2015 Addendum A List of APCs - AHD.com · 2020. 6. 5. · 2015 Addendum A List of APCs 0209 Level II Extended EEG, Sleep, and Cardiovascular Studies S 3.1121 230.83 68.11 46.17 0213

2015 Addendum A List of APCs

APC Group Title

Status

Indicator

Relative

Weight Payment Rate

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

0004 Level I Needle Biopsy/ Aspiration Except Bone Marrow T 6.5703 487.34 97.47

0005 Level II Needle Biopsy/Aspiration Except Bone Marrow T 14.1916 1052.63 210.53

0006 Level I Incision & Drainage T 2.1836 161.96 32.4

0007 Level II Incision & Drainage T 11.6749 865.96 173.2

0008 Level III Incision and Drainage T 22.0535 1635.77 327.16

0012 Level I Debridement & Destruction T 1.3279 98.49 19.7

0015 Level II Debridement & Destruction T 1.9702 146.14 29.23

0016 Level III Debridement & Destruction T 3.8173 283.14 56.63

0017 Level IV Debridement & Destruction T 17.361 1287.72 257.55

0019 Level I Excision/ Biopsy T 5.1037 378.56 75.72

0020 Level II Excision/ Biopsy T 11.144 826.58 165.32

0021 Level III Excision/ Biopsy T 18.0849 1341.41 268.29

0022 Level IV Excision/ Biopsy T 24.5953 1824.31 364.87

0028 Level I Breast and Skin Surgery T 29.2241 2167.64 433.53

0029 Level II Breast and Skin Surgery T 40.6181 3012.77 602.56

0030 Level III Breast and Skin Surgery T 55.9563 4150.45 830.09

0031 Level I Health and Behavior Services S 0.3508 26.02 5.21

0034 Mental Health Services Composite S 2.6384 195.7 39.14

0039 Level III Neurostimulator & Related Procedures J1 230.6235 17106.04 3421.21

0041 Level I Arthroscopy T 29.0075 2151.57 430.32

0042 Level II Arthroscopy T 58.5867 4345.55 869.11

0045 Bone/Joint Manipulation Under Anesthesia T 15.5135 1150.68 256.86 230.14

0047 Arthroplasty T 45.3575 3364.3 672.86

0049 Level I Musculoskeletal Procedures Except Hand and Foot T 22.3913 1660.83 332.17

0050 Level II Musculoskeletal Procedures Except Hand and Foot T 35.0819 2602.13 520.43

0051 Level III Musculoskeletal Procedures Except Hand and Foot T 50.7327 3763 752.6

0052 Level IV Musculoskeletal Procedures Except Hand and Foot T 85.2438 6322.79 1264.56

0053 Level I Hand Musculoskeletal Procedures T 16.5603 1228.33 245.67

0054 Level II Hand Musculoskeletal Procedures T 29.7967 2210.11 442.03

0055 Level I Foot Musculoskeletal Procedures T 23.5061 1743.52 353.37 348.71

0056 Level II Foot Musculoskeletal Procedures T 70.3645 5219.15 1043.83

0057 Bunion Procedures T 36.084 2676.46 535.3

0058 Level II Strapping and Cast Application S 3.0104 223.29 44.66

0059 Level I Strapping and Cast Application S 1.724 127.87 25.58

0060 Manipulation Therapy S 0.2673 19.83 3.97

0061 Level II Neurostimulator & Related Procedures J1 71.3285 5290.65 1058.13

0062 Level I Treatment Fracture/Dislocation T 27.539 2042.65 408.53

0063 Level II Treatment Fracture/Dislocation T 57.0073 4228.4 845.68

0064 Level III Treatment Fracture/Dislocation T 75.0875 5569.47 1113.9

0066 Level V Radiation Therapy S 25.6592 1903.22 380.65

0067 Single Session Cranial Stereotactic Radiosurgery J1 131.7086 9769.22 1953.85

0069 Thoracoscopy T 41.4417 3073.86 614.78

0070 Thoracentesis/Lavage Procedures T 6.5974 489.35 97.87

0071 Level I Endoscopy Upper Airway T 2.0314 150.68 30.14

0072 Level II Endoscopy Upper Airway T 5.2094 386.4 77.28

0073 Level III Endoscopy Upper Airway T 16.9813 1259.55 251.91

0074 Level IV Endoscopy Upper Airway T 27.1023 2010.26 402.06

0075 Level V Endoscopy Upper Airway T 41.4 3070.76 614.16

0076 Level I Endoscopy Lower Airway T 14.2251 1055.12 211.03

0077 Pulmonary Treatment S 2.2195 164.63 32.93

0079 Ventilation Initiation and Management S 5.0449 374.2 74.84

0080 Diagnostic Cardiac Catheterization T 34.7342 2576.34 792.62 515.27

0083 Level I Endovascular Procedures J1 61.1978 4539.22 907.85

0084 Level I Electrophysiologic Procedures J1 11.7733 873.26 174.66

0085 Level II Electrophysiologic Procedures J1 62.491 4635.14 927.03

0086 Level III Electrophysiologic Procedures J1 193.6316 14362.24 2872.45

0088 Thrombectomy T 43.4236 3220.86 645.07 644.18

0089 Level III Pacemaker and Similar Procedures J1 127.9907 9493.45 1898.69

0090 Level II Pacemaker and Similar Procedures J1 88.2442 6545.34 1309.07

0093 Vascular Reconstruction/Fistula Repair T 33.7207 2501.17 500.24

0094 Resuscitation and Cardioversion S 6.3433 470.5 94.1

0095 Cardiac Rehabilitation S 1.3927 103.3 20.66

0096 Level II Noninvasive Physiologic Studies S 4.4459 329.77 65.96

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0097 Level I Noninvasive Physiologic Studies S 1.5196 112.71 22.55

