status relative payment unadjusted apc group title ... · 2019 addendum a list of apcs 1537 new...

2019 Addendum A List of APCs

APC Group Title

Status

Indicator

Relative

Weight

Payment

Rate

National

Unadjusted

Copayment

Minimum

Unadjusted

Copayment

0701 Sr89 strontium K 2045.702 0 409.14

0726 Dexrazoxane HCl injection K 194.341 0 38.87

0731 Sargramostim injection K 43.442 0 8.69

0736 Amphotericin b liposome inj K 26.087 0 5.22

0738 Rasburicase K 289.815 0 57.96

0751 Mechlorethamine hcl inj K 328.29 0 65.66

0752 Dactinomycin injection K 1098.2 0 219.64

0759 Naltrexone, depot form K 3.247 0 0.65

0800 Leuprolide acetate K 1269.227 0 253.85

0802 Etoposide oral K 75.355 0 15.07

0807 Aldesleukin injection K 4964.616 0 992.92

0810 Goserelin acetate implant K 497.719 0 99.54

0812 Carmustine injection K 3039.006 0 607.8

0820 Daunorubicin injection K 46.74 0 9.35

0823 Docetaxel injection K 0.865 0 0.17

0825 Nelarabine injection K 152.479 0 30.5

0836 Interferon alfa-2b inj K 34.239 0 6.85

0840 Inj melphalan hydrochl K 610.875 0 122.18

0843 Pegaspargase injection K 17566.886 0 3513.38

0844 Pentostatin injection K 1968.606 0 393.72

0850 Streptozocin injection K 349.701 0 69.94

0851 Thiotepa injection K 404.28 0 80.86

0856 Porfimer sodium injection K 21397.867 0 4279.57

0858 Inj cladribine K 18.999 0 3.8

0864 Mitoxantrone hydrochl K 27.385 0 5.48

0873 Hyalgan supartz visco-3 dose K 81.571 0 16.31

0874 Synvisc or synvisc-one K 11.412 0 2.28

0875 Euflexxa inj per dose K 145.079 0 29.02

0877 Orthovisc inj per dose K 143.397 0 28.68

0887 Azathioprine parenteral K 238.188 0 47.64

0890 Lymphocyte immune globulin K 2066.023 0 413.2

0901 Alpha 1 proteinase inhibitor K 4.55 0 0.91

0902 Injection,onabotulinumtoxinA K 6.123 0 1.22

0903 Cytomegalovirus imm IV /vial K 1129.154 0 225.83

0910 Interferon beta-1b / .25 MG K 386.238 0 77.25

0925 Factor viii K 1.069 0 0.21

0927 Factor viii recombinant K 1.254 0 0.25

0928 Factor ix complex K 1.469 0 0.29

0929 Anti-inhibitor K 1.897 0 0.38

0931 Factor IX non-recombinant K 1.149 0 0.23

0932 Factor ix recombinant nos K 1.502 0 0.3

0943 Octagam injection K 35.683 0 7.14

0944 Gammagard liquid injection K 37.468 0 7.49

0946 Hepagam b im injection K 60.057 0 12.01

0947 Flebogamma injection K 35.585 0 7.12

0948 Gamunex-C/Gammaked K 39.14 0 7.83

0961 Albumin (human),5%, 50ml K 10.49 0 2.1

0963 Albumin (human), 5%, 250 ml K 52.45 0 10.49

0964 Albumin (human), 25%, 20 ml K 20.98 0 4.2

0965 Albumin (human), 25%, 50ml K 52.45 0 10.49

1015 Injection glatiramer acetate K 163.404 0 32.68

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1064 I131 iodide cap, rx K 20.76 0 4.15

