Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered Surgical 

Procedures for CY 2012 (Including Ancillary Services for Which Payment is Packaged)

HCPCS CodeShort DescriptorCY 2012 Comment IndicatorCY 2012 Payment IndicatorCY 2012 

Payment Weight CY 2012 Payment

0042TCt perfusion w/contrast cbfN1

0073TDelivery comp imrtZ26.0383$255.60

0126TChd risk imt studyN1

0159TCad breast mriN1

0174TCad cxr with interpN1

0175TCad cxr remoteN1

0182THdr elect brachytherapyZ29.2473$391.43

0185TComptr probability analysisN1

70010Contrast x-ray of brainN1

70015Contrast x-ray of brainN1

70030X-ray eye for foreign bodyZ3$14.62

70100X-ray exam of jawZ3$17.97

70110X-ray exam of jawZ3$19.41

70120X-ray exam of mastoidsZ3$19.17

70130X-ray exam of mastoidsZ20.6016$25.47

70134X-ray exam of middle earZ3$27.32

70140X-ray exam of facial bonesZ3$14.38

70150X-ray exam of facial bonesZ3$21.09

70160X-ray exam of nasal bonesZ3$17.49

70170X-ray exam of tear ductN1

70190X-ray exam of eye socketsZ3$17.97

70200X-ray exam of eye socketsZ3$21.33

70210X-ray exam of sinusesZ3$16.06

70220X-ray exam of sinusesZ3$19.17

70240X-ray exam pituitary saddleZ3$14.38

70250X-ray exam of skullZ3$17.73

70260X-ray exam of skullZ3$21.57

70300X-ray exam of teethZ3$6.23

70310X-ray exam of teethZ20.4358$18.45

70320Full mouth x-ray of teethZ20.4358$18.45

70328X-ray exam of jaw jointZ3$15.58

70330X-ray exam of jaw jointsZ20.6016$25.47

70332X-ray exam of jaw jointN1

70336Magnetic image jaw jointZ24.5196$191.31

70350X-ray head for orthodontiaZ3$8.15

70355Panoramic x-ray of jawsZ3$7.19

70360X-ray exam of neckZ3$13.42

70370Throat x-ray & fluoroscopyZ21.1698$49.52

70371Speech evaluation complexZ3$37.38

70373Contrast x-ray of larynxN1

70380X-ray exam of salivary glandZ3$22.05

70390X-ray exam of salivary ductN1

70450Ct head/brain w/o dyeZ3$99.45

70460Ct head/brain w/dyeZ3$129.40

70470Ct head/brain w/o & w/dyeZ3$159.60

70480Ct orbit/ear/fossa w/o dyeZ22.5705$108.81

70481Ct orbit/ear/fossa w/dyeZ24.0122$169.83

70482Ct orbit/ear/fossa w/o&w/dyeZ24.4724$189.31

70486Ct maxillofacial w/o dyeZ22.5705$108.81

70487Ct maxillofacial w/dyeZ3$165.83

70488Ct maxillofacial w/o & w/dyeZ24.4724$189.31

70490Ct soft tissue neck w/o dyeZ22.5705$108.81

70491Ct soft tissue neck w/dyeZ3$158.16

70492Ct sft tsue nck w/o & w/dyeZ24.4724$189.31

70496Ct angiography headZ24.5395$192.15

70498Ct angiography neckZ24.5395$192.15

70540Mri orbit/face/neck w/o dyeZ24.5196$191.31

70542Mri orbit/face/neck w/dyeZ25.7993$245.48

70543Mri orbt/fac/nck w/o & w/dyeZ27.1603$303.09

70544Mr angiography head w/o dyeZ24.5196$191.31

70545Mr angiography head w/dyeZ25.7993$245.48

70546Mr angiograph head w/o&w/dyeZ27.1603$303.09
70547Mr angiography neck w/o dyeZ24.5196$191.31

70548Mr angiography neck w/dyeZ25.7993$245.48

70549Mr angiograph neck w/o&w/dyeZ27.1603$303.09

70551Mri brain w/o dyeZ24.5196$191.31

70552Mri brain w/dyeZ25.7993$245.48

70553Mri brain w/o & w/dyeZ27.1603$303.09

70554Fmri brain by techZ24.5196$191.31

70555Fmri brain by phys/psychZ24.5196$191.31

70557Mri brain w/o dyeZ24.5196$191.31

70558Mri brain w/dyeZ25.7993$245.48

70559Mri brain w/o & w/dyeZ27.1603$303.09

71010Chest x-rayZ3$10.30

71015Chest x-rayZ3$14.38

71020Chest x-rayZ3$13.90

71021Chest x-rayZ3$17.25

71022Chest x-rayZ3$22.77

71023Chest x-ray and fluoroscopyZ3$34.99

71030Chest x-rayZ3$22.05

71034Chest x-ray and fluoroscopyZ3$46.01

71035Chest x-rayZ3$18.93

71040Contrast x-ray of bronchiN1

71060Contrast x-ray of bronchiN1

71090X-ray & pacemaker insertionN1

71100X-ray exam of ribsZ3$15.34

71101X-ray exam of ribs/chestZ3$18.69

71110X-ray exam of ribsZ3$19.41

71111X-ray exam of ribs/chestZ3$26.60

71120X-ray exam of breastboneZ3$15.58

71130X-ray exam of breastboneZ3$18.69

71250Ct thorax w/o dyeZ22.5705$108.81

71260Ct thorax w/dyeZ3$161.27

71270Ct thorax w/o & w/dyeZ24.4724$189.31

71275Ct angiography chestZ24.5395$192.15

71550Mri chest w/o dyeZ24.5196$191.31

71551Mri chest w/dyeZ25.7993$245.48

71552Mri chest w/o & w/dyeZ27.1603$303.09

72010X-ray exam of spineZ3$38.82

72020X-ray exam of spineZ3$11.26

72040X-ray exam of neck spineZ3$19.89

72050X-ray exam of neck spineZ3$26.60

72052X-ray exam of neck spineZ3$35.47

72069X-ray exam of trunk spineZ3$18.69

72070X-ray exam of thoracic spineZ3$16.06

72072X-ray exam of thoracic spineZ3$18.93

72074X-ray exam of thoracic spineZ3$23.96

72080X-ray exam of trunk spineZ3$17.73

72090X-ray exam of trunk spineZ3$25.40

72100X-ray exam of lower spineZ3$21.09

72110X-ray exam of lower spineZ3$28.52

72114X-ray exam of lower spineZ3$40.50

72120X-ray exam of lower spineZ20.6016$25.47

72125Ct neck spine w/o dyeZ22.5705$108.81

72126Ct neck spine w/dyeZ3$162.23

72127Ct neck spine w/o & w/dyeZ24.4724$189.31

72128Ct chest spine w/o dyeZ22.5705$108.81

72129Ct chest spine w/dyeZ3$162.23

72130Ct chest spine w/o & w/dyeZ24.4724$189.31

72131Ct lumbar spine w/o dyeZ22.5705$108.81

72132Ct lumbar spine w/dyeZ3$161.75

72133Ct lumbar spine w/o & w/dyeZ24.4724$189.31

72141Mri neck spine w/o dyeZ24.5196$191.31

72142Mri neck spine w/dyeZ25.7993$245.48

72146Mri chest spine w/o dyeZ24.5196$191.31

72147Mri chest spine w/dyeZ25.7993$245.48

72148Mri lumbar spine w/o dyeZ24.5196$191.31

72149Mri lumbar spine w/dyeZ25.7993$245.48
72156Mri neck spine w/o & w/dyeZ27.1603$303.09