0099 Electrocardiograms/Cardiography S 1.0579 78.47 15.7

0100 Cardiac Stress Tests S 3.2093 238.04 47.61

0103 Miscellaneous Vascular Procedures T 21.2483 1576.05 315.21

0105 Level I Pacemaker & Similar Procedures T 31.6455 2347.24 469.45

0107 Level I ICD and Similar Procedures J1 308.9615 22916.6 4583.32

0108 Level II ICD and Similar Procedures J1 415.4941 30818.44 6163.69

0110 Transfusion S 4.0082 297.3 59.46

0111 Blood Product Exchange S 14.2289 1055.4 211.08

0112 Apheresis and Stem Cell Procedures S 38.3671 2845.8 569.16

0113 Excision Lymphatic System T 31.6086 2344.5 468.9

0114 Thyroid/Lymphadenectomy Procedures T 57.1584 4239.61 847.93

0121 Level I Tube or Catheter Changes or Repositioning T 6.58 488.06 97.62

0126 Level I Urinary and Anal Procedures T 1.5266 113.23 22.65

0129 Level I Closed Treatment Fracture T 2.2797 169.09 33.82

0130 Level I Laparoscopy T 40.6743 3016.93 659.53 603.39

0131 Level II Laparoscopy T 50.9538 3779.4 1001.89 755.88

0132 Level III Laparoscopy T 73.8696 5479.13 1236.99 1095.83

0138 Level II Closed Treatment Fracture T 2.8828 213.83 42.77

0139 Level III Closed Treatment Fracture T 9.6161 713.25 142.65

0141 Level I Upper GI Procedures T 10.0522 745.6 149.12

0142 Level I Small Intestine Endoscopy T 11.4924 852.43 170.49

0143 Lower GI Endoscopy T 10.6489 789.86 186.06 157.98

0146 Level I Sigmoidoscopy and Anoscopy T 6.6559 493.69 98.74

0147 Level II Sigmoidoscopy and Anoscopy T 11.1553 827.42 165.49

0148 Level I Anal/Rectal Procedures T 5.9659 442.51 88.51

0149 Level III Anal/Rectal Procedures T 26.1743 1941.43 388.29

0150 Level IV Anal/Rectal Procedures T 35.0675 2601.06 520.22

0151 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) T 26.3312 1953.06 390.62

