Addendum A.-Final OPPS APCs for CY 2012

APCGroup TitleSIRelative Weight Payment Rate National Unadjusted Copayment Minimum 

Unadjusted Copayment

0001Level I PhotochemotherapyS0.5043$35.31.$7.07

0002Fine Needle Biopsy/AspirationT1.6118$112.85.$22.57

0003Bone Marrow Biopsy/AspirationT3.5548$248.89.$49.78

0004Level I Needle Biopsy/ Aspiration Except Bone MarrowT4.5721$320.12.$64.03

0005Level II Needle Biopsy/Aspiration Except Bone MarrowT8.1596$571.30.$114.26

0006Level I Incision & DrainageT1.4209$99.49.$19.90

0007Level II Incision & DrainageT12.8082$896.78.$179.36

0008Level III Incision and DrainageT20.5510"$1,438.90".$287.78

0012Level I Debridement & DestructionT0.3878$27.15.$5.43

0013Level II Debridement & DestructionT0.8768$61.39.$12.28

0015Level III Debridement & DestructionT1.4966$104.79.$20.96

0016Level IV Debridement & DestructionT2.7597$193.22.$38.65

0017Level V Debridement & DestructionT21.6700"$1,517.25".$303.45

0019Level I Excision/ BiopsyT4.3953$307.74.$61.55

0020Level II Excision/ BiopsyT8.2918$580.56.$116.12

0021Level III Excision/ BiopsyT16.9957"$1,189.97".$238.00

0022Level IV Excision/ BiopsyT23.2636"$1,628.82"$350.74$325.77

0028Level I Breast SurgeryT25.5066"$1,785.87".$357.18

0029Level II Breast SurgeryT33.3398"$2,334.32"$580.94$466.87

0030Level III Breast SurgeryT45.0217"$3,152.24"$747.07$630.45

0031Smoking Cessation ServicesX0.2988$20.92.$4.19

0034Mental Health Services CompositeS2.7298$191.13.$38.23

0035Vascular Puncture and Minor Diagnostic ProceduresX0.2673$18.72.$3.75

0037Level IV Needle Biopsy/Aspiration Except Bone 

MarrowT15.3535"$1,074.99"$227.40$215.00

0039Level I Implantation of Neurostimulator 

GeneratorS216.9330"$15,188.78"."$3,037.76"

0040Level I Implantation/Revision/Replacement of Neurostimulator Electrodes 

S63.3729"$4,437.12".$887.43

0041Level I ArthroscopyT29.7721"$2,084.52".$416.91

0042Level II ArthroscopyT57.0707"$3,995.86"$804.74$799.18

0045Bone/Joint Manipulation Under AnesthesiaT15.4596"$1,082.42"$268.44$216.49

0047Arthroplasty without ProsthesisT41.2873"$2,890.77".$578.16

0048Level I Arthroplasty or Implantation with ProsthesisT60.9147"$4,265.00".$853.00

0049Level I Musculoskeletal Procedures Except Hand and 

FootT22.0797"$1,545.93".$309.19

0050Level II Musculoskeletal Procedures Except Hand and 

FootT32.4461"$2,271.75".$454.35

0051Level III Musculoskeletal Procedures Except Hand and 

FootT47.5032"$3,325.98".$665.20

0052Level IV Musculoskeletal Procedures Except Hand and 

FootT88.8483"$6,220.80"."$1,244.16"

0053Level I Hand Musculoskeletal ProceduresT17.1902"$1,203.59"$253.49$240.72

0054Level II Hand Musculoskeletal ProceduresT28.8625"$2,020.84".$404.17

0055Level I Foot Musculoskeletal ProceduresT22.0963"$1,547.09"$353.25$309.42

0056Level II Foot Musculoskeletal ProceduresT58.4586"$4,093.04".$818.61

0057Bunion ProceduresT32.7262"$2,291.36"$475.91$458.28

0058Level I Strapping and Cast ApplicationS1.1255$78.80.$15.76

0060Manipulation TherapyS0.3428$24.00.$4.80

0061Level II Implantation/Revision/Replacement of Neurostimulator Electrodes 

S88.6050"$6,203.77"."$1,240.76"

0062Level I Treatment Fracture/DislocationT26.1202"$1,828.83"$372.85$365.77

0063Level II Treatment Fracture/DislocationT49.8979"$3,493.65".$698.73

0064Level III Treatment Fracture/DislocationT68.1203"$4,769.51".$953.91

0065"Level I Stereotactic Radiosurgery, MRgFUS, and MEG"S12.8903$902.53.$180.51

0066"Level II Stereotactic Radiosurgery, MRgFUS, and MEG"S35.9961"$2,520.30".$504.06

0067"Level III Stereotactic Radiosurgery, MRgFUS, and 

MEG"S48.1833"$3,373.60".$674.72

0069ThoracoscopyT34.5272"$2,417.46"$591.64$483.50

0070Thoracentesis/Lavage ProceduresT5.5061$385.52.$77.11

0071Level I Endoscopy Upper AirwayT1.0729$75.12.$15.03

0072Level II Endoscopy Upper AirwayT1.8643$130.53.$26.11

0073Level III Endoscopy Upper AirwayT4.4119$308.90$67.83$61.78
0074Level IV Endoscopy Upper AirwayT21.2774"$1,489.76".$297.96

0075Level V Endoscopy Upper AirwayT30.3487"$2,124.89"$444.55$424.98

0076Level I Endoscopy Lower AirwayT10.4689$732.99$189.82$146.60

0077Level I Pulmonary TreatmentS0.4237$29.67$7.74$5.94

0078Level III Pulmonary TreatmentS1.4089$98.65.$19.73

0079Ventilation Initiation and ManagementS3.1979$223.90.$44.78

0080Diagnostic Cardiac CatheterizationT38.8523"$2,720.28"$836.90$544.06

0082Coronary or Non-Coronary AtherectomyT105.0651"$7,356.24"."$1,471.25"

0083"Coronary Angioplasty, Valvuloplasty, and Level I Endovascular Revascularization of 

the Lower Extremity "T65.8519"$4,610.69".$922.14

0084Level I Electrophysiologic ProceduresS9.9330$695.47.$139.10

0085Level II Electrophysiologic ProceduresT53.2719"$3,729.89".$745.98

0086Level III Electrophysiologic ProceduresT121.8174"$8,529.17"."$1,705.84"

0088ThrombectomyT41.0387"$2,873.37"$655.18$574.68

0089Insertion/Replacement of Permanent Pacemaker and 

ElectrodesT112.1218"$7,850.32""$1,643.98""$1,570.07"

0090Level I Insertion/Replacement of Permanent Pacemaker 

T94.2220"$6,597.05""$1,593.50""$1,319.41"

0091Level II Vascular LigationT44.2272"$3,096.61".$619.33

0092Level I Vascular LigationT26.8120"$1,877.27".$375.46

0093Vascular Reconstruction/Fistula Repair without DeviceT31.1505"$2,181.03".$436.21

