Addendum A.-Final OPPS APCs for CY 2012 APC Group Title SI Relative Weight Payment Rate National Unadjusted Copayment Minimum Unadjusted Copayment 0001 Level I Photochemotherapy S 0.5043 $35.31 . $7.07 0002 Fine Needle Biopsy/Aspiration T 1.6118 $112.85 . $22.57 0003 Bone Marrow Biopsy/Aspiration T 3.5548 $248.89 . $49.78 0004 Level I Needle Biopsy/ Aspiration Except Bone Marrow T 4.5721 $320.12 . $64.03 0005 Level II Needle Biopsy/Aspiration Except Bone Marrow T 8.1596 $571.30 . $114.26 0006 Level I Incision & Drainage T 1.4209 $99.49 . $19.90 0007 Level II Incision & Drainage T 12.8082 $896.78 . $179.36 0008 Level III Incision and Drainage T 20.5510 "$1,438.90" . $287.78 0012 Level I Debridement & Destruction T 0.3878 $27.15 . $5.43 0013 Level II Debridement & Destruction T 0.8768 $61.39 . $12.28 0015 Level III Debridement & Destruction T 1.4966 $104.79 . $20.96 0016 Level IV Debridement & Destruction T 2.7597 $193.22 . $38.65 0017 Level V Debridement & Destruction T 21.6700 "$1,517.25" . $303.45 0019 Level I Excision/ BiopsyT 4.3953 $307.74 . $61.55 0020 Level II Excision/ BiopsyT 8.2918 $580.56 . $116.12 0021 Level III Excision/ BiopsyT 16.9957 "$1,189.97" . $238.00 0022 Level IV Excision/ BiopsyT 23.2636 "$1,628.82" $350.74 $325.77 0028 Level I Breast SurgeryT 25.5066 "$1,785.87" . $357.18 0029 Level II Breast SurgeryT 33.3398 "$2,334.32" $580.94 $466.87 0030 Level III Breast SurgeryT 45.0217 "$3,152.24" $747.07 $630.45 0031 Smoking Cessation Services X 0.2988 $20.92 . $4.19 0034 Mental Health Services Composite S 2.7298 $191.13 . $38.23 0035 Vascular Puncture and Minor Diagnostic Procedures X 0.2673 $18.72 . $3.75 0037 Level IV Needle Biopsy/Aspiration Except Bone MarrowT 15.3535 "$1,074.99" $227.40 $215.00 0039 Level I Implantation of Neurostimulator Generator S 216.9330 "$15,188.78" . "$3,037.76" 0040 Level I Implantation/Revision/Replacement of Neurostimulator Electrodes S 63.3729 "$4,437.12" . $887.43 0041 Level I ArthroscopyT 29.7721 "$2,084.52" . $416.91 0042 Level II ArthroscopyT 57.0707 "$3,995.86" $804.74 $799.18 0045 Bone/Joint Manipulation Under Anesthesia T 15.4596 "$1,082.42" $268.44 $216.49 0047 Arthroplasty without Prosthesis T 41.2873 "$2,890.77" . $578.16 0048 Level I Arthroplasty or Implantation with Prosthesis T 60.9147 "$4,265.00" . $853.00 0049 Level I Musculoskeletal Procedures Except Hand and Foot T 22.0797 "$1,545.93" . $309.19 0050 Level II Musculoskeletal Procedures Except Hand and Foot T 32.4461 "$2,271.75" . $454.35 0051 Level III Musculoskeletal Procedures Except Hand and Foot T 47.5032 "$3,325.98" . $665.20 0052 Level IV Musculoskeletal Procedures Except Hand and Foot T 88.8483 "$6,220.80" . "$1,244.16" 0053 Level I Hand Musculoskeletal Procedures T 17.1902 "$1,203.59" $253.49 $240.72 0054 Level II Hand Musculoskeletal Procedures T 28.8625 "$2,020.84" . $404.17 0055 Level I Foot Musculoskeletal Procedures T 22.0963 "$1,547.09" $353.25 $309.42 0056 Level II Foot Musculoskeletal Procedures T 58.4586 "$4,093.04" . $818.61 0057 Bunion Procedures T 32.7262 "$2,291.36" $475.91 $458.28 0058 Level I Strapping and Cast Application S 1.1255 $78.80 . $15.76 0060 Manipulation Therapy S 0.3428 $24.00 . $4.80 0061 Level II Implantation/Revision/Replacement of Neurostimulator Electrodes S 88.6050 "$6,203.77" . "$1,240.76" 0062 Level I Treatment Fracture/Dislocation T 26.1202 "$1,828.83" $372.85 $365.77 0063 Level II Treatment Fracture/Dislocation T 49.8979 "$3,493.65" . $698.73 0064 Level III Treatment Fracture/Dislocation T 68.1203 "$4,769.51" . $953.91 0065 "Level I Stereotactic Radiosurgery, MRgFUS, and MEG" S 12.8903 $902.53 . $180.51 0066 "Level II Stereotactic Radiosurgery, MRgFUS, and MEG" S 35.9961 "$2,520.30" . $504.06 0067 "Level III Stereotactic Radiosurgery, MRgFUS, and MEG" S 48.1833 "$3,373.60" . $674.72 0069 ThoracoscopyT 34.5272 "$2,417.46" $591.64 $483.50 0070 Thoracentesis/Lavage Procedures T 5.5061 $385.52 . $77.11 0071 Level I Endoscopy Upper AirwayT 1.0729 $75.12 . $15.03 0072 Level II Endoscopy Upper AirwayT 1.8643 $130.53 . $26.11 0073 Level III Endoscopy Upper AirwayT 4.4119 $308.90 $67.83 $61.780074 Level IV Endoscopy Upper AirwayT 21.2774 "$1,489.76" . $297.96 0075 Level V Endoscopy Upper AirwayT 30.3487 "$2,124.89" $444.55 $424.98 0076 Level I Endoscopy Lower AirwayT 10.4689 $732.99 $189.82 $146.60 0077 Level I Pulmonary Treatment S 0.4237 $29.67 $7.74 $5.94 0078 Level III Pulmonary Treatment S 1.4089 $98.65 . $19.73 0079 Ventilation Initiation and Management S 3.1979 $223.90 . $44.78 0080 Diagnostic Cardiac Catheterization T 38.8523 "$2,720.28" $836.90 $544.06 0082 Coronary or Non-Coronary AtherectomyT 105.0651 "$7,356.24" . "$1,471.25" 0083 "Coronary Angioplasty, Valvuloplasty, and Level I Endovascular Revascularization of the Lower Extremity " T 65.8519 "$4,610.69" . $922.14 0084 Level I Electrophysiologic Procedures S 9.9330 $695.47 . $139.10 0085 Level II Electrophysiologic Procedures T 53.2719 "$3,729.89" . $745.98 0086 Level III Electrophysiologic Procedures T 121.8174 "$8,529.17" . "$1,705.84" 0088 ThrombectomyT 41.0387 "$2,873.37" $655.18 $574.68 0089 Insertion/Replacement of Permanent Pacemaker and Electrodes T 112.1218 "$7,850.32" "$1,643.98" "$1,570.07" 0090 Level I Insertion/Replacement of Permanent Pacemaker T 94.2220 "$6,597.05" "$1,593.50" "$1,319.41" 0091 Level II Vascular Ligation T 44.2272 "$3,096.61" . $619.33 0092 Level I Vascular Ligation T 26.8120 "$1,877.27" . $375.46 0093 Vascular Reconstruction/Fistula Repair without Device T 31.1505 "$2,181.03" . $436.21 0094 Level I Resuscitation and Cardioversion S 2.2326 $156.32 $43.83 $31.27 0095 Cardiac Rehabilitation S 0.9930 $69.53 . $13.91 0096 Level II Noninvasive Physiologic Studies S 1.5248 $106.76 $36.86 $21.36 0097 Level I Noninvasive Physiologic Studies S 0.9350 $65.46 . $13.10 0099 Electrocardiograms/Cardiography S 0.3817 $26.73 . $5.35 0100 Cardiac Stress Tests X 2.5439 $178.11 $41.37 $35.63 0101 Tilt Table Evaluation S 4.2669 $298.75 $100.24 $59.75 0102 Level II Pulmonary Treatment S 0.5346 $37.43 . $7.49 0103 Miscellaneous Vascular Procedures T 16.3852 "$1,147.23" . $229.45 0104 Transcatheter Placement of Intracoronary Stents T 81.1503 "$5,681.82" . "$1,136.37" 0105 "Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices" T 21.7420 "$1,522.29" . $304.46 0106 Insertion/Replacement of Pacemaker Leads and/or Electrodes T 47.1769 "$3,303.14" . $660.63 0107 Insertion of Cardioverter-Defibrillator Pulse Generator T 341.5859 "$23,916.48" . "$4,783.30" 0108 "Insertion/Replacement/Repair of AICD Leads, Generator, and Pacing Electrodes" T 426.1201 "$29,835.22" . "$5,967.05" 0110 Transfusion S 3.4217 $239.57 . $47.92 0111 Blood Product Exchange S 11.6629 $816.59 $189.89 $163.32 0112 Apheresis and Stem Cell Procedures S 35.6252 "$2,494.33" . $498.87 0113 Excision Lymphatic SystemT 25.2738 "$1,769.57" . $353.92 0114 Thyroid/Lymphadenectomy Procedures T 51.2792 "$3,590.36" . $718.08 0115 Cannula/Access Device Procedures T 37.4593 "$2,622.75" . $524.55 0121 Level I Tube or Catheter Changes or Repositioning T 6.2123 $434.96 . $87.00 0126 Level I Urinary and Anal Procedures T 1.1095 $77.68 $16.21 $15.54 0127 "Level IV Stereotactic Radiosurgery, MRgFUS, and MEG" S 106.5454 "$7,459.88" . "$1,491.98" 0128 Echocardiogram with Contrast S 7.9593 $557.28 $166.16 $111.46 0129 Level I Closed Treatment Fracture T 1.5020 $105.16 . $21.04 0130 Level I LaparoscopyT 38.9223 "$2,725.18" $659.53 $545.04 0131 Level II LaparoscopyT 47.9394 "$3,356.53" "$1,001.89" $671.31 0132 Level III LaparoscopyT 71.5658 "$5,010.75" "$1,236.99" "$1,002.15" 0133 Level I Skin Repair T 1.1922 $83.47 $23.34 $16.70 0134 Level II Skin Repair T 3.2354 $226.53 . $45.31 0135 Level III Skin Repair T 4.9271 $344.98 . $69.00 0136 Level IV Skin Repair T 16.7703 "$1,174.19" . $234.84 0137 Level V Skin Repair T 21.4409 "$1,501.21" . $300.25 0138 Level II Closed Treatment Fracture T 5.0454 $353.26 . $70.66 0139 Level III Closed Treatment Fracture T 18.9489 "$1,326.73" . $265.35 0140 Esophageal Dilation without EndoscopyT 6.5866 $461.17 . $92.24 0141 Level I Upper GI Procedures T 8.4511 $591.71 $138.69 $118.35 0142 Level I Small Intestine EndoscopyT 10.4394 $730.93 $152.78 $146.19 0143 Lower GI EndoscopyT 9.3693 $656.00 $186.06 $131.20 0146 Level I Sigmoidoscopy and AnoscopyT 6.2205 $435.53 . $87.110147 Level II Sigmoidoscopy and AnoscopyT 11.0417 $773.10 . $154.62 0148 Level I Anal/Rectal Procedures T 5.5158 $386.19 . $77.24 0149 Level III Anal/Rectal Procedures T 24.4382 "$1,711.07" . $342.22 0150 Level IV Anal/Rectal Procedures T 32.9805 "$2,309.16" . $461.84 0151 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) T 24.6966 "$1,729.16" . $345.84 0152 Level I Percutaneous Abdominal and Biliary Procedures T 29.1415 "$2,040.37" . $408.08 0153 Peritoneal and Abdominal Procedures T 27.2798 "$1,910.02" . $382.01 0154 Hernia/Hydrocele Procedures T 32.9294 "$2,305.58" $464.85 $461.12 0155 Level II Anal/Rectal Procedures T 15.4175 "$1,079.47" . $215.90 0156 Level III Urinary and Anal Procedures T 3.1886 $223.25 . $44.65 0157 Colorectal Cancer Screening: Barium Enema S 2.7510 $192.61 . $38.53 0158 Colorectal Cancer Screening: ColonoscopyT 8.3164 $582.28 $0.00 $0.00 0159 Colorectal Cancer Screening: Flexible Sigmoidoscopy S 5.3772 $376.49 $0.00 $0.00 0160 Level I Cystourethroscopy and other Genitourinary Procedures T 6.7736 $474.26 . $94.86 0161 Level II Cystourethroscopy and other Genitourinary Procedures T 17.4715 "$1,223.28" . $244.66 0162 Level III Cystourethroscopy and other Genitourinary Procedures T 26.2973 "$1,841.23" . $368.25 0163 Level IV Cystourethroscopy and other Genitourinary Procedures T 37.0730 "$2,595.70" . $519.14 0164 Level II Urinary and Anal Procedures T 1.9499 $136.52 . $27.31 0165 Level IV Urinary and Anal Procedures T 20.4158 "$1,429.43" . $285.89 0166 Level I Urethral Procedures T 21.0031 "$1,470.55" . $294.11 0168 Level II Urethral Procedures T 32.3061 "$2,261.94" . $452.39 0169 LithotripsyT 52.0882 "$3,647.01" $997.74 $729.41 0170 Dialysis S 6.2419 $437.03 . $87.41 0172 Level I Partial Hospitalization (3 services) for CMHCs P 1.3944 $97.63 . $19.53 0173 Level II Partial Hospitalization (4 or more services) for CMHCs P 1.6255 $113.81 . $22.77 0174 Level IV LaparoscopyT 111.6495 "$7,817.25" "$2,055.58" "$1,563.45" 0175 Level I Partial Hospitalization (3 services) for Hospital-based PHPs P 2.2954 $160.71 . $32.15 0176 Level II Partial Hospitalization (4 or more services) for Hospital-based PHPs P 2.7298 $191.13 . $38.23 0181 Level II Male Genital Procedures T 34.6069 "$2,423.04" $607.60 $484.61 0183 Level I Male Genital Procedures T 23.5454 "$1,648.55" . $329.71 0184 Prostate BiopsyT 13.7727 $964.31 . $192.87 0188 Level II Female Reproductive Proc T 1.5841 $110.91 . $22.19 0189 Level III Female Reproductive Proc T 3.4818 $243.78 . $48.76 0190 Level I HysteroscopyT 23.0098 "$1,611.05" $424.28 $322.21 0191 Level I Female Reproductive Proc T 0.1337 $9.36 $1.95 $1.88 0192 Level IV Female Reproductive Proc T 6.6979 $468.96 . $93.80 0193 Level V Female Reproductive Proc T 20.6493 "$1,445.78" . $289.16 0195 Level VI Female Reproductive Procedures T 35.9087 "$2,514.18" . $502.84 0202 Level VII Female Reproductive Procedures T 45.9895 "$3,220.00" $981.50 $644.00 0203 Level IV Nerve Injections T 12.7996 $896.18 . $179.24 0204 Level I Nerve Injections T 2.6055 $182.43 . $36.49 0206 Level II Nerve Injections T 3.8754 $271.34 . $54.27 0207 Level III Nerve Injections T 7.4537 $521.88 . $104.38 0208 Laminotomies and Laminectomies T 50.7343 "$3,552.21" . $710.45 0209 "Level II Extended EEG, Sleep, and Cardiovascular Studies" S 11.3569 $795.16 $268.73 $159.04 0213 "Level I Extended EEG, Sleep, and Cardiovascular Studies" S 2.4298 $170.12 $53.58 $34.03 0215 Level I Nerve and Muscle Tests S 0.6335 $44.36 . $8.88 0216 Level III Nerve and Muscle Tests S 2.6488 $185.46 . $37.10 0218 Level II Nerve and Muscle Tests S 1.2025 $84.19 . $16.84 0220 Level I Nerve Procedures T 18.8921 "$1,322.75" . $264.55 0221 Level II Nerve Procedures T 36.1290 "$2,529.61" . $505.93 0224 Implantation of Catheter/Reservoir/Shunt T 41.5547 "$2,909.49" . $581.90 0227 Implantation of Drug Infusion Device T 192.7379 "$13,494.74" . "$2,698.95" 0229 Level II Endovascular Revascularization of the Lower Extremity T 115.5014 "$8,086.95" . "$1,617.39" 0230 Level I Eye Tests & Treatments S 0.6424 $44.98 . $9.000231 Level III Eye Tests & Treatments S 2.0294 $142.09 . $28.42 0232 Level I Anterior Segment Eye