| Document Date: 2011-09-20 09:13:21
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City mCi Gadolinium / / Company Deca / mCi / / Currency USD / pence / / Facility ***J7187 Von Willebrand Factor Complex / FACILITY EFFECTIVE DATE / Somatuline Depot / FACILITY EFFECTIVE DATE Biologics ***J0129 Abatacept / J7194 Factor IX Complex / FACILITY NON-FACILITY EFFECTIVE DATE / J7187 Von Willebrand Factor Complex / Lupron ***J1950 Depot / FACILITY ***J9095 Cyclophosphamide / / IndustryTerm iodide solution / sodium iodine solution / preservative-free sterile solution / iodine solution / saline solution / inhalation solution / oil / / MedicalCondition ESRD / non ESRD / / MedicalTreatment dialysis / Botox / / Person Immune Globulin / IV / / Position Physician / human / 150IU Physician / / Product Brethine / Pentam / Cimetidine hydrochloride / Procainamide HCl / Cisplatin / Velcade / Terramycin / Pronestyl / Anzemet / Bentyl / Demadex / Infergen / Primacor / Aranesp / Ceftriaxone Sodium / Cerezyme / Flolan / Vistide / Vidaza / Granisetron hydrochloride / Cytarabine / Glucagon / Proleukin / Sumatriptan Succinate / Bleomycin sulfate / Aredia / Milrinone lactate / Nembutal Sodium / Ranitidine hydrochloride / Catapres / Sodium bicarbonate / Dextrose / Nalbuphine / Deferoxamine Mesylate / Neulasta / Remicade / Torsemide / Stadol / Estradiol valerate / Cefoxitin / Elitek / Avastin / Kefzol / Norflex / Vincristine sulfate / Depo-estradiol / Kytril / Methotrexate sodium / Tagamet / Penicillin G potassium / Kantrex / Succinylcholine chloride / Platinol / Levorphanol tartrate / Adrucil / Mesnex / Dobutrex / Diazepam / Mylotarg / Fludara / Orencia / Vectibix / VePesid / Fentanyl Citrate / Ancef / Librium / NebuPent / Zofran / Methylprednisolone acetate / Keppra / Depo-Testosterone / Baclofen / Digoxin / Dilantin / Cytosar-U / Omnipen-N / Vinblastine sulfate / Zoladex / Epinephrine / Pegasys / Ifex / Totect / Hyaluronidase injection / Levo-Dromoran / Campath / Torisel / Abilify / Fragmin / Triamcinolone Acetonide / Cortrosyn / prohance multipack / Xolair / Tysabri / Numorphan / CODE DESCRIPTION EFFECTIVE DATE FACILITY NON-FACILITY ***J0540 injection / Glucagen / Desmopressin acetate / Aristocort / Calcitriol / Potassium Chloride / Foscavir / Cosmegen / Inderal / Lincocin / Metoclopramide HCl / Methocarbamol / Morphine sulfate / DDAVP / Regitine / Erythromycin lactobionate / Wellcovorin / Lincomycin HCl / Penicillin / Hyperstat / Medrol / Prednisolone acetate / Cladribine / Dihydroergotamine mesylate / Acyclovir / Blenoxane / Reglan / Eloxatin / Cefotaxime Sodium / Venofer / Cyclophosphamide / Persantine / Zinecard / Triamcinolone / Pralidoxime chloride / Corvert / Oncaspar / Calcijex / Primaxin / Ifosfamide / Treanda / Fluphenazine decanoate / Premarin / DepoCyt / Atropine sulfate / Pentostatin / Zemplar / Levocarnitine / Indium / Cerubidine / Sodium iodide / Lanoxin / Ceftazidime / Levofloxacin / Triamcinolone diacetate / Cosyntropin / Novantrone / Estradiol / F-18 / Beta / Tigan / Ferrlecit / Tazidime / Narcan / Orphenadrine citrate / Somatuline Depot / Ganciclovir / Depo-Medrol / Lasix / Adenocard / Myozyme / Boniva / Robaxin / Dipyridamole / Leustatin / Ketorolac tromethamine / Camptosar / Cubicin / Apresoline / Daunoxome / Inapsine / Fluorouracil / Elspar / Levaquin / cyanocobalamin / Totacillin-N / Furosemide / Actimmune / Aldomet / Fabrazyme / Levoleucovorin / Heparin sodium / Methylprednisolone sodium succinate / Dacarbazine / Ondansetron / Indium IN-111 oxyquinoline / iobenguane sulfate / BAL / Delestrogen / Hycamtin / Talwin / Dexferrum / Carboplatin / Methylprednisolone / Colistimethate / Clonidine hydrochloride / Lovenox / Leucovorin Calcium / Herceptin / Zenapax / Protamine sulfate / Oncovin / DTIC - Dome / Dimenhydrinate / Rituxan / Amevive / Alkeran / Neupogen / Promethazine / Linezolid / Cefuroxime sodium / Cytoxan / Thioplex / Naloxone HCl / Nandrolone decanoate / Rocephin / Technetium / Diuril / Medroxyprogesterone Acetate / Kanamycin sulfate / Plenaxis / Ethyol / Chorionic Gonadotropin / Navelbine / gentamicin / Macugen / Xenon Xe / vitamin K / Doxil / Desferal / Cytovene / ACTH / Claforan / Peginterferon / Anectine / Thorazine / Etidronate disodium / Viadur / Hydroxyzine / Oxacillin sodium / Methergine / multihance / Phenergan / Mitomycin / Diazoxide / Aldurazyme / Ambisome / Thyrogen / multihance multipack / Cefazolin Sodium / Heparin Lock Flush / Solu-Medrol / Zanosar / Haloperidol decanoate / Bicillin C-R / Dexrazoxane / Piperacillin / Paraplatin / Etoposide / Garamycin / Ertapenem injection / Protopam Chloride / Lioresal / Testosterone enanthate / Paclitaxel / Acetazolamide sodium / Floxuridine / Ellence / Supprelin LA / Vancoled / Compazine / Ceredase / Retavase / Hydrocortisone sodium succinate / Lidocaine / Vivitrol / Pfizerpen / Phytonadione / trelstar / Zyvox / Nipent / Zovirax / Kenalog / Prochlorperazine / Cipro / Diamox / Iron dextran / Prostaphlin / Ciprofloxacin / Vinorelbine tartrate / Erbitux / Vantas / Nebcin / Carnitor / Toradol / Dacogen / Idamycin / AquaMephyton / Demerol / Testosterone Cypionate / Mesna / Zantac / Vancomycin HCl / BiCNU / Phentolamine mesylate / Pamidronate disodium / Wydase / Aramine / General Electric J1250 Digital Camera / Gemzar / Haloperidol / Benadryl / Betamethasone sodium phosphate / Unasyn / Temodar / Chloramphenicol sodium succinate / Pentobarbital sodium / Leukine / Activase / Neutrexin / Zithromax / Droperidol / Chloromycetin / Zosyn / Soliris / Pentamidine isethionate / Dexamethasone sodium phosphate / Cefizox / Abraxane / Haldol / J7324 injection / Risperidone / DTIC- Dome / Zometa / Lupron / Prialt / Lucentis / FUDR / Mannitol / Thiotepa / Valium / Trisenox / Vistaril / Oxytocin / Astramorph PF / Fortaz / Bicillin L-A / Corticotropin / Doribax / Nubain / Ampicillin sodium / Metaraminol bitartrate / Nesacaine / Supprelin / Tobramycin sulfate / Reclast / Leuprolide acetate / Amphotericin B / Azithromycin / Mefoxin / Foscarnet sodium / J7321 injection / Depo-Provera / Faslodex / Amifostine / Chlorothiazide / Xylocaine / Vitrasert / Visudyne / ReoPro / Testosterone / Infed / Arranon / Lorazepam / Carbocaine / Ativan / IM injection / Aminophylline / Penicillin G procaine / Ganciclovir sodium / Streptase / Aloxi / Risperdal Consta / Terbutaline sulfate / Coly-Mycin M / Fludarabine phosphate / dimethyl sulfoxide / Maxipime / Methyldopate HCl / Deca-Durabolin / Neosar / Adenosine / Technetium TC-99M mebrofenin / Taxol / Ontak / Phenytoin sodium / Velban / Acthar / Aristospan / Mitoxantrone / Dexamethasone acetate / Taxotere / Prolixin / Pitocin / Dilaudid / / ProvinceOrState South Carolina / / Technology dialysis / Alpha / Radiopharmaceuticals / /
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Physician Drug Program Procedure Codes And Rates as of November 1, 2009 CODE DESCRIPTION