INJECTABLE MEDICATIONS FEE SCHEDULE …
CODEDESCRIPTIONMAX QTYRATECOMMENTS/NOTESC9492DURVALUMAB J0594BUSULFAN J0640LEUCOVORIN CALCIUM J0641LEVOLEUCOVORIN CALCIUM J0881DARBEPOETIN ALFA NON-ESRD USEJ0882DARBEPOETIN ALFA ESRD ON DIALYSISJ0885EPOETIN ALFA 1,000 NON-ESRD USEJ0894DECITABINE J0897DENOSUMAB J1050MEDROXYPROGESTERONE ACETATE 1MG1, J1190DEXRAZOXANE HCL J1260DOLASETRON MESYLATE G-CSF J1447TBO FILGRASTIM J1453FOSAPREPITANT J1457GALLIUM NITRATE HYDROCHLORIDE J1640HEMIN J1930LANREOTIDE J2355OPRELVEKIN HCL J2430PAMIDRONATE DISODIUM PER J2469PALONOSETRON J2505PEGFILGRASTIM 6MG15, J2562PLERIXAFOR J2783RASBURICASE J2820SARGRAMOSTIM (GM-CSF) J3240THYROTROPIN ALPHA J3315TRIPTORELIN PAMOATE J3489ZOLEDRONIC ACID INJECTABLE MEDICATIONS FEE SCHEDULE ONCOLOGY 01/01/2018Page 1 of 5CODEDESCRIPTIONMAX QTYRATECOMMENTS/NOTESINJECTABLE MEDICATIONS FEE SCHEDULE ONCOLOGY 01/01/2018J9000DOXORUBICIN HCL J9015ALDESLEUKIN PER SINGLE USE J9017ARSENIC TRIOXIDE J9019ASPARAGINASE (ERWINAZE) 1, J9022ATEZOLIZUMAB J9025AZACITIDINE J9027CLOFARABINE J9031BCG LIVE INTRAVESICAL PER
code description max qty rate comments/notes injectable medications fee schedule oncology 01/01/2018 j9151 daunorubicin citrate, liposomal formulation
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