Addendum A.-Proposed OPPS APCs for CY 

2012

APCGroup Title SIRelative Weight Payment Rate National Unadjusted Copayment 

Minimum Unadjusted Copayment 

0001Level I 

PhotochemotherapyS0.5025$34.88.$6.98

0002Fine Needle 

Biopsy/AspirationT1.7462$121.22.$24.25

0003Bone Marrow 

Biopsy/AspirationT3.9075$271.26.$54.26

0004Level I Needle Biopsy/ Aspiration Except Bone 

MarrowT4.5956$319.03.$63.81

0005Level II Needle Biopsy/Aspiration Except Bone 

MarrowT8.1415$565.18.$113.04

0006Level I Incision & 

DrainageT1.4481$100.53.$20.11

0007Level II Incision & 

DrainageT13.4779$935.64.$187.13

0008Level III Incision and 

DrainageT20.5401"$1,425.89".$285.18

0012Level I Debridement & 

DestructionT0.4047$28.09.$5.62

0013Level II Debridement & 

DestructionT0.9786$67.93.$13.59

0015Level III Debridement & 

DestructionT1.4936$103.69.$20.74

0016Level IV Debridement & 

DestructionT2.8248$196.10.$39.22

0017Level V Debridement & 

DestructionT22.0631"$1,531.62".$306.33

0019Level I Excision/ 

BiopsyT4.8763$338.51.$67.71
0020Level II Excision/ 

BiopsyT8.6164$598.15.$119.63

0021Level III Excision/ 

BiopsyT17.1909"$1,193.39".$238.68

0022Level IV Excision/ 

BiopsyT23.4169"$1,625.60"$350.05$325.12

0028Level I Breast 

SurgeryT25.8383"$1,793.69".$358.74

0029Level II Breast 

SurgeryT33.8417"$2,349.29"$581.52$469.86

0030Level III Breast 

SurgeryT45.0972"$3,130.65"$747.07$626.13

0031Smoking Cessation 

ServicesX0.2941$20.42.$4.09

0034Mental Health Services 

CompositeS2.6400$183.27.$36.66

0035Vascular Puncture and Minor Diagnostic 

ProceduresX0.2717$18.86.$3.78

0037Level IV Needle Biopsy/Aspiration Except Bone 

MarrowT15.3594"$1,066.25"$225.55$213.25

0039Level I Implantation of Neurostimulator 

GeneratorS209.6958"$14,557.08"."$2,911.42"

0040Level I Implantation/Revision/Replacement of Neurostimulator Electrodes 

S62.7889"$4,358.81".$871.77

0041Level I 

ArthroscopyT29.4235"$2,042.58".$408.52

0042Level II 

ArthroscopyT48.4545"$3,363.71"$804.74$672.75

0045Bone/Joint Manipulation Under 

AnesthesiaT15.5166"$1,077.16"$268.44$215.44

0047Arthroplasty without 

ProsthesisT41.2971"$2,866.84".$573.37

0048Level I Arthroplasty or Implantation with 

ProsthesisT60.0335"$4,167.53".$833.51
0049Level I Musculoskeletal Procedures Except Hand and 

FootT22.1674"$1,538.86".$307.78

0050Level II Musculoskeletal Procedures Except Hand and 

FootT32.4101"$2,249.91".$449.99

0051Level III Musculoskeletal Procedures Except Hand and 

FootT47.1841"$3,275.52".$655.11

0052Level IV Musculoskeletal Procedures Except Hand and 

FootT87.5671"$6,078.91"."$1,215.79"

0053Level I Hand Musculoskeletal 

ProceduresT17.4096"$1,208.57"$253.49$241.72

0054Level II Hand Musculoskeletal 

ProceduresT29.0181"$2,014.44".$402.89

0055Level I Foot Musculoskeletal 

ProceduresT22.1739"$1,539.31"$351.47$307.87

0056Level II Foot Musculoskeletal 

ProceduresT57.2099"$3,971.51".$794.31

0057Bunion 

ProceduresT32.5456"$2,259.32"$469.58$451.87

0058Level I Strapping and Cast 

ApplicationS1.1378$78.99.$15.80

0060Manipulation 

TherapyS0.3234$22.45.$4.49

0061Level II Implantation/Revision/Replacement of Neurostimulator Electrodes 

S86.9786"$6,038.05"."$1,207.61"

0062Level I Treatment 

Fracture/DislocationT26.2376"$1,821.41"$371.33$364.29

0063Level II Treatment 

Fracture/DislocationT49.4864"$3,435.35".$687.07

0064Level III Treatment 

Fracture/DislocationT67.0623"$4,655.46".$931.10

0065"Level I Stereotactic Radiosurgery, MRgFUS, and 

MEG"S12.4513$864.37.$172.88
0066"Level II Stereotactic Radiosurgery, MRgFUS, and 

MEG"S35.2457"$2,446.76".$489.36

0067"Level III Stereotactic Radiosurgery, MRgFUS, and 

MEG"S46.8279"$3,250.79".$650.16

0069ThoracoscopyT34.9007"$2,422.81"$591.64$484.57

0070Thoracentesis/Lavage 

ProceduresT5.5572$385.78.$77.16

0071Level I Endoscopy Upper 

AirwayT1.0521$73.04.$14.61

0072Level II Endoscopy Upper 

AirwayT1.9475$135.20.$27.04

0073Level III Endoscopy Upper 

AirwayT4.5122$313.24$67.83$62.65

0074Level IV Endoscopy Upper 

AirwayT21.3691"$1,483.44".$296.69

0075Level V Endoscopy Upper 

AirwayT30.2222"$2,098.03"$438.93$419.61

0076Level I Endoscopy Lower 

AirwayT10.4123$722.82$189.71$144.57

0077Level I Pulmonary 

TreatmentS0.4224$29.32$7.74$5.87

0078Level III Pulmonary 

TreatmentS1.4008$97.24.$19.45

0079Ventilation Initiation and 

ManagementS3.0221$209.79.$41.96

0080Diagnostic Cardiac 

CatheterizationT39.2392"$2,723.99"$838.04$544.80

0082Coronary or Non-Coronary 

AtherectomyT104.8857"$7,281.17"."$1,456.24"

0083Level I Endovascular Revascularization of the Lower Extremity 

T65.1118"$4,520.06".$904.02

0084Level I Electrophysiologic 

ProceduresS9.6404$669.24.$133.85
0085Level II Electrophysiologic 

ProceduresT52.8540"$3,669.12".$733.83

0086Level III Electrophysiologic 

ProceduresT133.7624"$9,285.79"."$1,857.16"

0088ThrombectomyT41.2260"$2,861.91"$652.56$572.39

0089Insertion/Replacement of Permanent Pacemaker and 

ElectrodesT110.9465"$7,701.91""$1,620.86""$1,540.39"

0090Insertion/Replacement of Pacemaker Pulse 

GeneratorT93.4566"$6,487.76""$1,570.21""$1,297.56"

0091Level II Vascular 

LigationT43.6864"$3,032.71".$606.55

0092Level I Vascular 

LigationT26.9181"$1,868.65".$373.73

0093Vascular Reconstruction/Fistula Repair without 

DeviceT30.7767"$2,136.52".$427.31

0094Level I Resuscitation and 

CardioversionS2.2773$158.09$44.32$31.62

0095Cardiac 

RehabilitationS0.9648$66.98$13.49$13.40

0096Level II Noninvasive Physiologic 

StudiesS1.5324$106.38$36.83$21.28

0097Level I Noninvasive Physiologic 

StudiesS0.9478$65.80$23.63$13.16

0099Electrocardiograms/CardiographyS0.3895$27.04.$5.41

0100Cardiac Stress 

TestsX2.5348$175.97$40.87$35.20

0101Tilt Table 

EvaluationS4.2610$295.80$100.24$59.16

0102Level II Pulmonary 

TreatmentS0.5308$36.85.$7.37

0103Miscellaneous Vascular 

ProceduresT16.7686"$1,164.08".$232.82
0104Transcatheter Placement of Intracoronary 