0152 Level I Percutaneous Abdominal and Biliary Procedures T 24.7191 1833.49 366.7

0153 Peritoneal and Abdominal Procedures T 30.8186 2285.91 457.19

0154 Hernia/Hydrocele Procedures T 36.0701 2675.43 535.09

0155 Level II Anal/Rectal Procedures T 19.6184 1455.16 291.04

0156 Level III Urinary and Anal Procedures T 5.0397 373.81 74.77

0157 Colorectal Cancer Screening: Barium Enema S 4.6315 343.53 0

0158 Colorectal Cancer Screening: Colonoscopy T 8.8312 655.04 0

0159 Colorectal Cancer Screening: Flexible Sigmoidoscopy S 6.3219 468.91 0

0160 Level I Cystourethroscopy and other Genitourinary Procedures T 7.4007 548.93 109.79

0161 Level II Cystourethroscopy and other Genitourinary Procedures T 16.5418 1226.95 245.39

0162 Level III Cystourethroscopy and other Genitourinary Procedures T 28.1079 2084.85 416.97

0163 Level IV Cystourethroscopy and other Genitourinary Procedures T 41.9797 3113.76 622.76

0164 Level II Urinary and Anal Procedures T 2.8822 213.78 42.76

0165 Level IV Urinary and Anal Procedures T 18.548 1375.76 275.16

0166 Level I Urethral Procedures T 21.9589 1628.76 325.76

0168 Level II Urethral Procedures T 33.834 2509.57 501.92

0170 Dialysis S 8.2721 613.57 122.72

0172 Level I Partial Hospitalization (3 services) for CMHCs P 1.3016 96.54 19.31

0173 Level II Partial Hospitalization (4 or more services) for CMHCs P 1.5406 114.27 22.86

0174 Level IV Laparoscopy T 108.7985 8069.91 1795.16 1613.99

0175 Level I Partial Hospitalization (3 services) for Hospital-based PHPs P 2.4157 179.18 35.84

0176 Level II Partial Hospitalization (4 or more services) for Hospital-based PHP 2.6384 195.7 39.14

0177 Level I Echocardiogram with Contrast S 6.6127 490.48 126.79 98.1

0178 Level II Echocardiogram with Contrast S 9.284 688.62 172.48 137.73

0181 Level II Male Genital Procedures T 30.1349 2235.2 447.04

0183 Level I Male Genital Procedures T 24.4318 1812.18 362.44

0184 Prostate Biopsy T 19.7147 1462.3 292.46

0188 Level I Gynecologic Procedures T 1.7659 130.98 26.2

0189 Level II Gynecologic Procedures T 3.0491 226.16 45.24

0192 Level III Gynecologic Procedures T 6.5691 487.25 97.45

0193 Level IV Gynecologic Procedures T 24.8904 1846.2 369.24

0202 Level V Gynecologic Procedures J1 53.6473 3979.18 981.5 795.84

0203 Level IV Nerve Injections T 19.819 1470.03 294.01

0204 Level I Nerve Injections T 2.8475 211.21 42.25

0205 Level III Male Genital Procedures T 46.059 3416.33 683.27

0206 Level II Nerve Injections T 5.0256 372.76 74.56

0207 Level III Nerve Injections T 9.0607 672.06 134.42

0208 Laminotomies and Laminectomies T 55.4537 4113.17 822.64



0209 Level II Extended EEG, Sleep, and Cardiovascular Studies S 3.1121 230.83 68.11 46.17

0213 Level I Extended EEG, Sleep, and Cardiovascular Studies S 2.3813 176.63 52.11 35.33

0215 Level I Nerve and Muscle Services S 1.2804 94.97 19

0216 Level III Nerve and Muscle Services S 3.6766 272.7 54.54

0218 Level II Nerve and Muscle Services S 2.1417 158.86 31.78

0219 Vascular Ligation T 29.2791 2171.72 434.35

0220 Level I Nerve Procedures T 18.66 1384.07 276.82

0221 Level II Nerve Procedures T 39.7387 2947.54 589.51

0224 Implantation of Catheter/Reservoir/Shunt T 49.3784 3662.54 732.51

0227 Implantation of Drug Infusion Device J1 209.9474 15572.43 3114.49

0229 Level II Endovascular Procedures J1 129.8028 9627.86 1925.58

0230 Level I Eye Tests & Treatments S 0.7019 52.06 10.42

0231 Level III Eye Tests & Treatments S 4.2389 314.41 62.89

0233 Level II Intraocular Procedures T 23.6288 1752.62 350.53

0238 Level I Extraocular, Repair, and Plastic Eye Procedures T 4.0224 298.35 59.67

0239 Level II Extraocular, Repair, and Plastic Eye Procedures T 9.4598 701.66 140.34

0240 Level III Extraocular, Repair, and Plastic Eye Procedures T 20.6904 1534.67 306.94

0242 Level IV Extraocular, Repair, and Plastic Eye Procedures T 35.9699 2668 533.6

0247 Laser Eye Procedures T 5.981 443.63 102.26 88.73

0250 Level I ENT Procedures T 1.7489 129.72 25.95

0251 Level II ENT Procedures T 4.8979 363.29 72.66

0252 Level III ENT Procedures T 8.7183 646.66 129.34

0253 Level IV ENT Procedures T 17.0798 1266.86 253.38

0254 Level V ENT Procedures T 26.2386 1946.2 389.24

0255 Level I Intraocular Procedures T 10.1409 752.18 150.44

0256 Level VI ENT Procedures T 50.2882 3730.03 746.01

0259 Level VII ENT Procedures J1 400.6642 29718.47 7653.14 5943.7

0260 Level I Plain Film Including Bone Density Measurement S 0.8004 59.37 11.88

0261 Level II Plain Film Including Bone Density Measurement S 1.281 95.02 19.01

0263 Level I Miscellaneous Radiology Procedures S 4.5438 337.03 67.41

0265 Level I Diagnostic and Screening Ultrasound S 1.2362 91.69 22.26 18.34

0266 Level II Diagnostic and Screening Ultrasound S 1.8181 134.85 37.23 26.97

0267 Level III Diagnostic and Screening Ultrasound S 2.5565 189.62 37.93

0269 Level I Echocardiogram Without Contrast S 5.6995 422.75 84.55

0270 Level II Echocardiogram Without Contrast S 8.0142 594.44 128.73 118.89

0272 Fluoroscopy and Other Radiology Services S 2.1508 159.53 31.91

0274 Myelography S 8.2817 614.28 122.86

0275 Arthrography S 4.5657 338.65 68.76 67.73

0276 Level I Digestive Radiology S 1.371 101.69 32.79 20.34

0277 Level II Digestive Radiology S 2.0357 150.99 46.44 30.2

0278 Diagnostic Urography S 3.5761 265.25 58.44 53.05

0279 Level II Angiography and Venography S 34.5196 2560.42 512.09

0280 Level III Angiography and Venography S 71.7863 5324.61 1064.93

0283 Computed Tomography with Contrast S 3.2481 240.92 77.39 48.19

0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with ContrastS 5.7574 427.04 137.54 85.41

0293 Level IV Intraocular Procedures J1 113.9208 8449.85 1689.97

0300 Level I Radiation Therapy S 1.35 100.13 20.03

0301 Level II Radiation Therapy S 2.6053 193.24 38.65

0303 Treatment Device Construction S 2.9071 215.63 66.95 43.13

0304 Level I Therapeutic Radiation Treatment Preparation S 1.5257 113.17 34.18 22.64

0305 Level II Therapeutic Radiation Treatment Preparation S 4.2408 314.55 88.78 62.91

0308 Positron Emission Tomography (PET) imaging S 17.3409 1286.23 257.25

0310 Level III Therapeutic Radiation Treatment Preparation S 14.0014 1038.53 325.27 207.71

0312 Radioelement Applications S 5.3378 395.92 79.19

0313 Brachytherapy S 9.8375 729.68 258.4 145.94

0317 Level II Miscellaneous Radiology Procedures S 10.9636 813.2 162.64

0318 Level IV Neurostimulator & Related Procedures J1 352.7212 26162.39 5232.48

0319 Level III Endovascular Procedures J1 200.1597 14846.45 2969.29

0320 Electroconvulsive Therapy S 6.0169 446.29 89.26

0322 Brief Individual Psychotherapy S 1.2065 89.49 17.9

0323 Extended Individual Psychotherapy S 1.5574 115.52 23.11

0324 Family Psychotherapy S 1.6717 124 24.8

0325 Group Psychotherapy S 0.8905 66.05 13.21

0326 Level I Skin Procedures T 2.9651 219.93 43.99

0327 Level II Skin Procedures T 5.7989 430.12 86.03

0328 Level III Skin Procedures T 18.9748 1407.42 281.49

0329 Level IV Skin Procedures T 31.0293 2301.54 460.31



0330 Dental Procedures S 3.4106 252.97 50.6

0331 Combined Abdomen and Pelvis CT without Contrast S 3.1933 236.86 91.57 47.38

0332 Computed Tomography without Contrast S 1.6181 120.02 46.41 24.01

0333 Computed Tomography without Contrast followed by Contrast S 3.6362 269.71 93.67 53.95

0334 Combined Abdomen and Pelvis CT with Contrast S 5.0634 375.57 121.04 75.12

0336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without ContrS 3.8614 286.41 112.86 57.29

