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 
Addendum A.-Proposed OPPS APCs for CY 2012

APC 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

0035 Vascular 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

0047 Arthroplasty 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 FootT 32.4101 $2,249.91

0051 Level III Musculoskeletal Procedures Except Hand and FootT 47.1841 $3,275.52

0052 Level IV Musculoskeletal Procedures Except Hand and FootT 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 $864.37
0066 Level II Stereotactic Radiosurgery, MRgFUS, and MEG S 35.2457 $2,446.76

0067 Level III Stereotactic Radiosurgery, MRgFUS, and MEG S 46.8279 $3,250.79

0069 Thoracoscopy T 34.9007 $2,422.81

0070 Thoracentesis/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

0079 Ventilation 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

0088 Thrombectomy 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

0093 Vascular Reconstruction/Fistula Repair without Device T 30.7767 $2,136.52

0094 Level I Resuscitation and Cardioversion S 2.2773 $158.09

0095 Cardiac 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

0104 Transcatheter 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

0110 Transfusion S 3.3671 $233.74

0111 Blood Product Exchange S 11.7368 $814.77

0112 Apheresis and Stem Cell Procedures S 32.6016 $2,263.20

0113 Excision Lymphatic System T 25.4874 $1,769.34

0114 Thyroid/Lymphadenectomy Procedures T 51.2321 $3,556.53

0115 Cannula/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 MEG S 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 $3,312.47
0132 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 Procedures T 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

0157 Colorectal Cancer Screening: Barium Enema S 2.2553 $156.56

0158 Colorectal Cancer Screening: Colonoscopy T 8.3174 $577.39

0159 Colorectal 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 $3,164.27
0203 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 Studies S 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

0243 Strabismus/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 Film Except Teeth X 0.6418 $44.55

0261 Level II Plain Film Except Teeth Including Bone Density Measurement X 1.0831 $75.19

0262 Plain Film of 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 $483.70
0275 Arthrography 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

0283 Computed Tomography with Contrast S 4.2806 $297.16

0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography S with Contrast 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

0303 Treatment 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) imaging S 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 Brachytherapy 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

0325 Group 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

0333 Computed 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 S without Contrast 4.8219 $334.74

0337 Magnetic Resonance Imaging and Magnetic Resonance Angiography S without Contrast followed by 7.6393 $530.32 Contrast

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

0350 Administration 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 $85.66
0366 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

0370 Allergy Tests X 1.3506 $93.76

0373 Level I Neuropsychological Testing X 1.3767 $95.57

0375 Ancillary 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

0383 Cardiac 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

0395 GI Tract Imaging S 3.4576 $240.03

0396 Bone Imaging S 3.5140 $243.94

0397 Vascular 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 Procedures T 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 $11,537.64
0436 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

0617 Critical Care S 6.8172 $473.25

0618 Trauma 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 Phlebotomy and Minor Vascular Access Device ProceduresX 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

0653 Vascular 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

0656 Transcatheter 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 Beam Radiation Therapy S 14.2952 $992.37

0665 Bone Density:AppendicularSkeleton S 0.4570 $31.72

0667 Level II Proton Beam Radiation 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

0676 Thrombolysis 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 $1,440.23
0688 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

0735 Ampho b cholesteryl sulfate K $13.74

0736 Amphotericin b liposome inj K $14.77

0738 Rasburicase K $183.08

0747 Chlorothiazide sodium inj 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

0807 Aldesleukin 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

0814 Asparaginase 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

0835 Cosyntropin 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

0850 Streptozocin 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

0868 Oral aprepitant K $5.90

0873 Hyalgan/supartz inj per dose K $88.80

0874 Synvisc or synvisc-one K $11.81

0875 Euflexxa inj per dose K $147.16
0877 Orthovisc inj per dose

K $167.00

0884 Rho d immune globulin inj

K $82.16

0887 Azathioprine parenteral

K $104.77

0890 Lymphocyte immune globulin

K $542.36

0900 Alglucerase injection

K $41.19

0901 Alpha 1 proteinase inhibitor

K $3.79

0902 Injection,onabotulinumtoxinA

K $5.38

0903 Cytomegalovirus imm IV /vial

K $922.07

0910 Interferon beta-1b / .25 MG

K $197.14

0913 Ganciclovir long act implant

K $16,640.00

0917 Adenosine injection

K $89.99

0925 Factor viii

K $0.87

0927 Factor viii recombinant

K $1.09

0928 Factor ix complex

K $0.85

0929 Anti-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

0943 Octagam 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

0950 Whole 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 leukocytes 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