72157Mri chest spine w/o & w/dyeZ27.1603$303.09

72158Mri lumbar spine w/o & w/dyeZ27.1603$303.09

72170X-ray exam of pelvisZ3$12.70

72190X-ray exam of pelvisZ3$22.53

72191Ct angiograph pelv w/o&w/dyeZ24.5395$192.15

72192Ct pelvis w/o dyeZ22.5705$108.81

72193Ct pelvis w/dyeZ3$153.13

72194Ct pelvis w/o & w/dyeZ24.4724$189.31

72195Mri pelvis w/o dyeZ24.5196$191.31

72196Mri pelvis w/dyeZ25.7993$245.48

72197Mri pelvis w/o & w/dyeZ27.1603$303.09

72200X-ray exam sacroiliac jointsZ3$15.10

72202X-ray exam sacroiliac jointsZ3$17.97

72220X-ray exam of tailboneZ3$14.62

72240Contrast x-ray of neck spineN1

72255Contrast x-ray thorax spineN1

72265Contrast x-ray lower spineN1

72270Contrast x-ray spineN1

72275EpidurographyN1

72285X-ray c/t spine diskN1

72291Perq verte/sacroplsty fluorN1

72292Perq verte/sacroplsty ctN1

72295X-ray of lower spine diskN1

73000X-ray exam of collar boneZ3$14.62

73010X-ray exam of shoulder bladeZ3$15.58

73020X-ray exam of shoulderZ3$11.50

73030X-ray exam of shoulderZ3$14.86

73040Contrast x-ray of shoulderN1

73050X-ray exam of shouldersZ3$20.61

73060X-ray exam of humerusZ3$14.62

73070X-ray exam of elbowZ3$14.62

73080X-ray exam of elbowZ3$17.97

73085Contrast x-ray of elbowN1

73090X-ray exam of forearmZ3$13.90

73092X-ray exam of arm infantZ3$17.73

73100X-ray exam of wristZ3$16.06

73110X-ray exam of wristZ3$20.37

73115Contrast x-ray of wristN1

73120X-ray exam of handZ3$13.90

73130X-ray exam of handZ3$17.01

73140X-ray exam of finger(s)Z3$18.45

73200Ct upper extremity w/o dyeZ22.5705$108.81

73201Ct upper extremity w/dyeZ3$158.16

73202Ct uppr extremity w/o&w/dyeZ24.4724$189.31

73206Ct angio upr extrm w/o&w/dyeZ24.5395$192.15

73218Mri upper extremity w/o dyeZ24.5196$191.31

73219Mri upper extremity w/dyeZ25.7993$245.48

73220Mri uppr extremity w/o&w/dyeZ27.1603$303.09

73221Mri joint upr extrem w/o dyeZ24.5196$191.31

73222Mri joint upr extrem w/dyeZ25.7993$245.48

73223Mri joint upr extr w/o&w/dyeZ27.1603$303.09

73500X-ray exam of hipZ3$12.70

73510X-ray exam of hipZ3$19.65

73520X-ray exam of hipsZ3$19.65

73525Contrast x-ray of hipN1

73530X-ray exam of hipN1

73540X-ray exam of pelvis & hipsZ3$23.72

73542X-ray exam sacroiliac jointN1

73550X-ray exam of thighZ3$13.90

73560X-ray exam of knee 1 or 2Z3$15.34

73562X-ray exam of knee 3Z3$19.41

73564X-ray exam knee 4 or moreZ3$22.29

73565X-ray exam of kneesZ3$18.21

73580Contrast x-ray of knee jointN1

73590X-ray exam of lower legZ3$13.42
73592X-ray exam of leg infantZ3$17.01

73600X-ray exam of ankleZ3$14.62

73610X-ray exam of ankleZ3$17.49

73615Contrast x-ray of ankleN1

73620X-ray exam of footZ3$14.14

73630X-ray exam of footZ3$16.53

73650X-ray exam of heelZ3$14.38

73660X-ray exam of toe(s)Z3$16.53

73700Ct lower extremity w/o dyeZ22.5705$108.81

73701Ct lower extremity w/dyeZ3$160.32

73702Ct lwr extremity w/o&w/dyeZ24.4724$189.31

73706Ct angio lwr extr w/o&w/dyeZ24.5395$192.15

73718Mri lower extremity w/o dyeZ24.5196$191.31

73719Mri lower extremity w/dyeZ25.7993$245.48

73720Mri lwr extremity w/o&w/dyeZ27.1603$303.09

73721Mri jnt of lwr extre w/o dyeZ24.5196$191.31

73722Mri joint of lwr extr w/dyeZ25.7993$245.48

73723Mri joint lwr extr w/o&w/dyeZ27.1603$303.09

74000X-ray exam of abdomenZ3$11.02

74010X-ray exam of abdomenZ3$19.17

74020X-ray exam of abdomenZ3$19.17

74022X-ray exam series abdomenZ3$23.24

74150Ct abdomen w/o dyeZ22.5705$108.81

74160Ct abdomen w/dyeZ24.0122$169.83

74170Ct abdomen w/o & w/dyeZ24.4724$189.31

74175Ct angio abdom w/o & w/dyeZ24.5395$192.15

74176Ct abd & pelvisZ3$96.57

74177Ct abd & pelv w/contrastCHZ27.7175$326.67

74178Ct abd & pelv 1/>regnsZ3$243.71

74181Mri abdomen w/o dyeZ24.5196$191.31

74182Mri abdomen w/dyeZ25.7993$245.48

74183Mri abdomen w/o & w/dyeZ27.1603$303.09

74190X-ray exam of peritoneumN1

74210Contrst x-ray exam of throatZ3$43.85

74220Contrast x-ray esophagusCHZ21.1519$48.76

74230Cine/vid x-ray throat/esophZ3$46.97

74235Remove esophagus obstructionN1

74240X-ray exam upper gi tractZ21.1519$48.76

74241X-ray exam upper gi tractZ21.1519$48.76

74245X-ray exam upper gi tractZ21.8824$79.68

74246Contrst x-ray uppr gi tractZ21.1519$48.76

74247Contrst x-ray uppr gi tractZ21.1519$48.76

74249Contrst x-ray uppr gi tractZ21.8824$79.68

74250X-ray exam of small bowelZ21.1519$48.76

74251X-ray exam of small bowelZ21.8824$79.68

74260X-ray exam of small bowelZ21.1519$48.76

74261Ct colonography dxZ22.5705$108.81

74262Ct colonography dx w/dyeZ24.0122$169.83

74270Contrast x-ray exam of colonZ21.1519$48.76

74280Contrast x-ray exam of colonZ21.8824$79.68

74283Contrast x-ray exam of colonZ21.1519$48.76

74290Contrast x-ray gallbladderCHZ21.1519$48.76

74291Contrast x-rays gallbladderCHZ21.1519$48.76

74300X-ray bile ducts/pancreasN1

74301X-rays at surgery add-onN1

74305X-ray bile ducts/pancreasN1

74320Contrast x-ray of bile ductsN1

74327X-ray bile stone removalN1

74328X-ray bile duct endoscopyN1

74329X-ray for pancreas endoscopyN1

74330X-ray bile/panc endoscopyN1

74340X-ray guide for GI tubeN1

74355X-ray guide intestinal tubeN1

74360X-ray guide gi dilationN1

74363X-ray bile duct dilationN1

74400Contrst x-ray urinary tractZ3$63.02
74410Contrst x-ray urinary tractZ3$63.50

74415Contrst x-ray urinary tractZ3$80.52

74420Contrst x-ray urinary tractZ22.4272$102.74

74425Contrst x-ray urinary tractN1

74430Contrast x-ray bladderN1

74440X-ray male genital tractN1

74445X-ray exam of penisN1

74450X-ray urethra/bladderN1

74455X-ray urethra/bladderN1

74470X-ray exam of kidney lesionN1

74475X-ray control cath insertN1

74480X-ray control cath insertN1

74485X-ray guide gu dilationN1

74710X-ray measurement of pelvisZ3$15.10

74740X-ray female genital tractN1

74742X-ray fallopian tubeN1

74775X-ray exam of perineumZ22.4272$102.74

75557Cardiac mri for morphZ24.5196$191.31

75559Cardiac mri w/stress imgZ24.5196$191.31

75561Cardiac mri for morph w/dyeZ3$300.50

75563Card mri w/stress img & dyeZ27.1603$303.09

75565Card mri veloc flow mappingN1

75571Ct hrt w/o dye w/ca testZ20.6316$26.73

75572Ct hrt w/3d imageZ23.4956$147.97

75573Ct hrt w/3d image congenZ23.4956$147.97

75574Ct angio hrt w/3d imageZ23.4956$147.97

75600Contrast x-ray exam of aortaN1

75605Contrast x-ray exam of aortaN1

75625Contrast x-ray exam of aortaN1

75630X-ray aorta leg arteriesN1

75635Ct angio abdominal arteriesN1

75650Artery x-rays head & neckN1

75658Artery x-rays armN1

75660Artery x-rays head & neckN1

75662Artery x-rays head & neckN1

75665Artery x-rays head & neckN1

75671Artery x-rays head & neckN1

75676Artery x-rays neckN1

75680Artery x-rays neckN1

75685Artery x-rays spineN1

75705Artery x-rays spineN1

75710Artery x-rays arm/legN1

75716Artery x-rays arms/legsN1

75722Artery x-rays kidneyN1

75724Artery x-rays kidneysN1

75726Artery x-rays abdomenN1

75731Artery x-rays adrenal glandN1

75733Artery x-rays adrenalsN1

75736Artery x-rays pelvisN1

75741Artery x-rays lungN1

75743Artery x-rays lungsN1

75746Artery x-rays lungN1

75756Artery x-rays chestN1

75774Artery x-ray each vesselN1

75791Av dialysis shunt imagingN1

75801Lymph vessel x-ray arm/legN1

75803Lymph vessel x-ray arms/legsN1

75805Lymph vessel x-ray trunkN1

75807Lymph vessel x-ray trunkN1

75809Nonvascular shunt x-rayN1

75810Vein x-ray spleen/liverN1

75820Vein x-ray arm/legN1

75822Vein x-ray arms/legsN1

75825Vein x-ray trunkN1

75827Vein x-ray chestN1

75831Vein x-ray kidneyN1
75833Vein x-ray kidneysN1

75840Vein x-ray adrenal glandN1

75842Vein x-ray adrenal glandsN1

75860Vein x-ray neckN1

75870Vein x-ray skullN1

75872Vein x-ray skullN1

75880Vein x-ray eye socketN1

75885Vein x-ray liverN1

75887Vein x-ray liverN1

75889Vein x-ray liverN1

75891Vein x-ray liverN1

75893Venous sampling by catheterN1

75894X-rays transcath therapyN1

75896X-rays transcath therapyN1

75898Follow-up angiographyN1

75901Remove cva device obstructN1

75902Remove cva lumen obstructN1

75940X-ray placement vein filterN1

75945Intravascular usN1

75946Intravascular us add-onN1

75960Transcath iv stent rs&iN1

75961Retrieval broken catheterN1

75962Repair arterial blockageN1

75964Repair artery blockage eachN1

75966Repair arterial blockageN1

75968Repair artery blockage eachN1

75970Vascular biopsyN1

75978Repair venous blockageN1

75980Contrast xray exam bile ductN1

75982Contrast xray exam bile ductN1

75984Xray control catheter changeN1

75989Abscess drainage under x-rayN1

76000Fluoroscope examinationN1

76001Fluoroscope exam extensiveN1

76010X-ray nose to rectumZ3$12.94

76080X-ray exam of fistulaN1

76098X-ray exam breast specimenN1

76100X-ray exam of body sectionZ21.0152$42.97

76101Complex body section x-rayZ3$92.50

76102Complex body section x-raysZ3$133.00

76120Cine/video x-raysZ3$41.22

76125Cine/video x-rays add-onN1

763763d render w/o postprocessN1

763773d rendering w/postprocessN1

76380CAT scan follow-up studyZ21.4484$61.31

76496Fluoroscopic procedureZ21.1698$49.52

76497Ct procedureZ21.4484$61.31

76498Mri procedureZ24.5196$191.31

76499Radiographic procedureZ20.6016$25.47

76506Echo exam of headZ20.8431$35.69

76510Ophth us b & quant aZ3$54.64

76511Ophth us quant a onlyZ3$34.27

76512Ophth us b w/non-quant aZ3$28.04

76513Echo exam of eye water bathZ3$39.78

76514Echo exam of eye thicknessZ3$3.35

76516Echo exam of eyeZ3$31.63

76519Echo exam of eyeZ3$35.23

76529Echo exam of eyeZ3$30.91

76536Us exam of head and neckZ21.2851$54.40

76604Us exam chestZ20.8431$35.69

76645Us exam breast(s)Z20.8431$35.69

76700Us exam abdom completeZ21.2851$54.40

76705Echo exam of abdomenZ21.2851$54.40

76770Us exam abdo back wall compZ21.2851$54.40

76775Us exam abdo back wall limZ21.2851$54.40

76776Us exam k transpl w/dopplerZ21.2851$54.40
76800Us exam spinal canalZ21.2851$54.40

