Fee* Effective CPT Code Short Description 02/15/2017hp/@public/...90633 hep a vacc, ped/adol, 2 dose...

CPT Code Short Description

Fee* Effective

02/15/2017

90281 HUMAN IG, IM $70.38

90283 HUMAN IG, IV $45.14

90284 HUMAN IG, SC $11.48

90291 CMV IG, IV $1,311.21

90371 HEP B IG, IM $131.58

90375 RABIES IG, IM/SC $307.53

90376 RABIES IG, HEAT TREATED $368.73

90378 RSV IG, IM, 50MG $1,498.64

90384 RH IG, FULL-DOSE, IM $77.27

90385 RH IG, MINIDOSE, IM $29.84

90386 RH IG, IV $10.71

90389 TETANUS IG, IM $466.65

90581 ANTHRAX VACCINE, SC $101.75

90585 BCG VACCINE, PERCUT $148.41

90586 BCG VACCINE, INTRAVESICAL $148.41

90620 MENB RP W/OMV VACCINE IM $164.48

90621 MENB RLP VACCINE IM $125.46

90625 CHOLERA VACCINE LIVE ORAL $229.50

90630 FLU VACC IIV4 NO PRESERV ID $18.36

90632 HEP A VACCINE, ADULT IM $65.03

90633 HEP A VACC, PED/ADOL, 2 DOSE $31.37

90636 HEP A/HEP B VACC, ADULT IM $97.92

90644 MENINGOCCL HIB VAC 4 DOSE IM $25.25

90647 HIB VACCINE, PRP-OMP, IM $26.01

90648 HIB VACCINE, PRP-T, IM $10.71

90649 H PAPILLOMA VACC 3 DOSE IM $163.71

90650 H PAPILLOMA VACC 3 DOSE IM $135.41

90651 HPV VACCINE NON VALENT IM $198.14

90653 FLU VACCINE ADJUVANT IM $33.66

90654 FLU VACCINE NO PRESERV, INTRADERMAL $17.60

90656 FLU VACCINE NO PRESERV 3 & >, TRIVALENT $16.07

90658 FLU VACCINE AGE 3 & OVER, IM, TRIVALENT $15.30

90662 FLU VACCINE, NO PRESERV, ENHANCED IMMUNO $39.02

90670 PNEUMOCOCCAL CONJ VACC, 13 VALENT $172.89

90672 FLU VACCINE 4 VALENT NASAL $24.48

90673 FLU VACCINE, RIV3 PRSV FREE $37.49

90674 CCIIV4 VAC NO PRSV 0.5 ML IM $20.66

90675 RABIES VACCINE, IM $309.83

90680 ROTOVIRUS VACC 3 DOSE, ORAL $83.39

90681 ROTOVIRUS VACC 2 DOSE, ORAL $112.46

90685 FLU VAC NO PRSV 4 VAL 6-35 M $23.72

90686 FLU VAC NO PRSV 4 VAL 3 YRS+ $17.60

90687 FLU VACCINE 4 VAL 6-35 MO IM $9.18

90688 FLU VACC 4 VAL 3YRS PLUS IM $16.83

This list includes injectable and immunization fees that are changing effective 02/15/2017.

Not Otherwise Classified codes (i.e. J3490) will be reimbursed at AWP-15%.