1083 Adalimumab injection K 1371.138 0 274.23

1138 Hepagam b intravenous, inj K 60.057 0 12.01

1139 Protein c concentrate K 15.097 0 3.02

1142 Supprelin LA implant K 36647.599 0 7329.52

1150 I131 iodide sol, rx K 13.57 0 2.71

1166 Cytarabine liposome inj K 81.42 0 16.28

1168 Inj, temsirolimus K 53.135 0 10.63

1178 Busulfan injection K 4.579 0 0.92

1203 Verteporfin injection K 11.078 0 2.22

1207 Octreotide injection, depot K 206.565 0 41.31

1213 Antihemophilic viii/vwf comp K 1.059 0 0.21

1214 Inj IVIG privigen 500 mg K 40.122 0 8.02

1232 Mitomycin injection K 87.749 0 17.55

1235 Valrubicin injection K 1438.588 0 287.72

1236 Inj levoleucovorin nos 0.5mg K 0.396 0 0.08

1237 Inj iron dextran K 14.407 0 2.88

1253 Triamcinolone A inj PRS-free K 3.85 0 0.77

1263 Antithrombin iii injection K 3.319 0 0.66

1268 Xyntha inj K 1.266 0 0.25

1274 Edetate calcium disodium inj K 5594.422 0 1118.88

1281 Bevacizumab injection K 2.03 0 0.41

1289 AbobotulinumtoxinA K 8.432 0 1.69

1295 Sm 153 lexidronam K 16040.561 0 3208.11

1296 Degarelix injection K 3.965 0 0.79

1297 Ferumoxytol, non-esrd K 0.997 0 0.2

1311 Canakinumab injection K 111.013 0 22.2

1312 Hizentra injection K 10.437 0 2.09

1327 Imiglucerase injection K 42.937 0 8.59

1340 Collagenase, clost hist inj K 48.76 0 9.75

1341 Amobarbital 125 MG inj K 56.62 0 11.32

1352 Wilate injection K 0.971 0 0.19

1353 Belimumab injection K 44.824 0 8.96

1408 Cyclophosphamide 100 MG inj K 34.139 0 6.83

1413 Lumizyme injection K 171.046 0 34.21

1415 Glassia injection K 4.823 0 0.96

1416 Factor xiii anti-hem factor K 8.469 0 1.69

1417 Gel-one K 1166 0 233.2

1420 Aflibercept injection K 952.473 0 190.49

1421 Imported lipodox inj K 470.4 0 94.08

1426 Eribulin mesylate injection K 114.274 0 22.85

1431 Centruroides immune f(ab) K 4822.428 0 964.49

1433 Calcitonin salmon injection K 2661.047 0 532.21

1440 Inj desmopressin acetate K 12.143 0 2.43

1442 Non-HEU TC-99M add-on/dose K 10 0 2

1443 Icatibant injection K 377.08 0 75.42

1446 Visualization adjunct K 6.401 0 1.28

1458 Phentolaine mesylate inj K 377.567 0 75.51

1466 Inj, vincristine sul lip 1mg K 3080.04 0 616.01

1467 Factor ix recombinan rixubis K 1.323 0 0.26

1468 Inj Aripiprazole Ext Rel 1mg K 5.704 0 1.14

1469 Inj filgrastim excl biosimil K 0.964 0 0.19

1471 Injection, Pertuzumab, 1 mg K 12.29 0 2.46

1472 Inj beta interferon im 1 mcg K 53.583 0 10.72

1474 Certolizumab pegol inj 1mg K 8.023 0 1.6

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1475 Golimumab for iv use 1mg K 21.58 0 4.32

1476 Obinutuzumab inj K 62.864 0 12.57

1478 Inj human fibrinogen con nos K 1.197 0 0.24

1480 Elosulfase alfa, injection K 241.453 0 48.29

1482 Darbepoetin alfa, esrd use K 3.852 0 0.77

1485 Ferumoxytol, esrd use K 0.997 0 0.2

1486 Factor ix fc fusion recomb K 3.11 0 0.62

1488 Injection, ramucirumab K 58.419 0 11.68

1489 Injection, vedolizumab K 19.864 0 3.97

1490 Inj pembrolizumab K 49.389 0 9.88

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

1492 New Technology - Level 1B ($11-$20) S 15.5 0 3.1

1493 New Technology - Level 1C ($21-$30) S 25.5 0 5.1

1494 New Technology - Level 1D ($31-$40) S 35.5 0 7.1

1495 New Technology - Level 1E ($41-$50) S 45.5 0 9.1

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

1497 New Technology - Level 1B ($11-$20) T 15.5 0 3.1

1498 New Technology - Level 1C ($21-$30) T 25.5 0 5.1

1499 New Technology - Level 1D ($31-$40) T 35.5 0 7.1

1500 New Technology - Level 1E ($41-$50) T 45.5 0 9.1

1502 New Technology - Level 2 ($51 - $100) S 75.5 0 15.1












1514 New Technology - Level 14 ($1201- $1300) S 1250.5 0 250.1



1517 New Technology - Level 17 ($1501-$1600) S 1550.5 0 310.1




















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1539 New Technology - Level 2 ($51 - $100) T 75.5 0 15.1












1551 New Technology - Level 14 ($1201- $1300) T 1250.5 0 250.1



1554 New Technology - Level 17 ($1501-$1600) T 1550.5 0 310.1





















1575 New Technology - Level 38 ($10,001-$15,000) S 12500.5 0 2500.1











1589 New Technology - Level 38 ($10,001-$15,000) T 12500.5 0 2500.1







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1607 Eptifibatide injection K 4.286 0 0.86

