
01/01/2002
07/31/2002
1 ML SR
IV
ML
10 U
01/01/2002
99/99/9999
2 ML SR
IV
ML
10 U
01/01/2002
99/99/9999
3 ML SR
IV
ML
10 U
01/01/2002
99/99/9999
5 ML SR
IV
ML
10 U
01/01/2002
99/99/9999
10 ML SR
IV
ML
10 U
01/01/2002
99/99/9999
3 ML SR
IV
ML
10 U
01/01/2002
99/99/9999
5 ML SR
IV
ML
10 U
01/01/2002
99/99/9999
1 ML SR
IV
ML
10 U
10
01/01/2002
07/31/2002
2 ML SR
IV
ML
10 U
10
01/01/2002
07/31/2002
1 ML SR
IV
ML
10 U
10
01/01/2002
99/99/9999
2 ML SR
IV
ML
10 U
10
01/01/2002
99/99/9999
3 ML SR
IV
ML
10 U
10
01/01/2002
99/99/9999
5 ML SR
IV
ML
10 U
10
01/01/2002
99/99/9999
10 ML SR
IV
ML
10 U
10
01/01/2002
99/99/9999
3 ML SR
IV
ML
10 U
10
01/01/2002
99/99/9999
5 ML SR
IV
ML
10 U
10
01/01/2002
99/99/9999
1 ML SR
IV
ML
10 U
0.1
10/10/2003
99/99/9999
2 ML SR
IV
ML
10 U
0.1
10/10/2003
99/99/9999
3 ML SR
IV
ML
10 U
0.1
10/10/2003
99/99/9999
5 ML SR
IV
ML
10 U
0.1
10/10/2003
99/99/9999
10 ML SR
IV
ML
10 U
0.1
10/10/2003
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
HEPARIN LOCK FLUSH (12ML PREFILLED SYRINGE) 1 U/ML

HEPARIN LOCK FLUSH (12ML PREFILLED SYRINGE) 1 U/ML
PROVOCHOLINE 100 MG
64253-0444-33
J1642
64253-0444-35
64281-0100-06
J1642
J7699
64281-0100-06
64281-0100-12
J7674
J7699
METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION THROUGH A
1/1/2005 99/99/9999 NEBULIZER, PER 1 MG
PROVOCHOLINE 100 MG
PROVOCHOLINE 100 MG
METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION THROUGH A
1/1/2005 99/99/9999 NEBULIZER, PER 1 MG
PROVOCHOLINE 100 MG
ML
10 U
0.1
10/10/2003
99/99/9999
IV
IH
ML
EA
10 U
1 EA
0.1
1
10/10/2003
01/01/2002
99/99/9999
12/31/2004
1 EA VL
1 EA VL
IH
IH
EA
EA
1 MG
1 EA
100
1
01/01/2005
01/01/2002
99/99/9999
12/31/2004
99/99/9999
J7674
J9160
64370-0532-01
J9390
64370-0532-02
64370-3086-01
64370-3086-02
64523-0100-01
J9390
J9390
J9390
J9218

1/1/2002
64679-0661-02
J1626
64679-0661-03
J1626
64679-0662-01
64679-0701-01
64679-0701-02
64679-0701-03
64679-0702-01
64679-0702-02
64679-0703-01
64679-0703-02
J1626
J0696
J0696
J0696
J0696
J0696
J0696
J0696
64679-0726-01
64679-0727-01
J2405
J2405
64679-0729-01
Q2009
64679-0730-01
Q2009
64679-0757-01
J1885
64679-0757-02
J1885
64679-0758-01
J1885
64679-0758-02
J1885
64679-0758-04
J1885
64679-0758-05
J1885
64679-0758-06
J1885
64679-0759-01
J1940
64679-0759-02
J1940
64679-0759-03
64679-0759-04
64679-0759-05
64679-0759-06
J1940
J1940
J1940
J1940
4/12/2007
4/12/2007
4/12/2007
4/12/2007
64679-0759-07
J1940
64679-0759-08
J1940
64679-0759-09
J1940
ONTAK (SINGLE USE VIAL) 150 MCG/ML

NAVELBINE (1X1ML,SINGLE USE,PF) 10
MG/ML
NAVELBINE (1X5ML,SINGLE USE,PF) 10
MG/ML
OAKLIDE 5 MG/ML
(1X4ML) 1 MG/ML
(1X1ML) 1 MG/ML
(5X1ML,PF) 0.1 MG/ML
MG/ML
FOSPHENYTOIN SODIUM
FOSPHENYTOIN SODIUM
(USP,SDV) 15 MG/ML
(USP,SDV) 15 MG/ML
(USP,SDV) 30 MG/ML
(USP,SDV,25X2ML) 30 MG/ML
(USP,SDV) 30 MG/ML
(USP,S.D.V.) 30 MG/ML
(USP,SDV,2X10ML) 30 MG/ML
FUROSEMIDE (USP,SDV,25X2ML) 10
MG/ML
MG/ML
MG/ML
FUROSEMIDE (USP,SDV) 10 MG/ML
MG/ML
MG/ML
MG/ML
64679-0961-01
Q0144
30 EA BO
PO
EA
1 GM
64679-0961-04
Q0144
6 EA BX
PO
EA
1 GM
64679-0961-05
Q0144

MG
18 EA DP
PO
EA
1 GM
64679-0962-01
Q0144
AZITHROMYCIN (FILM COATED) 600 MG
30 EA BO
PO
EA
64679-0964-01
Q0144
30 EA BO
PO
EA
64679-0964-03
Q0144
3 EA BX
PO
EA
4/25/2008
5/18/2007
5/18/2007
5/18/2007
5/18/2007
5/18/2007
5/18/2007
5/18/2007



Page 357 of 374
1 EA VL
IH
EA
1 MG
100
01/01/2005
2 ML VL
IV
ML
300 MCG
0.5
01/01/2002
01/16/2008
1 ML VL
IV
ML
10 MG
06/23/2008
99/99/9999
IV
IV
IV
SC
ML
ML
ML
ML
10 MG
10 MG
10 MG
1 MG
1
1
1
5
06/23/2008
03/26/2007
03/26/2007
01/01/2002
99/99/9999
06/22/2008
06/22/2008
01/01/2003
4 MG VL
IV
ML
100 MCG
10
7/1/2008
99/99/9999
1 MG VL
IV
ML
100 MCG
10
7/1/2008
99/99/9999
1 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
VL
VL
VL
VL
VL
VL
VL
VL
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
EA
EA
EA
100 MCG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
1
1
1
1
2
2
8
8
04/25/2008
05/18/2007
05/18/2007
05/18/2007
05/18/2007
05/18/2007
05/18/2007
05/18/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML VL
20 ML VL
IJ
IJ
ML
ML
1 MG
1 MG
2
2
12/26/2006
12/26/2006
99/99/9999
99/99/9999
5 ML
1 ML
5 ML
2.8 ML
VL
VL
VL
NA
2 ML VL
IJ
ML
50 MG
1.5
07/25/2007
99/99/9999
10 ML VL
IJ
ML
50 MG
1.5
07/25/2007
99/99/9999
1 ML VL
IJ
ML
15 MG
04/12/2007
99/99/9999
1 ML VL
IJ
ML
15 MG
04/12/2007
99/99/9999
1 ML VL
IJ
ML
15 MG
04/12/2007
99/99/9999
2 ML VL
IJ
ML
15 MG
04/12/2007
99/99/9999
1 ML VL
IJ
ML
15 MG
04/12/2007
99/99/9999
2 ML VL
IJ
ML
15 MG
04/12/2007
99/99/9999
2 ML VL
IJ
ML
15 MG
04/12/2007
99/99/9999
2 ML VL
IJ
ML
20 MG
0.5
04/12/2007
99/99/9999
4 ML VL
IJ
ML
20 MG
0.5
04/12/2007
99/99/9999
VL
VL
VL
VL
IJ
IJ
IJ
IJ
ML
ML
ML
ML
20 MG
20 MG
20 MG
20 MG
0.5
0.5
0.5
0.5
04/12/2007
04/12/2007
04/12/2007
04/12/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
2 ML VL
IJ
ML
20 MG
0.5
04/12/2007
99/99/9999
4 ML VL
IJ
ML
20 MG
0.5
04/12/2007
99/99/9999
10 ML VL
IJ
ML
20 MG
0.5
04/12/2007
99/99/9999
0.25
02/11/2008
99/99/9999
0.25
02/14/2008
99/99/9999
0.25
02/11/2008
99/99/9999
1 GM
0.6
02/11/2008
99/99/9999
1 GM
0.5
02/11/2008
99/99/9999
1 GM
0.5
02/14/2008
99/99/9999
10 ML
2 ML
4 ML
10 ML
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
IV
5 ML SR
1 EA VL
64365-0503-01
1/16/2008 INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS
Start Date #1
3 ML SR
64281-0100-12
1/1/2002
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
64679-0964-05
64679-0983-01
64679-0983-02
64679-0986-01
64679-0986-02
64679-0986-03
64679-0986-04
Q0144
J0696
J0696
J0698
J0698
J0698
J0698
2/11/2008
5/26/2006
5/26/2006
9/20/2006
9/20/2006
9/20/2006
9/20/2006
64720-0198-02
Q0166
12/29/2007
64720-0198-98
64894-0820-50
64894-0840-50
Q0166
J1270
J1270
12/29/2007
1/1/2002
1/1/2002
64899-0094-32
Q0163
1/1/2002
64899-0097-24
Q0163
4/2/2002
64899-0524-44
64938-0009-01
64938-0009-01
65162-0088-10
Q0163
A4323
A4217
J8499
1/1/2002
11/1/2003
1/1/2004
9/1/2004
65162-0156-10
Q0163
9/1/2004
65162-0156-11
Q0163
9/1/2004
65162-0516-10
Q0163
9/1/2004
65162-0516-11
Q0163
9/1/2004
65162-0518-10
Q0163
9/1/2004
65162-0518-11
Q0163
9/1/2004
65271-0001-12
J7644
1/1/2002
65271-0001-12 KO J7644
65271-0001-25
J7644
65271-0001-25 KO J7644
65271-0001-30
KO
1/1/2002
1/1/2002
KO
J7644
65271-0001-60 KO J7644
1/1/2002
1/1/2002
J7644
65271-0001-30 KO J7644
65271-0001-60
KO
1/1/2002
1/1/2002
KO
1/1/2002
AZITHROMYCIN (3X3,FILM COATED) 500

