Addendum A.-Proposed OPPS APCs for CY

2012

APC Group Title SI Relative Weight Payment Rate National Unadjusted Copayment

Minimum Unadjusted Copayment

0001 Level I

Photochemotherapy S 0.5025 $34.88

. $6.98

0002 Fine Needle

Biopsy/Aspiration T 1.7462 $121.22

. $24.25

0003 Bone Marrow

Biopsy/Aspiration T 3.9075 $271.26

. $54.26

0004 Level I Needle Biopsy/ Aspiration Except Bone

Marrow T 4.5956 $319.03

. $63.81

0005 Level II Needle Biopsy/Aspiration Except Bone

Marrow T 8.1415 $565.18

. $113.04

0006 Level I Incision &

Drainage T 1.4481 $100.53

. $20.11

0007 Level II Incision &

Drainage T 13.4779 $935.64

. $187.13

0008 Level III Incision and

Drainage T 20.5401 "$1,425.89"

. $285.18

0012 Level I Debridement &

Destruction T 0.4047 $28.09

. $5.62

0013 Level II Debridement &

Destruction T 0.9786 $67.93

. $13.59

0015 Level III Debridement &

Destruction T 1.4936 $103.69

. $20.74

0016 Level IV Debridement &

Destruction T 2.8248 $196.10

. $39.22

0017 Level V Debridement &

Destruction T 22.0631 "$1,531.62"

. $306.33

0019 Level I Excision/

Biopsy T 4.8763 $338.51

. $67.710020 Level II Excision/

Biopsy T 8.6164 $598.15

. $119.63

0021 Level III Excision/

Biopsy T 17.1909 "$1,193.39"

. $238.68

0022 Level IV Excision/

Biopsy T 23.4169 "$1,625.60" $350.05 $325.12

0028 Level I Breast

Surgery T 25.8383 "$1,793.69"

. $358.74

0029 Level II Breast

Surgery T 33.8417 "$2,349.29" $581.52 $469.86

0030 Level III Breast

Surgery T 45.0972 "$3,130.65" $747.07 $626.13

0031 Smoking Cessation

Services X 0.2941 $20.42

. $4.09

0034 Mental Health Services

Composite S 2.6400 $183.27

. $36.66

0035 Vascular Puncture and Minor Diagnostic

Procedures X 0.2717 $18.86

. $3.78

0037 Level IV Needle Biopsy/Aspiration Except Bone

Marrow T 15.3594 "$1,066.25" $225.55 $213.25

0039 Level I Implantation of Neurostimulator

Generator S 209.6958 "$14,557.08"

. "$2,911.42"

0040 Level I Implantation/Revision/Replacement of Neurostimulator Electrodes

S 62.7889 "$4,358.81"

. $871.77

0041 Level I

Arthroscopy T 29.4235 "$2,042.58"

. $408.52

0042 Level II

Arthroscopy T 48.4545 "$3,363.71" $804.74 $672.75

0045 Bone/Joint Manipulation Under

Anesthesia T 15.5166 "$1,077.16" $268.44 $215.44

0047 Arthroplasty without

Prosthesis T 41.2971 "$2,866.84"

. $573.37

0048 Level I Arthroplasty or Implantation with

Prosthesis T 60.0335 "$4,167.53"

. $833.510049 Level I Musculoskeletal Procedures Except Hand and

Foot T 22.1674 "$1,538.86"

. $307.78

0050 Level II Musculoskeletal Procedures Except Hand and

Foot T 32.4101 "$2,249.91"

. $449.99

0051 Level III Musculoskeletal Procedures Except Hand and

Foot T 47.1841 "$3,275.52"

. $655.11

0052 Level IV Musculoskeletal Procedures Except Hand and

Foot T 87.5671 "$6,078.91"

. "$1,215.79"

0053 Level I Hand Musculoskeletal

Procedures T 17.4096 "$1,208.57" $253.49 $241.72

0054 Level II Hand Musculoskeletal

Procedures T 29.0181 "$2,014.44"

. $402.89

0055 Level I Foot Musculoskeletal

Procedures T 22.1739 "$1,539.31" $351.47 $307.87

0056 Level II Foot Musculoskeletal

Procedures T 57.2099 "$3,971.51"

. $794.31

0057 Bunion

Procedures T 32.5456 "$2,259.32" $469.58 $451.87

0058 Level I Strapping and Cast

Application S 1.1378 $78.99

. $15.80

0060 Manipulation

Therapy S 0.3234 $22.45

. $4.49

0061 Level II Implantation/Revision/Replacement of Neurostimulator Electrodes

S 86.9786 "$6,038.05"

. "$1,207.61"

0062 Level I Treatment

Fracture/Dislocation T 26.2376 "$1,821.41" $371.33 $364.29

0063 Level II Treatment

Fracture/Dislocation T 49.4864 "$3,435.35"

. $687.07

0064 Level III Treatment

Fracture/Dislocation T 67.0623 "$4,655.46"

. $931.10

0065 "Level I Stereotactic Radiosurgery, MRgFUS, and

MEG" S 12.4513 $864.37

. $172.880066 "Level II Stereotactic Radiosurgery, MRgFUS, and

MEG" S 35.2457 "$2,446.76"

. $489.36

0067 "Level III Stereotactic Radiosurgery, MRgFUS, and

MEG" S 46.8279 "$3,250.79"

. $650.16

0069 Thoracoscopy T 34.9007 "$2,422.81" $591.64 $484.57

0070 Thoracentesis/Lavage

Procedures T 5.5572 $385.78

. $77.16

0071 Level I Endoscopy Upper

Airway T 1.0521 $73.04

. $14.61

0072 Level II Endoscopy Upper

Airway T 1.9475 $135.20

. $27.04

0073 Level III Endoscopy Upper

Airway T 4.5122 $313.24 $67.83 $62.65

0074 Level IV Endoscopy Upper

Airway T 21.3691 "$1,483.44"

. $296.69

0075 Level V Endoscopy Upper

Airway T 30.2222 "$2,098.03" $438.93 $419.61

0076 Level I Endoscopy Lower

Airway T 10.4123 $722.82 $189.71 $144.57

0077 Level I Pulmonary

Treatment S 0.4224 $29.32 $7.74 $5.87

0078 Level III Pulmonary

Treatment S 1.4008 $97.24

. $19.45

0079 Ventilation Initiation and

Management S 3.0221 $209.79

. $41.96

0080 Diagnostic Cardiac

Catheterization T 39.2392 "$2,723.99" $838.04 $544.80

0082 Coronary or Non-Coronary

Atherectomy T 104.8857 "$7,281.17"

. "$1,456.24"

0083 Level I Endovascular Revascularization of the Lower Extremity

T 65.1118 "$4,520.06"

. $904.02

0084 Level I Electrophysiologic

Procedures S 9.6404 $669.24

. $133.850085 Level II Electrophysiologic

Procedures T 52.8540 "$3,669.12"

. $733.83

0086 Level III Electrophysiologic

Procedures T 133.7624 "$9,285.79"

. "$1,857.16"

0088 Thrombectomy T 41.2260 "$2,861.91" $652.56 $572.39

0089 Insertion/Replacement of Permanent Pacemaker and

Electrodes T 110.9465 "$7,701.91" "$1,620.86" "$1,540.39"

0090 Insertion/Replacement of Pacemaker Pulse

Generator T 93.4566 "$6,487.76" "$1,570.21" "$1,297.56"

0091 Level II Vascular

Ligation T 43.6864 "$3,032.71"

. $606.55

0092 Level I Vascular

Ligation T 26.9181 "$1,868.65"

. $373.73

0093 Vascular Reconstruction/Fistula Repair without

Device T 30.7767 "$2,136.52"

. $427.31

0094 Level I Resuscitation and

Cardioversion S 2.2773 $158.09 $44.32 $31.62

0095 Cardiac

Rehabilitation S 0.9648 $66.98 $13.49 $13.40

0096 Level II Noninvasive Physiologic

Studies S 1.5324 $106.38 $36.83 $21.28

0097 Level I Noninvasive Physiologic

Studies S 0.9478 $65.80 $23.63 $13.16

0099 Electrocardiograms/Cardiography S 0.3895 $27.04

. $5.41

0100 Cardiac Stress

Tests X 2.5348 $175.97 $40.87 $35.20

0101 Tilt Table

Evaluation S 4.2610 $295.80 $100.24 $59.16

0102 Level II Pulmonary

Treatment S 0.5308 $36.85

. $7.37

0103 Miscellaneous Vascular

Procedures T 16.7686 "$1,164.08"

. $232.820104 Transcatheter Placement of Intracoronary

Stents T 79.9047 "$5,546.98"

. "$1,109.40"

0105 "Repair/Revision/Removal of Pacemakers, AICDs, or Vascular

Devices" T 23.2424 "$1,613.49"