*Fees include 2% MN Care Tax where appropriate

1/16/2017


Fee* Effective

02/15/2017

90690 TYPHOID VACCINE, ORAL $66.56

90691 TYPHOID VACCINE, IM $65.79

90696 DTAP-IPV VACCINE, IM $50.88

90698 DTAP-HIB-IP VACCINE, IM $91.80

90700 DTAP VACCINE, < 7 YRS, IM $22.95

90702 DT VACCINE < 7, IM $26.01

90707 MMR VACCINE, SC $68.85

90710 MMRV VACCINE, SC $195.08

90713 POLIOVIRUS, IPV, SC/IM $32.13

90714 TD VACCINE NO PRSRV >/= 7 IM $22.95

90715 TDAP VACCINE >7 IM $39.78

90716 CHICKEN POX VACCINE, SC $117.81

90717 YELLOW FEVER VACCINE, SC $143.82

90723 DTAP-HEP B-IPV VACCINE, IM $74.21

90732 PNEUMOCOCCAL VACCINE $88.74

90733 MENINGOCOCCAL VACCINE, SC $126.23

90734 MENINGOCOCCAL VACCINE, IM $115.52

90736 ZOSTER VACC, SC $201.20

90738 INACTIVATED JE VACC IM $248.63

90740 HEPB VACC, ILL PAT 3 DOSE IM $169.45

90743 HEP B VACC, ADOL, 2 DOSE, IM $60.44

90744 HEPB VACC PED/ADOL 3 DOSE IM $23.72

90746 HEP B VACCINE, ADULT, 3 DOSE IM $55.85

90747 HEPB VACC, ILL PAT 4 DOSE IM $110.93

90748 HEP B/HIB VACCINE, IM $43.61

A9575 INJ GADOTERATE MEGLUMI 0.1ML $0.38

A9576 INJ PROHANCE MULTIPACK $1.53

A9577 INJ MULTIHANCE $2.30

A9578 INJ MULTIHANCE MULTIPACK $2.30

A9579 GAD-BASE MR CONTRAST NOS,1ML $1.91

A9581 GADOXETATE DISODIUM INJ $14.54

A9583 GADOFOSVESET TRISODIUM INJ $19.13

A9585 GADOBUTROL INJECTION $0.38

J0129 ABATACEPT INJECTION $48.20

J0130 ABCIXIMAB INJECTION $1,203.73

J0132 ACETYLCYSTEINE INJECTION $1.53

J0133 ACYCLOVIR INJECTION $0.38

J0135 ADALIMUMAB INJECTION $953.57

J0153 ADENOSINE INJ 1MG $0.77

J0171 ADRENALIN EPINEPHRINE INJECT $0.38

J0178 AFLIBERCEPT INJECTION $1,028.16

J0180 AGALSIDASE BETA INJECTION $172.89

J0202 INJECTION, ALEMTUZUMAB $1,836.38

J0207 AMIFOSTINE $432.23




1/16/2017


Fee* Effective

02/15/2017

J0221 LUMIZYME INJECTION $167.54

J0256 ALPHA 1 PROTEINASE INHIBITOR $4.97

J0257 GLASSIA INJECTION $4.59

J0278 AMIKACIN SULFATE INJECTION $1.91

J0280 AMINOPHYLLIN 250 MG INJ $9.56

J0285 AMPHOTERICIN B $31.75

J0287 AMPHOTERICIN B LIPID COMPLEX $15.30

J0289 AMPHOTERICIN B LIPOSOME INJ $20.66

J0290 AMPICILLIN 500 MG INJ $1.15

J0295 AMPICILLIN SODIUM PER 1.5 GM $3.06

J0348 ANIDULAFUNGIN INJECTION $0.38

J0360 HYDRALAZINE HCL INJECTION $4.97

J0401 INJ ARIPIPRAZOLE EXT REL 1MG $4.97

J0456 AZITHROMYCIN $3.44

J0461 ATROPINE SULFATE INJECTION $0.38

J0470 DIMECAPROL INJECTION $47.43

J0475 BACLOFEN 10 MG INJECTION $175.57

J0476 BACLOFEN INTRATHECAL TRIAL $80.33

J0480 BASILIXIMAB $3,504.47

J0485 BELATACEPT INJECTION $4.21

J0490 BELIMUMAB INJECTION $43.99

J0500 DICYCLOMINE INJECTION $72.68

J0515 INJ BENZTROPINE MESYLATE $27.16

J0558 PENG BENZATHINE/PROCAINE INJ $8.80

J0561 PENICILLIN G BENZATHINE INJ $11.09

J0570 BUPRENORPHINE IMPLANT 74.2MG $1,342.96

J0583 BIVALIRUDIN $1.53

J0585 INJECTION,ONABOTULINUMTOXINA $6.12

J0586 ABOBOTULINUMTOXINA $8.03