0094Level I Resuscitation and CardioversionS2.2326$156.32$43.83$31.27

0095Cardiac RehabilitationS0.9930$69.53.$13.91

0096Level II Noninvasive Physiologic StudiesS1.5248$106.76$36.86$21.36

0097Level I Noninvasive Physiologic StudiesS0.9350$65.46.$13.10

0099Electrocardiograms/CardiographyS0.3817$26.73.$5.35

0100Cardiac Stress TestsX2.5439$178.11$41.37$35.63

0101Tilt Table EvaluationS4.2669$298.75$100.24$59.75

0102Level II Pulmonary TreatmentS0.5346$37.43.$7.49

0103Miscellaneous Vascular ProceduresT16.3852"$1,147.23".$229.45

0104Transcatheter Placement of Intracoronary StentsT81.1503"$5,681.82"."$1,136.37"

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

Devices"T21.7420"$1,522.29".$304.46

0106Insertion/Replacement of Pacemaker Leads and/or 

ElectrodesT47.1769"$3,303.14".$660.63

0107Insertion of Cardioverter-Defibrillator Pulse 

GeneratorT341.5859"$23,916.48"."$4,783.30"

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

Electrodes"T426.1201"$29,835.22"."$5,967.05"

0110TransfusionS3.4217$239.57.$47.92

0111Blood Product ExchangeS11.6629$816.59$189.89$163.32

0112Apheresis and Stem Cell ProceduresS35.6252"$2,494.33".$498.87

0113Excision Lymphatic SystemT25.2738"$1,769.57".$353.92

0114Thyroid/Lymphadenectomy ProceduresT51.2792"$3,590.36".$718.08

0115Cannula/Access Device ProceduresT37.4593"$2,622.75".$524.55

0121Level I Tube or Catheter Changes or RepositioningT6.2123$434.96.$87.00

0126Level I Urinary and Anal ProceduresT1.1095$77.68$16.21$15.54

0127"Level IV Stereotactic Radiosurgery, MRgFUS, and 

MEG"S106.5454"$7,459.88"."$1,491.98"

0128Echocardiogram with ContrastS7.9593$557.28$166.16$111.46

0129Level I Closed Treatment FractureT1.5020$105.16.$21.04

0130Level I LaparoscopyT38.9223"$2,725.18"$659.53$545.04

0131Level II LaparoscopyT47.9394"$3,356.53""$1,001.89"$671.31

0132Level III LaparoscopyT71.5658"$5,010.75""$1,236.99""$1,002.15"

0133Level I Skin RepairT1.1922$83.47$23.34$16.70

0134Level II Skin RepairT3.2354$226.53.$45.31

0135Level III Skin RepairT4.9271$344.98.$69.00

0136Level IV Skin RepairT16.7703"$1,174.19".$234.84

0137Level V Skin RepairT21.4409"$1,501.21".$300.25

0138Level II Closed Treatment Fracture T5.0454$353.26.$70.66

0139Level III Closed Treatment Fracture T18.9489"$1,326.73".$265.35

0140Esophageal Dilation without EndoscopyT6.5866$461.17.$92.24

0141Level I Upper GI ProceduresT8.4511$591.71$138.69$118.35

0142Level I Small Intestine EndoscopyT10.4394$730.93$152.78$146.19

0143Lower GI EndoscopyT9.3693$656.00$186.06$131.20

0146Level I Sigmoidoscopy and AnoscopyT6.2205$435.53.$87.11
0147Level II Sigmoidoscopy and AnoscopyT11.0417$773.10.$154.62

0148Level I Anal/Rectal ProceduresT5.5158$386.19.$77.24

0149Level III Anal/Rectal ProceduresT24.4382"$1,711.07".$342.22

0150Level IV Anal/Rectal ProceduresT32.9805"$2,309.16".$461.84

0151Endoscopic Retrograde Cholangio-Pancreatography 

(ERCP)T24.6966"$1,729.16".$345.84

0152Level I Percutaneous Abdominal and Biliary ProceduresT29.1415"$2,040.37".$408.08

0153Peritoneal and Abdominal ProceduresT27.2798"$1,910.02".$382.01

0154Hernia/Hydrocele ProceduresT32.9294"$2,305.58"$464.85$461.12

0155Level II Anal/Rectal ProceduresT15.4175"$1,079.47".$215.90

0156Level III Urinary and Anal ProceduresT3.1886$223.25.$44.65

0157Colorectal Cancer Screening: Barium EnemaS2.7510$192.61.$38.53

0158Colorectal Cancer Screening: ColonoscopyT8.3164$582.28$0.00$0.00

0159Colorectal Cancer Screening: Flexible SigmoidoscopyS5.3772$376.49$0.00$0.00

0160Level I Cystourethroscopy and other Genitourinary 

ProceduresT6.7736$474.26.$94.86

0161Level II Cystourethroscopy and other Genitourinary 

ProceduresT17.4715"$1,223.28".$244.66

0162Level III Cystourethroscopy and other Genitourinary 

ProceduresT26.2973"$1,841.23".$368.25

0163Level IV Cystourethroscopy and other Genitourinary 

ProceduresT37.0730"$2,595.70".$519.14

0164Level II Urinary and Anal ProceduresT1.9499$136.52.$27.31

0165Level IV Urinary and Anal ProceduresT20.4158"$1,429.43".$285.89

0166Level I Urethral ProceduresT21.0031"$1,470.55".$294.11

0168Level II Urethral ProceduresT32.3061"$2,261.94".$452.39

0169LithotripsyT52.0882"$3,647.01"$997.74$729.41

0170DialysisS6.2419$437.03.$87.41

0172Level I Partial Hospitalization (3 services) for CMHCsP1.3944$97.63.$19.53

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

CMHCsP1.6255$113.81.$22.77

0174Level IV LaparoscopyT111.6495"$7,817.25""$2,055.58""$1,563.45"

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

PHPsP2.2954$160.71.$32.15

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

PHPsP2.7298$191.13.$38.23

0181Level II Male Genital ProceduresT34.6069"$2,423.04"$607.60$484.61

0183Level I Male Genital ProceduresT23.5454"$1,648.55".$329.71

0184Prostate BiopsyT13.7727$964.31.$192.87

0188Level II Female Reproductive ProcT1.5841$110.91.$22.19

0189Level III Female Reproductive ProcT3.4818$243.78.$48.76

0190Level I HysteroscopyT23.0098"$1,611.05"$424.28$322.21

0191Level I Female Reproductive ProcT0.1337$9.36$1.95$1.88

0192Level IV Female Reproductive ProcT6.6979$468.96.$93.80

0193Level V Female Reproductive ProcT20.6493"$1,445.78".$289.16

0195Level VI Female Reproductive ProceduresT35.9087"$2,514.18".$502.84

0202Level VII Female Reproductive ProceduresT45.9895"$3,220.00"$981.50$644.00

0203Level IV Nerve InjectionsT12.7996$896.18.$179.24

0204Level I Nerve InjectionsT2.6055$182.43.$36.49

0206Level II Nerve InjectionsT3.8754$271.34.$54.27

0207Level III Nerve InjectionsT7.4537$521.88.$104.38

0208Laminotomies and LaminectomiesT50.7343"$3,552.21".$710.45

0209"Level II Extended EEG, Sleep, and Cardiovascular 

Studies"S11.3569$795.16$268.73$159.04

0213"Level I Extended EEG, Sleep, and Cardiovascular 

Studies"S2.4298$170.12$53.58$34.03

0215Level I Nerve and Muscle TestsS0.6335$44.36.$8.88

0216Level III Nerve and Muscle TestsS2.6488$185.46.$37.10

0218Level II Nerve and Muscle TestsS1.2025$84.19.$16.84

0220Level I Nerve ProceduresT18.8921"$1,322.75".$264.55

0221Level II Nerve ProceduresT36.1290"$2,529.61".$505.93

0224Implantation of Catheter/Reservoir/ShuntT41.5547"$2,909.49".$581.90

0227Implantation of Drug Infusion DeviceT192.7379"$13,494.74"."$2,698.95"

