APC Category APC Category Description 1 Skin 2 Cardiovascular tests/procedures 3 GI tests/procedures 4 Genitourinary /Renal procedures 5 Musculoskeletal procedures 

### 6 Access device procedures (Vascular /Other) 7 Access device procedures (Endoscopy /Laproscopy) 8 Nerve/Neuro tests/procedures 9 Drug administration 10 Pathology 11 Prostate tests/procedures 12 Female Reproductive tests/procedures 13 Male Reproductive tests/procedures 14 Biopsies 15 Psych tests/treatments 16 ENT 17 Eye 18 Blood/Lymph/Marrow procedures 19 E&M 20 Imaging 21 Breast procedures 22 Screening tests 23 Radiation therapies 24 Nuclear Medicine 

### 25 Special OPPS Payment Status 26 Special OPPS Payment Status 27 Other Minor Services 28 Pulmonary tests/procedures 29 Drugs, Vaccines 

### 30 Brachytherapy Sources 31 Devices 32 Blood and Blood Products**Ad dendum A** **.-Proposed OPPS A PCs for CY 2012** 

**AP C**  **Group Title SI**  **Relative Weight**  **Payment Rate** 0001 Level I Photochemotherapy S 0.5025 $34.88 0002 Fine Needle Biopsy /Aspiration T 1.7462 $121.22 0003 Bone Marrow Biopsy /Aspiration T 3.9075 $271.26 0004 Level I Needle Biopsy / Aspiration Except Bone Marrow T 4.5956 $319.03 0005 Level II Needle Biopsy /Aspiration Except Bone Marrow T 8.1415 $565.18 0006 Level I Incision & Drainage T 1.4481 $100.53 0007 Level II Incision & Drainage T 13.4779 $935.64 0008 Level III Incision and Drainage T 20.5401 $1,425.89 0012 Level I Debridement & Destruction T 0.4047 $28.09 0013 Level II Debridement & Destruction T 0.9786 $67.93 0015 Level III Debridement & Destruction T 1.4936 $103.69 0016 Level IV Debridement & Destruction T 2.8248 $196.10 0017 Level V Debridement & Destruction T 22.0631 $1,531.62 0019 Level I Excision/ Biopsy T 4.8763 $338.51 0020 Level II Excision/ Biopsy T 8.6164 $598.15 0021 Level III Excision/ Biopsy T 17.1909 $1,193.39 0022 Level IV Excision/ Biopsy T 23.4169 $1,625.60 0028 Level I Breast Surgery T 25.8383 $1,793.69 0029 Level II Breast Surgery T 33.8417 $2,349.29 0030 Level III Breast Surgery T 45.0972 $3,130.65 0031 Smoking Cessation Services X 0.2941 $20.42 0034 Mental Health Services Composite S 2.6400 $183.27 0035Vascular Puncture and Minor Diagnostic Procedures X 0.2717 $18.86 0037 Level IV Needle Biopsy /Aspiration Except Bone Marrow T 15.3594 $1,066.25 0039 Level I Implantation of Neurostimulator Generator S 209.6958 $14,557.08 0040 Level I Implantation/Revision/Replacement of Neurostimulator Electrodes S 62.7889 $4,358.81 0041 Level I Arthroscopy T 29.4235 $2,042.58 0042 Level II Arthroscopy T 48.4545 $3,363.71 0045 Bone/Joint Manipulation Under Anesthesia T 15.5166 $1,077.16 0047Arthroplasty

without Prosthesis T 41.2971 $2,866.84 0048 Level I Arthroplasty or Implantation with Prosthesis T 60.0335 $4,167.53 0049 Level I Musculoskeletal Procedures Except Hand and FootT 22.1674 $1,538.86 0050 Level II Musculoskeletal Procedures Except Hand and Foot T 32.4101 $2,249.91 0051 Level III Musculoskeletal Procedures Except Hand and Foot T 47.1841 $3,275.52 0052 Level IV Musculoskeletal Procedures Except Hand and Foot T 87.5671 $6,078.91 0053 Level I Hand Musculoskeletal Procedures T 17.4096 $1,208.57 0054 Level II Hand Musculoskeletal Procedures T 29.0181 $2,014.44 0055 Level I Foot Musculoskeletal Procedures T 22.1739 $1,539.31 0056 Level II Foot Musculoskeletal Procedures T 57.2099 $3,971.51 0057 Bunion Procedures T 32.5456 $2,259.32 0058 Level I Strapping and Cast Application S 1.1378 $78.99 0060 Manipulation Therapy S 0.3234 $22.45 0061 Level II Implantation/Revision/Replacement of Neurostimulator Electrodes S 86.9786 $6,038.05 0062 Level I Treatment Fracture/Dislocation T 26.2376 $1,821.41 0063 Level II Treatment Fracture/Dislocation T 49.4864 $3,435.35 0064 Level III Treatment Fracture/Dislocation T 67.0623 $4,655.46 0065 Level I Stereotactic Radiosurgery, MRgFUS, and MEG S 12.4513 $864.370066 Level II Stereotactic Radiosurgery, MRgFUS, and MEG S 35.2457 $2,446.76

0067 Level III Stereotactic Radiosurgery, MRgFUS, and MEGS 46.8279 $3,250.79 0069Thoracoscopy T 34.9007 $2,422.81 0070Thoracentesis/Lavage Procedures T 5.5572 $385.78 0071 Level I Endoscopy Upper Airway T 1.0521 $73.04 0072 Level II Endoscopy Upper Airway T 1.9475 $135.20 0073 Level III Endoscopy Upper Airway T 4.5122 $313.24 0074 Level IV Endoscopy Upper Airway T 21.3691 $1,483.44 0075 Level V Endoscopy Upper Airway T 30.2222 $2,098.03 0076 Level I Endoscopy Lower Airway T 10.4123 $722.82 0077 Level I Pulmonary Treatment S 0.4224 $29.32 0078 Level III Pulmonary Treatment S 1.4008 $97.24 0079Ventilation Initiation and Management S 3.0221 $209.79 0080 Diagnostic Cardiac Catheterization T 39.2392 $2,723.99 0082 Coronary

or Non-Coronary

Atherectomy T 104.8857 $7,281.17 0083 Level I Endovascular Revascularization of the Lower Extremity T 65.1118 $4,520.06 0084 Level I Electrophysiologic Procedures S 9.6404 $669.24 0085 Level II Electrophysiologic Procedures T 52.8540 $3,669.12 0086 Level III Electrophysiologic Procedures T 133.7624 $9,285.79 0088Thrombectomy T 41.2260 $2,861.91 0089 Insertion/Replacement of Permanent Pacemaker and Electrodes T 110.9465 $7,701.91 0090 Insertion/Replacement of Pacemaker Pulse Generator T 93.4566 $6,487.76 0091 Level II Vascular Ligation T 43.6864 $3,032.71 0092 Level I Vascular Ligation T 26.9181 $1,868.65 0093Vascular Reconstruction/Fistula Repair without Device T 30.7767 $2,136.52 0094 Level I Resuscitation and Cardioversion S 2.2773 $158.09 0095Cardiac Rehabilitation S 0.9648 $66.98 0096 Level II Noninvasive Physiologic Studies S 1.5324 $106.38 0097 Level I Noninvasive Physiologic Studies S 0.9478 $65.80 0099 Electrocardiograms/Cardiography S 0.3895 $27.04 0100 Cardiac Stress Tests X 2.5348 $175.97 0101 Tilt Table Evaluation S 4.2610 $295.80 0102 Level II Pulmonary Treatment S 0.5308 $36.85 0103 Miscellaneous Vascular Procedures T 16.7686 $1,164.08 0104Transcatheter Placement of Intracoronary Stents T 79.9047 $5,546.98 0105 Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices T 23.2424 $1,613.49 0106 Insertion/Replacement of Pacemaker Leads and/or Electrodes T 48.5765 $3,372.18 0107 Insertion of Cardioverter-Defibrillator T 329.3230 $22,861.60 0108 Insertion/Replacement/Repair of AICD Leads, Generator, and Pacing Electrodes T 379.7887 $26,364.93 0110Transfusion S 3.3671 $233.74 0111 Blood Product Exchange S 11.7368 $814.77 0112Apheresis and Stem Cell Procedures S 32.6016 $2,263.20 0113 Excision Lymphatic System T 25.4874 $1,769.34 0114Thyroid/Lymphadenectomy Procedures T 51.2321 $3,556.53 0115Cannula/Access Device Procedures T 36.8791 $2,560.15 0121 Level I Tube or Catheter Changes or Repositioning T 6.3178 $438.58 0126 Level I Urinary

and Anal Procedures T 1.1699 $81.21 0127 Level IV Stereotactic Radiosurgery, MRgFUS, and MEGS 106.1294 $7,367.50 0128 Echocardiogram with Contrast S 8.1207 $563.74 0129 Level I Closed Treatment Fracture Finger/Toe/Trunk T 1.6063 $111.51 0130 Level I Laparoscopy T 39.0865 $2,713.38 0131 Level II Laparoscopy T 47.7164 $3,312.470132 Level III Laparoscopy T 71.0451 $4,931.95

