Transcription of INJECTABLE MEDICATIONS FEE SCHEDULE …
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INJECTABLE MEDICATIONS FEE SCHEDULE …
CODEDESCRIPTIONMAX QTYRATECOMMENTS/NOTESC9492 DURVALUMAB J0594 BUSULFAN J0640 LEUCOVORIN CALCIUM J0641 LEVOLEUCOVORIN CALCIUM J0881 DARBEPOETIN ALFA NON-ESRD USEJ0882 DARBEPOETIN ALFA ESRD ON DIALYSISJ0885 EPOETIN ALFA 1,000 NON-ESRD USEJ0894 DECITABINE J0897 DENOSUMAB J1050 MEDROXYPROGESTERONE ACETATE 1MG1, J1190 DEXRAZOXANE HCL J1260 DOLASETRON MESYLATE G-CSF J1447 TBO FILGRASTIM J1453 FOSAPREPITANT J1457 GALLIUM NITRATE HYDROCHLORIDE J1640 HEMIN J1930 LANREOTIDE J2355 OPRELVEKIN HCL J2430 PAMIDRONATE DISODIUM PER J2469 PALONOSETRON J2505 PEGFILGRASTIM 6MG15, J2562 PLERIXAFOR J2783 RASBURICASE J2820 SARGRAMOSTIM (GM-CSF) J3240 THYROTROPIN ALPHA J3315 TRIPTORELIN PAMOATE J3489 ZOLEDRONIC ACID INJECTABLE MEDICATIO
page 4 of 5 code description max qty rate comments/notes injectable medications fee schedule oncology 01/01/2018 j9230 mechlorethamine hcl (nitrogen mustard)10mg5 259.80 j9245 melphalan hydrochloride 50mg 1 1487.88
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