0337 Magnetic Resonance Imaging and Magnetic Resonance Angiography without ContrS 6.5129 483.08 173.76 96.62

0340 Level II Minor Procedures S 0.7061 52.37 10.48

0342 Level I Pathology S 0.7318 54.28 10.86

0345 Level I Transfusion Laboratory Procedures S 1.0256 76.07 15.22

0346 Level II Transfusion Laboratory Procedures S 1.6869 125.12 25.03

0351 Level V Intraocular Procedures J1 311.2228 23084.33 4616.87

0360 Level I Alimentary Tests S 1.9033 141.17 32.67 28.24

0361 Level II Alimentary Tests S 4.432 328.73 83.23 65.75

0363 Otorhinolaryngologic and Related Tests S 1.928 143.01 28.61

0364 Level I Audiometry S 0.5841 43.32 8.67

0365 Level II Audiometry S 1.5902 117.95 23.59

0367 Level I Pulmonary Tests S 2.1744 161.28 32.26

0369 Level II Pulmonary Tests S 3.1934 236.86 47.38

0373 Neuropsychological Testing S 2.6874 199.33 39.87

0375 Ancillary Outpatient Services When Patient Expires S 84.8146 6290.95 1258.19

0377 Level II Cardiac Imaging S 15.3768 1140.54 228.11

0378 Level II Pulmonary Imaging S 5.9367 440.34 126.64 88.07

0383 Cardiac Computed Tomographic Imaging S 2.9128 216.05 43.21

0384 GI Procedures with Stents J1 42.8063 3175.07 635.02

0385 Level I Urogenital Procedures J1 92.0148 6825.01 1365.01

0386 Level II Urogenital Procedures J1 188.3897 13973.43 2794.69

0388 Discography S 44.9321 3332.75 666.55

0389 Level I Non-imaging Nuclear Medicine S 2.5502 189.16 37.84

0390 Level I Endocrine Imaging S 2.5605 189.92 47.69 37.99

0391 Level II Endocrine Imaging S 3.8019 282 64.33 56.4

0392 Level II Non-imaging Nuclear Medicine S 3.7786 280.27 56.06

0393 Hematologic Processing & Studies S 8.4693 628.19 125.64

0394 Hepatobiliary Imaging S 5.0295 373.05 90.78 74.61

0395 GI Tract Imaging S 4.408 326.95 87.01 65.39

0396 Bone Imaging S 4.4802 332.31 94.2 66.47

0398 Level I Cardiac Imaging S 5.0364 373.56 91.01 74.72

0400 Hematopoietic Imaging S 4.983 369.6 90.9 73.92

0401 Level I Pulmonary Imaging S 4.2588 315.89 71.16 63.18

0402 Level II Nervous System Imaging S 7.5128 557.25 111.45

0403 Level I Nervous System Imaging S 2.3871 177.06 44.61 35.42

0404 Renal and Genitourinary Studies S 5.6713 420.66 84.14

0406 Level I Tumor/Infection Imaging S 5.0871 377.33 75.47

0407 Radionuclide Therapy S 3.7336 276.93 78.13 55.39

0408 Level III Tumor/Infection Imaging S 16.0266 1188.74 237.75

0412 Level III Radiation Therapy S 6.8455 507.75 101.55

0414 Level II Tumor/Infection Imaging S 9.5281 706.73 141.35

0415 Level II Endoscopy Lower Airway T 30.4203 2256.36 451.28

0419 Level II Upper GI Procedures T 14.3565 1064.86 212.98

0420 Level III Minor Procedures S 1.7762 131.75 26.35

0422 Level III Upper GI Procedures T 25.8201 1915.15 383.03

0423 Level II Percutaneous Abdominal and Biliary Procedures T 55.2208 4095.89 819.18

0424 Level II Small Intestine Endoscopy T 16.8444 1249.4 249.88

0425 Level V Musculoskeletal Procedures Except Hand and Foot J1 137.8399 10224 2044.8

0427 Level II Tube or Catheter Changes or Repositioning T 17.3792 1289.07 257.82

0428 Level III Sigmoidoscopy and Anoscopy T 22.3487 1657.67 331.54

0431 Level IV Closed Treatment Fracture T 17.6908 1312.18 262.44

0432 Level II Health and Behavior Services S 0.6773 50.24 10.05

0433 Level II Pathology S 2.4765 183.69 36.74

0435 Level III Extended EEG, Sleep, and Cardiovascular Studies S 11.5176 854.29 265.18 170.86

0436 Level I Drug Administration S 0.4393 32.58 6.52

0437 Level II Drug Administration S 0.7218 53.54 10.71

0438 Level III Drug Administration S 1.4593 108.24 21.65

0439 Level IV Drug Administration S 2.3404 173.59 34.72

0440 Level V Drug Administration S 3.8439 285.11 57.03

0442 Dosimetric Drug Administration S 15.5257 1151.59 230.32

0446 Level IV Nerve and Muscle Services S 17.5395 1300.96 260.2



0450 Level I Minor Procedures S 0.3942 29.24 5.85

0609 Level 1 Type A Emergency Visits V 0.8155 60.49 12.1





0617 Critical Care S 8.8569 656.94 131.39

0618 Trauma Response with Critical Care S 11.9898 889.32 177.87

0621 Level I Vascular Access Procedures T 11.372 843.5 168.7

0622 Level II Vascular Access Procedures T 30.1495 2236.28 447.26

0624 Phlebotomy and Minor Vascular Access Device Procedures S 1.0626 78.82 15.77

0626 Level 1 Type B Emergency Visits V 0.8456 62.72 12.55





0631 Level 1 Examinations & Related Services V 0.7242 53.72 10.75



0634 Hospital Clinic Visits V 1.2977 96.25 19.25

0648 Level IV Breast and Skin Surgery J1 100.6339 7464.32 1492.87

0651 Complex Interstitial Radiation Source Application S 12.8413 952.48 190.5

0652 Insertion of Intraperitoneal and Pleural Catheters T 30.85 2288.24 457.65

0655 Level IV Pacemaker and Similar Procedures J1 221.2044 16407.39 3281.48

0659 Hyperbaric Oxygen S 1.4734 109.29 21.86

0661 Level III Pathology S 3.9671 294.25 58.85

0662 CT Angiography S 3.8011 281.94 95.05 56.39

0667 Level IV Radiation Therapy S 14.4577 1072.37 214.48

0668 Level I Angiography and Venography T 11.1566 827.52 165.51

0673 Level III Intraocular Procedures T 42.0983 3122.56 635.64 624.52

0676 Thrombolysis and Other Device Revisions T 2.6317 195.2 39.04

0688 Level I Neurostimulator & Related Procedures T 28.7006 2128.81 484.65 425.77

0690 Level I Electronic Analysis of Devices S 0.4739 35.15 7.03

0691 Level III Electronic Analysis of Devices S 3.3374 247.54 49.51

0692 Level II Electronic Analysis of Devices S 1.7288 128.23 25.65

0698 Level II Eye Tests & Treatments S 1.3596 100.85 20.17

0701 Sr89 strontium K 1160.34 232.07

0726 Dexrazoxane HCl injection K 146.38 29.28

0731 Sargramostim injection K 31.68 6.34

0736 Amphotericin b liposome inj K 18.23 3.65