76801Ob us < 14 wks single fetusZ21.2851$54.40

76802Ob us < 14 wks addl fetusZ3$19.89

76805Ob us >/= 14 wks sngl fetusZ21.2851$54.40

76810Ob us >/= 14 wks addl fetusZ3$35.71

76811Ob us detailed sngl fetusZ3$69.01

76812Ob us detailed addl fetusZ20.8431$35.69

76813Ob us nuchal meas 1 gestZ20.8431$35.69

76814Ob us nuchal meas add-onZ3$23.00

76815Ob us limited fetus(s)Z20.8431$35.69

76816Ob us follow-up per fetusZ20.8431$35.69

76817Transvaginal us obstetricZ20.8431$35.69

76818Fetal biophys profile w/nstZ3$51.04

76819Fetal biophys profil w/o nstZ3$37.86

76820Umbilical artery echoZ3$13.42

76821Middle cerebral artery echoZ20.8431$35.69

76825Echo exam of fetal heartZ3$98.73

76826Echo exam of fetal heartZ3$63.02

76827Echo exam of fetal heartZ3$25.40

76828Echo exam of fetal heartZ3$13.66

76830Transvaginal us non-obZ21.2851$54.40

76831Echo exam uterusZ3$65.66

76856Us exam pelvic completeZ21.2851$54.40

76857Us exam pelvic limitedZ20.8431$35.69

76870Us exam scrotumZ21.2851$54.40

76872Us transrectalZ21.2851$54.40

76873Echograp trans r pros studyZ21.2851$54.40

76881Us xtr non-vasc completeZ21.2851$54.40

76882Us xtr non-vasc lmtdZ3$7.43

76885Us exam infant hips dynamicZ20.8431$35.69

76886Us exam infant hips staticZ20.8431$35.69

76930Echo guide cardiocentesisN1

76932Echo guide for heart biopsyN1

76936Echo guide for artery repairZ21.4363$60.80

76937Us guide vascular accessN1

76940Us guide tissue ablationN1

76941Echo guide for transfusionN1

76942Echo guide for biopsyN1

76945Echo guide villus samplingN1

76946Echo guide for amniocentesisN1

76948Echo guide ova aspirationN1

76950Echo guidance radiotherapyN1

76965Echo guidance radiotherapyN1

76970Ultrasound exam follow-upZ20.8431$35.69

76975GI endoscopic ultrasoundN1

76977**Us bone density measureZ3$4.07

76998Us guide intraopN1

76999Echo examination procedureZ20.8431$35.69

77001Fluoroguide for vein deviceN1

77002Needle localization by xrayN1

77003Fluoroguide for spine injectN1

77011Ct scan for localizationN1

77012Ct scan for needle biopsyN1

77013Ct guide for tissue ablationN1

77014Ct scan for therapy guideN1

77021Mr guidance for needle placeN1

77022Mri for tissue ablationN1

77031Stereotact guide for brst bxN1

77032Guidance for needle breastN1

77053X-ray of mammary ductN1

77054X-ray of mammary ductsN1

77071X-ray stress viewZ3$23.72

77072X-rays for bone ageZ3$9.83

77073X-rays bone length studiesZ3$17.25

77074X-rays bone survey limitedZ3$33.55

77075X-rays bone survey completeZ21.0152$42.97
77076X-rays bone survey infantZ21.0152$42.97

77077Joint survey single viewZ3$17.73

77078**Ct bone density axialZ20.9575$40.53

77079**Ct bone density peripheralZ3$24.68

77080**Dxa bone density axialZ3$32.59

77081**Dxa bone density/peripheralZ3$12.22

77082Dxa bone density vert fxZ3$13.90

77083**Radiographic absorptiometryZ3$10.30

77084Magnetic image bone marrowZ24.5196$191.31

77280Set radiation therapy fieldZ21.4009$59.30

77285Set radiation therapy fieldZ23.4689$146.84

77290Set radiation therapy fieldZ23.4689$146.84

77295Set radiation therapy fieldZ3$188.83

77299Radiation therapy planningZ21.4009$59.30

77300Radiation therapy dose planZ3$25.40

77301Radiotherapy dose plan imrtZ212.4155$525.54

77305Teletx isodose plan simpleZ3$18.93

77310Teletx isodose plan intermedZ3$25.40

77315Teletx isodose plan complexZ3$41.70

77321Special teletx port planZ3$35.23

77326Brachytx isodose calc simpZ21.4009$59.30

77327Brachytx isodose calc intermZ3$91.30

77328Brachytx isodose plan complZ3$115.02

77331Special radiation dosimetryZ3$12.94

77332Radiation treatment aid(s)Z3$34.75

77333Radiation treatment aid(s)Z3$9.11

77334Radiation treatment aid(s)Z3$60.15

77336Radiation physics consultZ3$31.87

77338Design mlc device for imrtZ23.4689$146.84

77370Radiation physics consultZ21.4009$59.30

77371Srs multisourceZ299.4751"$4,210.68"

77399External radiation dosimetryZ21.4009$59.30

77401Radiation treatment deliveryZ3$15.10

77402Radiation treatment deliveryZ21.2774$54.07

77403Radiation treatment deliveryZ21.2774$54.07

77404Radiation treatment deliveryZ21.2774$54.07

77406Radiation treatment deliveryZ21.2774$54.07

77407Radiation treatment deliveryZ21.2774$54.07

77408Radiation treatment deliveryZ22.2195$93.95

77409Radiation treatment deliveryZ22.2195$93.95

77411Radiation treatment deliveryZ22.2195$93.95

77412Radiation treatment deliveryZ22.2195$93.95

77413Radiation treatment deliveryZ22.2195$93.95

77414Radiation treatment deliveryZ22.2195$93.95

77416Radiation treatment deliveryZ22.2195$93.95

77417Radiology port film(s)N1

77418Radiation tx delivery imrtZ26.0383$255.60

77421Stereoscopic x-ray guidanceN1

77422Neutron beam tx simpleZ22.2195$93.95

77423Neutron beam tx complexZ22.2195$93.95

77435Sbrt managementN1

77470Special radiation treatmentZ3$48.89

77520Proton trmt simple w/o compZ213.3989$567.16

77522Proton trmt simple w/compZ213.3989$567.16

77523Proton trmt intermediateZ217.5276$741.93

77525Proton treatment complexZ217.5276$741.93

77600Hyperthermia treatmentZ25.2577$222.55

77605Hyperthermia treatmentZ25.2577$222.55

77610Hyperthermia treatmentZ25.2577$222.55

77615Hyperthermia treatmentZ25.2577$222.55

77620Hyperthermia treatmentZ25.2577$222.55

77750Infuse radioactive materialsZ3$70.45

77761Apply intrcav radiat simpleZ3$122.21

77762Apply intrcav radiat intermZ3$140.67

77763Apply intrcav radiat complZ3$182.84

77776Apply interstit radiat simplZ3$124.61
77777Apply interstit radiat interZ3$129.88

77778Apply interstit radiat complZ3$187.15

77785Hdr brachytx 1 channelZ3$111.43

77786Hdr brachytx 2-12 channelZ3$275.34

77787Hdr brachytx over 12 chanZ29.2473$391.43

77789Apply surface radiationZ3$37.86

77790Radiation handlingN1

77799Radium/radioisotope therapyZ24.4066$186.53

78000Thyroid single uptakeZ21.4184$60.04

78001Thyroid multiple uptakesZ21.4184$60.04

78003Thyroid suppress/stimulZ21.4184$60.04

78006Thyroid imaging with uptakeZ22.9759$125.97

78007Thyroid image mult uptakesZ22.9759$125.97

78010Thyroid imagingZ21.749$74.03

78011Thyroid imaging with flowZ21.749$74.03

78015Thyroid met imagingZ23.7843$160.19

78016Thyroid met imaging/studiesZ23.7843$160.19

78018Thyroid met imaging bodyZ23.7843$160.19

78020Thyroid met uptakeN1

78070Parathyroid nuclear imagingZ22.9759$125.97

78075Adrenal nuclear imagingZ26.5434$276.98

78099Endocrine nuclear procedureZ21.749$74.03

78102Bone marrow imaging ltdZ23.4804$147.32

78103Bone marrow imaging multZ23.4804$147.32

78104Bone marrow imaging bodyZ23.4804$147.32

78110Plasma volume singleZ25.9086$250.11

78111Plasma volume multipleZ25.9086$250.11

78120Red cell mass singleZ25.9086$250.11

78121Red cell mass multipleZ25.9086$250.11

78122Blood volumeZ25.9086$250.11

78130Red cell survival studyZ25.9086$250.11

78135Red cell survival kineticsZ25.9086$250.11

78140Red cell sequestrationZ25.9086$250.11

78185Spleen imagingZ23.4804$147.32

78190Platelet survival kineticsZ22.377$100.62

78191Platelet survivalZ22.377$100.62

78195Lymph system imagingZ23.4804$147.32

78199Blood/lymph nuclear examZ23.4804$147.32

78201Liver imagingZ23.8979$164.99

78202Liver imaging with flowZ23.8979$164.99

78205Liver imaging (3D)Z23.8979$164.99

78206Liver image (3d) with flowZ23.8979$164.99

78215Liver and spleen imagingZ23.8979$164.99

78216Liver & spleen image/flowZ23.8979$164.99

78220Liver function studyZ23.8979$164.99

78223Hepatobiliary imagingZ23.8979$164.99

78230Salivary gland imagingZ23.2408$137.18

78231Serial salivary imagingZ23.2408$137.18

78232Salivary gland function examZ23.2408$137.18

78258Esophageal motility studyZ23.2408$137.18

78261Gastric mucosa imagingZ23.2408$137.18

78262Gastroesophageal reflux examZ23.2408$137.18

78264Gastric emptying studyZ23.2408$137.18

78270Vit B-12 absorption examZ22.377$100.62

78271Vit b-12 absrp exam int facZ22.377$100.62

78272Vit b-12 absorp combinedZ22.377$100.62

78278Acute GI blood loss imagingZ23.2408$137.18

78282GI protein loss examZ23.2408$137.18

78290Meckels divert examZ23.2408$137.18

78291Leveen/shunt patency examZ23.2408$137.18

78299GI nuclear procedureZ23.2408$137.18

78300Bone imaging limited areaZ23.2937$139.42

78305Bone imaging multiple areasZ23.2937$139.42

78306Bone imaging whole bodyZ23.2937$139.42

78315Bone imaging 3 phaseZ23.2937$139.42

78320Bone imaging (3D)Z23.2937$139.42
78399Musculoskeletal nuclear examZ23.2937$139.42