1608 Etanercept injection K 685.563 0 137.11

1609 Rho(D) immune globulin h, sd K 29.784 0 5.96

1613 Trastuzumab injection K 106.622 0 21.32

1630 Hep b ig, im K 110.667 0 22.13

1643 Y90 ibritumomab, rx K 42472.671 0 8494.53

1656 Factor viii fc fusion recomb K 2.08 0 0.42

1658 Injection, belinostat, 10mg K 40.07 0 8.01

1660 Injection, oritavancin K 23.78 0 4.76

1662 Inj tedizolid phosphate K 1.489 0 0.3

1669 Erythro lactobionate /500 mg K 75.764 0 15.15

1670 Tetanus immune globulin inj K 432.663 0 86.53

1675 P32 Na phosphate K 730.03 0 146.01

1683 Basiliximab K 3799.932 0 759.99

1684 Corticorelin ovine triflutal K 9.04 0 1.81

1685 Darbepoetin alfa, non-esrd K 3.852 0 0.77

1686 Epoetin alfa, non-esrd K 11.031 0 2.21

1687 Digoxin immune fab (ovine) K 3780.193 0 756.04

1688 Ethanolamine oleate K 444.099 0 88.82

1689 Fomepizole K 8.541 0 1.71

1690 Hemin K 23.719 0 4.74

1694 Ziconotide injection K 7.914 0 1.58

1695 Nesiritide injection K 74.801 0 14.96

1696 Palifermin injection K 21.275 0 4.26

1700 Inj secretin synthetic human K 34.781 0 6.96

1701 Treprostinil injection K 63.853 0 12.77

1704 Humate-P, inj K 1.159 0 0.23

1705 Factor viia K 2.15 0 0.43

1709 Azacitidine injection K 1.161 0 0.23

1710 Clofarabine injection K 61.69 0 12.34

1711 Vantas implant K 4085.605 0 817.12

1712 Paclitaxel protein bound K 12.513 0 2.5

1739 Pegademase bovine, 25 iu K 367.961 0 73.59

1743 Nandrolone decanoate 50 mg K 21.69 0 4.34

1745 Radium ra223 dichloride ther K 138.815 0 27.76

1746 Factor xiii recomb a-subunit K 15.519 0 3.1

1747 Monovisc inj per dose K 769.506 0 153.9

1748 Inj tbo filgrastim 1 microg K 0.566 0 0.11

1761 Rolapitant, oral, 1mg K 2.118 0 0.42

1809 Injection, alemtuzumab K 1917.042 0 383.41

1822 Injection, zarxio K 0.573 0 0.11

1823 Injection, dalbavancin K 14.945 0 2.99

1824 Ceftaroline fosamil inj K 3.19 0 0.64

1825 Ceftazidime and avibactam K 92.052 0 18.41

1826 Hyqvia 100mg immuneglobulin K 14.556 0 2.91

1827 Factor viii recomb obizur K 3.178 0 0.64

1829 Penicillin g benzathine inj K 13.82 0 2.76

1832 Dimethyl sulfoxide 50% 50 ml K 586.511 0 117.3

1844 Factor viii pegylated recomb K 1.741 0 0.35

1846 Factor viii nuwiq recomb 1iu K 1.24 0 0.25

1847 Injection, inflectra G 49.247 0 9.85

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1848 Artiss fibrin sealant K 164.845 0 32.97

1849 Foscarnet sodium injection K 82.268 0 16.45

1850 Gamma globulin 1 cc inj K 39.909 0 7.98

1851 Gamma globulin > 10 cc inj K 399.09 0 79.82

1852 Interferon beta-1a inj K 2785.97 0 557.19

1853 Minocycline hydrochloride K 1.811 0 0.36

1854 Pentobarbital sodium inj K 37.015 0 7.4

1856 Factor viii recomb novoeight K 1.307 0 0.26

1857 Inj, factor x, (human), 1iu K 7.513 0 1.5

1859 Argatroban nonesrd use 1mg K 1.194 0 0.24

1861 Inj., bendeka 1 mg G 22.849 0 4.57

1862 Gelsyn-3 injection 0.1 mg G 2.177 0 0.44









2616 Brachytx, non-str,Yttrium-90 U 209.1569 16625.88 0 3325.18

2632 Iodine I-125 sodium iodide U 0.4764 37.87 0 7.58

2634 Brachytx, non-str, HA, I-125 U 1.7435 138.59 0 27.72

2635 Brachytx, non-str, HA, P-103 U 0.3412 27.12 0 5.43

2636 Brachy linear, non-str,P-103 U 0.6206 49.33 0 9.87

2638 Brachytx, stranded, I-125 U 0.4579 36.4 0 7.28

2639 Brachytx, non-stranded,I-125 U 0.4404 35.01 0 7.01

2640 Brachytx, stranded, P-103 U 0.9394 74.67 0 14.94

2641 Brachytx, non-stranded,P-103 U 0.7564 60.13 0 12.03

2642 Brachytx, stranded, C-131 U 1.0056 79.94 0 15.99

2643 Brachytx, non-stranded,C-131 U 0.9858 78.36 0 15.68

2645 Brachytx, non-str, Gold-198 U 1.0855 86.29 0 17.26

2646 Brachytx, non-str, HDR Ir-192 U 3.6581 290.78 0 58.16

2647 Brachytx, NS, Non-HDRIr-192 U 1.0683 84.92 0 16.99

2648 Brachytx planar, p-103 U 0.059 4.69 0 0.94

2698 Brachytx, stranded, NOS U 0.4579 36.4 0 7.28

2699 Brachytx, non-stranded, NOS U 0.3412 27.12 0 5.43

2731 Immune globulin, powder K 61.203 0 12.24

2770 Quinupristin/dalfopristin K 417.49 0 83.5

2993 Gen, neuro, trans sen/stim H 0 0

4001 Echo guidance radiotherapy S 51.9 0 10.38

4002 Stereoscopic x-ray guidance S 56.22 0 11.25

4003 Radiation treatment delivery, MeV <= 5; simple S 199.3 0 39.86

4004 Radiation treatment delivery, 6-10 MeV; simple S 145.96 0 29.2

4005 Radiation treatment delivery, 11-19 MeV; simple S 145.96 0 29.2

4006 Radiation treatment delivery, MeV>=20; simple S 145.6 0 29.12

4007 Radiation treatment delivery, MeV<=5; intermediate S 276.06 0 55.22

4008 Radiation treatment delivery, 6-10 MeV; intermediate S 201.46 0 40.3

4009 Radiation treatment delivery, 11-19 MeV; intermediateS 200.38 0 40.08

4010 Radiation treatment delivery, MeV >=20; intermediateS 200.38 0 40.08

4011 Radiation treatment delivery, MeV<=5; complex S 272.46 0 54.5

4012 Radiation treatment delivery, 6-10 MeV; complex S 267.05 0 53.41

4013 Radiation treatment delivery, 11-19 MeV; complex S 267.41 0 53.49

4014 Radiation treatment delivery, MeV >=20; complex S 267.41 0 53.49

4015 Radiation tx delivery imrt S 362.55 0 72.51

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4016 Delivery comp imrt S 361.47 0 72.3