0738 Rasburicase K 227.61 45.52

0747 Chlorothiazide sodium inj K 119.93 23.99

0751 Mechlorethamine hcl inj K 241.99 48.4

0752 Dactinomycin injection K 1164.57 232.91

0759 Naltrexone, depot form K 3.18 0.64

0800 Leuprolide acetate K 900.87 180.17

0802 Etoposide oral K 68.74 13.75

0807 Aldesleukin injection K 2667.51 533.5

0809 Bcg live intravesical vac K 122.88 24.58

0810 Goserelin acetate implant K 281.05 56.21

0812 Carmustine injection K 2973.34 594.67

0814 Asparaginase, NOS K 64.56 12.91

0820 Daunorubicin injection K 26.45 5.29

0821 Daunorubicin citrate inj K 238.86 47.77

0823 Docetaxel injection K 3.49 0.7

0825 Nelarabine injection K 148.57 29.71

0827 Floxuridine injection K 67.69 13.54

0831 Ifosfamide injection K 32.2 6.44

0832 Idarubicin hcl injection K 34.88 6.98

0835 Cosyntropin injection NOS K 101.68 20.34

0836 Interferon alfa-2b inj K 24.05 4.81

0838 Interferon gamma 1-b inj K 5265.95 1053.19

0840 Inj melphalan hydrochl K 1285.4 257.08

0842 Fludarabine phosphate inj K 72.85 14.57

0843 Pegaspargase injection K 6189.74 1237.95

0844 Pentostatin injection K 1471.48 294.3

0849 Rituximab injection K 748.7 149.74



0850 Streptozocin injection K 324.02 64.8

0851 Thiotepa injection K 630.7 126.14

0856 Porfimer sodium injection K 20438.61 4087.72

0858 Inj cladribine K 20.91 4.18

0864 Mitoxantrone hydrochl K 32.12 6.42

0868 Oral aprepitant K 9.54 1.91

0873 Hyalgan/supartz inj per dose K 88.61 17.72

0874 Synvisc or synvisc-one K 12.87 2.57

0875 Euflexxa inj per dose K 152 30.4

0877 Orthovisc inj per dose K 172.63 34.53

0887 Azathioprine parenteral K 217.3 43.46

0890 Lymphocyte immune globulin K 1069.33 213.87

0901 Alpha 1 proteinase inhibitor K 4.45 0.89

0902 Injection,onabotulinumtoxinA K 5.72 1.14

0903 Cytomegalovirus imm IV /vial K 1064.77 212.95

0910 Interferon beta-1b / .25 MG K 357.22 71.44

0913 Ganciclovir long act implant K 16960 3392

0925 Factor viii K 0.96 0.19

0927 Factor viii recombinant K 1.16 0.23

0928 Factor ix complex K 1.19 0.24

0929 Anti-inhibitor K 1.83 0.37

0931 Factor IX non-recombinant K 1.07 0.21

0932 Factor ix recombinant nos K 1.46 0.29

0934 Capecitabine, oral K 19.5 3.9

0943 Octagam injection K 42.8 8.56

0944 Gammagard liquid injection K 38.56 7.71

0945 Rhophylac injection K 4.75 0.95

0946 Hepagam b im injection K 54.43 10.89

0947 Flebogamma injection K 35.66 7.13

0948 Gamunex-C/Gammaked K 40.3 8.06

0949 Frozen plasma, pooled, sd R 0.9341 69.28 13.86

0950 Whole blood for transfusion R 2.9289 217.25 43.45

0952 Cryoprecipitate each unit R 0.9548 70.82 14.17

0954 RBC leukocytes reduced R 2.5541 189.45 37.89

0955 Plasma, frz between 8-24hour R 0.9624 71.38 14.28

0956 Plasma protein fract,5%,50ml R 0.3108 23.05 4.61

0957 Platelets, each unit R 1.5552 115.35 23.07

0958 Plaelet rich plasma unit R 1.8326 135.93 27.19

0959 Red blood cells unit R 2.03 150.57 30.12

0960 Washed red blood cells unit R 4.3185 320.32 64.07

0961 Albumin (human),5%, 50ml K 10.91 2.18

0963 Albumin (human), 5%, 250 ml K 54.54 10.91

0964 Albumin (human), 25%, 20 ml K 22.49 4.5

0965 Albumin (human), 25%, 50ml K 53.44 10.69

0966 Plasmaprotein fract,5%,250ml R 0.4535 33.64 6.73

0967 Blood split unit R 1.7588 130.46 26.1

0968 Platelets leukoreduced irrad R 2.1875 162.25 32.45

0969 RBC leukoreduced irradiated R 3.7139 275.47 55.1

1009 Cryoprecipitatereducedplasma R 1.0592 78.56 15.72

1010 Blood, l/r, cmv-neg R 2.2109 163.99 32.8

1011 Platelets, hla-m, l/r, unit R 9.4963 704.37 140.88

1013 Platelets leukocytes reduced R 1.5117 112.13 22.43

1015 Injection glatiramer acetate K 194.25 38.85

1016 Blood, l/r, froz/degly/wash R 3.292 244.18 48.84

1017 Plt, aph/pher, l/r, cmv-neg R 5.3132 394.1 78.82

1018 Blood, l/r, irradiated R 1.8137 134.53 26.91

1019 Plate pheres leukoredu irrad R 9.0926 674.43 134.89

1020 Plt, pher, l/r cmv-neg, irr R 8.8777 658.49 131.7

1021 RBC, frz/deg/wsh, l/r, irrad R 6.0513 448.84 89.77

1022 RBC, l/r, cmv-neg, irrad R 3.7045 274.77 54.96

1023 Pralidoxime chloride inj K 91.9 18.38

1052 Injection, voriconazole K 4.19 0.84

1064 I131 iodide cap, rx K 40.7 8.14

1083 Adalimumab injection K 742.96 148.59

1086 Temozolomide K 2.66 0.53

1138 Hepagam b intravenous, inj K 54.43 10.89

1139 Protein c concentrate K 15.12 3.02



1142 Supprelin LA implant K 22170.84 4434.17

1150 I131 iodide sol, rx K 10.28 2.06

1166 Cytarabine liposome inj K 576.48 115.3

1168 Inj, temsirolimus K 62.5 12.5

1178 Busulfan injection K 33.2 6.64

1203 Verteporfin injection K 10.99 2.2

1207 Octreotide injection, depot K 156.94 31.39

1213 Antihemophilic viii/vwf comp K 0.96 0.19

1214 Inj IVIG privigen 500 mg K 38.05 7.61

1232 Mitomycin injection K 73.03 14.61

1235 Valrubicin injection K 1117.31 223.46

1236 Levoleucovorin injection K 1.92 0.38

1237 Inj iron dextran K 12.08 2.42

1238 Topotecan oral K 101.36 20.27

1253 Triamcinolone A inj PRS-free K 3.72 0.74

1263 Antithrombin iii injection K 3.37 0.67

1268 Xyntha inj K 1.42 0.28

1272 Acetylcysteine injection K 2 0.4

1274 Edetate calcium disodium inj K 5594.42 1118.88

1280 Corticotropin injection K 3468.13 693.63

1281 Bevacizumab injection K 1.74 0.35

1289 AbobotulinumtoxinA K 8.06 1.61

1291 Rilonacept injection K 24.09 4.82

1295 Sm 153 lexidronam K 10962.42 2192.48

1296 Degarelix injection K 3.59 0.72

1297 Ferumoxytol, non-esrd K 0.81 0.16

1311 Canakinumab injection K 91.78 18.36

1312 Hizentra injection K 8.47 1.69

1327 Imiglucerase injection K 42 8.4

1331 Olanzapine long-acting inj K 2.92 0.58

1332 Antithrombin recombinant K 103.35 20.67