MG
9 EA DP
1 EA VL
1 EA VL
1 EA VL
1 EA VL
1 EA VL
1 EA VL
20 EA BO
2 EA DP
HECTOROL (AMP) 2 MCG/ML
1 ML AM
HECTOROL (AMP) 2 MCG/ML
2 ML AM
HEALTH CARE AMERICA SLEEP-EX
(MAXIUMUM STRENGTH) 50 MG
32 EA BO
HEALTH CARE AMERICA ALLERGY
RELIEF (CAPLET) 50 MG
24 EA BX
HEALTH CARE AMERICA TOTAL
ALLERGY (AF,CHERRY) 12.5 MG/5 ML
118 ML BO
SALJET (SINGLE DOSE,STERILE) 0.9%
30 ML PC
SALJET (SINGLE DOSE,STERILE) 0.9%
30 ML PC
ACYCLOVIR 400 MG
100 EA BO
(CAPLET) 25 MG
100 EA BO
(CAPLET) 25 MG
1000 EA BO
25 MG
100 EA BO
25 MG
1000 EA BO
100 EA BO
1000 EA BO
IPRATROPIUM BROMIDE 0.02%
2.5 ML PC
1/31/2005 MILLIGRAM
2.5 ML PC
1/31/2005 MILLIGRAM
2.5 ML PC
1/31/2005 MILLIGRAM
2.5 ML PC
1/31/2005 MILLIGRAM
2.5 ML PC
1/31/2005 MILLIGRAM
2.5 ML PC
1/31/2005 MILLIGRAM
1/31/2005 MILLIGRAM
2.5 ML PC
2.5 ML PC
1/31/2005 MILLIGRAM
Page 358 of 374
PO
IJ
IJ
IJ
IJ
IJ
IJ
EA
EA
EA
EA
EA
EA
EA
1 GM
250 MG
250 MG
1 GM
1 GM
1 GM
1 GM
0.5
4
4
1
1
1
1
02/11/2008
05/26/2006
05/26/2006
09/20/2006
09/20/2006
09/20/2006
09/20/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
PO
EA
1 MG
12/29/2007
99/99/9999
PO
IV
IV
EA
ML
ML
1 MG
1 MCG
1 MCG
1
2
2
12/29/2007
01/01/2002
01/01/2002
99/99/9999
10/01/2002
05/31/2006
PO
EA
50 MG
01/01/2002
6/1/2006
PO
EA
50 MG
04/02/2002
06/01/2006
PO
IR
IR
PO
ML
ML
ML
EA
50 MG
1000 ML
500 ML
1 EA
0.05
0.001
0.002
1
01/01/2002
11/01/2003
01/01/2004
09/01/2004
6/1/2006
12/31/2003
11/09/2006
06/23/2005
PO
EA
50 MG
0.5
09/01/2004
11/5/2009
PO
EA
50 MG
0.5
09/01/2004
11/5/2009
PO
EA
50 MG
0.5
09/01/2004
11/5/2009
PO
EA
50 MG
0.5
09/01/2004
11/5/2009
PO
EA
50 MG
09/01/2004
99/99/9999
PO
EA
50 MG
09/01/2004
99/99/9999
IH
ML
1 MG
0.2
01/01/2002
1/31/2005
IH
ML
1 MG
0.2
01/01/2002
1/31/2005
IH
ML
1 MG
0.2
01/01/2002
1/31/2005
IH
ML
1 MG
0.2
01/01/2002
1/31/2005
IH
ML
1 MG
0.2
01/01/2002
1/31/2005
IH
ML
1 MG
0.2
01/01/2002
1/31/2005
IH
ML
1 MG
0.2
01/01/2002
1/31/2005
IH
ML
1 MG
0.2
01/01/2002
1/31/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
65580-0251-01
65649-0231-41
65649-0241-41
65847-0205-25
65847-0205-25
J7510
J7500
J7500
J2324
J2325
5/9/2002
10/31/2003
10/31/2003
1/1/2003
1/1/2006
65862-0187-03
Q0179
10/31/2007
65862-0187-05
Q0179
10/31/2007
65862-0187-30
Q0179
10/31/2007
65862-0188-03
Q0179
10/31/2007
65862-0188-05
Q0179
10/31/2007
65862-0188-30
66105-0507-01
66105-0507-03
66105-0507-06
66105-0507-09
66105-0507-10
66105-0549-10
66105-0653-01
66105-0653-03
66105-0653-05
66105-0653-06
66105-0653-19
66105-0670-01
66105-0670-03
66105-0670-05
66105-0670-06
66105-0670-18
66105-0832-01
66105-0832-03
66105-0832-06
66105-0832-09
66105-0832-10
66116-0174-82
Q0179
Q0144
Q0144
Q0144
Q0144
Q0144
J7507
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
Q0144
J8999
J8999
J8999
J8999
J8999
J7510
10/31/2007
8/22/2006
1/1/2006
8/22/2006
8/22/2006
8/22/2006
1/1/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
9/13/2006
1/1/2002
66116-0226-20
66116-0245-50
66116-0246-50
66116-0271-35
Q0165
J8499
J8499
J8499
1/10/2002
1/8/2002
1/8/2002
3/18/2002
66116-0284-12
66116-0410-05
66116-0410-30
66116-0420-05
66116-0420-15
66143-7510-05
66143-7510-05
Q0170
J7506
J7506
J7506
J7506
J1820
J1815
3/18/2002
1/1/2002
1/7/2002
1/1/2002
3/15/2002
10/8/2002
1/1/2003
66203-2300-01
J1652
1/1/2003
66203-2300-02
J1652
6/9/2004
66220-0107-30
J7608
5/15/2004
66220-0107-30 KO J7608

1/1/2004 99/99/9999 INJECTION, BIVALIRUDIN, 1 MG
KO
5/15/2004

12/31/2005 INJECTION, NESIRITIDE, 0.25 MG
99/99/9999 INJECTION, NESIRITIDE, 0.1 MG
(FILM-COATED) 4 MG
(FILM-COATED) 4 MG
(FILM-COATED) 4 MG
(FILM-COATED) 8 MG
(FILM-COATED) 8 MG
(FILM-COATED) 8 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
PROGRAF 1 MG
AZITHROMYCIN 500 MG
AZITHROMYCIN 500 MG
AZITHROMYCIN 500 MG
AZITHROMYCIN 500 MG
AZITHROMYCIN 500 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
AZITHROMYCIN 250 MG
NOLVADEX 10 MG
NOLVADEX 10 MG
NOLVADEX 10 MG
NOLVADEX 10 MG
NOLVADEX 10 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 200 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
LISPRO-PFC (RDNA ORIGIN) 100 U/ML
LISPRO-PFC (RDNA ORIGIN) 100 U/ML
MG/0.5 ML
MG/0.5 ML
ACETADOTE (PF) 200 MG/ML
Page 359 of 374
BO
BO
BO
VL
VL
PO
PO
PO
IV
IV
ML
EA
EA
EA
EA
5 MG
50 MG
50 MG
0.25 MG
0.1 MG
0.268
1.5
2
6
15
05/09/2002
10/31/2003
10/31/2003
01/01/2003
01/01/2006
99/99/9999
99/99/9999
99/99/9999
12/31/2005
99/99/9999
3 EA BX
PO
EA
8 MG
0.5
10/31/2007
99/99/9999
500 EA BO
PO
EA
8 MG
0.5
10/31/2007
99/99/9999
30 EA BO
PO
EA
8 MG
0.5
10/31/2007
99/99/9999
3 EA BX
PO
EA
8 MG
10/31/2007
99/99/9999
500 EA BO
PO
EA
8 MG
10/31/2007
99/99/9999
30 EA
10 EA
30 EA
60 EA
90 EA
100 EA
100 EA
10 EA
30 EA
50 EA
60 EA
9 EA
10 EA
30 EA
50 EA
60 EA
18 EA
10 EA
30 EA
60 EA
90 EA
100 EA
60 ML
BO
BO
BO
BO
BO
BO
NA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
ML
8 MG
1 GM
1 GM
1 GM
1 GM
1 GM
1 MG
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 GM
1 EA
1 EA
1 EA
1 EA
1 EA
5 MG
1
0.25
0.25
0.25
0.25
0.25
1
0.5
0.5
0.5
0.5
0.5
0.25
0.25
0.25
0.25
0.25
1
1
1
1
1
0.6
10/31/2007
08/22/2006
01/01/2006
08/22/2006
08/22/2006
08/22/2006
01/01/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
09/13/2006
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
03/07/2002
20 EA
50 EA
50 EA
35 EA
BO
BO
BO
BO
PO
PO
PO
PO
EA
EA
EA
EA
10 MG
1 EA
1 EA
1 EA
1
1
1
1
01/10/2002
01/08/2002
01/08/2002
03/18/2002
08/01/2003
08/01/2003
08/01/2003
08/01/2003
12 EA
5 EA
30 EA
5 EA
15 EA
3.15 ML
3.15 ML
BO
BO
BO
BO
BO
EA
EA
PO
PO
PO
PO
PO
SC
SC
EA
EA
EA
EA
EA
ML
ML
25 MG
5 MG
5 MG
5 MG
5 MG
100 U
5U
1
2
2
4
4
1
20
03/18/2002
01/01/2002
01/07/2002
01/01/2002
03/15/2002
10/08/2002
01/01/2003
08/01/2003
08/01/2003
08/01/2003
08/01/2003
08/01/2003
12/31/2002
99/99/9999
0.5 ML SR
SC
ML
0.5 MG
10
01/01/2003
99/99/9999
0.5 ML SR
SC
ML
0.5 MG
10
06/09/2004
06/02/2005
30 ML VL
IV
ML
1 GM
0.2
05/15/2004
12/31/2005
30 ML VL
IV
ML
1 GM
0.2
05/15/2004
12/31/2005
CF
HCPCS Amount #1
120 ML
100 EA
100 EA
1 EA
1 EA
Prior End Date #3
12/31/2003
99/99/9999
02/28/2004
99/99/9999
Prior Start Date #3
06/25/2003
01/01/2004
01/01/2002
01/01/2002
1
250
1
1
Prior End Date #2
1 EA
1 MG
100 MG
50 MG
End Date #1
EA
EA
EA
EA
Start Date #1
IV
IV
IV
PO
HCPCS Measure #1
VL
VL
VL
BO
Billing Units
1 EA
1 EA
1 EA
100 EA
Prior Start Date #2

Package
HCPCS Description
NDC Label
ANGIOMAX (VIAL,GLASS) 250 MG
ANGIOMAX (VIAL,GLASS) 250 MG
IMURAN (VIAL) 100 MG
IMURAN 50 MG
(DYE-FREE,RASPBERRY) 6.7 MG/5 ML
AZASAN 75 MG
AZASAN 100 MG
NATRECOR (S.D.V.) 1.5 MG
NATRECOR (S.D.V.) 1.5 MG
NDC Package Type
J3490
J0583
J7501
J7500
NDC Package Measure
65293-0001-01
65293-0001-01
65483-0551-01
65483-0590-10
HCPCS Mod
HCPCS
NDC Mod
NDC
66220-0107-30
J0132
66220-0107-34
J7608
66220-0107-34 KO J7608
66220-0107-34
J0132
66267-0006-25
J8499
66267-0006-40
J8499
66267-0006-50
J8499
66267-0007-15
J8499
66267-0007-21
J8499
66267-0007-25
J8499
66267-0007-30
J8499
66267-0066-12
66267-0066-12
Q0181
J8540
66267-0080-15
Q0163
66267-0080-20
Q0163
66267-0080-30
Q0163
66267-0080-60
Q0163
66267-0081-15
Q0163
66267-0081-20
Q0163
66267-0081-30
Q0163
66267-0081-60
66267-0171-15
66267-0171-20
66267-0171-21
66267-0171-30
66267-0171-40
66267-0171-42
66267-0172-10
66267-0172-15
66267-0172-20
66267-0172-30
66267-0173-20
66267-0173-30
66267-0173-40
66267-0173-42
66267-0173-60
Q0163
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
66267-0208-10
Q0173
66267-0208-20
66267-0399-30
Q0173
J8499
66267-0921-03
Q4084
66267-0921-03
66267-0928-06
66267-0948-21
66267-0961-21
J7322
Q0144
J7506
J7509
KO
1/1/2006 99/99/9999 INJECTION, ACETYLCYSTEINE, 100 MG