Procedures T 2.8247 $197.77 $42.27 $39.56 0233 Level III Anterior Segment Eye Procedures T 16.6214 "$1,163.76" . $232.76 0234 Level IV Anterior Segment Eye Procedures T 23.2851 "$1,630.33" $347.90 $326.07 0235 Level I Posterior Segment Eye Procedures T 4.8135 $337.02 . $67.41 0237 Level II Posterior Segment Eye Procedures T 21.5368 "$1,507.92" . $301.59 0238 Level I Repair and Plastic Eye Procedures T 3.1036 $217.30 . $43.46 0239 Level II Repair and Plastic Eye Procedures T 7.6566 $536.08 . $107.22 0240 Level III Repair and Plastic Eye Procedures T 19.7786 "$1,384.82" $296.20 $276.97 0241 Level IV Repair and Plastic Eye Procedures T 27.3416 "$1,914.35" $383.45 $382.87 0242 Level V Repair and Plastic Eye Procedures T 40.4039 "$2,828.92" $597.36 $565.79 0243 Strabismus/Muscle Procedures T 24.8671 "$1,741.09" $411.91 $348.22 0244 Corneal and Amniotic Membrane Transplant T 37.8979 "$2,653.46" $794.94 $530.70 0246 Cataract Procedures with IOL Insert T 23.8810 "$1,672.05" $490.37 $334.41 0247 Laser Eye Procedures T 5.4120 $378.93 $102.28 $75.79 0249 Cataract Procedures without IOL Insert T 30.9855 "$2,169.48" $516.99 $433.90 0250 Level I ENT Procedures T 1.0709 $74.98 $24.12 $15.00 0251 Level II ENT Procedures T 3.1150 $218.10 . $43.62 0252 Level III ENT Procedures T 7.4614 $522.42 $104.55 $104.49 0253 Level IV ENT Procedures T 16.8699 "$1,181.16" $279.20 $236.24 0254 Level V ENT Procedures T 24.8895 "$1,742.66" . $348.54 0255 Level II Anterior Segment Eye Procedures T 7.2190 $505.45 $101.81 $101.09 0256 Level VI ENT Procedures T 45.0377 "$3,153.36" . $630.68 0259 Level VII ENT Procedures T 412.7299 "$28,897.70" "$7,948.75" "$5,779.54" 0260 Level I Plain Film Except TeethX 0.6409 $44.87 . $8.98 0261 Level II Plain Film Except Teeth Including Bone Density Measurement X 1.0790 $75.55 . $15.11 0262 Plain Film of TeethX 0.4640 $32.49 . $6.50 0263 Level I Miscellaneous Radiology Procedures X 3.3643 $235.55 . $47.11 0265 Level I Diagnostic and Screening Ultrasound S 0.8990 $62.94 $22.26 $12.59 0266 Level II Diagnostic and Screening Ultrasound S 1.3781 $96.49 $37.23 $19.30 0267 Level III Diagnostic and Screening Ultrasound S 2.1681 $151.80 $59.37 $30.36 0269 Level II Echocardiogram Without Contrast S 5.6156 $393.18 . $78.64 0270 Level III Echocardiogram Without Contrast S 8.2952 $580.80 $133.61 $116.16 0272 FluoroscopyX 1.2171 $85.22 $30.47 $17.05 0274 Myelography S 7.0678 $494.86 . $98.98 0275 Arthrography S 4.0104 $280.79 $68.90 $56.16 0276 Level I Digestive Radiology S 1.2186 $85.32 $33.87 $17.07 0277 Level II Digestive Radiology S 2.0340 $142.41 $53.90 $28.49 0278 Diagnostic Urography S 2.6196 $183.41 $58.44 $36.69 0279 Level II Angiography and Venography S 29.7209 "$2,080.94" . $416.19 0280 Level III Angiography and Venography S 49.6878 "$3,478.94" . $695.79 0282 Miscellaneous Computed Axial Tomography S 1.5251 $106.78 $35.57 $21.36 0283 Computed Tomography with Contrast S 4.2929 $300.57 $96.62 $60.12 0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast S 6.2343 $436.50 $146.69 $87.30 0288 Bone Density:Axial Skeleton S 1.0218 $71.54 $0.00 $0.00 0293 Level VI Anterior Segment Eye Procedures T 117.1298 "$8,200.96" . "$1,640.20" 0299 Hyperthermia and Radiation Treatment Procedures S 5.6386 $394.79 . $78.96 0300 Level I Radiation Therapy S 1.4252 $99.79 . $19.96 0301 Level II Radiation Therapy S 2.4149 $169.08 . $33.82 0303 Treatment Device ConstructionX 2.8573 $200.06 $66.95 $40.02 0304 Level I Therapeutic Radiation Treatment Preparation X 1.5329 $107.33 $34.63 $21.47 0305 Level II Therapeutic Radiation Treatment Preparation X 3.7681 $263.83 $88.76 $52.77 0308 Positron Emission Tomography (PET) imaging S 14.8260 "$1,038.06" . $207.62 0310 Level III Therapeutic Radiation Treatment PreparationX 13.6332 $954.54 $325.27 $190.91 0312 Radioelement Applications S 5.4044 $378.39 . $75.68 0313 Brachytherapy S 9.9687 $697.97 $263.92 $139.60 0315 Level II Implantation of Neurostimulator Generator S 285.5893 "$19,995.82" . "$3,999.17" 0317 Level II Miscellaneous Radiology Procedures X 5.7208 $400.55 . $80.11 0318 Implantation of Neurostimulator Pulse Generator and Electrode S 346.4693 "$24,258.39" "$9,121.76" "$4,851.68" 0319 Level III Endovascular Revascularization of the LowerExtremityT 203.0553 "$14,217.12" "$5,559.48" "$2,843.43" 0320 Electroconvulsive Therapy S 5.9715 $418.10 . $83.62 0322 Brief Individual Psychotherapy S 1.1395 $79.78 . $15.96 0323 Extended Individual Psychotherapy S 1.5910 $111.40 . $22.28 0324 Family Psychotherapy S 1.8190 $127.36 . $25.48 0325 Group Psychotherapy S 0.8088 $56.63 $11.70 $11.33 0330 Dental Procedures S 8.2687 $578.94 . $115.79 0331 Combined Abdomen and Pelvis CT without Contrast S 5.7930 $405.60 $156.82 $81.12 0332 Computed Tomography without Contrast S 2.7436 $192.10 $74.27 $38.42 0333 Computed Tomography without Contrast followed by Contrast S 4.7767 $334.45 $116.13 $66.89 0334 Combined Abdomen and Pelvis CT with Contrast S 8.2987 $581.04 $187.25 $116.21 0336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast S 4.8381 $338.74 $133.48 $67.75 0337 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast S 7.6347 $534.55 $197.64 $106.91 0340 Minor Ancillary Procedures X 0.6499 $45.50 . $9.10 0341 Skin Tests X 0.0806 $5.64 $2.09 $1.13 0342 Level I PathologyX 0.1601 $11.21 . $2.25 0343 Level III PathologyX 0.5259 $36.82 $10.84 $7.37 0344 Level IV PathologyX 0.8180 $57.27 $15.56 $11.46 0345 Level I Transfusion Laboratory Procedures X 0.2135 $14.95 . $2.99 0346 Level II Transfusion Laboratory Procedures X 0.3538 $24.77 . $4.96 0347 Level III Transfusion Laboratory Procedures X 0.6730 $47.12 . $9.43 0350 Administration of flu and PPV vaccine S 0.3545 $24.82 $0.00 $0.00 0360 Level I Alimentary Tests X 1.7152 $120.09 $33.87 $24.02 0361 Level II Alimentary Tests X 4.0827 $285.85 $83.23 $57.17 0363 Level I Otorhinolaryngologic Function Tests X 0.9638 $67.48 $17.10 $13.50 0364 Level I AudiometryX 0.4911 $34.38 $7.06 $6.88 0365 Level II AudiometryX 1.2175 $85.24 $18.05 $17.05 0366 Level III AudiometryX 1.6864 $118.07 $23.65 $23.62 0367 Level I Pulmonary Test X 0.7420 $51.95 $13.76 $10.39 0368 Level II Pulmonary Tests X 0.8906 $62.36 $20.93 $12.48 0369 Level III Pulmonary Tests X 2.6868 $188.12 $38.23 $37.63 