J0587 INJ, RIMABOTULINUMTOXINB $12.24

J0588 INCOBOTULINUMTOXIN A $4.97

J0592 BUPRENORPHINE HYDROCHLORIDE $3.44

J0594 BUSULFAN INJECTION $39.02

J0595 BUTORPHANOL TARTRATE 1 MG $2.68

J0597 C-1 ESTERASE, BERINERT $48.96

J0598 C-1 ESTERASE, CINRYZE $58.14

J0600 EDETATE CALCIUM DISODIUM INJ $5,867.93

J0610 CALCIUM GLUCONATE INJECTION $3.83

J0630 CALCITONIN SALMON INJECTION $2,413.96

J0636 INJ CALCITRIOL PER 0.1 MCG $0.38

J0637 CASPOFUNGIN ACETATE $12.24

J0638 CANAKINUMAB INJECTION $97.16

J0640 LEUCOVORIN CALCIUM INJECTION $3.06

J0641 LEVOLEUCOVORIN INJECTION $0.77




1/16/2017


Fee* Effective

02/15/2017

J0670 INJ MEPIVACAINE HCL/10 ML $2.68

J0690 CEFAZOLIN SODIUM INJECTION $1.15

J0692 CEFEPIME HCL FOR INJECTION $2.68

J0694 CEFOXITIN SODIUM INJECTION $4.59

J0696 CEFTRIAXONE SODIUM INJECTION $0.77

J0697 STERILE CEFUROXIME INJECTION $2.68

J0698 CEFOTAXIME SODIUM INJECTION $1.53

J0702 BETAMETHASONE ACET&SOD PHOSP $6.50

J0712 CEFTAROLINE FOSAMIL INJ $2.68

J0713 INJ CEFTAZIDIME PER 500 MG $2.30

J0717 CERTOLIZUMAB PEGOL INJ 1MG $7.65

J0720 CHLORAMPHENICOL SODIUM INJEC $42.08

J0725 CHORIONIC GONADOTROPIN/1000U $25.25

J0735 CLONIDINE HYDROCHLORIDE $14.15

J0740 CIDOFOVIR INJECTION $534.35

J0743 CILASTATIN SODIUM INJECTION $7.27

J0744 CIPROFLOXACIN IV $1.53

J0770 COLISTIMETHATE SODIUM INJ $11.48

J0775 COLLAGENASE, CLOST HIST INJ $43.22

J0780 PROCHLORPERAZINE INJECTION $12.62

J0795 CORTICORELIN OVINE TRIFLUTAL $8.42

J0800 CORTICOTROPIN INJECTION $3,709.10

J0834 COSYNTROPIN CORTROSYN INJ $40.16

J0840 CROTALIDAE POLY IMMUNE FAB $2,800.67

J0850 CYTOMEGALOVIRUS IMM IV /VIAL $1,182.69

J0875 INJECTION, DALBAVANCIN $15.68

J0878 DAPTOMYCIN INJECTION $0.77

J0881 DARBEPOETIN ALFA, NON-ESRD $4.21

J0882 DARBEPOETIN ALFA, ESRD USE $4.21

J0885 EPOETIN ALFA, NON-ESRD $13.01

J0887 EPOETIN BETA ESRD USE $1.53

J0888 EPOETIN BETA NON ESRD $1.53

J0894 DECITABINE INJECTION $20.66

J0895 DEFEROXAMINE MESYLATE INJ $9.18

J0897 DENOSUMAB INJECTION $17.21

J1000 DEPO-ESTRADIOL CYPIONATE INJ $18.74

J1020 METHYLPREDNISOLONE 20 MG INJ $5.36



J1050 MEDROXYPROGESTERONE ACETATE $0.38

J1071 INJ TESTOSTERONE CYPIONATE $0.38

J1100 DEXAMETHASONE SODIUM PHOS $0.38

J1110 INJ DIHYDROERGOTAMINE MESYLT $142.29

J1120 ACETAZOLAMID SODIUM INJECTIO $20.66




1/16/2017


Fee* Effective

02/15/2017

J1160 DIGOXIN INJECTION $8.80

J1162 DIGOXIN IMMUNE FAB (OVINE) $3,188.14

J1165 PHENYTOIN SODIUM INJECTION $0.77

J1170 HYDROMORPHONE INJECTION $2.30

J1190 DEXRAZOXANE HCL INJECTION $206.55

J1200 DIPHENHYDRAMINE HCL INJECTIO $0.77

J1205 CHLOROTHIAZIDE SODIUM INJ $88.74

J1212 DIMETHYL SULFOXIDE 50% 50 ML $522.11

J1230 METHADONE INJECTION $19.89

J1240 DIMENHYDRINATE INJECTION $8.03

J1245 DIPYRIDAMOLE INJECTION $0.77

J1250 INJ DOBUTAMINE HCL/250 MG $5.74

J1265 DOPAMINE INJECTION $0.38