1/1/2006
1/3/2006 INJECTION, ACETYLCYSTEINE, 100 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
4/8/2002 12/31/2005 REGIMEN
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
ACYCLOVIR 800 MG
HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER SYNVISC (3X2ML SRN,PREFILLED) 8
1/1/2007 12/31/2007 DOSE
MG/ML
HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER SYNVISC (3X2ML SRN,PREFILLED) 8
1/1/2008 12/31/2009 DOSE
MG/ML
ZITHROMAX 250 MG
Page 360 of 374
30 ML VL
IV
ML
100 MG
01/01/2006
99/99/9999
30 ML VL
IV
ML
1 GM
0.2
05/15/2004
12/31/2005
30 ML
30 ML
25 EA
40 EA
50 EA
15 EA
25 EA
25 EA
30 EA
VL
VL
BO
BO
BO
BO
BO
BO
BO
IV
IV
PO
PO
PO
PO
PO
PO
PO
ML
ML
EA
EA
EA
EA
EA
EA
EA
1 GM
100 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
0.2
2
1
1
1
1
1
1
1
05/15/2004
01/01/2006
04/08/2002
08/01/2002
04/08/2002
04/08/2002
04/08/2002
04/08/2002
04/08/2002
12/31/2005
01/03/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12 EA BO
12 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
04/08/2002
01/01/2006
12/31/2005
99/99/9999
15 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
04/05/2002
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
60 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
15 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
04/05/2002
99/99/9999
30 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
60 EA
15 EA
20 EA
21 EA
30 EA
40 EA
42 EA
10 EA
15 EA
20 EA
30 EA
20 EA
30 EA
40 EA
42 EA
60 EA
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
2
2
2
2
2
2
4
4
4
4
1
1
1
1
1
09/04/2002
01/01/2002
04/04/2002
01/01/2002
01/01/2002
01/01/2002
04/04/2002
01/01/2002
01/01/2002
01/01/2002
01/01/2002
04/04/2002
01/01/2002
01/01/2002
03/24/2003
01/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10 EA BO
PO
EA
250 MG
01/01/2002
99/99/9999
20 EA BO
30 EA BO
PO
PO
EA
EA
250 MG
1 EA
1
1
01/01/2002
03/15/2005
99/99/9999
99/99/9999
IJ
ML
1 DOSE
0.5
01/01/2007
12/31/2007
IJ
PO
PO
PO
ML
EA
EA
EA
1 DOSE
1 GM
5 MG
4 MG
0.5
0.25
1
1
01/01/2008
01/01/2002
01/01/2002
01/01/2002
12/31/2009
99/99/9999
99/99/9999
99/99/9999
2 ML SR
2 ML
6 EA
21 EA
21 EA
SR
BO
DP
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/1/2002
10/1/2002
10/1/2002
10/1/2002
10/1/2002
10/1/2002
12/1/2004
10/1/2003
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006
10/1/2003
1/1/2006
8/15/2006
8/15/2006
8/15/2006
66336-0045-06
Q0163
10/22/2004
66336-0045-15
Q0163
10/22/2004
66336-0045-20
Q0163
10/22/2004
66336-0045-30
Q0163
11/23/2003
66336-0045-60
Q0163
11/23/2003
66336-0045-90
66336-0058-10
66336-0058-12
66336-0058-20
66336-0058-21
66336-0058-30
66336-0058-60
Q0163
J7506
J7506
J7506
J7506
J7506
J7506
11/23/2003
10/22/2004
11/4/2005
10/22/2004
10/22/2004
4/16/2002
10/22/2004
66336-0079-14
G9017
12/1/2004
66336-0079-20
G9017
12/1/2004
66336-0085-10
Q0170
10/22/2004
66336-0085-12
Q0170
10/22/2004
66336-0085-20
Q0170
5/29/2008
66336-0085-25
Q0170
5/29/2008
66336-0085-30
Q0170
10/22/2004
66336-0085-60
66336-0094-10
66336-0094-18
Q0170
J7506
J7506
5/29/2008
10/22/2004
10/22/2004
PO
EA
50 MG
10/22/2004
99/99/9999
15 EA BO
PO
EA
50 MG
10/22/2004
99/99/9999
20 EA BO
PO
EA
50 MG
10/22/2004
09/10/2006
30 EA BO
PO
EA
50 MG
11/23/2003
99/99/9999
60 EA BO
PO
EA
50 MG
11/23/2003
12/17/2007
90 EA
10 EA
12 EA
20 EA
21 EA
30 EA
60 EA
BO
BO
BO
BO
BO
BO
BO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
1
2
2
2
2
2
2
11/23/2003
10/22/2004
11/04/2005
10/22/2004
10/22/2004
04/16/2002
10/22/2004
09/10/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
10 EA BO
PO
EA
25 MG
10/22/2004
99/99/9999
12 EA BO
PO
EA
25 MG
10/22/2004
99/99/9999
20 EA BO
PO
EA
25 MG
05/29/2008
99/99/9999
25 EA BO
PO
EA
25 MG
05/29/2008
99/99/9999
30 EA BO
PO
EA
25 MG
10/22/2004
99/99/9999
60 EA BO
10 EA BO
18 EA BO
PO
PO
PO
EA
EA
EA
25 MG
5 MG
5 MG
1
4
4
05/29/2008
10/22/2004
10/22/2004
99/99/9999
99/99/9999
99/99/9999
CF
HCPCS Amount #1
6 EA BO
Prior End Date #3
99/99/9999
99/99/9999
99/99/9999
10/01/2006
10/01/2006
10/01/2006
10/01/2006
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
01/01/2002
10/01/2002
10/01/2002
10/01/2002
10/01/2002
10/01/2002
12/01/2004
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
10/01/2003
01/01/2006
08/15/2006
08/15/2006
08/15/2006
0.05
2
2
1.33333
1.33333
1
1
1
1
2.5
2.5
5
5
10
10
2
0.1
0.1
Prior End Date #2
50 MG
500 MG
500 MG
750 MG
750 MG
1 EA
1 GM
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
1 MG
10 MG
10 ML
10 ML
End Date #1
ML
GM
GM
GM
GM
GM
GM
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
Start Date #1
PO
IJ
IJ
IJ
IJ
IJ
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
HCPCS Measure #1
BO
FC
FC
FC
FC
FC
FC
VL
VL
VL
VL
VL
VL
VL
VL
NA
NA
NA
Billing Units
120 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
20 ML
20 ML
20 ML
20 ML
20 ML
20 ML
20 ML
20 ML
1.8 ML
1.8 ML
1.8 ML
Prior Start Date #2

Package
HCPCS Description
NDC Label
Page 361 of 374
NDC Package Type
Q0163
J0690
J0690
J0697
J0697
J3490
J0694
Q4077
J3285
Q4077
J3285
Q4077
J3285
Q4077
J3285
J2001
J0670
J0670

CEFUROXIME SODIUM 75 GM
CEFUROXIME SODIUM 225 GM
CEFOXITIN 100 GM
12/31/2005 INJECTION, TREPROSTINIL, 1 MG
REMODULIN (M.D.V.) 1 MG/ML
REMODULIN (M.D.V.) 2.5 MG/ML
REMODULIN (M.D.V.) 2.5 MG/ML
XYLOCAINE DENTAL (1.8MLX100) 2%
POLOCAINE DENTAL (1.8MLX100) 3%
POLOCAINE DENTAL (1.8MLX100) 2%
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
MG
MG
PROMETHAZINE 25 MG
MG
PREDNISONE 20 MG
PREDNISONE 20 MG
NDC Package Measure
66267-0977-04
66288-1100-01
66288-1300-01
66288-2075-01
66288-2225-01
66288-3200-01
66288-4100-01
66302-0101-01
66302-0101-01
66302-0102-01
66302-0102-01
66302-0105-01
66302-0105-01
66302-0110-01
66302-0110-01
66312-0170-14
66312-0440-14
66312-0460-14
HCPCS Mod
HCPCS
NDC Mod
NDC
66336-0094-20
66336-0094-30
J7506
J7506
66336-0150-03
66336-0150-03
66336-0150-06
K0416
J8498
J8498
66336-0208-20
Q0177
66336-0208-30
Q0177
66336-0268-03
66336-0400-05
Q0179
Q0144
66336-0434-06
Q0164
66336-0434-10
66336-0466-44
Q0164
Q0144
66336-0479-06
66336-0479-06
Q0181
J8540
66336-0479-15
66336-0479-15
Q0181
J8540
66336-0492-12
66336-0515-10
66336-0515-21
66336-0515-30
66336-0515-40
K0416
J7506
J7506
J7506
J7506
66336-0550-12
66336-0550-12
Q0181
J8540
66336-0589-15
Q0163
66336-0589-20
Q0163
66336-0589-30
Q0163
66336-0589-60
66336-0608-20
Q0163
J7509
66336-0629-10
66336-0642-25
66336-0642-30
66336-0642-40
66336-0642-50
66336-0735-10
66336-0735-15
66336-0735-25
66336-0735-40
Q0173
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499

PREDNISONE 20 MG
PREDNISONE 20 MG
(FILM-COATED) 8 MG
AZITHROMYCIN 500 MG
ZITHROMAX 250 MG
DEXAMETHASONE 4 MG
10/22/2004 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
1/19/2004 12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
PHENERGAN 25 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
11/20/2005 12/31/2005 REGIMEN
1/1/2002
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
Page 362 of 374
20 EA BO
30 EA BO
PO
PO
EA
EA
5 MG
5 MG
4
4
10/22/2004
10/22/2004
99/99/9999
99/99/9999
3 EA BO
3 EA BO
6 EA BX
RC
RC
RC
EA
EA
EA
1 MG
1 EA
1 EA
25
1
1
08/03/2005
01/01/2006
04/20/2007
12/31/2005
99/99/9999
99/99/9999
20 EA BO
PO
EA
25 MG
10/22/2004
99/99/9999
30 EA BO
PO
EA
25 MG
10/22/2004
99/99/9999
3 EA BO
5 EA BO
PO
PO
EA
EA
8 MG
1 GM
1
0.5
03/17/2008
12/03/2007
99/99/9999
99/99/9999
6 EA BO
PO
EA
5 MG
10/22/2004
99/99/9999
10 EA BO
4 EA BO
PO
PO
EA
EA
5 MG
1 GM
1
0.25
08/18/2005
10/22/2004
99/99/9999
12/17/2007
6 EA BO
6 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
10/22/2004
01/01/2006
12/31/2005
99/99/9999
15 EA BO
15 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
01/19/2004
01/01/2006
12/31/2005
09/10/2006
12 EA
10 EA
21 EA
30 EA
40 EA
NA
BO
BO
BO
BO
RC
PO
PO
PO
PO
EA
EA
EA
EA
EA
1 MG
5 MG
5 MG
5 MG
5 MG
25
1
1
1
1
10/22/2004
10/22/2004
10/22/2004
10/22/2004
10/22/2004
11/14/2005
12/17/2007
99/99/9999
99/99/9999
99/99/9999
12 EA BO
12 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
11/20/2005
01/01/2006
12/31/2005
99/99/9999
15 EA BO
PO
EA
50 MG
0.5
01/01/2002
99/99/9999
20 EA BO
PO
EA
50 MG
0.5
10/22/2004
99/99/9999
30 EA BO
PO
EA
50 MG
0.5
10/22/2004
99/99/9999
60 EA BO
20 EA NA
PO
PO
EA
EA
50 MG
4 MG
0.5
1
10/22/2004
01/01/2002
99/99/9999
04/01/2006
10 EA
25 EA
30 EA
40 EA
50 EA
10 EA
15 EA
25 EA
40 EA
PO
PO
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
EA
EA
EA
250 MG
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
1
1
1
1
01/01/2002
10/22/2004
06/22/2005
10/22/2004
01/07/2008
01/01/2002
10/22/2004
10/22/2004
10/22/2004
09/10/2006
12/17/2007
99/99/9999
99/99/9999
99/99/9999
09/10/2006
99/99/9999
99/99/9999
99/99/9999
NA
BO
BO
BO
BO
NA
BO
BO
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
66336-0793-03
66336-0862-50
Q0179
J8499
3/17/2008
5/1/2006
66336-0921-15
Q0165
12/3/2007
66336-0921-60
Q0165
5/29/2008
66375-0107-02
Q0163
1/1/2002
66375-0108-02
66435-0301-51
66435-0302-01
66440-0150-08
66440-0150-16
66479-0025-39
Q0163
J0288
J0288
J7510
J7510
J3490
1/1/2002
11/1/2006
8/14/2008
10/2/2003
10/2/2003
1/1/2002
66479-0135-01
J9250
1/1/2002
66479-0135-09
J9250
1/1/2002
66479-0136-11
J9250
1/1/2002
66479-0136-13
J9250
1/1/2002
66479-0136-19
J9250
1/1/2002
66479-0137-21
J9250
1/1/2002
66479-0139-29
66479-0247-25
66479-0301-10
66479-0520-01
66479-0521-01
J9260
J0640
J7500
J0735
J0735
66479-0530-02
J1230
66490-0041-01
J1110
66591-0221-41
J7500
66591-0231-41
J7500
66591-0241-41
J7500
66591-0315-12
J0636
66591-0325-12
J0636
66591-0335-12
J0636
66591-0345-12
J0636
66591-0434-11
J3105
66591-0435-11
J3105
66591-0815-51
J1230
66591-0965-41
J0735
66591-0975-41
J0735
66657-0301-05
J3490
66657-0301-05
J1457
66689-0681-55
J1230
66733-0948-23
J9999
J9055
66733-0948-23
66733-0948-23 QR J9055
66733-0958-23
J9055
66733-0958-23 QR J9055
66758-0001-19
J2250

(FILM-COATED) 4 MG
DISPENSEQUICK ACYCLOVIR 800 MG
AMPHOTEC (SDV) 50 MG
AMPHOTEC (SDV) 100 MG
AMICAR (S.D.V.) 250 MG/ML
25 MG/ML
25 MG/ML
MG/ML
MG/ML
MG/ML
MG

QR
QR
1/9/2007
12/31/2002
7/16/2002
2/21/2003
2/21/2003
3/7/2003
3/7/2003
3/28/2003
3/28/2003
5/23/2003
9/21/2004
12/12/2003
11/16/2005
9/23/2005
10/6/2003
1/1/2005
2/1/2002
2/23/2004
1/1/2005
1/28/2005
5/3/2007
5/3/2007
10/1/2002

9/4/2008 INJECTION, TERBUTALINE SULFATE, UP TO 1 MG
9/4/2008 INJECTION, TERBUTALINE SULFATE, UP TO 1 MG
99/99/9999 INJECTION, GALLIUM NITRATE, 1 MG
99/99/9999 INJECTION, CETUXIMAB, 10 MG
66758-0011-01
J1600
6/11/2004
66758-0011-02
J1600
6/11/2004
66758-0011-03
J1600
6/11/2004
66758-0014-01
J2440
66758-0014-02
J2440
66758-0015-01
J2440
METHOTREXATE SODIUM (S.D.V.) 1 GM