0370 Multiple Allergy Tests X 1.1369 $79.60 . $15.92 0373 Level I Neuropsychological Testing X 1.3842 $96.92 . $19.39 0375 Ancillary Outpatient Services When Patient Expires S 86.2468 "$6,038.66" . "$1,207.74" 0377 Level II Cardiac Imaging S 9.6018 $672.28 . $134.46 0378 Level II Pulmonary Imaging S 4.5192 $316.42 $126.56 $63.29 0381 Single Allergy Tests X 0.4426 $30.99 . $6.20 0382 Level II Neuropsychological Testing X 2.5717 $180.06 . $36.02 0383 Cardiac Computed Tomographic Imaging S 3.7417 $261.98 . $52.40 0384 GI Procedures with Stents T 29.2172 "$2,045.67" . $409.14 0385 Level I Prosthetic Urological Procedures S 104.8530 "$7,341.39" . "$1,468.28" 0386 Level II Prosthetic Urological Procedures S 169.3017 "$11,853.83" . "$2,370.77" 0387 Level II HysteroscopyT 38.3457 "$2,684.81" $655.55 $536.97 0388 Discography S 22.7689 "$1,594.19" . $318.84 0389 Level I Non-imaging Nuclear Medicine S 1.5569 $109.01 $26.88 $21.81 0390 Level I Endocrine Imaging S 1.8944 $132.64 $47.64 $26.53 0391 Level II Endocrine Imaging S 3.1610 $221.32 $65.46 $44.27 0392 Level II Non-imaging Nuclear Medicine S 2.2892 $160.28 $39.07 $32.06 0393 Hematologic Processing & Studies S 6.9196 $484.48 . $96.90 0394 Hepatobiliary Imaging S 4.1909 $293.43 $90.78 $58.69 0395 GI Tract Imaging S 3.4841 $243.94 $87.01 $48.79 0396 Bone Imaging S 3.5304 $247.18 $94.20 $49.44 0397 Vascular Imaging S 2.0980 $146.89 $33.94 $29.38 0398 Level I Cardiac Imaging S 4.2548 $297.90 $93.33 $59.58 0400 Hematopoietic Imaging S 3.6580 $256.12 $90.92 $51.23 0401 Level I Pulmonary Imaging S 2.8915 $202.45 $71.16 $40.49 0402 Level II Nervous System Imaging S 8.6793 $607.69 . $121.54 0403 Level I Nervous System Imaging S 3.4408 $240.91 $72.42 $48.19 0404 Renal and Genitourinary Studies S 4.5536 $318.82 $81.52 $63.77 0406 Level I Tumor/Infection Imaging S 4.0053 $280.44 $85.08 $56.09 0407 Level I Radionuclide Therapy S 3.2941 $230.64 $78.13 $46.13 0408 Level III Tumor/Infection Imaging S 13.6750 $957.47 . $191.50 0409 Red Blood Cell Tests X 0.1101 $7.71 $2.17 $1.550412 IMRT Treatment Delivery S 6.5452 $458.27 . $91.66 0413 Level II Radionuclide Therapy S 4.0373 $282.68 . $56.54 0414 Level II Tumor/Infection Imaging S 7.0664 $494.76 . $98.96 0415 Level II Endoscopy Lower AirwayT 28.9051 "$2,023.82" $459.92 $404.77 0419 Level II Upper GI Procedures T 12.6671 $886.90 $207.88 $177.38 0422 Level III Upper GI Procedures T 25.9792 "$1,818.96" . $363.80 0423 Level II Percutaneous Abdominal and Biliary Procedures T 58.4890 "$4,095.17" . $819.04 0424 Level II Small Intestine Endoscopy T 15.7819 "$1,104.99" $240.64 $221.00 0425 Level II Arthroplasty or Implantation with Prosthesis T 132.5319 "$9,279.35" . "$1,855.87" 0426 Level II Strapping and Cast Application S 2.5699 $179.93 . $35.99 0427 Level II Tube or Catheter Changes or Repositioning T 16.2412 "$1,137.14" . $227.43 0428 Level III Sigmoidoscopy and AnoscopyT 23.9777 "$1,678.82" . $335.77 0429 Level V Cystourethroscopy and other Genitourinary Procedures T 45.7676 "$3,204.46" . $640.90 0432 Health and Behavior Services S 0.5154 $36.09 . $7.22 0433 Level II PathologyX 0.2434 $17.04 $5.06 $3.41 0434 Cardiac Defect Repair T 171.3141 "$11,994.73" . "$2,398.95" 0436 Level I Drug Administration S 0.3545 $24.82 . $4.97 0437 Level II Drug Administration S 0.4972 $34.81 . $6.97 0438 Level III Drug Administration S 1.0388 $72.73 . $14.55 0439 Level IV Drug Administration S 1.8098 $126.71 . $25.35 0440 Level V Drug Administration S 2.9679 $207.80 . $41.56 0442 Dosimetric Drug Administration S 21.9850 "$1,539.30" . $307.86 0604 Level 1 Hospital Clinic Visits V 0.7689 $53.84 . $10.77 0605 Level 2 Hospital Clinic Visits V 1.0311 $72.19 . $14.44 0606 Level 3 Hospital Clinic Visits V 1.3588 $95.14 . $19.03 0607 Level 4 Hospital Clinic Visits V 1.8647 $130.56 . $26.12 0608 Level 5 Hospital Clinic Visits V 2.5237 $176.70 . $35.34 0609 Level 1 Type A Emergency Visits V 0.7181 $50.28 $12.04 $10.06 0613 Level 2 Type A Emergency Visits V 1.2356 $86.51 $20.79 $17.31 0614 Level 3 Type A Emergency Visits V 1.9447 $136.16 $33.59 $27.24 0615 Level 4 Type A Emergency Visits V 3.1277 $218.99 $47.70 $43.80 0616 Level 5 Type A Emergency Visits V 4.6152 $323.14 $71.44 $64.63 0617 Critical Care S 6.6453 $465.28 $104.95 $93.06 0618 Trauma Response with Critical Care S 11.2658 $788.79 . $157.76 0621 Level I Vascular Access Procedures T 11.0639 $774.65 . $154.93 0622 Level II Vascular Access Procedures T 25.2672 "$1,769.11" . $353.83 0623 Level III Vascular Access Procedures T 30.3507 "$2,125.03" . $425.01 0624 Phlebotomy and Minor Vascular Access Device Procedures X 0.6068 $42.49 $12.33 $8.50 0626 Level 1 Type B Emergency Visits V 0.5627 $39.40 . $7.88 0627 Level 2 Type B Emergency Visits V 0.7972 $55.82 . $11.17 0628 Level 3 Type B Emergency Visits V 1.3178 $92.27 . $18.46 0629 Level 4 Type B Emergency Visits V 1.9503 $136.55 . $27.31 0630 Level 5 Type B Emergency Visits V 3.7639 $263.53 . $52.71 0648 Level IV Breast SurgeryT 62.4125 "$4,369.87" . $873.98 0651 Complex Interstitial Radiation Source Application S 11.9274 $835.11 . $167.03 0652 Insertion of Intraperitoneal and Pleural Catheters T 30.8430 "$2,159.50" . $431.90 0653 Vascular Reconstruction/Fistula Repair with Device T 43.8023 "$3,066.86" . $613.38 0654 Level II Insertion/Replacement of Permanent Pacemaker T 103.3418 "$7,235.58" . "$1,447.12" 0655 Insertion/Replacement/Conversion of a Permanent Dual Chamber Pacemaker or Pacing Electrode T 137.6558 "$9,638.11" . "$1,927.63" 0656 Transcatheter Placement of Intracoronary Drug-Eluting Stents T 105.6644 "$7,398.20" . "$1,479.64" 0659 Hyperbaric Oxygen S 1.4941 $104.61 . $20.93 0660 Level II Otorhinolaryngologic Function Tests X 1.8189 $127.35 $27.10 $25.47 0661 Level V PathologyX 2.3496 $164.51 . $32.91 0662 CT Angiography S 4.8375 $338.70 $114.37 $67.74 0664 Level I Proton Beam Radiation Therapy S 16.9101 "$1,183.98" . $236.80 0665 Bone Density:AppendicularSkeleton S 0.4865 $34.06 $0.00 $0.00 0667 Level II Proton Beam Radiation Therapy S 22.1209 "$1,548.82" . $309.77 0668 Level I Angiography and VenographyT 9.4045 $658.47 . $131.70 0672 Level III Posterior Segment Eye Procedures T 41.0159 "$2,871.77" . $574.36 0673 Level V Anterior Segment Eye Procedures T 41.5778 "$2,911.11" $634.95 $582.230674 Prostate Cryoablation T 113.8112 "$7,968.60" . "$1,593.72" 0676 Thrombolysis and Other Device Revisions T 2.3021 $161.18 . $32.24 0678 External Counterpulsation T 1.3360 $93.54 . $18.71 0679 Level II Resuscitation and Cardioversion S 5.3254 $372.86 $95.30 $74.58 0680 Insertion of Patient Activated Event Recorders S 80.3579 "$5,626.34" . "$1,125.27" 0683 Level II Photochemotherapy S 3.0368 $212.62 . $42.53 0685 Level III Needle Biopsy/Aspiration Except Bone Marrow T 9.6713 $677.15 . $135.43 0687 Revision/Removal of Neurostimulator Electrodes T 20.7198 "$1,450.72" $385.30 $290.15 0688 Revision/Removal of Neurostimulator Pulse Generator Receiver T 31.1002 "$2,177.51" $768.94 $435.51 0690 Level I Electronic Analysis of Devices S 0.4928 $34.50 . $6.90 0691 Level III Electronic Analysis of Devices S 2.3930 $167.55 . $33.51 0692 Level II Electronic Analysis of Devices S 1.5944 $111.63 . $22.33 0694 Mohs SurgeryT 5.0714 $355.08 $88.08 $71.02 0697 Level I Echocardiogram Without Contrast S 3.1615 $221.36 . $44.28 0698 Level II Eye Tests & Treatments S 1.0589 $74.14 . $14.83 0699 Level IV Eye Tests & Treatments T 15.4248 "$1,079.98" . $216.00 0701 Sr89 strontiumK $954.77 . $190.96 0726 Dexrazoxane HCl injection K $207.92 . $41.59 0728 Filgrastim 300 mcg injection K $246.80 . $49.36 0731 Sargramostim injection K $24.22 . $4.85 0735 Ampho b cholesteryl sulfate K $14.56 . $2.92 0736 Amphotericin b liposome inj K $14.25 . $2.85 0738 Rasburicase K $188.98 . $37.80 0747 Chlorothiazide sodium inj K $269.86 . $53.98 0751 Mechlorethamine hcl inj K $154.88 . $30.98 0752 Dactinomycin injection K $567.28 . $113.46 0759 "Naltrexone, depot form" K $2.78 . $0.56 0800 Leuprolide acetate K $590.71 . $118.15 0802 Etoposide oral K $37.54 . $7.51 0807 Aldesleukin injection K $969.60 . $193.92 0809 Bcg live intravesical vac K $117.34 . $23.47 0810 Goserelin acetate implant K $186.43 . $37.29 0812 Carmustine injection K $172.53 . $34.51 0814 Asparaginase injection K $62.08 . $12.42 0820 Daunorubicin injection K $15.60 . $3.12 0821 Daunorubicin citrate inj K $56.58 . $11.32 0823 Docetaxel injection K $15.75 . $3.15 0825 Nelarabine injection K $113.99 . $22.80 0827 Floxuridine injection K $60.82 . $12.17 0828 Gemcitabine hcl injection K $89.64 . $17.93 0830 Irinotecan injection K $6.42 . $1.29 0831 Ifosfamide injection K $32.03 . $6.41 0832 Idarubicin hcl injection K $58.32 . $11.67 0835 Cosyntropin injection NOS K $99.76 . $19.96 0836 Interferon alfa-2b inj K $16.82 . $3.37 0838 Interferon gamma 1-b inj K $582.59 . $116.52 0840 Inj melphalan hydrochl K "$1,512.71" . $302.55 0842 Fludarabine phosphate inj K $101.84 . $20.37 0843 Pegaspargase injection K "$2,675.40" . $535.08 0844 Pentostatin injection K "$1,084.10" . $216.82 0849 Rituximab injection K $615.22 . $123.05 0850 Streptozocin injection K $265.69 . $53.14 0851 Thiotepa injection K $131.18 . $26.24 0856 Porfimer sodium injection K "$19,348.11" . "$3,869.63" 0858 Inj cladribine K $23.94 . $4.79 0861 Leuprolide acetate injeciton K $4.42 . $0.89 0864 Mitoxantrone hydrochl K $37.36 . $7.48 0865 Interferon alfa-n3 inj K $31.20 . $6.24 0868 Oral aprepitant K $6.06 . $1.22 0873 Hyalgan/supartz inj per dose K $88.00 . $17.60 0874 Synvisc or synvisc-one K $11.93 . $2.39 0875 Euflexxa inj per dose K $146.10 . $29.22 0877 Orthovisc inj per dose K $166.14 . $33.23 0884 Rho d immune globulin inj K $82.14 . $16.43 0887 Azathioprine parenteral K $122.53 . $24.510890 Lymphocyte immune globulin K $556.51 . $111.31 0900 Alglucerase injection K $41.24 . $8.25 0901 Alpha 1 proteinase inhibitor K $3.83 . $0.77 0902 "Injection,onabotulinumtoxinA" K $5.38 . $1.08 0903 Cytomegalovirus imm IV /vial K $947.86 . $189.58 0910 Interferon beta-1b / .25 MGK $211.59 . $42.32 0913 Ganciclovir long act implant K "$16,640.00" . "$3,328.00" 0917 Adenosine injection K $94.42 . $18.89 0925 Factor viii K $0.85 . $0.17 0927 Factor viii recombinant K $1.09 . $0.22 0928 Factor ix complexK $0.91 . $0.19 0929 Anti-inhibitor K $1.60 . $0.32 0931 Factor IX non-recombinant K $0.89 . $0.18 0932 Factor IX recombinant K $1.14 . $0.23 0933 Gamma globulin > 10 CC inj K $206.16 . $41.24 0934 "Capecitabine, oral" K $24.63 . $4.93 0943 Octagam injection K $55.80 . $11.16 0944 Gammagard liquid injection K $37.08 . $7.42 0945 Rhophylac injection K $5.09 . $1.02 0946 Hepagam b im injection K $52.11 . $10.43 0947 Flebogamma injection G $35.15 . $6.90 0948 Gamunex/gamunex c K $36.78 . $7.36 0949 "Frozen plasma, pooled, sd" R 0.9547 $66.84 . $13.37 0950 Whole blood for transfusion R 2.7245 $190.76 . $38.16 0951 Reclast injection K $218.44 . $43.69 0952 Cryoprecipitate each unit R 1.1823 $82.78 . $16.56 0954 RBC leukocytes reduced R 2.8408 $198.90 . $39.78 0955 "Plasma, frz between 8-24hour" R 1.0400 $72.82 . $14.57 0956 "Plasma protein fract,5%,50ml" R 0.2574 $18.02 . $3.61 0957 "Platelets, each unit" R 1.2822 $89.77 . $17.96 0958 Plaelet rich plasma unit R 2.0257 $141.83 . $28.37 0959 Red blood cells unit R 2.1303 $149.16 . $29.84 0960 Washed red blood cells unit R 4.1045 $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" R 1.0362 $72.55 . $14.51 0967 Blood split unit R 1.6761 $117.35 . $23.47 0968 Platelets leukoreduced irrad R 1.9996 $140.00 . $28.00 0969 RBC leukoreduced irradiated R 3.7309 $261.22 . $52.25 1009 Cryoprecipitatereducedplasma R 1.0622 $74.37 . $14.88 1010 "Blood, l/r, cmv-neg" R 2.6930 $188.55 . $37.71 1011 "Platelets, hla-m, l/r, unit" R 11.4695 $803.05 . $160.61 1013 Platelets leukocytes reduced R 1.8720 $131.07 . $26.22 1015 Injection glatiramer acetate K $109.30 . $21.86 1016 "Blood, l/r, froz/degly/wash" R 1.4989 $104.95 . $20.99 1017 "Plt, aph/pher, l/r, cmv-neg" R 5.4802 $383.70 . $76.74 1018 "Blood, l/r, irradiated" R 2.0966 $146.80 . $29.36 1019 Plate pheres leukoredu irrad R 9.8804 $691.79 . $138.36 1020 "Plt, pher, l/r cmv-neg, irr" R 8.7936 $615.69 . $123.14 1021 "RBC, frz/deg/wsh, l/r, irrad" R 6.4103 $448.82 . $89.77 1022 "RBC, l/r, cmv-neg, irrad" R 4.3700 $305.97 . $61.20 1023 Pralidoxime chloride inj K $88.51 . $17.71 1052 "Injection, voriconazole" K $6.07 . $1.22 1064 "I131 iodide cap, rx" K $17.26 . $3.46 1083 Adalimumab injection K $410.95 . $82.19 1084 Denileukin diftitox inj