. $322.70

0106 Insertion/Replacement of Pacemaker Leads and/or

Electrodes T 48.5765 "$3,372.18"

. $674.44

0107 Insertion of

Cardioverter-Defibrillator T 329.3230 "$22,861.60"

. "$4,572.32"

0108 "Insertion/Replacement/Repair of AICD Leads, Generator, and Pacing Electrodes

" T 379.7887 "$26,364.93"

. "$5,272.99"

0110 Transfusion S 3.3671 $233.74

. $46.75

0111 Blood Product

Exchange S 11.7368 $814.77 $189.47 $162.96

0112 Apheresis and Stem Cell

Procedures S 32.6016 "$2,263.20"

. $452.64

0113 Excision Lymphatic

System T 25.4874 "$1,769.34"

. $353.87

0114 Thyroid/Lymphadenectomy

Procedures T 51.2321 "$3,556.53"

. $711.31

0115 Cannula/Access Device

Procedures T 36.8791 "$2,560.15"

. $512.03

0121 Level I Tube or Catheter Changes or

Repositioning T 6.3178 $438.58

. $87.72

0126 Level I Urinary and Anal

Procedures T 1.1699 $81.21

. $16.25

0127 "Level IV Stereotactic Radiosurgery, MRgFUS, and

MEG" S 106.1294 "$7,367.50"

. "$1,473.50"

0128 Echocardiogram with

Contrast S 8.1207 $563.74 $166.16 $112.75

0129 Level I Closed Treatment Fracture

Finger/Toe/Trunk T 1.6063 $111.51

. $22.310130 Level I

Laparoscopy T 39.0865 "$2,713.38" $659.53 $542.68

0131 Level II

Laparoscopy T 47.7164 "$3,312.47" "$1,001.89" $662.50

0132 Level III

Laparoscopy T 71.0451 "$4,931.95" "$1,236.99" $986.39

0133 Level I Skin

Repair T 1.2139 $84.27 $23.56 $16.86

0134 Level II Skin

Repair T 3.2846 $228.02

. $45.61

0135 Level III Skin

Repair T 5.1973 $360.80

. $72.16

0136 Level IV Skin

Repair T 17.2745 "$1,199.20"

. $239.84

0137 Level V Skin

Repair T 21.8041 "$1,513.64"

. $302.73

0138 Level II Closed Treatment Fracture

Finger/Toe/Trunk T 4.9874 $346.23

. $69.25

0139 Level III Closed Treatment Fracture

Finger/Toe/Trunk T 18.6922 "$1,297.61"

. $259.53

0140 Esophageal Dilation without

Endoscopy T 6.5430 $454.22

. $90.85

0141 Level I Upper GI

Procedures T 8.3787 $581.65 $136.33 $116.33

0142 Level I Small Intestine

Endoscopy T 10.1643 $705.61 $152.78 $141.13

0143 Lower GI

Endoscopy T 9.3183 $646.88 $186.06 $129.38

0146 Level I Sigmoidoscopy and

Anoscopy T 6.3038 $437.61

. $87.53

0147 Level II Sigmoidoscopy and

Anoscopy T 11.0219 $765.14

. $153.03

0148 Level I Anal/Rectal

Procedures T 6.1052 $423.82

. $84.770149 Level III Anal/Rectal

Procedures T 24.4472 "$1,697.12"

. $339.43

0150 Level IV Anal/Rectal

Procedures T 32.9730 "$2,288.99"

. $457.80

0151 Endoscopic Retrograde Cholangio-Pancreatography

(ERCP) T 24.4009 "$1,693.91"

. $338.79

0152 Level I Percutaneous Abdominal and Biliary

Procedures T 31.2779 "$2,171.31"

. $434.27

0153 Peritoneal and Abdominal

Procedures T 26.6476 "$1,849.88" $375.24 $369.98

0154 Hernia/Hydrocele

Procedures T 32.9744 "$2,289.08" $464.85 $457.82

0155 Level II Anal/Rectal

Procedures T 16.0235 "$1,112.35"

. $222.47

0156 Level III Urinary and Anal

Procedures T 3.1976 $221.98

. $44.40

0157 Colorectal Cancer Screening: Barium

Enema S 2.2553 $156.56

. $31.32

0158 Colorectal Cancer Screening:

Colonoscopy T 8.3174 $577.39

. $0.00

0159 Colorectal Cancer Screening: Flexible

Sigmoidoscopy S 5.4345 $377.26

. $0.00

0160 Level I Cystourethroscopy and other Genitourinary

Procedures T 7.3594 $510.89

. $102.18

0161 Level II Cystourethroscopy and other Genitourinary

Procedures T 17.6738 "$1,226.92"

. $245.39

0162 Level III Cystourethroscopy and other Genitourinary

Procedures T 26.2690 "$1,823.59"

. $364.72

0163 Level IV Cystourethroscopy and other Genitourinary

Procedures T 36.9605 "$2,565.80"

. $513.16

0164 Level II Urinary and Anal

Procedures T 2.0973 $145.59

. $29.120165 Level IV Urinary and Anal

Procedures T 20.1960 "$1,402.01"

. $280.41

0166 Level I Urethral

Procedures T 20.7987 "$1,443.85"

. $288.77

0168 Level II Urethral

Procedures T 32.1043 "$2,228.68"

. $445.74

0169 Lithotripsy T 51.4038 "$3,568.45" $997.74 $713.69

0170 Dialysis S 5.9462 $412.79

. $82.56

0172 Level I Partial Hospitalization (3 services) for

CMHCs P 1.3595 $94.38

. $18.88

0173 Level II Partial Hospitalization (4 or more services) for

CMHCs P 1.5798 $109.67

. $21.94

0174 Level IV

Laparoscopy T 107.5115 "$7,463.45" "$1,962.55" "$1,492.69"

0175 Level I Partial Hospitalization (3 services) for Hospital-based

PHPs P 2.2572 $156.69

. $31.34

0176 Level II Partial Hospitalization (4 or more services) for Hospital-based

PHPs P 2.6400 $183.27

. $36.66

0181 Level II Male Genital

Procedures T 34.3803 "$2,386.68" $598.48 $477.34

0183 Level I Male Genital

Procedures T 23.7235 "$1,646.89"

. $329.38

0184 Prostate

Biopsy T 14.2476 $989.07

. $197.82

0188 Level II Female Reproductive

Proc T 1.6099 $111.76

. $22.36

0189 Level III Female Reproductive

Proc T 3.6121 $250.75

. $50.15

0190 Level I

Hysteroscopy T 23.1868 "$1,609.63" $424.28 $321.93

0191 Level I Female Reproductive

Proc T 0.1274 $8.84 $1.85 $1.770192 Level IV Female Reproductive

Proc T 7.0332 $488.24

. $97.65

0193 Level V Female Reproductive

Proc T 20.7771 "$1,442.35"

. $288.47

0195 Level VI Female Reproductive

Procedures T 35.9320 "$2,494.40"

. $498.88

0202 Level VII Female Reproductive

Procedures T 45.5816 "$3,164.27" $981.50 $632.86

0203 Level IV Nerve

Injections T 12.9066 $895.98

. $179.20

0204 Level I Nerve

Injections T 2.7693 $192.24 $40.13 $38.45

0206 Level II Nerve

Injections T 3.9371 $273.31

. $54.67

0207 Level III Nerve

Injections T 7.5480 $523.98

. $104.80

0208 Laminotomies and

Laminectomies T 51.1173 "$3,548.56"

. $709.72

0209 "Level II Extended EEG, Sleep, and Cardiovascular

Studies" S 11.3894 $790.65 $268.73 $158.13

0213 "Level I Extended EEG, Sleep, and Cardiovascular

Studies" S 2.3958 $166.32 $53.48 $33.27

0215 Level I Nerve and Muscle

Tests S 0.6352 $44.10

. $8.82

0216 Level III Nerve and Muscle

Tests S 2.6231 $182.10

. $36.42

0218 Level II Nerve and Muscle

Tests S 1.1945 $82.92

. $16.59

0220 Level I Nerve

Procedures T 19.0626 "$1,323.33"

. $264.67

0221 Level II Nerve

Procedures T 37.4067 "$2,596.77"

. $519.36

0224 Implantation of

Catheter/Reservoir/Shunt T 42.5188 "$2,951.66"

. $590.340227 Implantation of Drug Infusion

Device T 190.0513 "$13,193.36"

. "$2,638.68"

0229 Level II Endovascular Revascularization of the Lower Extremity

T 114.2626 "$7,932.11"

. "$1,586.43"

0230 Level I Eye Tests &

Treatments S 0.6929 $48.10

. $9.62

0231 Level III Eye Tests &

Treatments S 2.3088 $160.28

. $32.06

0232 Level I Anterior Segment Eye

Procedures T 2.9435 $204.34 $42.27 $40.87

0233 Level III Anterior Segment Eye

Procedures T 16.8777 "$1,171.65"