0960 Washed red blood cells unit

R 4.0969 $284.41

0961 Albumin (human),5%, 50ml

K $20.37

0963 Albumin (human), 5%, 250 ml

K $67.07

0964 Albumin (human), 25%, 20 ml

K $29.16

0965 Albumin (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

1009 Cryoprecipitatereducedplasma

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 leukocytes 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 $149.97
1019 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

1083 Adalimumab injection

K $394.16

1084 Denileukin diftitox inj

K $1,559.54

1086 Temozolomide

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 Cytarabine liposome inj

K $479.02

1167 Inj, epirubicin hcl

K $1.87

1168 Inj, temsirolimus

K $49.87

1178 Busulfan injection

K $16.29

1203 Verteporfin injection

K $9.55

1207 Octreotide injection, depot

K $113.48

1213 Antihemophilic 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

1235 Valrubicin injection

K $946.64

1236 Levoleucovorin injection

K $1.78

1237 Inj iron dextran

K $11.59

1238 Topotecan oral

K $76.40

1239 Rotavirus vacc 2 dose oral

K $100.56

1240 Apligraf 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

1249 Cymetra 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

1253 Triamcinolone A inj PRS-free

K $3.17

1263 Antithrombin iii injection

K $2.48

1268 Xyntha inj

K $1.05

1270 Alloderm skin sub

K $31.11

1272 Acetylcysteine injection K $2.67

1274 Edetate calcium disodium inj K $192.07

1275 Vivaglobin, inj K $7.11

1279 Factor VIII (porcine)

K $1.17

1280 Corticotropin injection

K $2,395.22
1281 Bevacizumab injection

K $1.47

1287 Alloskin skin sub

K $6.07

1289 AbobotulinumtoxinA

K $7.41

1290 Human fibrinogen conc inj

K $71.52

1291 Rilonacept injection

K $23.63

1295 Sm 153 lexidronam

K $7,555.71

1296 Degarelix injection

K $2.79

1297 Ferumoxytol, non-esrd

K $0.69

1304 Perphenazine injeciton

K $30.91

1306 Urea injection

K $82.18

1307 Oral 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

1332 Antithrombin recombinant

K $101.40

1338 Methyl aminolevulinate, top

K $68.27

1339 Oral 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

1345 Theraskin

K $20.32

1349 Anidulafungin injection

K $1.29

1350 Topotecan 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 $850.00
1511 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 $4,250.00
1564 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