1338 Methyl aminolevulinate, top K 83.69 16.74

1340 Collagenase, clost hist inj K 38.06 7.61

1341 Amobarbital 125 MG inj K 194.26 38.85

1350 Topotecan injection K 2.05 0.41

1352 Wilate injection K 1.02 0.2

1353 Belimumab injection K 40.54 8.11

1354 Hydroxyprogesterone caproate K 2.61 0.52

1356 Zoledronic Acid 1mg K 34.97 6.99

1361 Enfuvirtide injection K 18.63 3.73

1408 Cyclophosphamide 100 MG inj K 48.95 9.79

1413 Lumizyme injection K 153.6 30.72

1415 Glassia injection K 4.11 0.82

1416 Factor xiii anti-hem factor K 7.41 1.48

1417 Gel-one K 578.11 115.62

1419 Dermacell G 36.36 0

1420 Aflibercept injection K 980.5 196.1

1421 Imported lipodox inj K 508.43 101.69

1422 Anthrax vaccine sc or im K 94.05 18.81

1424 Nabilone oral K 34.1 6.82

1426 Eribulin mesylate injection K 102.53 20.51

1431 Centruroides immune f(ab) K 3635.8 727.16

1433 Calcitonin salmon injection K 2006.85 401.37

1440 Inj desmopressin acetate K 8.97 1.79

1442 Non-HEU TC-99M add-on/dose K 10 2

1443 Icatibant injection K 298.9 59.78

1446 Visualization adjunct K 10.8 2.16

1448 Opthalmic mitomycin G 372.66 0

1449 Talymed G 14.12 0

1456 Pentobarbital sodium inj K 40.74 8.15

1457 Totazoline hcl injection K 1600.4 320.08

1458 Phentolaine mesylate inj K 159 31.8

1459 Urea injection K 39.97 7.99

1460 Interferon alfa-2a inj K 733.57 146.71

1463 Tc99 Tilmanocept diag 0.5mci G 497 0

1464 Factor VIII (porcine) K 0.2 0.04

1465 Tacrolimus ex rel oral 0.1mg G 0.39 0.08



1466 Inj, vincristine sul lip 1mg G 2321.82 464.36

1467 Factor ix recombinan rixubis G 1.23 0.25

1468 Inj Aripiprazole Ext Rel 1mg K 4.1 0.82

1469 Inj, Filgrastim G-CSF 1mcg K 1 0.2

1471 Injection, Pertuzumab, 1 mg K 10.22 2.04

1472 Inj beta interferon im 1 mcg K 40.52 8.1

1474 Certolizumab pegol inj 1mg K 6.62 1.32

1475 Golimumab for iv use 1mg K 24.33 4.87

1476 Obinutuzumab inj G 54.21 10.84

1477 Inj, tbo-filgrastim, 5 mcg G 3.86 0.77

1478 Human fibrinogen conc inj K 1.05 0.21

1479 Theraskin G 36 0

1480 Elosulfase alfa, injection G 221.54 44.31

1482 Darbepoetin alfa, esrd use K 4.38 0.88

1484 Pentazocine injection K 121.83 24.37

1485 Ferumoxytol, esrd use K 0.81 0.16

1486 Factor ix fc fusion recomb G 2.81 0.56

1487 Testosterone undecanoate 1mg G 1.17 0.23

1488 Injection, ramucirumab G 53.97 10.79

1489 Injection, vedolizumab G 17.03 3.41

1490 Injection, pembrolizumab G 45.69 9.14

1491 New Technology - Level IA ($0-$10) S 5 1

1492 New Technology - Level IB ($10-$20) S 15 3

1493 New Technology - Level IC ($20-$30) S 25 5

1494 New Technology - Level ID ($30-$40) S 35 7

1495 New Technology - Level IE ($40-$50) S 45 9

1496 New Technology - Level IA ($0-$10) T 5 1

1497 New Technology - Level IB($10-$20) T 15 3

1498 New Technology - Level IC ($20-$30) T 25 5

1499 New Technology - Level ID($30-$40) T 35 7

1500 New Technology - Level IE ($40-$50) T 45 9

1502 New Technology - Level II ($50 - $100) S 75 15

1503 New Technology - Level III ($100 - $200) S 150 30

1504 New Technology - Level IV ($200 - $300) S 250 50

1505 New Technology - Level V ($300 - $400) S 350 70

1506 New Technology - Level VI ($400 - $500) S 450 90

1507 New Technology - Level VII ($500 - $600) S 550 110

1508 New Technology - Level VIII ($600 - $700) S 650 130

1509 New Technology - Level IX ($700 - $800) S 750 150

1510 New Technology - Level X ($800 - $900) S 850 170

1511 New Technology - Level XI ($900 - $1000) S 950 190

1512 New Technology - Level XII ($1000 - $1100) S 1050 210

1513 New Technology - Level XIII ($1100 - $1200) S 1150 230

1514 New Technology - Level XIV ($1200- $1300) S 1250 250

1515 New Technology - Level XV ($1300 - $1400) S 1350 270

1516 New Technology - Level XVI ($1400 - $1500) S 1450 290

1517 New Technology - Level XVII ($1500-$1600) S 1550 310

1518 New Technology - Level XVIII ($1600-$1700) S 1650 330

1519 New Technology - Level IXX ($1700-$1800) S 1750 350

1520 New Technology - Level XX ($1800-$1900) S 1850 370

1521 New Technology - Level XXI ($1900-$2000) S 1950 390

1522 New Technology - Level XXII ($2000-$2500) S 2250 450

1523 New Technology - Level XXIII ($2500-$3000) S 2750 550

1524 New Technology - Level XXIV ($3000-$3500) S 3250 650

1525 New Technology - Level XXV ($3500-$4000) S 3750 750

1526 New Technology - Level XXVI ($4000-$4500) S 4250 850

1527 New Technology - Level XXVII ($4500-$5000) S 4750 950

1528 New Technology - Level XXVIII ($5000-$5500) S 5250 1050

1529 New Technology - Level XXIX ($5500-$6000) S 5750 1150

1530 New Technology - Level XXX ($6000-$6500) S 6250 1250

1531 New Technology - Level XXXI ($6500-$7000) S 6750 1350

1532 New Technology - Level XXXII ($7000-$7500) S 7250 1450

1533 New Technology - Level XXXIII ($7500-$8000) S 7750 1550

1534 New Technology - Level XXXIV ($8000-$8500) S 8250 1650

1535 New Technology - Level XXXV ($8500-$9000) S 8750 1750

1536 New Technology - Level XXXVI ($9000-$9500) S 9250 1850

1537 New Technology - Level XXXVII ($9500-$10000) S 9750 1950



1539 New Technology - Level II ($50 - $100) T 75 15

1540 New Technology - Level III ($100 - $200) T 150 30

1541 New Technology - Level IV ($200 - $300) T 250 50

1542 New Technology - Level V ($300 - $400) T 350 70

1543 New Technology - Level VI ($400 - $500) T 450 90

1544 New Technology - Level VII ($500 - $600) T 550 110

1545 New Technology - Level VIII ($600 - $700) T 650 130

1546 New Technology - Level IX ($700 - $800) T 750 150

1547 New Technology - Level X ($800 - $900) T 850 170

1548 New Technology - Level XI ($900 - $1000) T 950 190

1549 New Technology - Level XII ($1000 - $1100) T 1050 210