. $234.33

0234 Level IV Anterior Segment Eye

Procedures T 25.2649 "$1,753.89" $511.31 $350.78

0235 Level I Posterior Segment Eye

Procedures T 4.9132 $341.07

. $68.22

0237 Level II Posterior Segment Eye

Procedures T 22.7865 "$1,581.84"

. $316.37

0238 Level I Repair and Plastic Eye

Procedures T 3.3278 $231.02

. $46.21

0239 Level II Repair and Plastic Eye

Procedures T 8.3090 $576.81

. $115.37

0240 Level III Repair and Plastic Eye

Procedures T 20.3065 "$1,409.68" $296.20 $281.94

0241 Level IV Repair and Plastic Eye

Procedures T 27.0493 "$1,877.76" $383.45 $375.56

0242 Level V Repair and Plastic Eye

Procedures T 40.9376 "$2,841.89" $597.36 $568.38

0243 Strabismus/Muscle

Procedures T 25.2851 "$1,755.29" $415.27 $351.06

0244 Corneal and Amniotic Membrane

Transplant T 38.4709 "$2,670.65" $800.09 $534.130245 Level I Cataract Procedures without IOL

Insert T 15.2776 "$1,060.57"

. $212.12

0246 Cataract Procedures with IOL

Insert T 24.0158 "$1,667.18" $488.94 $333.44

0247 Laser Eye

Procedures T 5.5801 $387.37 $104.31 $77.48

0249 Level II Cataract Procedures without IOL

Insert T 30.7811 "$2,136.82" $516.99 $427.37

0250 Level I ENT

Procedures T 1.0875 $75.49 $24.28 $15.10

0251 Level II ENT

Procedures T 3.3531 $232.77

. $46.56

0252 Level III ENT

Procedures T 8.0353 $557.81

. $111.57

0253 Level IV ENT

Procedures T 16.9180 "$1,174.45" $277.61 $234.89

0254 Level V ENT

Procedures T 25.1379 "$1,745.07"

. $349.02

0255 Level II Anterior Segment Eye

Procedures T 7.8512 $545.03 $124.97 $109.01

0256 Level VI ENT

Procedures T 45.1286 "$3,132.83"

. $626.57

0259 Level VII ENT

Procedures T 395.1320 "$27,430.06" "$7,545.06" "$5,486.02"

0260 Level I Plain Film Except

Teeth X 0.6418 $44.55

. $8.91

0261 Level II Plain Film Except Teeth Including Bone Density

Measurement X 1.0831 $75.19

. $15.04

0262 Plain Film of

Teeth X 0.4650 $32.28

. $6.46

0263 Level I Miscellaneous Radiology

Procedures X 3.3928 $235.53

. $47.11

0265 Level I Diagnostic and Screening

Ultrasound S 0.8995 $62.44 $22.26 $12.490266 Level II Diagnostic and Screening

Ultrasound S 1.3711 $95.18 $36.80 $19.04

0267 Level III Diagnostic and Screening

Ultrasound S 2.1881 $151.90 $59.41 $30.38

0269 Level II Echocardiogram Without Contrast

S 5.5306 $383.93

. $76.79

0270 Level III Echocardiogram Without Contrast

S 8.1675 $566.99 $133.61 $113.40

0272 Fluoroscopy X 1.2481 $86.64 $30.47 $17.33

0274 Myelography S 6.9677 $483.70

. $96.74

0275 Arthrography S 3.9868 $276.76 $68.90 $55.36

0276 Level I Digestive

Radiology S 1.2290 $85.32 $33.87 $17.07

0277 Level II Digestive

Radiology S 2.0083 $139.42 $52.93 $27.89

0278 Diagnostic

Urography S 2.5896 $179.77 $58.44 $35.96

0279 Level II Angiography and

Venography S 29.6734 "$2,059.93"

. $411.99

0280 Level III Angiography and

Venography S 49.6711 "$3,448.17"

. $689.64

0282 Miscellaneous Computed Axial

Tomography S 1.5453 $107.27 $35.74 $21.46

0283 Computed Tomography with

Contrast S 4.2806 $297.16 $95.77 $59.44

0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with

Contrast S 6.1872 $429.52 $144.34 $85.91

0288 Bone Density:Axial

Skeleton S 1.0215 $70.91

. $0.00

0293 Level VI Anterior Segment Eye

Procedures T 117.7956 "$8,177.37"

. "$1,635.48"0299 Hyperthermia and Radiation Treatment

Procedures S 5.6094 $389.40

. $77.88

0300 Level I Radiation

Therapy S 1.3628 $94.61

. $18.93

0301 Level II Radiation

Therapy S 2.3680 $164.39

. $32.88

0303 Treatment Device

Construction X 2.7910 $193.75 $64.95 $38.75

0304 Level I Therapeutic Radiation Treatment

Preparation X 1.4946 $103.76 $34.39 $20.76

0305 Level II Therapeutic Radiation Treatment

Preparation X 3.7009 $256.92 $86.44 $51.39

0307 Myocardial Positron Emission Tomography (PET)

imaging S 13.2711 $921.28

. $184.26

0308 Non-Myocardial Positron Emission Tomography (PET)

imaging S 14.6171 "$1,014.72"

. $202.95

0310 Level III Therapeutic Radiation Treatment

Preparation X 13.2460 $919.54 $322.74 $183.91

0312 Radioelement

Applications S 4.7014 $326.37

. $65.28

0313 Brachytherapy S 9.8659 $684.89 $258.98 $136.98

0315 Level II Implantation of Neurostimulator Generator

S 284.8462 "$19,774.02"

. "$3,954.81"

0317 Level II Miscellaneous Radiology

Procedures X 6.2675 $435.09

. $87.02

0318 Implantation of Cranial Neurostimulator Pulse Generator and Electrode

S 337.4240 "$23,423.97" "$9,121.76" "$4,684.80"

0319 Level III Endovascular Revascularization of the Lower

Extremity T 202.3898 "$14,049.90" "$5,559.48" "$2,809.98"

0320 Electroconvulsive

Therapy S 5.9679 $414.29

. $82.86

0322 Brief Individual

Psychotherapy S 1.0957 $76.06

. $15.220323 Extended Individual

Psychotherapy S 1.5885 $110.27

. $22.06

0324 Family

Psychotherapy S 1.8739 $130.09

. $26.02

0325 Group

Psychotherapy S 0.7798 $54.13 $11.54 $10.83

0330 Dental

Procedures S 9.5583 $663.54

. $132.71

0331 Combined Abdomen and Pelvis CT without Contrast

S 5.8040 $402.91 $155.78 $80.59

0332 Computed Tomography without

Contrast S 2.7424 $190.38 $73.61 $38.08

0333 Computed Tomography without Contrast followed by

Contrast S 4.7716 $331.24 $115.09 $66.25

0334 Combined Abdomen and Pelvis CT with Contrast

S 8.2338 $571.59 $184.21 $114.32

0336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without

Contrast S 4.8219 $334.74 $131.90 $66.95

0337 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast

followed by

Contrast S 7.6393 $530.32 $196.43 $106.07

0340 Minor Ancillary

Procedures X 0.6739 $46.78

. $9.36

0341 Skin

Tests X 0.0776 $5.39 $2.02 $1.08

0342 Level I

Pathology X 0.1639 $11.38

. $2.28

0343 Level III

Pathology X 0.5225 $36.27 $10.78 $7.26

0344 Level IV

Pathology X 0.8204 $56.95 $15.56 $11.39

0345 Level I Transfusion Laboratory

Procedures X 0.2109 $14.64

. $2.930346 Level II Transfusion Laboratory

Procedures X 0.3580 $24.85

. $4.97

0347 Level III Transfusion Laboratory

Procedures X 0.6541 $45.41

. $9.09

0350 Administration of flu and PPV

vaccine S 0.3780 $26.24

. $0.00

0360 Level I Alimentary

Tests X 1.7147 $119.03 $33.57 $23.81

0361 Level II Alimentary

Tests X 4.1026 $284.80 $83.23 $56.96

0363 Level I Otorhinolaryngologic Function

Tests X 0.9462 $65.69 $17.10 $13.14

0364 Level I

Audiometry X 0.4896 $33.99 $7.06 $6.80

0365 Level II

Audiometry X 1.2340 $85.66 $18.14 $17.14

0366 Level III

Audiometry X 1.6976 $117.85 $23.61 $23.57

0367 Level I Pulmonary

Test X 0.7369 $51.16 $13.76 $10.24

0368 Level II Pulmonary

Tests X 0.8927 $61.97 $20.93 $12.40

0369 Level III Pulmonary

Tests X 2.6420 $183.41 $37.27 $36.69

0370 Allergy

Tests X 1.3506 $93.76

. $18.76

0373 Level I Neuropsychological

Testing X 1.3767 $95.57

. $19.12

0375 Ancillary Outpatient Services When Patient

Expires S 79.4058 "$5,512.35"

