HCPCS Range Other Drugs and Service Fees

• 1 Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose ( Q2041 )

• 2 Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion ( Q2043 )

• 3 Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10 mg ( Q2049 )

• 4 Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg ( Q2050 )

• 5 Services, supplies, and accessories used in the home for the administration of intravenous immune globulin (ivig) ( Q2052 )

• 6 Radioelements for brachytherapy, any type, each ( Q3001 )

• 7 Telehealth originating site facility fee ( Q3014 )

• 8 Injection, interferon beta-1a, 1 mcg for intramuscular use ( Q3027 )

• 9 Injection, interferon beta-1a, 1 mcg for subcutaneous use ( Q3028 )

• 10 Collagen skin test ( Q3031 )

• 11 Tisagenlecleucel, up to 600 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose ( Q2042 )

• 12 Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose ( Q2053 )

• 13 Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose ( Q2054 )

• 14 Idecabtagene vicleucel, up to 460 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose ( Q2055 )

• 15 Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose ( Q2056 )