5012 Clinic Visits and Related Services V 1.4574 115.85 0 23.17

5021 Level 1 Type A ED Visits V 0.8772 69.73 0 13.95





5031 Level 1 Type B ED Visits V 0.9792 77.84 0 15.57





5041 Critical Care S 9.3096 740.02 0 148.01

5045 Trauma Response with Critical Care S 11.8927 945.35 0 189.07

5051 Level 1 Skin Procedures T 2.2198 176.45 0 35.29





5061 Hyperbaric Oxygen S 1.4392 114.4 0 22.88

5071 Level 1 Excision/ Biopsy/ Incision and Drainage T 7.2882 579.34 0 115.87

5072 Level 2 Excision/ Biopsy/ Incision and Drainage J1 17.3041 1375.5 0 275.1

5073 Level 3 Excision/ Biopsy/ Incision and Drainage J1 29.9194 2378.29 0 475.66

5091 Level 1 Breast/Lymphatic Surgery and Related ProceduresJ1 35.426 2816.01 0 563.21




5101 Level 1 Strapping and Cast Application T 1.6936 134.62 0 26.93

5102 Level 2 Strapping and Cast Application T 2.9636 235.58 0 47.12

5111 Level 1 Musculoskeletal Procedures T 2.8317 225.09 0 45.02

5112 Level 2 Musculoskeletal Procedures J1 16.5221 1313.34 0 262.67





5151 Level 1 Airway Endoscopy T 2.0628 163.97 0 32.8

5152 Level 2 Airway Endoscopy T 4.8623 386.5 0 77.3

5153 Level 3 Airway Endoscopy J1 17.226 1369.29 0 273.86



5161 Level 1 ENT Procedures T 2.5933 206.14 0 41.23

5162 Level 2 ENT Procedures T 6.1282 487.13 0 97.43

5163 Level 3 ENT Procedures J1 16.0913 1279.1 0 255.82



5166 Cochlear Implant Procedure J1 402.1609 31967.77 7683.79 6393.56

5181 Level 1 Vascular Procedures T 7.7999 620.01 0 124.01

5182 Level 2 Vascular Procedures T 13.7581 1093.63 0 218.73

5183 Level 3 Vascular Procedures J1 33.2309 2641.52 0 528.31

5184 Level 4 Vascular Procedures J1 55.0575 4376.52 0 875.31

5191 Level 1 Endovascular Procedures J1 35.3555 2810.41 864.64 562.09

5192 Level 2 Endovascular Procedures J1 58.8568 4678.53 0 935.71



5200 Implantation Wireless PA Pressure Monitor J1 369.1122 29340.73 0 5868.15

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5211 Level 1 Electrophysiologic Procedures J1 11.5653 919.33 0 183.87



5221 Level1 Pacemaker and Similar Procedures T 39.3827 3130.53 0 626.11

5222 Level 2 Pacemaker and Similar Procedures J1 93.1452 7404.11 0 1480.83



5231 Level 1 ICD and Similar Procedures J1 276.7199 21996.46 0 4399.3

5232 Level 2 ICD and Similar Procedures J1 385.6633 30656.38 0 6131.28

5241 Level 1 Blood Product Exchange and Related ServicesS 4.8169 382.9 0 76.58

5242 Level 2 Blood Product Exchange and Related ServicesS 15.6875 1247 0 249.4

5243 Level 3 Blood Product Exchange and Related ServicesS 49.3458 3922.5 0 784.5

5244 Level 4 Blood Product Exchange and Related ServicesJ1 476.6985 37892.76 0 7578.56

5301 Level 1 Upper GI Procedures T 9.5805 761.55 0 152.31

5302 Level 2 Upper GI Procedures J1 18.6608 1483.35 0 296.67

5303 Level 3 Upper GI Procedures J1 35.5351 2824.69 0 564.94

5311 Level 1 Lower GI Procedures T 9.3709 744.89 0 148.98

5312 Level 2 Lower GI Procedures T 12.326 979.79 0 195.96

5313 Level 3 Lower GI Procedures J1 29.3695 2334.58 0 466.92

5331 Complex GI Procedures J1 56.5614 4496.07 0 899.22

5341 Abdominal/Peritoneal/Biliary and Related ProceduresJ1 37.0779 2947.32 0 589.47

5361 Level 1 Laparoscopy and Related Services J1 57.8167 4595.85 0 919.17

5362 Level 2 Laparoscopy and Related Services J1 97.3913 7741.63 0 1548.33

5371 Level 1 Urology and Related Services T 2.9113 231.42 0 46.29

5372 Level 2 Urology and Related Services T 7.0732 562.25 0 112.45

5373 Level 3 Urology and Related Services J1 21.8864 1739.75 0 347.95





5401 Dialysis S 7.6957 611.73 0 122.35

5411 Level 1 Gynecologic Procedures T 2.0874 165.93 0 33.19

5412 Level 2 Gynecologic Procedures T 3.4344 273 0 54.6

5413 Level 3 Gynecologic Procedures T 7.0203 558.04 0 111.61

5414 Level 4 Gynecologic Procedures J1 29.7052 2361.27 0 472.26

5415 Level 5 Gynecologic Procedures J1 51.9037 4125.83 902.82 825.17

5416 Level 6 Gynecologic Procedures J1 79.8139 6344.41 1405.7 1268.89

5431 Level 1 Nerve Procedures J1 20.5243 1631.48 0 326.3

5432 Level 2 Nerve Procedures J1 57.442 4566.06 0 913.22

5441 Level 1 Nerve Injections T 3.1133 247.48 0 49.5



5461 Level 1 Neurostimulator and Related Procedures T 36.2285 2879.8 0 575.96

5462 Level 2 Neurostimulator and Related Procedures J1 75.2237 5979.53 0 1195.91



5471 Implantation of Drug Infusion Device J1 202.131 16067.39 0 3213.48

5481 Laser Eye Procedures T 6.242 496.18 101.51 99.24

5491 Level 1 Intraocular Procedures J1 24.1182 1917.16 0 383.44




5501 Level 1 Extraocular, Repair, and Plastic Eye ProceduresT 3.5667 283.52 0 56.71

5502 Level 2 Extraocular, Repair, and Plastic Eye ProceduresT 10.1559 807.29 0 161.46

5503 Level 3 Extraocular, Repair, and Plastic Eye ProceduresJ1 22.8039 1812.68 0 362.54

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5504 Level 4 Extraocular, Repair, and Plastic Eye ProceduresJ1 37.4295 2975.27 0 595.06