0133 Level I Skin Repair T 1.2139 $84.27 0134 Level II Skin Repair T 3.2846 $228.02 0135 Level III Skin Repair T 5.1973 $360.80 0136 Level IV Skin Repair T 17.2745 $1,199.20 0137 Level V Skin Repair T 21.8041 $1,513.64 0138 Level II Closed Treatment Fracture Finger/Toe/Trunk T 4.9874 $346.23 0139 Level III Closed Treatment Fracture Finger/Toe/Trunk T 18.6922 $1,297.61 0140 Esophageal Dilation without Endoscopy T 6.5430 $454.22 0141 Level I Upper GI Procedures T 8.3787 $581.65 0142 Level I Small Intestine Endoscopy T 10.1643 $705.61 0143 Lower GI Endoscopy T 9.3183 $646.88 0146 Level I Sigmoidoscopy and Anoscopy T 6.3038 $437.61 0147 Level II Sigmoidoscopy and Anoscopy T 11.0219 $765.14 0148 Level I Anal/Rectal Procedures T 6.1052 $423.82 0149 Level III Anal/Rectal Procedures T 24.4472 $1,697.12 0150 Level IV Anal/Rectal Procedures T 32.9730 $2,288.99 0151 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) T 24.4009 $1,693.91 0152 Level I Percutaneous Abdominal and Biliary ProceduresT 31.2779 $2,171.31 0153 Peritoneal and Abdominal Procedures T 26.6476 $1,849.88 0154 Hernia/Hydrocele Procedures T 32.9744 $2,289.08 0155 Level II Anal/Rectal Procedures T 16.0235 $1,112.35 0156 Level III Urinary and Anal Procedures T 3.1976 $221.98 0157Colorectal Cancer Screening: Barium Enema S 2.2553 $156.56 0158Colorectal Cancer Screening: Colonoscopy T 8.3174 $577.39 0159Colorectal Cancer Screening: Flexible Sigmoidoscopy S 5.4345 $377.26 0160 Level I Cystourethroscopy and other Genitourinary Procedures T 7.3594 $510.89 0161 Level II Cystourethroscopy and other Genitourinary Procedures T 17.6738 $1,226.92 0162 Level III Cystourethroscopy and other Genitourinary Procedures T 26.2690 $1,823.59 0163 Level IV Cystourethroscopy and other Genitourinary Procedures T 36.9605 $2,565.80 0164 Level II Urinary and Anal Procedures T 2.0973 $145.59 0165 Level IV Urinary and Anal Procedures T 20.1960 $1,402.01 0166 Level I Urethral Procedures T 20.7987 $1,443.85 0168 Level II Urethral Procedures T 32.1043 $2,228.68 0169 Lithotripsy T 51.4038 $3,568.45 0170 Dialysis S 5.9462 $412.79 0172 Level I Partial Hospitalization (3 services) for CMHCs P 1.3595 $94.38 0173 Level II Partial Hospitalization (4 or more services) for CMHCs P 1.5798 $109.67 0174 Level IV Laparoscopy T 107.5115 $7,463.45 0175 Level I Partial Hospitalization (3 services) for Hospital-based PHPs P 2.2572 $156.69 0176 Level II Partial Hospitalization (4 or more services) for Hospital-based PHPs P 2.6400 $183.27 0181 Level II Male Genital Procedures T 34.3803 $2,386.68 0183 Level I Male Genital Procedures T 23.7235 $1,646.89 0184 Prostate Biopsy T 14.2476 $989.07 0188 Level II Female Reproductive Proc T 1.6099 $111.76 0189 Level III Female Reproductive Proc T 3.6121 $250.75 0190 Level I Hysteroscopy T 23.1868 $1,609.63 0191 Level I Female Reproductive Proc T 0.1274 $8.84 0192 Level IV Female Reproductive Proc T 7.0332 $488.24 0193 Level V Female Reproductive Proc T 20.7771 $1,442.35 0195 Level VI Female Reproductive Procedures T 35.9320 $2,494.40 0202 Level VII Female Reproductive Procedures T 45.5816 $3,164.270203 Level IV Nerve Injections T 12.9066 $895.98

0204 Level I Nerve Injections T 2.7693 $192.24 0206 Level II Nerve Injections T 3.9371 $273.31 0207 Level III Nerve Injections T 7.5480 $523.98 0208 Laminotomies and Laminectomies T 51.1173 $3,548.56 0209 Level II Extended EEG, Sleep, and Cardiovascular StudiesS 11.3894 $790.65 0213 Level I Extended EEG, Sleep, and Cardiovascular StudiesS 2.3958 $166.32 0215 Level I Nerve and Muscle Tests S 0.6352 $44.10 0216 Level III Nerve and Muscle Tests S 2.6231 $182.10 0218 Level II Nerve and Muscle Tests S 1.1945 $82.92 0220 Level I Nerve Procedures T 19.0626 $1,323.33 0221 Level II Nerve Procedures T 37.4067 $2,596.77 0224 Implantation of Catheter/Reservoir/Shunt T 42.5188 $2,951.66 0227 Implantation of Drug Infusion Device T 190.0513 $13,193.36 0229 Level II Endovascular Revascularization of the Lower Extremity T 114.2626 $7,932.11 0230 Level I Eye Tests & Treatments S 0.6929 $48.10 0231 Level III Eye Tests & Treatments S 2.3088 $160.28 0232 Level I Anterior Segment Eye Procedures T 2.9435 $204.34 0233 Level III Anterior Segment Eye Procedures T 16.8777 $1,171.65 0234 Level IV Anterior Segment Eye Procedures T 25.2649 $1,753.89 0235 Level I Posterior Segment Eye Procedures T 4.9132 $341.07 0237 Level II Posterior Segment Eye Procedures T 22.7865 $1,581.84 0238 Level I Repair and Plastic Eye Procedures T 3.3278 $231.02 0239 Level II Repair and Plastic Eye Procedures T 8.3090 $576.81 0240 Level III Repair and Plastic Eye Procedures T 20.3065 $1,409.68 0241 Level IV Repair and Plastic Eye Procedures T 27.0493 $1,877.76 0242 Level V Repair and Plastic Eye Procedures T 40.9376 $2,841.89 0243Strabismus/Muscle Procedures T 25.2851 $1,755.29 0244 Corneal and Amniotic Membrane Transplant T 38.4709 $2,670.65 0245 Level I Cataract Procedures without IOL Insert T 15.2776 $1,060.57 0246 Cataract Procedures with IOL Insert T 24.0158 $1,667.18 0247 Laser Eye Procedures T 5.5801 $387.37 0249 Level II Cataract Procedures without IOL Insert T 30.7811 $2,136.82 0250 Level I ENT Procedures T 1.0875 $75.49 0251 Level II ENT Procedures T 3.3531 $232.77 0252 Level III ENT Procedures T 8.0353 $557.81 0253 Level IV ENT Procedures T 16.9180 $1,174.45 0254 Level V ENT Procedures T 25.1379 $1,745.07 0255 Level II Anterior Segment Eye Procedures T 7.8512 $545.03 0256 Level VI ENT Procedures T 45.1286 $3,132.83 0259 Level VII ENT Procedures T 395.1320 $27,430.06 0260 Level I Plain FilmExcept Teeth X 0.6418 $44.55 0261 Level II Plain FilmExcept Teeth Including Bone Density Measurement X 1.0831 $75.19 0262 Plain Filmof Teeth X 0.4650 $32.28 0263 Level I Miscellaneous Radiology Procedures X 3.3928 $235.53 0265 Level I Diagnostic and Screening Ultrasound S 0.8995 $62.44 0266 Level II Diagnostic and Screening Ultrasound S 1.3711 $95.18 0267 Level III Diagnostic and Screening Ultrasound S 2.1881 $151.90 0269 Level II Echocardiogram Without Contrast S 5.5306 $383.93 0270 Level III Echocardiogram Without Contrast S 8.1675 $566.99 0272 Fluoroscopy X 1.2481 $86.64 0274 Myelography S 6.9677 $483.700275Arthrography S 3.9868 $276.76