StentsT79.9047"$5,546.98"."$1,109.40"

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

Devices"T23.2424"$1,613.49".$322.70

0106Insertion/Replacement of Pacemaker Leads and/or 

ElectrodesT48.5765"$3,372.18".$674.44

0107Insertion of 

Cardioverter-DefibrillatorT329.3230"$22,861.60"."$4,572.32"

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

"T379.7887"$26,364.93"."$5,272.99"

0110TransfusionS3.3671$233.74.$46.75

0111Blood Product 

ExchangeS11.7368$814.77$189.47$162.96

0112Apheresis and Stem Cell 

ProceduresS32.6016"$2,263.20".$452.64

0113Excision Lymphatic 

SystemT25.4874"$1,769.34".$353.87

0114Thyroid/Lymphadenectomy 

ProceduresT51.2321"$3,556.53".$711.31

0115Cannula/Access Device 

ProceduresT36.8791"$2,560.15".$512.03

0121Level I Tube or Catheter Changes or 

RepositioningT6.3178$438.58.$87.72

0126Level I Urinary and Anal 

ProceduresT1.1699$81.21.$16.25

0127"Level IV Stereotactic Radiosurgery, MRgFUS, and 

MEG"S106.1294"$7,367.50"."$1,473.50"

0128Echocardiogram with 

ContrastS8.1207$563.74$166.16$112.75

0129Level I Closed Treatment Fracture 

Finger/Toe/TrunkT1.6063$111.51.$22.31
0130Level I 

LaparoscopyT39.0865"$2,713.38"$659.53$542.68

0131Level II 

LaparoscopyT47.7164"$3,312.47""$1,001.89"$662.50

0132Level III 

LaparoscopyT71.0451"$4,931.95""$1,236.99"$986.39

0133Level I Skin 

RepairT1.2139$84.27$23.56$16.86

0134Level II Skin 

RepairT3.2846$228.02.$45.61

0135Level III Skin 

RepairT5.1973$360.80.$72.16

0136Level IV Skin 

RepairT17.2745"$1,199.20".$239.84

0137Level V Skin 

RepairT21.8041"$1,513.64".$302.73

0138Level II Closed Treatment Fracture 

Finger/Toe/TrunkT4.9874$346.23.$69.25

0139Level III Closed Treatment Fracture 

Finger/Toe/TrunkT18.6922"$1,297.61".$259.53

0140Esophageal Dilation without 

EndoscopyT6.5430$454.22.$90.85

0141Level I Upper GI 

ProceduresT8.3787$581.65$136.33$116.33

0142Level I Small Intestine 

EndoscopyT10.1643$705.61$152.78$141.13

0143Lower GI 

EndoscopyT9.3183$646.88$186.06$129.38

0146Level I Sigmoidoscopy and 

AnoscopyT6.3038$437.61.$87.53

0147Level II Sigmoidoscopy and 

AnoscopyT11.0219$765.14.$153.03

0148Level I Anal/Rectal 

ProceduresT6.1052$423.82.$84.77
0149Level III Anal/Rectal 

ProceduresT24.4472"$1,697.12".$339.43

0150Level IV Anal/Rectal 

ProceduresT32.9730"$2,288.99".$457.80

0151Endoscopic Retrograde Cholangio-Pancreatography 

(ERCP)T24.4009"$1,693.91".$338.79

0152Level I Percutaneous Abdominal and Biliary 

ProceduresT31.2779"$2,171.31".$434.27

0153Peritoneal and Abdominal 

ProceduresT26.6476"$1,849.88"$375.24$369.98

0154Hernia/Hydrocele 

ProceduresT32.9744"$2,289.08"$464.85$457.82

0155Level II Anal/Rectal 

ProceduresT16.0235"$1,112.35".$222.47

0156Level III Urinary and Anal 

ProceduresT3.1976$221.98.$44.40

0157Colorectal Cancer Screening: Barium 

EnemaS2.2553$156.56.$31.32

0158Colorectal Cancer Screening: 

ColonoscopyT8.3174$577.39.$0.00

0159Colorectal Cancer Screening: Flexible 

SigmoidoscopyS5.4345$377.26.$0.00

0160Level I Cystourethroscopy and other Genitourinary 

ProceduresT7.3594$510.89.$102.18

0161Level II Cystourethroscopy and other Genitourinary 

ProceduresT17.6738"$1,226.92".$245.39

0162Level III Cystourethroscopy and other Genitourinary 

ProceduresT26.2690"$1,823.59".$364.72

0163Level IV Cystourethroscopy and other Genitourinary 

ProceduresT36.9605"$2,565.80".$513.16

0164Level II Urinary and Anal 

ProceduresT2.0973$145.59.$29.12
0165Level IV Urinary and Anal 

ProceduresT20.1960"$1,402.01".$280.41

0166Level I Urethral 

ProceduresT20.7987"$1,443.85".$288.77

0168Level II Urethral 

ProceduresT32.1043"$2,228.68".$445.74

0169LithotripsyT51.4038"$3,568.45"$997.74$713.69

0170DialysisS5.9462$412.79.$82.56

0172Level I Partial Hospitalization (3 services) for 

CMHCsP1.3595$94.38.$18.88

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

CMHCsP1.5798$109.67.$21.94

0174Level IV 

LaparoscopyT107.5115"$7,463.45""$1,962.55""$1,492.69"

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

PHPsP2.2572$156.69.$31.34

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

PHPsP2.6400$183.27.$36.66

0181Level II Male Genital 

ProceduresT34.3803"$2,386.68"$598.48$477.34

0183Level I Male Genital 

ProceduresT23.7235"$1,646.89".$329.38

0184Prostate 

BiopsyT14.2476$989.07.$197.82

0188Level II Female Reproductive 

ProcT1.6099$111.76.$22.36

0189Level III Female Reproductive 

ProcT3.6121$250.75.$50.15

0190Level I 

HysteroscopyT23.1868"$1,609.63"$424.28$321.93

0191Level I Female Reproductive 

ProcT0.1274$8.84$1.85$1.77
0192Level IV Female Reproductive 

ProcT7.0332$488.24.$97.65

0193Level V Female Reproductive 

ProcT20.7771"$1,442.35".$288.47

0195Level VI Female Reproductive 

ProceduresT35.9320"$2,494.40".$498.88

0202Level VII Female Reproductive 

ProceduresT45.5816"$3,164.27"$981.50$632.86

0203Level IV Nerve 

InjectionsT12.9066$895.98.$179.20

0204Level I Nerve 

InjectionsT2.7693$192.24$40.13$38.45

0206Level II Nerve 

InjectionsT3.9371$273.31.$54.67

0207Level III Nerve 

InjectionsT7.5480$523.98.$104.80

0208Laminotomies and 

LaminectomiesT51.1173"$3,548.56".$709.72

0209"Level II Extended EEG, Sleep, and Cardiovascular 

Studies"S11.3894$790.65$268.73$158.13

0213"Level I Extended EEG, Sleep, and Cardiovascular 

Studies"S2.3958$166.32$53.48$33.27

0215Level I Nerve and Muscle 

TestsS0.6352$44.10.$8.82

0216Level III Nerve and Muscle 

TestsS2.6231$182.10.$36.42

0218Level II Nerve and Muscle 

TestsS1.1945$82.92.$16.59

0220Level I Nerve 

ProceduresT19.0626"$1,323.33".$264.67

0221Level II Nerve 

ProceduresT37.4067"$2,596.77".$519.36

0224Implantation of 

Catheter/Reservoir/ShuntT42.5188"$2,951.66".$590.34
0227Implantation of Drug Infusion 

DeviceT190.0513"$13,193.36"."$2,638.68"

0229Level II Endovascular Revascularization of the Lower Extremity 

T114.2626"$7,932.11"."$1,586.43"