J1267 DORIPENEM INJECTION $0.77

J1270 INJECTION, DOXERCALCIFEROL $0.77

J1290 ECALLANTIDE INJECTION $440.26

J1300 ECULIZUMAB INJECTION $234.09

J1325 EPOPROSTENOL INJECTION $16.45

J1335 ERTAPENEM INJECTION $51.26

J1364 ERYTHRO LACTOBIONATE /500 MG $62.73

J1380 ESTRADIOL VALERATE 10 MG INJ $17.98

J1410 INJ ESTROGEN CONJUGATE 25 MG $292.23

J1430 ETHANOLAMINE OLEATE 100 MG $423.81

J1439 INJ FERRIC CARBOXYMALTOS 1MG $1.15

J1442 INJ FILGRASTIM EXCL BIOSIMIL $1.15

J1447 INJ TBO FILGRASTIM 1 MICROG $0.77

J1450 FLUCONAZOLE $4.59

J1453 FOSAPREPITANT INJECTION $1.91

J1458 GALSULFASE INJECTION $382.12

J1459 INJ IVIG PRIVIGEN 500 MG $40.55

J1460 GAMMA GLOBULIN 1 CC INJ $37.49

J1556 INJ, IMM GLOB BIVIGAM, 500MG $39.02

J1557 GAMMAPLEX INJECTION $40.93

J1559 HIZENTRA INJECTION $10.33

J1560 GAMMA GLOBULIN > 10 CC INJ $376.00

J1561 GAMUNEX-C/GAMMAKED $38.25

J1566 IMMUNE GLOBULIN, POWDER $33.66

J1568 OCTAGAM INJECTION $37.10

J1569 GAMMAGARD LIQUID INJECTION $42.08

J1570 GANCICLOVIR SODIUM INJECTION $64.64

J1571 HEPAGAM B IM INJECTION $61.58

J1572 FLEBOGAMMA INJECTION $34.43

J1575 HYQVIA 100MG IMMUNEGLOBULIN $13.77

J1580 GARAMYCIN GENTAMICIN INJ $1.53




1/16/2017


Fee* Effective

02/15/2017

J1602 GOLIMUMAB FOR IV USE 1MG $25.63

J1610 GLUCAGON HYDROCHLORIDE/1 MG $226.44

J1626 GRANISETRON HCL INJECTION $0.38

J1630 HALOPERIDOL INJECTION $0.77

J1631 HALOPERIDOL DECANOATE INJ $18.74

J1640 HEMIN, 1 MG $24.10

J1642 INJ HEPARIN SODIUM PER 10 U $0.38

J1644 INJ HEPARIN SODIUM PER 1000U $0.38

J1645 DALTEPARIN SODIUM $16.83

J1650 INJ ENOXAPARIN SODIUM $0.77

J1652 FONDAPARINUX SODIUM $2.30

J1670 TETANUS IMMUNE GLOBULIN INJ $394.74

J1720 HYDROCORTISONE SODIUM SUCC I $9.56

J1725 INJECTION HPC 1 MG (MAKENA) $3.06

J1740 IBANDRONATE SODIUM INJECTION $101.36

J1742 IBUTILIDE FUMARATE INJECTION $192.02

J1743 IDURSULFASE INJECTION $547.36

J1745 INFLIXIMAB NOT BIOSIMIL 10MG $86.06

J1750 INJ IRON DEXTRAN $13.01

J1756 IRON SUCROSE INJECTION $0.38

J1786 IMUGLUCERASE INJECTION $43.99

J1800 PROPRANOLOL INJECTION $1.91

J1815 INSULIN INJECTION $0.77

J1817 INSULIN FOR INSULIN PUMP USE $10.33

J1885 KETOROLAC TROMETHAMINE INJ $0.77

J1930 LANREOTIDE INJECTION $54.70

J1931 LARONIDASE INJECTION $32.13

J1940 FUROSEMIDE INJECTION $1.53

J1950 LEUPROLIDE ACETATE /3.75 MG $1,082.09

J1953 LEVETIRACETAM INJECTION $0.38

J1955 INJ LEVOCARNITINE PER 1 GM $21.80

J1956 LEVOFLOXACIN INJECTION $1.53

J1980 HYOSCYAMINE SULFATE INJ $29.07

J2001 LIDOCAINE INJECTION $0.38

J2010 LINCOMYCIN INJECTION $12.62

J2020 LINEZOLID INJECTION $16.83

J2060 LORAZEPAM INJECTION $0.77

J2150 MANNITOL INJECTION $2.30

J2175 MEPERIDINE HYDROCHL /100 MG $4.97

J2185 MEROPENEM $1.53

J2210 METHYLERGONOVIN MALEATE INJ $8.03

J2248 MICAFUNGIN SODIUM INJECTION $1.15

J2250 INJ MIDAZOLAM HYDROCHLORIDE $0.38

J2270 MORPHINE SULFATE INJECTION $1.91