78414Non-imaging heart functionZ23.9603$167.64

78428Cardiac shunt imagingZ23.9603$167.64

78445Vascular flow imagingZ22.2701$96.09

78451Ht muscle image spect singZ29.1371$386.76

78452Ht muscle image spect multZ29.1371$386.76

78453Ht muscle image planar singZ29.1371$386.76

78454Ht musc image planar multZ29.1371$386.76

78456Acute venous thrombus imageZ22.2701$96.09

78457Venous thrombosis imagingZ22.2701$96.09

78458Ven thrombosis images bilatZ22.2701$96.09

78459Heart muscle imaging (PET)Z212.439$526.53

78466Heart infarct imageZ23.9603$167.64

78468Heart infarct image (ef)Z23.9603$167.64

78469Heart infarct image (3D)Z23.9603$167.64

78472Gated heart planar singleZ23.9603$167.64

78473Gated heart multipleZ23.9603$167.64

78481Heart first pass singleZ23.9603$167.64

78483Heart first pass multipleZ23.9603$167.64

78491Heart image (pet) singleZ212.439$526.53

78492Heart image (pet) multipleZ212.439$526.53

78494Heart image spectZ23.9603$167.64

78496Heart first pass add-onN1

78499Cardiovascular nuclear examZ23.9603$167.64

78580Lung perfusion imagingZ22.6643$112.78

78584Lung V/Q image single breathZ24.2234$178.77

78585Lung V/Q imagingZ24.2234$178.77

78586Aerosol lung image singleZ22.6643$112.78

78587Aerosol lung image multipleZ22.6643$112.78

78588Perfusion lung imageZ24.2234$178.77

78591Vent image 1 breath 1 projZ22.6643$112.78

78593Vent image 1 proj gasZ22.6643$112.78

78594Vent image mult proj gasZ22.6643$112.78

78596Lung differential functionZ24.2234$178.77

78599Respiratory nuclear examZ22.6643$112.78

78600Brain image < 4 viewsZ23.1546$133.53

78601Brain image w/flow < 4 viewsZ28.1621$345.49

78605Brain image 4+ viewsZ23.1546$133.53

78606Brain image w/flow 4 + viewsZ28.1621$345.49

78607Brain imaging (3D)Z28.1621$345.49

78608Brain imaging (PET)Z213.7006$579.93

78610Brain flow imaging onlyZ23.1546$133.53

78630Cerebrospinal fluid scanZ28.1621$345.49

78635CSF ventriculographyZ28.1621$345.49

78645CSF shunt evaluationZ23.1546$133.53

78647Cerebrospinal fluid scanZ28.1621$345.49

78650CSF leakage imagingZ28.1621$345.49

78660Nuclear exam of tear flowZ23.1546$133.53

78699Nervous system nuclear examZ23.1546$133.53

78700Kidney imaging morpholZ24.2849$181.38

78701Kidney imaging with flowZ24.2849$181.38

78707K flow/funct image w/o drugZ24.2849$181.38

78708K flow/funct image w/drugZ24.2849$181.38

78709K flow/funct image multipleZ24.2849$181.38

78710Kidney imaging (3D)Z24.2849$181.38

78725Kidney function studyZ22.377$100.62

78730Urinary bladder retentionZ21.4184$60.04

78740Ureteral reflux studyZ24.2849$181.38

78761Testicular imaging w/flowZ24.2849$181.38

78799Genitourinary nuclear examZ24.2849$181.38

78800Tumor imaging limited areaZ23.7843$160.19

78801Tumor imaging mult areasZ26.5434$276.98

78802Tumor imaging whole bodyZ26.5434$276.98

78803Tumor imaging (3D)Z26.5434$276.98

78804Tumor imaging whole bodyZ212.8657$544.59

78805Abscess imaging ltd areaZ26.5434$276.98
78806Abscess imaging whole bodyZ26.5434$276.98