0230Level I Eye Tests & 

TreatmentsS0.6929$48.10.$9.62

0231Level III Eye Tests & 

TreatmentsS2.3088$160.28.$32.06

0232Level I Anterior Segment Eye 

ProceduresT2.9435$204.34$42.27$40.87

0233Level III Anterior Segment Eye 

ProceduresT16.8777"$1,171.65".$234.33

0234Level IV Anterior Segment Eye 

ProceduresT25.2649"$1,753.89"$511.31$350.78

0235Level I Posterior Segment Eye 

ProceduresT4.9132$341.07.$68.22

0237Level II Posterior Segment Eye 

ProceduresT22.7865"$1,581.84".$316.37

0238Level I Repair and Plastic Eye 

ProceduresT3.3278$231.02.$46.21

0239Level II Repair and Plastic Eye 

ProceduresT8.3090$576.81.$115.37

0240Level III Repair and Plastic Eye 

ProceduresT20.3065"$1,409.68"$296.20$281.94

0241Level IV Repair and Plastic Eye 

ProceduresT27.0493"$1,877.76"$383.45$375.56

0242Level V Repair and Plastic Eye 

ProceduresT40.9376"$2,841.89"$597.36$568.38

0243Strabismus/Muscle 

ProceduresT25.2851"$1,755.29"$415.27$351.06

0244Corneal and Amniotic Membrane 

TransplantT38.4709"$2,670.65"$800.09$534.13
0245Level I Cataract Procedures without IOL 

InsertT15.2776"$1,060.57".$212.12

0246Cataract Procedures with IOL 

InsertT24.0158"$1,667.18"$488.94$333.44

0247Laser Eye 

ProceduresT5.5801$387.37$104.31$77.48

0249Level II Cataract Procedures without IOL 

InsertT30.7811"$2,136.82"$516.99$427.37

0250Level I ENT 

ProceduresT1.0875$75.49$24.28$15.10

0251Level II ENT 

ProceduresT3.3531$232.77.$46.56

0252Level III ENT 

ProceduresT8.0353$557.81.$111.57

0253Level IV ENT 

ProceduresT16.9180"$1,174.45"$277.61$234.89

0254Level V ENT 

ProceduresT25.1379"$1,745.07".$349.02

0255Level II Anterior Segment Eye 

ProceduresT7.8512$545.03$124.97$109.01

0256Level VI ENT 

ProceduresT45.1286"$3,132.83".$626.57

0259Level VII ENT 

ProceduresT395.1320"$27,430.06""$7,545.06""$5,486.02"

0260Level I Plain Film Except 

TeethX0.6418$44.55.$8.91

0261Level II Plain Film Except Teeth Including Bone Density 

MeasurementX1.0831$75.19.$15.04

0262Plain Film of 

TeethX0.4650$32.28.$6.46

0263Level I Miscellaneous Radiology 

ProceduresX3.3928$235.53.$47.11

0265Level I Diagnostic and Screening 

UltrasoundS0.8995$62.44$22.26$12.49
0266Level II Diagnostic and Screening 

UltrasoundS1.3711$95.18$36.80$19.04

0267Level III Diagnostic and Screening 

UltrasoundS2.1881$151.90$59.41$30.38

0269Level II Echocardiogram Without Contrast 

S5.5306$383.93.$76.79

0270Level III Echocardiogram Without Contrast 

S8.1675$566.99$133.61$113.40

0272FluoroscopyX1.2481$86.64$30.47$17.33

0274MyelographyS6.9677$483.70.$96.74

0275ArthrographyS3.9868$276.76$68.90$55.36

0276Level I Digestive 

RadiologyS1.2290$85.32$33.87$17.07

0277Level II Digestive 

RadiologyS2.0083$139.42$52.93$27.89

0278Diagnostic 

UrographyS2.5896$179.77$58.44$35.96

0279Level II Angiography and 

VenographyS29.6734"$2,059.93".$411.99

0280Level III Angiography and 

VenographyS49.6711"$3,448.17".$689.64

0282Miscellaneous Computed Axial 

TomographyS1.5453$107.27$35.74$21.46

0283Computed Tomography with 

ContrastS4.2806$297.16$95.77$59.44

0284Magnetic Resonance Imaging and Magnetic Resonance Angiography with 

ContrastS6.1872$429.52$144.34$85.91

0288Bone Density:Axial 

SkeletonS1.0215$70.91.$0.00

0293Level VI Anterior Segment Eye 

ProceduresT117.7956"$8,177.37"."$1,635.48"
0299Hyperthermia and Radiation Treatment 

ProceduresS5.6094$389.40.$77.88

0300Level I Radiation 

TherapyS1.3628$94.61.$18.93

0301Level II Radiation 

TherapyS2.3680$164.39.$32.88

0303Treatment Device 

ConstructionX2.7910$193.75$64.95$38.75

0304Level I Therapeutic Radiation Treatment 

PreparationX1.4946$103.76$34.39$20.76

0305Level II Therapeutic Radiation Treatment 

PreparationX3.7009$256.92$86.44$51.39

0307Myocardial Positron Emission Tomography (PET) 

imagingS13.2711$921.28.$184.26

0308Non-Myocardial Positron Emission Tomography (PET) 

imagingS14.6171"$1,014.72".$202.95

0310Level III Therapeutic Radiation Treatment 

PreparationX13.2460$919.54$322.74$183.91

0312Radioelement 

ApplicationsS4.7014$326.37.$65.28

0313BrachytherapyS9.8659$684.89$258.98$136.98

0315Level II Implantation of Neurostimulator Generator 

S284.8462"$19,774.02"."$3,954.81"

0317Level II Miscellaneous Radiology 

ProceduresX6.2675$435.09.$87.02

0318Implantation of Cranial Neurostimulator Pulse Generator and Electrode 

S337.4240"$23,423.97""$9,121.76""$4,684.80"

0319Level III Endovascular Revascularization of the Lower 

ExtremityT202.3898"$14,049.90""$5,559.48""$2,809.98"

0320Electroconvulsive 

TherapyS5.9679$414.29.$82.86

0322Brief Individual 

PsychotherapyS1.0957$76.06.$15.22
0323Extended Individual 

PsychotherapyS1.5885$110.27.$22.06

0324Family 

PsychotherapyS1.8739$130.09.$26.02

0325Group 

PsychotherapyS0.7798$54.13$11.54$10.83

0330Dental 

ProceduresS9.5583$663.54.$132.71

0331Combined Abdomen and Pelvis CT without Contrast 

S5.8040$402.91$155.78$80.59

0332Computed Tomography without 

ContrastS2.7424$190.38$73.61$38.08

0333Computed Tomography without Contrast followed by 

ContrastS4.7716$331.24$115.09$66.25

0334Combined Abdomen and Pelvis CT with Contrast 

S8.2338$571.59$184.21$114.32

0336Magnetic Resonance Imaging and Magnetic Resonance Angiography without 

ContrastS4.8219$334.74$131.90$66.95

0337Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast 

followed by 

ContrastS7.6393$530.32$196.43$106.07

0340Minor Ancillary 

ProceduresX0.6739$46.78.$9.36

0341Skin 

TestsX0.0776$5.39$2.02$1.08

0342Level I 

PathologyX0.1639$11.38.$2.28

0343Level III 

PathologyX0.5225$36.27$10.78$7.26

0344Level IV 

PathologyX0.8204$56.95$15.56$11.39

0345Level I Transfusion Laboratory 

ProceduresX0.2109$14.64.$2.93
0346Level II Transfusion Laboratory 

ProceduresX0.3580$24.85.$4.97

0347Level III Transfusion Laboratory 

ProceduresX0.6541$45.41.$9.09

0350Administration of flu and PPV 

vaccineS0.3780$26.24.$0.00

0360Level I Alimentary 

TestsX1.7147$119.03$33.57$23.81

0361Level II Alimentary 

TestsX4.1026$284.80$83.23$56.96

0363Level I Otorhinolaryngologic Function 

TestsX0.9462$65.69$17.10$13.14

0364Level I 

AudiometryX0.4896$33.99$7.06$6.80

0365Level II 

AudiometryX1.2340$85.66$18.14$17.14

0366Level III 

AudiometryX1.6976$117.85$23.61$23.57

0367Level I Pulmonary 

TestX0.7369$51.16$13.76$10.24

0368Level II Pulmonary 

TestsX0.8927$61.97$20.93$12.40

0369Level III Pulmonary 

TestsX2.6420$183.41$37.27$36.69

0370Allergy 

TestsX1.3506$93.76.$18.76

0373Level I Neuropsychological 

TestingX1.3767$95.57.$19.12

0375Ancillary Outpatient Services When Patient 

ExpiresS79.4058"$5,512.35"."$1,102.47"