0229Level II Endovascular Revascularization of the Lower Extremity 

T115.5014"$8,086.95"."$1,617.39"

0230Level I Eye Tests & TreatmentsS0.6424$44.98.$9.00
0231Level III Eye Tests & TreatmentsS2.0294$142.09.$28.42

0232Level I Anterior Segment Eye ProceduresT2.8247$197.77$42.27$39.56

0233Level III Anterior Segment Eye ProceduresT16.6214"$1,163.76".$232.76

0234Level IV Anterior Segment Eye ProceduresT23.2851"$1,630.33"$347.90$326.07

0235Level I Posterior Segment Eye ProceduresT4.8135$337.02.$67.41

0237Level II Posterior Segment Eye ProceduresT21.5368"$1,507.92".$301.59

0238Level I Repair and Plastic Eye ProceduresT3.1036$217.30.$43.46

0239Level II Repair and Plastic Eye ProceduresT7.6566$536.08.$107.22

0240Level III Repair and Plastic Eye ProceduresT19.7786"$1,384.82"$296.20$276.97

0241Level IV Repair and Plastic Eye ProceduresT27.3416"$1,914.35"$383.45$382.87

0242Level V Repair and Plastic Eye ProceduresT40.4039"$2,828.92"$597.36$565.79

0243Strabismus/Muscle ProceduresT24.8671"$1,741.09"$411.91$348.22

0244Corneal and Amniotic Membrane TransplantT37.8979"$2,653.46"$794.94$530.70

0246Cataract Procedures with IOL InsertT23.8810"$1,672.05"$490.37$334.41

0247Laser Eye ProceduresT5.4120$378.93$102.28$75.79

0249Cataract Procedures without IOL InsertT30.9855"$2,169.48"$516.99$433.90

0250Level I ENT ProceduresT1.0709$74.98$24.12$15.00

0251Level II ENT ProceduresT3.1150$218.10.$43.62

0252Level III ENT ProceduresT7.4614$522.42$104.55$104.49

0253Level IV ENT ProceduresT16.8699"$1,181.16"$279.20$236.24

0254Level V ENT ProceduresT24.8895"$1,742.66".$348.54

0255Level II Anterior Segment Eye ProceduresT7.2190$505.45$101.81$101.09

0256Level VI ENT ProceduresT45.0377"$3,153.36".$630.68

0259Level VII ENT ProceduresT412.7299"$28,897.70""$7,948.75""$5,779.54"

0260Level I Plain Film Except TeethX0.6409$44.87.$8.98

0261Level II Plain Film Except Teeth Including Bone Density 

MeasurementX1.0790$75.55.$15.11

0262Plain Film of TeethX0.4640$32.49.$6.50

0263Level I Miscellaneous Radiology ProceduresX3.3643$235.55.$47.11

0265Level I Diagnostic and Screening UltrasoundS0.8990$62.94$22.26$12.59

0266Level II Diagnostic and Screening UltrasoundS1.3781$96.49$37.23$19.30

0267Level III Diagnostic and Screening UltrasoundS2.1681$151.80$59.37$30.36

0269Level II Echocardiogram Without Contrast S5.6156$393.18.$78.64

0270Level III Echocardiogram Without Contrast S8.2952$580.80$133.61$116.16

0272FluoroscopyX1.2171$85.22$30.47$17.05

0274MyelographyS7.0678$494.86.$98.98

0275ArthrographyS4.0104$280.79$68.90$56.16

0276Level I Digestive RadiologyS1.2186$85.32$33.87$17.07

0277Level II Digestive RadiologyS2.0340$142.41$53.90$28.49

0278Diagnostic UrographyS2.6196$183.41$58.44$36.69

0279Level II Angiography and VenographyS29.7209"$2,080.94".$416.19

0280Level III Angiography and VenographyS49.6878"$3,478.94".$695.79

0282Miscellaneous Computed Axial TomographyS1.5251$106.78$35.57$21.36

0283Computed Tomography with ContrastS4.2929$300.57$96.62$60.12

0284Magnetic Resonance Imaging and Magnetic Resonance Angiography with 

ContrastS6.2343$436.50$146.69$87.30

0288Bone Density:Axial SkeletonS1.0218$71.54$0.00$0.00

0293Level VI Anterior Segment Eye ProceduresT117.1298"$8,200.96"."$1,640.20"

0299Hyperthermia and Radiation Treatment ProceduresS5.6386$394.79.$78.96

0300Level I Radiation TherapyS1.4252$99.79.$19.96

0301Level II Radiation TherapyS2.4149$169.08.$33.82

0303Treatment Device ConstructionX2.8573$200.06$66.95$40.02

0304Level I Therapeutic Radiation Treatment PreparationX1.5329$107.33$34.63$21.47

0305Level II Therapeutic Radiation Treatment PreparationX3.7681$263.83$88.76$52.77

0308Positron Emission Tomography (PET) imagingS14.8260"$1,038.06".$207.62

0310Level III Therapeutic Radiation Treatment 

PreparationX13.6332$954.54$325.27$190.91

0312Radioelement ApplicationsS5.4044$378.39.$75.68

0313BrachytherapyS9.9687$697.97$263.92$139.60

0315Level II Implantation of Neurostimulator Generator 

S285.5893"$19,995.82"."$3,999.17"

0317Level II Miscellaneous Radiology ProceduresX5.7208$400.55.$80.11

0318Implantation of Neurostimulator Pulse Generator and Electrode 

S346.4693"$24,258.39""$9,121.76""$4,851.68"

0319Level III Endovascular Revascularization of the Lower 
ExtremityT203.0553"$14,217.12""$5,559.48""$2,843.43"