1550 New Technology - Level XIII ($1100 - $1200) T 1150 230

1551 New Technology - Level XIV ($1200- $1300) T 1250 250

1552 New Technology - Level XV ($1300 - $1400) T 1350 270

1553 New Technology - Level XVI ($1400 - $1500) T 1450 290

1554 New Technology - Level XVII ($1500-$1600) T 1550 310

1555 New Technology - Level XVIII ($1600-$1700) T 1650 330

1556 New Technology - Level XIX ($1700-$1800) T 1750 350

1557 New Technology - Level XX ($1800-$1900) T 1850 370

1558 New Technology - Level XXI ($1900-$2000) T 1950 390

1559 New Technology - Level XXII ($2000-$2500) T 2250 450

1560 New Technology - Level XXIII ($2500-$3000) T 2750 550

1561 New Technology - Level XXIV ($3000-$3500) T 3250 650

1562 New Technology - Level XXV ($3500-$4000) T 3750 750

1563 New Technology - Level XXVI ($4000-$4500) T 4250 850

1564 New Technology - Level XXVII ($4500-$5000) T 4750 950

1565 New Technology - Level XXVIII ($5000-$5500) T 5250 1050

1566 New Technology - Level XXIX ($5500-$6000) T 5750 1150

1567 New Technology - Level XXX ($6000-$6500) T 6250 1250

1568 New Technology - Level XXXI ($6500-$7000) T 6750 1350

1569 New Technology - Level XXXII ($7000-$7500) T 7250 1450

1570 New Technology - Level XXXIII ($7500-$8000) T 7750 1550

1571 New Technology - Level XXXIV ($8000-$8500) T 8250 1650

1572 New Technology - Level XXXV ($8500-$9000) T 8750 1750

1573 New Technology - Level XXXVI ($9000-$9500) T 9250 1850

1574 New Technology - Level XXXVII ($9500-$10000) T 9750 1950

1605 Abciximab injection K 965.13 193.03

1607 Eptifibatide injection K 32.39 6.48

1608 Etanercept injection K 330.81 66.16

1609 Rho(D) immune globulin h, sd K 19.4 3.88

1612 Daclizumab, parenteral K 526.34 105.27

1613 Trastuzumab injection K 87.36 17.47

1630 Hep b ig, im K 110.39 22.08

1631 Baclofen intrathecal trial K 76.07 15.21

1633 Alefacept K 41.64 8.33

1643 Y90 ibritumomab, rx K 46304.42 9260.88

1656 Factor VIII FC Fusion Recomb G 1.9 0.38

1657 PuraPly, PuraPly Antimic G 109.18 0

1658 Injection, belinostat G 31.64 6.33

1659 Injection, dalbavancin G 28.55 5.71

1660 Injection, oritavancin G 25.07 5.01

1662 Inj, tedizolid phosphate G 0.12 0.02

1663 Inj, phenylephrine ketorolac G 492.9 0

1664 Florbetapir f18 G 2756 0

1665 Capsaicin 8% patch K 2.81 0.56

1666 Tetracyclin injection K 97.97 19.59

1667 Alatrofloxacin mesylate K 38.86 7.77

1668 Chorionic gonadotropin/1000u K 22.59 4.52

1669 Erythro lactobionate /500 mg K 50.75 10.15

1670 Tetanus immune globulin inj K 255.21 51.04

1675 P32 Na phosphate K 213.56 42.71

1676 P32 chromic phosphate K 906.62 181.32

1683 Basiliximab K 2851.52 570.3

1684 Corticorelin ovine triflutal K 7.74 1.55

1685 Darbepoetin alfa, non-esrd K 4.38 0.88

1686 Epoetin alfa, non-esrd K 12.62 2.52

1687 Digoxin immune fab (ovine) K 2639.26 527.85



1688 Ethanolamine oleate K 404.09 80.82

1689 Fomepizole K 7.01 1.4

1690 Hemin K 21.77 4.35

1693 Lepirudin K 235.52 47.1

1694 Ziconotide injection K 7.08 1.42

1695 Nesiritide injection K 72.98 14.6

1696 Palifermin injection K 15.59 3.12

1697 Pegaptanib sodium injection K 1031.85 206.37

1700 Inj secretin synthetic human K 34.78 6.96

1701 Treprostinil injection K 61.24 12.25

1704 Humate-P, inj K 0.99 0.2

1705 Factor viia K 2.07 0.41

1709 Azacitidine injection K 3.05 0.61

1710 Clofarabine injection K 138.38 27.68

1711 Vantas implant K 3012.29 602.46

1712 Paclitaxel protein bound K 9.77 1.95

1716 Brachytx, non-str, Gold-198 U 0.503 37.31 7.47

1717 Brachytx, non-str, HDR Ir-192 U 3.6722 272.38 54.48

1719 Brachytx, NS, Non-HDRIr-192 U 0.7244 53.73 10.75

1738 Oxaliplatin K 0.48 0.1

1739 Pegademase bovine, 25 iu K 281.12 56.22

1741 Urofollitropin, 75 iu K 64.69 12.94

1742 Gold sodium thiomaleate inj K 4.27 0.85

1743 Nandrolone decanoate 50 mg K 122.78 24.56

1744 Zidovudine K 1.5 0.3

1745 Radium ra223 dichloride ther K 112.3 22.46

1746 Factor xiii recomb a-subunit G 14.07 2.81

1747 Monovisc inj per dose K 958.45 191.69

1807 Menb pr w/omv vaccine im K 155.7 31.14

1808 Menb rlp vaccine im K 122.7 24.54

1809 Injection, Alemtuzumab K 1743.19 348.64

1822 Inj filgrastim g-csf biosim K 0.97 0.19

1841 Retinal prosth int/ext comp H

2613 Lung bx plug w/del sys H

2616 Brachytx, non-str,Yttrium-90 U 210.0856 15582.68 3116.54

2623 Cath, translumin, drug-coat H

2624 Wireless pressure sensor H

2632 Iodine I-125 sodium iodide U 0.1787 13.25 2.65

2634 Brachytx, non-str, HA, I-125 U 1.1569 85.81 17.17

2635 Brachytx, non-str, HA, P-103 U 0.348 25.81 5.17

2636 Brachy linear, non-str,P-103 U 0.2621 19.44 3.89

2638 Brachytx, stranded, I-125 U 0.5719 42.42 8.49

2639 Brachytx, non-stranded,I-125 U 0.4995 37.05 7.41

2640 Brachytx, stranded, P-103 U 0.8831 65.5 13.1

2641 Brachytx, non-stranded,P-103 U 0.9158 67.93 13.59

2642 Brachytx, stranded, C-131 U 1.4209 105.39 21.08

2643 Brachytx, non-stranded,C-131 U 0.7376 54.71 10.95

2644 Brachytx cesium-131 chloride U 0.1787 13.25 2.65

2698 Brachytx, stranded, NOS U 0.5719 42.42 8.49

2699 Brachytx, non-stranded, NOS U 0.2621 19.44 3.89

2731 Immune globulin, powder K 33.11 6.62

2770 Quinupristin/dalfopristin K 311.04 62.21

3041 Bivalirudin K 3.71 0.74

7000 Amifostine K 363.93 72.79

7011 Oprelvekin injection K 417.79 83.56

7034 Somatropin injection K 81.59 16.32

7035 Teniposide K 3494.46 698.89

7041 Tirofiban HCl K 8.94 1.79

7042 Capecitabine, oral K 5.53 1.11

7043 Infliximab injection K 78.76 15.75

7046 Doxorubicin inj 10mg K 443.83 88.77

7048 Alteplase recombinant K 73.74 14.75

7308 Aminolevulinic acid hcl top K 292.79 58.56

8001 LDR Prostate Brachytherapy Composite T 48.668 3609.85 721.97