0377Level II Cardiac 

ImagingS9.7483$676.73.$135.35

0378Level II Pulmonary 
ImagingS4.5059$312.80$120.71$62.56

0381Single Allergy 

TestsX0.4731$32.84.$6.57

0382Level II Neuropsychological 

TestingX2.6658$185.06.$37.02

0383Cardiac Computed Tomographic 

ImagingS3.7294$258.89.$51.78

0384GI Procedures with 

StentsT29.0233"$2,014.80".$402.96

0385Level I Prosthetic Urological 

ProceduresS103.8680"$7,210.52"."$1,442.11"

0386Level II Prosthetic Urological 

ProceduresS168.5335"$11,699.60"."$2,339.92"

0387Level II 

HysteroscopyT37.9124"$2,631.88"$650.74$526.38

0388DiscographyS23.0551"$1,600.49".$320.10

0389Level I Non-imaging Nuclear 

MedicineS1.5133$105.05$26.88$21.01

0390Level I Endocrine 

ImagingS1.8660$129.54$46.52$25.91

0391Level II Endocrine 

ImagingS3.1750$220.41$65.46$44.09

0392Level II Non-imaging Nuclear 

MedicineS2.5360$176.05$42.39$35.21

0393Hematologic Processing & 

StudiesS6.3038$437.61.$87.53

0394Hepatobiliary 

ImagingS4.1587$288.70$90.78$57.74

0395GI Tract 

ImagingS3.4576$240.03$87.01$48.01

0396Bone 

ImagingS3.5140$243.94$93.91$48.79
0397Vascular 

ImagingS2.4220$168.14$38.85$33.63

0398Level I Cardiac 

ImagingS4.2252$293.31$93.33$58.67

0400Hematopoietic 

ImagingS3.7132$257.77$91.24$51.56

0401Level I Pulmonary 

ImagingS2.8425$197.33$71.16$39.47

0402Level II Nervous System 

ImagingS8.7081$604.52.$120.91

0403Level I Nervous System 

ImagingS3.3656$233.64$70.43$46.73

0404Renal and Genitourinary 

StudiesS4.5715$317.35$81.14$63.47

0406Level I Tumor/Infection 

ImagingS4.0374$280.28$85.03$56.06

0407Level I Radionuclide 

TherapyS3.2808$227.75$78.13$45.55

0408Level III Tumor/Infection 

ImagingS13.7263$952.88.$190.58

0409Red Blood Cell 

TestsX0.1103$7.66$2.16$1.54

0412IMRT Treatment 

DeliveryS6.4422$447.22.$89.45

0413Level II Radionuclide 

TherapyS4.0894$283.89.$56.78

0414Level II Tumor/Infection 

ImagingS6.9811$484.63.$96.93

0415Level II Endoscopy Lower 

AirwayT29.1250"$2,021.86"$459.92$404.38

0419Level II Upper GI Procedures 

T12.5693$872.56$204.51$174.52

0422Level III Upper GI 

ProceduresT25.4890"$1,769.45".$353.89
0423Level II Percutaneous Abdominal and Biliary 

ProceduresT57.1703"$3,968.76".$793.76

0424Level II Small Intestine Endoscopy 

T15.8412"$1,099.70"$239.49$219.94

0425Level II Arthroplasty or Implantation with 

ProsthesisT130.4476"$9,055.67"."$1,811.14"

0426Level II Strapping and Cast 

ApplicationS2.7059$187.84.$37.57

0427Level II Tube or Catheter Changes or 

RepositioningT16.2153"$1,125.67".$225.14

0428Level III Sigmoidoscopy and 

AnoscopyT23.9719"$1,664.13".$332.83

0429Level V Cystourethroscopy and other Genitourinary 

ProceduresT45.8647"$3,183.93".$636.79

0432Health and Behavior 

ServicesS0.4940$34.29.$6.86

0433Level II 

PathologyX0.2464$17.11$5.17$3.43

0434Cardiac Defect 

RepairT166.2005"$11,537.64"."$2,307.53"

0436Level I Drug 

AdministrationS0.3780$26.24.$5.25

0437Level II Drug 

AdministrationS0.5280$36.65.$7.33

0438Level III Drug 

AdministrationS1.0547$73.22.$14.65

0439Level IV Drug 

AdministrationS1.9117$132.71.$26.55

0440Level V Drug 

AdministrationS3.0395$211.00.$42.20

0442Dosimetric Drug 

AdministrationS22.9208"$1,591.16".$318.24
0604Level 1 Hospital Clinic 

VisitsV0.6941$48.18.$9.64

0605Level 2 Hospital Clinic 

VisitsV1.0430$72.41.$14.49

0606Level 3 Hospital Clinic 

VisitsV1.4647$101.68.$20.34

0607Level 4 Hospital Clinic 

VisitsV1.9242$133.58.$26.72

0608Level 5 Hospital Clinic 

VisitsV2.4718$171.59.$34.32

0609Level 1 Type A Emergency 

VisitsV0.7290$50.61$12.12$10.13

0613Level 2 Type A Emergency 

VisitsV1.2424$86.25$20.73$17.25

0614Level 3 Type A Emergency 

VisitsV1.9769$137.24$33.86$27.45

0615Level 4 Type A Emergency 

VisitsV3.1815$220.86$48.11$44.18

0616Level 5 Type A Emergency 

VisitsV4.7283$328.24$72.57$65.65

0617Critical 

CareS6.8172$473.25$104.95$94.65

0618Trauma Response with Critical 

CareS11.6401$808.06.$161.62

0621Level I Vascular Access 

ProceduresT11.1622$774.88.$154.98

0622Level II Vascular Access 

ProceduresT25.1290"$1,744.46".$348.90

0623Level III Vascular Access 

ProceduresT30.2967"$2,103.20".$420.64

0624Phlebotomy and Minor Vascular Access Device 

ProceduresX0.6235$43.28$12.56$8.66

0626Level 1 Type B Emergency 

VisitsV0.5673$39.38.$7.88
0627Level 2 Type B Emergency 

VisitsV0.8183$56.81.$11.37

0628Level 3 Type B Emergency 

VisitsV1.3027$90.43.$18.09

0629Level 4 Type B Emergency 

VisitsV1.9652$136.42.$27.29

0630Level 5 Type B Emergency 

VisitsV3.7640$261.30.$52.26

0648Level IV Breast 

SurgeryT61.6690"$4,281.06".$856.22

0651Complex Interstitial Radiation Source 

ApplicationS12.4760$866.08.$173.22

0652Insertion of Intraperitoneal and Pleural 

CathetersT30.6257"$2,126.04".$425.21

0653Vascular Reconstruction/Fistula Repair with 

DeviceT43.1404"$2,994.81".$598.97

0654Insertion/Replacement of a Permanent Dual Chamber 

PacemakerT100.4629"$6,974.13"."$1,394.83"

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

ElectrodeT136.0608"$9,445.34"."$1,889.07"

0656Transcatheter Placement of Intracoronary Drug-Eluting 

StentsT104.4584"$7,251.50"."$1,450.30"

0659Hyperbaric 

OxygenS1.4834$102.98.$20.60

0660Level II Otorhinolaryngologic Function 

TestsX1.8827$130.70$27.10$26.14

0661Level V 

PathologyX2.3755$164.91.$32.99

0662CT 

AngiographyS4.8432$336.21$113.59$67.25

0664Level I Proton Beam Radiation 

TherapyS14.2952$992.37.$198.48
0665Bone 

Density:AppendicularSkeletonS0.4570$31.72.$0.00

0667Level II Proton Beam Radiation 

TherapyS18.7001"$1,298.16".$259.64

0668Level I Angiography and 

VenographyS9.4312$654.71.$130.95

0672Level III Posterior Segment Eye 

ProceduresT41.3248"$2,868.77".$573.76

0673Level V Anterior Segment Eye 

ProceduresT41.7832"$2,900.59"$632.65$580.12

0674Prostate 

CryoablationT111.0864"$7,711.62"."$1,542.33"