. "$1,102.47"

0377 Level II Cardiac

Imaging S 9.7483 $676.73

. $135.35

0378 Level II PulmonaryImaging S 4.5059 $312.80 $120.71 $62.56

0381 Single Allergy

Tests X 0.4731 $32.84

. $6.57

0382 Level II Neuropsychological

Testing X 2.6658 $185.06

. $37.02

0383 Cardiac Computed Tomographic

Imaging S 3.7294 $258.89

. $51.78

0384 GI Procedures with

Stents T 29.0233 "$2,014.80"

. $402.96

0385 Level I Prosthetic Urological

Procedures S 103.8680 "$7,210.52"

. "$1,442.11"

0386 Level II Prosthetic Urological

Procedures S 168.5335 "$11,699.60"

. "$2,339.92"

0387 Level II

Hysteroscopy T 37.9124 "$2,631.88" $650.74 $526.38

0388 Discography S 23.0551 "$1,600.49"

. $320.10

0389 Level I Non-imaging Nuclear

Medicine S 1.5133 $105.05 $26.88 $21.01

0390 Level I Endocrine

Imaging S 1.8660 $129.54 $46.52 $25.91

0391 Level II Endocrine

Imaging S 3.1750 $220.41 $65.46 $44.09

0392 Level II Non-imaging Nuclear

Medicine S 2.5360 $176.05 $42.39 $35.21

0393 Hematologic Processing &

Studies S 6.3038 $437.61

. $87.53

0394 Hepatobiliary

Imaging S 4.1587 $288.70 $90.78 $57.74

0395 GI Tract

Imaging S 3.4576 $240.03 $87.01 $48.01

0396 Bone

Imaging S 3.5140 $243.94 $93.91 $48.790397 Vascular

Imaging S 2.4220 $168.14 $38.85 $33.63

0398 Level I Cardiac

Imaging S 4.2252 $293.31 $93.33 $58.67

0400 Hematopoietic

Imaging S 3.7132 $257.77 $91.24 $51.56

0401 Level I Pulmonary

Imaging S 2.8425 $197.33 $71.16 $39.47

0402 Level II Nervous System

Imaging S 8.7081 $604.52

. $120.91

0403 Level I Nervous System

Imaging S 3.3656 $233.64 $70.43 $46.73

0404 Renal and Genitourinary

Studies S 4.5715 $317.35 $81.14 $63.47

0406 Level I Tumor/Infection

Imaging S 4.0374 $280.28 $85.03 $56.06

0407 Level I Radionuclide

Therapy S 3.2808 $227.75 $78.13 $45.55

0408 Level III Tumor/Infection

Imaging S 13.7263 $952.88

. $190.58

0409 Red Blood Cell

Tests X 0.1103 $7.66 $2.16 $1.54

0412 IMRT Treatment

Delivery S 6.4422 $447.22

. $89.45

0413 Level II Radionuclide

Therapy S 4.0894 $283.89

. $56.78

0414 Level II Tumor/Infection

Imaging S 6.9811 $484.63

. $96.93

0415 Level II Endoscopy Lower

Airway T 29.1250 "$2,021.86" $459.92 $404.38

0419 Level II Upper GI Procedures

T 12.5693 $872.56 $204.51 $174.52

0422 Level III Upper GI

Procedures T 25.4890 "$1,769.45"

. $353.890423 Level II Percutaneous Abdominal and Biliary

Procedures T 57.1703 "$3,968.76"

. $793.76

0424 Level II Small Intestine Endoscopy

T 15.8412 "$1,099.70" $239.49 $219.94

0425 Level II Arthroplasty or Implantation with

Prosthesis T 130.4476 "$9,055.67"

. "$1,811.14"

0426 Level II Strapping and Cast

Application S 2.7059 $187.84

. $37.57

0427 Level II Tube or Catheter Changes or

Repositioning T 16.2153 "$1,125.67"

. $225.14

0428 Level III Sigmoidoscopy and

Anoscopy T 23.9719 "$1,664.13"

. $332.83

0429 Level V Cystourethroscopy and other Genitourinary

Procedures T 45.8647 "$3,183.93"

. $636.79

0432 Health and Behavior

Services S 0.4940 $34.29

. $6.86

0433 Level II

Pathology X 0.2464 $17.11 $5.17 $3.43

0434 Cardiac Defect

Repair T 166.2005 "$11,537.64"

. "$2,307.53"

0436 Level I Drug

Administration S 0.3780 $26.24

. $5.25

0437 Level II Drug

Administration S 0.5280 $36.65

. $7.33

0438 Level III Drug

Administration S 1.0547 $73.22

. $14.65

0439 Level IV Drug

Administration S 1.9117 $132.71

. $26.55

0440 Level V Drug

Administration S 3.0395 $211.00

. $42.20

0442 Dosimetric Drug

Administration S 22.9208 "$1,591.16"

. $318.240604 Level 1 Hospital Clinic

Visits V 0.6941 $48.18

. $9.64

0605 Level 2 Hospital Clinic

Visits V 1.0430 $72.41

. $14.49

0606 Level 3 Hospital Clinic

Visits V 1.4647 $101.68

. $20.34

0607 Level 4 Hospital Clinic

Visits V 1.9242 $133.58

. $26.72

0608 Level 5 Hospital Clinic

Visits V 2.4718 $171.59

. $34.32

0609 Level 1 Type A Emergency

Visits V 0.7290 $50.61 $12.12 $10.13

0613 Level 2 Type A Emergency

Visits V 1.2424 $86.25 $20.73 $17.25

0614 Level 3 Type A Emergency

Visits V 1.9769 $137.24 $33.86 $27.45

0615 Level 4 Type A Emergency

Visits V 3.1815 $220.86 $48.11 $44.18

0616 Level 5 Type A Emergency

Visits V 4.7283 $328.24 $72.57 $65.65

0617 Critical

Care S 6.8172 $473.25 $104.95 $94.65

0618 Trauma Response with Critical

Care S 11.6401 $808.06

. $161.62

0621 Level I Vascular Access

Procedures T 11.1622 $774.88

. $154.98

0622 Level II Vascular Access

Procedures T 25.1290 "$1,744.46"

. $348.90

0623 Level III Vascular Access

Procedures T 30.2967 "$2,103.20"

. $420.64

0624 Phlebotomy and Minor Vascular Access Device

Procedures X 0.6235 $43.28 $12.56 $8.66

0626 Level 1 Type B Emergency

Visits V 0.5673 $39.38

. $7.880627 Level 2 Type B Emergency

Visits V 0.8183 $56.81

. $11.37

0628 Level 3 Type B Emergency

Visits V 1.3027 $90.43

. $18.09

0629 Level 4 Type B Emergency

Visits V 1.9652 $136.42

. $27.29

0630 Level 5 Type B Emergency

Visits V 3.7640 $261.30

. $52.26

0648 Level IV Breast

Surgery T 61.6690 "$4,281.06"

. $856.22

0651 Complex Interstitial Radiation Source

Application S 12.4760 $866.08

. $173.22

0652 Insertion of Intraperitoneal and Pleural

Catheters T 30.6257 "$2,126.04"

. $425.21

0653 Vascular Reconstruction/Fistula Repair with

Device T 43.1404 "$2,994.81"

. $598.97

0654 Insertion/Replacement of a Permanent Dual Chamber

Pacemaker T 100.4629 "$6,974.13"

. "$1,394.83"

0655 Insertion/Replacement/Conversion of a Permanent Dual Chamber Pacemaker or Pacing

Electrode T 136.0608 "$9,445.34"

. "$1,889.07"

0656 Transcatheter Placement of Intracoronary Drug-Eluting

Stents T 104.4584 "$7,251.50"

. "$1,450.30"

0659 Hyperbaric

Oxygen S 1.4834 $102.98

. $20.60

0660 Level II Otorhinolaryngologic Function

Tests X 1.8827 $130.70 $27.10 $26.14

0661 Level V

Pathology X 2.3755 $164.91

. $32.99

0662 CT

Angiography S 4.8432 $336.21 $113.59 $67.25

0664 Level I Proton Beam Radiation

Therapy S 14.2952 $992.37

. $198.480665 Bone

Density:AppendicularSkeleton S 0.4570 $31.72

. $0.00

0667 Level II Proton Beam Radiation

Therapy S 18.7001 "$1,298.16"

. $259.64

0668 Level I Angiography and

Venography S 9.4312 $654.71

. $130.95

0672 Level III Posterior Segment Eye

Procedures T 41.3248 "$2,868.77"

. $573.76

0673 Level V Anterior Segment Eye

Procedures T 41.7832 "$2,900.59" $632.65 $580.12

0674 Prostate

Cryoablation T 111.0864 "$7,711.62"

. "$1,542.33"