0320Electroconvulsive TherapyS5.9715$418.10.$83.62

0322Brief Individual PsychotherapyS1.1395$79.78.$15.96

0323Extended Individual PsychotherapyS1.5910$111.40.$22.28

0324Family PsychotherapyS1.8190$127.36.$25.48

0325Group PsychotherapyS0.8088$56.63$11.70$11.33

0330Dental ProceduresS8.2687$578.94.$115.79

0331Combined Abdomen and Pelvis CT without Contrast S5.7930$405.60$156.82$81.12

0332Computed Tomography without ContrastS2.7436$192.10$74.27$38.42

0333Computed Tomography without Contrast followed by 

ContrastS4.7767$334.45$116.13$66.89

0334Combined Abdomen and Pelvis CT with Contrast S8.2987$581.04$187.25$116.21

0336Magnetic Resonance Imaging and Magnetic Resonance Angiography without 

ContrastS4.8381$338.74$133.48$67.75

0337Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast 

followed by ContrastS7.6347$534.55$197.64$106.91

0340Minor Ancillary ProceduresX0.6499$45.50.$9.10

0341Skin TestsX0.0806$5.64$2.09$1.13

0342Level I PathologyX0.1601$11.21.$2.25

0343Level III PathologyX0.5259$36.82$10.84$7.37

0344Level IV PathologyX0.8180$57.27$15.56$11.46

0345Level I Transfusion Laboratory ProceduresX0.2135$14.95.$2.99

0346Level II Transfusion Laboratory ProceduresX0.3538$24.77.$4.96

0347Level III Transfusion Laboratory ProceduresX0.6730$47.12.$9.43

0350Administration of flu and PPV vaccineS0.3545$24.82$0.00$0.00

0360Level I Alimentary TestsX1.7152$120.09$33.87$24.02

0361Level II Alimentary TestsX4.0827$285.85$83.23$57.17

0363Level I Otorhinolaryngologic Function TestsX0.9638$67.48$17.10$13.50

0364Level I AudiometryX0.4911$34.38$7.06$6.88

0365Level II AudiometryX1.2175$85.24$18.05$17.05

0366Level III AudiometryX1.6864$118.07$23.65$23.62

0367Level I Pulmonary TestX0.7420$51.95$13.76$10.39

0368Level II Pulmonary TestsX0.8906$62.36$20.93$12.48

0369Level III Pulmonary TestsX2.6868$188.12$38.23$37.63

0370Multiple Allergy TestsX1.1369$79.60.$15.92

0373Level I Neuropsychological TestingX1.3842$96.92.$19.39

0375Ancillary Outpatient Services When Patient 

ExpiresS86.2468"$6,038.66"."$1,207.74"

0377Level II Cardiac ImagingS9.6018$672.28.$134.46

0378Level II Pulmonary ImagingS4.5192$316.42$126.56$63.29

0381Single Allergy TestsX0.4426$30.99.$6.20

0382Level II Neuropsychological TestingX2.5717$180.06.$36.02

0383Cardiac Computed Tomographic ImagingS3.7417$261.98.$52.40

0384GI Procedures with StentsT29.2172"$2,045.67".$409.14

0385Level I Prosthetic Urological ProceduresS104.8530"$7,341.39"."$1,468.28"

0386Level II Prosthetic Urological ProceduresS169.3017"$11,853.83"."$2,370.77"

0387Level II HysteroscopyT38.3457"$2,684.81"$655.55$536.97

0388DiscographyS22.7689"$1,594.19".$318.84

0389Level I Non-imaging Nuclear MedicineS1.5569$109.01$26.88$21.81

0390Level I Endocrine ImagingS1.8944$132.64$47.64$26.53

0391Level II Endocrine ImagingS3.1610$221.32$65.46$44.27

0392Level II Non-imaging Nuclear MedicineS2.2892$160.28$39.07$32.06

0393Hematologic Processing & StudiesS6.9196$484.48.$96.90

0394Hepatobiliary ImagingS4.1909$293.43$90.78$58.69

0395GI Tract ImagingS3.4841$243.94$87.01$48.79

0396Bone ImagingS3.5304$247.18$94.20$49.44

0397Vascular ImagingS2.0980$146.89$33.94$29.38

0398Level I Cardiac ImagingS4.2548$297.90$93.33$59.58

0400Hematopoietic ImagingS3.6580$256.12$90.92$51.23

0401Level I Pulmonary ImagingS2.8915$202.45$71.16$40.49

0402Level II Nervous System ImagingS8.6793$607.69.$121.54

0403Level I Nervous System ImagingS3.4408$240.91$72.42$48.19

0404Renal and Genitourinary StudiesS4.5536$318.82$81.52$63.77

0406Level I Tumor/Infection ImagingS4.0053$280.44$85.08$56.09

0407Level I Radionuclide TherapyS3.2941$230.64$78.13$46.13

0408Level III Tumor/Infection ImagingS13.6750$957.47.$191.50

0409Red Blood Cell TestsX0.1101$7.71$2.17$1.55
0412IMRT Treatment DeliveryS6.5452$458.27.$91.66

0413Level II Radionuclide TherapyS4.0373$282.68.$56.54

0414Level II Tumor/Infection ImagingS7.0664$494.76.$98.96

0415Level II Endoscopy Lower AirwayT28.9051"$2,023.82"$459.92$404.77

0419Level II Upper GI Procedures T12.6671$886.90$207.88$177.38

0422Level III Upper GI ProceduresT25.9792"$1,818.96".$363.80

0423Level II Percutaneous Abdominal and Biliary 

ProceduresT58.4890"$4,095.17".$819.04

0424Level II Small Intestine Endoscopy T15.7819"$1,104.99"$240.64$221.00

0425Level II Arthroplasty or Implantation with 

ProsthesisT132.5319"$9,279.35"."$1,855.87"

0426Level II Strapping and Cast ApplicationS2.5699$179.93.$35.99

0427Level II Tube or Catheter Changes or RepositioningT16.2412"$1,137.14".$227.43

0428Level III Sigmoidoscopy and AnoscopyT23.9777"$1,678.82".$335.77

0429Level V Cystourethroscopy and other Genitourinary 

ProceduresT45.7676"$3,204.46".$640.90

0432Health and Behavior ServicesS0.5154$36.09.$7.22

0433Level II PathologyX0.2434$17.04$5.06$3.41

0434Cardiac Defect RepairT171.3141"$11,994.73"."$2,398.95"

0436Level I Drug AdministrationS0.3545$24.82.$4.97

0437Level II Drug AdministrationS0.4972$34.81.$6.97

0438Level III Drug AdministrationS1.0388$72.73.$14.55

0439Level IV Drug AdministrationS1.8098$126.71.$25.35

0440Level V Drug AdministrationS2.9679$207.80.$41.56

0442Dosimetric Drug AdministrationS21.9850"$1,539.30".$307.86

0604Level 1 Hospital Clinic VisitsV0.7689$53.84.$10.77

0605Level 2 Hospital Clinic VisitsV1.0311$72.19.$14.44

0606Level 3 Hospital Clinic VisitsV1.3588$95.14.$19.03

0607Level 4 Hospital Clinic VisitsV1.8647$130.56.$26.12

0608Level 5 Hospital Clinic VisitsV2.5237$176.70.$35.34

0609Level 1 Type A Emergency VisitsV0.7181$50.28$12.04$10.06

0613Level 2 Type A Emergency VisitsV1.2356$86.51$20.79$17.31

0614Level 3 Type A Emergency VisitsV1.9447$136.16$33.59$27.24

0615Level 4 Type A Emergency VisitsV3.1277$218.99$47.70$43.80

0616Level 5 Type A Emergency VisitsV4.6152$323.14$71.44$64.63

0617Critical CareS6.6453$465.28$104.95$93.06

0618Trauma Response with Critical CareS11.2658$788.79.$157.76

0621Level I Vascular Access ProceduresT11.0639$774.65.$154.93

0622Level II Vascular Access ProceduresT25.2672"$1,769.11".$353.83

0623Level III Vascular Access ProceduresT30.3507"$2,125.03".$425.01

0624Phlebotomy and Minor Vascular Access Device ProceduresX0.6068$42.49$12.33$8.50