1/16/2017


Fee* Effective

02/15/2017

J2274 IN MORPHINE PRESERVATIV FREE $10.33

J2278 ZICONOTIDE INJECTION $7.65

J2280 INJ, MOXIFLOXACIN 100 MG $8.80

J2300 INJ NALBUPHINE HYDROCHLORIDE $2.68

J2310 INJ NALOXONE HYDROCHLORIDE $30.60

J2315 NALTREXONE, DEPOT FORM $3.44

J2323 NATALIZUMAB INJECTION $19.51

J2353 OCTREOTIDE INJECTION, DEPOT $183.22

J2354 OCTREOTIDE INJ, NON-DEPOT $1.15

J2355 OPRELVEKIN INJECTION $489.98

J2357 OMALIZUMAB INJECTION $34.04

J2358 OLANZAPINE LONG-ACTING INJ $3.06

J2360 ORPHENADRINE INJECTION $3.83

J2400 CHLOROPROCAINE HCL INJECTION $28.69

J2405 ONDANSETRON HCL INJECTION $0.38

J2407 INJECTION, ORITAVANCIN $26.01

J2410 OXYMORPHONE HCL INJECTION $3.06

J2425 PALIFERMIN INJECTION $18.36

J2426 PALIPERIDONE PALMITATE INJ $9.95

J2430 PAMIDRONATE DISODIUM /30 MG $10.71

J2469 PALONOSETRON HCL $23.72

J2501 PARICALCITOL $1.15

J2503 PEGAPTANIB SODIUM INJECTION $1,106.19

J2504 PEGADEMASE BOVINE, 25 IU $360.32

J2505 INJECTION, PEGFILGRASTIM 6MG $4,318.43

J2507 PEGLOTICASE INJECTION $1,881.90

J2510 PENICILLIN G PROCAINE INJ $29.45

J2515 PENTOBARBITAL SODIUM INJ $52.02

J2540 PENICILLIN G POTASSIUM INJ $1.15

J2543 PIPERACILLIN/TAZOBACTAM $2.68

J2545 PENTAMIDINE NON-COMP UNIT $132.35

J2550 PROMETHAZINE HCL INJECTION $2.30

J2560 PHENOBARBITAL SODIUM INJ $30.98

J2562 PLERIXAFOR INJECTION $327.42

J2597 INJ DESMOPRESSIN ACETATE $14.15

J2675 INJ PROGESTERONE PER 50 MG $1.53

J2680 FLUPHENAZINE DECANOATE 25 MG $22.57

J2690 PROCAINAMIDE HCL INJECTION $58.91

J2700 OXACILLIN SODIUM INJECITON $1.91

J2704 INJ, PROPOFOL, 10 MG $0.38

J2720 INJ PROTAMINE SULFATE/10 MG $1.15

J2724 PROTEIN C CONCENTRATE $16.07

J2765 METOCLOPRAMIDE HCL INJECTION $0.77

J2770 QUINUPRISTIN/DALFOPRISTIN $456.71




1/16/2017


Fee* Effective

02/15/2017

J2778 RANIBIZUMAB INJECTION $398.95

J2780 RANITIDINE HYDROCHLORIDE INJ $1.15

J2783 RASBURICASE $267.37

J2785 REGADENOSON INJECTION $58.14

J2788 RHO D IMMUNE GLOBULIN 50 MCG $26.39

J2790 RHO D IMMUNE GLOBULIN INJ $84.15

J2791 RHOPHYLAC INJECTION $4.97

J2792 RHO(D) IMMUNE GLOBULIN H, SD $23.33

J2794 RISPERIDONE, LONG ACTING $8.42

J2795 ROPIVACAINE HCL INJECTION $0.38

J2796 ROMIPLOSTIM INJECTION $67.32

J2800 METHOCARBAMOL INJECTION $40.93

J2805 SINCALIDE INJECTION $101.75

J2810 INJ THEOPHYLLINE PER 40 MG $0.38

J2820 SARGRAMOSTIM INJECTION $39.02

J2850 INJ SECRETIN SYNTHETIC HUMAN $36.34

J2916 NA FERRIC GLUCONATE COMPLEX $2.30

J2920 METHYLPREDNISOLONE INJECTION $4.21

J2930 METHYLPREDNISOLONE INJECTION $5.74

J2997 ALTEPLASE RECOMBINANT $85.30

J3000 STREPTOMYCIN INJECTION $13.39

J3010 FENTANYL CITRATE INJECITON $0.38

J3060 INJ, TALIGLUCERACE ALFA 10 U $42.46

J3070 PENTAZOCINE INJECTION $147.26

J3090 INJ TEDIZOLID PHOSPHATE $1.15

J3095 TELAVANCIN INJECTION $5.36

J3101 TENECTEPLASE INJECTION $107.48