0276 Level I Digestive Radiology S 1.2290 $85.32 0277 Level II Digestive Radiology S 2.0083 $139.42 0278 Diagnostic Urography S 2.5896 $179.77 0279 Level II Angiography and Venography S 29.6734 $2,059.93 0280 Level III Angiography and Venography S 49.6711 $3,448.17 0282 Miscellaneous Computed Axial Tomography S 1.5453 $107.27 0283Computed Tomography with Contrast S 4.2806 $297.16 0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast S 6.1872 $429.52 0288 Bone Density:Axial Skeleton S 1.0215 $70.91 0293 Level VI Anterior Segment Eye Procedures T 117.7956 $8,177.37 0299 Hyperthermia and Radiation Treatment Procedures S 5.6094 $389.40 0300 Level I Radiation Therapy S 1.3628 $94.61 0301 Level II Radiation Therapy S 2.3680 $164.39 0303Treatment Device Construction X 2.7910 $193.75 0304 Level I Therapeutic Radiation Treatment Preparation X 1.4946 $103.76 0305 Level II Therapeutic Radiation Treatment Preparation X 3.7009 $256.92 0307 Myocardial Positron Emission Tomography (PET) imagingS 13.2711 $921.28 0308 Non-Myocardial Positron Emission Tomography (PET) imaging

S 14.6171 $1,014.72 0310 Level III Therapeutic Radiation Treatment Preparation X 13.2460 $919.54 0312 Radioelement Applications S 4.7014 $326.37 0313 Brachy

therapy S 9.8659 $684.89 0315 Level II Implantation of Neurostimulator Generator S 284.8462 $19,774.02 0317 Level II Miscellaneous Radiology Procedures X 6.2675 $435.09 0318 Implantation of Cranial Neurostimulator Pulse Generator and Electrode S 337.4240 $23,423.97 0319 Level III Endovascular Revascularization of the Lower Extremity T 202.3898 $14,049.90 0320 Electroconvulsive Therapy S 5.9679 $414.29 0322 Brief Individual Psychotherapy S 1.0957 $76.06 0323 Extended Individual Psychotherapy S 1.5885 $110.27 0324 Family

Psychotherapy S 1.8739 $130.09 0325Group Psychotherapy S 0.7798 $54.13 0330 Dental Procedures S 9.5583 $663.54 0331 Combined Abdomen and Pelvis CT without Contrast S 5.8040 $402.91 0332 Computed Tomography without Contrast S 2.7424 $190.38 0333Computed Tomography without Contrast followed by Contrast S 4.7716 $331.24 0334 Combined Abdomen and Pelvis CT with Contrast S 8.2338 $571.59 0336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast S 4.8219 $334.74 0337 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast S 7.6393 $530.32 0340 Minor Ancillary Procedures X 0.6739 $46.78 0341 Skin Tests X 0.0776 $5.39 0342 Level I Pathology X 0.1639 $11.38 0343 Level III Pathology X 0.5225 $36.27 0344 Level IV Pathology X 0.8204 $56.95 0345 Level I Transfusion Laboratory Procedures X 0.2109 $14.64 0346 Level II Transfusion Laboratory Procedures X 0.3580 $24.85 0347 Level III Transfusion Laboratory Procedures X 0.6541 $45.41 0350Administration of flu and PPV vaccine S 0.3780 $26.24 0360 Level I Alimentary Tests X 1.7147 $119.03 0361 Level II Alimentary Tests X 4.1026 $284.80 0363 Level I Otorhinolaryngologic Function Tests X 0.9462 $65.69 0364 Level I Audiometry X 0.4896 $33.99 0365 Level II Audiometry X 1.2340 $85.660366 Level III Audiometry X 1.6976 $117.85

0367 Level I Pulmonary Test X 0.7369 $51.16 0368 Level II Pulmonary Tests X 0.8927 $61.97 0369 Level III Pulmonary Tests X 2.6420 $183.41 0370Allergy

Tests X 1.3506 $93.76 0373 Level I Neuropsychological Testing X 1.3767 $95.57 0375Ancillary

Outpatient Services When Patient Expires S 79.4058 $5,512.35 0377 Level II Cardiac Imaging S 9.7483 $676.73 0378 Level II Pulmonary Imaging S 4.5059 $312.80 0381 Single Allergy

Tests X 0.4731 $32.84 0382 Level II Neuropsychological Testing X 2.6658 $185.06 0383Cardiac Computed Tomographic Imaging S 3.7294 $258.89 0384 GI Procedures with Stents T 29.0233 $2,014.80 0385 Level I Prosthetic Urological Procedures S 103.8680 $7,210.52 0386 Level II Prosthetic Urological Procedures S 168.5335 $11,699.60 0387 Level II Hysteroscopy T 37.9124 $2,631.88 0388 Discography S 23.0551 $1,600.49 0389 Level I Non-imaging Nuclear Medicine S 1.5133 $105.05 0390 Level I Endocrine Imaging S 1.8660 $129.54 0391 Level II Endocrine Imaging S 3.1750 $220.41 0392 Level II Non-imaging Nuclear Medicine S 2.5360 $176.05 0393 Hematologic Processing & Studies S 6.3038 $437.61 0394 Hepatobiliary

Imaging S 4.1587 $288.70 0395GI Tract Imaging S 3.4576 $240.03 0396 Bone Imaging S 3.5140 $243.94 0397Vascular Imaging S 2.4220 $168.14 0398 Level I Cardiac Imaging S 4.2252 $293.31 0400 Hematopoietic Imaging S 3.7132 $257.77 0401 Level I Pulmonary Imaging S 2.8425 $197.33 0402 Level II Nervous System Imaging S 8.7081 $604.52 0403 Level I Nervous System Imaging S 3.3656 $233.64 0404 Renal and Genitourinary Studies S 4.5715 $317.35 0406 Level I Tumor/Infection Imaging S 4.0374 $280.28 0407 Level I Radionuclide Therapy S 3.2808 $227.75 0408 Level III Tumor/Infection Imaging S 13.7263 $952.88 0409 Red Blood Cell Tests X 0.1103 $7.66 0412 IMRT Treatment Delivery S 6.4422 $447.22 0413 Level II Radionuclide Therapy S 4.0894 $283.89 0414 Level II Tumor/Infection Imaging S 6.9811 $484.63 0415 Level II Endoscopy Lower Airway T 29.1250 $2,021.86 0419 Level II Upper GI Procedures T 12.5693 $872.56 0422 Level III Upper GI Procedures T 25.4890 $1,769.45 0423 Level II Percutaneous Abdominal and Biliary ProceduresT 57.1703 $3,968.76 0424 Level II Small Intestine Endoscopy T 15.8412 $1,099.70 0425 Level II Arthroplasty or Implantation with Prosthesis T 130.4476 $9,055.67 0426 Level II Strapping and Cast Application S 2.7059 $187.84 0427 Level II Tube or Catheter Changes or Repositioning T 16.2153 $1,125.67 0428 Level III Sigmoidoscopy and Anoscopy T 23.9719 $1,664.13 0429 Level V Cystourethroscopy and other Genitourinary Procedures T 45.8647 $3,183.93 0432 Health and Behavior Services S 0.4940 $34.29 0433 Level II Pathology X 0.2464 $17.11 0434 Cardiac Defect Repair T 166.2005 $11,537.640436 Level I Drug Administration S 0.3780 $26.24