0626Level 1 Type B Emergency VisitsV0.5627$39.40.$7.88

0627Level 2 Type B Emergency VisitsV0.7972$55.82.$11.17

0628Level 3 Type B Emergency VisitsV1.3178$92.27.$18.46

0629Level 4 Type B Emergency VisitsV1.9503$136.55.$27.31

0630Level 5 Type B Emergency VisitsV3.7639$263.53.$52.71

0648Level IV Breast SurgeryT62.4125"$4,369.87".$873.98

0651Complex Interstitial Radiation Source ApplicationS11.9274$835.11.$167.03

0652Insertion of Intraperitoneal and Pleural CathetersT30.8430"$2,159.50".$431.90

0653Vascular Reconstruction/Fistula Repair with DeviceT43.8023"$3,066.86".$613.38

0654Level II Insertion/Replacement of Permanent Pacemaker 

T103.3418"$7,235.58"."$1,447.12"

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

ElectrodeT137.6558"$9,638.11"."$1,927.63"

0656Transcatheter Placement of Intracoronary Drug-Eluting 

StentsT105.6644"$7,398.20"."$1,479.64"

0659Hyperbaric OxygenS1.4941$104.61.$20.93

0660Level II Otorhinolaryngologic Function TestsX1.8189$127.35$27.10$25.47

0661Level V PathologyX2.3496$164.51.$32.91

0662CT AngiographyS4.8375$338.70$114.37$67.74

0664Level I Proton Beam Radiation TherapyS16.9101"$1,183.98".$236.80

0665Bone Density:AppendicularSkeletonS0.4865$34.06$0.00$0.00

0667Level II Proton Beam Radiation TherapyS22.1209"$1,548.82".$309.77

0668Level I Angiography and VenographyT9.4045$658.47.$131.70

0672Level III Posterior Segment Eye ProceduresT41.0159"$2,871.77".$574.36

0673Level V Anterior Segment Eye ProceduresT41.5778"$2,911.11"$634.95$582.23
0674Prostate CryoablationT113.8112"$7,968.60"."$1,593.72"

0676Thrombolysis and Other Device Revisions T2.3021$161.18.$32.24

0678External CounterpulsationT1.3360$93.54.$18.71

0679Level II Resuscitation and CardioversionS5.3254$372.86$95.30$74.58

0680Insertion of Patient Activated Event RecordersS80.3579"$5,626.34"."$1,125.27"

0683Level II PhotochemotherapyS3.0368$212.62.$42.53

0685Level III Needle Biopsy/Aspiration Except Bone MarrowT9.6713$677.15.$135.43

0687Revision/Removal of Neurostimulator ElectrodesT20.7198"$1,450.72"$385.30$290.15

0688Revision/Removal of Neurostimulator Pulse Generator 

ReceiverT31.1002"$2,177.51"$768.94$435.51

0690Level I Electronic Analysis of DevicesS0.4928$34.50.$6.90

0691Level III Electronic Analysis of DevicesS2.3930$167.55.$33.51

0692Level II Electronic Analysis of DevicesS1.5944$111.63.$22.33

0694Mohs SurgeryT5.0714$355.08$88.08$71.02

0697Level I Echocardiogram Without Contrast S3.1615$221.36.$44.28

0698Level II Eye Tests & TreatmentsS1.0589$74.14.$14.83

0699Level IV Eye Tests & TreatmentsT15.4248"$1,079.98".$216.00

0701Sr89 strontiumK$954.77.$190.96

0726Dexrazoxane HCl injectionK$207.92.$41.59

0728Filgrastim 300 mcg injectionK$246.80.$49.36

0731Sargramostim injectionK$24.22.$4.85

0735Ampho b cholesteryl sulfateK$14.56.$2.92

0736Amphotericin b liposome injK$14.25.$2.85

0738RasburicaseK$188.98.$37.80

0747Chlorothiazide sodium injK$269.86.$53.98

0751Mechlorethamine hcl injK$154.88.$30.98

0752Dactinomycin injectionK$567.28.$113.46

0759"Naltrexone, depot form"K$2.78.$0.56

0800Leuprolide acetateK$590.71.$118.15

0802Etoposide oralK$37.54.$7.51

0807Aldesleukin injectionK$969.60.$193.92

0809Bcg live intravesical vacK$117.34.$23.47

0810Goserelin acetate implantK$186.43.$37.29

0812Carmustine injectionK$172.53.$34.51

0814Asparaginase injectionK$62.08.$12.42

0820Daunorubicin injectionK$15.60.$3.12

0821Daunorubicin citrate injK$56.58.$11.32

0823Docetaxel injectionK$15.75.$3.15

0825Nelarabine injectionK$113.99.$22.80

0827Floxuridine injectionK$60.82.$12.17

0828Gemcitabine hcl injectionK$89.64.$17.93

0830Irinotecan injectionK$6.42.$1.29

0831Ifosfamide injectionK$32.03.$6.41

0832Idarubicin hcl injectionK$58.32.$11.67

0835Cosyntropin injection NOSK$99.76.$19.96

0836Interferon alfa-2b injK$16.82.$3.37

0838Interferon gamma 1-b injK$582.59.$116.52

0840Inj melphalan hydrochlK"$1,512.71".$302.55

0842Fludarabine phosphate injK$101.84.$20.37

0843Pegaspargase injectionK"$2,675.40".$535.08

0844Pentostatin injectionK"$1,084.10".$216.82

0849Rituximab injectionK$615.22.$123.05

0850Streptozocin injectionK$265.69.$53.14

0851Thiotepa injectionK$131.18.$26.24

0856Porfimer sodium injectionK"$19,348.11"."$3,869.63"

0858Inj cladribineK$23.94.$4.79

0861Leuprolide acetate injecitonK$4.42.$0.89

0864Mitoxantrone hydrochlK$37.36.$7.48

0865Interferon alfa-n3 injK$31.20.$6.24

0868Oral aprepitantK$6.06.$1.22

0873Hyalgan/supartz inj per doseK$88.00.$17.60

0874Synvisc or synvisc-oneK$11.93.$2.39

0875Euflexxa inj per doseK$146.10.$29.22

0877Orthovisc inj per doseK$166.14.$33.23

0884Rho d immune globulin injK$82.14.$16.43

0887Azathioprine parenteralK$122.53.$24.51
0890Lymphocyte immune globulinK$556.51.$111.31

0900Alglucerase injectionK$41.24.$8.25

0901Alpha 1 proteinase inhibitorK$3.83.$0.77

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

0903Cytomegalovirus imm IV /vialK$947.86.$189.58

0910Interferon beta-1b / .25 MGK$211.59.$42.32

0913Ganciclovir long act implantK"$16,640.00"."$3,328.00"

