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 MEDICATIONS FEE SCHEDULE ONCOLOGY 01/01/2018 Page 1 of 5 CODEDESCRIPTIONMAX QTYRATECOMMENTS/NOTESINJECTABLE MEDICATIONS FEE SCHEDULE ONCOLOGY 01/01/2018J9000 DOXORUBICIN HCL J9015 ALDESLEUKIN PER SINGLE USE J9017 ARSENIC TRIOXIDE J9019 ASPARAGINASE (ERWINAZE) 1, J9022 ATEZOLIZUMAB J9025 AZACITIDINE J9027 CLOFARABINE J9031 BCG LIVE INTRAVESICAL PER INSTILLATION BCG VACCINE TICE J9032 BELINOSTAT J9033 BENDAMUSTINE HCL 1MG (TREANDA) J9034 BENDAMUSTINE HCL 1MG (BENDEKA) J9039 BLINATUMOMAB J9040 BLEOMYCIN SULFATE 15 J9041 BORTEZOMIB J9042 BRENTUXIMAB VEDOTIN J9043 CABAZITAXEL J9045 CARBOPLATIN J9047 CARFILZOMIB J9050 CARMUSTINE J9
page 5 of 5 code description max qty rate comments/notes injectable medications fee schedule oncology 01/01/2018 j9354 ado-trastuzumab emtansine 1mg 400 29.00
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