J3105 TERBUTALINE SULFATE INJ $3.44

J3121 INJ TESTOSTERO ENANTHATE 1MG $0.38

J3230 CHLORPROMAZINE HCL INJECTION $25.63

J3240 THYROTROPIN INJECTION $1,651.64

J3243 TIGECYCLINE INJECTION $3.44

J3250 TRIMETHOBENZAMIDE HCL INJ $28.31

J3260 TOBRAMYCIN SULFATE INJECTION $2.30

J3262 TOCILIZUMAB INJECTION $4.59

J3285 TREPROSTINIL INJECTION $64.26

J3300 TRIAMCINOLONE A INJ PRS-FREE $3.83

J3301 TRIAMCINOLONE ACET INJ NOS $1.91

J3303 TRIAMCINOLONE HEXACETONL INJ $3.83

J3315 TRIPTORELIN PAMOATE $421.90

J3357 USTEKINUMAB SUB CU INJ, 1 MG $181.69

J3360 DIAZEPAM INJECTION $9.95

J3370 VANCOMYCIN HCL INJECTION $3.06

J3380 INJECTION, VEDOLIZUMAB $18.36




1/16/2017


Fee* Effective

02/15/2017

J3385 VELAGLUCERASE ALFA $359.93

J3396 VERTEPORFIN INJECTION $11.09

J3410 HYDROXYZINE HCL INJECTION $2.30

J3411 THIAMINE HCL 100 MG $3.44

J3415 PYRIDOXINE HCL 100 MG $12.62

J3420 VITAMIN B12 INJECTION $4.21

J3430 VITAMIN K PHYTONADIONE INJ $3.83

J3465 INJECTION, VORICONAZOLE $3.83

J3471 OVINE, UP TO 999 USP UNITS $0.38

J3473 HYALURONIDASE RECOMBINANT $0.38

J3475 INJ MAGNESIUM SULFATE $0.38

J3480 INJ POTASSIUM CHLORIDE $0.38

J3485 ZIDOVUDINE $1.53

J3486 ZIPRASIDONE MESYLATE $21.04

J3489 ZOLEDRONIC ACID 1MG $13.01

J7030 NORMAL SALINE SOLUTION INFUS $1.91


J7042 5% DEXTROSE/NORMAL SALINE $0.77


J7060 5% DEXTROSE/WATER $1.91

J7070 D5W INFUSION $3.83

J7120 RINGERS LACTATE INFUSION $2.30

J7180 FACTOR XIII ANTI-HEM FACTOR $8.42

J7182 FACTOR VIII RECOMB NOVOEIGHT $1.53

J7183 WILATE INJECTION $1.15

J7185 XYNTHA INJ $1.15

J7186 ANTIHEMOPHILIC VIII/VWF COMP $1.15

J7187 HUMATE-P, INJ $1.15

J7189 FACTOR VIIA $1.91

J7190 FACTOR VIII $1.15

J7192 FACTOR VIII RECOMBINANT NOS $1.15

J7193 FACTOR IX NON-RECOMBINANT $1.15

J7194 FACTOR IX COMPLEX $1.53

J7195 FACTOR IX RECOMBINANT NOS $1.53

J7197 ANTITHROMBIN III INJECTION $3.44

J7198 ANTI-INHIBITOR $1.91

J7200 FACTOR IX RECOMBINAN RIXUBIS $1.15

J7201 FACTOR IX ALPROLIX RECOMB $3.06

J7205 FACTOR VIII FC FUSION RECOMB $1.91

J7297 LEVONORGESTREL IU CONTRACEPTIVE, 52MG, 3 YEAR $638.01

J7298 LEVONORGESTREL IU CONTRACEPTIVE, 52MG, 5 YEAR $875.93

J7300 INTRAUT COPPER CONTRACEPTIVE $754.29

J7301 LEVONORGESTREL IU CONTRACEPTIVE, (SKYLA) $729.05

J7307 ETONOGESTREL IMPLANT SYSTEM $865.22




1/16/2017


Fee* Effective

02/15/2017

J7308 AMINOLEVULINIC ACID HCL TOP $364.14

J7311 FLUOCINOLONE ACETONIDE IMPLT $21,097.55

J7312 DEXAMETHASONE INTRA IMPLANT $210.76

J7313 FLUOCINOL ACET INTRAVIT IMP $514.85

J7316 INJ, OCRIPLASMIN, 0.125 MG $1,097.78

J7320 GENVISC 850, INJ, 1MG $8.42

J7321 HYALGAN/SUPARTZ INJ PER DOSE $90.27

J7323 EUFLEXXA INJ PER DOSE $164.86

J7324 ORTHOVISC INJ PER DOSE $158.36

J7325 SYNVISC OR SYNVISC-ONE $13.77

J7326 GEL-ONE $642.60

J7327 MONOVISC INJ PER DOSE $950.90

J7336 CAPSAICIN 8% PATCH $3.06

J7500 AZATHIOPRINE ORAL 50MG $0.38