0917Adenosine injectionK$94.42.$18.89

0925Factor viiiK$0.85.$0.17

0927Factor viii recombinantK$1.09.$0.22

0928Factor ix complexK$0.91.$0.19

0929Anti-inhibitorK$1.60.$0.32

0931Factor IX non-recombinantK$0.89.$0.18

0932Factor IX recombinantK$1.14.$0.23

0933Gamma globulin > 10 CC injK$206.16.$41.24

0934"Capecitabine, oral"K$24.63.$4.93

0943Octagam injectionK$55.80.$11.16

0944Gammagard liquid injectionK$37.08.$7.42

0945Rhophylac injectionK$5.09.$1.02

0946Hepagam b im injectionK$52.11.$10.43

0947Flebogamma injectionG$35.15.$6.90

0948Gamunex/gamunex cK$36.78.$7.36

0949"Frozen plasma, pooled, sd"R0.9547$66.84.$13.37

0950Whole blood for transfusionR2.7245$190.76.$38.16

0951Reclast injectionK$218.44.$43.69

0952Cryoprecipitate each unitR1.1823$82.78.$16.56

0954RBC leukocytes reducedR2.8408$198.90.$39.78

0955"Plasma, frz between 8-24hour"R1.0400$72.82.$14.57

0956"Plasma protein fract,5%,50ml"R0.2574$18.02.$3.61

0957"Platelets, each unit"R1.2822$89.77.$17.96

0958Plaelet rich plasma unitR2.0257$141.83.$28.37

0959Red blood cells unitR2.1303$149.16.$29.84

0960Washed red blood cells unitR4.1045$287.38.$57.48

0961"Albumin (human),5%, 50ml"K$21.32.$4.27

0963"Albumin (human), 5%, 250 ml"K$61.94.$12.39

0964"Albumin (human), 25%, 20 ml"K$26.84.$5.37

0965"Albumin (human), 25%, 50ml"K$68.03.$13.61

0966"Plasmaprotein fract,5%,250ml"R1.0362$72.55.$14.51

0967Blood split unitR1.6761$117.35.$23.47

0968Platelets leukoreduced irradR1.9996$140.00.$28.00

0969RBC leukoreduced irradiatedR3.7309$261.22.$52.25

1009CryoprecipitatereducedplasmaR1.0622$74.37.$14.88

1010"Blood, l/r, cmv-neg"R2.6930$188.55.$37.71

1011"Platelets, hla-m, l/r, unit"R11.4695$803.05.$160.61

1013Platelets leukocytes reducedR1.8720$131.07.$26.22

1015Injection glatiramer acetateK$109.30.$21.86

1016"Blood, l/r, froz/degly/wash"R1.4989$104.95.$20.99

1017"Plt, aph/pher, l/r, cmv-neg"R5.4802$383.70.$76.74

1018"Blood, l/r, irradiated"R2.0966$146.80.$29.36

1019Plate pheres leukoredu irradR9.8804$691.79.$138.36

1020"Plt, pher, l/r cmv-neg, irr"R8.7936$615.69.$123.14

1021"RBC, frz/deg/wsh, l/r, irrad"R6.4103$448.82.$89.77

1022"RBC, l/r, cmv-neg, irrad"R4.3700$305.97.$61.20

1023Pralidoxime chloride injK$88.51.$17.71

1052"Injection, voriconazole"K$6.07.$1.22

1064"I131 iodide cap, rx"K$17.26.$3.46

1083Adalimumab injectionK$410.95.$82.19

1084Denileukin diftitox injK"$1,603.01".$320.61

1086TemozolomideK$9.48.$1.90

1138"Hepagam b intravenous, inj"K$52.11.$10.43

1139Protein c concentrateK$12.90.$2.58

1142Supprelin LA implantK"$15,418.48"."$3,083.70"

1150"I131 iodide sol, rx"K$10.49.$2.10

1166Cytarabine liposome injK$503.48.$100.70

1167"Inj, epirubicin hcl"K$1.87.$0.38

1168"Inj, temsirolimus"K$50.57.$10.12
1178Busulfan injectionK$18.72.$3.75

1203Verteporfin injectionK$9.76.$1.96

1207"Octreotide injection, depot"K$117.11.$23.43

1213Antihemophilic viii/vwf compK$0.90.$0.18

1214Inj IVIG privigen 500 mgK$34.42.$6.89

1221Dimethyl sulfoxide 50%K$94.38.$18.88

1222Pentastarch 10% solutionK$13.23.$2.65

1226Inj streptokinase /250000 IUK$19.78.$3.96

1232Mitomycin 5 MG injK$19.55.$3.91

1235Valrubicin injectionK$959.07.$191.82

1236Levoleucovorin injectionK$1.58.$0.32

1237Inj iron dextranK$11.53.$2.31

1238Topotecan oralK$77.92.$15.59

1239Rotavirus vacc 2 dose oralK$106.60.$21.32

1240Apligraf skin subK$35.88.$7.18

1241Oasis wound matrix skin subK$5.74.$1.15

1242Oasis burn matrix skin subK$5.74.$1.15

1243Integra BMWD skin subK$16.26.$3.26

1244Integra DRT skin subK$9.62.$1.93

1245Dermagraft skin subK$40.51.$8.11

1246Graftjacket skin subK$94.95.$18.99

1247Integra matrix skin subK$21.73.$4.35

1248Primatrix skin subK$31.42.$6.29

1249Cymetra allograftK$332.25.$66.45

1250Graftjacket express allografK$332.25.$66.45

1251Integra flowable wound matriK"$1,019.89".$203.98

1252Gammagraft skin subK$6.78.$1.36

1253Triamcinolone A inj PRS-freeK$3.41.$0.69

1263Antithrombin iii injectionK$2.71.$0.55

1268Xyntha injK$1.07.$0.22

1270Alloderm skin subK$31.72.$6.35

1272Acetylcysteine injectionK$2.74.$0.55

1274Edetate calcium disodium injK$189.47.$37.90

1275"Vivaglobin, inj"K$12.48.$2.50

1279Factor VIII (porcine)K$9.12.$1.83

1280Corticotropin injectionK"$2,516.22".$503.25

1281Bevacizumab injectionK$1.50.$0.30

1287Alloskin skin subK$8.26.$1.66

1289AbobotulinumtoxinAK$7.29.$1.46

1290Human fibrinogen conc injK$71.57.$14.32

1291Rilonacept injectionK$23.64.$4.73

1295Sm 153 lexidronamK"$7,592.00"."$1,518.40"