0676 Thrombolysis and Other Device Revisions

T 2.3410 $162.51

. $32.51

0678 External

Counterpulsation T 1.3160 $91.36

. $18.28

0679 Level II Resuscitation and

Cardioversion S 5.3123 $368.78 $94.48 $73.76

0680 Insertion of Patient Activated Event

Recorders S 78.4050 "$5,442.88"

. "$1,088.58"

0683 Level II

Photochemotherapy S 2.9704 $206.21

. $41.25

0685 Level III Needle Biopsy/Aspiration Except Bone

Marrow T 9.7281 $675.32

. $135.07

0687 Revision/Removal of Neurostimulator

Electrodes T 20.7466 "$1,440.23" $382.52 $288.05

0688 Revision/Removal of Neurostimulator Pulse Generator

Receiver T 31.3873 "$2,178.91" $768.94 $435.79

0690 Level I Electronic Analysis of

Devices S 0.5148 $35.74 $8.67 $7.15

0691 Level III Electronic Analysis of

Devices S 2.4153 $167.67

. $33.54

0692 Level II Electronic Analysis of

Devices S 1.6659 $115.65

. $23.130694 Mohs

Surgery T 5.3689 $372.71 $91.69 $74.55

0697 Level I Echocardiogram Without Contrast

S 3.1535 $218.92

. $43.79

0698 Level II Eye Tests &

Treatments S 1.4030 $97.40

. $19.48

0699 Level IV Eye Tests &

Treatments T 15.6140 "$1,083.92"

. $216.79

0701 Sr89

strontium K $641.83

. $128.37

0726 Dexrazoxane HCl

injection K $274.42

. $54.89

0728 Filgrastim 300 mcg

injection K $238.72

. $47.75

0731 Sargramostim

injection K $23.62

. $4.73

0735 Ampho b cholesteryl

sulfate K $13.74

. $2.75

0736 Amphotericin b liposome

inj K $14.77

. $2.96

0738 Rasburicase K $183.08

. $36.62

0747 Chlorothiazide sodium

inj K $272.64

. $54.53

0751 Mechlorethamine hcl

inj K $154.88

. $30.98

0752 Dactinomycin

injection K $529.42

. $105.89

0759 "Naltrexone, depot

form" K $2.77

. $0.56

0800 Leuprolide

acetate K $547.54

. $109.51

0802 Etoposideoral K $34.34

. $6.87

0807 Aldesleukin

injection K $915.45

. $183.09

0809 Bcg live intravesical

vac K $114.38

. $22.88

0810 Goserelin acetate

implant K $195.16

. $39.04

0812 Carmustine

injection K $172.56

. $34.52

0814 Asparaginase

injection K $62.07

. $12.42

0820 Daunorubicin

injection K $13.16

. $2.64

0821 Daunorubicin citrate

inj K $56.58

. $11.32

0823 Docetaxel

injection K $20.84

. $4.17

0825 Nelarabine

injection K $110.19

. $22.04

0827 Floxuridine

injection K $36.60

. $7.32

0828 Gemcitabine hcl

injection K $111.40

. $22.28

0831 Ifosfomide

injection K $31.21

. $6.25

0832 Idarubicin hcl

injection K $46.43

. $9.29

0835 Cosyntropin injection

NOS K $99.76

. $19.96

0836 Interferon alfa-2b

inj K $16.19

. $3.24

0838 Interferon gamma 1-b

inj K $549.62

. $109.930840 Inj melphalan

hydrochl K "$1,272.01"

. $254.41

0843 Pegaspargase

injection K "$2,675.40"

. $535.08

0844 Pentostatin

injection K "$1,068.16"

. $213.64

0849 Rituximab

injection K $599.16

. $119.84

0850 Streptozocin

injection K $264.81

. $52.97

0851 Thiotepa

injection K $106.54

. $21.31

0856 Porfimer sodium

injection K "$3,017.82"

. $603.57

0858 Inj

cladribine K $23.59

. $4.72

0861 Leuprolide acetate

injeciton K $4.88

. $0.98

0864 Mitoxantrone

hydrochl K $33.95

. $6.79

0865 Interferon alfa-n3

inj K $20.87

. $4.18

0868 Oral

aprepitant K $5.90

. $1.18

0873 Hyalgan/supartz inj per

dose K $88.80

. $17.76

0874 Synvisc or

synvisc-one K $11.81

. $2.37

0875 Euflexxa inj per

dose K $147.16

. $29.44

0877 Orthovisc inj per

dose K $167.00

. $33.40

0884 Rho d immune globulininj K $82.16

. $16.44

0887 Azathioprine

parenteral K $104.77

. $20.96

0890 Lymphocyte immune

globulin K $542.36

. $108.48

0900 Alglucerase

injection K $41.19

. $8.24

0901 Alpha 1 proteinase

inhibitor K $3.79

. $0.76

0902 "Injection,onabotulinumtoxinA" K $5.38

. $1.08

0903 Cytomegalovirus imm IV

/vial K $922.07

. $184.42

0910 Interferon beta-1b / .25

MG K $197.14

. $39.43

0913 Ganciclovir long act

implant K "$16,640.00"

. "$3,328.00"

0917 Adenosine

injection K $89.99

. $18.00

0925 Factor

viii K $0.87

. $0.18

0927 Factor viii

recombinant K $1.09

. $0.22

0928 Factor ix

complex K $0.85

. $0.17

0929 Anti-inhibitor K $1.57

. $0.32

0931 Factor IX

non-recombinant K $0.88

. $0.18

0932 Factor IX

recombinant K $1.13

. $0.23

0933 Gamma globulin > 10 CC

inj K $179.06

. $35.82

0934 "Capecitabine,oral" K $22.48

. $4.50

0943 Octagam

injection K $55.80

. $11.16

0944 Gammagard liquid

injection K $37.67

. $7.54

0945 Rhophylac

injection K $5.09

. $1.02

0946 Hepagam b im

injection K $57.07

. $11.42

0947 Flebogamma

injection K $35.04

. $7.01

0948 Gamunex

injection K $36.91

. $7.39

0949 "Frozen plasma, pooled,

sd" R 1.0221 $70.95

. $14.19

0950 Whole blood for

transfusion R 2.7926 $193.86

. $38.78

0951 Reclast

injection K $218.47

. $43.70

0952 Cryoprecipitate each

unit R 1.0975 $76.19

. $15.24

0954 RBC leukocytes

reduced R 2.8046 $194.70

. $38.94

0955 "Plasma, frz between

8-24hour" R 1.0092 $70.06

. $14.02

0956 "Plasma protein

fract,5%,50ml" R 0.2513 $17.45

. $3.49

0957 "Platelets, each

unit" R 1.2522 $86.93

. $17.39

0958 Plaelet rich plasma

unit R 1.9703 $136.78

. $27.36

0959 Red blood cells

unit R 2.1382 $148.43

. $29.690960 Washed red blood cells

unit R 4.0969 $284.41

. $56.89

0961 "Albumin (human),5%,

50ml" K $20.37

. $4.08

0963 "Albumin (human), 5%, 250

ml" K $67.07

. $13.42

0964 "Albumin (human), 25%, 20

ml" K $29.16

. $5.84

0965 "Albumin (human), 25%,

50ml" K $70.39

. $14.08

0966 "Plasmaprotein

fract,5%,250ml" R 1.2214 $84.79

. $16.96

0967 Blood split

unit R 2.2455 $155.88

. $31.18

0968 Platelets leukoreduced

irrad R 2.0418 $141.74

. $28.35

0969 RBC leukoreduced

irradiated R 3.7077 $257.39

. $51.48

1009 Cryoprecipitatereducedplasma R 1.1839 $82.19

. $16.44

1010 "Blood, l/r,

cmv-neg" R 2.7475 $190.73

. $38.15

1011 "Platelets, hla-m, l/r,

unit" R 11.4189 $792.70

. $158.54

1013 Platelets leukocytes

reduced R 1.7459 $121.20

. $24.24

1015 Injection glatiramer

acetate K $95.57

. $19.12

1016 "Blood, l/r,

froz/degly/wash" R 1.8650 $129.47

. $25.90

1017 "Plt, aph/pher, l/r,

cmv-neg" R 5.7123 $396.55

. $79.31

1018 "Blood, l/r,

irradiated" R 2.1603 $149.97

. $30.001019 Plate pheres leukoredu

irrad R 9.9046 $687.58

. $137.52

1020 "Plt, pher, l/r cmv-neg,

irr" R 8.6696 $601.84

. $120.37

1021 "RBC, frz/deg/wsh, l/r,

irrad" R 6.2606 $434.61

. $86.93

1022 "RBC, l/r, cmv-neg,

irrad" R 4.0635 $282.09

. $56.42

1023 Pralidoxime chloride

inj K $88.57

. $17.72

1052 "Injection,

voriconazole" K $6.02

. $1.21

1064 "I131 iodide cap,

rx" K $17.58

. $3.52

1083 Adalimumab

injection K $394.16

. $78.84

1084 Denileukin diftitox

inj K "$1,559.54"