0437 Level II Drug Administration S 0.5280 $36.65 0438 Level III Drug Administration S 1.0547 $73.22 0439 Level IV Drug Administration S 1.9117 $132.71 0440 Level V Drug Administration S 3.0395 $211.00 0442 Dosimetric Drug Administration S 22.9208 $1,591.16 0604 Level 1 Hospital Clinic Visits V 0.6941 $48.18 0605 Level 2 Hospital Clinic Visits V 1.0430 $72.41 0606 Level 3 Hospital Clinic Visits V 1.4647 $101.68 0607 Level 4 Hospital Clinic Visits V 1.9242 $133.58 0608 Level 5 Hospital Clinic Visits V 2.4718 $171.59 0609 Level 1 Type A Emergency Visits V 0.7290 $50.61 0613 Level 2 Type A Emergency Visits V 1.2424 $86.25 0614 Level 3 Type A Emergency Visits V 1.9769 $137.24 0615 Level 4 Type A Emergency Visits V 3.1815 $220.86 0616 Level 5 Type A Emergency Visits V 4.7283 $328.24 0617Critical Care S 6.8172 $473.25 0618Trauma Response with Critical Care S 11.6401 $808.06 0621 Level I Vascular Access Procedures T 11.1622 $774.88 0622 Level II Vascular Access Procedures T 25.1290 $1,744.46 0623 Level III Vascular Access Procedures T 30.2967 $2,103.20 0624 Phlebotomyand Minor Vascular Access Device Procedures X 0.6235 $43.28 0626 Level 1 Type B Emergency Visits V 0.5673 $39.38 0627 Level 2 Type B Emergency Visits V 0.8183 $56.81 0628 Level 3 Type B Emergency Visits V 1.3027 $90.43 0629 Level 4 Type B Emergency Visits V 1.9652 $136.42 0630 Level 5 Type B Emergency Visits V 3.7640 $261.30 0648 Level IV Breast Surgery T 61.6690 $4,281.06 0651 Complex Interstitial Radiation Source Application S 12.4760 $866.08 0652 Insertion of Intraperitoneal and Pleural Catheters T 30.6257 $2,126.04 0653Vascular Reconstruction/Fistula Repair with Device T 43.1404 $2,994.81 0654 Insertion/Replacement of a Permanent Dual Chamber Pacemaker T 100.4629 $6,974.13 0655 Insertion/Replacement/Conversion of a Permanent Dual Chamber Pacemaker or Pacing Electrode T 136.0608 $9,445.34 0656Transcatheter Placement of Intracoronary Drug-Eluting Stents

T 104.4584 $7,251.50 0659 Hyperbaric Oxygen S 1.4834 $102.98 0660 Level II Otorhinolaryngologic Function Tests X 1.8827 $130.70 0661 Level V Pathology X 2.3755 $164.91 0662 CT Angiography S 4.8432 $336.21 0664 Level I Proton BeamRadiation Therapy S 14.2952 $992.37 0665 Bone Density:AppendicularSkeleton S 0.4570 $31.72 0667 Level II Proton BeamRadiation Therapy S 18.7001 $1,298.16 0668 Level I Angiography and Venography S 9.4312 $654.71 0672 Level III Posterior Segment Eye Procedures T 41.3248 $2,868.77 0673 Level V Anterior Segment Eye Procedures T 41.7832 $2,900.59 0674 Prostate Cryoablation T 111.0864 $7,711.62 0676Thrombolysis and Other Device Revisions T 2.3410 $162.51 0678 External Counterpulsation T 1.3160 $91.36 0679 Level II Resuscitation and Cardioversion S 5.3123 $368.78 0680 Insertion of Patient Activated Event Recorders S 78.4050 $5,442.88 0683 Level II Photochemotherapy S 2.9704 $206.21 0685 Level III Needle Biopsy /Aspiration Except Bone Marrow T 9.7281 $675.32 0687 Revision/Removal of Neurostimulator Electrodes T 20.7466 $1,440.230688 Revision/Removal of Neurostimulator Pulse Generator Receiver T 31.3873 $2,178.91 0690 Level I Electronic Analysis of Devices S 0.5148 $35.74 0691 Level III Electronic Analysis of Devices S 2.4153 $167.67 0692 Level II Electronic Analysis of Devices S 1.6659 $115.65 0694 Mohs Surgery T 5.3689 $372.71 0697 Level I Echocardiogram Without Contrast S 3.1535 $218.92 0698 Level II Eye Tests & Treatments S 1.4030 $97.40 0699 Level IV Eye Tests & Treatments T 15.6140 $1,083.92 0701 Sr89 strontium K $641.83 0726 Dexrazoxane HCl injection K $274.42 0728 Filgrastim 300 mcg injection K $238.72 0731 Sargramostim injection K $23.62 0735Ampho b cholesteryl sulfate K $13.74 0736Amphotericin b liposome inj K $14.77 0738 Rasburicase K $183.08 0747Chlorothiazide sodiuminj K $272.64 0751 Mechlorethamine hcl inj K $154.88 0752 Dactinomycin injection K $529.42 0759 Naltrexone, depot form K $2.77 0800 Leuprolide acetate K $547.54 0802 Etoposide oral K $34.34 0807Aldesleukin injection K $915.45 0809 Bcg live intravesical vac K $114.38 0810 Goserelin acetate implant K $195.16 0812 Carmustine injection K $172.56 0814Asparaginase injection K $62.07 0820 Daunorubicin injection K $13.16 0821 Daunorubicin citrate inj K $56.58 0823 Docetaxel injection K $20.84 0825 Nelarabine injection K $110.19 0827 Floxuridine injection K $36.60 0828 Gemcitabine hcl injection K $111.40 0831 Ifosfomide injection K $31.21 0832 Idarubicin hcl injection K $46.43 0835Cosyntropin injection NOS K $99.76 0836 Interferon alfa-2b inj K $16.19 0838 Interferon gamma 1-b inj K $549.62 0840 Inj melphalan hydrochl K $1,272.01 0843 Pegaspargase injection K $2,675.40 0844 Pentostatin injection K $1,068.16 0849 Rituximab injection K $599.16 0850Streptozocin injection K $264.81 0851 Thiotepa injection K $106.54 0856 Porfimer sodium injection K $3,017.82 0858 Inj cladribine K $23.59 0861 Leuprolide acetate injeciton K $4.88 0864 Mitoxantrone hydrochl K $33.95 0865 Interferon alfa-n3 inj K $20.87 0868Oral aprepitant K $5.90 0873 Hyalgan/supartz inj per dose K $88.80 0874Synvisc or synvisc-one K $11.81 0875 Euflexxa inj per dose K $147.160877Orthovisc inj per dose K $167.00

0884 Rho d immune globulin inj K $82.16 0887Azathioprine parenteral K $104.77 0890 Lymphocy

te immune globulin K $542.36 0900Alglucerase injection K $41.19 0901 Alpha 1 proteinase inhibitor K $3.79 0902 Injection,onabotulinumtoxinA K $5.38 0903Cy

tomegalovirus imm IV /vial K $922.07 0910 Interferon beta-1b / .25 MG K $197.14 0913 Ganciclovir long act implant K $16,640.00 0917Adenosine injection K $89.99 0925 Factor viii K $0.87 0927 Factor viii recombinant K $1.09 0928 Factor ix complex K $0.85 0929Anti-inhibitor K $1.57 0931 Factor IX non-recombinant K $0.88 0932 Factor IX recombinant K $1.13 0933 Gamma globulin > 10 CC inj K $179.06 0934 Capecitabine, oral K $22.48 0943Octagam injection K $55.80 0944 Gammagard liquid injection K $37.67 0945 Rhophylac injection K $5.09 0946 Hepagam b im injection K $57.07 0947 Flebogamma injection K $35.04 0948 Gamunex injection K $36.91 0949 Frozen plasma, pooled, sd R 1.0221 $70.95 0950Whole blood for transfusion R 2.7926 $193.86 0951 Reclast injection K $218.47 0952 Cryoprecipitate each unit R 1.0975 $76.19 0954 RBC leukocy

tes reduced R 2.8046 $194.70 0955 Plasma, frz between 8-24hour R 1.0092 $70.06 0956 Plasma protein fract,5%,50ml R 0.2513 $17.45 0957 Platelets, each unit R 1.2522 $86.93 0958 Plaelet rich plasma unit R 1.9703 $136.78 0959 Red blood cells unit R 2.1382 $148.43 0960Washed red blood cells unit R 4.0969 $284.41 0961 Albumin (human),5%, 50ml K $20.37 0963Albumin (human), 5%, 250 ml K $67.07 0964Albumin (human), 25%, 20 ml K $29.16 0965Albumin (human), 25%, 50ml K $70.39 0966 Plasmaprotein fract,5%,250ml R 1.2214 $84.79 0967 Blood split unit R 2.2455 $155.88 0968 Platelets leukoreduced irrad R 2.0418 $141.74 0969 RBC leukoreduced irradiated R 3.7077 $257.39 1009Cryoprecipitatereducedplasma R 1.1839 $82.19 1010 Blood, l/r, cmv-neg R 2.7475 $190.73 1011 Platelets, hla-m, l/r, unit R 11.4189 $792.70 1013 Platelets leukocy tes reduced R 1.7459 $121.20 1015 Injection glatiramer acetate K $95.57 1016 Blood, l/r, froz/degly /wash R 1.8650 $129.47 1017 Plt, aph/pher, l/r, cmv-neg R 5.7123 $396.55 1018 Blood, l/r, irradiated R 2.1603 $149.971019 Plate pheres leukoredu irrad R 9.9046 $687.58