LEUCOVORIN CALCIUM (PF) 350 MG
DURACLON (SDV,PF) 0.1 MG/ML
METHADONE HYDROCHLORIDE
(USP,MDV) 10 MG/ML
D.H.E. 45 (AMP) 1 MG/ML
AZATHIOPRINE 50 MG
AZASAN 75 MG
AZASAN 100 MG
CALCITRIOL 1 MCG/ML
CALCITRIOL 2 MCG/ML
CALCITRIOL 1 MCG/ML
CALCITRIOL 2 MCG/ML
BRETHINE (VIALS) 1 MG/ML
METHADONE HCL 10 MG/ML
DURACLON (SDV) 0.1 MG/ML
GANITE (PF) 25 MG/ML
GANITE (PF) 25 MG/ML
METHADONE HCL
ERBITUX (PF) 2 MG/ML
GOLD SODIUM THIOMALATE (S.D.V.) 50
MG/ML
GOLD SODIUM THIOMALATE (S.D.V.) 50
MG/ML
MG/ML
PAPAVERINE HYDROCHLORIDE
PAPAVERINE HYDROCHLORIDE
PAPAVERINE HYDROCHLORIDE (USP)
30 MG/ML
Page 363 of 374
3 EA BO
50 EA BO
PO
PO
EA
EA
8 MG
1 EA
0.5
1
03/17/2008
05/01/2006
99/99/9999
99/99/9999
15 EA BO
PO
EA
10 MG
12/03/2007
99/99/9999
60 EA BO
PO
EA
10 MG
05/29/2008
99/99/9999
100 EA BX
PO
EA
50 MG
0.5
01/01/2002 12/29/2008
100 EA
1 EA
1 EA
240 ML
480 ML
20 ML
PO
IV
IV
PO
PO
IV
EA
EA
MG
ML
ML
ML
50 MG
10 MG
10 MG
5 MG
5 MG
1 EA
1
5
10
0.6
0.6
1
01/01/2002 12/29/2009
11/01/2006 99/99/9999
8/14/2008 99/99/9999
10/02/2003 09/23/2007
10/02/2003 09/24/2007
01/01/2002 05/13/2005
BX
VL
VL
BO
BO
VL
2 ML VL
IJ
ML
5 MG
01/01/2002
09/15/2005
10 ML VL
IJ
ML
5 MG
01/01/2002
09/15/2005
2 ML VL
IJ
ML
5 MG
01/01/2002
09/15/2005
4 ML VL
IJ
ML
5 MG
01/01/2002
09/15/2005
10 ML VL
IJ
ML
5 MG
01/01/2002
09/15/2005
1 EA VL
IJ
EA
5 MG
01/01/2002
09/15/2005
1 EA
1 EA
100 EA
10 ML
10 ML
VL
VL
BO
VL
VL
IJ
IJ
PO
EP
EP
EA
EA
EA
ML
ML
50 MG
50 MG
50 MG
1 MG
1 MG
20
7
1
0.1
0.5
01/01/2002
01/01/2002
09/26/2006
06/28/2006
06/14/2006
09/15/2005
09/15/2005
05/20/2008
99/99/9999
99/99/9999
20 ML
1 ML
100 EA
100 EA
100 EA
1 ML
1 ML
1 ML
1 ML
1 ML
1 ML
20 ML
10 ML
10 ML
20 ML
20 ML
1 EA
50 ML
50 ML
50 ML
100 ML
100 ML
10 ML
VL
AM
BO
BO
BO
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
BO
VL
VL
VL
VL
VL
NA
IJ
IJ
PO
PO
PO
IV
IV
IV
IV
SC
SC
IJ
EP
EP
IV
IV
NA
IV
IV
IV
IV
IV
IJ
ML
ML
EA
EA
EA
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
GM
ML
ML
ML
ML
ML
ML
10 MG
1 MG
50 MG
50 MG
50 MG
0.1 MCG
0.1 MCG
0.1 MCG
0.1 MCG
1 MG
1 MG
10 MG
1 MG
1 MG
1 EA
1 MG
10 MG
1 EA
10 MG
10 MG
10 MG
10 MG
1 MG
1
1
1
1.5
2
10
20
10
20
1
1
1
0.1
0.5
1
25
100
1
0.2
0.2
0.2
0.2
5
01/09/2007
12/31/2002
07/26/2005
02/21/2003
02/21/2003
03/07/2003
03/07/2003
03/28/2003
03/28/2003
05/23/2003
09/21/2004
07/26/2005
11/16/2005
09/23/2005
10/06/2003
01/01/2005
02/01/2002
02/23/2004
01/01/2005
01/28/2005
05/03/2007
05/03/2007
10/01/2002
99/99/9999
99/99/9999
09/25/2006 7/16/2002
11/01/2003
11/01/2003
07/31/2004
07/31/2004
01/16/2005
01/17/2005
09/04/2008
09/04/2008
01/08/2007 12/12/2003
06/27/2006
06/13/2006
12/31/2004
99/99/9999
99/99/9999
12/31/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
10/13/2003
1 ML VL
IM
ML
50 MG
06/11/2004
05/31/2006
1 ML VL
IM
ML
50 MG
06/11/2004
5/31/2006
10 ML VL
IM
ML
50 MG
06/11/2004
5/31/2006
2 ML VL
IJ
ML
60 MG
0.5
02/20/2004
99/99/9999
2 ML VL
IJ
ML
60 MG
0.5
02/20/2004
99/99/9999
10 ML VL
IJ
ML
60 MG
0.5
02/20/2004
99/99/9999
7/25/2005
7/25/2005
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
66758-0016-01
J2370
1/8/2004
66758-0016-02
J2370
1/8/2004
66758-0016-03
J2370
66758-0016-04
J2370
66758-0017-01
66758-0018-01
66758-0018-02
66758-0019-01
66758-0019-02
66758-0020-01
66758-0020-02
66758-0025-01
66758-0025-02
66758-0025-03
66758-0025-04
J2370
J2250
J2250
J2250
J2250
J3360
J3360
J3490
J3490
J3490
J3490
1/8/2004
10/2/2003
10/2/2003
10/2/2003
10/2/2003
10/2/2003
10/2/2003
12/18/2003
12/18/2003
12/18/2003
12/18/2003
11/15/2005

66758-0026-01
J2910
66758-0035-01
J1626
66758-0036-01
J1626
66758-0037-02
J1626
66758-0043-01
J9265
66758-0043-02
J9265
66758-0043-03
66758-0045-01
66758-0045-02
J9265
J9390
J9390

66758-0046-01
66758-0501-22
J9185
J1100
66758-0601-19
J2550
7/23/2003
66794-0001-25
J7603
1/1/2008
66794-0001-25 KO J7603
66794-0001-25
66794-0001-30
66794-0001-60
J7644
4/1/2008
1/1/2008
KO
1/1/2008
4/1/2008
KO
4/1/2008
1/1/2008
KO
J7613
66794-0001-60 KO J7613
66794-0002-25
KO
J7603
66794-0001-60 KO J7603
1/1/2008
4/1/2008
J7613
66794-0001-30 KO J7613
66794-0001-60
KO
J7603
66794-0001-30 KO J7603
66794-0001-30

J7613
66794-0001-25 KO J7613
6/6/2006 INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG
1/1/2008
4/1/2008
KO
4/1/2008
4/15/2002
PHENYLEPHRINE HCL (USP, S.D.V.,PF)

10 MG/ML
PHENYLEPHRINE HCL (USP, S.D.V.,PF)
10 MG/ML
PHENYLEPHRINE HCL (USP,PF) 10
MG/ML
PHENYLEPHRINE HCL (USP,25X5ML,PF)
10 MG/ML
PHENYLEPHRINE HCL (USP, BULK
PACKAGE,PF) 10 MG/ML
DIAZEPAM 5 MG/ML
DIAZEPAM 5 MG/ML
AUROTHIOGLUCOSE (M.D.V.) 50 MG/ML
(1X4ML,MULTI-USE) 1 MG/ML
(5X1ML) 0.1 MG/ML
PACLITAXEL (USP,1X5ML,MULTI-DOSE)
6 MG/ML
PACLITAXEL (USP,1X16.7ML,MULTIDOSE) 6 MG/ML
PACLITAXEL (USP,1X50ML,MULTI-DOSE)
6 MG/ML
VINORELBINE (1X1ML,PF) 10 MG/ML
VINORELBINE (1X5ML,PF) 10 MG/ML
FLUDARABINE PHOSPHATE (SDV,PF) 25
MG/ML
DEXAMETHASONE 4 MG/ML

Page 364 of 374
1 ML VL
IJ
ML
1 ML
01/08/2004
6/1/2009
1 ML VL
IJ
ML
1 ML
01/08/2004
6/1/2009
5 ML VL
IJ
ML
1 ML
06/08/2005
99/99/9999
5 ML VL
IJ
ML
1 ML
06/08/2005
99/99/9999
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IV
IV
IV
IV
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
ML
1 ML
1 MG
1 MG
1 MG
1 MG
5 MG
5 MG
1 EA
1 EA
1 EA
1 EA
1
1
1
5
5
1
1
1
1
1
1
01/08/2004
10/02/2003
10/02/2003
10/02/2003
10/02/2003
10/02/2003
10/02/2003
12/18/2003
12/18/2003
12/18/2003
12/18/2003
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
03/09/2007
03/09/2007
03/01/2007
03/01/2007
03/01/2007
03/01/2007
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
10 ML
20 ML
20 ML
50 ML
50 ML
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
VL
10 ML VL
IM
ML
50 MG
11/15/2005
06/06/2006
1 ML VL
IV
ML
100 MCG
10
06/30/2008
99/99/9999
1 ML VL
IV
ML
100 MCG
10
06/30/2008
99/99/9999
1 ML VL
IV
ML
100 MCG
06/30/2008
99/99/9999
5 ML VL
IV
ML
30 MG
0.2
01/11/2008
99/99/9999
16.7 ML VL
IV
ML
30 MG
0.2
01/11/2008
99/99/9999
50 ML VL
1 ML VL
5 ML VL
IV
IV
IV
ML
ML
ML
30 MG
10 MG
10 MG
0.2
1
1
01/11/2008
03/05/2008
03/05/2008
99/99/9999
99/99/9999
99/99/9999
2 ML VL
30 ML VL
IV
IJ
ML
ML
50 MG
1 MG
0.5
4
10/12/2007
10/01/2002
99/99/9999
10/13/2003
10 ML VL
IJ
ML
50 MG
0.5
07/23/2003
5/31/2006
3 ML VL
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML VL
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML VL
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML VL
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML VL
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.83
01/01/2008
03/31/2008
3 ML VL
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
3 ML VL
IH
ML
1 MG
0.83
04/01/2008
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/15/2002
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
66794-0002-30
J7644
66794-0002-30 KO J7644
66794-0002-60
KO
J7644
66794-0002-60 KO J7644
66860-0001-03
J0690
66860-0002-03
J0690
66860-0003-02
J0690
66860-0020-01
J0170
66860-0021-02
66860-0030-03
66860-0031-03
J0170
J0697
J0697
66860-0032-02
J0697
66860-0090-02
66860-0098-03
66860-0099-03
66860-0902-03
J1800
J2550
J2550
J0690
66993-0805-02
Q0164
66993-0810-02
Q0165
66993-0810-05
66993-0840-02
66993-0840-21
66993-0842-25
Q0165
J7509
J7509
J7509
67046-0125-30
Q0163
67046-0126-30
Q0163
67046-0281-30
Q0177
67046-0282-30
Q0178
67046-0282-60
67066-0001-01
67066-0006-01
67066-0006-01
67211-0102-01
67211-0102-01
67211-0342-08
67211-0342-53
67253-0100-10
67253-0100-11
67253-0101-10
67253-0101-11
67253-0102-10
67253-0102-50
67253-0320-10
Q0178
J3490
J3490
J2850
J3490
J9025
J1655
J1655
J8499
J8499
J8499
J8499
J8499
J8499
None
KO