78807Nuclear localization/abscessZ26.5434$276.98

78808Iv inj ra drug dx studyN1

78811Pet image ltd areaZ213.7006$579.93

78812Pet image skull-thighZ213.7006$579.93

78813Pet image full bodyZ213.7006$579.93

78814Pet image w/ct lmtdZ213.7006$579.93

78815Pet image w/ct skull-thighZ213.7006$579.93

78816Pet image w/ct full bodyZ213.7006$579.93

78999Nuclear diagnostic examZ21.4184$60.04

79005Nuclear rx oral adminZ3$35.47

79101Nuclear rx iv adminZ3$38.10

79200Nuclear rx intracav adminZ3$46.01

79300Nuclr rx interstit colloidZ23.0751$130.17

79403Hematopoietic nuclear txZ3$58.47

79440Nuclear rx intra-articularZ3$39.54

79445Nuclear rx intra-arterialZ23.0751$130.17

79999Nuclear medicine therapyZ23.0751$130.17

90371Hep b ig imK2$112.16

90375Rabies ig im/scK2$159.86

90376Rabies ig heat treatedK2$154.18

90378Rsv mab im 50mgCHN1

90385Rh ig minidose imN1

90396Varicella-zoster ig imK2$129.48

90476Adenovirus vaccine type 4CHN1

90585Bcg vaccine percutK2$112.46

90632Hep a vaccine adult imN1

90633Hep a vacc ped/adol 2 doseN1

90634Hep a vacc ped/adol 3 doseN1

90636Hep a/hep b vacc adult imN1

90645Hib vaccine hboc imN1

90646Hib vaccine prp-d imN1

90647Hib vaccine prp-omp imN1

90648Hib vaccine prp-t imN1

90655**Flu vaccine no preserv 6-35mL1

90656**Flu vaccine no preserv 3 & >L1

90657**Flu vaccine 3 yrs imL1

90660**Flu vaccine nasalL1

90662**Flu vacc prsv free inc antigL1

90665Lyme disease vaccine imN1

90669**Pneumococcal vacc 7 val imL1

90670**Pneumococcal vacc 13 val imL1

90675Rabies vaccine imK2$190.82

90676Rabies vaccine idK2$107.83

90680Rotovirus vacc 3 dose oralCHN1

90681Rotavirus vacc 2 dose oralK2$100.56

90690Typhoid vaccine oralN1

90691Typhoid vaccine imN1

90692Typhoid vaccine h-p sc/idN1

90696Dtap-ipv vacc 4-6 yr imN1

90698Dtap-hib-ip vaccine imN1

90700Dtap vaccine < 7 yrs imN1

90701Dtp vaccine imN1

90702Dt vaccine < 7 imN1

90703Tetanus vaccine imN1

90704Mumps vaccine scN1

90705Measles vaccine scN1

90706Rubella vaccine scN1

90707Mmr vaccine scN1

90708Measles-rubella vaccine scN1

90710Mmrv vaccine scN1

90712Oral poliovirus vaccineN1

90713Poliovirus ipv sc/imN1

90714Td vaccine no prsrv >/= 7 imN1

90715Tdap vaccine >7 imN1

90717Yellow fever vaccine scN1
90718Td vaccine > 7 imN1

90719Diphtheria vaccine imN1

90720Dtp/hib vaccine imN1

90721Dtap/hib vaccine imN1

90732**Pneumococcal vaccineL1

90733Meningococcal vaccine scK2$104.49

90734Meningococcal vaccine imK2$83.39

90735Encephalitis vaccine scK2$100.16

90740**Hepb vacc ill pat 3 dose imF4

90743**Hep b vacc adol 2 dose imF4

90744**Hepb vacc ped/adol 3 dose imF4

90746**Hep b vaccine adult imF4

90747**Hepb vacc ill pat 4 dose imF4

90749Vaccine toxoidN1

A4218Sterile saline or waterN1

A4220Infusion pump refill kitN1

A4248Chlorhexidine antiseptN1

A4262Temporary tear duct plugN1

A4263Permanent tear duct plugN1

A4270Disposable endoscope sheathN1

A4300Cath impl vasc access portalN1

A4301Implantable access syst percN1

A4305Drug delivery system >=50 MLN1

A4306Drug delivery system <=50 mlN1

A4641Radiopharm dx agent nocN1

A4642In111 satumomabN1

A4648Implantable tissue markerN1

A4650Implant radiation dosimeterN1

A9500Tc99m sestamibiN1

A9501Technetium TC-99m teboroximeN1

A9502Tc99m tetrofosminN1

A9503Tc99m medronateN1

A9504Tc99m apcitideN1

A9505TL201 thalliumN1

A9507In111 capromabN1

A9508"I131 iodobenguate, dx"N1

A9509Iodine I-123 sod iodide milN1

A9510Tc99m disofeninN1

A9512Tc99m pertechnetateN1

A9516Iodine I-123 sod iodide micN1

A9521Tc99m exametazimeN1

A9524"I131 serum albumin, dx"N1

A9526Nitrogen N-13 ammoniaN1

A9527Iodine I-125 sodium iodideH2$19.91

A9528"Iodine I-131 iodide cap, dx"N1

A9529"I131 iodide sol, dx"N1

A9531I131 max 100uCiN1

A9532"I125 serum albumin, dx"N1

A9536Tc99m depreotideN1

A9537Tc99m mebrofeninN1

A9538Tc99m pyrophosphateN1

A9539Tc99m pentetateN1

A9540Tc99m MAAN1

A9541Tc99m sulfur colloidN1

A9542"In111 ibritumomab, dx"N1

A9544"I131 tositumomab, dx"N1

A9546Co57/58N1

A9547In111 oxyquinolineN1

A9548In111 pentetateN1

A9550Tc99m gluceptateN1

A9551Tc99m succimerN1

A9552F18 fdgN1

A9553Cr51 chromateN1

A9554"I125 iothalamate, dx"N1

A9555Rb82 rubidiumN1

A9556Ga67 galliumN1
A9557Tc99m bicisateN1

A9558Xe133 xenon 10mciN1

A9559Co57 cyanoN1

A9560Tc99m labeled rbcN1

A9561Tc99m oxidronateN1

A9562Tc99m mertiatideN1

A9566Tc99m fanolesomabN1

A9567Technetium TC-99m aerosolN1

A9568Technetium tc99m arcitumomabN1

A9569Technetium TC-99m auto WBCN1

A9570Indium In-111 auto WBCN1

A9571Indium IN-111 auto plateletN1

A9572Indium In-111 pentetreotideN1

A9576Inj prohance multipackN1

A9577Inj multihanceN1

A9578Inj multihance multipackN1

A9579"Gad-base MR contrast NOS,1ml"N1

A9580Sodium fluoride F-18N1

A9581Gadoxetate disodium injN1

A9582Iodine I-123 iobenguaneCHN1

A9583Gadofosveset trisodium injCHN1

A9698Non-rad contrast materialNOCN1

C1713"Anchor/screw bn/bn,tis/bn"N1

C1714"Cath, trans atherectomy, dir"N1

C1715Brachytherapy needleN1

C1716"Brachytx, non-str, Gold-198"H2$70.25

C1717"Brachytx, non-str,HDR Ir-192"H2$219.93

C1719"Brachytx, NS, Non-HDRIr-192"H2$31.14

C1721"AICD, dual chamber"N1

C1722"AICD, single chamber"N1

C1724"Cath, trans atherec,rotation"N1

C1725"Cath, translumin non-laser"N1

C1726"Cath, bal dil, non-vascular"N1

C1727"Cath, bal tis dis, non-vas"N1

C1728"Cath, brachytx seed adm"N1

C1729"Cath, drainage"N1

C1730"Cath, EP, 19 or few elect"N1

C1731"Cath, EP, 20 or more elec"N1

C1732"Cath, EP, diag/abl, 3D/vect"N1

C1733"Cath, EP, othr than cool-tip"N1

C1749"Endo, colon, retro imaging"J7

C1750"Cath, hemodialysis,long-term"N1

C1751"Cath, inf, per/cent/midline"N1

C1752"Cath,hemodialysis,short-term"N1

C1753"Cath, intravas ultrasound"N1

C1754"Catheter, intradiscal"N1

C1755"Catheter, intraspinal"N1

C1756"Cath, pacing, transesoph"N1

C1757"Cath, thrombectomy/embolect"N1

C1758"Catheter, ureteral"N1

C1759"Cath, intra echocardiography"N1

C1760"Closure dev, vasc"N1

C1762"Conn tiss, human(inc fascia)"N1

C1763"Conn tiss, non-human"N1

C1764"Event recorder, cardiac"N1

C1765Adhesion barrierN1

C1766"Intro/sheath,strble,non-peel"N1

C1767"Generator, neuro non-recharg"N1

C1768"Graft, vascular"N1

C1769Guide wireN1

C1770"Imaging coil, MR, insertable"N1

C1771"Rep dev, urinary, w/sling"N1

C1772"Infusion pump, programmable"N1

C1773"Ret dev, insertable"N1

C1776Joint device (implantable)N1

C1777"Lead, AICD, endo single coil"N1
C1778"Lead, neurostimulator"N1

C1779"Lead, pmkr, transvenous VDD"N1

C1780"Lens, intraocular (new tech)"N1

C1781Mesh (implantable)N1

C1782MorcellatorN1

C1783"Ocular imp, aqueous drain de"N1

C1784"Ocular dev, intraop, det ret"N1

C1785"Pmkr, dual, rate-resp"N1

C1786"Pmkr, single, rate-resp"N1

C1787"Patient progr, neurostim"N1

C1788"Port, indwelling, imp"N1

C1789"Prosthesis, breast, imp"N1

C1813"Prosthesis, penile, inflatab"N1

C1814"Retinal tamp, silicone oil"N1

C1815"Pros, urinary sph, imp"N1

C1816"Receiver/transmitter, neuro"N1

C1817Septal defect imp sysN1

C1818Integrated keratoprosthesisN1

C1819Tissue localization-excisionN1

C1820Generator neuro rechg bat syN1

C1821Interspinous implantN1

C1874"Stent, coated/cov w/del sys"N1

C1875"Stent, coated/cov w/o del sy"N1

C1876"Stent, non-coa/non-cov w/del"N1

C1877"Stent, non-coat/cov w/o del"N1

C1878Matrl for vocal cordN1

C1879"Tissue marker, implantable"N1

C1880Vena cava filterN1

C1881Dialysis access systemN1

C1882"AICD, other than sing/dual"N1

C1883"Adapt/ext, pacing/neuro lead"N1

C1884Embolization Protect systN1

C1885"Cath, translumin angio laser"N1

C1887"Catheter, guiding"N1

C1888Endovas non-cardiac abl cathN1

C1891"Infusion pump,non-prog, perm"N1

C1892"Intro/sheath,fixed,peel-away"N1

C1893"Intro/sheath, fixed,non-peel"N1

C1894"Intro/sheath, non-laser"N1

C1895"Lead, AICD, endo dual coil"N1

C1896"Lead, AICD, non sing/dual"N1

C1897"Lead, neurostim test kit"N1

C1898"Lead, pmkr, other than trans"N1

C1899"Lead, pmkr/AICD combination"N1

C1900"Lead, coronary venous"N1

C2614"Probe, perc lumb disc"N1

C2615"Sealant, pulmonary, liquid"N1

C2616"Brachytx, non-str,Yttrium-90"H2"$16,126.38"

C2617"Stent, non-cor, tem w/o del"N1

C2618"Probe, cryoablation"N1

C2619"Pmkr, dual, non rate-resp"N1

C2620"Pmkr, single, non rate-resp"N1

C2621"Pmkr, other than sing/dual"N1

C2622"Prosthesis, penile, non-inf"N1

C2625"Stent, non-cor, tem w/del sy"N1

C2626"Infusion pump, non-prog,temp"N1

C2627"Cath, suprapubic/cystoscopic"N1

C2628"Catheter, occlusion"N1

C2629"Intro/sheath, laser"N1

C2630"Cath, EP, cool-tip"N1

C2631"Rep dev, urinary, w/o sling"N1

C2634"Brachytx, non-str, HA, I-125"H2$54.90

C2635"Brachytx, non-str, HA, P-103"H2$23.87

C2636"Brachy linear, non-str,P-103"H2$35.49

C2638"Brachytx, stranded, I-125"H2$43.21

C2639"Brachytx, non-stranded,I-125"H2$34.65
C2640"Brachytx, stranded, P-103"H2$73.65

C2641"Brachytx, non-stranded,P-103"H2$64.30

C2642"Brachytx, stranded, C-131"H2$117.47

C2643"Brachytx, non-stranded,C-131"H2$74.52

C2698"Brachytx, stranded, NOS"H2$43.21

C2699"Brachytx, non-stranded, NOS"H2$23.87

C8900"MRA w/cont, abd"Z25.7993$245.48

C8901"MRA w/o cont, abd"Z24.5196$191.31

C8902"MRA w/o fol w/cont, abd"Z27.1603$303.09

C8903"MRI w/cont, breast, uni"Z25.7993$245.48

C8904"MRI w/o cont, breast, uni"Z24.5196$191.31

C8905"MRI w/o fol w/cont, brst, un"Z27.1603$303.09

C8906"MRI w/cont, breast, bi"Z25.7993$245.48

C8907"MRI w/o cont, breast, bi"Z24.5196$191.31

C8908"MRI w/o fol w/cont, breast,"Z27.1603$303.09

C8909"MRA w/cont, chest"Z25.7993$245.48

C8910"MRA w/o cont, chest"Z24.5196$191.31

C8911"MRA w/o fol w/cont, chest"Z27.1603$303.09

C8912"MRA w/cont, lwr ext"Z25.7993$245.48

C8913"MRA w/o cont, lwr ext"Z24.5196$191.31

C8914"MRA w/o fol w/cont, lwr ext"Z27.1603$303.09

C8918"MRA w/cont, pelvis"Z25.7993$245.48

C8919"MRA w/o cont, pelvis"Z24.5196$191.31

C8920"MRA w/o fol w/cont, pelvis"Z27.1603$303.09

C8931"MRA, w/dye, spinal canal"Z25.7993$245.48

C8932"MRA, w/o dye, spinal canal"Z24.5196$191.31

C8933"MRA, w/o&w/dye, spinal canal"Z27.1603$303.09

C8934"MRA, w/dye, upper extremity"Z25.7993$245.48

C8935"MRA, w/o dye, upper extr"Z24.5196$191.31

C8936"MRA, w/o&w/dye, upper extr"Z27.1603$303.09

C9113"Inj pantoprazole sodium, via"N1

C9121"Injection, argatroban"K2$18.71

C9248"Inj, clevidipine butyrate"K2$6.03

C9250Artiss fibrin sealantK2$121.80

C9254"Injection, lacosamide"K2$0.15

C9257Bevacizumab injectionK2$1.47

C9270Gammaplex IVIGK2$37.29

C9272"Inj, denosumab"K2$14.52

C9273"Sipuleucel-T, per infusion"K2"$32,860.00"

C9274Crotalidae Poly Immune FabK2"$2,111.36"

C9275Hexaminolevulinate HClK2$636.00

C9276Cabazitaxel injectionK2$135.05

C9277"Lumizyme, 1 mg"K2$14.83

C9279"Injection, ibuprofen"K2$1.39

C9280"Injection, eribulin mesylate"K2$901.00

C9281"Injection, pegloticase"K2$304.75

C9282"Inj, ceftaroline fosamil"K2$0.72

C9352"Neuragen nerve guide, per cm"N1

C9353"Neurawrap nerve protector,cm"N1

C9354"Veritas collagen matrix, cm2"N1

C9355"Neuromatrix nerve cuff, cm"N1

C9356"TenoGlide tendon prot, cm2"N1

C9358"SurgiMend, fetal"K2$11.09

C9359"Implnt,bon void filler-putty"N1

C9360"SurgiMend, neonatal"K2$11.59

C9361NeuroMend nerve wrapCHN1

C9362"Implnt,bon void filler-strip"CHN1

C9363Integra Meshed Bil Wound MatK2$19.17

C9364"Porcine implant, Permacol"CHN1

C9367Endoform Dermal TemplateK2$4.35

C9399Unclassified drugs or biologK7

E0616Cardiac event recorderN1

E0749Elec osteogen stim implantedN1

E0782Non-programble infusion pumpN1

E0783Programmable infusion pumpN1

E0785Replacement impl pump cathetN1
E0786Implantable pump replacementN1

G0130**Single energy x-ray studyZ3$15.82

G0173Linear acc stereo radsur comZ243.8918"$1,857.90"