. $311.91

1086 Temozolomide K $9.31

. $1.87

1138 "Hepagam b intravenous,

inj" K $57.07

. $11.42

1139 Protein c

concentrate K $12.50

. $2.50

1142 Supprelin LA

implant K "$15,184.53"

. "$3,036.91"

1150 "I131 iodide sol,

rx" K $13.26

. $2.66

1166 Cytarabine liposome

inj K $479.02

. $95.81

1167 "Inj, epirubicin

hcl" K $1.87

. $0.38

1168 "Inj,temsirolimus" K $49.87

. $9.98

1178 Busulfan

injection K $16.29

. $3.26

1203 Verteporfin

injection K $9.55

. $1.91

1207 "Octreotide injection,

depot" K $113.48

. $22.70

1213 Antihemophilic viii/vwf

comp K $0.90

. $0.18

1214 Inj IVIG privigen 500

mg K $34.45

. $6.89

1221 Dimethyl sulfoxide

50% K $82.68

. $16.54

1222 Pentastarch 10%

solution K $158.76

. $31.76

1226 Inj streptokinase /250000

IU K $47.57

. $9.52

1232 Mitomycin 5 MG

inj K $20.36

. $4.08

1235 Valrubicin

injection K $946.64

. $189.33

1236 Levoleucovorin

injection K $1.78

. $0.36

1237 Inj iron

dextran K $11.59

. $2.32

1238 Topotecan

oral K $76.40

. $15.28

1239 Rotavirus vacc 2 dose

oral K $100.56

. $20.12

1240 Apligraf skin

sub K $34.06

. $6.82

1241 Oasis wound matrix skin

sub K $4.68

. $0.941243 Integra BMWD skin

sub K $15.45

. $3.09

1244 Integra DRT skin

sub K $10.95

. $2.19

1245 Dermagraft skin

sub K $39.39

. $7.88

1246 Graftjacket skin

sub K $92.79

. $18.56

1247 Integra matrix skin

sub K $20.95

. $4.19

1248 Primatrix skin

sub K $31.67

. $6.34

1249 Cymetra

allograft K $334.07

. $66.82

1250 Graftjacket express

allograf K $334.07

. $66.82

1251 Integra flowable wound

matri K $972.75

. $194.55

1252 Gammagraft skin

sub K $7.17

. $1.44

1253 Triamcinolone A inj

PRS-free K $3.17

. $0.64

1263 Antithrombin iii

injection K $2.48

. $0.50

1268 Xyntha

inj K $1.05

. $0.21

1270 Alloderm skin

sub K $31.11

. $6.23

1272 Acetylcysteine injection K

$2.67

. $0.54

1274 Edetate calcium disodium inj K

$192.07

. $38.42

1275 "Vivaglobin, inj" K$7.11

. $1.43

1279 Factor VIII

(porcine) K $1.17

. $0.24

1280 Corticotropin

injection K "$2,395.22"

. $479.05

1281 Bevacizumab

injection K $1.47

. $0.30

1287 Alloskin skin

sub K $6.07

. $1.22

1289 AbobotulinumtoxinA K $7.41

. $1.49

1290 Human fibrinogen conc

inj K $71.52

. $14.31

1291 Rilonacept

injection K $23.63

. $4.73

1295 Sm 153

lexidronam K "$7,555.71"

. "$1,511.15"

1296 Degarelix

injection K $2.79

. $0.56

1297 "Ferumoxytol,

non-esrd" K $0.69

. $0.14

1304 Perphenazine

injeciton K $30.91

. $6.19

1306 Urea

injection K $82.18

. $16.44

1307 Oral

busulfan K $3.59

. $0.72

1308 Mecasermin

injection K $20.18

. $4.04

1311 Canakinumab

injection K $87.45

. $17.49

1312 Hizentra

injection K $7.15

. $1.431327 Imiglucerase

injection K $41.19

. $8.24

1331 Olanzapine long-acting

inj K $2.70

. $0.54

1332 Antithrombin

recombinant K $101.40

. $20.28

1338 "Methyl aminolevulinate,

top" K $68.27

. $13.66

1339 Oral fludarabine

phosphate G $79.44

. $15.89

1340 "Collagenase, clost hist

inj" G $37.51

. $7.51

1341 Amobarbital 125 MG

inj K $23.38

. $4.68

1342 Matristem

micromatrix K $3.13

. $0.63

1343 Ganciclovir sodium

injection K $62.51

. $12.51

1344 Gonadorelin hydroch/ 100

mcg K $94.82

. $18.97

1345 Theraskin K $20.32

. $4.07

1349 Anidulafungin

injection K $1.29

. $0.26

1350 Topotecan

injection K $19.30

. $3.86

1351 Matristem wound

matrix K $6.04

. $1.21

1355 Itraconazole

injection K $359.59

. $71.92

1356 Inj desmopressin

acetate K $3.93

. $0.79

1357 Inj protirelin per 250

mcg K $27.03

. $5.411358 Phentolaine mesylate

inj K $56.35

. $11.27

1359 Foscarnet sodium

injection K $13.06

. $2.62

1491 New Technology - Level IA

($0-$10) S $5.00

. $1.00

1492 New Technology - Level IB

($10-$20) S $15.00

. $3.00

1493 New Technology - Level IC

($20-$30) S $25.00

. $5.00

1494 New Technology - Level ID

($30-$40) S $35.00

. $7.00

1495 New Technology - Level IE

($40-$50) S $45.00

. $9.00

1496 New Technology - Level IA

($0-$10) T $5.00

. $1.00

1497 New Technology - Level

IB($10-$20) T $15.00

. $3.00

1498 New Technology - Level IC

($20-$30) T $25.00

. $5.00

1499 New Technology - Level

ID($30-$40) T $35.00

. $7.00

1500 New Technology - Level IE

($40-$50) T $45.00

. $9.00

1502 New Technology - Level II ($50 -

$100) S $75.00

. $15.00

1503 New Technology - Level III ($100 -

$200) S $150.00

. $30.00

1504 New Technology - Level IV ($200 -

$300) S $250.00

. $50.00

1505 New Technology - Level V ($300 -

$400) S $350.00

. $70.00

1506 New Technology - Level VI ($400 -$500) S $450.00

. $90.00

1507 New Technology - Level VII ($500 -

$600) S $550.00

. $110.00

1508 New Technology - Level VIII ($600 -

$700) S $650.00

. $130.00

1509 New Technology - Level IX ($700 -

$800) S $750.00

. $150.00

1510 New Technology - Level X ($800 -

$900) S $850.00

. $170.00

1511 New Technology - Level XI ($900 -

$1000) S $950.00

. $190.00

1512 New Technology - Level XII ($1000 -

$1100) S "$1,050.00"

. $210.00

1513 New Technology - Level XIII ($1100 -

$1200) S "$1,150.00"

. $230.00

1514 New Technology - Level XIV ($1200-

$1300) S "$1,250.00"

. $250.00

1515 New Technology - Level XV ($1300 -

$1400) S "$1,350.00"

. $270.00

1516 New Technology - Level XVI ($1400 -

$1500) S "$1,450.00"

. $290.00

1517 New Technology - Level XVII

($1500-$1600) S "$1,550.00"

. $310.00

1518 New Technology - Level XVIII

($1600-$1700) S "$1,650.00"

. $330.00

1519 New Technology - Level IXX

($1700-$1800) S "$1,750.00"

. $350.00

1520 New Technology - Level XX

($1800-$1900) S "$1,850.00"

. $370.00

1521 New Technology - Level XXI

($1900-$2000) S "$1,950.00"

. $390.00

1522 New Technology - Level XXII

($2000-$2500) S "$2,250.00"

. $450.001523 New Technology - Level XXIII

($2500-$3000) S "$2,750.00"

. $550.00

1524 New Technology - Level XXIV

($3000-$3500) S "$3,250.00"

. $650.00

1525 New Technology - Level XXV

($3500-$4000) S "$3,750.00"

. $750.00

1526 New Technology - Level XXVI

($4000-$4500) S "$4,250.00"

. $850.00

1527 New Technology - Level XXVII

($4500-$5000) S "$4,750.00"

. $950.00

1528 New Technology - Level XXVIII

($5000-$5500) S "$5,250.00"

. "$1,050.00"

1529 New Technology - Level XXIX

($5500-$6000) S "$5,750.00"

. "$1,150.00"

1530 New Technology - Level XXX

($6000-$6500) S "$6,250.00"

. "$1,250.00"

1531 New Technology - Level XXXI

($6500-$7000) S "$6,750.00"

. "$1,350.00"

1532 New Technology - Level XXXII

($7000-$7500) S "$7,250.00"

. "$1,450.00"

1533 New Technology - Level XXXIII

($7500-$8000) S "$7,750.00"