K "$1,603.01" . $320.61 1086 Temozolomide K $9.48 . $1.90 1138 "Hepagam b intravenous, inj" K $52.11 . $10.43 1139 Protein c concentrate K $12.90 . $2.58 1142 Supprelin LA implant K "$15,418.48" . "$3,083.70" 1150 "I131 iodide sol, rx" K $10.49 . $2.10 1166 Cytarabine liposome inj K $503.48 . $100.70 1167 "Inj, epirubicin hcl" K $1.87 . $0.38 1168 "Inj, temsirolimus" K $50.57 . $10.121178 Busulfan injection K $18.72 . $3.75 1203 Verteporfin injection K $9.76 . $1.96 1207 "Octreotide injection, depot" K $117.11 . $23.43 1213 Antihemophilic viii/vwf comp K $0.90 . $0.18 1214 Inj IVIG privigen 500 mg K $34.42 . $6.89 1221 Dimethyl sulfoxide 50% K $94.38 . $18.88 1222 Pentastarch 10% solution K $13.23 . $2.65 1226 Inj streptokinase /250000 IUK $19.78 . $3.96 1232 Mitomycin 5 MG inj K $19.55 . $3.91 1235 Valrubicin injection K $959.07 . $191.82 1236 Levoleucovorin injection K $1.58 . $0.32 1237 Inj iron dextran K $11.53 . $2.31 1238 Topotecan oral K $77.92 . $15.59 1239 Rotavirus vacc 2 dose oral K $106.60 . $21.32 1240 Apligraf skin subK $35.88 . $7.18 1241 Oasis wound matrix skin subK $5.74 . $1.15 1242 Oasis burn matrix skin subK $5.74 . $1.15 1243 Integra BMWD skin subK $16.26 . $3.26 1244 Integra DRT skin subK $9.62 . $1.93 1245 Dermagraft skin subK $40.51 . $8.11 1246 Graftjacket skin subK $94.95 . $18.99 1247 Integra matrix skin subK $21.73 . $4.35 1248 Primatrix skin subK $31.42 . $6.29 1249 Cymetra allograft K $332.25 . $66.45 1250 Graftjacket express allograf K $332.25 . $66.45 1251 Integra flowable wound matri K "$1,019.89" . $203.98 1252 Gammagraft skin subK $6.78 . $1.36 1253 Triamcinolone A inj PRS-free K $3.41 . $0.69 1263 Antithrombin iii injection K $2.71 . $0.55 1268 Xyntha inj K $1.07 . $0.22 1270 Alloderm skin subK $31.72 . $6.35 1272 Acetylcysteine injection K $2.74 . $0.55 1274 Edetate calcium disodium inj K $189.47 . $37.90 1275 "Vivaglobin, inj" K $12.48 . $2.50 1279 Factor VIII (porcine) K $9.12 . $1.83 1280 Corticotropin injection K "$2,516.22" . $503.25 1281 Bevacizumab injection K $1.50 . $0.30 1287 Alloskin skin subK $8.26 . $1.66 1289 AbobotulinumtoxinAK $7.29 . $1.46 1290 Human fibrinogen conc inj K $71.57 . $14.32 1291 Rilonacept injection K $23.64 . $4.73 1295 Sm 153 lexidronamK "$7,592.00" . "$1,518.40" 1296 Degarelix injection K $2.71 . $0.55 1297 "Ferumoxytol, non-esrd" K $0.65 . $0.13 1304 Perphenazine injeciton K $19.54 . $3.91 1306 Urea injection K $72.00 . $14.40 1307 Oral busulfan K $3.77 . $0.76 1308 Mecasermin injection K $25.65 . $5.13 1311 Canakinumab injection G $88.97 . $17.46 1312 Hizentra injection K $7.15 . $1.43 1327 Imiglucerase injection K $41.20 . $8.24 1331 Olanzapine long-acting inj K $2.70 . $0.54 1332 Antithrombin recombinant K $101.40 . $20.28 1338 "Methyl aminolevulinate, top" K $74.52 . $14.91 1339 Oral fludarabine phosphate G $77.93 . $15.30 1340 "Collagenase, clost hist inj" G $37.51 . $7.36 1341 Amobarbital 125 MG inj K $113.08 . $22.62 1342 Matristem micromatrixK $2.94 . $0.59 1343 Ganciclovir sodium injection K $66.58 . $13.32 1344 Gonadorelin hydroch/ 100 mcg K $167.25 . $33.45 1345 Theraskin K $32.84 . $6.57 1347 Oxacillin sodium injeciton K $2.51 . $0.51 1349 Anidulafungin injection K $1.20 . $0.24 1350 Topotecan injection K $9.85 . $1.97 1351 Matristem wound matrixK $4.52 . $0.91 1352 Wilate injection G $0.87 . $0.171353 Belimumab injection G $38.61 . $7.58 1354 Hydroxyprogesterone caproate K $2.52 . $0.51 1355 Itraconazole injection K $372.55 . $74.51 1357 Inj protirelin per 250 mcg K $27.03 . $5.41 1358 Phentolaine mesylate inj K $53.76 . $10.76 1359 Foscarnet sodium injection K $14.37 . $2.88 1360 Apomorphine hydrochloride K $5.12 . $1.03 1361 Enfuvirtide injection K $0.51 . $0.11 1362 Inj heparin sodium per 10 u K $0.18 . $0.04 1373 Inj heparin sodium per 1000u K $0.27 . $0.06 1374 Sumatriptan succinate / 6 MGK $76.71 . $15.35 1408 Cyclophosphamide 100 MG inj K $13.43 . $2.69 1412 Vinorelbine tartrate inj K $17.45 . $3.49 1413 Lumizyme injection G $148.30 . $29.10 1415 Glassia injection K $3.81 . $0.77 1416 Factor XIII anti-hem factor G $8.44 . $1.66 1417 Gel-one K "$1,014.00" . $202.80 1418 Oral everolimus K $5.68 . $1.14 1419 Dermacell K $31.52 . $6.31 1426 Eribulin mesylate injection G $90.06 . $17.68 1491 New Technology - Level IA ($0-$10) S $5.00 . $1.00 1492 New Technology - Level IB ($10-$20) S $15.00 . $3.00 1493 New Technology - Level IC ($20-$30) S $25.00 . $5.00 1494 New Technology - Level ID ($30-$40) S $35.00 . $7.00 1495 New Technology - Level IE ($40-$50) S $45.00 . $9.00 1496 New Technology - Level IA ($0-$10) T $5.00 . $1.00 1497 New Technology - Level IB($10-$20) T $15.00 . $3.00 1498 New Technology - Level IC ($20-$30) T $25.00 . $5.00 1499 New Technology - Level ID($30-$40) T $35.00 . $7.00 1500 New Technology - Level IE ($40-$50) T $45.00 . $9.00 1502 New Technology - Level II ($50 - $100) S $75.00 . $15.00 1503 New Technology - Level III ($100 - $200) S $150.00 . $30.00 1504 New Technology - Level IV ($200 - $300) S $250.00 . $50.00 1505 New Technology - Level V ($300 - $400) S $350.00 . $70.00 1506 New Technology - Level VI ($400 - $500) S $450.00 . $90.00 1507 New Technology - Level VII ($500 - $600) S $550.00 . $110.00 1508 New Technology - Level VIII ($600 - $700) S $650.00 . $130.00 1509 New Technology - Level IX ($700 - $800) S $750.00 . $150.00 1510 New Technology - Level X ($800 - $900) S $850.00 . $170.00 1511 New Technology - Level XI ($900 - $1000) S $950.00 . $190.00 1512 New Technology - Level XII ($1000 - $1100) S "$1,050.00" . $210.00 1513 New Technology - Level XIII ($1100 - $1200) S "$1,150.00" . $230.00 1514 New Technology - Level XIV ($1200- $1300) S "$1,250.00" . $250.00 1515 New Technology - Level XV ($1300 - $1400) S "$1,350.00" . $270.00 1516 New Technology - Level XVI ($1400 - $1500) S "$1,450.00" . $290.00 1517 New Technology - Level XVII ($1500-$1600) S "$1,550.00" . $310.00 1518 New Technology - Level XVIII ($1600-$1700) S "$1,650.00" . $330.00 1519 New Technology - Level IXX ($1700-$1800) S "$1,750.00" . $350.00 1520 New Technology - Level XX ($1800-$1900) S "$1,850.00" . $370.00 1521 New Technology - Level XXI ($1900-$2000) S "$1,950.00" . $390.00 1522 New Technology - Level XXII ($2000-$2500) S "$2,250.00" . $450.00 1523 New Technology - Level XXIII ($2500-$3000) S "$2,750.00" . $550.00 1524 New Technology - Level XXIV ($3000-$3500) S "$3,250.00" . $650.00 1525 New Technology - Level XXV ($3500-$4000) S "$3,750.00" . $750.00 1526 New Technology - Level XXVI ($4000-$4500) S "$4,250.00" . $850.00 1527 New Technology - Level XXVII ($4500-$5000) S "$4,750.00" . $950.00 1528 New Technology - Level XXVIII ($5000-$5500) S "$5,250.00" . "$1,050.00" 1529 New Technology - Level XXIX ($5500-$6000) S "$5,750.00" . "$1,150.00" 1530 New Technology - Level XXX ($6000-$6500) S "$6,250.00" . "$1,250.00" 1531 New Technology - Level XXXI ($6500-$7000) S "$6,750.00" . "$1,350.00" 1532 New Technology - Level XXXII ($7000-$7500) S "$7,250.00" . "$1,450.00" 1533 New Technology - Level XXXIII ($7500-$8000) S "$7,750.00" . "$1,550.00" 1534 New Technology - Level XXXIV ($8000-$8500) S "$8,250.00" . "$1,650.00" 1535 New Technology - Level XXXV ($8500-$9000) S "$8,750.00" . "$1,750.00" 1536 New Technology - Level XXXVI ($9000-$9500) S "$9,250.00" . "$1,850.00" 1537 New Technology - Level XXXVII ($9500-$10000) S "$9,750.00" . "$1,950.00"1539 New Technology - Level II ($50 - $100) T $75.00 . $15.00 1540 New Technology - Level III ($100 - $200) T $150.00 . $30.00 1541 New Technology - Level IV ($200 - $300) T $250.00 . $50.00 1542 New Technology - Level V ($300 - $400) T $350.00 . $70.00 1543 New Technology - Level VI ($400 - $500) T $450.00 . $90.00 1544 New Technology - Level VII ($500 - $600) T $550.00 . $110.00 1545 New Technology - Level VIII ($600 - $700) T $650.00 . $130.00 1546 New Technology - Level IX ($700 - $800) T $750.00 . $150.00 1547 New Technology - Level X ($800 - $900) T $850.00 . $170.00 1548 New Technology - Level XI ($900 - $1000) T $950.00 . $190.00 1549 New Technology - Level XII ($1000 - $1100) T "$1,050.00" . $210.00 1550 New Technology - Level XIII ($1100 - $1200) T "$1,150.00" . $230.00 1551 New Technology - Level XIV ($1200- $1300) T "$1,250.00" . $250.00 1552 New Technology - Level XV ($1300 - $1400) T "$1,350.00" . $270.00 1553 New Technology - Level XVI ($1400 - $1500) T "$1,450.00" . $290.00 1554 New Technology - Level XVII ($1500-$1600) T "$1,550.00" . $310.00 1555 New Technology - Level XVIII ($1600-$1700) T "$1,650.00" . $330.00 1556 New Technology - Level XIX ($1700-$1800) T "$1,750.00" . $350.00 1557 New Technology - Level XX ($1800-$1900) T "$1,850.00" . $370.00 1558 New Technology - Level XXI ($1900-$2000) T "$1,950.00" . $390.00 1559 New Technology - Level XXII ($2000-$2500) T "$2,250.00" . $450.00 1560 New Technology - Level XXIII ($2500-$3000) T "$2,750.00" . $550.00 1561 New Technology - Level XXIV ($3000-$3500) T "$3,250.00" . $650.00 1562 New Technology - Level XXV ($3500-$4000) T "$3,750.00" . $750.00 1563 New Technology - Level XXVI ($4000-$4500) T "$4,250.00" . $850.00 1564 New Technology - Level XXVII ($4500-$5000) T "$4,750.00" . $950.00 1565 New Technology - Level XXVIII ($5000-$5500) T "$5,250.00" . "$1,050.00" 1566 New Technology - Level XXIX ($5500-$6000) T "$5,750.00" . "$1,150.00" 1567 New Technology - Level XXX ($6000-$6500) T "$6,250.00" . "$1,250.00" 1568 New Technology - Level XXXI ($6500-$7000) T "$6,750.00" . "$1,350.00" 1569 New Technology - Level XXXII ($7000-$7500) T "$7,250.00" . "$1,450.00" 1570 New Technology - Level XXXIII ($7500-$8000) T "$7,750.00" . "$1,550.00" 1571 New Technology - Level XXXIV ($8000-$8500) T "$8,250.00" . "$1,650.00" 1572 New Technology - Level XXXV ($8500-$9000) T "$8,750.00" . "$1,750.00" 1573 New Technology - Level XXXVI ($9000-$9500) T "$9,250.00" . "$1,850.00" 1574 New Technology - Level XXXVII ($9500-$10000) T "$9,750.00" . "$1,950.00" 1605 Abciximab injection K $548.95 . $109.79 1607 Eptifibatide injection K $22.02 . $4.41 1608 Etanercept injection K $204.31 . $40.87 1609 "Rho(D) immune globulin h, sd" K $17.21 . $3.45 1612 "Daclizumab, parenteral" K $516.41 . $103.29 1613 Trastuzumab injection K $71.08 . $14.22 1630 "Hep b ig, im" K $113.50 . $22.70 1631 Baclofen intrathecal trial K $76.39 . $15.28 1633 Alefacept K $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" 1670 Tetanus immune globulin inj K $245.02 . $49.01 1675 P32 Na phosphate K $126.14 . $25.23 1676 P32 chromic phosphate K $579.98 . $116.00 1683 BasiliximabK "$2,190.58" . $438.12 1684 Corticorelin ovine triflutal K $5.58 . $1.12 1685 "Darbepoetin alfa, non-esrd" K $3.14 . $0.63 1686 "Epoetin alfa, non-esrd" K $9.70 . $1.94 1687 Digoxin immune fab (ovine) K $626.71 . $125.35 1688 Ethanolamine oleate K $294.28 . $58.86 1689 Fomepizole K $6.91 . $1.39 1690 HeminK $10.41 . $2.09 1693 Lepirudin K $346.19 . $69.24 1694 Ziconotide injection K $6.48 . $1.30 1695 Nesiritide injection K $46.36 . $9.28 1696 Palifermin injection K $11.45 . $2.29 1697 Pegaptanib sodium injection K "$1,001.34" . $200.27 1700 Inj secretin synthetic human K $26.98 . $5.40 1701 Treprostinil injection K $60.08 . $12.02 1704 "Humate-P, inj" K $0.88 . $0.181705 Factor viia K $1.52 . $0.31 1709 Azacitidine injection K $5.15 . $1.03 1710 Clofarabine injection K $119.68 . $23.94 1711 Vantas implant K "$3,816.98" . $763.40 1712 Paclitaxel protein bound K $9.33 . $1.87 1716 "Brachytx, non-str, Gold-198" U 0.5004 $35.04 . $7.01 1717 "Brachytx, non-str, HDR Ir-192" U 3.3224 $232.62 . $46.53 1719 "Brachytx, NS, Non-HDRIr-192" U 0.4544 $31.82 . $6.37 1738 Oxaliplatin K $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 1830 Power bone marrow bx needle H 1840 Telescopic intraocular lens H 1886 "Catheter, ablation" H 2210 Methyldopate hcl injection K $39.16 . $7.84 2616 "Brachytx, non-str,Yttrium-90" U 224.7054 "$15,732.97" . "$3,146.60" 2632 Iodine I-125 sodium iodide U 0.2404 $16.83 . $3.37 2634 "Brachytx, non-str, HA, I-125" U 0.8944 $62.62 . $12.53 2635 "Brachytx, non-str, HA, P-103" U 0.3855 $26.99 . $5.40 2636 "Brachy linear, non-str,P-103" U 0.5294 $37.07 . $7.42 2638 "Brachytx, stranded, I-125" U 0.6498 $45.50 . $9.10 2639 "Brachytx, non-stranded,I-125" U 0.5078 $35.55 . $7.11 2640 "Brachytx, stranded, P-103" U 1.1433 $80.05 . $16.01 2641 "Brachytx, non-stranded,P-103" U 0.9180 $64.27 . $12.86 2642 "Brachytx, stranded, C-131" U 1.7379 $121.68 . $24.34 2643 "Brachytx, non-stranded,C-131" U 1.1044 $77.33 . $15.47 2698 "Brachytx, stranded, NOS" U 0.6498 $45.50 . $9.10 2699 "Brachytx, non-stranded, NOS" U 0.3855 $26.99 . $5.40 2731 "Immune globulin, powder" K $30.46 . $6.10 2770 Quinupristin/dalfopristin K $171.48 . $34.30 3041 Bivalirudin K $2.71 . $0.55 3043 Gamma globulin 1 CC inj K $20.62 . $4.13 3050 Sermorelin acetate injection K $1.77 . $0.36 7000 Amifostine K $315.94 . $63.19 7011 Oprelvekin injection K $239.90 . $47.98 7034 Somatropin injection K $61.81 . $12.37 7035 Teniposide K $316.31 . $63.27 7036 "Urokinase 250,000 IU inj" K $449.09 . $89.82 7038 Monoclonal antibodies K "$1,111.59" . $222.32 7041 Tirofiban HCl K $8.92 . $1.79 7042 "Capecitabine, oral" K $7.32 . $1.47 7043 Infliximab injection K $62.01 . $12.41 7046 Doxorubicin hcl liposome inj K $525.35 . $105.07 7048 Alteplase recombinant K $42.24 . $8.45 7049 Filgrastim 480 mcg injection K $390.07 . $78.02 7051 Leuprolide acetate implant K "$4,728.88" . $945.78 7308 Aminolevulinic acid hcl top K $147.80 . $29.56 8000 Cardiac Electrophysiologic Evaluation and Ablation Composite T 161.5528 "$11,311.28" . "$2,262.26" 8001 LDR Prostate Brachytherapy Composite T 47.7031 "$3,339.98" . $668.00 8002 Level I Extended Assessment & Management Composite V 5.6151 $393.15 . $78.63 8003 Level II Extended Assessment & Management Composite V 10.2925 $720.64 . $144.13 8004 Ultrasound Composite S 2.7374 $191.66 . $38.34 8005 CT and CTA without Contrast Composite S 6.1687 $431.91 . $86.39 8006 CT and CTA with Contrast Composite S 10.3084 $721.75 . $144.35 8007 MRI and MRA without Contrast Composite S 9.9975 $699.98 . $140.00 8008 MRI and MRA with Contrast Composite S 14.2917 "$1,000.65" . $200.13 9001 Linezolid injection K $34.48 . $6.90 9002 Tenecteplase injection K $57.15 . $11.43 9003 PalivizumabK "$1,158.85" . $231.77 9004 Gemtuzumab ozogamicin inj K "$2,690.84" . $538.17 9005 Reteplase injection K "$1,623.59" . $324.72 9006 Tacrolimus injection K $136.86 . $27.38 9012 Arsenic trioxide injection K $40.10 . $8.02 9018 "Inj, rimabotulinumtoxinB" K $10.78 . $2.169019 Caspofungin acetate K $13.32 . $2.67 9022 IM inj interferon beta 1-a K $238.30 . $47.66 9023 Rho d immune globulin K $21.52 . $4.31 9024 Amphotericin b lipid complexK $8.42 . $1.69 9032 Baclofen 10 MG injection K $187.46 . $37.50 9033 Cidofovir injection K $742.66 . $148.54 9038 Inj estrogen conjugate K $103.54 . $20.71 9042 Glucagon hydrochloride K $101.30 . $20.26 9044 Ibutilide fumarate injection K $133.80 . $26.76 9046 Iron sucrose injection K $0.32 . $0.07 9104 Antithymocyte globuln rabbit K $432.20 . $86.44 9108 Thyrotropin injection K "$1,032.25" . $206.45 9110 Alemtuzumab injection K $575.18 . $115.04 9115 Zoledronic acid K $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 9122 Triptorelin pamoate K $176.18 . $35.24 9124 Daptomycin injection K $0.48 . $0.10 9125 "Risperidone, long acting" K $5.07 . $1.02 9126 Natalizumab injection K $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 9207 Bortezomib injection K $40.67 . $8.14 9208 Agalsidase beta injection K $138.53 . $27.71 9209 Laronidase injection K $26.33 . $5.27 9210 Palonosetron hcl K $18.83 . $3.77 9213 Pemetrexed injection K $52.76 . $10.56 9214 Bevacizumab injection K $59.98 . $12.00 9215 Cetuximab injection K $49.53 . $9.91 9217 Leuprolide acetate suspnsion K $216.90 . $43.38 9224 Galsulfase injection K $341.40 . $68.28 9225 Fluocinolone acetonide implt K "$18,980.00" . "$3,796.00" 9227 Micafungin sodium injection K $0.98 . $0.20 9228 Tigecycline injection K $1.30 . $0.26 9229 Ibandronate sodium injection K $148.02 . $29.61 9230 Abatacept injection K $20.72 . $4.15 9231 Decitabine injection K $31.94 . $6.39 9232 Idursulfase injection K $446.44 . $89.29 9233 Ranibizumab injection K $395.53 . $79.11 9234 Alglucosidase alfa injection K $155.84 . $31.17 9235 Panitumumab injection K $85.59 . $17.12 9236 Eculizumab injection K $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 9243 Bendamustine injection K $18.47 . $3.70 9244 Regadenoson injection K $51.22 . $10.25 9245 Romiplostim injection K $45.87 . $9.18 9248 "Inj, clevidipine butyrate" K $2.66 . $0.54 9249 Certolizumab pegol inj K $4.12 . $0.83 9250 Artiss fibrin sealant K $129.72 . $25.95 9251 C1 esterase inhibitor inj K $43.37 . $8.68 9252 Plerixafor injection K $275.80 . $55.16 9253 Temozolomide injection K $4.75 . $0.95 9254 "Injection, lacosamide" K $0.15 . $0.03 9255 Paliperidone palmitate inj K $6.56 . $1.32 9256 Dexamethasone intra implant K $192.26 . $38.46 9258 Telavancin injection G $2.10 . $0.429259 Pralatrexate injection G $165.63 . $32.50 9260 Ofatumumab injection G $45.41 . $8.91 9261 Ustekinumab injection G $117.56 . $23.07 9263 Ecallantide injection G $289.07 . $56.73 9264 Tocilizumab injection G $3.47 . $0.68 9265 Romidepsin injection G $224.79 . $44.11 9268 Capsaicin 8% patchG $25.55 . $5.02 9269 "C-1 esterase, berinert" G $30.23 . $5.94 9270 Gammaplex IVIG G $37.29 . $7.32 9271 Velaglucerase alfa G $349.51 . $68.59 9272 "Inj, denosumab" G $14.47 . $2.84 9273 Sipuleucel-T auto CD54+ G "$32,860.00" . "$6,448.00" 9274 Crotalidae Poly Immune Fab G "$2,111.36" . $414.31 9275 Hexaminolevulinate HCl G $623.28 $0.00 $0.00 9276 Cabazitaxel injection G $135.57 . $26.61 9278 Incobotulinumtoxin 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 9284 Ipilimumab injection G $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 9300 Omalizumab injection K $21.34 . $4.27 9358 "SurgiMend, fetal" K $10.91 . $2.19 9360 "SurgiMend, neonatal" K $11.23 . $2.25 9363 Integra Meshed Bil Wound Mat K $20.60 . $4.12 9365 Oasis tri-layer wound matrix G $10.39 . $2.04 9366 EpiFix wound cover G $177.77 . $34.89 9367 Endoform Dermal Template G $4.35 . $0.86 9406 Iodine I-123 ioflupane G "$1,908.00" $0.00 $0.00 9500 "Platelets, irradiated" R 1.8342 $128.42 . $25.69 9501 Platelet pheres leukoreduced R 7.6960 $538.84 . $107.77 9502 Platelet pheresis irradiated R 7.9257 $554.93 . $110.99 9503 Fr frz plasma donor retested R 1.1562 $80.95 . $16.19 9504 RBC deglycerolizedR 3.4084 $238.64 . $47.73 9505 RBC irradiatedR 2.8419 $198.98 . $39.80 9506 "Granulocytes, pheresis unit" R 19.1478 "$1,340.65" . $268.13 9507 "Platelets, pheresis" R 6.3148 $442.14 . $88.43 9508 Plasma 1 donor frz w/in 8 hr R 1.1408 $79.87 . $15.98