4/15/2002 99/99/9999 MILLIGRAM
4/15/2002 99/99/9999 MILLIGRAM
4/15/2002 99/99/9999 MILLIGRAM
4/15/2002 99/99/9999 MILLIGRAM
4/15/2002 99/99/9999 MILLIGRAM
10 GM
EPINEPHRINE 1:1000 (MDV,USP) 1
MG/ML
EPINEPHRINE 1:1000 (10X1ML AMPS,PF)
1 MG/ML
CEFUROXIME (PHARMACY BULK,USP)
7.5 GM
(1MLX10,USP) 1 MG/ML
PROMETHAZINE HCL (1X25) 25 MG/ML
CEFAZOLIN AMERINET CHOICE 1 GM
10/1/2002
10/1/2002
10/1/2002
10/1/2002
10/1/2002
SECREFLO 16 MCG
SECREFLO 16 MCG
1/1/2006 9/30/2008 INJECTION, SECRETIN, SYNTHETIC, HUMAN, 1 MICROGRAM
SECREFLO 16 MCG
VIDAZA 100 MG
1/1/2006 4/30/2009 INJECTION, AZACITIDINE, 1 MG
VIDAZA 100 MG
ACYCLOVIR 200 MG
ACYCLOVIR 200 MG
ACYCLOVIR 400 MG
ACYCLOVIR 400 MG
ACYCLOVIR 800 MG
ACYCLOVIR 800 MG
METHOTREXATE (USP) 2.5 MG
Page 365 of 374
2.5 ML PC
IH
ML
1 MG
0.2
04/15/2002
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/15/2002
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/15/2002
99/99/9999
2.5 ML PC
IH
ML
1 MG
0.2
04/15/2002
99/99/9999
2.5 ML PC
1 EA VL
1 EA VL
IH
IJ
IJ
ML
EA
EA
1 MG
500 MG
500 MG
0.2
1
2
04/15/2002
07/10/2002
07/10/2002
99/99/9999
99/99/9999
99/99/9999
06/01/2002
99/99/9999
1 EA VL
IJ
EA
500 MG
20
30 ML VL
IJ
ML
1 ML
01/01/2003 12/30/2007
1 ML AM IJ
1 EA VL IJ
1 EA VL IJ
ML
EA
EA
1 ML
750 MG
750 MG
1
1
2
01/01/2002
06/01/2002
06/01/2002
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA VL
IJ
EA
750 MG
10
01/01/2003
1 ML
1 ML
1 ML
1 EA
IV
IJ
IJ
IJ
ML
ML
ML
EA
1 MG
50 MG
50 MG
500 MG
1
0.5
1
2
01/01/2003
5/31/2007
3/26/2009 99/99/9999
3/26/2009 99/99/9999
09/01/2005 11/30/2007
100 EA BO
PO
EA
5 MG
02/14/2003 12/31/2008
100 EA BO
PO
EA
10 MG
02/14/2003 12/31/2008
BO
BO
DP
BO
PO
PO
PO
PO
EA
EA
EA
EA
10 MG
4 MG
4 MG
4 MG
1
1
1
2
02/14/2003 06/30/2007
01/21/2003 12/31/2008
01/21/2003 12/31/2008
04/29/2004 12/31/2008
30 EA BX
PO
EA
50 MG
0.5
10/01/2002
08/01/2004
30 EA BX
PO
EA
50 MG
10/01/2002
08/01/2004
30 EA NA
PO
EA
25 MG
10/01/2002
08/01/2004
30 EA NA
PO
EA
50 MG
10/01/2002
08/01/2004
PO
IV
IV
IV
SC
SC
SC
SC
PO
PO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
EA
ML
ML
EA
EA
EA
EA
EA
EA
EA
50 MG
1 EA
1 EA
1 MCG
1 EA
1 MG
1000 IU
1000 IU
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
2.5 MG
1
1
1
16
1
100
20
20
1
1
1
1
1
1
1
10/01/2002
10/09/2002
10/11/2005
01/01/2006
05/19/2004
01/01/2006
01/01/2002
01/01/2002
10/01/2003
07/15/2003
10/01/2003
07/15/2003
07/15/2003
07/15/2003
10/29/2007
08/01/2004
10/10/2005
12/31/2005
9/30/2008
12/31/2005
4/30/2009
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999 12/30/2005
1000 EA
100 EA
21 EA
25 EA
60 EA
1 EA
1 EA
1 EA
1 EA
1 EA
2 ML
2 ML
100 EA
1000 EA
100 EA
1000 EA
100 EA
500 EA
100 EA
VL
EA
EA
VL
NA
VL
VL
VL
VL
VL
VL
VL
BO
BO
BO
BO
BO
BO
BO
1/1/2007
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
KO
NDC Mod
66794-0002-25 KO J7644
NDC
HCPCS
10/17/2005
10/17/2005

67253-0360-10
67253-0360-21
J7509
J7509
67253-0417-12
Q0166
67253-0417-22
Q0166
20 EA BO
PO
EA
1 MG
05/15/2008
99/99/9999
67253-0580-42
None
8 EA DP
PO
EA
2.5 MG
07/01/2003
99/99/9999
67253-0580-43
None
12 EA DP
PO
EA
2.5 MG
07/01/2003
99/99/9999
67253-0580-44
None
16 EA DP
PO
EA
2.5 MG
07/01/2003
99/99/9999
67253-0580-45
None
20 EA DP
PO
EA
2.5 MG
07/01/2003
99/99/9999
67253-0580-46
None
24 EA DP
PO
EA
2.5 MG
07/01/2003
99/99/9999
67286-0040-01
J2993
11/30/2005
2 EA BX
IV
EA
18.1 MG
11/30/2005
03/09/2008
67286-0040-02
67286-0053-08
67286-0053-08
67286-0054-08
J2993
J9999
J0594
J0594
11/30/2005
3/9/2008 INJECTION, RETEPLASE, 18.1 MG
1/1/2007 8/22/2007 INJECTION, BUSULFAN, 1 MG
7/30/2007 11/2/2008 INJECTION, BUSULFAN, 1 MG
BX
AM
AM
VL
IV
IV
IV
IV
EA
ML
ML
ML
18.1 MG
1 EA
1 MG
1 MG
1
1
6
6
11/30/2005
06/10/2004
01/01/2007
07/30/2007
03/09/2008
12/31/2006
8/22/2007
11/2/2008
67286-0400-01
J2993
3/10/2008
2 EA BX
IV
EA
18.1 MG
03/10/2008
11/8/2009
67286-0400-02
J2993
3/10/2008
1 EA BX
IV
EA
18.1 MG
03/10/2008
11/8/2009
67308-0101-01
J7308
1/1/2003
1 EA SK
TP
EA
354 MG
01/01/2003
99/99/9999
67308-0101-06
67386-0411-51
67386-0501-52
67386-0501-55
67386-0611-52
67386-0701-54
67386-0701-54
67386-0711-55
67386-0811-55
J7308
J9020
J2515
J2515
J0515
Q2011
J1640
J1205
J9120
1/1/2003
11/16/2006
6/11/2003
6/11/2003
1/21/2006
3/18/2005
1/1/2006
1/21/2006
1/21/2006
SK
VL
VL
VL
AM
VL
VL
VL
VL
TP
IJ
IJ
IJ
IJ
IV
IV
IV
IV
EA
EA
ML
ML
ML
EA
EA
EA
EA
354 MG
10000 U
50 MG
50 MG
1 MG
1 MG
1 MG
500 MG
0.5 MG
1
1
1
1
1
313
313
1
1
01/01/2003
11/16/2006
06/11/2003
06/11/2003
01/21/2006
03/18/2005
01/01/2006
01/21/2006
01/21/2006
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
12/31/2005
99/99/9999
99/99/9999
99/99/9999
67386-0911-51
67425-0001-01
67425-0001-10
J9230
J3470
J3470
1 EA VL
1 EA NA
1 EA NA
IV
SC
SC
EA
EA
EA
10 MG
150 U
150 U
1
41.33333
41.33333
01/21/2006
01/28/2005
01/28/2005
99/99/9999
99/99/9999
12/07/2006
67425-0002-10
J3470
1.2 ML VL
SC
ML
150 U
1.33333
01/28/2005
99/99/9999
67457-0124-10
67457-0145-50
J1200
J1212
10 ML VL
50 ML VL
IJ
IL
ML
ML
50 MG
50 %
1
0.02
05/01/2007
07/01/2005
99/99/9999
08/01/2006
67457-0147-20
J3520
7/1/2005
EDETATE DISODIUM (S.D.V.) 150 MG/ML
20 ML VL
IV
ML
150 MG
07/01/2005
04/18/2008
67457-0152-10
67457-0153-03
J2550
J0282


(9X10ML) 50 MG/ML
AMIODARONE HYDROCHLORIDE 50
MG/ML
MILRINONE LACTATE (S.D.V.,PF,LATEXFREE) 1 MG/ML
RIMSO-50 (ODORLESS) 50%
OCTAGAM (1GM/VIAL,S/D TREATED) 50
MG/ML
MG/ML
OCTAGAM (2.5GM/VIAL,S/D TREATED)
50 MG/ML
OCTAGAM (2.5GM/VIAL,S/D TREATED)
50 MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
10 ML VL
3 ML VL
IJ
IV
ML
ML
50 MG
30 MG
0.5
1.66666
07/01/2005
07/01/2005
1/15/2009
99/99/9999

99/99/9999 DOSAGE FORM (354 MG)
99/99/9999 DOSAGE FORM (354 MG)
99/99/9999 INJECTION, ASPARAGINASE, 10,000 UNITS
12/31/2005 INJECTION, HEMIN, PER 1 MG
99/99/9999 INJECTION, HEMIN, 1 MG
99/99/9999 INJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MG
99/99/9999 INJECTION, DACTINOMYCIN, 0.5 MG
67457-0153-09
J0282
J0282
67457-0160-20
67457-0177-50
J2260
J1212
10/30/2003
INJECTION, IMMUNE GLOBULIN (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED
1/1/2008 99/99/9999 (E.G.LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G.LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G.LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G.LIQUID), 500 MG
67467-0843-01
Q4087
J1568
67467-0843-02
Q4087
67467-0843-02
J1568
67467-0843-03
Q4087
67467-0843-03
J1568
67467-0843-04
Q4087
67467-0843-04
J1568

ELSPAR 10000 IU
NEMBUTAL SODIUM 50 MG/ML
NEMBUTAL SODIUM (VIAL) 50 MG/ML
COGENTIN (5X2ML) 1 MG/ML
PANHEMATIN 313 MG
PANHEMATIN 313 MG
DIURIL SODIUM 0.5 GM
COSMEGEN 0.5 MG
1/21/2006 99/99/9999 INJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG MUSTARGEN 10 MG

VITRASE (PF) 6200 U
VITRASE (OVINE) 6200 U
VITRASE (LYOPHILIZED,OVINE,SDV) 200
U/ML
(MDV,USP) 50 MG/ML
7/1/2005
DIMETHYL SULFOXIDE 50%
67457-0153-18
67467-0843-01

BUSULFEX (8X10ML) 6 MG/ML
Page 366 of 374
100 EA BO
21 EA DP
PO
PO
EA
EA
4 MG
4 MG
1
1
10/17/2005
10/17/2005
01/01/2007
01/01/2007
2 EA BO
PO
EA
1 MG
05/15/2008
99/99/9999
1 EA
10 ML
10 ML
10 ML
1 EA
1 EA
20 ML
50 ML
2 ML
1 EA
1 EA
1 EA
1 EA
9 ML VL
IV
ML
30 MG
1.66666
11/29/2005
99/99/9999
18 ML VL
IV
ML
30 MG
1.66666
11/29/2005
99/99/9999
20 ML VL
50 ML VL
IV
IL
ML
ML
5 MG
50 %
0.2
0.02
10/30/2003
06/22/2007
08/07/2007
99/99/9999
20 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
20 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
50 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
50 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
100 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
100 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
200 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
200 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
67467-0843-05
Q4087
67467-0843-05
67817-0061-12
67817-0063-12
67817-0066-12
67817-0067-12
67870-0103-08
67870-0103-16
J1568
J9045
J9045
J9045
J9045
J7510
J7510
67871-0007-10
Q2002
67871-0007-10
67871-4790-06
67871-4790-06
67871-7729-02
67919-0011-01
67919-0011-01
67979-0001-01
67979-0001-02
67979-0002-01
67979-0002-01
67979-0500-01
67979-0500-01
68084-0035-85
J9175
Q2007
J1430
J3490
J9999
J0878
J9357
J9357
J9225
J9226
J9225
J9226
J7506
68084-0156-01
68084-0229-01
68084-0245-21
Q0170
J7500
J8515
68094-0518-59
J8999
68094-0518-61
J8999
68094-0518-62
J8999
68094-0528-59
J8999
68094-0528-61
68094-0528-62
68115-0005-10
68115-0005-25
68115-0005-30
68115-0005-40
68115-0006-10
68115-0006-15
68115-0006-21
68115-0006-25
68115-0006-30
68115-0006-60
68115-0007-30
68115-0007-40
J8999
J8999
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
J8499
68115-0018-06
G9017
68115-0018-14
G9017
68115-0018-20
G9017
68115-0018-30
G9017
68115-0096-12
68115-0096-12
Q0181
J8540
68115-0096-14
68115-0096-14
Q0181
J8540
68115-0096-30
68115-0096-30
Q0181
J8540

7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G.LIQUID), 500 MG
5/28/2003 12/31/2005 INJECTION, ELLIOTTS B SOLUTION, PER ML
OCTAGAM (PF,SUCROSE-FREE) 50
MG/ML
MG/ML
ELLIOTTS B (FOR INTRATHECAL
USE,PF)
ELLIOTTS B (FOR INTRATHECAL
USE,PF)
ETHAMOLIN (10X2ML AMP) 50 MG/ML
ETHAMOLIN (10X2ML AMP) 50 MG/ML
GLOFIL-125
CUBICIN (PF) 500 MG
CUBICIN (PF) 500 MG
VALSTAR (4X5ML,PF) 40 MG/ML
VALSTAR (24X5ML,PF) 40 MG/ML
SUPPRELIN LA 50 MG
SUPPRELIN LA 50 MG
VANTAS 50 MG
VANTAS 50 MG
1/1/2006 99/99/9999 INJECTION, ELLIOTTS' B SOLUTION, 1 ML