G0251Linear acc based stero radioZ211.6706$494.00

G0288"Recon, CTA for surg plan"N1

G0339"Robot lin-radsurg com, first"Z243.8918"$1,857.90"

G0340Robt lin-radsurg fractx 2-5Z233.0358"$1,398.37"

J0120Tetracyclin injectionN1

J0129Abatacept injectionK2$20.26

J0130Abciximab injectionK2$515.32

J0132Acetylcysteine injectionK2$2.67

J0133Acyclovir injectionN1

J0135Adalimumab injectionK2$394.16

J0150Injection adenosine 6 MGN1

J0152Adenosine injectionK2$89.99

J0171Adrenalin epinephrine injectN1

J0180Agalsidase beta injectionK2$133.65

J0200Alatrofloxacin mesylateN1

J0205Alglucerase injectionK2$41.19

J0207AmifostineK2$314.05

J0210Methyldopate hcl injectionK2$39.24

J0215AlefaceptK2$35.86

J0220Alglucosidase alfa injectionK2$155.84

J0256Alpha 1 proteinase inhibitorK2$3.79

J0278Amikacin sulfate injectionN1

J0280Aminophyllin 250 MG injN1

J0282Amiodarone HClN1

J0285Amphotericin BN1

J0287Amphotericin b lipid complexK2$8.76

J0288Ampho b cholesteryl sulfateK2$13.74

J0289Amphotericin b liposome injK2$14.77

J0290Ampicillin 500 MG injN1

J0295Ampicillin sodium per 1.5 gmN1

J0300Amobarbital 125 MG injCHK2$23.38

J0330Succinycholine chloride injN1

J0348Anidulafungin injectionK2$1.29

J0360Hydralazine hcl injectionN1

J0364Apomorphine hydrochlorideN1

J0365"Aprotonin, 10,000 kiu"N1

J0380Inj metaraminol bitartrateN1

J0390Chloroquine injectionN1

J0400Aripiprazole injectionN1

J0456AzithromycinN1

J0461Atropine sulfate injectionN1

J0470Dimecaprol injectionN1

J0475Baclofen 10 MG injectionK2$200.54

J0476Baclofen intrathecal trialK2$72.18

J0480BasiliximabK2"$2,027.27"

J0500Dicyclomine injectionN1

J0515Inj benztropine mesylateCHN1

J0520Bethanechol chloride injectN1

J0558PenG benzathine/procaine injN1

J0561Penicillin g benzathine injN1

J0583BivalirudinK2$2.54

J0585"Injection,onabotulinumtoxinA"K2$5.38

J0586AbobotulinumtoxinAK2$7.41

J0587"Inj, rimabotulinumtoxinB"K2$10.33

J0592Buprenorphine hydrochlorideN1

J0594Busulfan injectionK2$16.29

J0595Butorphanol tartrate 1 mgN1

J0597"C-1 esterase, berinert"K2$27.53

J0598"C-1 esterase, cinryze"K2$43.78

J0600Edetate calcium disodium injK2$192.07

J0610Calcium gluconate injectionN1

J0620Calcium glycer & lact/10 MLN1

J0630Calcitonin salmon injectionCHN1
J0636Inj calcitriol per 0.1 mcgN1

J0637Caspofungin acetateK2$12.13

J0638Canakinumab injectionK2$87.45

J0640Leucovorin calcium injectionN1

J0641Levoleucovorin injectionK2$1.78

J0670Inj mepivacaine HCL/10 mlN1

J0690Cefazolin sodium injectionN1

J0692Cefepime HCl for injectionN1

J0694Cefoxitin sodium injectionN1

J0696Ceftriaxone sodium injectionN1

J0697Sterile cefuroxime injectionN1

J0698Cefotaxime sodium injectionN1

J0702Betamethasone acet&sod phospN1

J0706Caffeine citrate injectionN1

J0710Cephapirin sodium injectionN1

J0713Inj ceftazidime per 500 mgN1

J0715Ceftizoxime sodium / 500 MGN1

J0718Certolizumab pegol injK2$3.99

J0720Chloramphenicol sodium injecN1

J0725Chorionic gonadotropin/1000uN1

J0735Clonidine hydrochlorideCHN1

J0740Cidofovir injectionK2$740.09

J0743Cilastatin sodium injectionN1

J0744Ciprofloxacin ivN1

J0745Inj codeine phosphate /30 MGN1

J0760Colchicine injectionN1

J0770Colistimethate sodium injN1

J0775"Collagenase, clost hist inj"K2$37.51

J0780Prochlorperazine injectionN1

J0795Corticorelin ovine triflutalK2$5.06

J0800Corticotropin injectionK2"$2,395.22"