. "$1,550.00"

1534 New Technology - Level XXXIV

($8000-$8500) S "$8,250.00"

. "$1,650.00"

1535 New Technology - Level XXXV

($8500-$9000) S "$8,750.00"

. "$1,750.00"

1536 New Technology - Level XXXVI

($9000-$9500) S "$9,250.00"

. "$1,850.00"

1537 New Technology - Level XXXVII

($9500-$10000) S "$9,750.00"

. "$1,950.00"

1539 New Technology - Level II ($50 -

$100) T $75.00

. $15.00

1540 New Technology - Level III ($100 -$200) T $150.00

. $30.00

1541 New Technology - Level IV ($200 -

$300) T $250.00

. $50.00

1542 New Technology - Level V ($300 -

$400) T $350.00

. $70.00

1543 New Technology - Level VI ($400 -

$500) T $450.00

. $90.00

1544 New Technology - Level VII ($500 -

$600) T $550.00

. $110.00

1545 New Technology - Level VIII ($600 -

$700) T $650.00

. $130.00

1546 New Technology - Level IX ($700 -

$800) T $750.00

. $150.00

1547 New Technology - Level X ($800 -

$900) T $850.00

. $170.00

1548 New Technology - Level XI ($900 -

$1000) T $950.00

. $190.00

1549 New Technology - Level XII ($1000 -

$1100) T "$1,050.00"

. $210.00

1550 New Technology - Level XIII ($1100 -

$1200) T "$1,150.00"

. $230.00

1551 New Technology - Level XIV ($1200-

$1300) T "$1,250.00"

. $250.00

1552 New Technology - Level XV ($1300 -

$1400) T "$1,350.00"

. $270.00

1553 New Technology - Level XVI ($1400 -

$1500) T "$1,450.00"

. $290.00

1554 New Technology - Level XVII

($1500-$1600) T "$1,550.00"

. $310.00

1555 New Technology - Level XVIII

($1600-$1700) T "$1,650.00"

. $330.00

1556 New Technology - Level XIX

($1700-$1800) T "$1,750.00"

. $350.001557 New Technology - Level XX

($1800-$1900) T "$1,850.00"

. $370.00

1558 New Technology - Level XXI

($1900-$2000) T "$1,950.00"

. $390.00

1559 New Technology - Level XXII

($2000-$2500) T "$2,250.00"

. $450.00

1560 New Technology - Level XXIII

($2500-$3000) T "$2,750.00"

. $550.00

1561 New Technology - Level XXIV

($3000-$3500) T "$3,250.00"

. $650.00

1562 New Technology - Level XXV

($3500-$4000) T "$3,750.00"

. $750.00

1563 New Technology - Level XXVI

($4000-$4500) T "$4,250.00"

. $850.00

1564 New Technology - Level XXVII

($4500-$5000) T "$4,750.00"

. $950.00

1565 New Technology - Level XXVIII

($5000-$5500) T "$5,250.00"

. "$1,050.00"

1566 New Technology - Level XXIX

($5500-$6000) T "$5,750.00"

. "$1,150.00"

1567 New Technology - Level XXX

($6000-$6500) T "$6,250.00"

. "$1,250.00"

1568 New Technology - Level XXXI

($6500-$7000) T "$6,750.00"

. "$1,350.00"

1569 New Technology - Level XXXII

($7000-$7500) T "$7,250.00"

. "$1,450.00"

1570 New Technology - Level XXXIII

($7500-$8000) T "$7,750.00"

. "$1,550.00"

1571 New Technology - Level XXXIV

($8000-$8500) T "$8,250.00"

. "$1,650.00"

1572 New Technology - Level XXXV

($8500-$9000) T "$8,750.00"

. "$1,750.00"

1573 New Technology - Level XXXVI($9000-$9500) T "$9,250.00"

. "$1,850.00"

1574 New Technology - Level XXXVII

($9500-$10000) T "$9,750.00"

. "$1,950.00"

1605 Abciximab

injection K $515.32

. $103.07

1607 Eptifibatide

injection K $20.31

. $4.07

1608 Etanercept

injection K $203.01

. $40.61

1609 "Rho(D) immune globulin h,

sd" K $18.83

. $3.77

1612 "Daclizumab,

parenteral" K $516.41

. $103.29

1613 Trastuzumab

injection K $69.06

. $13.82

1630 "Hep b ig,

im" K $112.16

. $22.44

1631 Baclofen intrathecal

trial K $72.18

. $14.44

1633 Alefacept K $35.86

. $7.18

1643 "Y90 ibritumomab,

rx" K "$32,078.39"

. "$6,415.68"

1645 "I131 tositumomab,

rx" K "$29,460.02"

. "$5,892.01"

1670 Tetanus immune globulin

inj K $222.97

. $44.60

1675 P32 Na

phosphate K $162.87

. $32.58

1676 P32 chromic

phosphate K $154.15

. $30.83

1683 Basiliximab K "$2,027.27"

. $405.46

1684 Corticorelin ovinetriflutal K $5.06

. $1.02

1685 "Darbepoetin alfa,

non-esrd" K $2.98

. $0.60

1686 "Epoetin alfa,

non-esrd" K $9.57

. $1.92

1687 Digoxin immune fab

(ovine) K $583.90

. $116.78

1688 Ethanolamine

oleate K $147.14

. $29.43

1689 Fomepizole K $6.76

. $1.36

1690 Hemin K $8.33

. $1.67

1693 Lepirudin K $299.56

. $59.92

1694 Ziconotide

injection K $6.48

. $1.30

1695 Nesiritide

injection K $43.93

. $8.79

1696 Palifermin

injection K $11.15

. $2.23

1697 Pegaptanib sodium

injection K "$1,002.20"

. $200.44

1700 Inj secretin synthetic

human K $26.97

. $5.40

1701 Treprostinil

injection K $60.08

. $12.02

1704 "Humate-P,

inj" K $0.87

. $0.18

1705 Factor

viia K $1.50

. $0.30

1709 Azacitidine

injection K $5.16

. $1.04

1710 Clofarabine

injection K $114.37

. $22.881711 Vantas

implant K "$3,223.57"

. $644.72

1712 Paclitaxel protein

bound K $9.21

. $1.85

1716 "Brachytx, non-str,

Gold-198" U 1.0120 $70.25

. $14.05

1717 "Brachytx, non-str, HDR

Ir-192" U 3.1681 $219.93

. $43.99

1719 "Brachytx, NS,

Non-HDRIr-192" U 0.4486 $31.14

. $6.23

1738 Oxaliplatin K $8.36

. $1.68

1739 "Pegademase bovine, 25

iu" K $242.67

. $48.54

1741 "Urofollitropin, 75

iu" K $63.60

. $12.72

1749 "Endo, colon, retro

imaging" H

. .

2210 Methyldopate hcl

injection K $39.24

. $7.85

2616 "Brachytx,

non-str,Yttrium-90" U 232.3017 "$16,126.38"

. "$3,225.28"

2632 Iodine I-125 sodium

iodide U 0.2868 $19.91

. $3.99

2634 "Brachytx, non-str, HA,

I-125" U 0.7908 $54.90

. $10.98

2635 "Brachytx, non-str, HA,

P-103" U 0.3438 $23.87

. $4.78

2636 "Brachy linear,

non-str,P-103" U 0.5112 $35.49

. $7.10

2638 "Brachytx, stranded,

I-125" U 0.6225 $43.21

. $8.65

2639 "Brachytx,non-stranded,I-125" U 0.4992 $34.65

. $6.93

2640 "Brachytx, stranded,

P-103" U 1.0610 $73.65

. $14.73

2641 "Brachytx,

non-stranded,P-103" U 0.9263 $64.30

. $12.86

2642 "Brachytx, stranded,

C-131" U 1.6922 $117.47

. $23.50

2643 "Brachytx,

non-stranded,C-131" U 1.0735 $74.52

. $14.91

2698 "Brachytx, stranded,

NOS" U 0.6225 $43.21

. $8.65

2699 "Brachytx, non-stranded,

NOS" U 0.3438 $23.87

. $4.78

2731 "Immune globulin,

powder" K $30.62

. $6.13

2770 Quinupristin/dalfopristin K $157.23

. $31.45

3041 Bivalirudin K $2.54

. $0.51

3043 Gamma globulin 1 CC

inj K $17.91

. $3.59

3050 Sermorelin acetate

injection K $1.76

. $0.36

7000 Amifostine K $314.05

. $62.81

7011 Oprelvekin

injection K $240.88

. $48.18

7034 Somatropin

injection K $56.09

. $11.22

7035 Teniposide K $316.52

. $63.31

7036 "Urokinase 250,000 IU

inj" K $449.09

. $89.82

7038 Monoclonal

antibodies K "$1,112.14"