1296Degarelix injectionK$2.71.$0.55

1297"Ferumoxytol, non-esrd"K$0.65.$0.13

1304Perphenazine injecitonK$19.54.$3.91

1306Urea injectionK$72.00.$14.40

1307Oral busulfanK$3.77.$0.76

1308Mecasermin injectionK$25.65.$5.13

1311Canakinumab injectionG$88.97.$17.46

1312Hizentra injectionK$7.15.$1.43

1327Imiglucerase injectionK$41.20.$8.24

1331Olanzapine long-acting injK$2.70.$0.54

1332Antithrombin recombinantK$101.40.$20.28

1338"Methyl aminolevulinate, top"K$74.52.$14.91

1339Oral fludarabine phosphateG$77.93.$15.30

1340"Collagenase, clost hist inj"G$37.51.$7.36

1341Amobarbital 125 MG injK$113.08.$22.62

1342Matristem micromatrixK$2.94.$0.59

1343Ganciclovir sodium injectionK$66.58.$13.32

1344Gonadorelin hydroch/ 100 mcgK$167.25.$33.45

1345TheraskinK$32.84.$6.57

1347Oxacillin sodium injecitonK$2.51.$0.51

1349Anidulafungin injectionK$1.20.$0.24

1350Topotecan injectionK$9.85.$1.97

1351Matristem wound matrixK$4.52.$0.91

1352Wilate injectionG$0.87.$0.17
1353Belimumab injectionG$38.61.$7.58

1354Hydroxyprogesterone caproateK$2.52.$0.51

1355Itraconazole injectionK$372.55.$74.51

1357Inj protirelin per 250 mcgK$27.03.$5.41

1358Phentolaine mesylate injK$53.76.$10.76

1359Foscarnet sodium injectionK$14.37.$2.88

1360Apomorphine hydrochlorideK$5.12.$1.03

1361Enfuvirtide injectionK$0.51.$0.11

1362Inj heparin sodium per 10 uK$0.18.$0.04

1373Inj heparin sodium per 1000uK$0.27.$0.06

1374Sumatriptan succinate / 6 MGK$76.71.$15.35

1408Cyclophosphamide 100 MG injK$13.43.$2.69

1412Vinorelbine tartrate injK$17.45.$3.49

1413Lumizyme injectionG$148.30.$29.10

1415Glassia injectionK$3.81.$0.77

1416Factor XIII anti-hem factorG$8.44.$1.66

1417Gel-oneK"$1,014.00".$202.80

1418Oral everolimusK$5.68.$1.14

1419DermacellK$31.52.$6.31

1426Eribulin mesylate injectionG$90.06.$17.68

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$548.95.$109.79

1607Eptifibatide injectionK$22.02.$4.41

1608Etanercept injectionK$204.31.$40.87

1609"Rho(D) immune globulin h, sd"K$17.21.$3.45

1612"Daclizumab, parenteral"K$516.41.$103.29

1613Trastuzumab injectionK$71.08.$14.22

1630"Hep b ig, im"K$113.50.$22.70

1631Baclofen intrathecal trialK$76.39.$15.28

1633AlefaceptK$38.72.$7.75

1643"Y90 ibritumomab, rx"K"$36,100.41"."$7,220.09"

1645"I131 tositumomab, rx"K"$29,618.96"."$5,923.80"

1670Tetanus immune globulin injK$245.02.$49.01

1675P32 Na phosphateK$126.14.$25.23

1676P32 chromic phosphateK$579.98.$116.00

1683BasiliximabK"$2,190.58".$438.12

1684Corticorelin ovine triflutalK$5.58.$1.12

1685"Darbepoetin alfa, non-esrd"K$3.14.$0.63

1686"Epoetin alfa, non-esrd"K$9.70.$1.94

1687Digoxin immune fab (ovine)K$626.71.$125.35

1688Ethanolamine oleateK$294.28.$58.86

1689FomepizoleK$6.91.$1.39

1690HeminK$10.41.$2.09

1693LepirudinK$346.19.$69.24

1694Ziconotide injectionK$6.48.$1.30

1695Nesiritide injectionK$46.36.$9.28

1696Palifermin injectionK$11.45.$2.29

1697Pegaptanib sodium injectionK"$1,001.34".$200.27

1700Inj secretin synthetic humanK$26.98.$5.40

1701Treprostinil injectionK$60.08.$12.02

1704"Humate-P, inj"K$0.88.$0.18
1705Factor viiaK$1.52.$0.31

1709Azacitidine injectionK$5.15.$1.03

1710Clofarabine injectionK$119.68.$23.94

1711Vantas implantK"$3,816.98".$763.40

1712Paclitaxel protein boundK$9.33.$1.87

1716"Brachytx, non-str, Gold-198"U0.5004$35.04.$7.01

1717"Brachytx, non-str, HDR Ir-192"U3.3224$232.62.$46.53

1719"Brachytx, NS, Non-HDRIr-192"U0.4544$31.82.$6.37

1738OxaliplatinK$9.96.$2.00

1739"Pegademase bovine, 25 iu"K$248.56.$49.72

1741"Urofollitropin, 75 iu"K$65.66.$13.14

1749"Endo, colon, retro imaging"H

1830Power bone marrow bx needleH

1840Telescopic intraocular lensH

1886"Catheter, ablation"H

2210Methyldopate hcl injectionK$39.16.$7.84

2616"Brachytx, non-str,Yttrium-90"U224.7054"$15,732.97"."$3,146.60"

2632Iodine I-125 sodium iodideU0.2404$16.83.$3.37

2634"Brachytx, non-str, HA, I-125"U0.8944$62.62.$12.53

2635"Brachytx, non-str, HA, P-103"U0.3855$26.99.$5.40

2636"Brachy linear, non-str,P-103"U0.5294$37.07.$7.42

2638"Brachytx, stranded, I-125"U0.6498$45.50.$9.10

2639"Brachytx, non-stranded,I-125"U0.5078$35.55.$7.11

2640"Brachytx, stranded, P-103"U1.1433$80.05.$16.01

2641"Brachytx, non-stranded,P-103"U0.9180$64.27.$12.86

2642"Brachytx, stranded, C-131"U1.7379$121.68.$24.34

2643"Brachytx, non-stranded,C-131"U1.1044$77.33.$15.47

2698"Brachytx, stranded, NOS"U0.6498$45.50.$9.10

2699"Brachytx, non-stranded, NOS"U0.3855$26.99.$5.40

2731"Immune globulin, powder"K$30.46.$6.10

2770Quinupristin/dalfopristinK$171.48.$34.30

3041BivalirudinK$2.71.$0.55

3043Gamma globulin 1 CC injK$20.62.$4.13

3050Sermorelin acetate injectionK$1.77.$0.36

7000AmifostineK$315.94.$63.19

7011Oprelvekin injectionK$239.90.$47.98

7034Somatropin injectionK$61.81.$12.37

7035TeniposideK$316.31.$63.27

7036"Urokinase 250,000 IU inj"K$449.09.$89.82

7038Monoclonal antibodiesK"$1,111.59".$222.32

7041Tirofiban HClK$8.92.$1.79

7042"Capecitabine, oral"K$7.32.$1.47

7043Infliximab injectionK$62.01.$12.41

7046Doxorubicin hcl liposome injK$525.35.$105.07

7048Alteplase recombinantK$42.24.$8.45

7049Filgrastim 480 mcg injectionK$390.07.$78.02

7051Leuprolide acetate implantK"$4,728.88".$945.78

7308Aminolevulinic acid hcl topK$147.80.$29.56

8000Cardiac Electrophysiologic Evaluation and Ablation 

CompositeT161.5528"$11,311.28"."$2,262.26"