0676Thrombolysis and Other Device Revisions 

T2.3410$162.51.$32.51

0678External 

CounterpulsationT1.3160$91.36.$18.28

0679Level II Resuscitation and 

CardioversionS5.3123$368.78$94.48$73.76

0680Insertion of Patient Activated Event 

RecordersS78.4050"$5,442.88"."$1,088.58"

0683Level II 

PhotochemotherapyS2.9704$206.21.$41.25

0685Level III Needle Biopsy/Aspiration Except Bone 

MarrowT9.7281$675.32.$135.07

0687Revision/Removal of Neurostimulator 

ElectrodesT20.7466"$1,440.23"$382.52$288.05

0688Revision/Removal of Neurostimulator Pulse Generator 

ReceiverT31.3873"$2,178.91"$768.94$435.79

0690Level I Electronic Analysis of 

DevicesS0.5148$35.74$8.67$7.15

0691Level III Electronic Analysis of 

DevicesS2.4153$167.67.$33.54

0692Level II Electronic Analysis of 

DevicesS1.6659$115.65.$23.13
0694Mohs 

SurgeryT5.3689$372.71$91.69$74.55

0697Level I Echocardiogram Without Contrast 

S3.1535$218.92.$43.79

0698Level II Eye Tests & 

TreatmentsS1.4030$97.40.$19.48

0699Level IV Eye Tests & 

TreatmentsT15.6140"$1,083.92".$216.79

0701Sr89 

strontiumK$641.83.$128.37

0726Dexrazoxane HCl 

injectionK$274.42.$54.89

0728Filgrastim 300 mcg 

injectionK$238.72.$47.75

0731Sargramostim 

injectionK$23.62.$4.73

0735Ampho b cholesteryl 

sulfateK$13.74.$2.75

0736Amphotericin b liposome 

injK$14.77.$2.96

0738RasburicaseK$183.08.$36.62

0747Chlorothiazide sodium 

injK$272.64.$54.53

0751Mechlorethamine hcl 

injK$154.88.$30.98

0752Dactinomycin 

injectionK$529.42.$105.89

0759"Naltrexone, depot 

form"K$2.77.$0.56

0800Leuprolide 

acetateK$547.54.$109.51

0802Etoposide 
oralK$34.34.$6.87

0807Aldesleukin 

injectionK$915.45.$183.09

0809Bcg live intravesical 

vacK$114.38.$22.88

0810Goserelin acetate 

implantK$195.16.$39.04

0812Carmustine 

injectionK$172.56.$34.52

0814Asparaginase 

injectionK$62.07.$12.42

0820Daunorubicin 

injectionK$13.16.$2.64

0821Daunorubicin citrate 

injK$56.58.$11.32

0823Docetaxel 

injectionK$20.84.$4.17

0825Nelarabine 

injectionK$110.19.$22.04

0827Floxuridine 

injectionK$36.60.$7.32

0828Gemcitabine hcl 

injectionK$111.40.$22.28

0831Ifosfomide 

injectionK$31.21.$6.25

0832Idarubicin hcl 

injectionK$46.43.$9.29

0835Cosyntropin injection 

NOSK$99.76.$19.96

0836Interferon alfa-2b 

injK$16.19.$3.24

0838Interferon gamma 1-b 

injK$549.62.$109.93
0840Inj melphalan 

hydrochlK"$1,272.01".$254.41

0843Pegaspargase 

injectionK"$2,675.40".$535.08

0844Pentostatin 

injectionK"$1,068.16".$213.64

0849Rituximab 

injectionK$599.16.$119.84

0850Streptozocin 

injectionK$264.81.$52.97

0851Thiotepa 

injectionK$106.54.$21.31

0856Porfimer sodium 

injectionK"$3,017.82".$603.57

0858Inj 

cladribineK$23.59.$4.72

0861Leuprolide acetate 

injecitonK$4.88.$0.98

0864Mitoxantrone 

hydrochlK$33.95.$6.79

0865Interferon alfa-n3 

injK$20.87.$4.18

0868Oral 

aprepitantK$5.90.$1.18

0873Hyalgan/supartz inj per 

doseK$88.80.$17.76

0874Synvisc or 

synvisc-oneK$11.81.$2.37

0875Euflexxa inj per 

doseK$147.16.$29.44

0877Orthovisc inj per 

doseK$167.00.$33.40

0884Rho d immune globulin 
injK$82.16.$16.44

0887Azathioprine 

parenteralK$104.77.$20.96

0890Lymphocyte immune 

globulinK$542.36.$108.48

0900Alglucerase 

injectionK$41.19.$8.24

0901Alpha 1 proteinase 

inhibitorK$3.79.$0.76

0902"Injection,onabotulinumtoxinA"K$5.38.$1.08

0903Cytomegalovirus imm IV 

/vialK$922.07.$184.42

0910Interferon beta-1b / .25 

MGK$197.14.$39.43

0913Ganciclovir long act 

implantK"$16,640.00"."$3,328.00"

0917Adenosine 

injectionK$89.99.$18.00

0925Factor 

viiiK$0.87.$0.18

0927Factor viii 

recombinantK$1.09.$0.22

0928Factor ix 

complexK$0.85.$0.17

0929Anti-inhibitorK$1.57.$0.32

0931Factor IX 

non-recombinantK$0.88.$0.18

0932Factor IX 

recombinantK$1.13.$0.23

0933Gamma globulin > 10 CC 

injK$179.06.$35.82

0934"Capecitabine, 
oral"K$22.48.$4.50

0943Octagam 

injectionK$55.80.$11.16

0944Gammagard liquid 

injectionK$37.67.$7.54

0945Rhophylac 

injectionK$5.09.$1.02

0946Hepagam b im 

injectionK$57.07.$11.42

0947Flebogamma 

injectionK$35.04.$7.01

0948Gamunex 

injectionK$36.91.$7.39

0949"Frozen plasma, pooled, 

sd"R1.0221$70.95.$14.19

0950Whole blood for 

transfusionR2.7926$193.86.$38.78

0951Reclast 

injectionK$218.47.$43.70

0952Cryoprecipitate each 

unitR1.0975$76.19.$15.24

0954RBC leukocytes 

reducedR2.8046$194.70.$38.94

0955"Plasma, frz between 

8-24hour"R1.0092$70.06.$14.02

0956"Plasma protein 

fract,5%,50ml"R0.2513$17.45.$3.49

0957"Platelets, each 

unit"R1.2522$86.93.$17.39

0958Plaelet rich plasma 

unitR1.9703$136.78.$27.36

0959Red blood cells 

unitR2.1382$148.43.$29.69
0960Washed red blood cells 

unitR4.0969$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"R1.2214$84.79.$16.96

0967Blood split 

unitR2.2455$155.88.$31.18

0968Platelets leukoreduced 

irradR2.0418$141.74.$28.35

0969RBC leukoreduced 

irradiatedR3.7077$257.39.$51.48

1009CryoprecipitatereducedplasmaR1.1839$82.19.$16.44

1010"Blood, l/r, 

cmv-neg"R2.7475$190.73.$38.15

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

unit"R11.4189$792.70.$158.54

1013Platelets leukocytes 

reducedR1.7459$121.20.$24.24

1015Injection glatiramer 

acetateK$95.57.$19.12

1016"Blood, l/r, 

froz/degly/wash"R1.8650$129.47.$25.90

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

cmv-neg"R5.7123$396.55.$79.31

1018"Blood, l/r, 

irradiated"R2.1603$149.97.$30.00
1019Plate pheres leukoredu 

irradR9.9046$687.58.$137.52

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

irr"R8.6696$601.84.$120.37

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

irrad"R6.2606$434.61.$86.93

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

irrad"R4.0635$282.09.$56.42

1023Pralidoxime chloride 

injK$88.57.$17.72

1052"Injection, 

voriconazole"K$6.02.$1.21

1064"I131 iodide cap, 

rx"K$17.58.$3.52

1083Adalimumab 

injectionK$394.16.$78.84

1084Denileukin diftitox 

injK"$1,559.54".$311.91

1086TemozolomideK$9.31.$1.87

1138"Hepagam b intravenous, 

inj"K$57.07.$11.42

1139Protein c 

concentrateK$12.50.$2.50

1142Supprelin LA 

implantK"$15,184.53"."$3,036.91"