1/1/2005 99/99/9999 INJECTION, DAPTOMYCIN, 1 MG
10/31/2007 99/99/9999 INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG
10/31/2007 99/99/9999 INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG
6/18/2007 12/31/2007 HISTRELIN IMPLANT, 50 MG
1/1/2008 99/99/9999 HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG
7/25/2007 12/31/2007 HISTRELIN IMPLANT, 50 MG
1/1/2008 99/99/9999 HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG
(USP,10X10) 50 MG
AZATHIOPRINE 50 MG
6/3/2008 99/99/9999 CABERGOLINE, ORAL, 0.25 MG
CABERGOLINE (3X10) 0.5 MG
MEGESTROL ACETATE (1X20ML,LEMON7/1/2007 99/99/9999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS
LIME) 40 MG/ML
MEGESTROL ACETATE
11/28/2006
(100X20ML,LEMON-LIME) 40 MG/ML
MEGESTROL ACETATE
(30X20ML,LEMON-LIME) 40 MG/ML
MEGESTROL ACETATE (1X10ML,LEMON7/1/2007 99/99/9999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS
LIME) 40 MG/ML
MEGESTROL ACETATE (10X10) 40
MG/ML
1/20/2005
ACYCLOVIR 200 MG
4/19/2004
ACYCLOVIR 200 MG
5/1/2005
ACYCLOVIR 200 MG
1/20/2005
ACYCLOVIR 200 MG
1/20/2005
ACYCLOVIR 400 MG
3/17/2004
ACYCLOVIR 400 MG
1/20/2005
ACYCLOVIR 400 MG
1/5/2004
ACYCLOVIR 400 MG
3/17/2004
ACYCLOVIR 400 MG
4/19/2004
ACYCLOVIR 400 MG
3/29/2004
ACYCLOVIR 800 MG
5/1/2005
ACYCLOVIR 800 MG
4/19/2004 12/31/2005 REGIMEN
1/1/2006
4/19/2004 12/31/2005 REGIMEN
1/1/2006
5/1/2005 12/31/2005 REGIMEN
1/1/2006
Page 367 of 374
500 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
500 ML
5 ML
15 ML
45 ML
60 ML
236 ML
473 ML
IV
IV
IV
IV
IV
PO
PO
ML
ML
ML
ML
ML
ML
ML
500 MG
50 MG
50 MG
50 MG
50 MG
5 MG
5 MG
0.1
0.2
0.2
0.2
0.2
0.6
0.6
01/01/2008
10/14/2004
10/14/2004
10/14/2004
10/14/2004
06/01/2003
06/01/2003
99/99/9999
02/15/2007
02/15/2007
02/15/2007
02/15/2007
99/99/9999
99/99/9999
10 ML AM IN
10 ML
2 ML
2 ML
4 ML
1 EA
1 EA
5 ML
5 ML
1 EA
1 EA
1 EA
1 EA
15 EA
VL
VL
VL
VL
VL
BO
BO
ML
1 ML
05/28/2003
12/31/2005
AM
AM
AM
VL
VL
VL
VL
VL
BX
BX
BX
BX
NA
IN
IV
IV
IV
IV
IV
IL
IL
SC
SC
SC
SC
PO
ML
ML
ML
ML
EA
EA
ML
ML
EA
EA
EA
EA
EA
1 ML
100 MG
100 MG
1 EA
1 EA
1 MG
200 MG
200 MG
50 MG
50 MG
50 MG
50 MG
5 MG
1
0.5
0.5
1
1
500
0.2
0.2
1
1
1
1
1
01/01/2006
10/01/2005
01/01/2006
10/01/2005
09/12/2003
01/01/2005
6/3/2009
6/3/2009
06/18/2007
01/01/2008
07/25/2007
01/01/2008
06/14/2004
99/99/9999
12/31/2005
99/99/9999
4/18/2008
12/31/2004
99/99/9999
99/99/9999 10/31/2007
99/99/9999 10/31/2007
12/31/2007
99/99/9999
12/31/2007
99/99/9999
01/17/2005
100 EA BX
100 EA BX
30 EA BX
PO
PO
PO
EA
EA
EA
25 MG
50 MG
0.25 MG
2
1
2
09/08/2006
03/14/2008
06/03/2008
02/22/2008
99/99/9999
99/99/9999
20 ML CP
PO
ML
1 EA
07/01/2007
99/99/9999
20 ML CP
PO
ML
1 EA
11/28/2006
03/01/2008
20 ML CP
PO
ML
1 EA
11/28/2006
99/99/9999
10 ML CP
PO
ML
1 EA
07/01/2007
99/99/9999
10 ML
10 ML
10 EA
25 EA
30 EA
40 EA
10 EA
15 EA
21 EA
25 EA
30 EA
60 EA
30 EA
40 EA
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
ML
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
02/26/2004
02/26/2004
01/20/2005
04/19/2004
05/01/2005
01/20/2005
01/20/2005
03/17/2004
01/20/2005
01/05/2004
03/17/2004
04/19/2004
03/29/2004
05/01/2005
99/99/9999
99/99/9999
4/1/2009
4/1/2009
4/1/2009
4/1/2009
4/1/2009
4/1/2009
4/1/2009
4/1/2009
4/1/2009
4/1/2009
4/1/2009
4/1/2009
CP
CP
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
6 EA BO
PO
EA
100 MG
05/01/2005
05/31/2005
14 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
20 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
30 EA BO
PO
EA
100 MG
12/01/2004
05/31/2005
12 EA BO
12 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
04/19/2004
01/01/2006
12/31/2005
4/1/2009
14 EA BO
14 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
04/19/2004
01/01/2006
12/31/2005
4/1/2009
30 EA BO
30 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
3
05/01/2005
01/01/2006
12/31/2005
4/1/2009
3/3/2009
3/3/2009
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
0.2
0.2
68115-0097-04
68115-0097-04
Q0181
J8540
5/1/2005
1/1/2006
68115-0097-15
68115-0097-15
Q0181
J8540
5/1/2005
1/1/2006
68115-0097-20
68115-0097-20
Q0181
J8540
10/26/2004
1/1/2006
68115-0097-30
68115-0097-30
Q0181
J8540
6/8/2004
1/1/2006
68115-0116-00
Q0163
3/17/2004
68115-0116-10
Q0163
3/17/2004
68115-0116-12
Q0163
5/1/2005
68115-0116-15
Q0163
10/1/2003
68115-0116-20
Q0163
3/17/2004
68115-0116-24
Q0163
10/26/2004
68115-0116-30
Q0163
10/1/2003
68115-0116-60
Q0163
3/17/2004
68115-0117-06
Q0163
3/29/2004
68115-0117-15
Q0163
10/1/2003
68115-0117-20
Q0163
1/5/2004
68115-0117-30
Q0163
10/1/2003
68115-0177-00
Q0177
5/5/2004
68115-0177-30
Q0177
3/17/2004
68115-0177-60
Q0177
10/1/2003

DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
DEXAMETHASONE 4 MG
12/31/2005 REGIMEN
DEXAMETHASONE 4 MG
Page 368 of 374
4 EA NA
4 EA NA
PO
PO
EA
EA
1 EA
0.25 MG
1
16
05/01/2005
01/01/2006
12/31/2005
4/1/2009
15 EA NA
15 EA NA
PO
PO
EA
EA
1 EA
0.25 MG
1
16
05/01/2005
01/01/2006
12/31/2005
4/1/2009
20 EA BO
20 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
10/26/2004
01/01/2006
12/31/2005
4/1/2009
30 EA BO
30 EA BO
PO
PO
EA
EA
1 EA
0.25 MG
1
16
06/08/2004
01/01/2006
12/31/2005
4/1/2009
100 EA BO
PO
EA
50 MG
0.5
03/17/2004
4/1/2009
10 EA BO
PO
EA
50 MG
0.5
03/17/2004
4/1/2009
12 EA NA
PO
EA
50 MG
0.5
05/01/2005
4/1/2009
15 EA BO
PO
EA
50 MG
0.5
10/01/2003
4/1/2009
20 EA BO
PO
EA
50 MG
0.5
03/17/2004
4/1/2009
24 EA BO
PO
EA
50 MG
0.5
10/26/2004
4/1/2009
30 EA BO
PO
EA
50 MG
0.5
10/01/2003
4/1/2009
60 EA BO
PO
EA
50 MG
0.5
03/17/2004
4/1/2009
6 EA BO
PO
EA
50 MG
03/29/2004
4/1/2009
15 EA BO
PO
EA
50 MG
10/01/2003
4/1/2009
20 EA BO
PO
EA
50 MG
01/05/2004
4/1/2009
30 EA BO
PO
EA
50 MG
10/01/2003
4/1/2009
100 EA BO
PO
EA
25 MG
05/05/2004
4/1/2009
30 EA BO
PO
EA
25 MG
03/17/2004
4/1/2009
60 EA BO
PO
EA
25 MG
10/01/2003
4/1/2009
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
1/5/2004
9/28/2004
10/26/2004
5/5/2004
1/5/2004
1/5/2004
9/28/2004
10/26/2004
6/8/2004
10/26/2004
1/5/2004
68115-0298-00
Q0165
7/27/2006
68115-0298-04
Q0165
7/27/2006
68115-0298-12
Q0165
5/11/2004
68115-0298-15
Q0165
7/27/2006
68115-0298-30
Q0165
7/27/2006
68115-0298-60
Q0165
7/1/2005
68115-0298-90
68115-0299-12
Q0165
J8498
7/27/2006
4/13/2006
68115-0300-10
Q0164
1/5/2004
68115-0302-00
Q0170
7/27/2006
68115-0302-04
Q0170
7/27/2006
68115-0302-10
Q0170
10/26/2004
68115-0302-20
Q0170
6/25/2004
68115-0302-30
Q0170
10/1/2003
68115-0302-60
Q0170
11/10/2004
68115-0302-90
Q0170
7/27/2006
68115-0339-20
68115-0364-04
68115-0364-50
Q0173
Q0144
Q0144
10/1/2003
10/26/2004
5/4/2005
PO
EA
10 MG
07/27/2006
99/99/9999
4 EA BO
PO
EA
10 MG
07/27/2006
99/99/9999
12 EA BO
PO
EA
10 MG
05/11/2004
99/99/9999
15 EA BO
PO
EA
10 MG
07/27/2006
99/99/9999
30 EA BO
PO
EA
10 MG
07/27/2006
99/99/9999
60 EA BO
PO
EA
10 MG
07/01/2005
99/99/9999
90 EA BO
12 EA BX
PO
RC
EA
EA
10 MG
1 EA
1
1
07/27/2006
04/13/2006
99/99/9999
08/01/2007
10 EA BO
PO
EA
5 MG
01/05/2004
99/99/9999
100 EA BO
PO
EA
25 MG
07/27/2006
99/99/9999
4 EA BO
PO
EA
25 MG
07/27/2006
99/99/9999
10 EA BO
PO
EA
25 MG
10/26/2004
99/99/9999
20 EA BO
PO
EA
25 MG
06/25/2004
99/99/9999
30 EA BO
PO
EA
25 MG
10/01/2003
99/99/9999
60 EA BO
PO
EA
25 MG
11/10/2004
99/99/9999
90 EA BO
PO
EA
25 MG
07/27/2006
99/99/9999
20 EA BO
4 EA BO
50 EA BO
PO
PO
PO
EA
EA
EA
250 MG
1 GM
1 GM
1
0.25
0.25
10/01/2003
10/26/2004
05/04/2005
99/99/9999
99/99/9999
99/99/9999
CF
HCPCS Amount #1
100 EA BO
Prior End Date #3
4/1/2009
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
Prior Start Date #3
01/05/2004
09/28/2004
10/26/2004
05/05/2004
01/05/2004
01/05/2004
09/28/2004
10/26/2004
06/08/2004
10/26/2004
01/05/2004
1
2
2
2
2
4
4
4
1
1
1
Prior End Date #2
50 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
5 MG
End Date #1
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
Start Date #1
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
HCPCS Measure #1
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
BO
Billing Units
20 EA
10 EA
21 EA
30 EA
42 EA
15 EA
20 EA
30 EA
100 EA
21 EA
30 EA
Prior Start Date #2

Package
HCPCS Description
NDC Label
Page 369 of 374
NDC Package Type
Q0178
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
J7506
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 10 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PREDNISONE 5 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
PROMETHAZINE 25 MG
ZITHROMAX 250 MG
ZITHROMAX 250 MG
NDC Package Measure
68115-0178-20
68115-0289-10
68115-0289-21
68115-0289-30
68115-0289-42
68115-0290-15
68115-0290-20
68115-0290-30
68115-0291-00
68115-0291-21
68115-0291-30
HCPCS Mod
HCPCS
NDC Mod
NDC
68115-0435-10
68115-0435-10
Q0181
J8540
6/28/2005
1/1/2006
68115-0535-03
Q4084
1/1/2007
68115-0535-03
68115-0541-50
J7322
Q0144
1/1/2008
5/4/2005
68115-0588-00
Q0173
6/25/2004
68115-0598-04
68115-0632-00
68115-0651-60
Q0170
None
J7699
10/26/2004
4/19/2004
4/19/2004
68115-0691-12
68115-0691-12
K0416
J8498
3/29/2004
1/1/2006
68115-0692-25
68115-0709-05
Q0168
J1815
3/29/2004
3/17/2004