J7502 CYCLOSPORINE ORAL 100 MG $3.06

J7503 TACROL ENVARSUS EX REL ORAL $1.15

J7504 LYMPHOCYTE IMMUNE GLOBULIN $1,551.80

J7507 TACROLIMUS IMME REL ORAL 1MG $0.77

J7508 TACROL ASTAGRAF EX REL ORAL $0.38

J7509 METHYLPREDNISOLONE ORAL $0.38

J7510 PREDNISOLONE ORAL PER 5 MG $0.38

J7511 ANTITHYMOCYTE GLOBULN RABBIT $722.16

J7512 PREDNISONE IR OR DR ORAL 1MG $0.38

J7515 CYCLOSPORINE ORAL 25 MG $0.77

J7516 CYCLOSPORIN PARENTERAL 250MG $42.46

J7517 MYCOPHENOLATE MOFETIL ORAL $1.15

J7518 MYCOPHENOLIC ACID $3.06

J7520 SIROLIMUS, ORAL $8.42

J7525 TACROLIMUS INJECTION $179.01

J7527 ORAL EVEROLIMUS $8.42

J7605 ARFORMOTEROL NON-COMP UNIT $9.95

J7606 FORMOTEROL FUMARATE, INH $11.09

J7608 ACETYLCYSTEINE NON-COMP UNIT $4.59

J7611 ALBUTEROL NON-COMP CON $0.38

J7612 LEVALBUTEROL NON-COMP CON $0.38

J7613 ALBUTEROL NON-COMP UNIT $0.38

J7614 LEVALBUTEROL NON-COMP UNIT $0.38

J7620 ALBUTEROL IPRATROP NON-COMP $0.38

J7626 BUDESONIDE NON-COMP UNIT $2.68

J7631 CROMOLYN SODIUM NONCOMP UNIT $0.77

J7639 DORNASE ALFA NON-COMP UNIT $44.75

J7644 IPRATROPIUM BROMIDE NON-COMP $0.38

J7674 METHACHOLINE CHLORIDE, NEB $0.38

J7682 TOBRAMYCIN NON-COMP UNIT $46.28




1/16/2017


Fee* Effective

02/15/2017

J7686 TREPROSTINIL, NON-COMP UNIT $557.30

J8501 ORAL APREPITANT $13.01

J8510 ORAL BUSULFAN $24.86

J8520 CAPECITABINE, ORAL, 150 MG $4.21

J8521 CAPECITABINE, ORAL, 500 MG $12.62

J8530 CYCLOPHOSPHAMIDE ORAL 25 MG $3.44

J8540 ORAL DEXAMETHASONE $0.38

J8560 ETOPOSIDE ORAL 50 MG $77.27

J8600 MELPHALAN ORAL 2 MG $12.24

J8610 METHOTREXATE ORAL 2.5 MG $0.77

J8655 NETUPITANT PALONOSETRON ORAL $466.65

J8700 TEMOZOLOMIDE $1.91

J8705 TOPOTECAN ORAL $109.01

J9000 DOXORUBICIN HCL INJECTION $2.68

J9017 ARSENIC TRIOXIDE INJECTION $68.09

J9019 ERWINAZE INJECTION $422.28

J9025 AZACITIDINE INJECTION $2.68

J9027 CLOFARABINE INJECTION $159.89

J9031 BCG LIVE INTRAVESICAL VAC $133.11

J9032 INJECTION, BELINOSTAT, 10MG $36.34

J9033 INJ., TREANDA 1 MG $29.45

J9034 INJ., BENDEKA 1 MG $24.86

J9035 BEVACIZUMAB INJECTION $77.27

J9040 BLEOMYCIN SULFATE INJECTION $52.79

J9041 BORTEZOMIB INJECTION $48.58

J9042 BRENTUXIMAB VEDOTIN INJ $141.14

J9043 CABAZITAXEL INJECTION $161.80

J9045 CARBOPLATIN INJECTION $3.83

J9047 INJECTION, CARFILZOMIB, 1 MG $33.28

J9050 CARMUSTINE INJECTION $4,038.05

J9055 CETUXIMAB INJECTION $59.29

J9060 CISPLATIN 10 MG INJECTION $2.30

J9065 INJ CLADRIBINE PER 1 MG $24.48

J9070 CYCLOPHOSPHAMIDE 100 MG INJ $44.37

J9098 CYTARABINE LIPOSOME INJ $624.24

J9100 CYTARABINE HCL 100 MG INJ $0.77

J9120 DACTINOMYCIN INJECTION $1,338.75

J9130 DACARBAZINE 100 MG INJ $4.59

J9145 INJECTION, DARATUMUMAB 10 MG $49.34

J9150 DAUNORUBICIN INJECTION $32.90

J9155 DEGARELIX INJECTION $3.83

J9171 DOCETAXEL INJECTION $2.68

J9176 INJECTION, ELOTUZUMAB, 1MG $6.50

J9178 INJ, EPIRUBICIN HCL, 2 MG $1.53




1/16/2017