1605 Abciximab 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

1613 Trastuzumab injection

K $69.06

1630 Hep b ig, im

K $112.16

1631 Baclofen intrathecal trial

K $72.18

1633 Alefacept

K $35.86

1643 Y90 ibritumomab, rx

K $32,078.39

1645 I131 tositumomab, rx

K $29,460.02

1670 Tetanus 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

1694 Ziconotide injection

K $6.48

1695 Nesiritide injection

K $43.93

1696 Palifermin injection

K $11.15

1697 Pegaptanib sodium injection

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

1709 Azacitidine 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 Brachytx, non-str, Gold-198

U 1.0120 $70.25

1717 Brachytx, non-str, HDR Ir-192

U 3.1681 $219.93

1719 Brachytx, NS, Non-HDRIr-192

U 0.4486 $31.14

1738 Oxaliplatin

K $8.36

1739 Pegademase bovine, 25 iu

K $242.67

1741 Urofollitropin, 75 iu

K $63.60
1749 Endo, colon, retro imaging H

2210 Methyldopate hcl injection K $39.24

2616 Brachytx, non-str,Yttrium-90 U 232.3017 $16,126.38

2632 Iodine I-125 sodium iodide U 0.2868 $19.91

2634 Brachytx, non-str, HA, I-125 U 0.7908 $54.90

2635 Brachytx, non-str, HA, P-103 U 0.3438 $23.87

2636 Brachy linear, non-str,P-103 U 0.5112 $35.49

2638 Brachytx, stranded, I-125 U 0.6225 $43.21

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

2640 Brachytx, stranded, P-103 U 1.0610 $73.65

2641 Brachytx, non-stranded,P-103 U 0.9263 $64.30

2642 Brachytx, stranded, C-131 U 1.6922 $117.47

2643 Brachytx, non-stranded,C-131 U 1.0735 $74.52

2698 Brachytx, stranded, NOS U 0.6225 $43.21

2699 Brachytx, non-stranded, NOS U 0.3438 $23.87

2731 Immune globulin, powder K $30.62

2770 Quinupristin/dalfopristin K $157.23

3041 Bivalirudin K $2.54

3043 Gamma globulin 1 CC inj K $17.91

3050 Sermorelin acetate injection K $1.76

7000 Amifostine K $314.05

7011 Oprelvekin injection K $240.88

7034 Somatropin injection K $56.09

7035 Teniposide 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

7048 Alteplase recombinant K $39.22

7049 Filgrastim 480 mcg injection K $376.20

7051 Leuprolide acetate implant K $4,728.88

7308 Aminolevulinic acid hcl top K $138.70

8000 Cardiac Electrophysiologic Evaluation and Ablation Composite T 161.2626 $11,194.85

8001 LDR Prostate Brachytherapy Composite T 46.7758 $3,247.18

8002 Level I Extended Assessment & Management Composite V 5.4881 $380.98

8003 Level II Extended Assessment & Management Composite V 10.2164 $709.22

8004 Ultrasound Composite S 2.7443 $190.51

8005 CT 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

8009 Cardiac Resynchronization Therapy with Defibrillator Composite T 379.7887 $26,364.93

9001 Linezolid injection K $33.99

9002 Tenecteplase injection K $51.95

9004 Gemtuzumab ozogamicin inj K $2,637.02

9005 Reteplase injection K $1,332.35

9006 Tacrolimus injection K $136.85

9012 Arsenic trioxide injection K $40.13

9018 Inj, rimabotulinumtoxinB K $10.33

9019 Caspofungin acetate K $12.13
9022 IM inj interferon beta 1-a

K $220.75

9023 Rho d immune globulin

K $24.81

9024 Amphotericin b lipid complex

K $8.76

9032 Baclofen 10 MG injection

K $200.54

9033 Cidofovir injection

K $740.09

9038 Inj estrogen conjugate

K $94.03

9042 Glucagon hydrochloride

K $95.59

9044 Ibutilide fumarate injection

K $129.32

9104 Antithymocyte globuln rabbit

K $387.17

9108 Thyrotropin injection

K $1,034.03

9110 Alemtuzumab injection

K $577.60

9115 Zoledronic acid

K $219.00

9119 Injection, pegfilgrastim 6mg

K $2,527.87

9120 Injection, Fulvestrant

K $81.81

9121 Injection, argatroban

K $18.71

9122 Triptorelin 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

9135 Varicella-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

9208 Agalsidase 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

9215 Cetuximab 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

9228 Tigecycline injection

K $1.22

9229 Ibandronate sodium injection

K $144.36

9230 Abatacept injection

K $20.26

9231 Decitabine injection

K $30.71

9232 Idursulfase injection

K $446.45

9233 Ranibizumab injection

K $398.10

9234 Alglucosidase 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 $18.15
9244 Regadenoson injection

K $51.36

9245 Romiplostim injection

K $44.84

9248 Inj, clevidipine butyrate

K $6.03

9249 Certolizumab pegol inj

K $3.99

9250 Artiss fibrin sealant

K $121.80

9251 C1 esterase inhibitor inj

K $43.78

9252 Plerixafor injection

K $278.36

9253 Temozolomide injection

K $4.86

9254 Injection, lacosamide

K $0.15

9255 Paliperidone palmitate inj

K $6.45

9256 Dexamethasone intra implant

K $194.17

9258 Telavancin 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

9264 Tocilizumab injection

G $3.47

9265 Romidepsin injection

G $219.30

9267 Wilate injection

G $70.14

9268 Capsaicin 8% patch

G $25.55

9269 C-1 esterase, berinert

G $27.53

9270 Gammaplex IVIG

G $37.29

9271 Velaglucerase alfa

G $349.88

9272 Inj, denosumab

G $14.52

9273 Sipuleucel-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

9358 SurgiMend, fetal

K $11.09

9360 SurgiMend, 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 Granulocytes, 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