1150"I131 iodide sol, 

rx"K$13.26.$2.66

1166Cytarabine liposome 

injK$479.02.$95.81

1167"Inj, epirubicin 

hcl"K$1.87.$0.38

1168"Inj, 
temsirolimus"K$49.87.$9.98

1178Busulfan 

injectionK$16.29.$3.26

1203Verteporfin 

injectionK$9.55.$1.91

1207"Octreotide injection, 

depot"K$113.48.$22.70

1213Antihemophilic viii/vwf 

compK$0.90.$0.18

1214Inj IVIG privigen 500 

mgK$34.45.$6.89

1221Dimethyl sulfoxide 

50%K$82.68.$16.54

1222Pentastarch 10% 

solutionK$158.76.$31.76

1226Inj streptokinase /250000 

IUK$47.57.$9.52

1232Mitomycin 5 MG 

injK$20.36.$4.08

1235Valrubicin 

injectionK$946.64.$189.33

1236Levoleucovorin 

injectionK$1.78.$0.36

1237Inj iron 

dextranK$11.59.$2.32

1238Topotecan 

oralK$76.40.$15.28

1239Rotavirus vacc 2 dose 

oralK$100.56.$20.12

1240Apligraf skin 

subK$34.06.$6.82

1241Oasis wound matrix skin 

subK$4.68.$0.94
1243Integra BMWD skin 

subK$15.45.$3.09

1244Integra DRT skin 

subK$10.95.$2.19

1245Dermagraft skin 

subK$39.39.$7.88

1246Graftjacket skin 

subK$92.79.$18.56

1247Integra matrix skin 

subK$20.95.$4.19

1248Primatrix skin 

subK$31.67.$6.34

1249Cymetra 

allograftK$334.07.$66.82

1250Graftjacket express 

allografK$334.07.$66.82

1251Integra flowable wound 

matriK$972.75.$194.55

1252Gammagraft skin 

subK$7.17.$1.44

1253Triamcinolone A inj 

PRS-freeK$3.17.$0.64

1263Antithrombin iii 

injectionK$2.48.$0.50

1268Xyntha 

injK$1.05.$0.21

1270Alloderm skin 

subK$31.11.$6.23

1272Acetylcysteine injectionK 

$2.67.$0.54

1274Edetate calcium disodium injK 

$192.07.$38.42

1275"Vivaglobin, inj"K 
$7.11.$1.43

1279Factor VIII 

(porcine)K$1.17.$0.24

1280Corticotropin 

injectionK"$2,395.22".$479.05

1281Bevacizumab 

injectionK$1.47.$0.30

1287Alloskin skin 

subK$6.07.$1.22

1289AbobotulinumtoxinAK$7.41.$1.49

1290Human fibrinogen conc 

injK$71.52.$14.31

1291Rilonacept 

injectionK$23.63.$4.73

1295Sm 153 

lexidronamK"$7,555.71"."$1,511.15"

1296Degarelix 

injectionK$2.79.$0.56

1297"Ferumoxytol, 

non-esrd"K$0.69.$0.14

1304Perphenazine 

injecitonK$30.91.$6.19

1306Urea 

injectionK$82.18.$16.44

1307Oral 

busulfanK$3.59.$0.72

1308Mecasermin 

injectionK$20.18.$4.04

1311Canakinumab 

injectionK$87.45.$17.49

1312Hizentra 

injectionK$7.15.$1.43
1327Imiglucerase 

injectionK$41.19.$8.24

1331Olanzapine long-acting 

injK$2.70.$0.54

1332Antithrombin 

recombinantK$101.40.$20.28

1338"Methyl aminolevulinate, 

top"K$68.27.$13.66

1339Oral fludarabine 

phosphateG$79.44.$15.89

1340"Collagenase, clost hist 

inj"G$37.51.$7.51

1341Amobarbital 125 MG 

injK$23.38.$4.68

1342Matristem 

micromatrixK$3.13.$0.63

1343Ganciclovir sodium 

injectionK$62.51.$12.51

1344Gonadorelin hydroch/ 100 

mcgK$94.82.$18.97

1345TheraskinK$20.32.$4.07

1349Anidulafungin 

injectionK$1.29.$0.26

1350Topotecan 

injectionK$19.30.$3.86

1351Matristem wound 

matrixK$6.04.$1.21

1355Itraconazole 

injectionK$359.59.$71.92

1356Inj desmopressin 

acetateK$3.93.$0.79

1357Inj protirelin per 250 

mcgK$27.03.$5.41
1358Phentolaine mesylate 

injK$56.35.$11.27

1359Foscarnet sodium 

injectionK$13.06.$2.62

1491New Technology - Level IA 

($0-$10)S$5.00.$1.00

1492New Technology - Level IB 

($10-$20)S$15.00.$3.00

1493New Technology - Level IC 

($20-$30)S$25.00.$5.00

1494New Technology - Level ID 

($30-$40)S$35.00.$7.00

1495New Technology - Level IE 

($40-$50)S$45.00.$9.00

1496New Technology - Level IA 

($0-$10)T$5.00.$1.00

1497New Technology - Level 

IB($10-$20)T$15.00.$3.00

1498New Technology - Level IC 

($20-$30)T$25.00.$5.00

1499New Technology - Level 

ID($30-$40)T$35.00.$7.00

1500New Technology - Level IE 

($40-$50)T$45.00.$9.00

1502New Technology - Level II ($50 - 

$100)S$75.00.$15.00

1503New Technology - Level III ($100 - 

$200)S$150.00.$30.00

1504New Technology - Level IV ($200 - 

$300)S$250.00.$50.00

1505New Technology - Level V ($300 - 

$400)S$350.00.$70.00

1506New Technology - Level VI ($400 - 
$500)S$450.00.$90.00

1507New Technology - Level VII ($500 - 

$600)S$550.00.$110.00

1508New Technology - Level VIII ($600 - 

$700)S$650.00.$130.00

1509New Technology - Level IX ($700 - 

$800)S$750.00.$150.00

1510New Technology - Level X ($800 - 

$900)S$850.00.$170.00

1511New Technology - Level XI ($900 - 

$1000)S$950.00.$190.00

1512New Technology - Level XII ($1000 - 

$1100)S"$1,050.00".$210.00

1513New Technology - Level XIII ($1100 - 

$1200)S"$1,150.00".$230.00

1514New Technology - Level XIV ($1200- 

$1300)S"$1,250.00".$250.00

1515New Technology - Level XV ($1300 - 

$1400)S"$1,350.00".$270.00

1516New Technology - Level XVI ($1400 - 

$1500)S"$1,450.00".$290.00

1517New Technology - Level XVII 

($1500-$1600)S"$1,550.00".$310.00

1518New Technology - Level XVIII 

($1600-$1700)S"$1,650.00".$330.00

1519New Technology - Level IXX 

($1700-$1800)S"$1,750.00".$350.00

1520New Technology - Level XX 

($1800-$1900)S"$1,850.00".$370.00

1521New Technology - Level XXI 

($1900-$2000)S"$1,950.00".$390.00

1522New Technology - Level XXII 

($2000-$2500)S"$2,250.00".$450.00
1523New Technology - Level XXIII 

($2500-$3000)S"$2,750.00".$550.00

1524New Technology - Level XXIV 

($3000-$3500)S"$3,250.00".$650.00

1525New Technology - Level XXV 

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

1526New Technology - Level XXVI 

($4000-$4500)S"$4,250.00".$850.00

1527New Technology - Level XXVII 

($4500-$5000)S"$4,750.00".$950.00

1528New Technology - Level XXVIII 

($5000-$5500)S"$5,250.00"."$1,050.00"