Fee* Effective

02/15/2017

J9179 ERIBULIN MESYLATE INJECTION $113.22

J9181 ETOPOSIDE INJECTION $0.77

J9185 FLUDARABINE PHOSPHATE INJ $62.73

J9190 FLUOROURACIL INJECTION $1.91

J9200 FLOXURIDINE INJECTION $78.41

J9201 GEMCITABINE HCL INJECTION $5.74

J9202 GOSERELIN ACETATE IMPLANT $343.49

J9205 INJ IRINOTECAN LIPOSOME 1 MG $41.31

J9206 IRINOTECAN INJECTION $3.83

J9207 IXABEPILONE INJECTION $80.33

J9208 IFOSFAMIDE INJECTION $29.84

J9209 MESNA INJECTION $1.91

J9211 IDARUBICIN HCL INJECTION $35.96

J9214 INTERFERON ALFA-2B INJ $27.92

J9217 LEUPROLIDE ACETATE SUSPNSION $231.80

J9218 LEUPROLIDE ACETATE INJECITON $23.72

J9225 VANTAS IMPLANT $3,306.33

J9226 SUPPRELIN LA IMPLANT $29,118.96

J9228 IPILIMUMAB INJECTION $149.56

J9230 MECHLORETHAMINE HCL INJ $278.84

J9245 INJ MELPHALAN HYDROCHL 50 MG $2,115.61

J9250 METHOTREXATE SODIUM INJ $0.38

J9260 METHOTREXATE SODIUM INJ $2.30

J9261 NELARABINE INJECTION $159.50

J9263 OXALIPLATIN $0.38

J9264 PACLITAXEL PROTEIN BOUND $10.71

J9266 PEGASPARGASE INJECTION $14,593.14

J9267 PACLITAXEL INJECTION $0.38

J9268 PENTOSTATIN INJECTION $1,973.70

J9271 INJ PEMBROLIZUMAB $48.96

J9280 MITOMYCIN INJECTION $109.78

J9293 MITOXANTRONE HYDROCHL / 5 MG $41.31

J9295 INJECTION, NECITUMUMAB, 1 MG $5.36

J9299 INJECTION, NIVOLUMAB $27.16

J9301 OBINUTUZUMAB INJ $60.05

J9302 OFATUMUMAB INJECTION $55.85

J9303 PANITUMUMAB INJECTION $112.84

J9305 PEMETREXED INJECTION $66.94

J9306 INJECTION, PERTUZUMAB, 1 MG $11.48

J9307 PRALATREXATE INJECTION $249.01

J9308 INJECTION, RAMUCIRUMAB $59.29

J9310 RITUXIMAB INJECTION $858.33

J9315 ROMIDEPSIN INJECTION $320.92

J9320 STREPTOZOCIN INJECTION $334.31




1/16/2017


Fee* Effective

02/15/2017

J9325 INJ TALIMOGENE LAHERPAREPVEC $48.58

J9328 TEMOZOLOMIDE INJECTION $8.42

J9330 TEMSIROLIMUS INJECTION $71.15

J9351 TOPOTECAN INJECTION $1.15

J9352 INJECTION TRABECTEDIN 0.1MG $297.20

J9354 INJ, ADO-TRASTUZUMAB EMT 1MG $30.98

J9355 TRASTUZUMAB INJECTION $99.07

J9357 VALRUBICIN INJECTION $1,204.88

J9360 VINBLASTINE SULFATE INJ $3.83

J9370 VINCRISTINE SULFATE 1 MG INJ $4.59

J9371 INJ, VINCRISTINE SUL LIP 1MG $2,625.10

J9390 VINORELBINE TARTRATE INJ $9.18

J9395 INJECTION, FULVESTRANT $100.60

J9400 INJ, ZIV-AFLIBERCEPT, 1MG $8.42

P9041 ALBUMIN (HUMAN),5%, 50ML $11.86

P9045 ALBUMIN (HUMAN), 5%, 250 ML $57.38

P9046 ALBUMIN (HUMAN), 25%, 20 ML $23.72

P9047 ALBUMIN (HUMAN), 25%, 50ML $56.23

Q0138 FERUMOXYTOL, NON-ESRD $0.77

Q0139 FERUMOXYTOL, ESRD USE $0.77

Q0162 ONDANSETRON ORAL $0.38

Q0163 DIPHENHYDRAMINE HCL 50MG $0.38




1/16/2017

Fee* Effective CPT Code Short Description 02/15/2017hp/@public/...90633 hep a vacc, ped/adol, 2 dose...

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Transcript of Fee* Effective CPT Code Short Description 02/15/2017hp/@public/...90633 hep a vacc, ped/adol, 2 dose...