1020 Plt, pher, l/r cmv-neg, irr R 8.6696 $601.84 1021 RBC, frz/deg/wsh, l/r, irrad R 6.2606 $434.61 1022 RBC, l/r, cmv-neg, irrad R 4.0635 $282.09 1023 Pralidoxime chloride inj K $88.57 1052 Injection, voriconazole K $6.02 1064 I131 iodide cap, rx K $17.58 1083Adalimumab injection K $394.16 1084 Denileukin diftitox inj K $1,559.54 1086Temozolomide K $9.31 1138 Hepagam b intravenous, inj K $57.07 1139 Protein c concentrate K $12.50 1142 Supprelin LA implant K $15,184.53 1150 I131 iodide sol, rx K $13.26 1166 Cy

tarabine liposome inj K $479.02 1167 Inj, epirubicin hcl K $1.87 1168 Inj, temsirolimus K $49.87 1178 Busulfan injection K $16.29 1203Verteporfin injection K $9.55 1207Octreotide injection, depot K $113.48 1213Antihemophilic viii/vwf comp K $0.90 1214 Inj IVIG privigen 500 mg K $34.45 1221 Dimethyl sulfoxide 50% K $82.68 1222 Pentastarch 10% solution K $158.76 1226 Inj streptokinase /250000 IU K $47.57 1232 Mitomycin 5 MG inj K $20.36 1235Valrubicin injection K $946.64 1236 Levoleucovorin injection K $1.78 1237 Inj iron dextran K $11.59 1238Topotecan oral K $76.40 1239 Rotavirus vacc 2 dose oral K $100.56 1240Apligraf skin sub K $34.06 1241 Oasis wound matrix skin sub K $4.68 1243 Integra BMWD skin sub K $15.45 1244 Integra DRT skin sub K $10.95 1245 Dermagraft skin sub K $39.39 1246 Graftjacket skin sub K $92.79 1247 Integra matrix skin sub K $20.95 1248 Primatrix skin sub K $31.67 1249Cymetra allograft K $334.07 1250 Graftjacket express allograf K $334.07 1251 Integra flowable wound matri K $972.75 1252 Gammagraft skin sub K $7.17 1253Triamcinolone A inj PRS-free K $3.17 1263Antithrombin iii injection K $2.48 1268Xyntha inj K $1.05 1270Allodermskin sub K $31.11 1272Acetylcysteine injection K $2.67 1274 Edetate calcium disodium inj K $192.07 1275Vivaglobin, inj K $7.11 1279 Factor VIII (porcine) K $1.17 1280 Corticotropin injection K $2,395.221281 Bevacizumab injection K $1.47

1287Alloskin skin sub K $6.07 1289AbobotulinumtoxinA K $7.41 1290 Human fibrinogen conc inj K $71.52 1291 Rilonacept injection K $23.63 1295Sm153 lexidronam K $7,555.71 1296 Degarelix injection K $2.79 1297 Ferumoxy

tol, non-esrd K $0.69 1304 Perphenazine injeciton K $30.91 1306 Urea injection K $82.18 1307Oral busulfan K $3.59 1308 Mecasermin injection K $20.18 1311 Canakinumab injection K $87.45 1312 Hizentra injection K $7.15 1327 Imiglucerase injection K $41.19 1331 Olanzapine long-acting inj K $2.70 1332Antithrombin recombinant K $101.40 1338 Methyl aminolevulinate, top K $68.27 1339Oral fludarabine phosphate G $79.44 1340 Collagenase, clost hist inj G $37.51 1341 Amobarbital 125 MG inj K $23.38 1342 Matristem micromatrix K $3.13 1343 Ganciclovir sodium injection K $62.51 1344 Gonadorelin hydroch/ 100 mcg K $94.82 1345Theraskin K $20.32 1349Anidulafungin injection K $1.29 1350Topotecan injection K $19.30 1351 Matristem wound matrix K $6.04 1355 Itraconazole injection K $359.59 1356 Inj desmopressin acetate K $3.93 1357 Inj protirelin per 250 mcg K $27.03 1358 Phentolaine mesylate inj K $56.35 1359 Foscarnet sodium injection K $13.06 1491 New Technology - Level IA ($0-$10) S $5.00 1492 New Technology - Level IB ($10-$20) S $15.00 1493 New Technology - Level IC ($20-$30) S $25.00 1494 New Technology - Level ID ($30-$40) S $35.00 1495 New Technology - Level IE ($40-$50) S $45.00 1496 New Technology - Level IA ($0-$10) T $5.00 1497 New Technology - Level IB($10-$20) T $15.00 1498 New Technology - Level IC ($20-$30) T $25.00 1499 New Technology - Level ID($30-$40) T $35.00 1500 New Technology - Level IE ($40-$50) T $45.00 1502 New Technology - Level II ($50 - $100) S $75.00 1503 New Technology - Level III ($100 - $200) S $150.00 1504 New Technology - Level IV ($200 - $300) S $250.00 1505 New Technology - Level V ($300 - $400) S $350.00 1506 New Technology - Level VI ($400 - $500) S $450.00 1507 New Technology - Level VII ($500 - $600) S $550.00 1508 New Technology - Level VIII ($600 - $700) S $650.00 1509 New Technology - Level IX ($700 - $800) S $750.00 1510 New Technology - Level X ($800 - $900) S $850.001511 New Technology - Level XI ($900 - $1000) S $950.00 1512 New Technology - Level XII ($1000 - $1100) S $1,050.00 1513 New Technology - Level XIII ($1100 - $1200) S $1,150.00 1514 New Technology - Level XIV ($1200- $1300) S $1,250.00 1515 New Technology - Level XV ($1300 - $1400) S $1,350.00 1516 New Technology - Level XVI ($1400 - $1500) S $1,450.00 1517 New Technology - Level XVII ($1500-$1600) S $1,550.00 1518 New Technology - Level XVIII ($1600-$1700) S $1,650.00 1519 New Technology - Level IXX ($1700-$1800) S $1,750.00 1520 New Technology - Level XX ($1800-$1900) S $1,850.00 1521 New Technology - Level XXI ($1900-$2000) S $1,950.00 1522 New Technology - Level XXII ($2000-$2500) S $2,250.00 1523 New Technology - Level XXIII ($2500-$3000) S $2,750.00 1524 New Technology - Level XXIV ($3000-$3500) S $3,250.00 1525 New Technology - Level XXV ($3500-$4000) S $3,750.00 1526 New Technology - Level XXVI ($4000-$4500) S $4,250.00 1527 New Technology - Level XXVII ($4500-$5000) S $4,750.00 1528 New Technology - Level XXVIII ($5000-$5500) S $5,250.00 1529 New Technology - Level XXIX ($5500-$6000) S $5,750.00 1530 New Technology - Level XXX ($6000-$6500) S $6,250.00 1531 New Technology - Level XXXI ($6500-$7000) S $6,750.00 1532 New Technology - Level XXXII ($7000-$7500) S $7,250.00 1533 New Technology - Level XXXIII ($7500-$8000) S $7,750.00 1534 New Technology - Level XXXIV ($8000-$8500) S $8,250.00 1535 New Technology - Level XXXV ($8500-$9000) S $8,750.00 1536 New Technology - Level XXXVI ($9000-$9500) S $9,250.00 1537 New Technology - Level XXXVII ($9500-$10000) S $9,750.00 1539 New Technology - Level II ($50 - $100) T $75.00 1540 New Technology - Level III ($100 - $200) T $150.00 1541 New Technology - Level IV ($200 - $300) T $250.00 1542 New Technology - Level V ($300 - $400) T $350.00 1543 New Technology - Level VI ($400 - $500) T $450.00 1544 New Technology - Level VII ($500 - $600) T $550.00 1545 New Technology - Level VIII ($600 - $700) T $650.00 1546 New Technology - Level IX ($700 - $800) T $750.00 1547 New Technology - Level X ($800 - $900) T $850.00 1548 New Technology - Level XI ($900 - $1000) T $950.00 1549 New Technology - Level XII ($1000 - $1100) T $1,050.00 1550 New Technology - Level XIII ($1100 - $1200) T $1,150.00 1551 New Technology - Level XIV ($1200- $1300) T $1,250.00 1552 New Technology - Level XV ($1300 - $1400) T $1,350.00 1553 New Technology - Level XVI ($1400 - $1500) T $1,450.00 1554 New Technology - Level XVII ($1500-$1600) T $1,550.00 1555 New Technology - Level XVIII ($1600-$1700) T $1,650.00 1556 New Technology - Level XIX ($1700-$1800) T $1,750.00 1557 New Technology - Level XX ($1800-$1900) T $1,850.00 1558 New Technology - Level XXI ($1900-$2000) T $1,950.00 1559 New Technology - Level XXII ($2000-$2500) T $2,250.00 1560 New Technology - Level XXIII ($2500-$3000) T $2,750.00 1561 New Technology - Level XXIV ($3000-$3500) T $3,250.00 1562 New Technology - Level XXV ($3500-$4000) T $3,750.00 1563 New Technology - Level XXVI ($4000-$4500) T $4,250.001564 New Technology - Level XXVII ($4500-$5000) T $4,750.00 1565 New Technology - Level XXVIII ($5000-$5500) T $5,250.00 1566 New Technology - Level XXIX ($5500-$6000) T $5,750.00 1567 New Technology - Level XXX ($6000-$6500) T $6,250.00 1568 New Technology - Level XXXI ($6500-$7000) T $6,750.00 1569 New Technology - Level XXXII ($7000-$7500) T $7,250.00 1570 New Technology - Level XXXIII ($7500-$8000) T $7,750.00 1571 New Technology - Level XXXIV ($8000-$8500) T $8,250.00 1572 New Technology - Level XXXV ($8500-$9000) T $8,750.00 1573 New Technology - Level XXXVI ($9000-$9500) T $9,250.00 1574 New Technology - Level XXXVII ($9500-$10000) T $9,750.00 1605Abciximab injection K $515.32 1607 Eptifibatide injection K $20.31 1608 Etanercept injection K $203.01 1609 Rho(D) immune globulin h, sd K $18.83 1612 Daclizumab, parenteral K $516.41 1613Trastuzumab injection K $69.06 1630 Hep b ig, im K $112.16 1631 Baclofen intrathecal trial K $72.18 1633Alefacept K $35.86 1643Y90 ibritumomab, rx K $32,078.39 1645 I131 tositumomab, rx K $29,460.02 1670Tetanus immune globulin inj K $222.97 1675 P32 Na phosphate K $162.87 1676 P32 chromic phosphate K $154.15 1683 Basiliximab K $2,027.27 1684 Corticorelin ovine triflutal K $5.06 1685 Darbepoetin alfa, non-esrd K $2.98 1686 Epoetin alfa, non-esrd K $9.57 1687 Digoxin immune fab (ovine) K $583.90 1688 Ethanolamine oleate K $147.14 1689 Fomepizole K $6.76 1690 Hemin K $8.33 1693 Lepirudin K $299.56 1694Ziconotide injection K $6.48 1695 Nesiritide injection K $43.93 1696 Palifermin injection K $11.15 1697 Pegaptanib sodiuminjection K $1,002.20 1700 Inj secretin synthetic human K $26.97 1701 Treprostinil injection K $60.08 1704 Humate-P, inj K $0.87 1705 Factor viia K $1.50 1709Azacitidine injection K $5.16 1710 Clofarabine injection K $114.37 1711 Vantas implant K $3,223.57 1712 Paclitaxel protein bound K $9.21 1716 Brachy