. $222.437041 Tirofiban

HCl K $8.83

. $1.77

7042 "Capecitabine,

oral" K $6.81

. $1.37

7043 Infliximab

injection K $58.90

. $11.78

7046 Doxorubicin hcl liposome

inj K $504.27

. $100.86

7048 Alteplase

recombinant K $39.22

. $7.85

7049 Filgrastim 480 mcg

injection K $376.20

. $75.24

7051 Leuprolide acetate

implant K "$4,728.88"

. $945.78

7308 Aminolevulinic acid hcl

top K $138.70

. $27.74

8000 Cardiac Electrophysiologic Evaluation and Ablation

Composite T 161.2626 "$11,194.85"

. "$2,238.97"

8001 LDR Prostate Brachytherapy

Composite T 46.7758 "$3,247.18"

. $649.44

8002 Level I Extended Assessment & Management

Composite V 5.4881 $380.98

. $76.20

8003 Level II Extended Assessment & Management

Composite V 10.2164 $709.22

. $141.85

8004 Ultrasound

Composite S 2.7443 $190.51

. $38.11

8005 CT and CTA without Contrast

Composite S 6.1891 $429.65

. $85.93

8006 CT and CTA with Contrast

Composite S 10.3444 $718.11

. $143.63

8007 MRI and MRA without Contrast

Composite S 9.9875 $693.33

. $138.67

8008 MRI and MRA with ContrastComposite S 14.3459 $995.89

. $199.18

8009 Cardiac Resynchronization Therapy with Defibrillator

Composite T 379.7887 "$26,364.93"

. "$5,272.99"

9001 Linezolid

injection K $33.99

. $6.80

9002 Tenecteplase

injection K $51.95

. $10.39

9004 Gemtuzumab ozogamicin

inj K "$2,637.02"

. $527.41

9005 Reteplase

injection K "$1,332.35"

. $266.47

9006 Tacrolimus

injection K $136.85

. $27.37

9012 Arsenic trioxide

injection K $40.13

. $8.03

9018 "Inj,

rimabotulinumtoxinB" K $10.33

. $2.07

9019 Caspofungin

acetate K $12.13

. $2.43

9022 IM inj interferon beta

1-a K $220.75

. $44.15

9023 Rho d immune

globulin K $24.81

. $4.97

9024 Amphotericin b lipid

complex K $8.76

. $1.76

9032 Baclofen 10 MG

injection K $200.54

. $40.11

9033 Cidofovir

injection K $740.09

. $148.02

9038 Inj estrogen

conjugate K $94.03

. $18.81

9042 Glucagon

hydrochloride K $95.59

. $19.129044 Ibutilide fumarate

injection K $129.32

. $25.87

9104 Antithymocyte globuln

rabbit K $387.17

. $77.44

9108 Thyrotropin

injection K "$1,034.03"

. $206.81

9110 Alemtuzumab

injection K $577.60

. $115.52

9115 Zoledronic

acid K $219.00

. $43.80

9119 "Injection, pegfilgrastim

6mg" K "$2,527.87"

. $505.58

9120 "Injection,

Fulvestrant" K $81.81

. $16.37

9121 "Injection,

argatroban" K $18.71

. $3.75

9122 Triptorelin

pamoate K $193.59

. $38.72

9124 Daptomycin

injection K $0.45

. $0.09

9125 "Risperidone, long

acting" K $4.93

. $0.99

9126 Natalizumab

injection K $9.88

. $1.98

9133 "Rabies ig,

im/sc" K $159.86

. $31.98

9134 "Rabies ig, heat

treated" K $154.18

. $30.84

9135 "Varicella-zoster ig,

im" K $129.48

. $25.90

9137 "Bcg vaccine,

percut" K $112.46

. $22.50

9139 "Rabies vaccine,im" K $190.82

. $38.17

9140 "Rabies vaccine,

id" K $107.83

. $21.57

9143 "Meningococcal vaccine,

sc" K $104.49

. $20.90

9144 "Encephalitis vaccine,

sc" K $100.16

. $20.04

9145 "Meningococcal vaccine,

im" K $83.39

. $16.68

9207 Bortezomib

injection K $39.60

. $7.92

9208 Agalsidase beta

injection K $133.65

. $26.73

9209 Laronidase

injection K $25.08

. $5.02

9210 Palonosetron

hcl K $18.51

. $3.71

9213 Pemetrexed

injection K $51.37

. $10.28

9214 Bevacizumab

injection K $58.72

. $11.75

9215 Cetuximab

injection K $49.52

. $9.91

9217 Leuprolide acetate

suspnsion K $210.96

. $42.20

9224 Galsulfase

injection K $338.26

. $67.66

9225 Fluocinolone acetonide

implt K "$18,980.00"

. "$3,796.00"

9227 Micafungin sodium

injection K $1.02

. $0.21

9228 Tigecycline

injection K $1.22

. $0.259229 Ibandronate sodium

injection K $144.36

. $28.88

9230 Abatacept

injection K $20.26

. $4.06

9231 Decitabine

injection K $30.71

. $6.15

9232 Idursulfase

injection K $446.45

. $89.29

9233 Ranibizumab

injection K $398.10

. $79.62

9234 Alglucosidase alfa

injection K $155.84

. $31.17

9235 Panitumumab

injection K $85.62

. $17.13

9236 Eculizumab

injection K $183.71

. $36.75

9237 "Inj, lanreotide

acetate" K $29.92

. $5.99

9240 "Injection,

ixabepilone" K $62.53

. $12.51

9242 "Injection,

fosaprepitant" K $1.71

. $0.35

9243 Bendamustine

injection K $18.15

. $3.63

9244 Regadenoson

injection K $51.36

. $10.28

9245 Romiplostim

injection K $44.84

. $8.97

9248 "Inj, clevidipine

butyrate" K $6.03

. $1.21

9249 Certolizumab pegol

inj K $3.99

. $0.80

9250 Artiss fibrinsealant K $121.80

. $24.36

9251 C1 esterase inhibitor

inj K $43.78

. $8.76

9252 Plerixafor

injection K $278.36

. $55.68

9253 Temozolomide

injection K $4.86

. $0.98

9254 "Injection,

lacosamide" K $0.15

. $0.03

9255 Paliperidone palmitate

inj K $6.45

. $1.29

9256 Dexamethasone intra

implant K $194.17

. $38.84

9258 Telavancin

injection G $1.96

. $0.40

9259 Pralatrexate

injection G $165.63

. $33.13

9260 Ofatumumab

injection G $45.41

. $9.09

9261 Ustekinumab

injection G $112.30

. $22.46

9263 Ecallantide

injection G $275.28

. $55.06

9264 Tocilizumab

injection G $3.47

. $0.70

9265 Romidepsin

injection G $219.30

. $43.86

9267 Wilate

injection G $70.14

. $14.03

9268 Capsaicin 8%

patch G $25.55

. $5.11

9269 "C-1 esterase,

berinert" G $27.53

. $5.519270 Gammaplex

IVIG G $37.29

. $7.46

9271 Velaglucerase

alfa G $349.88

. $69.98

9272 "Inj,

denosumab" G $14.52

. $2.91

9273 "Sipuleucel-T, per

infusion" G "$32,860.00"

. "$6,572.00"

9274 Crotalidae Poly Immune

Fab G "$2,111.36"

. $422.28

9275 Hexaminolevulinate

HCl G $636.00

. $0.00

9276 Cabazitaxel

injection G $135.05

. $27.01

9277 "Lumizyme, 1

mg" G $14.83

. $2.97

9278 Incobotulinumtoxin

A G $5.57

. $1.12

9279 "Injection,

ibuprofen" G $1.39

. $0.28

9280 "Injection, eribulin

mesylate" G $901.00

. $180.20

9281 "Injection, pegloticase

" G $304.75

. $60.95

9282 "Injection, ceftaroline fosamil

" G $0.72

. $0.15

9300 Omalizumab

injection K $20.64

. $4.13

9358 "SurgiMend,

fetal" K $11.09

. $2.22

9360 "SurgiMend,

neonatal" K $11.59

. $2.32

9363 Integra Meshed Bil WoundMat K $19.17

. $3.84

9367 Endoform Dermal

Template G $4.35

. $0.87

9500 "Platelets,

irradiated" R 2.1768 $151.11

. $30.23

9501 Platelet pheres

leukoreduced R 7.5524 $524.29

. $104.86

9502 Platelet pheresis

irradiated R 7.5964 $527.34

. $105.47

9503 Fr frz plasma donor

retested R 1.2624 $87.64

. $17.53

9504 RBC

deglycerolized R 3.4728 $241.08

. $48.22

9505 RBC

irradiated R 3.3729 $234.15

. $46.83

9506 "Granulocytes, pheresis

unit" R 22.1451 "$1,537.31"

. $307.47

9507 "Platelets,

pheresis" R 6.0636 $420.94

. $84.19

9508 Plasma 1 donor frz w/in 8

hr R 1.0927 $75.86

. $15.18