12/31/2005 REGIMEN
12/31/2007 DOSE
SYNVISC 8 MG/ML
12/31/2009 DOSE
SYNVISC 8 MG/ML
ZITHROMAX 250 MG
6.25 MG/5 ML
NOVOLIN R PENFILL 100 U/ML
HUMULIN N PEN 100 U/ML
68115-0711-20
J7602
1/1/2008
68115-0711-20
68115-0728-10
68115-0729-05
J7611
J1815
J1815
4/1/2008
3/17/2004
3/17/2004
68115-0746-10
68115-0749-10
J1817
J1650
68115-0750-30
J1595
2/12/2004 99/99/9999 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS HUMALOG 100 U/ML
3/17/2004
3/29/2004
MG/ML
WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, IMITREX (SRN,PREFILLED,UNIT/USE) 6
MG/0.5 ML
2/6/2004
ML
ZOFRAN 4 MG
1/20/2004
LANTUS 100 U/ML
5/4/2004
ZITHROMAX 250 MG
PREDNISONE 5 MG
10/1/2003
1/20/2004
NAGLAZYME (PF) 1 MG/ML
1/1/2007 99/99/9999 INJECTION, GALSULFASE, 1 MG
NAGLAZYME (PF) 1 MG/ML
ML
ORAPRED (20MLX10,DYE-FREE,GRAPE)
15 MG/5 ML
PLENAXIS (S.D.V.,PF) 100 MG-0.9%
1/1/2005 99/99/9999 INJECTION, ABARELIX, 10 MG
PLENAXIS (S.D.V.,PF) 100 MG-0.9%
CEFTRIAXONE 250 MG
CEFTRIAXONE 250 MG
CEFTRIAXONE 500 MG
CEFTRIAXONE 500 MG
CEFTRIAXONE 1 GM
CEFTRIAXONE 1 GM
CEFTRIAXONE 2 GM
CEFTRIAXONE 2 GM
ORAPRED ODT (GRAPE) 10 MG
OCTAGAM (1GM/1VIAL,S/D TREATED) 50
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
MG/ML
68115-0770-02
J3030
68115-0774-10
J1650
68115-0802-30
68115-0839-10
68115-0898-08
68115-0931-06
68115-0947-21
68115-0960-21
Q0179
J1815
J7510
Q0144
J7506
J7509
68115-0976-04
68135-0020-01
68135-0020-01
Q0163
J3490
J1458
68135-0455-02
J7510
68135-0455-03
68158-0149-51
68158-0149-51
68180-0611-01
68180-0611-10
68180-0622-01
68180-0622-10
68180-0633-01
68180-0633-10
68180-0644-01
68180-0644-10
68188-0480-02
68188-0482-02
68188-0484-02
J7510
J3590
J0128
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J7510
J7510
J7510
68209-0843-01
Q4087
Page 370 of 374
10 EA BO
10 EA BO
2 ML SR
PO
PO
EA
EA
1 EA
0.25 MG
1
6
06/28/2005
01/01/2006
12/31/2005
4/1/2009
IJ
ML
1 DOSE
0.5
01/01/2007
12/31/2007
2 ML SR
50 EA BO
IJ
PO
ML
EA
1 DOSE
1 GM
0.5
0.25
01/01/2008
05/04/2005
12/31/2009
99/99/9999
100 EA BO
PO
EA
250 MG
1.2
06/25/2004
99/99/9999
120 ML BO
100 EA BO
60 EA BO
PO
PO
IH
ML
EA
EA
25 MG
2.5 MG
1 EA
0.05
1
1
10/26/2004
04/19/2004
04/19/2004
99/99/9999
4/1/2009
4/1/2009
12 EA BX
12 EA BX
RC
RC
EA
EA
1 MG
1 EA
25
1
03/29/2004
01/01/2006
12/31/2005
99/99/9999
25 EA BX
3 ML CT
PO
IJ
EA
ML
5 MG
5U
1
20
03/29/2004
03/17/2004
4/1/2009
4/1/2009
20 ML BO
IH
ML
1 MG
01/01/2008
03/31/2008
20 ML BO
10 ML VL
3 ML CT
IH
IJ
SC
ML
ML
ML
1 MG
5U
5U
5
20
20
04/01/2008
03/17/2004
03/17/2004
4/1/2009
4/1/2009
4/1/2009
10 ML VL
0.4 ML SR
SC
SC
ML
ML
50 U
10 MG
2
10
02/12/2004
03/17/2004
99/99/9999
4/1/2009
1 ML DP
MR
EA
20 MG
30
03/29/2004
4/1/2009
0.5 ML BX
SC
ML
6 MG
01/20/2004
99/99/9999
0.6 ML SR
SC
ML
10 MG
10
02/06/2004
4/1/2009
30 EA
10 ML
240 ML
6 EA
21 EA
21 EA
BO
VL
BO
BO
BO
BO
PO
SC
PO
PO
PO
PO
EA
ML
ML
EA
EA
EA
8 MG
5U
5 MG
1 GM
5 MG
4 MG
0.5
20
0.6
0.25
1
1
01/20/2004
01/20/2004
05/04/2004
01/05/2004
05/04/2004
10/01/2003
99/99/9999
4/1/2009
08/01/2007
99/99/9999
99/99/9999
4/1/2009
120 ML BO
5 ML VL
5 ML VL
PO
IV
IV
ML
ML
ML
50 MG
1 EA
1 MG
0.05
1
1
01/20/2004
06/05/2005
01/01/2007
08/01/2007
12/31/2006
99/99/9999
237 ML BO
PO
ML
5 MG
0.6
02/01/2005
99/99/9999
PO
MR
MR
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
PO
PO
PO
ML
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
5 MG
1 EA
10 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
5 MG
5 MG
5 MG
0.6
1
10
1
1
2
2
4
4
8
8
2
3
6
09/01/2005
01/25/2004
01/01/2005
07/20/2005
07/20/2005
07/20/2005
07/20/2005
07/20/2005
07/20/2005
07/20/2005
07/20/2005
04/03/2007
07/10/2006
01/04/2008
99/99/9999
12/31/2004
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
20 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
10 EA
1 EA
1 EA
48 EA
48 EA
48 EA
BO
VL
VL
VL
VL
NA
NA
VL
VL
NA
NA
BX
BX
BX
20 ML VL
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
J1568
J0696
J0696
J0696
J0696
J0696
J0696
J0696
J0696

1/1/2008 99/99/9999 (E.G.LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G.LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G.LIQUID), 500 MG
7/1/2007 12/31/2007 (E.G. LIQUID), 500 MG
1/1/2008 99/99/9999 (E.G.LIQUID), 500 MG
OCTAGAM (1GM/1VIAL,S/D TREATED) 50

MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
MG/ML
68330-0005-01
J0696
CEFTRIAXONE (USP,PIGGYBACK) 1 GM
68330-0006-01
68382-0003-01
68382-0003-05
J0696
J7500
J7500
68382-0040-01
Q0169
68382-0040-10
Q0169
68382-0041-01
Q0170

CEFTRIAXONE (USP,PIGGYBACK) 2 GM
MG
MG
MG
MG
MYCOPHENOLATE MOFETIL, (FILM5/4/2009 99/99/9999 MYCOPHENOLATE MOFETIL, ORAL, 250 MG
COATED), 500MG
MYCOPHENOLATE MOFETIL, (FILM5/4/2009 99/99/9999 MYCOPHENOLATE MOFETIL, ORAL, 250 MG
COATED), 500MG
PREDNISONE 20 MG
PREDNISONE 20 MG
PREDNISONE 10 MG
MG
MG
MG
MG
25 MG
AZITHROMYCIN 250 MG
68209-0843-01
J1568
68209-0843-02
Q4087
68209-0843-02
J1568
68209-0843-03
Q4087
68209-0843-03
J1568
68209-0843-04
Q4087
68209-0843-04
68330-0001-01
68330-0001-10
68330-0002-01
68330-0002-10
68330-0003-01
68330-0003-10
68330-0004-01
68330-0004-10
68382-0041-10
Q0170
68382-0131-01
J7517
68382-0131-05
68387-0170-01
68387-0240-10
68387-0240-25
68387-0241-15
J7517
J7509
J7506
J7506
J7506
68387-0468-30
Q0178
68387-0469-30
Q0178
68387-0536-12
Q0170
68387-0536-30
Q0170
68387-0536-60
Q0170
68387-0536-90
Q0170
68387-0541-30
68387-0565-06
Q0163
Q0144
Page 371 of 374
20 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
50 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
50 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
100 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
100 ML VL
IV
ML
500 MG
0.1
01/01/2008
99/99/9999
200 ML VL
IV
ML
500 MG
0.1
07/01/2007
12/31/2007
200 ML
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
1 EA
IV
IJ
IJ
IJ
IJ
IJ
IJ
IJ
IJ
ML
EA
EA
EA
EA
EA
EA
EA
EA
500 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
250 MG
0.1
1
1
2
2
4
4
8
8
01/01/2008
09/15/2007
09/15/2007
09/15/2007
09/15/2007
09/15/2007
09/15/2007
09/15/2007
09/15/2007
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
1 EA GC IJ
EA
250 MG
11/05/2007
99/99/9999
1 EA GC IJ
100 EA BO PO
500 EA BO PO
EA
EA
EA
250 MG
50 MG
50 MG
8
1
1
11/05/2007
05/01/2007
05/01/2007
99/99/9999
99/99/9999
99/99/9999
100 EA BO
PO
EA
12.5 MG
12/01/2005
99/99/9999
1000 EA BO
PO
EA
12.5 MG
02/27/2007
99/99/9999
100 EA BO
PO
EA
25 MG
12/01/2005
99/99/9999
VL
VL
VL
VL
VL
VL
VL
VL
VL
1000 EA BO
PO
EA
25 MG
02/27/2007
99/99/9999
100 EA BO
PO
EA
250 MG
05/04/2009
99/99/9999
500 EA
21 EA
10 EA
25 EA
15 EA
BO
DP
DP
BO
BO
PO
PO
PO
PO
PO
EA
EA
EA
EA
EA
250 MG
4 MG
4 MG
5 MG
5 MG
2
1
4
4
2
05/04/2009
03/26/2004
05/29/2008
03/26/2004
07/23/2008
99/99/9999
99/99/9999
99/99/9999
99/99/9999
99/99/9999
30 EA BO
PO
EA
50 MG
03/01/2007
99/99/9999
30 EA BO
PO
EA
50 MG
03/01/2007
99/99/9999
12 EA BO
PO
EA
25 MG
03/08/2006
99/99/9999
30 EA BO
PO
EA
25 MG
05/01/2006
99/99/9999
60 EA BO
PO
EA
25 MG
05/04/2007
99/99/9999
90 EA BO
PO
EA
25 MG
05/01/2006
99/99/9999
30 EA BO
6 EA BX
PO
PO
EA
EA
50 MG
1 GM
0.5
0.25
05/01/2006
05/01/2006
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
68462-0105-30
Q0179
6/25/2007
68462-0106-30
Q0179
6/25/2007
68462-0157-13
Q0179
6/27/2007
68462-0158-11
Q0179
6/27/2007
68462-0158-13
Q0179
6/27/2007
68516-1612-01
Q9943
4/1/2005
68516-1612-01
J1567
1/1/2006
68516-1613-01
Q9943
4/1/2005
68516-1613-01
J1567
1/1/2006
68516-1614-01
Q9943
4/1/2005
68516-1614-01
J1567
1/1/2006
68516-1622-01
Q9943
4/1/2005
68516-1622-01
J1567
1/1/2006
68516-1623-01
Q9943
4/1/2005
68516-1623-01
J1567
1/1/2006
68516-1624-01
Q9943
4/1/2005
68516-1624-01
J1567
1/1/2006
68516-3200-02
J7194
7/25/2003
68516-3200-03
J7194
7/25/2003
68516-3600-02
J7193
7/25/2003
68516-4600-01
Q4096
4/1/2008
68516-4600-01
J7186
1/1/2009
68516-4600-02
Q4096
4/1/2008
68516-4600-02
J7186
1/1/2009
68516-4601-01
Q4096
4/1/2008
68516-4601-01
J7186
1/1/2009
68516-4602-01
Q4096
4/1/2008
68516-4602-01
J7186
1/1/2009
68516-4603-02
Q4096
4/1/2008
68516-4603-02
J7186
1/1/2009
68516-4604-02
Q4096
4/1/2008
68516-4604-02
68546-0317-30
68727-0200-02
68782-0001-01
68782-0001-01
68817-0134-50
68817-0134-50
68830-0319-80
J7186
J1595
J1451
J3490
J2503
J9265
J9264
J0636
1/1/2009
4/28/2008
11/9/2006
1/1/2005
1/1/2006
2/8/2005
1/1/2006
9/17/2003

