Procedure Procedure Code Desc Pricing …

1 Physician Administered Drugs Current CrosswalkProcedure CodeProcedure code DescProcedure RatePricing DescriptionQ4100 Skin substitute, NOS0 Manual PriceQ4112 Cymetra Fee ScheduleQ4114 Integra flowable wound Fee ScheduleJ9202 GOSERELIN ACETATE IMPLANT PER Fee ScheduleJ8530 CYCLOPHOSPHAMLIDE; ORAL, Fee ScheduleJ2310 INJ NALOXONE HCL PER Fee ScheduleJ1602 Golimumab for iv use Fee ScheduleJ1720 INJ., HYDROCORTISONE SOD SUCCINATE, Fee ScheduleJ1120 INJ., ACETAZOLAMIDE SODIUM, UP TO 500 Fee ScheduleJ9600 Porfimer sodium Fee ScheduleS4993 CONTRACEPTIVE PILLS FOR Fee ScheduleJ7040 INFUSION, NORMAL SALINE SOLUTION, 500 Fee ScheduleJ3411 Thiamine hcl 100 Fee ScheduleJ3490 UNCLASSIFIED DRUGS0 Manual PriceJ0745 INJECTION.

2 CODEINE Fee ScheduleJ7306 Levonorgestrel implant sys0 Manual PriceJ7599 IMMUNOSUPPRESSIVE DRUG NOC0 Manual PriceJ7635 Atropine comp con0 Manual PriceJ7638 Dexamethasone comp unit0 Manual PriceS0088 Imatinib 100 Fee ScheduleS0093 Morphine 500 Fee ScheduleJ0190 INJ., BIPERIDEN, 2 Fee ScheduleS0169 Calcitrol0 Manual PriceQ0180 DOLASETRON MESYLATE, 100 MG, Fee ScheduleJ3315 Triptorelin Fee ScheduleJ1230 INJ., METHADONE HCL, UP TO 10 Fee ScheduleJ7683 Triamcinolone comp con0 Manual PriceJ8520 Capecitabine, oral, 150 Fee ScheduleJ9155 Degarelix Fee ScheduleJ1940 INJ.

3 , FUROSEMIDE, UP TO 20 Fee ScheduleJ2793 Rilonacept injection0 Manual PriceJ7515 Cyclosporine oral 25 Fee ScheduleJ9070 CYCLOPHOSPHAMIDE Fee ScheduleS4989 Contracept Fee ScheduleJ1559 Hizentra Fee ScheduleJ7310 CANCICLOVIR LONG-ACT Fee ScheduleJ2920 INJ METHYLPREDNISOLN SOD SUC UP TO Fee ScheduleJ9310 Rituximab Fee ScheduleJ1020 INJ., METHYLPREDNISOLONE ACETATE, 20 Fee ScheduleJ7620 Albuterol ipratrop Fee ScheduleS0074 Injection, cefotetan Fee ScheduleJ0153 Adenosine inj 1mg0 Manual PriceJ2562 Plerixafor Fee ScheduleJ2997 Alteplase Fee ScheduleQ0515 Sermorelin acetate Fee ScheduleJ3320 INJ.

4 , SPECTINOMYCIN DIHYDROCHLORIDE, Fee ScheduleJ3350 INJ., UREA, UP TO 40 Fee ScheduleData - November 2015 Physician Administered Drugs Current CrosswalkJ7676 Pentamidine comp unit dose0 Manual PriceJ8515 Cabergoline, oral Fee Fee ScheduleQ4119 Matristem wound matrix0 Manual PriceQ2049 Imported Lipodox Fee Fee ScheduleJ1212 Dimethyl sulfoxide 50% 50 Fee ScheduleJ9178 Inj, epirubicin hcl, 2 Fee ScheduleJ1930 Lanreotide Fee ScheduleJ2278 Ziconotide Fee ScheduleJ1655 Tinzaparin sodium Fee ScheduleJ1327 Eptifibatide Fee ScheduleJ1335 Ertapenem Fee ScheduleJ9100 Cytarabine hcl 100 MG Fee ScheduleJ3489 Zoledronic acid Fee ScheduleJ0744 Ciprofloxacin Fee ScheduleJ1557 Gammaplex Fee ScheduleJ1561 Gamunex- Fee ScheduleJ7312 Dexamethasone intra Fee ScheduleJ7627 Budesonide comp unit0 Manual PriceJ3262 Tocilizumab Fee ScheduleQ0139 Ferumoxytol.

5 Esrd Fee ScheduleJ1100 Dexamethasone sodium Fee ScheduleS0176 Hydroxyurea 500 mg0 Manual PriceJ3303 INJ TRIAMCINOLONE HEXACETONIDE PER Fee ScheduleJ0735 INJ CLONIDINE HCL Fee ScheduleJ1160 INJECTION, DIGOXIN, UP TO Fee ScheduleJ1240 INJ., DIMENHYDRINATE, UP TO 50 Fee ScheduleJ0287 Amphotericin b lipid Fee ScheduleJ9120 Dactinomycin Fee ScheduleJ2710 INJ., NEOSTIGMINE METHYLSULFATE, TO Fee ScheduleJ1745 Infliximab Fee ScheduleJ0390 INJ., CHLOROQUINE HCL, UP TO 50 Fee ScheduleJ7520 Sirolimus, Fee ScheduleJ3410 INJ., HYDROXYZINE HCL, UP TO 25 Fee ScheduleJ1562 Vivaglobin, Fee ScheduleJ9020 Asparaginase, Fee ScheduleJ7178 Human fibrinogen conc inj0 Manual PriceJ7181 Factor xiii recomb a-subunit0 Manual PriceJ7191 Factor viii (porcine) Fee ScheduleJ7613 Albuterol non-comp Fee ScheduleJ7641 Flunisolide comp unit0 Manual PriceS0078 Injection, fosphenytoin Fee ScheduleJ0135 Adalimumab Fee ScheduleJ1756 Iron sucrose Fee ScheduleJ9213 Interferon alfa-2a Fee Fee ScheduleJ1170 INJ.