tx, non-str, Gold-198 U 1.0120 $70.25 1717 Brachy

tx, non-str, HDR Ir-192 U 3.1681 $219.93 1719 Brachy

tx, NS, Non-HDRIr-192 U 0.4486 $31.14 1738Oxaliplatin K $8.36 1739 Pegademase bovine, 25 iu K $242.67 1741 Urofollitropin, 75 iu K $63.601749 Endo, colon, retro imaging H

2210 Methyldopate hcl injection K $39.24 2616 Brachy

tx, non-str,Yttrium-90 U 232.3017 $16,126.38 2632 Iodine I-125 sodium iodide U 0.2868 $19.91 2634 Brachy

tx, non-str, HA, I-125 U 0.7908 $54.90 2635 Brachy

tx, non-str, HA, P-103 U 0.3438 $23.87 2636 Brachy

linear, non-str,P-103 U 0.5112 $35.49 2638 Brachy

tx, stranded, I-125 U 0.6225 $43.21 2639 Brachy

tx, non-stranded,I-125 U 0.4992 $34.65 2640 Brachy

tx, stranded, P-103 U 1.0610 $73.65 2641 Brachy

tx, non-stranded,P-103 U 0.9263 $64.30 2642 Brachy

tx, stranded, C-131 U 1.6922 $117.47 2643 Brachy

tx, non-stranded,C-131 U 1.0735 $74.52 2698 Brachy

tx, stranded, NOS U 0.6225 $43.21 2699 Brachy

tx, non-stranded, NOS U 0.3438 $23.87 2731 Immune globulin, powder K $30.62 2770Quinupristin/dalfopristin K $157.23 3041 Bivalirudin K $2.54 3043 Gamma globulin 1 CC inj K $17.91 3050Sermorelin acetate injection K $1.76 7000Amifostine K $314.05 7011 Oprelvekin injection K $240.88 7034Somatropin injection K $56.09 7035Teniposide K $316.52 7036 Urokinase 250,000 IU inj K $449.09 7038 Monoclonal antibodies K $1,112.14 7041 Tirofiban HCl K $8.83 7042 Capecitabine, oral K $6.81 7043 Infliximab injection K $58.90 7046 Doxorubicin hcl liposome inj K $504.27 7048Alteplase recombinant K $39.22 7049 Filgrastim 480 mcg injection K $376.20 7051 Leuprolide acetate implant K $4,728.88 7308Aminolevulinic acid hcl top K $138.70 8000 Cardiac Electrophysiologic Evaluation and Ablation Composite T 161.2626 $11,194.85 8001 LDR Prostate Brachy therapy Composite T 46.7758 $3,247.18 8002 Level I Extended Assessment & Management CompositeV 5.4881 $380.98 8003 Level II Extended Assessment & Management CompositeV 10.2164 $709.22 8004 Ultrasound Composite S 2.7443 $190.51 8005CT and CTA without Contrast Composite S 6.1891 $429.65 8006 CT and CTA with Contrast Composite S 10.3444 $718.11 8007 MRI and MRA without Contrast Composite S 9.9875 $693.33 8008 MRI and MRA with Contrast Composite S 14.3459 $995.89 8009Cardiac Resynchronization Therapy with Defibrillator Composite T 379.7887 $26,364.93 9001 Linezolid injection K $33.99 9002Tenecteplase injection K $51.95 9004 Gemtuzumab ozogamicin inj K $2,637.02 9005 Reteplase injection K $1,332.35 9006Tacrolimus injection K $136.85 9012Arsenic trioxide injection K $40.13 9018 Inj, rimabotulinumtoxinB K $10.33 9019Caspofungin acetate K $12.139022 IM inj interferon beta 1-a K $220.75

9023 Rho d immune globulin K $24.81 9024Amphotericin b lipid complex K $8.76 9032 Baclofen 10 MG injection K $200.54 9033Cidofovir injection K $740.09 9038 Inj estrogen conjugate K $94.03 9042 Glucagon hydrochloride K $95.59 9044 Ibutilide fumarate injection K $129.32 9104Antithymocy

te globuln rabbit K $387.17 9108Thyrotropin injection K $1,034.03 9110Alemtuzumab injection K $577.60 9115Zoledronic acid K $219.00 9119 Injection, pegfilgrastim 6mg K $2,527.87 9120 Injection, Fulvestrant K $81.81 9121 Injection, argatroban K $18.71 9122Triptorelin pamoate K $193.59 9124 Daptomycin injection K $0.45 9125 Risperidone, long acting K $4.93 9126 Natalizumab injection K $9.88 9133 Rabies ig, im/sc K $159.86 9134 Rabies ig, heat treated K $154.18 9135Varicella-zoster ig, im K $129.48 9137 Bcg vaccine, percut K $112.46 9139 Rabies vaccine, im K $190.82 9140 Rabies vaccine, id K $107.83 9143 Meningococcal vaccine, sc K $104.49 9144 Encephalitis vaccine, sc K $100.16 9145 Meningococcal vaccine, im K $83.39 9207 Bortezomib injection K $39.60 9208Agalsidase beta injection K $133.65 9209 Laronidase injection K $25.08 9210 Palonosetron hcl K $18.51 9213 Pemetrexed injection K $51.37 9214 Bevacizumab injection K $58.72 9215Cetuximab injection K $49.52 9217 Leuprolide acetate suspnsion K $210.96 9224 Galsulfase injection K $338.26 9225 Fluocinolone acetonide implt K $18,980.00 9227 Micafungin sodium injection K $1.02 9228Tigecycline injection K $1.22 9229 Ibandronate sodium injection K $144.36 9230Abatacept injection K $20.26 9231 Decitabine injection K $30.71 9232 Idursulfase injection K $446.45 9233 Ranibizumab injection K $398.10 9234Alglucosidase alfa injection K $155.84 9235 Panitumumab injection K $85.62 9236 Eculizumab injection K $183.71 9237 Inj, lanreotide acetate K $29.92 9240 Injection, ixabepilone K $62.53 9242 Injection, fosaprepitant K $1.71 9243 Bendamustine injection K $18.159244 Regadenoson injection K $51.36

