|
Q5101 |
 |
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram
| short | Injection, zarxio |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 1500.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup | | OPH | 1500.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup | | DME | 0.0 | 3 Date of Service Edit: Clinical | Published Contractor Policy |
|
|
|
|
Q5102 |
|
Injection, infliximab, biosimilar, 10 mg
| short | Inj., infliximab biosimilar |
|
|
|
Q5103 |
|
Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg
| short | Injection, inflectra |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 150.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | OPH | 150.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
Q5104 |
|
Injection, infliximab-abda, biosimilar, (renflexis), 10 mg
| short | Injection, renflexis |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 150.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | OPH | 150.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
Q5105 |
|
Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units
| short | Inj retacrit esrd on dialysi |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 100.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup | | OPH | 400.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
|
|
|
|
Q5106 |
|
Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units
| short | Inj retacrit non-esrd use |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 60.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | OPH | 60.0 | 3 Date of Service Edit: Clinical | Prescribing Information |
|
|
|
|
Q5107 |
|
Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg
| short | Inj mvasi 10 mg |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 170.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup | | OPH | 170.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup | | DME | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
Q5108 |
|
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg
| short | Injection, fulphila |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 12.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | OPH | 12.0 | 3 Date of Service Edit: Clinical | Prescribing Information |
|
|
|
|
Q5109 |
|
Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg
| short | Injection, ixifi, 10 mg |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 150.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | OPH | 150.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
Q5110 |
|
Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram
| short | Nivestym |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 1500.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | OPH | 1500.0 | 3 Date of Service Edit: Clinical | Prescribing Information |
|
|
|