8001LDR Prostate Brachytherapy CompositeT47.7031"$3,339.98".$668.00

8002Level I Extended Assessment & Management CompositeV5.6151$393.15.$78.63

8003Level II Extended Assessment & Management CompositeV10.2925$720.64.$144.13

8004Ultrasound CompositeS2.7374$191.66.$38.34

8005CT and CTA without Contrast CompositeS6.1687$431.91.$86.39

8006CT and CTA with Contrast CompositeS10.3084$721.75.$144.35

8007MRI and MRA without Contrast CompositeS9.9975$699.98.$140.00

8008MRI and MRA with Contrast CompositeS14.2917"$1,000.65".$200.13

9001Linezolid injectionK$34.48.$6.90

9002Tenecteplase injectionK$57.15.$11.43

9003PalivizumabK"$1,158.85".$231.77

9004Gemtuzumab ozogamicin injK"$2,690.84".$538.17

9005Reteplase injectionK"$1,623.59".$324.72

9006Tacrolimus injectionK$136.86.$27.38

9012Arsenic trioxide injectionK$40.10.$8.02

9018"Inj, rimabotulinumtoxinB"K$10.78.$2.16
9019Caspofungin acetateK$13.32.$2.67

9022IM inj interferon beta 1-aK$238.30.$47.66

9023Rho d immune globulinK$21.52.$4.31

9024Amphotericin b lipid complexK$8.42.$1.69

9032Baclofen 10 MG injectionK$187.46.$37.50

9033Cidofovir injectionK$742.66.$148.54

9038Inj estrogen conjugateK$103.54.$20.71

9042Glucagon hydrochlorideK$101.30.$20.26

9044Ibutilide fumarate injectionK$133.80.$26.76

9046Iron sucrose injectionK$0.32.$0.07

9104Antithymocyte globuln rabbitK$432.20.$86.44

9108Thyrotropin injectionK"$1,032.25".$206.45

9110Alemtuzumab injectionK$575.18.$115.04

9115Zoledronic acidK$220.30.$44.06

9119"Injection, pegfilgrastim 6mg"K"$2,676.49".$535.30

9120"Injection, Fulvestrant"K$83.63.$16.73

9121"Injection, argatroban"K$20.16.$4.04

9122Triptorelin pamoateK$176.18.$35.24

9124Daptomycin injectionK$0.48.$0.10

9125"Risperidone, long acting"K$5.07.$1.02

9126Natalizumab injectionK$10.32.$2.07

9133"Rabies ig, im/sc"K$185.74.$37.15

9134"Rabies ig, heat treated"K$177.81.$35.57

9135"Varicella-zoster ig, im"K$94.28.$18.86

9137"Bcg vaccine, percut"K$112.23.$22.45

9139"Rabies vaccine, im"K$205.48.$41.10

9140"Rabies vaccine, id"K$139.69.$27.94

9143"Meningococcal vaccine, sc"K$110.75.$22.15

9144"Encephalitis vaccine, sc"K$100.15.$20.03

9145"Meningococcal vaccine, im"K$92.92.$18.59

9207Bortezomib injectionK$40.67.$8.14

9208Agalsidase beta injectionK$138.53.$27.71

9209Laronidase injectionK$26.33.$5.27

9210Palonosetron hclK$18.83.$3.77

9213Pemetrexed injectionK$52.76.$10.56

9214Bevacizumab injectionK$59.98.$12.00

9215Cetuximab injectionK$49.53.$9.91

9217Leuprolide acetate suspnsionK$216.90.$43.38

9224Galsulfase injectionK$341.40.$68.28

9225Fluocinolone acetonide impltK"$18,980.00"."$3,796.00"

9227Micafungin sodium injectionK$0.98.$0.20

9228Tigecycline injectionK$1.30.$0.26

9229Ibandronate sodium injectionK$148.02.$29.61

9230Abatacept injectionK$20.72.$4.15

9231Decitabine injectionK$31.94.$6.39

9232Idursulfase injectionK$446.44.$89.29

9233Ranibizumab injectionK$395.53.$79.11

9234Alglucosidase alfa injectionK$155.84.$31.17

9235Panitumumab injectionK$85.59.$17.12

9236Eculizumab injectionK$186.37.$37.28

9237"Inj, lanreotide acetate"K$30.98.$6.20

9240"Injection, ixabepilone"K$63.47.$12.70

9242"Injection, fosaprepitant"K$1.69.$0.34

9243Bendamustine injectionK$18.47.$3.70

9244Regadenoson injectionK$51.22.$10.25

9245Romiplostim injectionK$45.87.$9.18

9248"Inj, clevidipine butyrate"K$2.66.$0.54

9249Certolizumab pegol injK$4.12.$0.83

9250Artiss fibrin sealantK$129.72.$25.95

9251C1 esterase inhibitor injK$43.37.$8.68

9252Plerixafor injectionK$275.80.$55.16

9253Temozolomide injectionK$4.75.$0.95

9254"Injection, lacosamide"K$0.15.$0.03

9255Paliperidone palmitate injK$6.56.$1.32

9256Dexamethasone intra implantK$192.26.$38.46

9258Telavancin injectionG$2.10.$0.42
9259Pralatrexate injectionG$165.63.$32.50

9260Ofatumumab injectionG$45.41.$8.91

9261Ustekinumab injectionG$117.56.$23.07

9263Ecallantide injectionG$289.07.$56.73

9264Tocilizumab injectionG$3.47.$0.68

9265Romidepsin injectionG$224.79.$44.11

9268Capsaicin 8% patchG$25.55.$5.02

9269"C-1 esterase, berinert"G$30.23.$5.94

9270Gammaplex IVIGG$37.29.$7.32

9271Velaglucerase alfaG$349.51.$68.59

9272"Inj, denosumab"G$14.47.$2.84

9273Sipuleucel-T auto CD54+G"$32,860.00"."$6,448.00"

9274Crotalidae Poly Immune FabG"$2,111.36".$414.31

9275Hexaminolevulinate HClG$623.28$0.00$0.00

9276Cabazitaxel injectionG$135.57.$26.61

9278Incobotulinumtoxin AG$5.53.$1.08

9279"Injection, ibuprofen"G$1.62.$0.32

9281"Injection, pegloticase"G$301.75.$59.22

9282"Inj, ceftaroline fosamil"G$0.74.$0.14

9283"Injection, acetaminophen"G$0.11.$0.03

9284Ipilimumab injectionG$127.20.$24.96

9285"Patch, lidocaine/tetracaine"G$13.57.$2.67

9286"Injection, belatacept"G$3.91.$0.77

9287"Inj, brentuximab vedotin"G$95.40.$18.72

9300Omalizumab injectionK$21.34.$4.27

9358"SurgiMend, fetal"K$10.91.$2.19

9360"SurgiMend, neonatal"K$11.23.$2.25

9363Integra Meshed Bil Wound MatK$20.60.$4.12

9365Oasis tri-layer wound matrixG$10.39.$2.04

9366EpiFix wound coverG$177.77.$34.89

9367Endoform Dermal TemplateG$4.35.$0.86

9406Iodine I-123 ioflupaneG"$1,908.00"$0.00$0.00

9500"Platelets, irradiated"R1.8342$128.42.$25.69

9501Platelet pheres leukoreducedR7.6960$538.84.$107.77

9502Platelet pheresis irradiatedR7.9257$554.93.$110.99

9503Fr frz plasma donor retestedR1.1562$80.95.$16.19

9504RBC deglycerolizedR3.4084$238.64.$47.73

9505RBC irradiatedR2.8419$198.98.$39.80

9506"Granulocytes, pheresis unit"R19.1478"$1,340.65".$268.13

9507"Platelets, pheresis"R6.3148$442.14.$88.43

9508Plasma 1 donor frz w/in 8 hrR1.1408$79.87.$15.98