J0833Cosyntropin injection NOSK2$99.76

J0834Cosyntropin cortrosyn injCHN1

J0850Cytomegalovirus imm IV /vialK2$922.07

J0878Daptomycin injectionK2$0.45

J0881"Darbepoetin alfa, non-esrd"K2$2.98

J0885"Epoetin alfa, non-esrd"K2$9.57

J0894Decitabine injectionK2$30.71

J0895Deferoxamine mesylate injN1

J0900Testosterone enanthate injN1

J0945Brompheniramine maleate injCHN1

J1000Depo-estradiol cypionate injN1

J1020Methylprednisolone 20 MG injN1

J1030Methylprednisolone 40 MG injN1

J1040Methylprednisolone 80 MG injN1

J1051Medroxyprogesterone injN1

J1060Testosterone cypionate 1 MLN1

J1070Testosterone cypionat 100 MGN1

J1080Testosterone cypionat 200 MGN1

J1094Inj dexamethasone acetateN1

J1100Dexamethasone sodium phosN1

J1110Inj dihydroergotamine mesyltN1

J1120Acetazolamid sodium injectioN1

J1160Digoxin injectionN1

J1162Digoxin immune fab (ovine)K2$583.90

J1165Phenytoin sodium injectionN1

J1170Hydromorphone injectionN1

J1180Dyphylline injectionN1

J1190Dexrazoxane HCl injectionK2$274.42

J1200Diphenhydramine hcl injectioN1

J1205Chlorothiazide sodium injK2$272.64

J1212Dimethyl sulfoxide 50% 50 MLK2$82.68

J1230Methadone injectionN1

J1240Dimenhydrinate injectionN1

J1245Dipyridamole injectionN1

J1250Inj dobutamine HCL/250 mgN1
J1260Dolasetron mesylateN1

J1265Dopamine injectionN1

J1267Doripenem injectionN1

J1270"Injection, doxercalciferol"N1

J1290Ecallantide injectionK2$275.28

J1300Eculizumab injectionK2$183.71

J1320Amitriptyline injectionN1

J1324Enfuvirtide injectionN1

J1325Epoprostenol injectionN1

J1327Eptifibatide injectionK2$20.31

J1330Ergonovine maleate injectionN1

J1335Ertapenem injectionN1

J1364Erythro lactobionate /500 MGN1

J1380Estradiol valerate 10 MG injN1

J1410Inj estrogen conjugate 25 MGK2$94.03

J1430Ethanolamine oleate 100 mgK2$147.14

J1436Etidronate disodium injN1

J1438Etanercept injectionK2$203.01

J1440Filgrastim 300 mcg injectionK2$238.72

J1441Filgrastim 480 mcg injectionK2$376.20

J1450FluconazoleN1

J1451"Fomepizole, 15 mg"K2$6.76

J1453Fosaprepitant injectionK2$1.71

J1455Foscarnet sodium injectionCHK2$13.06

J1457Gallium nitrate injectionCHN1

J1458Galsulfase injectionK2$338.26

J1459Inj IVIG privigen 500 mgK2$34.45

J1460Gamma globulin 1 CC injK2$17.91

J1559Hizentra injectionK2$7.15

J1560Gamma globulin > 10 CC injK2$179.06

J1561Gamunex injectionK2$36.91

J1562"Vivaglobin, inj"K2$7.11

J1566"Immune globulin, powder"K2$30.62

J1568Octagam injectionK2$55.80

J1569Gammagard liquid injectionK2$37.67

J1570Ganciclovir sodium injectionCHK2$62.51

J1571Hepagam b im injectionK2$57.07

J1572Flebogamma injectionK2$35.04

J1573"Hepagam b intravenous, inj"K2$57.07

J1580Garamycin gentamicin injN1

J1590Gatifloxacin injectionN1

J1595Injection glatiramer acetateK2$95.57

J1599"Ivig non-lyophilized, NOS"N1

J1600Gold sodium thiomaleate injN1

J1610Glucagon hydrochloride/1 MGK2$95.59

J1620Gonadorelin hydroch/ 100 mcgCHK2$94.82

J1626Granisetron hcl injectionN1

J1630Haloperidol injectionN1

J1631Haloperidol decanoate injN1

J1640"Hemin, 1 mg"K2$8.33

J1642Inj heparin sodium per 10 uN1

J1644Inj heparin sodium per 1000uN1

J1645Dalteparin sodiumN1

J1650Inj enoxaparin sodiumN1

J1652Fondaparinux sodiumN1

J1655Tinzaparin sodium injectionN1

J1670Tetanus immune globulin injK2$222.97

J1680Human fibrinogen conc injK2$71.52

J1700Hydrocortisone acetate injN1

J1710Hydrocortisone sodium ph injN1

J1720Hydrocortisone sodium succ iN1

J1730Diazoxide injectionCHN1

J1740Ibandronate sodium injectionK2$144.36

J1742Ibutilide fumarate injectionK2$129.32

J1743Idursulfase injectionK2$446.45

J1745Infliximab injectionK2$58.90
J1750Inj iron dextranK2$11.59

J1756Iron sucrose injectionCHN1

J1786Imuglucerase injectionK2$41.19

J1790Droperidol injectionN1

J1800Propranolol injectionN1

J1815Insulin injectionN1

J1817Insulin for insulin pump useN1

J1830Interferon beta-1b / .25 MGK2$197.14

J1835Itraconazole injectionCHK2$359.59

J1840Kanamycin sulfate 500 MG injN1

J1850Kanamycin sulfate 75 MG injN1

J1885Ketorolac tromethamine injN1

J1890Cephalothin sodium injectionN1

J1930Lanreotide injectionK2$29.92

J1931Laronidase injectionK2$25.08

J1940Furosemide injectionN1

J1945LepirudinK2$299.56

J1950Leuprolide acetate /3.75 MGK2$547.54

J1953Levetiracetam injectionN1

J1956Levofloxacin injectionN1

J1960Levorphanol tartrate injN1

J1980Hyoscyamine sulfate injN1

J1990Chlordiazepoxide injectionN1

J2001Lidocaine injectionN1

J2010Lincomycin injectionN1

J2020Linezolid injectionK2$33.99

J2060Lorazepam injectionN1

J2150Mannitol injectionN1

J2170Mecasermin injectionK2$20.18

J2175Meperidine hydrochl /100 MGN1

J2180Meperidine/promethazine injN1

J2185MeropenemN1

J2210Methylergonovin maleate injN1

J2248Micafungin sodium injectionK2$1.02

J2250Inj midazolam hydrochlorideN1

J2260Inj milrinone lactate / 5 MGN1

J2270Morphine sulfate injectionN1

J2271Morphine so4 injection 100mgN1

J2275Morphine sulfate injectionN1

J2278Ziconotide injectionK2$6.48

J2280"Inj, moxifloxacin 100 mg"N1

J2300Inj nalbuphine hydrochlorideN1

J2310Inj naloxone hydrochlorideN1

J2315"Naltrexone, depot form"K2$2.77

J2320Nandrolone decanoate 50 MGCHN1

J2323Natalizumab injectionK2$9.88

J2325Nesiritide injectionK2$43.93

J2353"Octreotide injection, depot"K2$113.48

J2354"Octreotide inj, non-depot"N1

J2355Oprelvekin injectionK2$240.88

J2357Omalizumab injectionK2$20.64

J2358Olanzapine long-acting injK2$2.70

J2360Orphenadrine injectionN1

J2370Phenylephrine hcl injectionN1

J2400Chloroprocaine hcl injectionN1

J2405Ondansetron hcl injectionN1

J2410Oxymorphone hcl injectionN1

J2425Palifermin injectionK2$11.15

J2426Paliperidone palmitate injK2$6.45

J2430Pamidronate disodium /30 MGN1

J2440Papaverin hcl injectionN1

J2469Palonosetron hclK2$18.51

J2501ParicalcitolN1

J2503Pegaptanib sodium injectionK2"$1,002.20"

J2504"Pegademase bovine, 25 iu"K2$242.67

J2505"Injection, pegfilgrastim 6mg"K2"$2,527.87"
J2510Penicillin g procaine injCHN1

J2513Pentastarch 10% solutionK2$158.76

J2515Pentobarbital sodium injN1

J2540Penicillin g potassium injN1

J2543Piperacillin/tazobactamN1

J2550Promethazine hcl injectionN1

J2560Phenobarbital sodium injN1

J2562Plerixafor injectionK2$278.36

J2590Oxytocin injectionN1

J2597Inj desmopressin acetateCHK2$3.93

J2650Prednisolone acetate injN1

J2670Totazoline hcl injectionN1

J2675Inj progesterone per 50 MGN1

J2680Fluphenazine decanoate 25 MGN1

J2690Procainamide hcl injectionN1

J2700Oxacillin sodium injecitonCHN1

J2710Neostigmine methylslfte injN1

J2720Inj protamine sulfate/10 MGN1

J2724Protein c concentrateK2$12.50

J2725Inj protirelin per 250 mcgCHK2$27.03

J2730Pralidoxime chloride injK2$88.57

J2760Phentolaine mesylate injCHK2$56.35

J2765Metoclopramide hcl injectionN1

J2770Quinupristin/dalfopristinK2$157.23

J2778Ranibizumab injectionK2$398.10

J2780Ranitidine hydrochloride injN1

J2783RasburicaseK2$183.08

J2785Regadenoson injectionK2$51.36

J2788Rho d immune globulin 50 mcgK2$24.81

J2790Rho d immune globulin injK2$82.16

J2791Rhophylac injectionK2$5.09

J2792"Rho(D) immune globulin h, sd"K2$18.83

J2793Rilonacept injectionK2$23.63

J2794"Risperidone, long acting"K2$4.93

J2795Ropivacaine HCl injectionN1

J2796Romiplostim injectionK2$44.84

J2800Methocarbamol injectionN1

J2805Sincalide injectionCHN1

J2810Inj theophylline per 40 MGN1

J2820Sargramostim injectionK2$23.62

J2850Inj secretin synthetic humanK2$26.97

J2910Aurothioglucose injecitonN1

J2916Na ferric gluconate complexN1

J2920Methylprednisolone injectionN1

J2930Methylprednisolone injectionN1

J2941Somatropin injectionK2$56.09

J2950Promazine hcl injectionN1

J2993Reteplase injectionK2"$1,332.35"

J2995Inj streptokinase /250000 IUK2$47.57

J2997Alteplase recombinantK2$39.22

J3000Streptomycin injectionN1

J3010Fentanyl citrate injecitonN1

J3030Sumatriptan succinate / 6 MGN1

J3070Pentazocine injectionN1

J3095Televancin injectionK2$1.96

J3101Tenecteplase injectionK2$51.95

J3105Terbutaline sulfate injN1

J3120Testosterone enanthate injN1

J3130Testosterone enanthate injN1

J3140Testosterone suspension injN1

J3150Testosteron propionate injN1

J3230Chlorpromazine hcl injectionN1

J3240Thyrotropin injectionK2"$1,034.03"

J3243Tigecycline injectionK2$1.22

J3246Tirofiban HClK2$8.83

J3250Trimethobenzamide hcl injN1
J3260Tobramycin sulfate injectionN1

J3262Tocilizumab injectionK2$3.47

J3265Injection torsemide 10 mg/mlN1

J3280Thiethylperazine maleate injN1

J3285Treprostinil injectionK2$60.08

J3300Triamcinolone A inj PRS-freeK2$3.17

J3301Triamcinolone acet inj NOSN1

J3302Triamcinolone diacetate injN1

J3303Triamcinolone hexacetonl injN1

J3310Perphenazine injecitonK2$30.91

J3315Triptorelin pamoateK2$193.59

J3350Urea injectionK2$82.18

J3355"Urofollitropin, 75 iu"K2$63.60

J3357Ustekinumab injectionK2$112.30

J3360Diazepam injectionN1

J3364Urokinase 5000 IU injectionN1

J3365"Urokinase 250,000 IU inj"K2$449.09

J3370Vancomycin hcl injectionN1

J3385Velaglucerase alfaK2$349.88

J3396Verteporfin injectionK2$9.55

J3410Hydroxyzine hcl injectionN1

J3411Thiamine hcl 100 mgN1

J3415Pyridoxine hcl 100 mgN1

J3420Vitamin b12 injectionN1

J3430Vitamin k phytonadione injN1

J3465"Injection, voriconazole"K2$6.02

J3470Hyaluronidase injectionN1

J3471"Ovine, up to 999 USP units"N1

J3472"Ovine, 1000 USP units"N1

J3473Hyaluronidase recombinantN1

J3475Inj magnesium sulfateN1

J3480Inj potassium chlorideN1

J3485ZidovudineN1

J3486Ziprasidone mesylateN1

J3487Zoledronic acidK2$219.00

J3488Reclast injectionK2$218.47

J3490Drugs unclassified injectionN1

J3530Nasal vaccine inhalationN1

J3590Unclassified biologicsN1

J7030Normal saline solution infusN1

J7040Normal saline solution infusN1

J70425% dextrose/normal salineN1

J7050Normal saline solution infusN1

J70605% dextrose/waterN1

J7070D5w infusionN1

J7100Dextran 40 infusionN1

J7110Dextran 75 infusionN1

J7120Ringers lactate infusionN1

J7130Hypertonic saline solutionN1

J7184Wilate injectionK2$70.14

J7185Xyntha injK2$1.05

J7186Antihemophilic viii/vwf compK2$0.90

J7187"Humate-P, inj"K2$0.87

J7189Factor viiaK2$1.50

J7190Factor viiiK2$0.87

J7191Factor VIII (porcine)K2$1.17

J7192Factor viii recombinant NOSK2$1.09

J7193Factor IX non-recombinantK2$0.88

J7194Factor ix complexK2$0.85

J7195Factor IX recombinantK2$1.13

J7196Antithrombin recombinantK2$101.40

J7197Antithrombin iii injectionK2$2.48

J7198Anti-inhibitorK2$1.57

J7308Aminolevulinic acid hcl topK2$138.70

J7309"Methyl aminolevulinate, top"K2$68.27

J7310Ganciclovir long act implantK2"$16,640.00"
J7311Fluocinolone acetonide impltK2"$18,980.00"

J7312Dexamethasone intra implantK2$194.17

J7321Hyalgan/supartz inj per doseK2$88.80

J7323Euflexxa inj per doseK2$147.16

J7324Orthovisc inj per doseK2$167.00

J7325Synvisc or Synvisc-OneK2$11.81

J7335Capsaicin 8% patchK2$25.55

J7500Azathioprine oral 50mgN1

J7501Azathioprine parenteralK2$104.77

J7502Cyclosporine oral 100 mgN1

J7504Lymphocyte immune globulinK2$542.36

J7505Monoclonal antibodiesK2"$1,112.14"