1529New Technology - Level XXIX 

($5500-$6000)S"$5,750.00"."$1,150.00"

1530New Technology - Level XXX 

($6000-$6500)S"$6,250.00"."$1,250.00"

1531New Technology - Level XXXI 

($6500-$7000)S"$6,750.00"."$1,350.00"

1532New Technology - Level XXXII 

($7000-$7500)S"$7,250.00"."$1,450.00"

1533New Technology - Level XXXIII 

($7500-$8000)S"$7,750.00"."$1,550.00"

1534New Technology - Level XXXIV 

($8000-$8500)S"$8,250.00"."$1,650.00"

1535New Technology - Level XXXV 

($8500-$9000)S"$8,750.00"."$1,750.00"

1536New Technology - Level XXXVI 

($9000-$9500)S"$9,250.00"."$1,850.00"

1537New Technology - Level XXXVII 

($9500-$10000)S"$9,750.00"."$1,950.00"

1539New Technology - Level II ($50 - 

$100)T$75.00.$15.00

1540New Technology - Level III ($100 - 
$200)T$150.00.$30.00

1541New Technology - Level IV ($200 - 

$300)T$250.00.$50.00

1542New Technology - Level V ($300 - 

$400)T$350.00.$70.00

1543New Technology - Level VI ($400 - 

$500)T$450.00.$90.00

1544New Technology - Level VII ($500 - 

$600)T$550.00.$110.00

1545New Technology - Level VIII ($600 - 

$700)T$650.00.$130.00

1546New Technology - Level IX ($700 - 

$800)T$750.00.$150.00

1547New Technology - Level X ($800 - 

$900)T$850.00.$170.00

1548New Technology - Level XI ($900 - 

$1000)T$950.00.$190.00

1549New Technology - Level XII ($1000 - 

$1100)T"$1,050.00".$210.00

1550New Technology - Level XIII ($1100 - 

$1200)T"$1,150.00".$230.00

1551New Technology - Level XIV ($1200- 

$1300)T"$1,250.00".$250.00

1552New Technology - Level XV ($1300 - 

$1400)T"$1,350.00".$270.00

1553New Technology - Level XVI ($1400 - 

$1500)T"$1,450.00".$290.00

1554New Technology - Level XVII 

($1500-$1600)T"$1,550.00".$310.00

1555New Technology - Level XVIII 

($1600-$1700)T"$1,650.00".$330.00

1556New Technology - Level XIX 

($1700-$1800)T"$1,750.00".$350.00
1557New Technology - Level XX 

($1800-$1900)T"$1,850.00".$370.00

1558New Technology - Level XXI 

($1900-$2000)T"$1,950.00".$390.00

1559New Technology - Level XXII 

($2000-$2500)T"$2,250.00".$450.00

1560New Technology - Level XXIII 

($2500-$3000)T"$2,750.00".$550.00

1561New Technology - Level XXIV 

($3000-$3500)T"$3,250.00".$650.00

1562New Technology - Level XXV 

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

1563New Technology - Level XXVI 

($4000-$4500)T"$4,250.00".$850.00

1564New Technology - Level XXVII 

($4500-$5000)T"$4,750.00".$950.00

1565New Technology - Level XXVIII 

($5000-$5500)T"$5,250.00"."$1,050.00"

1566New Technology - Level XXIX 

($5500-$6000)T"$5,750.00"."$1,150.00"

1567New Technology - Level XXX 

($6000-$6500)T"$6,250.00"."$1,250.00"

1568New Technology - Level XXXI 

($6500-$7000)T"$6,750.00"."$1,350.00"

1569New Technology - Level XXXII 

($7000-$7500)T"$7,250.00"."$1,450.00"

1570New Technology - Level XXXIII 

($7500-$8000)T"$7,750.00"."$1,550.00"

1571New Technology - Level XXXIV 

($8000-$8500)T"$8,250.00"."$1,650.00"

1572New Technology - Level XXXV 

($8500-$9000)T"$8,750.00"."$1,750.00"

1573New Technology - Level XXXVI 
($9000-$9500)T"$9,250.00"."$1,850.00"

1574New Technology - Level XXXVII 

($9500-$10000)T"$9,750.00"."$1,950.00"

1605Abciximab 

injectionK$515.32.$103.07

1607Eptifibatide 

injectionK$20.31.$4.07

1608Etanercept 

injectionK$203.01.$40.61

1609"Rho(D) immune globulin h, 

sd"K$18.83.$3.77

1612"Daclizumab, 

parenteral"K$516.41.$103.29

1613Trastuzumab 

injectionK$69.06.$13.82

1630"Hep b ig, 

im"K$112.16.$22.44

1631Baclofen intrathecal 

trialK$72.18.$14.44

1633AlefaceptK$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"

1670Tetanus immune globulin 

injK$222.97.$44.60

1675P32 Na 

phosphateK$162.87.$32.58

1676P32 chromic 

phosphateK$154.15.$30.83

1683BasiliximabK"$2,027.27".$405.46

1684Corticorelin ovine 
triflutalK$5.06.$1.02

1685"Darbepoetin alfa, 

non-esrd"K$2.98.$0.60

1686"Epoetin alfa, 

non-esrd"K$9.57.$1.92

1687Digoxin immune fab 

(ovine)K$583.90.$116.78

1688Ethanolamine 

oleateK$147.14.$29.43

1689FomepizoleK$6.76.$1.36

1690HeminK$8.33.$1.67

1693LepirudinK$299.56.$59.92

1694Ziconotide 

injectionK$6.48.$1.30

1695Nesiritide 

injectionK$43.93.$8.79

1696Palifermin 

injectionK$11.15.$2.23

1697Pegaptanib sodium 

injectionK"$1,002.20".$200.44

1700Inj secretin synthetic 

humanK$26.97.$5.40

1701Treprostinil 

injectionK$60.08.$12.02

1704"Humate-P, 

inj"K$0.87.$0.18

1705Factor 

viiaK$1.50.$0.30

1709Azacitidine 

injectionK$5.16.$1.04

1710Clofarabine 

injectionK$114.37.$22.88
1711Vantas 

implantK"$3,223.57".$644.72

1712Paclitaxel protein 

boundK$9.21.$1.85

1716"Brachytx, non-str, 

Gold-198"U1.0120$70.25.$14.05

1717"Brachytx, non-str, HDR 

Ir-192"U3.1681$219.93.$43.99

1719"Brachytx, NS, 

Non-HDRIr-192"U0.4486$31.14.$6.23

1738OxaliplatinK$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..