5521 Level 1 Imaging without Contrast S 0.7838 62.3 0 12.46




5571 Level 1 Imaging with Contrast S 2.5379 201.74 0 40.35



5591 Level 1 Nuclear Medicine and Related Services S 4.447 353.49 0 70.7




5611 Level 1 Therapeutic Radiation Treatment PreparationS 1.5571 123.77 32.03 24.76

5612 Level 2 Therapeutic Radiation Treatment PreparationS 4.0485 321.82 0 64.37

5613 Level 3 Therapeutic Radiation Treatment PreparationS 14.9946 1191.92 0 238.39

5621 Level 1 Radiation Therapy S 1.4718 116.99 0 23.4






5627 Level 7 Radiation Therapy J1 96.1661 7644.24 0 1528.85

5661 Therapeutic Nuclear Medicine S 2.9046 230.89 0 46.18

5671 Level 1 Pathology S 0.6414 50.98 0 10.2




5691 Level 1 Drug Administration S 0.4766 37.88 0 7.58




5721 Level1 Diagnostic Tests and Related Services S 1.7103 135.95 0 27.19

5722 Level 2 Diagnostic Tests and Related Services S 3.1741 252.31 0 50.47



5731 Level 1 Minor Procedures S 0.216 17.17 0 3.44





5741 Level 1 Electronic Analysis of Devices S 0.4675 37.16 0 7.44



5771 Cardiac Rehabilitation S 1.4863 118.15 0 23.63

5781 Resuscitation and Cardioversion S 6.6234 526.49 0 105.3

5791 Pulmonary Treatment S 2.4104 191.6 0 38.32

5801 Ventilation Initiation and Management S 6.4155 509.97 0 102

5811 Manipulation Therapy S 0.3117 24.78 0 4.96

5821 Level 1 Health and Behavior Services S 0.4199 33.38 0 6.68



5853 Partial Hospitalization (3 or more services) for CMHCsP 1.5169 120.58 0 24.12

5863 Partial Hospitalization (3 or more services) for Hospital-based PHPsP 2.7784 220.86 0 44.18

5871 Dental Procedures S 11.3119 899.18 0 179.84

5881 Ancillary Outpatient Services When Patient Dies J1 84.547 6720.64 0 1344.13

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7000 Amifostine K 1003.594 0 200.72