8004 Ultrasound Composite S 3.8466 285.31 57.07

8005 CT and CTA without Contrast Composite S 4.2248 313.37 62.68

8006 CT and CTA with Contrast Composite S 7.1261 528.56 105.72



8007 MRI and MRA without Contrast Composite S 8.1955 607.88 121.58

8008 MRI and MRA with Contrast Composite S 12.2851 911.22 182.25

8009 Extended Assessment & Management Composite V 16.6462 1234.7 246.94

9001 Linezolid injection K 31.62 6.32

9002 Tenecteplase injection K 93.96 18.79

9003 Palivizumab K 1947.49 389.5

9005 Reteplase injection K 2301.91 460.38

9006 Tacrolimus injection K 163.25 32.65

9012 Arsenic trioxide injection K 59.42 11.88

9018 Inj, rimabotulinumtoxinB K 11.65 2.33

9019 Caspofungin acetate K 12.75 2.55

9024 Amphotericin b lipid complex K 12.38 2.48

9032 Baclofen 10 MG injection K 170.03 34.01

9033 Cidofovir injection K 650.18 130.04

9038 Inj estrogen conjugate K 215.7 43.14

9042 Glucagon hydrochloride K 190.6 38.12

9044 Ibutilide fumarate injection K 63.1 12.62

9104 Antithymocyte globuln rabbit K 638.49 127.7

9108 Thyrotropin injection K 1432.17 286.43

9119 Injection, pegfilgrastim 6mg K 3772.79 754.56

9120 Injection, Fulvestrant K 93.44 18.69

9121 Injection, argatroban K 15.14 3.03

9122 Triptorelin pamoate K 144.59 28.92

9124 Daptomycin injection K 0.76 0.15

9125 Risperidone, long acting K 6.91 1.38

9126 Natalizumab injection K 16.24 3.25

9130 Inj, Imm Glob Bivigam, 500mg G 38.49 7.7

9131 Inj, Ado-trastuzumab Emt 1mg G 29.21 5.84

9132 Kcentra, per i.u. G 1.62 0.32

9133 Rabies ig, im/sc K 285.93 57.19

9134 Rabies ig, heat treated K 252.95 50.59

9135 Varicella-zoster ig, im K 1202.24 240.45

9137 Bcg vaccine, percut K 122.88 24.58

9139 Rabies vaccine, im K 263.54 52.71

9140 Rabies vaccine, id K 172.3 34.46

9143 Meningococcal vaccine, sc K 106.49 21.3

9144 Encephalitis vaccine, sc K 108.29 21.66

9207 Bortezomib injection K 46.75 9.35

9208 Agalsidase beta injection K 158.04 31.61

9209 Laronidase injection K 29.45 5.89

9210 Palonosetron hcl K 20.53 4.11

9213 Pemetrexed injection K 61.21 12.24

9214 Bevacizumab injection K 69.6 13.92

9215 Cetuximab injection K 53.48 10.7

9217 Leuprolide acetate suspnsion K 242.8 48.56

9224 Galsulfase injection K 364.78 72.96

9225 Fluocinolone acetonide implt K 20138.08 4027.62

9227 Micafungin sodium injection K 0.95 0.19

9228 Tigecycline injection K 2.35 0.47

9229 Ibandronate sodium injection K 116.67 23.33

9230 Abatacept injection K 37.33 7.47

9231 Decitabine injection K 22.13 4.43

9232 Idursulfase injection K 497.48 99.5

9233 Ranibizumab injection K 391.41 78.28

9234 Alglucosidase alfa injection K 206.64 41.33

9235 Panitumumab injection K 100.91 20.18

9236 Eculizumab injection K 215.92 43.18

9237 Inj, lanreotide acetate K 47.18 9.44

9240 Injection, ixabepilone K 72.08 14.42

9242 Injection, fosaprepitant K 1.73 0.35

9243 Bendamustine injection K 24.66 4.93

9245 Romiplostim injection K 57.47 11.49

9248 Inj, clevidipine butyrate K 4.32 0.86

9251 C1 esterase inhibitor inj K 54.46 10.89

9252 Plerixafor injection K 305.98 61.2

9253 Temozolomide injection K 6.84 1.37

9255 Paliperidone palmitate inj K 8.45 1.69



9256 Dexamethasone intra implant K 201.03 40.21

9258 Telavancin injection K 4.91 0.98

9259 Pralatrexate injection K 212.8 42.56

9260 Ofatumumab injection K 49.47 9.89

9261 Ustekinumab injection K 166.99 33.4

9263 Ecallantide injection K 402.44 80.49

9264 Tocilizumab injection K 3.85 0.77

9265 Romidepsin injection K 290.84 58.17

9269 C-1 esterase, berinert K 40.52 8.1

9270 Gammaplex IVIG K 37.28 7.46

9271 Velaglucerase alfa K 346.08 69.22

9272 Inj, denosumab K 15.24 3.05

9273 Sipuleucel-T auto CD54+ K 36704.05 7340.81

9274 Crotalidae Poly Immune Fab K 2542.98 508.6

9276 Cabazitaxel injection K 148.66 29.73

9278 Incobotulinumtoxin A K 4.67 0.93

9281 Injection, pegloticase K 1239.16 247.83

9284 Ipilimumab injection K 138.83 27.77

9286 Belatacept injection K 3.8 0.76

9287 Brentuximab vedotin inj K 119.62 23.92

9289 Erwinaze injection K 376.49 75.3

9293 Injection, glucarpidase K 271.24 54.25

9294 Inj, Taliglucerace Alfa 10 u G 36.48 7.3

9295 Injection, Carfilzomib, 1 mg G 31.06 6.21

9296 Inj, ziv-aflibercept, 1mg G 8.32 1.66

9297 Inj, Omacetaxine Mep, 0.01mg G 2.48 0.5

9298 Inj, Ocriplasmin, 0.125 mg G 1046.75 209.35

9300 Omalizumab injection K 29.91 5.98

9441 Inj ferric carboxymaltos 1mg G 1.06 0.21

9445 C-1 esterase, Ruconest G 23.29 4.66

9448 Netupitant Palonosetron oral G 474.85 94.97

9449 Inj, blinatumomab G 96 19.2

9450 Fluocinolone acetonide implt G 490.95 98.19

9451 Injection, peramivir G 1.68 0.34

9452 Inj, ceftolozane/tazobactam G 0.42 0.08

9453 Injection, nivolumab G 25.38 5.08

9454 Inj, pasireotide long acting G 251.26 50.25

9455 Injection, siltuximab G 8.9 1.78

9456 Inj, isavuconazonium sulfate G 0.68 0.14

9457 Lumason contrast agent G 33.06 0

9497 Loxapine, inhalation powder G 147.34 29.47

9500 Platelets, irradiated R 2.2736 168.64 33.73

9501 Platelet pheres leukoreduced R 6.7108 497.76 99.56

9502 Platelet pheresis irradiated R 7.6782 569.52 113.91

9503 Fr frz plasma donor retested R 0.793 58.82 11.77

9504 RBC deglycerolized R 6.2553 463.97 92.8

9505 RBC irradiated R 2.8023 207.85 41.57

9506 Granulocytes, pheresis unit R 24.7756 1837.68 367.54

9507 Platelets, pheresis R 5.6564 419.55 83.91

9508 Plasma 1 donor frz w/in 8 hr R 1.0091 74.85 14.97


Documents

2015 Addendum A List of APCs - AHD.com · 2020. 6. 5. · 2015 Addendum A List of APCs 0209 Level II Extended EEG, Sleep, and Cardiovascular Studies S 3.1121 230.83 68.11 46.17 0213