J7506Prednisone oralN1

J7507Tacrolimus oral per 1 MGN1

J7509Methylprednisolone oralN1

J7510Prednisolone oral per 5 mgN1

J7511Antithymocyte globuln rabbitK2$387.17

J7513"Daclizumab, parenteral"K2$516.41

J7515Cyclosporine oral 25 mgN1

J7516Cyclosporin parenteral 250mgN1

J7517Mycophenolate mofetil oralN1

J7518Mycophenolic acidN1

J7520"Sirolimus, oral"N1

J7525Tacrolimus injectionK2$136.85

J7599Immunosuppressive drug nocN1

J7674"Methacholine chloride, neb"N1

J7799Non-inhalation drug for DMEN1

J8501Oral aprepitantK2$5.90

J8510Oral busulfanK2$3.59

J8520"Capecitabine, oral, 150 mg"K2$6.81

J8521"Capecitabine, oral, 500 mg"K2$22.48

J8530Cyclophosphamide oral 25 MGN1

J8540Oral dexamethasoneN1

J8560Etoposide oral 50 MGK2$34.34

J8562Oral fludarabine phosphateK2$79.44

J8597Antiemetic drug oral NOSN1

J8600Melphalan oral 2 MGN1

J8610Methotrexate oral 2.5 MGN1

J8700TemozolomideK2$9.31

J8705Topotecan oralK2$76.40

J9000Doxorubicin hcl injectionN1

J9001Doxorubicin hcl liposome injK2$504.27

J9010Alemtuzumab injectionK2$577.60

J9015Aldesleukin injectionK2$915.45

J9017Arsenic trioxide injectionK2$40.13

J9020Asparaginase injectionK2$62.07

J9025Azacitidine injectionK2$5.16

J9027Clofarabine injectionK2$114.37

J9031Bcg live intravesical vacK2$114.38

J9033Bendamustine injectionK2$18.15

J9035Bevacizumab injectionK2$58.72

J9040Bleomycin sulfate injectionN1

J9041Bortezomib injectionK2$39.60

J9045Carboplatin injectionN1

J9050Carmustine injectionK2$172.56

J9055Cetuximab injectionK2$49.52

J9060Cisplatin 10 MG injectionN1

J9065Inj cladribine per 1 MGK2$23.59

J9070Cyclophosphamide 100 MG injN1

J9098Cytarabine liposome injK2$479.02

J9100Cytarabine hcl 100 MG injN1

J9120Dactinomycin injectionK2$529.42

J9130Dacarbazine 100 mg injN1

J9150Daunorubicin injectionK2$13.16

J9151Daunorubicin citrate injK2$56.58

J9155Degarelix injectionK2$2.79
J9160Denileukin diftitox injK2"$1,559.54"

J9171Docetaxel injectionK2$20.84

J9175Elliotts b solution per mlN1

J9178"Inj, epirubicin hcl, 2 mg"K2$1.87

J9181Etoposide injectionN1

J9185Fludarabine phosphate injCHN1

J9190Fluorouracil injectionN1

J9200Floxuridine injectionK2$36.60

J9201Gemcitabine hcl injectionK2$111.40

J9202Goserelin acetate implantK2$195.16

J9206Irinotecan injectionCHN1

J9207Ixabepilone injectionK2$62.53

J9208Ifosfomide injectionK2$31.21

J9209Mesna injectionN1

J9211Idarubicin hcl injectionK2$46.43

J9212Interferon alfacon-1 injCHN1

J9214Interferon alfa-2b injK2$16.19

J9215Interferon alfa-n3 injK2$20.87

J9216Interferon gamma 1-b injK2$549.62

J9217Leuprolide acetate suspnsionK2$210.96

J9218Leuprolide acetate injecitonK2$4.88

J9219Leuprolide acetate implantK2"$4,728.88"

J9225Vantas implantK2"$3,223.57"

J9226Supprelin LA implantK2"$15,184.53"

J9230Mechlorethamine hcl injK2$154.88

J9245Inj melphalan hydrochl 50 MGK2"$1,272.01"

J9250Methotrexate sodium injN1

J9260Methotrexate sodium injN1

J9261Nelarabine injectionK2$110.19

J9263OxaliplatinK2$8.36

J9264Paclitaxel protein boundK2$9.21

J9265Paclitaxel injectionCHN1

J9266Pegaspargase injectionK2"$2,675.40"

J9268Pentostatin injectionK2"$1,068.16"

J9270Plicamycin (mithramycin) injN1

J9280Mitomycin 5 MG injK2$20.36

J9293Mitoxantrone hydrochl / 5 MGK2$33.95

J9300Gemtuzumab ozogamicin injK2"$2,637.02"

J9302Ofatumumab injectionK2$45.41

J9303Panitumumab injectionK2$85.62

J9305Pemetrexed injectionK2$51.37

J9307Pralatrexate injectionK2$165.63

J9310Rituximab injectionK2$599.16

J9315Romidepsin injectionK2$219.30

J9320Streptozocin injectionK2$264.81

J9328Temozolomide injectionK2$4.86

J9330Temsirolimus injectionK2$49.87

J9340Thiotepa injectionK2$106.54

J9351Topotecan injectionK2$19.30

J9355Trastuzumab injectionK2$69.06

J9357Valrubicin injectionK2$946.64

J9360Vinblastine sulfate injN1

J9370Vincristine sulfate 1 MG injN1

J9390Vinorelbine tartrate injN1

J9395"Injection, Fulvestrant"K2$81.81

J9600Porfimer sodium injectionK2"$3,017.82"

J9999Chemotherapy drugN1

L8600Implant breast silicone/eqN1

L8603Collagen imp urinary 2.5 mlN1

L8604Dextranomer/hyaluronic acidN1

L8606Synthetic implnt urinary 1mlN1

L8609Artificial corneaN1

L8610Ocular implantN1

L8612Aqueous shunt prosthesisN1

L8613Ossicular implantN1

L8614Cochlear deviceN1
L8630Metacarpophalangeal implantN1

L8631MCP joint repl 2 pc or moreN1

L8641Metatarsal joint implantN1

L8642Hallux implantN1

L8658Interphalangeal joint spacerN1

L8659Interphalangeal joint replN1

L8670"Vascular graft, synthetic"N1

L8682Implt neurostim radiofq recN1

L8690"Aud osseo dev, int/ext comp"N1

L8699Prosthetic implant NOSN1

P9041"Albumin (human),5%, 50ml"K2$20.37

P9045"Albumin (human), 5%, 250 ml"K2$67.07

P9046"Albumin (human), 25%, 20 ml"K2$29.16

P9047"Albumin (human), 25%, 50ml"K2$70.39

Q0138"Ferumoxytol, non-esrd"K2$0.69

Q0163Diphenhydramine HCl 50mgN1

Q0164Prochlorperazine maleate 5mgN1

Q0166Granisetron hcl 1 mg oralN1

Q0167Dronabinol 2.5mg oralN1

Q0169Promethazine HCl 12.5mg oralN1

Q0171Chlorpromazine HCl 10mg oralN1

Q0173Trimethobenzamide HCl 250mgN1

Q0175Perphenazine 4mg oralN1

Q0177Hydroxyzine pamoate 25mgN1

Q0179Ondansetron hcl 8 mg oralN1

Q0180Dolasetron mesylate oralN1

Q0515Sermorelin acetate injectionK2$1.76

Q2004Bladder calculi irrig solN1

Q2009Fosphenytoin inj PEN1

Q2017"Teniposide, 50 mg"K2$316.52

Q2035**"Afluria vacc, 3 yrs & >, im"L1

Q2036**"Flulaval vacc, 3 yrs & >, im"L1

Q2037**"Fluvirin vacc, 3 yrs & >, im"L1

Q2038**"Fluzone vacc, 3 yrs & >, im"L1

Q2039**"NOS flu vacc, 3 yrs & >, im"L1

Q2040Incobotulinumtoxin AK2$5.57

Q3025IM inj interferon beta 1-aK2$220.75

Q4100"Skin substitute, NOS"N1

Q4101ApligrafK2$34.06

Q4102Oasis wound matrixK2$4.68

Q4103Oasis burn matrixCHN1

Q4104Integra BMWDK2$15.45

Q4105Integra DRTK2$10.95

Q4106DermagraftK2$39.39

Q4107GraftjacketK2$92.79

Q4108Integra matrixK2$20.95

Q4110PrimatrixK2$31.67

Q4111GammagraftK2$7.17

Q4112Cymetra injectableK2$334.07

Q4113Graftjacket xpressK2$334.07

Q4114Integra flowable wound matriK2$972.75

Q4115AlloskinK2$6.07

Q4116AllodermK2$31.11

Q4118Matristem micromatrixK2$3.13

Q4119Matristem wound matrixK2$6.04

Q4121TheraskinK2$20.32

Q9951"LOCM >= 400 mg/ml iodine,1ml"N1

Q9953"Inj Fe-based MR contrast,1ml"N1

Q9954"Oral MR contrast, 100 ml"N1

Q9955"Inj perflexane lip micros,ml"N1

Q9956"Inj octafluoropropane mic,ml"N1

Q9957"Inj perflutren lip micros,ml"N1

Q9958"HOCM <=149 mg/ml iodine, 1ml"N1

Q9959"HOCM 150-199mg/ml iodine,1ml"N1

Q9960"HOCM 200-249mg/ml iodine,1ml"N1

Q9961"HOCM 250-299mg/ml iodine,1ml"N1
Q9962"HOCM 300-349mg/ml iodine,1ml"N1

Q9963"HOCM 350-399mg/ml iodine,1ml"N1

Q9964"HOCM>= 400mg/ml iodine, 1ml"N1

Q9965"LOCM 100-199mg/ml iodine,1ml"N1

Q9966"LOCM 200-299mg/ml iodine,1ml"N1

Q9967"LOCM 300-399mg/ml iodine,1ml"N1

Q9968Visualization adjunctCHN1

V2630Anter chamber intraocul lensN1

V2631Iris support intraoclr lensN1

V2632Post chmbr intraocular lensN1

V2785Corneal tissue processingF4

V2790Amniotic membraneN1

NOTE 1: The Medicare program payment is 80 percent of the total payment amount and 

beneficiary coinsurance is 20 percent of the total payment amount. Sections 4104 and 

10406 of the Affordable Care Act (ACA) waive coinsurance and the Part B deductible for 

most preventive services. These preventive services are identified with a double 

asterisk (**).

"NOTE 2: In general, payment indicators for radiology services (Z2, Z3) are based on a 

comparison of the proposed rates according to the ASC standard ratesetting methodology 

and the MPFS proposed rates. Under current law, the MPFS payment rates will have a 

negative update for CY 2012. For a discussion of those rates, we refer readers to the CY 

2012 MPFS proposed rule."