7011 Oprelvekin injection K 163.98 0 32.8

7035 Teniposide K 2645.707 0 529.14

7041 Tirofiban HCl K 6.917 0 1.38

7043 Infliximab not biosimil 10mg K 63.285 0 12.66

7046 Doxorubicin inj 10mg K 355.07 0 71.01

7048 Alteplase recombinant K 87.638 0 17.53

7308 Aminolevulinic acid hcl top K 390.979 0 78.2

8004 Ultrasound Composite S 3.7693 299.62 0 59.93

8005 CT and CTA without Contrast Composite S 3.3331 264.95 0 52.99

8006 CT and CTA with Contrast Composite S 6.0482 480.77 0 96.16

8007 MRI and MRA without Contrast Composite S 6.8464 544.22 0 108.85

8008 MRI and MRA with Contrast Composite S 10.7636 855.6 0 171.12

8010 Mental Health Services Composite S 2.7784 220.86 0 44.18

8011 Comprehensive Observation Services J2 30.0264 2386.8 0 477.36

9002 Tenecteplase injection K 121.825 0 24.37

9003 Palivizumab K 1205.05 0 241.01

9005 Reteplase injection K 2634.535 0 526.91

9006 Tacrolimus injection K 211.839 0 42.37

9012 Arsenic trioxide injection K 44.314 0 8.86

9014 Inj., cerliponase alfa 1 mg G 93.506 0 18.7

9015 Inj., haegarda 10 units G 9.672 0 1.93

9016 Inj., triptorelin xr 3.75 mg G 2897.333 0 579.47

9018 Inj, rimabotulinumtoxinB K 11.987 0 2.4

9019 Caspofungin acetate K 6.853 0 1.37

9024 Amphotericin b lipid complex K 6.184 0 1.24

9028 Inj inotuzumab ozogam 0.1 mg G 2270.312 0 454.06

9029 Inj., guselkumab, 1 mg G 100.205 0 20.04

9030 Inj., copanlisib, 1 mg G 79.415 0 15.88

9031 Inj, etelcalcetide, 0.1 mg K 2.602 0 0.52

9032 Baclofen 10 MG injection K 169.513 0 33.9

9033 Cidofovir injection K 623.268 0 124.65

9034 Inj cuvitru, 100 mg K 13.787 0 2.76

9035 Axicabtagene ciloleucel car+ G 395380 0 79076

9036 Injection, renflexis G 53.395 0 10.68

9038 Inj estrogen conjugate K 308.93 0 61.79

9042 Glucagon hydrochloride K 199.272 0 39.85

9043 Inj, afstyla, 1 i.u. G 1.355 0 0.27

9044 Ibutilide fumarate injection K 278.77 0 55.75

9052 Fluciciovine F-18 G 424.53 0 0

9056 Gallium Ga-68 G 68.704 0 0

9058 Buprenorphine implant 74.2mg G 1303.529 0 260.71

9059 Vonvendi inj 1 iu vwf:rco G 1.828 0 0.37

9065 Argatroban esrd dialysis 1mg K 1.194 0 0.24

9067 Lutetium lu 177 dotatat ther G 259.17 0 51.83

9070 Inj luxturna 1 billion vec g G 2923.668 0 584.73

9071 Capsaicin 8% patch K 3.152 0 0.63

9073 Buprenorph xr 100 mg or less G 1673.362 0 334.67

9074 Makena, 10 mg K 22.396 0 4.48

9075 Inj, kovaltry, 1 i.u. K 1.255 0 0.25

9078 Testosterone undecanoate 1mg K 1.466 0 0.29

9079 Genvisc 850, inj, 1mg K 16.918 0 3.38

9084 Florbetapir f18 G 3028.844 0 0

9085 Inj sulf hexa lipid microsph G 19.535 0 0

9086 Hepa vacc ped/adol 3 dose K 28.904 0 5.78

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9087 Inj, clevidipine butyrate K 2.768 0 0.55

9088 Peng benzathine/procaine inj K 10.887 0 2.18

9089 Oral fludarabine phosphate K 504.98 0 101

9090 Melphalan oral 2 mg K 12 0 2.4

9091 Daunorubicin citrate inj K 0.32 0 0.06

9092 Interferon alfa-2a inj K 169.33 0 33.87

9093 Plicamycin (mithramycin) inj K 6.12 0 1.22

9094 Radiesse injection K 473.9 0 94.78

9095 Inj, sculptra, 0.5mg K 3.28 0 0.66

9096 Inj retacrit esrd on dialysi G 0.963 0 0.19

9097 Inj retacrit non-esrd use G 9.629 0 1.93

9098 Chorionic gonadotropin/1000u K 22.619 0 4.52

9099 Inj fosnetupitant, palonoset G 416.867 0 83.37

9104 Antithymocyte globuln rabbit K 768.555 0 153.71

9108 Thyrotropin injection K 1695.118 0 339.02

9119 Injection, pegfilgrastim 6mg K 4432.555 0 886.51

9120 Injection, Fulvestrant K 94.874 0 18.97

9122 Triptorelin pamoate K 258.739 0 51.75

9124 Daptomycin injection K 0.33 0 0.07

9125 Inj risperdal consta, 0.5 mg K 10.044 0 2.01

9126 Natalizumab injection K 20.242 0 4.05

9130 Inj, Imm Glob Bivigam, 500mg K 70.517 0 14.1

9131 Inj, Ado-trastuzumab Emt 1mg K 31.364 0 6.27

9132 Kcentra, per i.u. K 2.002 0 0.4

9133 Rabies ig, im/sc K 280.644 0 56.13

9134 Rabies ig, heat treated K 271.374 0 54.27

9135 Varicella-zoster ig, im K 1716.184 0 343.24

9139 Rabies vaccine, im K 297.589 0 59.52

9140 Rabies vaccine, id K 130.01 0 26

9171 Factor ix idelvion inj K 4.293 0 0.86

9172 Injection, dexamethasone 9% G 1.185 0 0.24

9173 Injection, fulphila G 327.413 0 65.48

9174 Inj, durolane 1 mg G 17.225 0 3.45

9175 Puraply 1 sq cm G 89.703 0 0

9176 Puraply am 1 sq cm G 104.832 0 0

9177 Antithrombin recombinant K 103.35 0 20.67

9178 Inj., meropenem, vaborbactam K 1.788 0 0.36

9179 Inj., aristada initio, 1 mg G 2.856 0 0.57

9180 Inj., patisiran, 0.1 mg G 98.322 0 19.66

9181 Inj., perseris, 0.5 mg G 9.866 0 1.97

9182 Inj mogamulizumab-kpkc, 1 mg G 200.87 0 40.17

9183 Inj., plazomicin, 5 mg G 3.219 0 0.64

9184 Iodine i-131 iobenguane, dx G 311.06 0 0

9185 Iodine i-131 iobenguane, tx G 311.06 0 62.21

9186 Inj., rituximab, 10 mg K 94.667 0 18.93

9187 Injection, burosumab-twza 1m K 353.21 0 70.64

9188 Inj crotalidae im f(ab')2 eq K 1264.421 0 252.88

9189 Inj., ibalizumab-uiyk, 10 mg K 60.155 0 12.03

9190 Inj., vestronidase alfa-vjbk K 218.332 0 43.67

9191 Inj., fibryga, 1 mg K 1.139 0 0.23

9192 Inj, bortezomib, nos, 0.1 mg K 25.039 0 5.01

9193 Nivestym G 0.635 0 0.13

9194 Tisagenlecleucel car-pos t G 441508.39 0 88301.68

9195 Injection, udenyca 0.5 mg G 347.056 0 69.41

9196 Inj, trivisc 1 mg K 7.195 0 1.44

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9197 Inj., fremanezumab-vfrm 1 mg G 2.505 0 0.5