2210Methyldopate hcl 

injectionK$39.24.$7.85

2616"Brachytx, 

non-str,Yttrium-90"U232.3017"$16,126.38"."$3,225.28"

2632Iodine I-125 sodium 

iodideU0.2868$19.91.$3.99

2634"Brachytx, non-str, HA, 

I-125"U0.7908$54.90.$10.98

2635"Brachytx, non-str, HA, 

P-103"U0.3438$23.87.$4.78

2636"Brachy linear, 

non-str,P-103"U0.5112$35.49.$7.10

2638"Brachytx, stranded, 

I-125"U0.6225$43.21.$8.65

2639"Brachytx, 
non-stranded,I-125"U0.4992$34.65.$6.93

2640"Brachytx, stranded, 

P-103"U1.0610$73.65.$14.73

2641"Brachytx, 

non-stranded,P-103"U0.9263$64.30.$12.86

2642"Brachytx, stranded, 

C-131"U1.6922$117.47.$23.50

2643"Brachytx, 

non-stranded,C-131"U1.0735$74.52.$14.91

2698"Brachytx, stranded, 

NOS"U0.6225$43.21.$8.65

2699"Brachytx, non-stranded, 

NOS"U0.3438$23.87.$4.78

2731"Immune globulin, 

powder"K$30.62.$6.13

2770Quinupristin/dalfopristinK$157.23.$31.45

3041BivalirudinK$2.54.$0.51

3043Gamma globulin 1 CC 

injK$17.91.$3.59

3050Sermorelin acetate 

injectionK$1.76.$0.36

7000AmifostineK$314.05.$62.81

7011Oprelvekin 

injectionK$240.88.$48.18

7034Somatropin 

injectionK$56.09.$11.22

7035TeniposideK$316.52.$63.31

7036"Urokinase 250,000 IU 

inj"K$449.09.$89.82

7038Monoclonal 

antibodiesK"$1,112.14".$222.43
7041Tirofiban 

HClK$8.83.$1.77

7042"Capecitabine, 

oral"K$6.81.$1.37

7043Infliximab 

injectionK$58.90.$11.78

7046Doxorubicin hcl liposome 

injK$504.27.$100.86

7048Alteplase 

recombinantK$39.22.$7.85

7049Filgrastim 480 mcg 

injectionK$376.20.$75.24

7051Leuprolide acetate 

implantK"$4,728.88".$945.78

7308Aminolevulinic acid hcl 

topK$138.70.$27.74

8000Cardiac Electrophysiologic Evaluation and Ablation 

CompositeT161.2626"$11,194.85"."$2,238.97"

8001LDR Prostate Brachytherapy 

CompositeT46.7758"$3,247.18".$649.44

8002Level I Extended Assessment & Management 

CompositeV5.4881$380.98.$76.20

8003Level II Extended Assessment & Management 

CompositeV10.2164$709.22.$141.85

8004Ultrasound 

CompositeS2.7443$190.51.$38.11

8005CT and CTA without Contrast 

CompositeS6.1891$429.65.$85.93

8006CT and CTA with Contrast 

CompositeS10.3444$718.11.$143.63

8007MRI and MRA without Contrast 

CompositeS9.9875$693.33.$138.67

8008MRI and MRA with Contrast 
CompositeS14.3459$995.89.$199.18

8009Cardiac Resynchronization Therapy with Defibrillator 

CompositeT379.7887"$26,364.93"."$5,272.99"

9001Linezolid 

injectionK$33.99.$6.80

9002Tenecteplase 

injectionK$51.95.$10.39

9004Gemtuzumab ozogamicin 

injK"$2,637.02".$527.41

9005Reteplase 

injectionK"$1,332.35".$266.47

9006Tacrolimus 

injectionK$136.85.$27.37

9012Arsenic trioxide 

injectionK$40.13.$8.03

9018"Inj, 

rimabotulinumtoxinB"K$10.33.$2.07

9019Caspofungin 

acetateK$12.13.$2.43

9022IM inj interferon beta 

1-aK$220.75.$44.15

9023Rho d immune 

globulinK$24.81.$4.97

9024Amphotericin b lipid 

complexK$8.76.$1.76

9032Baclofen 10 MG 

injectionK$200.54.$40.11

9033Cidofovir 

injectionK$740.09.$148.02

9038Inj estrogen 

conjugateK$94.03.$18.81

9042Glucagon 

hydrochlorideK$95.59.$19.12
9044Ibutilide fumarate 

injectionK$129.32.$25.87

9104Antithymocyte globuln 

rabbitK$387.17.$77.44

9108Thyrotropin 

injectionK"$1,034.03".$206.81

9110Alemtuzumab 

injectionK$577.60.$115.52

9115Zoledronic 

acidK$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

9122Triptorelin 

pamoateK$193.59.$38.72

9124Daptomycin 

injectionK$0.45.$0.09

9125"Risperidone, long 

acting"K$4.93.$0.99

9126Natalizumab 

injectionK$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

9207Bortezomib 

injectionK$39.60.$7.92

9208Agalsidase beta 

injectionK$133.65.$26.73

9209Laronidase 

injectionK$25.08.$5.02

9210Palonosetron 

hclK$18.51.$3.71

9213Pemetrexed 

injectionK$51.37.$10.28

9214Bevacizumab 

injectionK$58.72.$11.75

9215Cetuximab 

injectionK$49.52.$9.91

9217Leuprolide acetate 

suspnsionK$210.96.$42.20

9224Galsulfase 

injectionK$338.26.$67.66

9225Fluocinolone acetonide 

impltK"$18,980.00"."$3,796.00"

9227Micafungin sodium 

injectionK$1.02.$0.21

9228Tigecycline 

injectionK$1.22.$0.25
9229Ibandronate sodium 

injectionK$144.36.$28.88

9230Abatacept 

injectionK$20.26.$4.06

9231Decitabine 

injectionK$30.71.$6.15

9232Idursulfase 

injectionK$446.45.$89.29

9233Ranibizumab 

injectionK$398.10.$79.62

9234Alglucosidase alfa 

injectionK$155.84.$31.17

9235Panitumumab 

injectionK$85.62.$17.13

9236Eculizumab 

injectionK$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

9243Bendamustine 

injectionK$18.15.$3.63

9244Regadenoson 

injectionK$51.36.$10.28

9245Romiplostim 

injectionK$44.84.$8.97

9248"Inj, clevidipine 

butyrate"K$6.03.$1.21

9249Certolizumab pegol 

injK$3.99.$0.80

9250Artiss fibrin 
sealantK$121.80.$24.36

9251C1 esterase inhibitor 

injK$43.78.$8.76

9252Plerixafor 

injectionK$278.36.$55.68

9253Temozolomide 

injectionK$4.86.$0.98

9254"Injection, 

lacosamide"K$0.15.$0.03

9255Paliperidone palmitate 

injK$6.45.$1.29

9256Dexamethasone intra 

implantK$194.17.$38.84

9258Telavancin 

injectionG$1.96.$0.40

9259Pralatrexate 

injectionG$165.63.$33.13

9260Ofatumumab 

injectionG$45.41.$9.09

9261Ustekinumab 

injectionG$112.30.$22.46

9263Ecallantide 

injectionG$275.28.$55.06

9264Tocilizumab 

injectionG$3.47.$0.70

9265Romidepsin 

injectionG$219.30.$43.86

9267Wilate 

injectionG$70.14.$14.03

9268Capsaicin 8% 

patchG$25.55.$5.11

9269"C-1 esterase, 

berinert"G$27.53.$5.51
9270Gammaplex 

IVIGG$37.29.$7.46

9271Velaglucerase 

alfaG$349.88.$69.98

9272"Inj, 

denosumab"G$14.52.$2.91

9273"Sipuleucel-T, per 

infusion"G"$32,860.00"."$6,572.00"

9274Crotalidae Poly Immune 

FabG"$2,111.36".$422.28

9275Hexaminolevulinate 

HClG$636.00.$0.00

9276Cabazitaxel 

injectionG$135.05.$27.01

9277"Lumizyme, 1 

mg"G$14.83.$2.97

9278Incobotulinumtoxin 

AG$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

9300Omalizumab 

injectionK$20.64.$4.13

9358"SurgiMend, 

fetal"K$11.09.$2.22

9360"SurgiMend, 

neonatal"K$11.59.$2.32

9363Integra Meshed Bil Wound 
MatK$19.17.$3.84

9367Endoform Dermal 

TemplateG$4.35.$0.87

9500"Platelets, 

irradiated"R2.1768$151.11.$30.23

9501Platelet pheres 

leukoreducedR7.5524$524.29.$104.86

9502Platelet pheresis 

irradiatedR7.5964$527.34.$105.47

9503Fr frz plasma donor 

retestedR1.2624$87.64.$17.53

9504RBC 

deglycerolizedR3.4728$241.08.$48.22

9505RBC 

irradiatedR3.3729$234.15.$46.83

9506"Granulocytes, pheresis 

unit"R22.1451"$1,537.31".$307.47

9507"Platelets, 

pheresis"R6.0636$420.94.$84.19

9508Plasma 1 donor frz w/in 8 

hrR1.0927$75.86.$15.18