9245 Romiplostim injection K $44.84 9248 Inj, clevidipine butyrate K $6.03 9249Certolizumab pegol inj K $3.99 9250Artiss fibrin sealant K $121.80 9251 C1 esterase inhibitor inj K $43.78 9252 Plerixafor injection K $278.36 9253Temozolomide injection K $4.86 9254 Injection, lacosamide K $0.15 9255 Paliperidone palmitate inj K $6.45 9256 Dexamethasone intra implant K $194.17 9258Telavancin injection G $1.96 9259 Pralatrexate injection G $165.63 9260 Ofatumumab injection G $45.41 9261 Ustekinumab injection G $112.30 9263 Ecallantide injection G $275.28 9264Tocilizumab injection G $3.47 9265 Romidepsin injection G $219.30 9267Wilate injection G $70.14 9268Capsaicin 8% patch G $25.55 9269C-1 esterase, berinert G $27.53 9270 Gammaplex IVIG G $37.29 9271 Velaglucerase alfa G $349.88 9272 Inj, denosumab G $14.52 9273Sipuleucel-T, per infusion G $32,860.00 9274 Crotalidae Poly Immune Fab G $2,111.36 9275 Hexaminolevulinate HCl G $636.00 9276 Cabazitaxel injection G $135.05 9277 Lumizyme, 1 mg G $14.83 9278 Incobotulinumtoxin A G $5.57 9279 Injection, ibuprofen G $1.39 9280 Injection, eribulin mesylate G $901.00 9281 Injection, pegloticase G $304.75 9282 Injection, ceftaroline fosamil G $0.72 9300 Omalizumab injection K $20.64 9358SurgiMend, fetal K $11.09 9360SurgiMend, neonatal K $11.59 9363 Integra Meshed Bil Wound Mat K $19.17 9367 Endoform Dermal Template G $4.35 9500 Platelets, irradiated R 2.1768 $151.11 9501 Platelet pheres leukoreduced R 7.5524 $524.29 9502 Platelet pheresis irradiated R 7.5964 $527.34 9503 Fr frz plasma donor retested R 1.2624 $87.64 9504 RBC deglycerolized R 3.4728 $241.08 9505 RBC irradiated R 3.3729 $234.15 9506 Granulocy

tes, pheresis unit R 22.1451 $1,537.31 9507 Platelets, pheresis R 6.0636 $420.94 9508 Plasma 1 donor frz w/in 8 hr R 1.0927 $75.86**National**

**Unadjusted Copayment**  **Minimum**

**Unadjusted Copayment**  . $6.98 . $24.25 . $54.26 . $63.81 . $113.04 . $20.11 . $187.13 . $285.18 . $5.62 . $13.59 . $20.74 . $39.22 . $306.33 . $67.71 . $119.63 . $238.68 $350.05 $325.12 . $358.74 $581.52 $469.86 $747.07 $626.13 . $4.09 . $36.66 . $3.78 $225.55 $213.25 . $2,911.42 . $871.77 . $408.52 $804.74 $672.75 $268.44 $215.44 . $573.37 . $833.51 . $307.78 . $449.99 . $655.11 . $1,215.79 $253.49 $241.72 . $402.89 $351.47 $307.87 . $794.31 $469.58 $451.87 . $15.80 . $4.49 . $1,207.61 $371.33 $364.29 . $687.07 . $931.10 . $172.88. $489.36 . $650.16 $591.64 $484.57 . $77.16 . $14.61 . $27.04 $67.83 $62.65 . $296.69 $438.93 $419.61 $189.71 $144.57 $7.74 $5.87 . $19.45 . $41.96 $838.04 $544.80 . $1,456.24 . $904.02 . $133.85 . $733.83 . $1,857.16 $652.56 $572.39 $1,620.86 $1,540.39 $1,570.21 $1,297.56

. $606.55 . $373.73 . $427.31 $44.32 $31.62 $13.49 $13.40 $36.83 $21.28 $23.63 $13.16 . $5.41 $40.87 $35.20 $100.24 $59.16 . $7.37 . $232.82 . $1,109.40 . $322.70 . $674.44 . $4,572.32 . $5,272.99 . $46.75 $189.47 $162.96 . $452.64 . $353.87 . $711.31 . $512.03 . $87.72 . $16.25 . $1,473.50 $166.16 $112.75 . $22.31 $659.53 $542.68 $1,001.89 $662.50$1,236.99 $986.39

$23.56 $16.86 . $45.61 . $72.16 . $239.84 . $302.73 . $69.25 . $259.53 . $90.85 $136.33 $116.33 $152.78 $141.13 $186.06 $129.38 . $87.53 . $153.03 . $84.77 . $339.43 . $457.80 . $338.79 . $434.27 $375.24 $369.98 $464.85 $457.82 . $222.47 . $44.40 . $31.32 . $0.00 . $0.00 . $102.18 . $245.39 . $364.72 . $513.16 . $29.12 . $280.41 . $288.77 . $445.74 $997.74 $713.69 . $82.56 . $18.88 . $21.94 $1,962.55 $1,492.69

. $31.34 . $36.66 $598.48 $477.34 . $329.38 . $197.82 . $22.36 . $50.15 $424.28 $321.93 $1.85 $1.77 . $97.65 . $288.47 . $498.88 $981.50 $632.86. $179.20

$40.13 $38.45 . $54.67 . $104.80 . $709.72 $268.73 $158.13 $53.48 $33.27 . $8.82 . $36.42 . $16.59 . $264.67 . $519.36 . $590.34 . $2,638.68 . $1,586.43 . $9.62 . $32.06 $42.27 $40.87 . $234.33 $511.31 $350.78 . $68.22 . $316.37 . $46.21 . $115.37 $296.20 $281.94 $383.45 $375.56 $597.36 $568.38 $415.27 $351.06 $800.09 $534.13 . $212.12 $488.94 $333.44 $104.31 $77.48 $516.99 $427.37 $24.28 $15.10 . $46.56 . $111.57 $277.61 $234.89 . $349.02 $124.97 $109.01 . $626.57 $7,545.06 $5,486.02

. $8.91 . $15.04 . $6.46 . $47.11 $22.26 $12.49 $36.80 $19.04 $59.41 $30.38 . $76.79 $133.61 $113.40 $30.47 $17.33 . $96.74$68.90 $55.36

$33.87 $17.07 $52.93 $27.89 $58.44 $35.96 . $411.99 . $689.64 $35.74 $21.46 $95.77 $59.44 $144.34 $85.91 . $0.00 . $1,635.48 . $77.88 . $18.93 . $32.88 $64.95 $38.75 $34.39 $20.76 $86.44 $51.39 . $184.26 . $202.95 $322.74 $183.91 . $65.28 $258.98 $136.98 . $3,954.81 . $87.02 $9,121.76 $4,684.80 $5,559.48 $2,809.98

. $82.86 . $15.22 . $22.06 . $26.02 $11.54 $10.83 . $132.71 $155.78 $80.59 $73.61 $38.08 $115.09 $66.25 $184.21 $114.32 $131.90 $66.95 $196.43 $106.07 . $9.36 $2.02 $1.08 . $2.28 $10.78 $7.26 $15.56 $11.39 . $2.93 . $4.97 . $9.09 . $0.00 $33.57 $23.81 $83.23 $56.96 $17.10 $13.14 $7.06 $6.80 $18.14 $17.14$23.61 $23.57