9198 Inj, coagulation factor Xa G 291.5 0 58.3

9199 Injection, caplacizumab-yhdp G 683.545 0 136.71

9207 Inj., velcade 0.1 mg K 44.687 0 8.94

9208 Agalsidase beta injection K 183.43 0 36.69

9209 Laronidase injection K 32.136 0 6.43

9210 Palonosetron hcl K 7.933 0 1.59

9213 Pemetrexed injection K 69.472 0 13.89

9214 Bevacizumab injection K 81.182 0 16.24

9215 Cetuximab injection K 62.048 0 12.41

9217 Leuprolide acetate suspnsion K 224.698 0 44.94

9224 Galsulfase injection K 397.922 0 79.58

9225 Inj., retisert, 0.01 mg K 341.615 0 68.32

9228 Tigecycline injection K 1.566 0 0.31

9229 Ibandronate sodium injection K 43.48 0 8.7

9230 Abatacept injection K 54.318 0 10.86

9231 Decitabine injection K 7.485 0 1.5

9232 Idursulfase injection K 542.887 0 108.58

9233 Ranibizumab injection K 352.174 0 70.43

9234 Alglucosidase alfa injection K 141.14 0 28.23

9235 Panitumumab injection K 119.071 0 23.81

9236 Eculizumab injection K 230.479 0 46.1

9237 Inj, lanreotide acetate K 62.324 0 12.46

9239 Buprenorphine xr over 100 mg G 1673.362 0 334.67

9240 Injection, ixabepilone K 91.065 0 18.21

9242 Injection, fosaprepitant K 1.969 0 0.39

9243 Inj., treanda 1 mg K 27.844 0 5.57

9245 Romiplostim injection K 74.275 0 14.86

9251 C1 esterase inhibitor inj K 57.031 0 11.41

9252 Plerixafor injection K 347.712 0 69.54

9253 Temozolomide injection K 10.392 0 2.08

9255 Paliperidone palmitate inj K 11.63 0 2.33

9256 Dexamethasone intra implant K 200.026 0 40.01

9257 Inj., emicizumab-kxwh 0.5 mg G 47.348 0 9.47

9258 Telavancin injection K 5.737 0 1.15

9259 Pralatrexate injection K 291.264 0 58.25

9260 Ofatumumab injection K 60.093 0 12.02

9261 Ustekinumab sub cu inj, 1 mg K 191.387 0 38.28

9263 Ecallantide injection K 493.743 0 98.75

9264 Tocilizumab injection K 4.958 0 0.99

9265 Romidepsin injection K 297.586 0 59.52

9269 C-1 esterase, berinert K 51.305 0 10.26

9270 Gammaplex IVIG K 45.824 0 9.16

9271 Velaglucerase alfa K 345.522 0 69.1

9272 Inj, denosumab K 19.276 0 3.86

9273 Sipuleucel-T auto CD54+ K 46374.199 0 9274.84

9274 Crotalidae Poly Immune Fab K 3285.188 0 657.04

9276 Cabazitaxel injection K 173.666 0 34.73

9278 Incobotulinumtoxin A K 5.054 0 1.01

9281 Injection, pegloticase K 2512.548 0 502.51

9284 Ipilimumab injection K 153.128 0 30.63

9286 Belatacept injection K 3.776 0 0.76

9287 Brentuximab vedotin inj K 162.437 0 32.49

9289 Erwinaze injection K 414.825 0 82.97

9293 Injection, glucarpidase K 328.863 0 65.77

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9294 Inj, taliglucerase alfa 10 u K 40.084 0 8.02