(FILM-COATED) 4 MG
(FILM-COATED) 8 MG
VENOGLOBULIN-S 5% (2.5GM
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), VENOGLOBULIN-S 5% (2.5GM
6/28/2007 500 MG
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), VENOGLOBULIN-S 5% (5
6/28/2007 500 MG
6/28/2007 500 MG
6/28/2007 500 MG
6/28/2007 500 MG
6/28/2007 500 MG
PROFILNINE SD (APPROX. 500 IU/VIAL) 1
IU
PROFILNINE SD (APPROX 10004/30/2009 FACTOR IX, COMPLEX, PER I.U.
1500IU/VIAL) 1 IU
ALPHANINE SD (250-1500 FIX I.U/VIAL) 1
6/30/2008 FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.
IU
12/31/2008 COFACTOR (NOT OTHERWISE SPECIFIED), PER I.U. VWF:RCO
INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX
5/14/2009 (HUMAN), PER FACTOR VIII I.U.
IU
IU
ALPHANATE (SINGLE DOSE,250IU/5ML)
1 IU-1 IU
1 IU-1 IU
1 IU-1 IU
1 IU-1 IU
ALPHANATE (SINGLE
DOSE,1000IU/10ML) 1 IU-1 IU
ALPHANATE (SINGLE
ALPHANATE (SINGLE
ALPHANATE (SINGLE
COPAXONE 20 MG/ML
ANTIZOL (4X1.5ML,PF) 1 GM/ML
MACUGEN (PF) 0.3 MG/0.09 ML
99/99/9999 INJECTION, PEGAPTANIB SODIUM, 0.3 MG
MACUGEN (PF) 0.3 MG/0.09 ML
ABRAXANE 100 MG
99/99/9999 INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG
ABRAXANE 100 MG
CALCITRIOL 1 MCG/ML
Page 372 of 374
30 EA BO
PO
EA
8 MG
0.5
06/25/2007
99/99/9999
30 EA BO
PO
EA
8 MG
06/25/2007
99/99/9999
30 EA BX
PO
EA
8 MG
0.5
06/27/2007
99/99/9999
30 EA BX
PO
EA
8 MG
06/27/2007
99/99/9999
10 EA BX
PO
EA
8 MG
06/27/2007
99/99/9999
50 ML VL
IV
ML
1 GM
0.05
04/01/2005
12/31/2005
50 ML VL
IV
ML
500 MG
0.1
01/01/2006
06/28/2007
100 ML VL
IV
ML
1 GM
0.05
04/01/2005
12/31/2005
100 ML VL
IV
ML
500 MG
0.1
01/01/2006
06/28/2007
200 ML VL
IV
ML
1 GM
0.05
04/01/2005
12/31/2005
200 ML VL
IV
ML
500 MG
0.1
01/01/2006
06/28/2007
50 ML VL
IV
ML
1 GM
0.1
04/01/2005
12/31/2005
50 ML VL
IV
ML
500 MG
0.2
01/01/2006
06/28/2007
100 ML VL
IV
ML
1 GM
0.1
04/01/2005
12/31/2005
100 ML VL
IV
ML
500 MG
0.2
01/01/2006
06/28/2007
200 ML VL
IV
ML
1 GM
0.1
04/01/2005
12/31/2005
200 ML VL
IV
ML
500 MG
0.2
01/01/2006
06/28/2007
500 IU
VL
IV
EA
1 IU
07/25/2003
99/99/9999
1250 IU
VL
IV
EA
1 IU
07/25/2003
4/30/2009
850 IU
VL
IV
EA
1 IU
07/25/2003
6/30/2008
500 IU
VL
IV
EA
1 IU
04/01/2008
12/31/2008
500 IU
VL
IV
IU
1 IU
01/01/2009
5/14/2009
1500 IU
VL
IV
EA
1 IU
04/01/2008
12/31/2008
1500 IU
VL
IV
IU
1 IU
01/01/2009
5/29/2009
1 EA VL
IV
EA
1 IU
04/01/2008
12/31/2008
VL
IV
IU
1 IU
01/01/2009
99/99/9999
1 EA VL
IV
EA
1 IU
04/01/2008
12/31/2008
IV
IU
1 IU
01/01/2009
99/99/9999
250 IU
500 IU
VL
1 EA VL
1000 IU
VL
1 EA VL
1500 IU
1 ML
1.5 ML
0.09 ML
0.09 ML
1 EA
1 EA
1 ML
VL
DP
VL
SR
SR
VL
VL
NA
IV
EA
1 IU
04/01/2008
12/31/2008
IV
IU
1 IU
01/01/2009
99/99/9999
IV
EA
1 IU
IV
MR
IV
IO
IO
IV
IV
IV
IU
EA
ML
ML
ML
EA
EA
ML
1 IU
20 MG
15 MG
1 EA
0.3 MG
30 MG
1 MG
0.1 MCG
04/01/2008
12/31/2008
1
30
66.66666
1
11.11111
3.33333
100
10
01/01/2009
04/28/2008
11/09/2006
01/01/2005
01/01/2006
02/08/2005
01/01/2006
09/17/2003
99/99/9999
99/99/9999
99/99/9999
12/31/2005
99/99/9999
12/31/2005
99/99/9999
99/99/9999
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
68883-0010-03
J1642
68883-0010-05
J1642
68883-0010-06
J1642
68883-0100-03
J1642
68883-0100-04
J1642
68883-0100-05
J1642
68883-0100-06
J1642
68883-0900-01
J2912
68883-0900-01
A4216
68883-0900-03
J2912
68883-0900-03
A4216
68883-0900-04
J2912
68883-0900-04
A4216
68883-0900-05
J2912
68883-0900-05
A4216
68883-0900-10
J2912
68883-0900-10
A4216
68883-0900-16
J2912
68883-0900-16
A4216
74300-0001-33
Q0163
74300-0006-10
Q0163
74300-0006-11
Q0163
74300-0013-30
Q0163
74300-0061-00
Q0163
74300-0061-10
Q0163
75137-0212-03
Q0163
75137-0212-12
Q0163
75137-0212-15
Q0163
75137-2120-30
Q0163

1/1/2002
HEPARIN LOCK FLUSH (IN 6ML SD

SYRINGE,PF) 10 U/ML
SYRINGE,PF) 10 U/ML
SYRINGE,PF) 10 U/ML
SYRINGE,PF) 100 U/ML
SODIUM CHLORIDE FLUSH (IN 3ML SD
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
SYRINGE,PF) 0.9%
3 ML SR
IV
ML
10 U
01/05/2006
99/99/9999
5 ML SR
IV
ML
10 U
01/05/2006
99/99/9999
2.5 ML SR
IV
ML
10 U
01/05/2006
99/99/9999
3 ML SR
IV
ML
10 U
10
01/05/2006
99/99/9999
3 ML SR
IV
ML
10 U
10
01/05/2006
99/99/9999
5 ML SR
IV
ML
10 U
10
01/05/2006
99/99/9999
5 ML SR
IV
ML
10 U
10
01/05/2006
99/99/9999
2.5 ML SR
IV
ML
0.9 %
0.5
01/05/2006
12/31/2006
2.5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
0.9 %
0.5
01/05/2006
12/31/2006
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
0.9 %
0.5
01/05/2006
12/31/2006
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
5 ML SR
IV
ML
0.9 %
0.5
01/05/2006
12/31/2006
5 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
10 ML SR
IV
ML
0.9 %
0.5
01/05/2006
12/31/2006
10 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
3 ML SR
IV
ML
0.9 %
0.5
01/05/2006
12/31/2006
3 ML SR
IV
ML
10 ML
0.1
01/01/2007
99/99/9999
UNISOM SLEEPGELS MAXIMUM

32 EA NA
PO
EA
50 MG
01/01/2002
12/21/2006

8 EA PK
PO
EA
50 MG
01/01/2002
12/21/2006

16 EA NA
PO
EA
50 MG
01/01/2002
12/21/2006

32 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999

8 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999

16 EA BX
PO
EA
50 MG
01/01/2002
99/99/9999
COMPOZ NIGHTTIME SLEEP AID 50 MG
12 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
24 EA BO
PO
EA
50 MG
01/01/2002
09/01/2003
COMPOZ NIGHTTIME SLEEP AID

(GELCAPLET) 50 MG
16 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
12 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999
Page 373 of 374
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC
75137-2121-20
Q0163
1/1/2002
75137-2121-50
Q0163
1/1/2002
82468-0113-16
83490-0107-60
88395-0067-64
88395-0676-40
Q0163
A4216
J1955
J1955
4/19/2004
10/1/2007
9/3/2003
9/3/2003

24 EA BO
PO
EA
50 MG
01/01/2002
09/01/2003
COMPOZ NIGHTTIME SLEEP AID

(GELCAPLET) 50 MG
16 EA BO
PO
EA
50 MG
01/01/2002
99/99/9999

HYPER-SAL (4MLX60,PF) 7%
L-CARNITINE
L-CARNITINE
24 EA
4 ML
1 EA
1 EA
PO
IH
PO
PO
EA
ML
GM
GM
50 MG
10 ML
1 GM
1 GM
0.5
0.1
1
1
04/19/2004
10/01/2007
09/03/2003
09/03/2003
99/99/9999
99/99/9999
9/1/2008
99/99/9999
Page 374 of 374
NA
PC
NA
BO
Prior End Date #3
Prior Start Date #3
Prior End Date #2
Prior Start Date #2
End Date #1
Start Date #1
CF
HCPCS Measure #1
HCPCS Amount #1
Billing Units
NDC Package Type
NDC Package Measure

Package
NDC Label
HCPCS Description
HCPCS Mod
HCPCS
NDC Mod
NDC

NDC 2010

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

NDC 2010

Загружено:

Авторское право:

Доступные форматы

00002-0501-01

3/13/2002 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG

3/28/2003 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG

3/28/2003 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG

3/1/2006 99/99/9999 INJECTION, SOMATROPIN, 1 MG

Published by PDAC 01/05/2010

3/28/2003 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG

3/14/2003 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG

NEBCIN PEDIATRIC (M.D.V.) 10 MG/ML

NEBCIN (BULK VIAL) 1.2 GM

NEBCIN (BULK VIAL) 1.2 GM

NEBCIN (BULK VIAL) 1.2 GM

NEBCIN (BULK VIAL) 1.2 GM

Prior Conversion Factor #3

Prior End Date #3

Prior Start Date #3

Prior Conversion Factor #2

Prior End Date #2

Prior Start Date #2

NDC Package Type

NDC Package Measure

Number of Items in NDC

Relationship End Date

Relationship Start Date

01-05-2010 NDC-HCPCS XWalk

Noridian Administrative Services

1/1/2002 99/99/9999 INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG

1/1/2002 11/11/2005 INJECTION, SOMATROPIN, 1 MG

8/30/2005 99/99/9999 INJECTION, SOMATROPIN, 1 MG

8/30/2005 99/99/9999 INJECTION, SOMATROPIN, 1 MG

8/30/2005 99/99/9999 INJECTION, SOMATROPIN, 1 MG

1/1/2002 12/31/2002 INJECTION, INSULIN, UP TO 100 UNITS

1/1/2002 12/31/2002 INJECTION, INSULIN, UP TO 100 UNITS

12/31/2002 INJECTION, INSULIN, UP TO 100 UNITS

6/3/2005 INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG

11/7/2005 INJECTION, SOMATROPIN, 1 MG

4/1/2006 INJECTION, INSULIN, PER 5 UNITS

99/99/9999 INJECTION, INSULIN, PER 5 UNITS

1/1/2002 12/31/2002 INJECTION, INSULIN, UP TO 100 UNITS

1/1/2003 99/99/9999 INJECTION, INSULIN, PER 5 UNITS

1/1/2002 12/31/2002 INJECTION, INSULIN, UP TO 100 UNITS

1/1/2003 99/99/9999 INJECTION, INSULIN, PER 5 UNITS

1/1/2002 12/31/2002 INJECTION, INSULIN, UP TO 100 UNITS

1/1/2003 99/99/9999 INJECTION, INSULIN, PER 5 UNITS

1/20/2006 99/99/9999 INJECTION, INSULIN, PER 5 UNITS

1/1/2003 99/99/9999 INJECTION, INSULIN, PER 5 UNITS

12/10/2007 99/99/9999 INJECTION, INSULIN, PER 5 UNITS

3/13/2002 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG

8/12/2003 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG

6/5/2003 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG

3/28/2003 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG

3/28/2003 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG

3/28/2003 INJECTION, CEFAZOLIN SODIUM, 500 MG

Published by PDAC 01/05/2010

1/1/2002 12/31/2002 INJECTION, INSULIN, UP TO 100 UNITS

99/99/9999 INJECTION, INSULIN, PER 5 UNITS

HUMALOG (CARTRIDGE) 100 U/ML

Prior Conversion Factor #3

Prior End Date #3

Prior Start Date #3

Prior Conversion Factor #2

Prior End Date #2

Prior Start Date #2

Number of Items in NDC