6 , HYDROMORPHONE, UP TO 4 Fee ScheduleJ0330 INJ., SUCCINYCHOLINE CHLORIDE, TO 20 Fee ScheduleData - November 2015 Physician Administered Drugs Current CrosswalkJ0360 INJ., HYDRALAZINE HCL, UP TO 20 Fee ScheduleJ7686 Treprostinil, non-comp Fee ScheduleJ7699 Inhalation solution for DME0 Manual PriceJ1955 INJ LEVOCARNITINE PER Fee ScheduleQ9956 Inj octafluoropropane mic, Fee ScheduleJ1595 Injection glatiramer acetate0 Manual PriceJ1630 INJECTION, HALDOL, UP TO 5 Fee ScheduleJ1645 Dalteparin Fee ScheduleJ1742 INJ IBUTILIDE FUMARATE Fee ScheduleJ7665 Mannitol for inhaler0 Manual PriceJ1325 EPO PROSTENOL Fee ScheduleS5000 Prescription drug, generic0 Manual PriceJ3420 INJ.

7 , VIT B-12, CYANOCOBALAMIN, TO Fee ScheduleJ0897 Denosumab Fee ScheduleJ7070 INFUSION, D5W, 1,000 Fee ScheduleJ7632 Cromolyn sodium comp unit0 Manual PriceJ9270 Plicamycin (mithramycin) Fee ScheduleJ2505 Injection, pegfilgrastim Fee ScheduleJ2510 INJ., PENICILLIN G PROCAINE, AQUEOUS Fee ScheduleJ9215 Interferon alfa-n3 Fee ScheduleJ9150 Daunorubicin Fee ScheduleJ9175 Elliotts b solution per Fee ScheduleJ7681 Terbutaline sulf comp unit0 Manual PriceQ9959 HOCM 150-199 mg/ml iodine, 1 Fee ScheduleJ1599 Ivig non-lyophilized, NOS0 Manual PriceJ1626 Granisetron hcl Fee ScheduleJ1710 INJ.

8 , HYDROCORTISONE SOD PHOSPHATE, 50 Fee ScheduleJ0461 Atropine sulfate Fee ScheduleJ0475 INJECTION BACLOFEN Fee ScheduleJ7505 Monoclonal Fee ScheduleJ7508 Tacrolimus Fee ScheduleJ7647 Isoetharine comp con0 Manual PriceJ7189 Factor Fee Fee ScheduleJ2545 Pentamidine non-comp Fee Fee ScheduleJ1810 INJ., DROPERIDOL & FENTANYL CITR, 2ML Fee ScheduleJ9245 INJ MELPHALAN HCL Fee ScheduleQ4105 Integra Fee ScheduleJ9206 Irinotecan Fee ScheduleJ1205 INJ., CHLOROTHIAZIDE Fee ScheduleJ8501 Oral Fee ScheduleJ9179 Eribulin mesylate Fee ScheduleJ1950 Arthrodesis Anterior interbody Fee ScheduleJ0597C-1 esterase, Fee ScheduleJ7509 METHYLPREDNISOLONE ORAL PER Fee ScheduleJ2426 Paliperidone palmitate Fee ScheduleJ3480 INJ POTASSIUM CHL PER Fee ScheduleJ1556 Inj, imm glob bivigam, Fee ScheduleData - November 2015 Physician Administered Drugs Current CrosswalkJ9040 Bleomycin sulfate Fee ScheduleJ1450 INJECTION FLUCONAZOLE.

9 200 Fee ScheduleJ7199 Hemophilia clot factor noc0 Manual PriceJ1000 INJECTION, DEPO-ESTRADIOL CYPIONATE, Fee ScheduleJ7607 Levalbuterol comp con0 Manual PriceS0077 Injection, clindamycin Fee ScheduleS0092 Hydromorphone 250 Fee ScheduleJ0133 Acyclovir Fee ScheduleJ0180 AGALSIDASE BETA, 1 Fee ScheduleJ9266 Pegaspargase Fee ScheduleJ2590 INJ., OXYTOCIN, UP TO 10 Fee ScheduleQ0175 PERPHENZAINE, 4 MG, Fee Fee ScheduleJ2700 Oxacillin sodium Fee Fee ScheduleJ1110 INJ., DEHYDROERGOTAMINE, UP TO 1 Fee ScheduleJ1290 INJECTION ECALLANTIDE 1 Fee ScheduleJ1410 INJ.

10 , ESTROGEN CONJUGATED, 2MG OR Fee ScheduleJ7649 Isoetharine non-comp Fee ScheduleS50135% dextrose/45%saline,1000ml0 Manual PriceJ1455 Foscarnet sodium Fee ScheduleJ7300 INTRAUTERINE COPPER CONTRACEPTIVE (T38A) Fee ScheduleJ0945 INJ., BROMPHENIRAMINE Fee ScheduleJ7605 Arformoterol non-comp Fee ScheduleS0119 Ondansetron 4 mg0 Manual PriceJ0256 Alpha 1 proteinase Fee ScheduleJ2507 Pegloticase Fee ScheduleJ2560 INJ., PHENOBARBITAL SODIUM, TO 120 Fee ScheduleJ3095 Televancin Fee ScheduleJ0574 Buprenorph/nalox to Fee ScheduleJ3360 INJ.