9295 Injection, Carfilzomib, 1 mg K 37.599 0 7.52

9296 Inj, ziv-aflibercept, 1mg K 8.374 0 1.67

9297 Inj, Omacetaxine Mep, 0.01mg K 3.11 0 0.62

9298 Inj, Ocriplasmin, 0.125 mg K 1046.927 0 209.39

9299 Inj. jivi 1 iu G 2.018 0 0.4

9300 Omalizumab injection K 36.778 0 7.36

9301 Aminolevulinic acid, 10% gel G 1.448 0 0.29

9302 Inj daunorubicin, cytarabine G 192.306 0 38.46

9303 Injection, levoleucovorin G 4.08 0 0.82

9304 Inj., cemiplimab-rwlc, 1 mg G 27.447 0 5.49

9305 Inj., lumoxiti, 0.01 mg G 22.083 0 4.42

9306 Inj., tildrakizumab, 1 mg G 136.489 0 27.3

9307 Cocaine hcl nasal solution G 0.859 0 0.17

9308 Dexametha opth insert 0.1 mg G 151.41 0 30.28

9309 Inj. tagraxofusp-erzs 10 mcg G 258.958 0 51.79

9310 Inj., emapalumab-lzsg, 1 mg G 780.047 0 156.01

9311 Inj., omadacycline, 1 mg G 3.492 0 0.7

9312 Inj., ravulizumab-cwvz 10 mg G 226.275 0 45.26

9313 Inj. belrapzo/bendamustine G 24.355 0 4.87

9314 Inj. herceptin hylecta, 10mg G 80.258 0 16.05

9322 Bcg live intravesical 1mg K 2.821 0 0.56

9324 Phenylep ketorolac opth soln G 112.353 0 0

9325 Inj., eravacycline, 1 mg K 0.957 0 0.19

9326 Inj., lanadelumab-flyo, 1 mg K 76.344 0 15.27

9327 Inj. romosozumab-aqqg 1 mg G 8.951 0 1.79

9328 Inj., yutiq, 0.01 mg K 491.133 0 98.23

9329 Inj mvasi 10 mg K 69.772 0 13.95

9330 Inj., kanjinti, 10 mg K 90.671 0 18.13

9441 Inj ferric carboxymaltos 1mg K 1.097 0 0.22

9445 Injection, ruconest K 28.219 0 5.64

9448 Oral netupitant, palonosetro K 245.742 0 49.15

9449 Injection, blinatumomab K 113.397 0 22.68

9450 Inj., iluvien, 0.01 mg K 490.865 0 98.17

9451 Injection, peramivir K 1.642 0 0.33

9452 Inj ceftolozane tazobactam K 5.602 0 1.12

9453 Injection, nivolumab K 27.805 0 5.56

9454 Inj, pasireotide long acting K 303.034 0 60.61

9455 Injection, siltuximab K 103.062 0 20.61

9456 Injection, isavuconazonium K 0.784 0 0.16

9460 Injection, cangrelor K 15.378 0 3.08

9462 Injection, delafloxacin G 0.468 0 0.09

9463 Inj., aprepitant, 1 mg G 2.17 0 0.43

9464 Inj., rolapitant, 0.5 mg G 0.939 0 0.19

9466 Inj., benralizumab, 1 mg G 168.502 0 33.7

9467 Inj rituximab, hyaluronidase G 43.528 0 8.71

9468 Factor ix recomb gly rebinyn G 3.987 0 0.8

9469 Inj triamcinolone ace xr 1mg G 18.88 0 3.78

9470 Aripirazole lauroxil 1 mg K 2.778 0 0.56

9471 Hymovis injection 1 mg K 31.668 0 6.33

9472 Inj talimogene laherparepvec K 51.466 0 10.29

9473 Injection, mepolizumab, 1mg K 29.72 0 5.94

9474 Inj irinotecan liposome 1 mg K 49.913 0 9.98

9475 Injection, necitumumab, 1 mg K 5.744 0 1.15

9476 Injection, daratumumab 10 mg K 53.948 0 10.79

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9477 Injection, elotuzumab, 1mg K 6.496 0 1.3

9478 Inj sebelipase alfa 1 mg K 541.13 0 108.23

9479 Instill, ciprofloxacin otic K 29.972 0 5.99

9480 Injection trabectedin 0.1mg K 312.913 0 62.58

9481 Injection, reslizumab K 9.616 0 1.92

9482 Sotalol hydrochloride IV K 9.985 0 2

9483 Inj, atezolizumab,10 mg K 77.008 0 15.4

9484 Inj, eteplirsen, 10 mg G 167.364 0 33.47

9485 Inj, olaratumab, 10 mg G 52.134 0 10.43

9486 Inj, granisetron, xr, 0.1 mg G 2.744 0 0.55

9487 Ustekinumab, iv inject,1 mg G 12.037 0 2.41

9488 Conivaptan hcl G 31.564 0 6.31

9489 Inj, nusinersen, 0.1mg G 1101.828 0 220.37

9490 Inj, bezlotoxumab, 10 mg G 39.829 0 7.97

9491 Injection, avelumab, 10 mg G 82.969 0 16.59

9492 Inj., durvalumab, 10 mg G 74.636 0 14.93

9493 Injection, edaravone, 1 mg G 19.485 0 3.9

9494 Injection, ocrelizumab G 57.417 0 11.48

9495 Gemtuzumab ozogamicin inj G 199.23 0 39.85

9497 Loxapine for inhalation 1 mg K 15.378 0 3.08

9500 Platelets, irradiated R 2.1626 171.91 0 34.39

9501 Platelet pheres leukoreduced R 6.1177 486.3 0 97.26

9502 Platelet pheresis irradiated R 6.9557 552.91 0 110.59

9503 Fr frz plasma donor retested R 0.7901 62.81 0 12.57

9504 RBC deglycerolized R 4.1658 331.14 0 66.23

9505 RBC irradiated R 2.7847 221.36 0 44.28

9507 Platelets, pheresis R 4.2405 337.08 0 67.42

9508 Plasma 1 donor frz w/in 8 hr R 0.8998 71.53 0 14.31

9509 Frozen plasma, pooled, sd R 0.9556 75.96 0 15.2

9510 Whole blood for transfusion R 1.3987 111.18 0 22.24

9511 Cryoprecipitate each unit R 0.6214 49.4 0 9.88

9512 RBC leukocytes reduced R 2.3246 184.78 0 36.96

9513 Plasma, frz between 8-24hour R 0.9644 76.66 0 15.34

9514 Plasma protein fract,5%,50ml R 0.339 26.95 0 5.39

9515 Platelets, each unit R 1.3582 107.96 0 21.6

9516 Plaelet rich plasma unit R 1.5754 125.23 0 25.05

9517 Red blood cells unit R 1.7627 140.12 0 28.03

9518 Washed red blood cells unit R 4.4777 355.93 0 71.19

9519 Plasmaprotein fract,5%,250ml R 0.9684 76.98 0 15.4

9520 Blood split unit R 1.5859 126.06 0 25.22

9521 Platelets leukoreduced irrad R 2.1026 167.14 0 33.43

9522 RBC leukoreduced irradiated R 3.2153 255.58 0 51.12

9523 Cryoprecipitatereducedplasma R 1.1162 88.73 0 17.75

9524 Blood, l/r, cmv-neg R 2.2134 175.94 0 35.19

9525 Platelets, hla-m, l/r, unit R 10.6281 844.83 0 168.97

9526 Platelets leukocytes reduced R 1.7186 136.61 0 27.33

9527 Blood, l/r, froz/degly/wash R 3.7535 298.37 0 59.68

9528 Plt, aph/pher, l/r, cmv-neg R 5.599 445.06 0 89.02

9529 Blood, l/r, irradiated R 2.8365 225.47 0 45.1

9530 Plate pheres leukoredu irrad R 7.8618 624.93 0 124.99

9531 Plt, pher, l/r cmv-neg, irr R 6.1934 492.31 0 98.47

9532 RBC, frz/deg/wsh, l/r, irrad R 2.8244 224.51 0 44.91

9533 RBC, l/r, cmv-neg, irrad R 2.8845 229.29 0 45.86

9534 Pathogen reduced plasma pool R 0.5212 41.43 0 8.29

9535 Pathogen reduced plasma sing R 0.9856 78.35 0 15.67

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9536 Platelets pheresis path redu R 7.8618 624.93 0 124.99

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status relative payment unadjusted apc group title ... · 2019 addendum a list of apcs 1537 new...

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