$13.76 $10.24 $20.93 $12.40 $37.27 $36.69 . $18.76 . $19.12 . $1,102.47 . $135.35 $120.71 $62.56 . $6.57 . $37.02 . $51.78 . $402.96 . $1,442.11 . $2,339.92 $650.74 $526.38 . $320.10 $26.88 $21.01 $46.52 $25.91 $65.46 $44.09 $42.39 $35.21 . $87.53 $90.78 $57.74 $87.01 $48.01 $93.91 $48.79 $38.85 $33.63 $93.33 $58.67 $91.24 $51.56 $71.16 $39.47 . $120.91 $70.43 $46.73 $81.14 $63.47 $85.03 $56.06 $78.13 $45.55 . $190.58 $2.16 $1.54 . $89.45 . $56.78 . $96.93 $459.92 $404.38 $204.51 $174.52 . $353.89 . $793.76 $239.49 $219.94 . $1,811.14 . $37.57 . $225.14 . $332.83 . $636.79 . $6.86 $5.17 $3.43 . $2,307.53. $5.25 . $7.33 . $14.65 . $26.55 . $42.20 . $318.24 . $9.64 . $14.49 . $20.34 . $26.72 . $34.32 $12.12 $10.13 $20.73 $17.25 $33.86 $27.45 $48.11 $44.18 $72.57 $65.65 $104.95 $94.65 . $161.62 . $154.98 . $348.90 . $420.64 $12.56 $8.66 . $7.88 . $11.37 . $18.09 . $27.29 . $52.26 . $856.22 . $173.22 . $425.21 . $598.97 . $1,394.83 . $1,889.07 . $1,450.30 . $20.60 $27.10 $26.14 . $32.99 $113.59 $67.25 . $198.48 . $0.00 . $259.64 . $130.95 . $573.76 $632.65 $580.12 . $1,542.33 . $32.51 . $18.28 $94.48 $73.76 . $1,088.58 . $41.25 . $135.07 $382.52 $288.05$768.94 $435.79

$8.67 $7.15 . $33.54 . $23.13 $91.69 $74.55 . $43.79 . $19.48 . $216.79 . $128.37 . $54.89 . $47.75 . $4.73 . $2.75 . $2.96 . $36.62 . $54.53 . $30.98 . $105.89 . $0.56 . $109.51 . $6.87 . $183.09 . $22.88 . $39.04 . $34.52 . $12.42 . $2.64 . $11.32 . $4.17 . $22.04 . $7.32 . $22.28 . $6.25 . $9.29 . $19.96 . $3.24 . $109.93 . $254.41 . $535.08 . $213.64 . $119.84 . $52.97 . $21.31 . $603.57 . $4.72 . $0.98 . $6.79 . $4.18 . $1.18 . $17.76 . $2.37 . $29.44. $33.40 . $16.44 . $20.96 . $108.48 . $8.24 . $0.76 . $1.08 . $184.42 . $39.43 . $3,328.00 . $18.00 . $0.18 . $0.22 . $0.17 . $0.32 . $0.18 . $0.23 . $35.82 . $4.50 . $11.16 . $7.54 . $1.02 . $11.42 . $7.01 . $7.39 . $14.19 . $38.78 . $43.70 . $15.24 . $38.94 . $14.02 . $3.49 . $17.39 . $27.36 . $29.69 . $56.89 . $4.08 . $13.42 . $5.84 . $14.08 . $16.96 . $31.18 . $28.35 . $51.48 . $16.44 . $38.15 . $158.54 . $24.24 . $19.12 . $25.90 . $79.31 . $30.00. $137.52 . $120.37 . $86.93 . $56.42 . $17.72 . $1.21 . $3.52 . $78.84 . $311.91 . $1.87 . $11.42 . $2.50 . $3,036.91 . $2.66 . $95.81 . $0.38 . $9.98 . $3.26 . $1.91 . $22.70 . $0.18 . $6.89 . $16.54 . $31.76 . $9.52 . $4.08 . $189.33 . $0.36 . $2.32 . $15.28 . $20.12 . $6.82 . $0.94 . $3.09 . $2.19 . $7.88 . $18.56 . $4.19 . $6.34 . $66.82 . $66.82 . $194.55 . $1.44 . $0.64 . $0.50 . $0.21 . $6.23 . $0.54 . $38.42 . $1.43 . $0.24 . $479.05. $0.30 . $1.22 . $1.49 . $14.31 . $4.73 . $1,511.15 . $0.56 . $0.14 . $6.19 . $16.44 . $0.72 . $4.04 . $17.49 . $1.43 . $8.24 . $0.54 . $20.28 . $13.66 . $15.89 . $7.51 . $4.68 . $0.63 . $12.51 . $18.97 . $4.07 . $0.26 . $3.86 . $1.21 . $71.92 . $0.79 . $5.41 . $11.27 . $2.62 . $1.00 . $3.00 . $5.00 . $7.00 . $9.00 . $1.00 . $3.00 . $5.00 . $7.00 . $9.00 . $15.00 . $30.00 . $50.00 . $70.00 . $90.00 . $110.00 . $130.00 . $150.00 . $170.00. $190.00 . $210.00 . $230.00 . $250.00 . $270.00 . $290.00 . $310.00 . $330.00 . $350.00 . $370.00 . $390.00 . $450.00 . $550.00 . $650.00 . $750.00 . $850.00 . $950.00 . $1,050.00 . $1,150.00 . $1,250.00 . $1,350.00 . $1,450.00 . $1,550.00 . $1,650.00 . $1,750.00 . $1,850.00 . $1,950.00 . $15.00 . $30.00 . $50.00 . $70.00 . $90.00 . $110.00 . $130.00 . $150.00 . $170.00 . $190.00 . $210.00 . $230.00 . $250.00 . $270.00 . $290.00 . $310.00 . $330.00 . $350.00 . $370.00 . $390.00 . $450.00 . $550.00 . $650.00 . $750.00 . $850.00. $950.00 . $1,050.00 . $1,150.00 . $1,250.00 . $1,350.00 . $1,450.00 . $1,550.00 . $1,650.00 . $1,750.00 . $1,850.00 . $1,950.00 . $103.07 . $4.07 . $40.61 . $3.77 . $103.29 . $13.82 . $22.44 . $14.44 . $7.18 . $6,415.68 . $5,892.01 . $44.60 . $32.58 . $30.83 . $405.46 . $1.02 . $0.60 . $1.92 . $116.78 . $29.43 . $1.36 . $1.67 . $59.92 . $1.30 . $8.79 . $2.23 . $200.44 . $5.40 . $12.02 . $0.18 . $0.30 . $1.04 . $22.88 . $644.72 . $1.85 . $14.05 . $43.99 . $6.23 . $1.68 . $48.54 . $12.72.. . $7.85 . $3,225.28 . $3.99 . $10.98 . $4.78 . $7.10 . $8.65 . $6.93 . $14.73 . $12.86 . $23.50 . $14.91 . $8.65 . $4.78 . $6.13 . $31.45 . $0.51 . $3.59 . $0.36 . $62.81 . $48.18 . $11.22 . $63.31 . $89.82 . $222.43 . $1.77 . $1.37 . $11.78 . $100.86 . $7.85 . $75.24 . $945.78 . $27.74 . $2,238.97 . $649.44 . $76.20 . $141.85 . $38.11 . $85.93 . $143.63 . $138.67 . $199.18 . $5,272.99 . $6.80 . $10.39 . $527.41 . $266.47 . $27.37 . $8.03 . $2.07 . $2.43. $44.15 . $4.97 . $1.76 . $40.11 . $148.02 . $18.81 . $19.12 . $25.87 . $77.44 . $206.81 . $115.52 . $43.80 . $505.58 . $16.37 . $3.75 . $38.72 . $0.09 . $0.99 . $1.98 . $31.98 . $30.84 . $25.90 . $22.50 . $38.17 . $21.57 . $20.90 . $20.04 . $16.68 . $7.92 . $26.73 . $5.02 . $3.71 . $10.28 . $11.75 . $9.91 . $42.20 . $67.66 . $3,796.00 . $0.21 . $0.25 . $28.88 . $4.06 . $6.15 . $89.29 . $79.62 . $31.17 . $17.13 . $36.75 . $5.99 . $12.51 . $0.35 . $3.63. $10.28 . $8.97 . $1.21 . $0.80 . $24.36 . $8.76 . $55.68 . $0.98 . $0.03 . $1.29 . $38.84 . $0.40 . $33.13 . $9.09 . $22.46 . $55.06 . $0.70 . $43.86 . $14.03 . $5.11 . $5.51 . $7.46 . $69.98 . $2.91 . $6,572.00 . $422.28 . $0.00 . $27.01 . $2.97 . $1.12 . $0.28 . $180.20 . $60.95 . $0.15 . $4.13 . $2.22 . $2.32 . $3.84 . $0.87 . $30.23 . $104.86 . $105.47 . $17.53 . $48.22 . $46.83 . $307.47 . $84.19 . $15.18